43/3 : Lcc 17 London County Council. Sir shirley PUBLIC HEALTH-COUNTY OF LONDON. REPORT of the PUBLIC HEALTH COMMITTEE of the LONDON COUNTY COUNCIL, Submitting the REPORT of the MEDICAL OFFICER OF HEALTH OF THE COUNTY FOR THE YEAR 1908. 12-09 (Printed by order cf the Council.) printed for THE LONDON COUNTY COUNCIL by southwood, smith & co., ltd., And may be purchased, either directly or through any Bookseller, from P. S. KING & SON, 2 and 4, Great Smith-street, Victoria-street, Westminster, s.W., Agents for the sale of the Publications of the London County Council. 21322 S.S./10846 London County Council. Report of the Public Health Committee, submitting the report of the Medical Officer of Health of the County of London for the year 1908. The year 1908 has, for London, been a very exceptional one from the point of view of vital statistics, for the marriage-rate, birth-rate and death-rate are the lowest ever recorded. The deathrate has shown a decline for the past 40 years and a decided and an almost uninterrupted decline year by year for the past 10 years, while in the case of the birth-rate the fall year by year has been almost uninterrupted for some 30 years. The decline in the death-rate since 1904 was commented upon in last year's report, where it was stated that in 1905 the death-rate was 15.1, lower than ever before; in 1906 it was again 15.1; in 1907 it fell to 14. 6, and now in 1908 we have to record a further fall to 13 8. The Medical Officer points out, however, that these very low rates are obtained by applying the recorded deaths to estimates of population, and the correctness of these estimates is open to criticism, inasmuch as seven years have now elapsed since the census of 1901. It appears, for example, that in some of the London boroughs the death-rates would be raised or reduced by nearly 10 per cent., and in two instances by more than 10 per cent., if instead of using the Registrar-General's Annual Summary estimates of population, his estimates for the purposes of the Equalisation of Rates Act, based upon the number of rated houses in each borough, were employed. While the differences in individual boroughs are thus considerable, the death-rate of the County of London as a whole is but little affected by using one or other of the two estimates of population of the Registrar-General. Both estimates it must, however, be admitted may prove to be somewhat wide of the mark. Infant mortality.—The figure which gives the number of deaths per 1,000 births is the lowest ever recorded in London. The infant mortality rate is, moreover, lower in London for the last decennium than in all save one of the 13 other large English towns, and London has a lower figure for 1908 than any of those towns. This, as the Medical Officer says, is a matter for congratulation, though, as he adds, it needs to be remembered that the infant mortality rate is liable to considerable fluctuation owing to climatic conditions and varying degrees of prevalence of epidemic maladies. There are notable differences between the rates of infant mortality in districts well and badly circumstanced socially, a fact which sufficiently indicates the results which might be obtained if the infants of the less favoured districts had extended to them the same care as that bestowed upon infants of the better favoured districts. The Notification of Births Act, 1907, had been adopted in 1908 in all but eight boroughs, and the houses iu which births had taken place were being visited by women sanitary inspectors or health visitors. In some districts this work was supplemented by that of a staff supplied by local health societies; and in this connection "consultative centres" have been instituted in Paddington, Fulham, Westminster, Hampstead, St. Pancras, Finsburv and Poplar. To these centres mothers bring babies who need special attention, and advice is given as to their treatment, the progress of the child being watched and tested by weighing. The London County Council (General Powers) Act, 1908, section 6, provides for the appointment of health visitors and enables the Council to contribute to their salaries. Epidemic diseases.—Here, again, there is for 1908 a lowest recorded death-rate per 1,000. No death occurred from smallpox, and the deaths from measles, whooping cough, diphtheria, enteric fever, diarrhoea and phthisis were below the average of the last 10 years, but those from influenza and scarlet fever were above the average. In connection with enteric fever reference is made by the Medical Officer to two localised prevalencies occurring in poor populations in 1908, one in Bethnal Green, the other in Shoreditch, and to the investigations made into the causes of the outbreaks by the Medical Officers of Health. A report by Dr. Hamer on the subject of these outbreaks is appended to the Medical Officer's Report (Appendix I.). The mortality from puerperal fever shows a distinct diminution, as was the case also last year In dealing with phthisis the Medical Officer comments upon the work done in connection with the voluntary notification system in operation in 21 London boroughs in 1908, and he refers to the operation of the Order of the Local Government Board requiring the notification of cases of phthisis in London occurring in poor law practice, which came into force on 1st January, 1909. London is, as the Medical Officer points out, but very imperfectly provided with the opportunities which are needed 21322 A 2 4 for utilising the knowledge which will thus be gained. Cerebro-spinal fever notifications showed decline to 85 in 1908 as compared with 135 in the preceding year. There were 12 deaths registered from this cause in 1908. Dr. Wanklyn has continued his study of the London cases and the results of his observations are given in Appendix II. of the Medical Officer's report. Removal of house refuse.—The question of nuisance from flies in connection with deposits of house refuse and stable manure has again been studied on lines similar to those followed in 1907. (See Appendix III. of the Medical Officer's report.) One of the centres around which serious nuisance was experienced in 1907 (a dust depot) was not used after June, 1908, and in correspondence with this it was found (judging by the results obtained at 15 places of observation surrounding this centre) that there had been at least six million fewer flies in 1908 than in 1907 in houses within a radius of 200 yards from the depot. Common lodging houses.—In connection with this branch of administration reference should be made to Appendix IV. of the Medical Officer's report, which gives the results of a census of " Homeless Persons " taken on the night of 15th January, 1909. Seamen's lodging houses.—Further negotiations have been conducted with the Board of Trade on the subject of the annual licensing of seamen's lodging houses. Milk supply (Tuberculosis).—On the 1st July, 1908, the administration under the General Powers Act, 1907, Part IV., was brought into operation, and from that time until the end of the year 620 samples of milk were taken, principally from churns at the large railway stations. Of those samples in which it was found practicable to make a completed examination, 11.6 per cent. were found to be tuberculous. The farms supplying the samples giving positive results were inspected by the Council's veterinary inspector; 4,997 cows in all were examined, and of these 147 were found to present tuberculosis of the udder. Provincial local authorities have shown willingness to co-operate with the Council in preventing the sale of milk from cows which the Council's veterinary inspector has certified to be suffering from tubercular disease of the udder, and in a few instances veterinary inspectors have been appointed by the local authorities for the enforcement of the Dairies, Cowsheds and Milkshops Order of 1899. Legislation.—The London County Council (General Powers) Act, 1908.—We were not successful in 1908 in obtaining powers for dealing with unwholesome milk, i.e., milk which apart from being tuberculous was found to be so dirty and unwholesome as to be unfit for human food. Our proposals for legislation affecting London were not proceeded with, because we were informed that the matter would be dealt with by legislation for the country as a whole. During 1908, however, powers were obtained from Parliament for enabling sanitary authorities (1) to refuse to register, or to remove from the register, the names of dairymen carrying on their business on unsuitable premises, (2) to appoint health visitors, (3) to require proper provision for cooking food in tenement houses, (4) to enforce certain regulations as to cleanliness, etc., in places in which food is prepared. Education (Administrative Provisions) Act, 1907.—The Medical Officer shows the steps taken by the Council to give effect to the duties which devolve upon it under the Education (Administrative Provisions) Act, 1907, and in Appendix V. of the Medical Officer's report will be found a report by Dr. Kerr upon the medical work of the Council as the Education Authority. Gilbert Johnstone, County Hall, Chairman. Spring Gardens, S.W. 25th November, 1909. SEVENTEENTH ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH OF THE ADMINISTRATIVE COUNTY OF LONDON. TABLE OF CONTENTS. PArT I. Vital Statistics. page Population 5 Marriages 5 Of minors, per cent, of total marriages 6 Births 6 Rates per 1,000 persons living and legitimate births per 100 married females {aged 15-45) in sanitary areas 7 Deaths 7 London mortality in the year 1908 compared with the mortality in the decennium 1891-1900 9 Deaths from certain diseases and groups of diseases (increased or diminished incidence 1908) 10 Crude and corrected rates in sanitary areas 11 Deaths at the several age-periods in sanitary areas 13 Rates from all causes and from specified causes in sanitary areas 13 Infantile mortality 14 Deaths from stated causes 15 Life-table for the first 12 months of life in London 1908 17 In relation to overcrowding 18 Principal Epidemic Diseases 20 Smallpox and Vaccination 21 London vaccination returns 23 Number of children for whom certificates of conscientious objection were obtained together with the number of children not finally accounted for per cent, of births 23 Measles 24 Mortality among children at ages 0-5 in sanitary areas 25 Ln relation to overcrowding 26 Deaths at the several age-periods in sanitary areas 27 Scarlet Fever 28 Age and sex distribution 30 Scarlet fever and elementary schools 31 Diphtheria 32 Comparative case-rates in sanitary areas 34 Age and sex distribution 34 Diphtheria and elementary schools 35 Whooping-cough 37 In relation to overcrowding 39 Typhus 39 Enteric Fever 40 Age and sex distribution 43 Diarrhœa 43 Erysipelas 45 Puerperal Fever 46 Influenza, Bronchitis and Pneumonia 47 Phthisis 48 Crude and corrected death-rates in sanitary areas 48 Deaths at the several age-periods in sanitary areas 49 In relation to overcrowding 50 Voluntary notification 50 Cancer 52 Crude and corrected death-rates in sanitary areas 52 Deaths from sarcoma, carcinoma, and cancer (otherwise undefined) at the several age-periods in sanitary areas 53 In relation to overcrowding 55 Cerebro-spinal Fever 55 Anthrax 56 Glanders 56 Meteorology 56 PART II. « Public Health Administration. Dairies, Cowsheds and Milkshops 57 Tuberculosis of the udder in cows 58 Tuberculous milk supply in London 59 Offensive Businesses 61 Nuisances 62 Smoke nuisance 62 Nuisance from stable manure 63 Removal of house refuse 63 Nuisance from flies 64 Other nuisances 64 Housing of the Working Classes Act, 1890 64 Proceedings under Part I. of the Act 64 Proceedings under Part II. of the Act 64 Proceedings under Part III. of the Act 64 Death-rates among persons resident in the County Council's dwellings 65 Proceedings in respect of houses represented under Part II. of the Act as unfit for human habitation 65 TABLE OF CONTENTS—continued. page Common Lodging-houses 66 Death-rate of inmates of common lodging-houses 67 Homeless persons 67 Seamen's lodging-houses 67 Houses let in Lodgings 68 Water supply to tenement houses 70 Houses infested with Vermin 70 Revenue Act, 1903 71 Underground rooms 72 Overcrowding 72 Factory and Workshop Act, 1901 73 Table showing proceedings of sanitary authorities under the Factory and Workshop Act 74 Places where Food is Prepared for Sale 77 Sale of Ice Cream 77 Inspection of Food 78 Disinfection 79 Shelters 79 Mortuaries 80 Cleansing of Persons Act, 1897 80 London Equalisation of Eates Act, 1894 83 Midwives Act, 1902 84 Notification of Births Act, 1907 93 Legislation, 1908 94 Water Supply 94 Sanitary Inspectors and Health Visitors 95 Education (Administrative Provisions) Act, 1907 95 School attendance of children below the age of 5 years 96 Medical Officers of Health of London Sanitary Areas 97 A ppendices— I.—Eeport on the prevalence of Enteric Fever in Shoreditch and Bethnal Green in 1908. II.—Eeport on Cerebro-spinal Fever. III.—Eeport on Nuisance from Flies. IV.—Eeport on Homeless Persons in London. V.—Eeport of the Medical Officer (Education) for 21 months ended 31st December, 1908. LIST OF DIAGRAMS. Facing page Diagram I.—Marriages, 1851-1908 6 „ II.—Births, 1851-1908 6 ,, III.—Deaths (all causes) 1841-1908 8 „ IV.—Infantile Mortality, 1858-1908 14 „ V.—Infantile Mortality (weekly deaths, all causes, diarrhoea and respiratory diseases, in relation to weekly temperature), 1889-1908 16 ,, VI.—Smallpox (imortality) 1841-1908 22 ,, VII.—Measles (mortality) 1841-1908 24 ,, VIII.—Measles and Whooping-cough (monthly deaths) 1891-1908 25 ,, IX.—Scarlet Fever (mortality) 1859-1908 28 ,, X.—Scarlet Fever (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in London) 1890-1908 28 ,, XI.—Scarlet Fever (monthly notified cases and case-mortality) 1891-1908 29 ,, XII.—Diphtheria and Croup (mortality) 1859-1908 32 ,, XIII.—Diphtheria (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in London) 1890-1908 32 ,, XIV.—Diphtheria (monthly notified cases and case-mortality) 1891-1908 33 ,, XV.—Whooping-cough (mortality) 1841-1908 37 ,, XVI.—Typhus (mortality) 1869-1908 39 „ XVII.—Enteric Fever (mortality) 1869-1908 40 ,, XVIII.—Enteric Fever (weekly notified cases, 1908, and mean weekly notified cases, 1890-1908) 40 „ XIX.—Enteric Fever (monthly notified cases and case-mortality) 1891-1908 41 ,, XX.—Diarrhœa, Dysentery and Cholera (mortality) 1841-1908 44 ,, XXI.—Phthisis (mortality—males and females) 1851-1908 48 REPORT OF THE MEDICAL OFFICER OF HEALTH. 1980 PART I. The mean temperature of the air during 1908 was exactly equal to the average of the preceding 65 years. The monthly average was markedly exceeded in October and less so in May and November, while the April mean was considerably below the average, the deficiency being less marked in August and January. The rainfall during the year, as a whole, was slightly below the average, the difference being most marked in the months of November, September and October, and also manifested, although in less degree, in the months of May, January and February. In each of the remaining months of the year the rainfall was somewhat above the average, this difference being most marked in the month of July. The marriage-rate (15.9) was considerably below the marriage-rate of the preceding year (17.0), and was the lowest rate recorded in London since complete marriage statistics have been available. The birth-rate (25.2) was the lowest on record in London since the institution of civil registration, as were also the death-rate (13.8) and the infantile mortality (113). The deaths from diseases of the respiratory system and pneumonia were below the annual average number of the preceding 10 years, whilejthe deaths from influenza and cancer were above the average. No case of small-pox is known to have occurred in London, and the deaths from measles, whooping-cough, diphtheria, enteric fever, diarrhœa and phthisis were below the average. If the death-rate in 1908 be compared with that of the decennium 1891-1900 the result expressed in terms of lives and " life capital," shows a saving of 26,205 lives, representing a gain to the community of 1,066,770 years of " life capital." Population. The population of the Administrative County of London, estimated to the middle of the year 1908, was 4,795,757. The populations of the City of London and each of the metropolitan boroughs, as constituted by the London Government Act of 1899, estimated to the middle of 1908, are shown in the following table— Sanitary areas.—Population (middle of 1908). Sanitary area. Estimated population (middle of 1908). Sanitary area. Estimated population (middle of 1908). Paddington 150,923 Shoreditch 115,227 Kensington 182,752 Bethnal Green 131,066 Hammersmith 124,012 Stepney 310,706 Fulham 171,562 Poplar 171,516 Chelsea 75,049 Southwark 210,442 Westminster, City of 170,545 Bermondsey 127,910 St. Marylebone 126,867 Lambeth 321,344 Hampstead 92,654 Battersea 183,873 St. Pancras 237,075 Wandsworth 289,506 Islington 349,091 Camberwell 280,022 Stoke Newington 54,015 Deptford 117,539 Hackney 235,253 Greenwich 109,110 Holborn 54,466 Lewisham 156,627 Finsbury 96,007 Woolwich 131,346 London, City of 19,252 Marriages. The number of marriages in the Administrative County of London in 1908 was 38,209, giving an annual rate of persons married of 15'9 per 1,000 persons living. This, as previously stated, is the lowest rate recorded in London since complete marriage statistics have been available. The marriage-rate in s uccessive periods lias been as follows— Marriage-rates. Period. Marriage-rate per 1,000 persons living. Period. Marriage-rate per 1,000 persons living. 1851-60 20.6 1903 17.5 1861-70 20.3 1904 17.0 1871-80 19.1 1905 16.9 1881-90 17.6 1906 17.1 1891-1900 17.8 1907 17.0 1901 17.6 1908 15.9 1902 17.8 21322 b 6 The accompanying diagram (I.) shows the marriage-rate in each year since 1850, in relation to the mean marriage-rate of the period 1851-1908. In the year 1908 among the males 2.9 per cent, married were under 21 years of age, and among the females 11.3 per cent.; the figures for previous years are shown in the following table, the proportions in England and Wales being also given for the purpose of comparison. It will be seen that both in London and in England and Wales the proportion of male and female minors in every 100 marriages has been diminishing for a number of years :— Marriages of minors per cent, of total marriages. Period. London. England and Wales. Males. Females. Males. Females. 1851-60 2.8 11.9 5.7 18.0 1861-70 3.6 14.6 6.8 20.4 1871-80 4.7 16.9 8.0 22.0 1881-90 5.5 18.9 6.8 20.8 1891-1900 4.7 16.5 5.4 17.5 1901 4.4 15.0 5.0 16.0 1902 4.0 14.0 4.7 15.4 1903 3.8 13.7 4.6 15.2 1904 3.7 13.9 4.6 15.3 1905 3.6 130 4.4 14.7 1906 3.5 12.9 4.3 14.6 1907 3.2 11.8 4.1 14.2 The decline in the marriage-rate of London is discussed in the Annual Summary of the RegistrarGeneral, who shows that if the marriage-rate of 1908 be compared with the marriage-rate of 1870-72, it has decreased by 18 per cent., if based on the total population, and by 26 per cent., if based upon the total number of marriageable persons, i.e., on the unmarried and widowed portion of the population, aged 15 years and upwards. This latter figure, the Registrar-General states, may be said to represent more accurately than the former the fall in the marriage-rate in the period under review. Births. The number of births registered in the Administrative County of London in 1908 (53 weeks) was 122,898, giving a birth-rate of 25'2 per 1,000 persons living per annum. The steady decline in the London birth-rate noted in previous reports has continued, and the birth-rate for 1908 is the lowest recorded rate in London since the institution of civil registration. The birth-rate in successive periods has been as follows:— London—Birth-rates. Period. Birth-rate par 1,000 persons living. Period. Birth-rate per 1,000 persons living. 1851-60 33.6 1903 28.31 1861-70 35.4 1904 27.71 1871-80 35.4 1905 27.01 1881-90 33.2 1906 26.51 1891-1900 30.31 1907 25.61 1901 28.81 1908 25.21 1902 28.41 The corresponding figures for England and Wales are as follows:— England and Wales—Birth-rates. Period. Birth-rate per 1,000 persons living. Period. Birth-rate per 1,000 persons living. 1851-60 34.1 1903 28.4 1861-70 35.2 1904 27.9 1871-80 35.4 1905 27.2 1881-90 32.4 1906 27.1 1891-1900 29.9 1907 26.3 1901 28.5 1908 26.5 1902 28.5 1 For the purposes of these rates the births in the principal lying-in institutions have been distributed to the district to which they belong. Digram I Marriage s. — Mean Marriage rate 1851-1308. 18-5 per 1,000 living Diagram II Births. Mean Birth rate 1851-1308. 32-3 per 1,000 living 7 The accompanying diagram (II ) shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1908. 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 births have 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-rnte in the several sanitary areas per 1,000 persons living and per 100 married females aged 15-45 in the period 1903-7 and in the year 1908:— Birth-rates in sanitary areas. Sanitary area. Births,1 1908 (53 weeks). Birth-rate1 per 1,000 persons living. Legitimate births' per 100 married females aged 15-45. 1903-7. 1908. 1903-7. 1908. Paddington 3,384 22.9 22.1 18.9 18.2 Kensington 3,565 19.8 19.2 18.3 17.6 Hammersmith 3,204 26.7 25.4 20.4 19.3 Fulham 4,710 30.6 27.0 20.3 17.9 Chelsea 1,558 21.4 20.4 18.5 17.6 Westminster, City of 2,900 17.6 16.7 15.8 14.9 St. Marylebone 2,652 21.3 20.6 17.8 17.5 Hampstead 1,400 16.5 14.9 15.4 13.9 St, Pancras 5,918 26.6 24.6 19.8 18.6 Islington 8,782 26.1 24.7 19.9 18.9 Stoke Newington 1,084 21.2 19.7 17.7 16.2 Hackney 5,580 25.6 23.3 20.6 18.8 Holborn 1,086 21.8 19.6 17.3 15.8 Finsbury 3,038 31.5 31.1 23.9 23.8 London, City of 292 14.8 14.9 16.5 16.6 Shoreditch 3,744 33.4 320 25.8 24.6 Bethnal Green 4,341 34.4 32.6 27.0 25.5 Stepney 10,124 35.5 32.1 27.6 24.9 Poplar 5,492 32.7 31.5 25.8 24.8 Southwark 6,237 31.2 29.2 22.8 21.3 Bermondsey 4,230 32.5 32.5 25.8 25.7 Lambeth 8,035 26.4 24.6 20.1 18.7 Battersea 4,663 27.7 24.9 20.0 17.9 Wandsworth 7,403 26.4 25.2 20.9 20.0 Camberwell 6,885 26.3 24.2 21.0 19.3 Deptford 3,153 29.4 26.4 22.2 19.9 Greenwich 2,601 25.4 23.5 21.0 19.3 Lewisham 3,661 24.9 23.0 19.8 18.3 Woolwich 3,176 28.3 23.8 20.8 17.5 London 122,898 27. 25 .2 21.3 10.8 It will be seen from the above table that the differences in the birth.rates of the several sanitary districts are very marked, ranging from 13.9 in Hampstead to 25.7 in Bermondsey, when the rates based on the number of married females are compared. The Registrar-General has compared the birth-rate of London, in 1870-2 with that of subsequent periods, showing these rates calculated on the total population, and also on the female population aged 15-45 years, and further has compared the rates, for the same periods, of legitimate births calculated on the married female population, and of illegitimate births calculated on the unmarried and widowed female population aged 15-45 years. When compared with the birth-rate in 1870-2, the birth-rate of 1908 has decreased by 28.4 per cent, when calculated on the total population, and 31'3 per cent, when calculated on the female population aged 15-45 years; the legitimate birth-rate has declined 26-5 per cent, when calculated on the married female population aged 15-45 years; and the illegitimate birth-rate has declined 427 per cent, when calculated on the unmarried and female population of that age period. The Registrar-General finds reason for stating that approximately 18 percent, of the decline in the birth-rate, calculated on the female population aged 15-45 years, of the last 38 years is due to the decrease in the proportion of married women of conceptive ages in the female population, and 4 per cent, is due to the decrease in illegitimacy. Some of the remaining 78 per cent, of the decrease, he states, may be ascribed to changes in the age constitution of married women, but he thinks that much of it is due to other than natural causes. Deaths. The number of deaths in the Administrative County of London in 1908 (53 weeks) was 67,353 giving an annual death rate of 13.8 per 1,000 of the estimated population. This death-rate is the lowest recorded since the institution of civil registration. 1 See footnote (1), page 6. 21322 B 2 8 The death-rate in successive periods has been as follows :— All Causes—Death-rates. Period. Death-rate (All Causes) per 1,000 persons living. Period. Death-rate (All Causes) per 1,000 persons living. 1841-50 24.8 1902 17.21 1851-60 23.7 1903 15.21 1861-70 24.4 1904 16.11 1871-80 22.5 1905 15.11 1881-90 20.3 1906 15.11 1891-1900 19.21 1907 14.61 1901 17.11 1908 13.81 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1908 is shown in diagram III. The following table has been prepared for the purpose of comparing the death-rate of London with those of other English towns having populations which exceeded 200,000 persons at the census of 1901. The columns showing "death-rates corrected for age and sex distribution" have been obtained by multiplying the crude death-rates by the "factors for correction" published by the Registrar-General in the Annual Summary for 1908. All Causes—Death-rates per 1,000 persons living. Town. Estimated Population (middle of 1908.) Crude death-rate per 1,000 persons living. Death-rate per 1,000 persons living (corrected for age and sex distribution). Comparative mortality figure. 1898-1907. 1908. 1898-1907. 1908. 1908 England & Wales 35,348,780 16.4 14.7 16.4 14.7 1,000 London 4,795,757 16.71 13.81 17.61 14.51 989 Liverpool 753,203 21.9 19.2 23.4 20.5 1,398 Manchester 649,251 21.0 18.2 23.4 20.3 1,383 Birmingham 558,357 18.9 15.9 20.3 17.1 1,165 Leeds 477,107 17.7 15.3 19.3 16.7 1,135 Sheffield 463,222 18.7 15.8 20.2 17.1 1,162 Bristol 372,785 15.8 13.6 16.2 13.9 948 West Ham 315,000 16.9 13.9 18.1 14.8 1,009 Bradford 292,136 16.8 15.5 18.6 17.2 1,170 Newcastle.on.Tyne 277,257 19.7 16.0 21.2 17.2 1,172 Hull 271,137 17.9 16.2 18.3 16.6 1,128 Nottingham 260,449 17.8 15.2 18.8 16.0 1,091 Salford 239,294 20.6 17.8 22.8 19.7 1,340 Leicester 240,172 15.4 13.0 16.4 13.8 941 London had therefore (comparing the corrected death.rates) both in the decennium 1898-1907, and the year 1908 a lower death-rate than any of these towns except Bristol and Leicester. The following table enables comparison to be made of the crude death-rate of London with that of several foreign towns2:— All Causes—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 16.71 13.81 St. Petersburg 24.5 28-6 Paris 18.6 17.5 Berlin 17.1 15-4 Brussels 15.6 14.5 Vienna 19.1 17.6 Amsterdam 1.0 13.0 Rome 19.2 18.5 Copenhagen 16.7 16.4 New York 19.3 16.5 Stockholm 15.7 14.7 It will be seen from the foregoing table that in the decennium 1898-1907 the London deathrate was exceeded by the death-rates of Paris, St. Petersburg, Berlin, Vienna, Rome and New York, and in 1908 was lower than that of any except Amsterdam. 1These death-rates are fully corrected for institutions, i.e., by the exclusion of deaths of persons not belonging to, but occurring in, institutions situated within London, and by the inclusion of deaths of persons belonging to London, but occurring in London institutions situated outside the Administrative County. 2All death-rates in this report relating to foreign towns are calculated upon figures published by the Registrar. General. DiaqramlK DeathS (allCauses.) — Mean Death-rate 184-1-1308. 2!' 2 per tOOO living. 9 London mortality in 1908 compared with the mortality in the decennium 1891-1900. The following table shows the mean death-rates obtaining in London at the several age-periods and for each sex in the decennium 1891-1900 and in the year 1908. The figures for the year 1908 are fully corrected for institution deaths (see footnote (1), page 8), and the rates for the decennium 1891-1900 are based upon figures which have been corrected for institution deaths on the basis of the experience of the four years 1897-1900; a fuller discussion of this point will be found in the London Life Table appended to my report for the year 1901. Death-rates per 1,000 living at the several age-periods in 1908 as compared with those of the decennium 1891-1900. Age-period. Males. Females. Mean deathrate 1891-1900. Death-rate 1908. Difference per cent. Mean deathrate 1891-1900. Death-rate 1908. Difference per cent. 0— 71.97 42.90 —40.39 61.99 35.57 —42.62 5— 4.97 2.72 —45.27 5.17 2.86 —44.68 10— 2.46 1.78 —27.64 2.48 1.71 —31.05 15— 3.47 2.37 —31.70 2.94 1.90 —35.37 20— 4.59 3.12 —32.03 3.46 2.37 —31.50 25— 7.36 5.07 —31.11 5.65 3.46 —38.76 35— 14.22 9.90 —30.38 10.68 7.11 —33.43 45— 23.14 17.98 —22.30 17.12 12.97 —24.24 55— 40.68 34.36 —15.54 31.01 25.00 —19.38 65— 77.78 74.38 — 4.37 63.44 56.72 —10.59 75— 154.13 148.70 — 3.52 134.56 124.07 — 7.80 85 and upwards 284.10 305.53 + 7.54 265.77 300.67 + 13.13 All ages 20.88 15.02 —28.07 17.88 12.65 —29.25 It will be seen from this table that the rate of mortality in 1908 was considerably lower than that of the period 1891-1900 at each age-period of life and for each sex, except at the period 85 and upwards. In previous annual reports it has been shown that a more accurate estimate of the effect on the community of fluctuations of mortality could be obtained by the use of a Life Table, the method adopted being similar to that employed by Dr. Tatham in a report on the health of greater Manchester for the period 1891-3. The advantages of this method and the formulae used are set out in some detail in the London Life Table appended to the annual report for 1901. It will be seen from the description therein contained that in order to apply this method of comparison it is necessary in the first place to ascertain from the Life Table the mean future lifetime of males and females in groups of ages corresponding to those age-groups to which the deaths relate. The following table shows the results thus obtained from the London Life Table, 1891-1900:— Table I. Mean future lifetime of males and females in groups of ages, calculated from the London Life Table, 1891-1900. Age-group. Males. Females. Age-group. Males. Females. Years. Years. Years. Years. 0— 50.16 53.66 35— 23.98 26.89 5— 49.89 53.48 45— 17.75 20.04 10— 45.61 49.30 55— 12.35 13.93 15— 41.26 44.94 65— 7.98 8.90 20— 37.05 40.62 75— 4.91 5.37 25— 31.05 34.39 85 and upwards 3.02 3.19 In the following table the number of deaths occurring in the year 1908 at each age-period and for each sex is compared with the number of deaths which would have occurred had the death-rates of the period 1891-1900 been maintained in the year 1908. The number of lives gained in the latter period is also shown, and the figures in the last column of the table express this gain in terms of "life capital," these being obtained by applying the mean future lifetime figures given in Table I. to the number of lives gained at each age-group:— 10 Table II. Lives and "Life-capital" gained or lost in 1908, as compared with the decennium 1891-1900. Age-group. Deaths calculated according to mean death-rates of 1891-1900. Deaths occurring in the year 1908. Gain ( + ) or loss (—) of lives in the year 1908, by fluctuations of mortality. Gain (+) or loss ( —) of "life capital" in the year 1908 by fluctuations of mortality. Males. Years. 0— 18,914 11,273 +7,641 +383,273 5— 1,161 635 +526 +26,242 10— 542 391 +151 +6,887 15— 768 525 +243 +10,026 20— 1,058 718 +340 +12,597 25— 2,898 1,995 +903 +28,038 35— 4,231 2,946 +1,285 +30,814 45— 4,789 3,721 +1,068 +18,957 55— 5,119 4,324 +795 +9,818 65— 4,535 4,337 +198 +1,580 75— 2,783 2,685 +98 +481 85 and upwards 524 564 -40 121 All Ages—Males 47,322 34,114 +13,208 +528,592 Females. 0— 16,276 9,340 +6,936 +372,186 5— 1,219 675 +544 +29,093 10— 557 384 +173 +8,529 15— 726 470 +256 +11,505 20— 956 654 +302 +12,267 25— 2,622 1,604 +1,018 +35,009 35— 3,514 2,339 +1,175 +31,596 45— 3,962 3,001 +961 +19,258 55— 4,634 3,736 +898 +12,509 65— 5,230 4,676 +554 +4,931 75— 4,252 3,921 +331 +1,777 85 and upwards 1,153 1,304 -151 -482 All Ages—Females 45,101 32,104 +12,997 +538,178 Total—Persons 92,423 66,218 +26,205 +1,066,770 It will be seen from this table that during the year 1908, compared with the decennium 1891-1900, there has been a saving of 26,205 lives, representing a gain to the community of 1,066,770 years of " life-capital." Deaths at All Ages from certain Diseases and Groups of Diseases. The following table from the Annual Summary of the Registrar-General shows the diminution or excess in the year 1908 under certain of the more important headings in the list of causes of death, when compared with the annual average deaths of the preceding 10 years, corrected for increase of population. Number of deaths, 1908, compared with the annual average deaths of the preceding decennium, 1898-1907. Cause of death. Diminution in 1908. Excess in 1908. Smallpox 169 — Measles 711 — Scarlet Fever — 24 Typhus 2 — Influenza — 217 Whooping-Cough 803 — Diphtheria 467 — Pyrexia (origin uncertain) 4 - Enteric Fever 252 - Diarrhœa 1,174 - Pneumonia 217 - Erysipelas 51 - (Continued on next page.) 11 Cause of Death. Diminution in 1908. Excess in 1908. Tuberculous Phthisis 1,365 — Phthisis Tuberculous Meningitis 127 — Tuberculous Peritonitis 258 — Tabes Mesenterica Other Tuberculous Diseases (including Scrofula) 49 — Cancer — 304 Premature Birth 438 — Diseases of Nervous system 2,236 — Diseases of Circulatory system1 Diseases of Respiratory system 2,457 — Diseases of Digestive system 995 — Diseases of Urinary system - 26 Childbirth and Puerperal Septic Diseases 82 — Accident 461 — Homicide 10 — Suicide — 38 All other Causes 1,680 - Net diminution 13,399 The following table shows the crude death-rates, and the death-rates corrected for differences in the age and sex constitution of the population of the several sanitary districts during the year 1908; the mean death-rates for the period 1903-7 are also shown for the purposes of comparison. Crude and corrected death-rates 2 (All Causes), per 1,000 persons living, in the County of London, and the several sanitary districts. Area. standard deathrate. 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). 1903-7. 1908. 1903-7. 1908. 1903-7. 1908. England and Wales 18.19 1.0000 — — — — — — London 17.31 1.0511 15.2 13.8 16.0 14.5 1,000 1,000 Paddington 17.04 1.0677 13.3 12.4 14.1 13.2 885 909 Kensington 16.88 1.0778 13.9 12.9 15.0 13.9 940 955 Hammersmith 17.47 1.0414 14.6 14.0 15.2 14.5 949 1,000 Fulham 17.39 1.0462 14.3 12.4 14.9 12.9 932 890 Chelsea 17.56 1.0361 15.5 14.5 16.0 15.0 1,000 1,034 Westminster, City of 16.22 1.1217 13.3 12.6 14.9 14.2 935 976 St. Marylebone 17.08 1.0652 15.6 14.2 16.6 15.1 1,041 1,042 Hampstead 16.13 1.1280 9.6 8.5 10.8 9.6 677 659 St. Pancras 17.40 1.0456 16.1 14.7 16.8 15.4 1,050 1,060 Islington 17.51 1.0391 14.7 13.2 15.3 13.7 959 945 Stoke Newington 17.43 1.0438 12.4 12.3 12.9 12.9 808 886 Hackney 17.46 1.0420 13.9 13.2 14.5 13.7 910 943 Holborn 16.90 1.0766 18.0 16.4 19.4 17.6 1,211 1,213 Finsbury 17.57 1.0355 20.0 18.6 20.7 19.3 1,295 1,327 London, City of 16.55 1.0993 16.6 17.7 18.2 19.4 1,140 1,339 Shored itch 17.34 1.0493 19.9 17.4 20.9 18.3 1,308 1,259 Bethnal-green 18.01 1.0102 18.5 17.1 18.7 17.3 1,169 1,188 Stepney 17.41 1.0450 17.7 16.4 18.5 17.1 1,160 1,179 Poplar 17.64 1.0314 17.8 15.9 18.4 16.3 1,149 1,126 Southwark 17.41 1.0450 18.6 16.3 19.4 17.0 1,213 1,173 Bermondsey 17.76 1.0244 19.0 18.8 19.5 19.2 1,220 1,323 Lambeth 17.63 1.0320 15.1 13.3 15.6 13.7 976 943 Battersea 16.96 1.0728 14.0 12.2 15.0 13.1 939 901 Wandsworth 17.25 1.0547 12.7 11.6 13.4 12.2 838 839 Camberwell 17.54 1.0373 14.2 12.7 14.7 131 920 904 Deptford 17.31 1.0511 151 13.8 15.9 14.5 992 995 Greenwich 17.82 1.0210 13.5 12.6 13.8 12.9 860 885 Lewisham 17.46 1.0420 11.7 11.0 12.2 11.4 761 788 Woolwich 17.02 1.0690 13.2 11.4 14.2 12.1 887 836 1 For the purpose of comparison deaths from Infective Endocarditis are included under this heading. 2 All death-rates in this report relating to metropolitan sanitary areas are fully corrected for institutions—see footnote (1), page 8. 12 It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1903-7, Shoreditch (20.9) had the highest rate and Hampstead (10.8) the lowest; in the year 1908, City of London (19.4) had the highest, the lowest again obtaining in Hampstead (9.6). For the purposes of the calculation of the death-rates in the above table the populations of the several metropolitan boroughs have been estimated on the assumption that the rate of increase in the last intercensal period has been since maintained. The correctness of this assumption is open to doubt, especially in view of the fact that seven years have elapsed since the census of 1901, and the estimate of the populations used needs to be checked by figures obtained on some other assumption. The only official figures which can be thus used are the populations calculated by the Registrar-General for the purposes of the Equalisation of Rates Act, these populations being based upon the number of rated houses in each borough. The following table shows the populations estimated by the two methods referred to and the resulting death-rates for the year 1908. It will be noticed that the deathrate of the County of London is only slightly affected, but the difference in some districts is considerable. It should, however, be noted that migration and the declining birth-rate of recent years in addition to affecting the total number of the population may have considerably altered its age constitution since the date of the last census, and no reliable correction can be made for this effect until the figures of the next census are available. Death-rates in sanitary areas per 1,000 persons living in 1908, calculated (a) on Registrar-General's Annual Summary population and (b) on Equalisation of Rates population. Sanitary area. Population (estimated to the middle of the year). Crude Death-rate.1 Amount by which the death-rate based on estimate (b) differs from that based on (a). (a) Annual Summary estimate. (b) Equalisation of Rates estimate. Calculated on (a). Calculated on (b). Paddington 150,923 145,251 12.4 12.8 +0.4 Kensington 182,752 184,635 12.9 12.7 —0.2 Hammersmith 124,012 120,752 14.0 14.3 +0.3 Fulham 171,562 157,703 12.4 13.4 +10 Chelsea 75,049 71,495 14.5 15.2 +0.7 Westminster, City of 170,545 175,180 12.6 12.3 —0.3 Marylebone 126,867 124,614 14.2 14.5 +0.3 Hampstead 92,654 88,405 8.5 8.9 +0.4 Pancras 237,075 228,753 14.7 15.3 +0.6 Islington 349,091 336,815 13.2 13.7 +0.5 Stoke Newington 54,015 52,557 12.3 12.7 +0.4 Hackney 235,253 219,673 13.2 14.1 +0.9 Holborn 54,466 53,845 16.4 16.6 +0.2 Finsbury 96,007 102,331 18.6 17.5 —1.1 London, City of 19,252 24,464 17.7 13.9 —3.8 Shoreditch 115,227 116,646 17.4 17.2 —0.2 Bethnal Green 131,066 128,680 17.1 17.4 +0.3 Stepney 310,706 286,668 16.4 17.8 + 1.4 Poplar 171,516 167,169 15.9 16.3 +0.4 Southwark 210,442 197,914 16.3 17.3 +1.0 Bermondsey 127,910 128,723 18.8 18.6 —0.2 Lambeth 321,344 309,730 13.3 13.8 +0.5 Battersea 183,873 172,983 12.2 13.0 +0.8 Wandsworth 289,506 320,657 11.6 10.4 —1.2 Camberwell 280,022 269,397 12.7 13.2 +0.5 Deptford 117,539 112,576 13.8 14.4 +0.6 Greenwich 109,110 104,100 12.6 13.2 +0.6 Lewisham 156,627 167,849 11.0 10.2 —0.8 Woolwich 131,346 137,894 11.4 10.8 —0.6 London 4,795,757 4,707,459 13.8 14.1 +0.3 1 See footnote (1), page 8. 13 The following table shows the number of deaths1 (All Causes) occurring at the several age periods in each of the sanitary areas of the Administrative County of London during the year 1908 (366 days) All Causes—Deaths at the several age-periods in sanitary areas—1908 (366 days). Age-period. 0- 1- 2- 3- 4- Under 5. 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 & upwards All Ages. Paddington 338 79 31 21 14 483 27 21 18 33 99 141 217 260 276 215 66 1,856 Kensington 415 97 52 19 8 591 33 26 29 46 119 183 229 332 352 311 112 2,363 Hammersmith 379 87 28 12 10 516 34 21 22 39 99 121 175 221 253 177 56 1,734 Fulham 539 121 47 47 20 774 57 28 21 51 126 182 215 224 225 173 52 2,128 Chelsea 167 30 20 6 9 232 20 10 12 21 54 79 125 129 221 151 36 1,090 Westminster, City of 292 69 31 15 11 418 27 17 27 46 107 197 262 308 397 286 64 2,156 St. Marylebone ... 263 65 29 16 12 385 35 14 25 39 84 202 223 247 290 196 60 1,800 Hampstead 93 10 8 4 2 117 11 8 9 27 57 65 73 110 148 99 57 781 St. Pancras 631 175 67 44 21 938 51 39 44 62 197 313 407 427 518 383 97 3,476 Islington 881 244 96 37 41 1,299 93 66 66 101 255 398 476 588 617 505 147 4,611 Stoke Newington 100 16 8 6 4 134 14 6 12 8 27 49 83 91 123 82 32 661 Hackney 632 182 81 59 16 970 71 49 51 64 164 203 301 367 415 344 88 3,087 Holborn 120 39 15 9 5 188 16 8 9 15 51 93 127 140 136 90 16 889 Finsbury 398 130 49 28 9 614 40 25 25 32 100 149 175 238 237 120 30 1,785 London; City of 26 3 4 4 — 37 2 — 5 3 15 30 53 62 68 51 20 346 Shoreditch 510 146 53 37 19 765 44 32 33 33 117 171 199 240 227 111 33 2,005 Bethnal-green 560 177 84 46 32 899 56 27 37 53 124 171 211 207 233 162 46 2,226 Stepney 1,313 474 169 92 70 2,118 101 63 83 96 252 397 477 581 534 349 62 5,113 Poplar 662 232 14 39 40 1,047 45 34 42 59 134 188 249 287 355 219 42 2,701 South wark 810 237 88 55 22 1,212 49 40 56 62 177 287 403 403 410 266 60 3,425 Bermondsey 602 199 59 43 28 931 56 28 47 57 124 170 217 229 274 209 44 2,386 Lambeth 813 229 93 60 48 1,243 79 32 53 91 241 317 483 548 587 453 124 4,251 Battersea 485 140 51 35 20 731 62 25 60 54 111 155 209 277 287 215 48 2,234 Wandsworth 706 156 63 34 33 992 60 31 55 72 209 279 279 409 463 361 133 3,343 Camberwell 706 204 76 51 38 1,075 81 44 53 87 196 283 311 419 482 386 129 3,546 Deptford 377 102 45 22 16 562 28 20 28 29 83 124 136 178 225 166 40 1,619 Greenwich 312 67 35 19 9 442 24 22 14 29 82 98 124 150 183 161 46 1,375 Lewisham 313 76 45 23 16 473 46 17 23 36 93 118 150 223 266 215 75 1,735 Woolwich 297 68 33 12 17 427 48 22 36 27 102 122 133 165 211 150 53 1,496 London 13,740 3,854 1,534 895 590 20,613 1,310 775 995 1,372 3,599 5,285 6,722 8,060 9,013 6,606 1,868 66,218 Comparison can be made of death-rates from certain causes of death in sanitary areas by reference to the following table. The death-rates shown are fully corrected for deaths in institutions (see footnote (1) page 8) but are uncorrected for differences in the age and sex constitution of the population. In the case of phthisis and of "cancer," viz., carcinoma, sarcoma, and cancer (otherwise undefined) factors for correction for differences in age and sex constitution " have been calculated, and these factors and the corrected death-rates are shown on pages 48 and 52 respectively. Death-rates per 100,000 living from All Causes, and from Specified Causes, in each of the several sanitary areas, 1908 (366 days). Sanitary area. Measles. Rheumatic Fever. Carcinoma. Sarcoma. Cancer (nototherwise defined). Tabes Mesenterica. Tuberculous Meningitis. Phthisis. Other Tuberculous and Scrofulous Diseases. Pneumonia. Other Respiratory Disease. All other Causes. All Cause. Paddington 23 7 78 8 38 4 11 100 11 104 146 696 1,226 Kensington 17 6 54 6 44 9 20 101 16 117 125 774 1,289 Hammersmith 11 6 60 6 32 11 22 122 14 139 131 840 1,394 Fulham 41 5 43 3 22 8 26 114 16 132 98 729 1,237 Chelsea 16 4 43 1 54 7 12 126 11 141 154 879 1,448 Westminster, City of 13 4 71 4 44 6 16 124 19 138 111 711 1,261 St. Marylebone 19 2 69 8 54 6 16 109 23 123 149 837 1,415 Hampstead 4 4 67 8 23 1 9 75 3 62 59 526 841 St. Pancras 19 6 82 5 37 6 19 154 20 173 121 820 1,462 Islington 21 4 54 5 47 14 18 124 18 143 118 751 1,317 Stoke Newington 18 4 74 11 41 9 13 103 18 72 137 720 1,220 Hackney 31 5 47 6 42 14 15 123 19 116 118 773 1,309 Holborn 20 5 60 — 33 9 20 198 18 159 137 969 1,628 Finsbury 45 5 60 5 25 12 30 216 18 186 230 1,022 1,854 London, City of 16 16 78 5 57 10 10 181 10 171 254 984 1,792 Shoreditch 43 8 44 10 26 11 38 199 27 199 140 990 1,735 Bethnal Green 79 5 41 8 38 10 33 158 34 159 163 966 1,694 Stepney 84 7 46 4 25 8 32 157 21 192 139 926 1,641 Poplar 47 6 47 6 32 6 31 139 17 134 179 926 1,570 Southwark 35 9 63 7 17 8 18 187 27 190 147 915 1,623 Bermondsey 80 9 60 9 18 35 32 188 44 204 197 984 1,860 Lambeth 31 5 70 7 29 7 14 142 17 134 119 744 1,319 Battersea 28 7 47 4 33 6 20 119 21 133 111 683 1,212 Wandsworth 15 5 55 7 33 11 15 95 12 100 84 720 1,152 Camberwell 19 7 50 3 41 8 14 109 13 113 138 748 1,263 Deptford 28 6 61 6 16 5 24 114 18 107 154 835 1,374 Greenwich 14 6 58 6 24 12 16 112 16 101 97 795 1,257 Lewisham 30 5 62 4 28 6 15 85 15 68 90 697 1,105 Woolwich 8 4 46 3 24 10 21 121 21 80 88 710 1,136 London 31 6 57 6 33 9 20 131 19 135 128 802 1,377 21322 (1) footnote (1), page 8. c 14 Infantile Mortality. The deaths of children under one year of age in the Administrative County of London during 1908 (53 weeks) numbered 13,943, being in the proportion of 113 per 1,000 births. The rate in successive periods has been as follows:— Deaths under one year of age per 1,000 births. Period. Deaths under one year of age per 1,000 births. Period. Deaths under one year of age per 1,000 births. 1841-50 157* 1902 1401,2 1851-60 155* 1903 1301,2 1861-70 162* 1904 1451,2 1871-80 158* 1905 1301,2 1881-90 152 1906 1311,2 1891-1900 1591,2 1907 116 1901 1481,2 1908 1131, The accompanying diagram (IV.) shows the infantile mortality in each year since 1857 in relation to the mean infantile mortality of the period 1858-1908, and also the infantile mortality in each year after exclusion of the deaths from premature birth, which would in all probability be affected in greater degree than the deaths under any other heading by the more complete registration of recent years. It is thus seen that the rates of 1908 are the lowest recorded in this period. Diagram V. shows the seasonal mortality among children under one year from diarrhoea and respiratory diseases in relation to seasonal variations of temperature. The following table enables comparison to be made of the infantile mortality in London and other large English towns. Deaths under one year of age per 1,000 births. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 1431,2 1131,2 Bradford 155 143 Liverpool 174 141 West Ham 162 128 Manchester 177 151 Newcastle 160 136 Birmingham 175 144 Hull 163 145 Leeds 164 137 Nottingham 177 145 Sheffield 175 140 Salford 180 152 Bristol 132 126 Leicester 166 131 London had therefore in the period 1898-1907 a lower infantile mortality than any of these towns except Bristol, and has the lowest figure for the year 1908. The rates are uncorrected (except in the case of London) for births and deaths in institutions. The uncorrected London rate for 1908 was 115. 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 areas of the County of London for the period 1903-7 and for the year 1908:— Sanitary areas—Deaths under one year of age per 1,000 births. Sanitary area. Deaths under one year of age, 1908. (53 weeks) Deaths under one year of age per 1,000 births. 1903-7. 1908. Paddington 348 115 103 Kensington 424 137 119 Hammersmith 383 133 120 Fulham 545 136 116 Chelsea 167 131 107 Westminster, City of 296 110 102 St. Marylebone 268 122 101 Hampstead 97 87 69 St. Pancras 635 123 107 Islington 897 122 102 Stoke Newington 100 109 92 Hackney 641 126 115 Holborn 123 125 113 Finsbury 405 147 133 London, City of 27 115 92 Shoreditch 521 167 139 Bethnal Green 572 147 132 Stepney 1,320 138 130 Poplar 673 146 123 South wark 820 148 131 Bermondsey 609 150 144 Lambeth 832 131 104 Battersea 496 128 106 Wandsworth 717 114 97 Camberwell 716 126 104 Deptford 384 128 122 Greenwich 311 123 120 Lewisham 316 102 86 Woolwich 300 113 94 London 13,943 1301,2 1131,2 * The registration of births was not made compulsory until the beginning of 1875, before that year many births were probably unregistered. 1 See footnote (1) page 8. 2 See footnote (1) page 6. DiaqrarriTSL Infantile Mortality. (Deaths under one year of age per 1000 births) - . 15 It will be seen from the foregoing table that in the period 1903-7 and the year 1908 Shoreditch (167 and 139 respectively) and Bermondsey (150 and 144 respectively) had the highest infantile death-rates and Hampstead (87 and 69 repectively) had the lowest. The deaths under one year of age per 1000 births, during each of the four quarters of the year were as follows:— First quarter 110; second quarter 90; third quarter 129; fourth quarter 123. The reports of Medical Officers of Health of the several sanitary areas of the Administrative County for the year 1908 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 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. Infantile mortality during the year 1908. Deaths from stated causes in the first four weeks of life and in months under one year of age (53 weeks). Cause of death. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Montlis. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Mouths. 10-11 Months. 11-12 Months. Total Deaths under one year. Common Infectious Diseases— Small-pox — — — — — Ghicken-pox — — 1 — 1 — - 2 - - 3 Measles — — 1 1 2 7 3 2 2 12 18 39 42 54 60 92 333 Scarlet Fever — — — — — — — 1 1 — 5 — 3 5 2 7 24 Diphtheria and Group — — — 2 2 1 4 1 2 3 2 2 10 11 15 14 67 Whooping-cough — — 2 5 7 34 39 34 38 32 35 42 44 42 60 62 469 Diarrhœal Diseases— Diarrhœa, all forms 2 4 25 33 64 177 193 236 222 202 188 136 137 115 86 103 1,859 Enteritis (not tuberculous) 4 21 22 13 60 90 107 86 75 63 61 44 35 34 40 22 717 Gastritis, Gastrointestinal Catarrh 3 6 6 7 22 21 25 17 16 8 6 6 2 2 3 5 133 Wasting Diseases— Premature Birth 1,518 190 160 92 1,960 158 41 16 7 4 3 1 3 1 3 2,197 Congenital Defects 331 88 56 34 509 60 35 21 19 14 10 14 11 4 5 3 705 Injury at Birth 100 3 2 - 105 2 1 1 1 — — — — — — — 110 Want of Breast-milk 5 6 6 3 20 15 9 3 8 3 4 — 2 3 1 — 68 Atrophy, Debility, Marasmus 283 114 139 101 637 318 216 187 112 79 65 39 41 32 27 22 1,775 Tuberculous Diseases— Tuberculous Meningitis 1 1 — 2 4 4 16 15 18 28 25 22 31 33 37 26 259 Tuberculous Peritonitis: Tabes Mesenterica 1 — 2 2 5 18 22 22 21 15 9 10 16 10 10 10 168 Other Tuberculous Diseases 2 2 2 1 7 16 17 29 28 27 21 26 18 31 15 20 255 Erysipelas 1 2 1 4 8 4 2 8 3 2 3 4 — — 1 — 35 Syphilis 11 12 12 13 48 53 45 27 17 13 10 4 5 4 1 2 229 Rickets — — — — — — 6 1 3 1 5 8 6 6 7 8 51 Meningitis (not Tuberculous) 3 3 2 4 12 10 19 21 22 23 27 27 22 25 19 19 246 Convulsions 93 70 37 23 223 70 49 26 20 24 26 27 17 13 12 13 520 Bronchitis 8 31 46 37 122 178 110 93 78 72 59 51 70 52 51 46 982 Laryngitis 1 1 1 — 3 1 — 2 — 2 — 3 2 2 1 2 18 Pneumonia 14 27 31 36 108 154 117 101 99 112 102 113 127 114 143 141 1,431 Suffocation, overlaying 67 11 23 33 134 84 79 40 33 15 12 10 1 4 3 2 417 Other causes 197 59 54 39 349 91 56 45 53 49 42 45 39 42 41 33 885 Total (All Causes) 2,645 651 631 485 4,412 1,566 1,211 1,035 898 803 738 675 684 639 643 652 13,956 Comparison may be made between the number of deaths from the several causes in the above table with those of the three antecedent years by reference to the following table:— Cause of death. 1905. 1906. 1907. 1908. Small-pox - - - - Chicken-pox 3 3 5 3 Measles 389 420 400 333 Scarlet Fever 34 18 35 24 Diphtheria and Croup 52 59 53 67 Whooping-cough 623 502 746 469 (Continued on next paqe.) 21322 C 2 16 Cause of death. 1905. 1906. 1907. 1908. Diarrhœa 3,423 4,468 1,790 2,709 Enteritis (not tuberculous) Gastritis, Gastro-intestinal Catarrh Premature Birth 2,423 2,208 2,299 2,197 Congenital Defects 547 613 645 705 Injury at Birth 99 113 117 110 Want of Breast-milk Atrophy, Debility, Marasmus 2,281 2,130 1,922 1,843 Tuberculous Meningitis 273 241 239 259 Tuberculous Peritonitis: Tabes Mesenterica 192 225 153 168 Other Tuberculous Diseases 284 246 264 255 Erysipelas 64 50 52 35 Syphilis 271 233 226 229 Rickets 79 67 58 51 Meningitis (not tuberculous) 300 302 210 246 Convulsions 803 660 603 520 Bronchitis 1,276 1,043 1,284 982 Laryngitis 25 23 15 18 Pneumonia 1,490 1,335 1,629 1,431 Suffocation, overlaying 462 417 421 417 Other causes 1,004 1,009 979 885 Total 16,397 16,385 14,145 13,956 The total deaths from all causes at ages in 1908 may be compared with similar figures included in the Annual Reports for the years 1905, 1906 and 1907. The deaths in the four years are as follows:— Year. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under one year. 1905 2,886 808 667 564 4,925 1,796 1,411 1,211 1,033 983 932 853 880 846 821 706 16,397 1906 2,683 707 722 545 4,657 1,690 1,417 1,279 1,080 1,080 970 917 849 884 774 788 16,385 1907 2,758 760 676 533 4,727 1,579 1,198 1,060 820 700 723 680 684 668 631 675 14,145 1908 2,645 651 631 485 4,412 1,566 1,211 1,035 898 803 738 675 684 639 643 652 13,956 The fact that London experienced in 1908 the lowest recorded infantile mortality rate is matter for congratulation, but it needs to be remembered that this rate is liable to considerable fluctuation owing to climatic conditions and varying degrees of prevalence of epidemic maladies. Diarrhoea, which is largely dependent upon the temperature of the summer quarter, in 1908, caused 919 deaths more than in 1907, while bronchitis and pneumonia caused 500, and measles and whooping-cough 344 fewer deaths in 1908 than in 1907, compensating for all but 75 of the excess of deaths from diarrhœa, which, while more numerous than in 1907, was still markedly below the average number of deaths from this cause during the preceding ten years. The number of deaths from bronchitis and pneumonia appears often to vary with the prevalence of whooping cough and influenza. Thus, if the number of deaths from these causes during each of the last twenty years is compared with the number for the antecedent year, it is found that when the deaths from whooping-cough under one year of age, and from influenza at all ages, both show decline or increase above the number in the preceding year, the number of deaths from bronchitis and pneumonia under one year of age frequently show also decline or increase. Whooping-cough and influenza both declined or both increased ten times during this period, and on seven of these occasions there was corresponding decline or increase in the number of deaths from bronchitis and pneumonia under one year of age. The infantile mortality rate is in point of fact, extremely sensitive to influences which vary from year to year, and for the effects of which administrative effort can as yet but imperfectly compensate. The result, therefore, of the efforts which are now being made to lessen infantile mortality must not be judged by the mortahty of the moment. It is sufficient that these efforts should be rightly designed and properly applied, and there need be no feeling of doubt that when the accumulated experience of some years is available, it will prove them to be of value. The difference between the rates of infantile mortality in districts well and badly circumstanced socially is sufficient indication of the results which might be obtained if the infants of the less favoured districts had extended to them the same care as that bestowed upon infants of the better favoured districts. Diagram V Infantile Mortality, 1889-1908. Weekly Deaths of Infants under one year of age from All Causes,from Diarrhœa & Dysentery, and from Respiratory Diseases,in relation to mean weekly temperature. 17 The death-rates of infants in London under one year of age from all causes, and from certain causes, in each year of the present decennium are shown in the following table:— London—Deaths,1 per 1,000 births, of infants under one year of age from all causes and certain specified causes. Year. All causes. Measles. Whoopingcough. Diarrhœal diseases. Wasting diseases. Tuberculous diseases. Meningitis and convulsions. Bronchitis. Pneumonia. Other causes. 1901 149 3 5 33 42 7 13 13 12 21 1902 140 4 6 22 42 8 12 12 15 19 1903 131 3 6 23 41 7 10 10 15 18 1904 146 4 5 35 42 7 11 10 13 19 1905 131 3 5 28 41 6 9 10 13 16 1906 133 3 4 37 40 6 9 8 11 15 1907 117 3 6 15 41 5 7 10 15 15 1908 114 3 4 22 39 6 6 8 12 14 The following life table, which is based upon the figures shown in the table on page 15, shows the probability of living for one month at each month of the first year of life, and the number of survivors at the beginning of each of the first twelve months of life out of 100,000 born. The figures shown in the last three columns of the table are taken from similar tables published in recent annual reports, and will enable comparison to be made between the four years 1908, 1907, 190C and 1905 in this respect:— London—1908. Life Table for the first 12 months of life (based on the mortality of the year 1908). Age-period. x/12 Registered deaths. 1908. 1908. Probability of living for one month. px/12 1908. Number living at the beginning of each month of age. lx/12 1907. Number living at the beginning of each month of age. 1 X/12 1906. Number living at the beginning of each month of age. lx/12 1905. Number living at the beginning of each month of age. 1 X/12 0—1 month 4,412 .96381 100,000 100,000 100,000 100,000 1—2 months 1,566 .98671 96,381 96,139 96,298 96,115 2—3 „ 1,211 .98959 95,100 94,853 94,957 94,701 3—4 „ 1,035 .99103 94,110 93,879 93,834 93,594 4—5 „ 898 .99216 93,266 93,021 92,820 92,647 5—6 „ 803 .99293 92,535 92,359 91,963 91,841 6—7 „ 738 .99343 91,881 91,797 91,107 91,076 7—8 „ 675 .99394 91,277 91,217 90,338 90,354 8—9 „ 684 .99383 90,724 90,672 89,612 89,693 9—10 „ 639 .99422 90,164 90,124 88,939 89,011 10—11 „ 643 .99414 89,643 89,590 88,238 88,357 11—12 „ 652 .99402 89,118 89,087 87,627 87,722 0—1 year 13,956 — 88,585 88,551 87,005 87,177 It will be seen from the figures in the third column of the table that while there is generally a progressive icrease in the probability of living one month, the probabilities relating to the 8th and 10th months are slightly lower than those relating to the months immediately preceding them. 1 See footnote (2), page 37. 18 For the purpose of enabling comparison to be made of the age-distribution of the deaths under one year of age in the several sanitary areas of London, the following table has been prepared:— Deaths at each interval of age (under one year) from All Causes in sanitary areas in 1908 (53 weeks). Sanitary area. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-2 Months. 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total under 1 Year. Paddington 73 17 20 14 124 52 29 20 21 26 18 10 7 18 11 12 348 Kensington 83 27 20 9 139 38 37 41 21 26 24 16 22 19 19 26 428 Hammersmith 77 24 18 14 133 38 38 34 27 24 23 18 9 18 8 13 383 Fulham 112 22 28 15 177 62 42 41 28 34 30 28 32 19 26 26 545 Chelsea 35 9 4 4 52 16 11 14 12 12 12 7 12 6 6 6 166 Westminster,City of 66 15 18 6 105 39 26 15 14 14 20 13 17 14 10 6 293 St. Marylebone 71 11 13 8 103 36 25 12 17 8 10 11 9 13 16 7 267 Hampstead 23 5 9 6 43 9 14 4 5 2 5 1 7 2 4 1 97 St. Pancras 126 33 32 15 206 68 67 57 44 38 23 21 33 25 27 29 638 Islington 186 52 33 39 310 97 83 48 55 48 37 43 46 39 39 49 894 Stoke Newington 21 4 3 2 30 14 10 8 7 5 2 3 4 6 5 7 101 Hackney 110 45 39 24 218 86 60 47 35 26 35 27 42 32 33 25 666 Holborn 28 7 8 3 46 15 12 10 6 4 1 2 5 4 5 8 118 Finsbury 68 15 21 15 119 34 32 35 34 29 21 23 20 22 13 18 400 London, City of 3 2 2 1 8 1 1 — 2 1 3 — 1 1 — — 18 Shoreditch 74 14 17 6 111 57 61 37 42 34 33 28 27 31 32 17 510 Bethnal Green 124 14 27 21 186 53 44 45 33 40 34 22 34 24 30 27 572 Stepney 199 42 54 52 347 161 101 106 89 72 73 80 64 62 84 81 1,320 Poplar 110 30 23 26 189 69 59 48 41 41 54 35 40 41 30 28 675 Southwark 131 31 41 32 235 95 82 55 53 50 46 44 38 38 49 35 820 Bermondsey 107 23 21 17 168 68 51 60 56 33 34 23 24 31 21 41 610 Lambeth 152 40 40 34 266 90 58 64 53 58 38 53 46 40 28 35 829 Battersea 77 28 30 23 158 51 45 34 32 26 23 27 29 20 26 23 494 Wandsworth 142 36 31 26 235 90 66 56 39 37 37 32 30 33 40 25 720 Camberwell 158 39 28 24 249 69 47 62 45 45 40 37 31 32 31 52 740 Deptford 95 24 3 10 132 44 35 28 21 16 22 23 17 14 13 16 381 Greenwich 48 16 16 13 93 40 28 23 23 18 19 11 14 13 13 15 310 Lewisham 68 13 16 15 112 44 24 17 25 27 9 17 11 8 11 10 315 Woolwich 78 13 16 11 118 30 23 14 18 9 12 20 13 14 13 14 298 London 2,645 651 631 485 4,412 1,566 1,211 1,035 898 803 738 675 684 639 643 652 13,956 With a view to the consideration of the effect of social condition on the rates of infantile mortality at different periods during the first year of life, the following table has been prepared, in which the rates of infantile mortality obtaining for groups of districts (arranged on the basis of the amount of overcrowding shown by the census of 1901) can be compared:— Infantile mortality and overcrowding1—1908. Age-period. Proportion of overcrowding in groups of sanitary districts. I. Under 7.5 per cent. II. 7.5 to 12.5 per cent. III. 12.5 to 20.0 per cent. IV. 20.0 to 27.5 per cent. V. Over 27.5 per cent. Under 1 week 19.9 21.3 22.1 22.4 21.9 1-2 weeks 4.2 6.1 5.8 5.2 4.0 2-3 „ 4.5 5.2 4.6 5.9 5.6 3-4 „ 3.6 4.1 3.8 3.6 4.4 Under 1 month 32.2 36.7 36.3 37.1 35.9 1-2 months 11.2 12.3 12.7 13.5 14.4 2-3 „ 8. 9.0 9.9 11.7 11.2 3-4 ,, 5.9 8.5 8.2 8.4 10.5 4-5 „ 5.6 6.8 7.3 7.6 9.3 5-6 „ 4.8 6.4 6.7 6.3 8.2 6-7 „ 3.9 6.0 6.7 5.0 7.6 7-8 „ 4.3 5.7 4.9 4.9 7.2 8-9 „ 3.9 5.6 5.6 5.4 6.8 9-10 „ 3.8 4.8 5.6 5.0 6.6 10-11 „ 4.3 4.6 4.6 6.1 7.5 11-12 „ 3.4 5.2 5.6 5.0 6.7 0-3 months 51.6 58.0 58.9 62.3 61.5 3-6 „ 16.3 21.7 22.2 22.3 28.0 6-9 12.1 17.3 17.2 15.3 21.6 9-12 „ 11.5 14.6 15.8 16.1 20.8 0-12 months 91.5 111.6 114.1 116.0 131.9 The term "overcrowding" is used to apply to that proportion of the population shown by the census figures of 1901 to be living more than two in a room in tenements of less than five rooms. 19 It will be seen from the foregoing table that there is a marked difference in the mortality among children under one year of age when the least and most overcrowded groups of districts are compared. This agrees with the figures in corresponding tables published in previous annual reports. If the figures for each of the trimesters are considered in this connection, it will be seen that the same behaviour of the mortality is observable. This will be better appreciated by reference to the following table, in which the mortality of the least overcrowded group of districts is taken as 100:— Infantile mortality and overcrowding1—1908. Number of group of districts in order of overcrowding. Comparative mortality figure. Children aged 0-3 months. Children aged 3-6 months. Children aged 6-9 months. Children aged 9-12 months. Children under 1 year. 1905-7. 1908. 1905-7. 1908. 1905-7. 1908. 1905-7. 1908. 1905-7. 1908. I. 100 100 100 100 100 100 100 100 100 100 II. 109 113 119 133 129 143 152 127 119 122 III. 112 114 119 136 132 142 149 137 121 125 IV. 108 121 120 136 123 126 158 140 118 127 V. 115 119 136 172 154 178 185 180 133 144 It will be seen from this table that in each successive trimester of the first year of life the difference in the mortality obtaining for the several groups of districts becomes more pronounced. These figures, it will be seen, are in general agreement with the results obtained from a comparison of the figures for the period 1905-7. The account given in the annual reports of medical officers of health shows that systematic efforts are being made in the large majority of districts to lessen infantile mortality. The Notification of Births Act has been adopted in all but eight boroughs and the homes in which births have taken place are visited by women sanitary inspectors or health visitors. In some districts the work of these officers is supplemented by that of a staff supplied by local health societies who act in co-operation with the officers appointed by the borough councils, and in this connection "consultative centres" have been instituted in Paddington, Fulham, Westminster, Hampstead, St. Pancras, Finsbury, and Poplar. To these centres mothers bring babies needing special attention, and advice is given as to their treatment, the progress of the child being watched, and tested by weighing. At the milk depots in Battersea, Finsbury and Woolwich, the same course is pursued and here specially prepared milk is supplied for children who cannot be fed from the breast. The value of these several measures is attested by the medical officers of health in whose districts this provision has been made, and there can, indeed, be no reason for doubting that they must be making available knowledge and experience all important for the preservation of infant life. In a few districts voluntary associations provide, at a charge of 1d., dinners for nursing mothers and those about to be confined, the requirement being that the dinner shall be eaten on the premises, and in this way effort is made to deal with poverty which may prejudice the infant. In Kensington the case of necessitous mothers is brought to the knowledge of local charities, and where want of employment of the husband is the cause of the poverty, endeavour is made to find him work. In Chelsea 220 nursing mothers were given 9,276 dinners. In Westminster necessitous women can obtain dinners from two months before to nine months after the birth of their child. The London County Council (General Powers) Act, 1908, section 6 provides for the appointment of health visitors and enables the Council to contribute to their salaries. It is to be hoped that the provisions of this Act will encourage the appointment of such officers in London. In the following table is a statement of the number of health visitors and of female sanitary inspectors, who are employed in this work at the present time. The table also indicates districts in which the services of voluntry health visitors are utilised. Sanitary area. Staff engaged in visiting homes where births have recently occurred. Female sanitary Inspectors. Health visitors. Whether voluntary health visitors are employed. Paddington 2 1 or 2 Student Inspectors. Yes Kensington — 2 Health Society Hammersmith - 1 — Fulham 1 - Yes Chelsea 1 part time - Health Society Westminster, City of - 1 Yes (Continued on next page). 1 See footnote (1), page 18. 20 Sanitary area. Staff engaged in visiting homes where births have recently occurred. Female sanitary Inspectors. Health visitors. Whether voluntary health visitors are employed. St. Marylebone 2 (and 1 temporary) — Health Society Hampstead 2 — Health Society St. Pancras 1 — Yes Islington — — — Stoke Newington — 1 Yes Hackney — — Yes Holborn 1 — — Finsbury 1 2 — London, City of 1 — — Shoreditch — 1 — Bethnal Green — Appointment under consideration. — Stepney — 1 to be appointed Yes Poplar — 1 Yes Southwark 3 — Health Society Bermondsey — 1 Yes Lambeth — 1 (temporary) — Battersea 2 (1 part time) 1 (part time) Yes Wandsworth 2 — Yes Camberwell — — — Deptford — — — Greenwich — Yes Yes Lewisham 2 — — Woolwich 1 — — Principal Epidemic Diseases. The number of deaths in the Administrative County of London from the principal epidemic diseases, viz., smallpox, measles, scarlet fever, diphtheria, whooping-cough, typhus, enteric fever, pyrexia1 and diarrhœa during 1908 (53 weeks) was 6,599, giving an annual death-rate of 1.35 per 1,000 persons living. The death-rates in successive periods have been as follows:— Principal Epidemic Diseases. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-50 5.20 1902 2.212 1851-60 5.13 1903 1.76 2 1861-70 5.23 1904 2.14 2 1871-80 3.86 1905 1.69 2 1881-90 3.02 1906 1.92 2 1891-1900 2.66 2 1907 1.42 2 1901 2.232 1908 1.35 2 It will be seen from the following table that in the decennium 1898-1907, London had a lower death-rate from these diseases than any of the undermentioned English towns, except Bristol, Bradford and Newcastle-on-Tyne, and in 1908 had a lower death-rate than any, except Bristol, Newcastle-on-Tyne and Nottingham. Principal Epidemic Diseases—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 2.092 1.352 West Ham 3.30 2.39 Liverpool 3.18 2.19 Bradford 1.76 1.36 Manchester 2.87 2.25 Newcastle-on-Tyne 1.88 1.26 Birmingham 2.64 1.86 Hull 2.82 2.19 Leeds 2.35 1.49 Nottingham 2.39 1.25 Sheffield 3.22 1.85 Salford 3.47 3.04 Bristol 1.76 1.16 Leicester 2.31 1.53 1 Origin uncertain. Originally described as simple continued fever. 2 See footnote (1), page 8. 21 The following table shows that the London death-rate from six of these principal epidemic diseases, viz.: smallpox, measles, scarlet fever, diphtheria (including croup), whooping cough and enteric fever was, in the decennium 1898-1907, higher than the death-rates of all the undermentioned foreign towns, except St. Petersburg and in 1908 higher than that of all except St. Petersburg, Vienna, Rome and New York:— Six Principal Epidemic Diseases—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 1.331 0.821 St. Petersburg 2.97 3.59 Paris 0.74 0.50 Berlin 0.95 0.77 Brussels 0.60 0.59 Vienna 0.86 0.89 Amsterdam 0.87 0.74 Rome 0.97 1.49 Copenhagen 0.80 0.72 New York 1.21 1.08 Stockholm 0.85 0.39 The following table shows the deaths from the principal epidemic diseases and the death-rates per 1,000 persons living in each of the sanitary areas of the County in 1908, and the death-rates for the period 1903-7:— Principal Epidemic Diseases.—Death-rates in sanitary areas. Sanitary area. Deaths, 1908 (53 weeks). Death-rate per 1,000 persons living. 1903-7. 1908. Paddington 133 1.34 0.87 Kensington 169 1.39 0.92 Hammersmith 137 1.83 1.09 Fulham 277 2.31 1.59 Chelsea 90 1.43 1.18 Westminster, City of 102 0.85 0.58 St. Marylebone 110 1.30 0.85 Hampstead 39 0.56 0.40 St. Pancras 255 1.65 1.06 Islington 353 1.50 1.01 Stoke Newington 45 1.17 0.82 Hackney 365 1.77 1.52 Holborn 59 1.41 1.07 Finsbury 205 2.50 2.09 London, City of 8 0.79 0.40 Shoreditch 245 3.05 2.09 Bethnal Green 329 2.39 2.48 Stepney 800 2.50 2.53 Poplar 394 2.81 2.26 Southwark 378 232 1.76 Bermondsey 299 2.46 2.30 Lambeth 387 1.66 1.18 Battersea 222 1.83 1.19 Wandsworth 275 1.51 0.93 Camberwell 306 1.57 1.06 Deptford 157 1.99 1.32 Greenwich 140 1.71 1.25 Lewisham 197 1.13 1.25 Woolwich 123 1.49 0.92 London 6,599 1.801 1.351 It will be seen from the foregoing table that the death-rate from the principal epidemic diseases in the period 1903-7 was highest in Shoreditch (3.05) and lowest in Hampstead (0.56) and in the year 1908. was highest in Stepney (2.53) and lowest in Hampstead and the City of London (0.40). The death-rates from these diseases during each of the four quarters of the year were as follows: First quarter, 1.18; second quarter, 106; third quarter, 194; and fourth quarter, 1.25 per 1,000 persons living. Smallpox and Vaccination. No case of smallpox is known to have occurred in the Administrative County of London during the year 1908; two deaths were attributed to cowpox. 1 See footnote (1), page 8. 21322 D 22 The death-rates from smallpox in successive periods have been as follows:— Smallpox. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-50 0.402 1902 0.2821 1851-60 0.280 1003 0.0031 1861-70 0.276 1904 0.0051 1871-80 0.457 1905 0.0021 1881-90 0.142 1906 — 1891-1900 0.0091 1907 — 1901 0.0511 1908 — The small-pox death-rate in each year since 1840 in relation to the mean death-rate during the period 1841-1908 is shown in diagram VI. During the complete years in which the notification of infectious diseases has been obligatory, the number of cases of smallpox (uncorrected for errors in diagnosis) notified to the medical officers of health in the various sanitary districts comprised in the Administrative County has been as follows:— Smallpox.— Case-rates per 1,000 living. Year. Cases notified. Case-rate per 1,000 persons living. 1890 60 0.014 1891 114 0.027 1892 425 0.100 1893 2,815 0.653 1894 1,193 0.274 1895 980 0.223 1896 225 0.050 1897 104 0.023 1898 33 0.007 1899 29 0.006 1900 86 0.019 1901 1,700 0.375 1902 7,796 1.675 1903 416 0.090 1904 489 0.105 1905 74 0.016 1906 31 0.007 1907 8 0.002 1908 42 0.001 If the London smallpox death-rate be compared with the death-rates of the following large English towns, it will be seen that in the decennium 1898-1907 the London death-rate was higher than that of any, except Liverpool, West Ham and Hull; in 1908 there were no deaths from smallpox in any of these towns. Smallpox—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.031 — West Ham 0.06 — Liverpool 0.03 — Bradford 0.01 — Manchester 0.01 — Newcastle-on-Tyne 0.01 — Birmingham 0.00 — Hull 0.08 — Leeds 0.01 — Nottingham 0.01 — Sheffield 0.00 — Salford 0.00 — Bristol 0.00 — Leicester 0.01 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005; where no death occurred—is inserted. 1 See footnote (1), page 8. 2 In each of these cases the diagnosis of smallpox was not subsequently confirmed. Diagram.VI Smallpox. 23 The following table shows that the London smallpox death-rate was in the decennium 1898— 1907 higher than that of any of the under-mentioned foreign towns except Paris, Brussels, and St Petersburg. In 1908 St. Petersburg was the only town which had an appreciable death-rate from smallpox:— Smallpox—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.031 — St. Petersburg 0.07 0.15 Paris 0.04 0.00 Berlin 0.00 0.00 Brussels 0.03 — Vienna 0.00 — Amsterdam 0.00 — Rome 0.00 0.00 Copenhagen — — New York 0.02 0.00 Stockholm 0.00 — In this table 0.00 indicates that the deaths were too few to give a rate of 0.005; where no death occurred—is inserted. London vaccination returns. The following table shows the proportion of children born in each year who were not finally accounted for in respect of vaccination. It will be observed that this number has, since 1898, been gradually decreasing:— Vaccination. Year Children not finally accounted for (including cases postponed) per cent. of total births. Year. Children not finally accounted for (including cases postponed) per cent. of total births. 1872 8.8 1890 13.9 1873 8.7 1891 16.4 1874 8.8 1892 18.4 1875 9.3 1893 18.2 1876 6.5 1894 20.6 1877 7.1 1895 24.9 1878 7.1 1896 26.4 1879 7.8 1897 29.1 1880 7.0 1898 33.0 1881 5.7 1899 27.7 1882 6.6 1900 25.8 1883 6.5 1901 24.1 1884 6.8 1902 21.3 1885 7.0 1903 20.7 1886 7.8 1904 19.1 1887 9.0 1905 18.9 1888 10.3 1906 21.2 1889 11.6 The percentage of children born who were exempted by "conscientious objection" certificates since and including 1898 has been as follows:—1898, 1.4; 1899, 1.0; 1900, 1.0; 1901, 1.1; 1902, 0.8; 1903, 1.0; 1904, 1.1; 1905, 1.2; 1906, 1.5. 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 follows:— Number of children for whom certificates of conscientious objection were obtained together with the number of children not finally accounted for (including cases postponed) per cent. of births. Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. Bethnal-green 67.0 48.2 49.2 52.2 44.1 44.9 42.8 42.0 48.3 Camberwell 41.2 29.7 23.0 20.0 21.4 21.8 23.6 23.4 26.8 Chelsea 17.3 14.9 16.0 13.4 14.9 13.9 10.0 8.9 13.0 Fulham 15.4 12.6 13.7 12.0 11.8 12.7 11.5 10.8 14.6 St. George, Hanover-square 11.1 9.0 7.1 5.8 7.5 5.1 4.9 4.4 4.3 St. George-in-the-East 34.6 35.0 33.5 30.6 29.7 27.7 15.7 17.3 16.8 St. Giles and St. George 32.5 33.0 33.6 30.7 27.1 24.9 17.9 20.4 20.8 Greenwich 17.2 14.2 138 12.6 11.1 11.1 10.4 9.7 9.8 (Continued on next page). (1) See footnote (1) page 8. 21322 D 2 24 Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. Hackney 49.0 38.6 40.4 38.5 26.1 25.5 26.9 28.2 36.8 Hammersmith 13.8 11.7 9.1 8.3 9.4 7.2 7.4 8.0 10.1 Hampstead 15.4 10.3 11.0 10.0 9.2 9.5 9.2 9.2 10.4 Holborn 43.8 31.8 28.5 27.6 23.2 20.7 20.4 20.6 24.5 Islington 31.1 29.2 26.2 21.6 17.7 17.0 15.9 17.5 18.2 Kensington 13.5 10.2 9.2 9.0 7.2 6.6 6.6 5.5 7.2 Lambeth 30.6 25.2 20.6 22.2 20.4 21.0 16.9 17.3 19.6 Lewisham 27.8 22.6 20.7 15.7 13.5 15.4 14.0 13.8 16.2 London, City of 25.4 18.3 14.2 11.3 11.3 11.8 13.0 15.3 16.8 Marylebone 18.0 20.9 17.7 14.6 12.5 10.8 10.4 10.8 12.1 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 59.8 47.3 47.1 48.4 St. Olave (Bermondsey) 32.5 23.6 21.8 18.0 17.5 16.3 16.6 15.7 17.2 Paddington 14.7 14.6 13.5 11.0 10.1 11.7 12.7 13.3 13.3 St. Pancras 36.7 36.1 32.9 32.8 26.2 25.3 23.1 22.1 26.0 Poplar 63.6 50.1 49.0 49.1 44.2 46.9 45.4 45.3 49.3 Shoreditch 68.8 52.4 53.0 44.7 36.4 36.6 34.8 36.7 33.3 Southwark 32.6 30.3 27.6 26.8 25.4 24.9 24.3 24.2 28.4 Stepney 48.6 46.9 44.4 44.3 37.2 35.8 32.9 32.9 32.9 Strand 25.2 19.7 19.2 16.1 19.0 18.6 15.0 11.8 11.7 Wandsworth and Clapham 32.2 25.1 23.0 20.5 19.2 17.2 16.3 14.8 18.0 Westminster 17.4 14.8 12.2 13.3 13.4 12.1 11.0 8.2 9.4 Whitechapel 11.8 14.5 13.1 10.5 9.5 10.1 9.1 10.6 11.5 Woolwich 10.2 8.3 7.5 9.8 9.7 7.1 7.2 6.6 9.3 London 34.4 28.7 26.8 25.2 22.1 21.7 20.2 20.1 22.7 Measles. The deaths from measles in the Administrative County of London during 1908 (53 weeks) numbered 1,524, as compared with 1,801 in 1907 (52 weeks). The death-rates from this disease per 1,000 persons living in 1908 and preceding periods have been as follows:— Measles. Period. Death-rate per 1,000 persona living. Period. Death-rate per 1,000 persons living. 1841-50 0.62 1902 0.511 1851-60 0.53 1903 0.44l 1861-70 0.58 1904 0.491 1871-80 0.51 1905 0.37l 1881-90 0.64 1906 0.411 1891-1900 0.581 1907 0.381 1901 0.431 1908 0-3l' Inasmuch as the birth-rate has not been constant during these periods and the proportion of population in the early years of life has diminished in recent years, the death-rate of children under five years of age deserves to be stated. The following table shows the death-rate from measles of children at this age in successive periods:— Measles—Mortality among children at ages 0—5. Period. Death-rate per 1,000 children living at ages 0—5. Period. Death-rate per 1,000 children living at ages 0—5. 1851-60 3.89 1903 3.901 1861-70 4.18 1904 4.301 1871-80 3.65 1905 3.191 1881-90 4.74 1906 3.571 1891-1900 4.821 1907 3.291 1901 3.701 1908 2.711 1902 4.421 1 See footnote (1) page 8. Diagram VII Measles Diagram VIII. Measles & Whooping Cough. (Deaths 1891 -1908.) 25 The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1908, calculated on the population at all ages, is shown in diagram VII. The monthly deaths from measles in relation to the mean of the period 1891-1908 is shown in diagram VIII. The following table shows the deaths and death-rates from measles in 1908 (53 weeks) in each of the sanitary areas of the County:— Measles—Death-rates1 in sanitary areas. Sanitary area. Deaths, 1908 (53 weeks). Death-rate per 1,000 persons living. 1903-7. 1908. Paddington 35 0.26 0.23 Kensington 32 0.30 0.17 Hammersmith 15 0.46 0.12 Fulham 71 0.43 0.41 Chelsea 12 0.39 0.16 Westminster, City of 23 0.17 0.13 St. Marylebone 25 0.29 0.19 Hampstead 5 0.12 0.05 St. Pancras 46 0.50 0.19 Islington 80 0.44 0.23 Stoke Newington 10 0.23 0.18 Hackney 75 0.35 0.31 Holborn 11 0.38 0.20 Finsbury 44 0.70 0.45 London, City of 3 0.07 0.15 Shoreditch 51 0.76 0.44 Bethnal-green 104 0.54 0.78 Stepney 264 0.55 0.84 Poplar 82 0.63 0.47 Southwark 77 0.61 0.36 Bermondsey 107 0.61 0.82 Lambeth 101 0.37 0.31 Battersea 48 0.46 0.26 Wandsworth 44 0.33 0.15 Camberwell 54 0.37 0.19 Deptford 33 0.48 0.28 Greenwich 16 0.33 0.14 Lewisham 46 0.19 0.29 Woolwich 10 0.27 0.07 London 1,524 0.42 0.31 In the distribution of measles mortality throughout the year 1908, the highest death-rate obtained in Stepney (0.84), and the lowest in Hampstead (0.05). For the period 1903.7, Shoreditch (0.76) had the highest measles death-rate, and the City of London (0.07) the lowest. The death-rates from this disease in each of the four quarters of the year 1908 were as follows—first quarter, 0.29; second quarter, 0.40; third quarter, 0.21; and fourth quarter, 0.35, per 1,000 persons living. The following table shows the measles death-rate at ages 0.5 obtaining in the several sanitary areas of the County of London during the year 1908. Measles1—Mortality among children at ages 0-5 in sanitary areas—1908. Sanitary area. Death-rate per 1,000 children living aged 0-5, 1908. Sanitary area. Death-rate per 1,000 children living aged 0-5, 1908. Sanitary area . Death-rate per 1,000 children living aged 0-5, 1908. Paddington 2.31 Stoke Newington 1.60 Bermondsey 6.08 Kensington 2.04 Hackney 2.73 Lambeth 2.77 Hammersmith 0.89 Holborn 2.27 Battersea 2.16 Fulham 3.04 Finsbury 3.44 Wandsworth 1.37 Chelsea 1.88 London, City of 2.73 Camberwell 1.44 Westminster, City of 1.59 Shoreditch 3.38 Deptford 2.32 St. Marylebone 2.09 Bethnal Green 5.58 Greenwich 1.03 Hampstead 0.30 Stepney 6.21 Lewisham 2.64 St. Pancras 1.76 Poplar 3.51 Woolwich 0.64 Islington 1.81 Southwark 2.74 London 2.71 1 See footnote (1) page 8. 26 The mortality from measles in the several districts is in a large degree determined by the social condition of the population. If London districts be grouped in relation to overcrowding, it is found that the groups having the largest proportion of their population "overcrowded" have the highest death-rates from measles. The following table shows the measles mortality under five years of age in five groups of districts, arranged in order, according to the proportion of their population living more than two in a room in tenements of less than five rooms:— Measles and overcrowding,1 1901-8. Proportion of overcrowding1 in groups of sanitary areas. Measles death-rate at ages 0-5 per 1,000 living 1901-8. Under 7.5 per cent. 2.12 7.5 to 12.5 per cent. 3.34 12.5 to 20.0 per cent. 3.84 20.0 to 27.5 per cent. 4.31 Over 27.5 per cent. 4.57 If the London measles death-rate be compared with the death-rates of the following large English towns, it will be seen that in the decennium 1898-1907 the London death-rate was exceeded by the death-rates of Liverpool, Manchester, Sheffield, West Ham, Hull and Salford, and in the year 1908, was lower than that of any of these towns, except Birmingham, Sheffield, Bristol, Bradford, Newcastle and Nottingham. Measles—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.462 0.312 West Ham 0.53 0.71 Liverpool 0.49 0.34 Bradford 0.31 0.24 Manchester 0.62 0.56 Newcastle-on-Tyne 0.39 0.11 Birmingham 0.41 0.11 Hull 0.50 0.35 Leeds 0.45 0.37 Nottingham 0.40 0.12 Sheffield 0.55 0.23 Salford 0.65 0.69 Bristol 0.43 0.26 Leicester 0.32 0.73 The following table shows that the London measles death-rate in the decennium 18981907 was higher than that of any of the undermentioned foreign towns, except St. Petersburg, but in 1908 it was exceeded by those of Amsterdam, St. Petersburg, Vienna and Rome:— Measles—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.462 0.312 St. Petersburg 0.64 1.02 Paris 0.24 0.18 Berlin 0.22 0.14 Brussels 0.16 0.26 Vienna 0.38 0.46 Amsterdam 0.39 0.32 Rome 0.30 1.00 Copenhagen 0.18 0.08 New York 0.19 0.22 Stockholm 0.14 0.04 The following table shows the number of deaths from measles at the several age-periods in each of the sanitary areas. For the purposes of this table deaths occurring in public institutions belonging to London have been distributed to the sanitary areas in which the deceased had previously resided. (See footnote page 8). 1 See footnote (1), page 18. 2 See footnote (1), page 8. 27 Measles'-Deaths at the several age-periods in sanitary areas—1908 (366 days). Age-period. 0— 1— 2— 3— 4— Under 5. 5— 10— 15 and upwards. All Ages. Paddington 7 18 1 3 2 31 2 — 2 35 Kensington 7 15 6 1 1 30 — — 1 31 Hammersmith 3 6 3 — — 12 1 — 1 14 Fulham 19 23 13 10 3 68 3 — — 71 Chelsea 4 3 4 — 1 12 — — — 12 Westminster, City of 4 7 5 2 1 19 2 — 1 22 St. Marylebone 5 10 4 1 2 22 1 — 1 24 Hampstead — 1 1 — — 2 — — 2 4 St, Pancras 11 16 6 8 2 43 2 — — 45 Islington 21 29 12 1 5 68 4 2 — 74 Stoke Newington 3 3 1 1 — 8 — 1 1 10 Hackney 20 28 12 9 2 71 2 — — 73 Holborn — 8 1 1 — 10 1 — — 11 Finsbury 11 18 8 3 — 40 2 — 1 43 London, City of 1 2 — — — 3 — — — 3 Shoreditch 11 22 6 6 4 49 1 — — 50 Bethnal Green 21 40 19 14 6 100 4 — — 104 Stepney 71 110 43 22 12 258 3 — — 261 Poplar 11 41 16 7 2 77 4 — — 81 Southwark 14 36 13 6 2 71 3 — — 74 Bermondsey 15 55 13 12 5 100 3 — — 103 Lambeth 16 43 17 13 7 96 2 — 1 99 Battersea 10 23 10 4 1 48 3 — — 51 Wandsworth 12 14 7 7 2 42 — 1 1 44 Camberwell 9 22 7 5 3 46 7 — — 53 Deptford 4 19 7 1 2 33 — — — 33 Greenwich 4 2 5 1 1 13 2 — — 15 Lewisham 7 20 11 3 3 44 2 — 1 47 Woolwich 1 4 3 — 2 10 — — — 10 London 322 638 254 141 71 1,426 54 4 18 1,497 Medical officers of health derive their information as to the existence of cases of measles mainly from the teachers of elementary schools. The majority of the annual reports show the number of cases of this disease concerning which the medical officers of health received intimation, and the following table has been compiled from the information thus supplied:— Measles. Sanitary area. No. of cases of measles, 1908. Sanitary area. No. of cases of measles, 1908. Sanitary area. No. of cases of measles, 1908. Paddington 779 Hackney 1,070 Lambeth 1,998 Kensington 474 Holborn 86 Battersea 437 Hammersmith 161 Finsbury 245 Wandsworth 1,756 Fulham 594 Shoreditch 4712 Deptford 850 Chelsea 190 Bethnal Green 7192 Greenwich 497 Westminster 566 Poplar 643 Lewisham 1,174 Hampstead 280 Bermondsey 671 Woolwich 519 Islington 1,095 The age distribution of the cases made known to the medical officer of health is shown in the reports relating to Paddington and Fulham, thus: Paddington. Age period 0— 1— 2— 3— 4— 5— 13— 15— Number of cases 44 84 77 103 120 313 7 31 Fulham. Age period 0— 1— 2— 3— 4— 5— 6— 7— 10— Number of cases 16 20 16 61 129 199 91 49 13 1See footnote (1), page 8. 2 Excluded from school on account of measles infection. 28 The number of houses in which more than one case of measles occurred is shown in the reports relating to Paddington and Hampstead: Paddington. Hampstead. Houses with 2 cases 130 31 „ 3 „ 55 13 „ 4 „ 15 4 „ 5 „ 6 2 „ 9 „ 1 — The annual reports give account of the efforts which are being made to impress upon the public the need for precautions in dealing with measles; these efforts in the main consist of the distribution of appropriate literature and personal visits to houses which are known to be invaded. In several of the reports mention is made of the large part infant schools play in the dissemination of measles, and the majority of the reports give account of the closure of classes and infant departments with a view to the limitation of measles prevalence. In Dr. Kerr's report (pages 44-7, Appendix V.) is shown the method adopted to limit measles' infection in the schools with the least disturbance of education. The principle adopted is to make the closure of class-rooms when measles appears among the pupils depend upon the number of children who have not already passed through this malady, and who are, therefore, presumably susceptible to attack. The exclusion of susceptible children in preference to class closure has often been found to be the more profitable course; and it has further been observed that school closure to be useful, must be effected when the existence of the disease among the pupils first manifests itself, and before there is infection of the class from the earliest cases. Dr. Kerr states that the experience of Woolwich, where for five years effort has been made to determine the conditions under which the method of school closure, or exclusion of susceptible children can be more usefully employed, has justified the application to all the elementary schools in London of the principles deduced from that enquiry. Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1908 (53 weeks) numbered 22,072, compared with 25,925 in 1907 (52 weeks). The number of deaths registered from this cause was 548 in the year 1908 (53 weeks), compared with 644 in 1907 (52 weeks). The scarlet fever case-rates, death-rates and case-mortality for 1908 and preceding periods are shown in the following table:— Scarlet Fever. Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Casemortality per cent. 1861-70 1.13 1 1 1871-80 0.60 1 1 1881-90 0.33 1 1 1891-1900 0.192 4.8 3.8 1901 0.132 4.1 3.2 1902 0.122 3.9 3.1 1903 0.082 2.7 2.9 1904 0.082 2.9 2.7 1905 0.122 4.2 2.8 1906 0.112 4.3 2.6 1907 0.142 5.5 2.5 1908 0.1l2 4.5 2.5 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859— 1908 will be seen on reference to diagram IX. The monthly case-rate and case-mortality in each of the years 1891-1908 in relation to the mean of the whole period is shown in diagram XI. It will be seen from the following table that in the decennium 1898-1907 the London scarlet fever death-rate was lower than that of any of the undermentioned English towns, except Bristol, West Ham and Hull, and in 1908 was exceeded by the death-rates of Liverpool, Manchester, Birmingham, West Ham and Salford:— 1The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (1), page 8. Diagram IV Scarlet Fever. Diaqram X Number of admissions to Hospitals of the Metropolitan Asylums Board percent of total cases notified in London. Diagram XI. Scarlet Fever. 29 Scarlet Fever—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.111 0.111 West Ham 0.11 0.16 Liverpool 0.26 0.28 Bradford 0.17 0.04 Manchester 0.17 0.15 Newcastle-on-Tyne 0.12 0.04 Birmingham 0.19 0.13 Hull 0.09 0.01 Leeds 0.15 0.03 Nottingham 0.12 0.04 Sheffield 0.22 0.08 Salford 0.29 0.27 Bristol 0.10 0.03 Leicester 0.13 0.11 The following table shows that in the year 1908 the London scarlet fever death-rate was higher than that of Paris, Brussels, Amsterdam, Copenhagen and Rome, but in the decennium 1898-1907 was exceeded by the death-rates of Stockholm, St. Petersburg, Berlin, Vienna and New York:— Scarlet Fever—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.11 0.ll1 St. Petersburg 0.52 0.41 Paris 0.05 0.08 Berlin 0.21 0.13 Brussels 0.04 0.09 Vienna 0.12 0.13 Amsterdam 0.03 0.02 Rome 0.01 0.06 Copenhagen 0.09 0.09 New York 0.19 0.30 Stockholm 0.13 0.14 The following table shows the scarlet fever cases, deaths, case-rates, and death-rates for the year 1908, the case-rates for the decennium 1898-1907, and the death-rates for the period 1903-7 in the several sanitary districts of the County:— Scarlet Fever—Case-rates and death-rates in sanitary areas. Sanitary area. Notified cases, 1908 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1908 (53 weeks). Death-rate per 1,000 persons living. 1898-1907. 1908. 1903-1907. 1908. Paddington 682 30 4.4 15 0.08 0.10 Kensington 453 2.3 2.4 9 0.07 0.05 Hammersmith 394 3.4 3.1 11 0.08 0.09 Fulham 596 4.2 3.4 17 0.08 0.10 Chelsea 174 2.8 2.3 8 0.08 0.10 Westminster, City of 627 2.4 3.6 7 0.07 0.04 St. Marylebone 411 2.7 3.2 13 0.12 0.10 Hampstead 280 2.9 3.0 7 0.05 0.07 St. Pancras 952 3.9 4.0 20 0.11 0.08 Islington 1,411 3.8 4.0 31 0.09 0.09 Stoke Newington 202 3.7 3.7 5 0.07 0.09 Hackney 1,276 4.6 5.3 31 0.11 0.13 Holborn 194 2.9 3.5 7 0.05 0.13 Finsbury 409 4.3 4.2 13 0.16 0.13 London, City of 53 31 2.7 — 0.10 — Shoreditch 600 4.2 5.1 29 0.16 0.25 Bethnal Green 1,010 5.1 7.6 40 0.19 0.30 Stepney 2,358 4.6 7.5 55 0.15 0.17 Poplar 1,280 4.0 7.3 37 0.15 0.21 Southwark 775 4.5 3.6 24 0.13 0.11 Bermondsey 641 5.4 4.9 25 0.19 0.19 Lambeth 1,454 3.4 4.5 42 0.09 0.13 Battersea 1,152 4.2 6.2 24 0.09 0.13 Wandsworth 1,261 3.8 4.3 21 0.08 0.07 Camberwell 1,054 4.4 3.7 24 0.09 0.08 Deptford 723 5.0 61 7 0.12 0.06 Greenwich 428 4.1 3.9 6 0.08 0.05 Lewisham 620 3.6 3.9 11 0.07 0.07 Woolwich 601 4.6 4.5 9 0.08 0.07 Port of London 1 London 22,072 3.9 4.5 548 0.111 0.111 21322 1See footnote (1) page 8. E 30 It will be seen from the foregoing table that the scarlet fever death-rate was, in the period 1903-7, highest in Bermondsey and Bethnal Green (0.19) and lowest in Hampstead and Holborn (0.05); in the year 1908, Bethnal-green (0.30) had the highest death-rate, and Westminster (0.04) the lowest, while in the City of London no deaths occurred. The scarlet fever death-rates obtaining in London in the four quarters of the year 1908 were as follows: first quarter, 0.16; second quarter, 0.10; third quarter, 0.09; and fourth quarter, 0.ll per 1,000 persons living. Scarlet Fever—Age and sex distribution. 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 1908. It will be seen that at "all ages" the case-rate was higher among females than among males, while the death-rate and fatality were higher among the latter. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon both males and females of four years of age. The greatest incidence of death was upon males of three and females of one and two years of age. The fatality, it will be observed, was highest among male children under one year of age and among female children of one year of age:— Scarlet Fever1 —1908. Age-period. Males. Females. Notified cases. Deaths. Casemortaiity per cent. Rates per 100,000 living. Notified cases. Deaths. Casemortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 10,392 281 2.7 451 12 11,680 272 2.3 454 11 0— 134 12 9.0 226 20 131 11 8.4 223 19 1— 429 28 6.5 819 53 349 40 11.5 666 76 2— 700 43 6.1 1,323 81 654 40 6.1 1,241 76 3— 925 52 5.6 1,795 101 904 39 4.3 1,733 75 4— 1,110 38 3.4 2,201 75 1,131 33 2.9 2,254 66 5— 4,327 66 1.5 1,828 28 4,921 73 1.5 2,059 31 10— 1,653 18 1.1 740 8 2,022 16 0.8 886 7 15— 511 10 2.0 228 4 561 5 0.9 224 2 20— 275 4 1.5 118 2 452 5 1.1 161 2 25— 237 5 2.1 59 1 406 7 1.7 86 1 35— 62 3 4.8 21 1 115 3 2.6 34 1 45— 24 2 8.3 11 1 24 — — 10 — 55 & upwards 5 — — 2 — 10 — — 4 — With a view to ascertaining whether the age incidence of notified cases of scarlet fever has undergone variation in recent years, the following tables have been prepared. When the corrected case-rates of 1906-8 are compared with those of 1893-5 the figures show that ages 3—, 4— and 5— in males, and ages 4—, 5— and 20— in females, have not exhibited the decline shown at the other ages:— Scarlet fever. Case-rates per 100,000 living at certain ages, 1893—1908. Males. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + All ages. 1893-5 385 1,009 1,602 2,115 2,308 2,000 985 382 164 82 29 11 4 584 1896-1900 254 731 1,252 1,756 1,914 1,488 707 278 126 59 21 9 3 436 1901-5 214 671 1,189 1,596 1,831 1,368 538 213 114 48 16 5 2 360 1906-8 231 855 1,395 2,011 2,343 1,900 755 247 127 62 21 8 1 474 Females. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55+ All ages. 1893-5 346 959 1,553 2,099 2,427 2,189 1,095 351 176 103 39 13 5 571 1896-1900 223 690 1,209 1,730 1,972 1,695 824 237 137 76 28 9 3 432 1901-5 172 610 1,122 1,611 1,870 1,522 608 198 124 66 19 8 2 352 1906-8 203 740 1,386 1,934 2,374 2,162 919 240 165 88 29 8 3 478 1In the preparation of this table the rates and percentages are calculated on the number of cases notified in London, and the number of deaths occurring in London and the institutions belonging to London. 31 Comparative case-rates (1893-5=1,000 for each age). (These figures are corrected for difference in the age and sex constitution of the population, and the number of cases annually has been assumed to be constant.) Males. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + 1893-5 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1896-1900 820 948 1,016 1,084 1,091 975 956 1,038 1,075 1,003 1,034 1,247 1,054 1901-5 803 1,007 1,104 1,120 1,186 1,020 830 874 1,061 904 895 812 730 1906-8 665 958 980 1,072 1,149 1,076 890 784 908 889 898 882 351 Females. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + 1893-5 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1896-1900 811 908 990 1,054 1,044 1,006 996 918 1,084 999 937 907 673 1901-5 746 943 1,069 1,134 1,145 1,038 835 866 1,110 999 761 889 527 1906-8 642 830 971 994 1,066 1,086 937 780 1,084 973 860 741 600 Scarlet Fever and Elementary Schools. In connection with the reduction in the number of notified cases during the summer holiday of the schools it may be stated that the summer holiday of the London County Council schools began in 1908 on Thursday, the 23rd July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 24th August, i.e., at the beginning of the 35th week. If the number of cases notified in the four weeks which would be most subject to holiday influence be compared with the number of cases notified in the four preceding and four subsequent weeks, the results shown in the following table are obtained:— Period. Notified cases—Age-periods. Increase ( + ) or decrease ( —) per cent. 13 0-3 3-13 and wards. 13 0-3 , 3-13 and wards. Four weeks preceding weeks of 161 1,206 230 — — — holiday influence (28th to 31st) Four weeks of holiday influence 169 1,075 214 +5.0 -10.9 —7.0 (32nd to 35th) Four weeks following weeks of 234 1,537 323 +38.5 +43.0 +50.9 holiday influence (36th to 39th) In a number of the annual reports reference is made to the maintenance of the prevalence of scarlet fever through infection derived from mild and unrecognised cases of the disease. In this connection it is interesting to note that when the figures of the period 1891-1900 are compared with those of 1908, it is seen that the death-rate in the latter period has declined 40 per cent., and the fatality rate by 35 Per cent., while the case-rate has only declined 6 per cent. In several of the reports information is given of the number of multiple cases in houses, thus:— Paddington. Fulham. Westminster. Holborn. Battersea. Houses with 2 cases 57 61 46 12 99 „ 3 , 30 14 15 5 50 „ 4 „ 13 1 5 2 12 „ 5 „ 5 3 — — 4 „ 6 „ 1 1 — — 1 „ 7 ,, 2 1 — — 2 „ 8 „ — — - - 1 In these districts 3,251 cases were notified, and of these, 1,145, or 35 per cent., occurred in association with other cases in the same house. The total number of houses in these districts with multiple cases was 443, and these houses supplied 702 more cases than they would have done if the incidence of disease upon them had not been greater than other houses which supplied only one case. It must not, of course, be assumed that the 702 cases necessarily contracted their disease from an antecedent case in the same house, but in all probability this occurred in a number of instances. 21322 E2 32 In these circumstances it is evident that the ability to limit the spread of the disease depends upon the opportunity for early detection of the first case. The absence of a child from school is often the first indication to others than members of the family that the child may be ill. Any arrangement which can be made to secure earlier knowledge of the cause of this absence promises to lessen the opportunity for infection of other members of the family if the school child is suffering from an infective malady. In the same way such improved arrangements would lessen the probability that a child suffering from a mild attack of scarlet fever would return to school after a few days' absence and before it had ceased to be infectious. Mention is made in several of the reports of schools and classes being temporarily closed on account of scarlet fever prevalence among the scholars. Such prevalence is commented on in the reports relating to Paddington, Chelsea, Westminster, Lambeth, Battersea and Wandsworth. Dr. Allan, in discussing the prevalence of scarlet fever among the pupils of certain schools in Westminster, mentions the results found on inquiries at the houses of pupils absent from these schools. In summary —11 cases of scarlet fever occurred in a school in St. John's Ward, and 38 children absent from school were visited. Among those visited was one child having a sore throat and enlarged glands. No medical man had been in attendance. In connection with an outbreak of scarlet fever among children attending the Buckingham-gate School, visits to the houses of absentees showed that other children were affected than those previously known to be attacked, and similar cases were observed on visiting at the homes of absentees from the Pulteney-street and St. George's-road schools, among the pupils of which, respectively, 22 and 25 cases of scarlet fever occurred in the months of October and November. The occurrence of "return cases" is mentioned in several of the reports. In Fulham there were 16, in Westminster a few, in Stoke Newington 3, in Holborn 6, in Stepney 9, in Bermondsey 15, in Battersea the return cases were slightly more numerous than in the two preceding years, inWoolwich there were 38, and in Greenwich 8. Dr. Davies, in discussing the return cases in Woolwich, refers to the information supplied to him by the superintendents of the fever hospitals when any child is discharged from the hospitals while suffering from rhinorrhcea, and he expresses the wish that he might also be informed of any cases in which this condition occurred during the illness and appeared to have ceased. He mentions that of cases occurring in Woolwich, 515 were removed to hospital and 81 isolated at home. Only one secondary case occurred among those isolated at home and there was no "home return case." Proportion of cases of scarlet fever removed to hospital. It will be seen from diagram X that the proportion of cases of scarlet fever admitted to the hospitals of the Metropolitan Asylums Board was about the same as in the preceding year. Diphtheria. The cases of diphtheria (including membranous croup) notified in the Administrative County of London in 1908 (53 weeks) numbered 8002,, compared with 8,771 in 1907. The number of deaths registered from this cause was 724 in 1908 (53 weeks) compared with 781 in 1907 (52 weeks). It is well to bear 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 notified number of clinically mild cases of the disease. The diphtheria case-rates, death-rates, and case-mortality in 1908, and preceding periods, are shown in the following table:— Diphtheria. Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case-mortality per cent. 1861-70 0.18 1 -1 1871-80 0.12 -1 1 1881-90 0.26 1 1 1891-1900 0.492 2.6 18.8 1901 0.292 2.7 10.9 1902 0.252 2.3 10.8 1903 0.162 1.7 9.6 1904 0.162 1.6 10.0 1905 0.122 1.4 8.4 1906 0.152 1.7 8.6 1907 0.162 1.8 8.9 1908 0.152 1.6 9.0 The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591908 is shown for diphtheria and also for diphtheria and croup combined in diagram XII. The monthly case-rate and case-mortality in each of the years 1891-1908 in relation to the mean of the period is shown in diagram XIV. If the London diphtheria death-rate be compared with the death-rates of the following large English towns, it will be seen that in the decennium 1898-1907 the London rate was higher than that of any except Leeds, Sheffield, Bristol, West Ham, Salford and Leicester, and in 1908 was exceeded by the rates of Liverpool, Manchester, Birmingham, Bristol, West Ham, Hull and Salford. 1The Infectious Disease (Notification) Act came into force in 1889. 2 See footnote (1), page 8. Diagram XII Diphtheria. Diagram XIII Number of admissions to Hospitals of the Metropolitan Asylums Board per cent of total cases notified in London. 1890-1908. Diagram XIV Diphtheria 35 Diphtheria—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.25 1 0.15 1 West Ham 0.44 0.17 Liverpool 0.24 0.17 Bradford 0.21 0.14 Manchester 0.19 0.18 Newcastle-on-Tyne 0.17 0.12 Birmingham 0.21 0.19 Hull 0.24 0.18 Leeds 0.32 0.09 Nottingham 0.17 0.11 Sheffield 0.43 0.08 Salford 0.38 0.51 Bristol 0.27 0.17 Leicester 0.43 0.03 The following table shows that in the decennium 1898-1907 the London diphtheria death-rate exceeded that of any of the undermentioned foreign towns, except Stockholm, St. Petersburg and New York, and in 1908 was higher than that of any except St. Petersburg, Berlin, Vienna, Rome and New York :— Diphtheria2—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.25 0.15 St. Petersburg 0.72 0.48 Paris 0.14 0.07 Berlin 0.22 0.27 Brussels 0.10 0.09 Vienna 0.23 0.17 Amsterdam 0.11 0.07 Rome 0.10 0.16 Copenhagen 0.12 0.11 New York 0.50 0.40 Stockholm 0.37 0.13 The following table shows the diphtheria cases, deaths, case-rates, and death-rates for the year 1908, the case-rates for the decennium 1898-1907, and the death-rates for the period 1903-7, in the several sanitary districts;— Diphtheria.—Case-rates and death-rates in sanitary areas. Sanitary area. Notified Cases, 1908 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1908. (53 weeks). Death-rate per 1,000 persons living. 1898-1907. 1903. 1903-7. 1908. Paddington 150 1.5 1.0 16 0.10 0.10 Kensington 238 1.2 1.3 27 0.10 0.15 Hammersmith 204 1.9 1.6 13 0.18 0.10 Fulham 400 3.2 2.3 32 0.18 0.18 Chelsea 141 1.6 1.8 12 0.10 0.16 Westminster, City of 187 1.2 1.1 16 0.07 0.09 St. Marylebone 119 1.4 0.9 14 0.11 0.11 Hampstead 64 1.3 0.7 5 0.07 0.05 St. Pancras 308 2.2 1.3 22 0.13 0.09 Islington 530 1.7 1.5 57 0.10 0.16 Stoke Newington 65 1.8 1.2 1 0.12 0.02 Hackney 389 2.9 1.6 45 0.17 0.19 Holborn 50 1.7 0.9 5 0.11 0.09 Finsbury 170 2.3 1.7 16 0.16 0.16 London, City of 29 1.9 1.5 2 0.12 0.10 Shoreditch 210 2.1 1.8 13 0.16 0.11 Bethnal Green 278 2.7 2.1 28 0.22 0.21 Stepney 658 2.6 2.1 75 0.24 0.24 Poplar 315 3.0 1.8 33 0.31 0.19 Southwark 270 2.8 1.3 32 0.15 0.15 Bermondsey 252 2.6 1.9 23 0.16 0.18 Lambeth 345 1.9 1.1 45 0.13 0.14 Battersea 366 2.1 2.0 22 0.13 0.12 Wandsworth 591 2.1 2.0 37 0.15 0.13 Camberwell 398 2.3 1.4 41 0.11 0.14 Deptford 208 2.7 1.7 10 0.20 0.08 Greenwich 223 2.3 2.0 18 0.20 0.16 Lewisham 471 2.2 3.0 43 0.11 0.27 Woolwich 368 2.2 2.8 21 0.16 0.16 Port of London 5 London 8,002 2.2 1.6 724 0.151 0.151 It will be seen from the foregoing table that in the period 1903-7 the diphtheria death-rate was highest in Poplar (0.31) and lowest in the City of Westminster and Hampstead (0.07); in the year 1908, Lewisham (0.27) had the highest death-rate, and Stoke Newington (0.02) the lowest. The diphtheria death-rates in each of the four quarters of the year 1908 were as follows: first quarter, 0"20; second quarter, 0-11; third quarter, 011; and fourth quarter, 0-17 per 1,000 persons living. 1 See footnote (1), page 8. 2 The death-rates in this table relate to diphtheria including croup. 34 To enable the variations in diphtheria prevalence in the several sanitary areas to be more clearly appreciated, the following table has been prepared. This table shows the comparative case-rates of each area in each of the years 1891-1908 inclusive, i.e., the case-rates of each area are shown in relation to the London case-rate of the same year, the London rates being taken as 100 — Diphtheria. Sanitary areas.—Comparative case-rates (London taken as 100). Sanitary area. 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. Paddington 104 77 73 117 74 66 91 98 68 44 89 65 59 63 50 71 61 60 Kensington 78 60 68 63 86 70 67 49 51 74 52 43 59 63 50 59 78 78 Hammersmith 195 164 87 72 77 67 49 58 58 85 74 70 82 106 143 135 100 99 Fulham 61 58 78 126 139 99 109 145 135 178 174 126 118 125 129 147 200 140 Chelsea 138 110 83 107 143 184 107 79 61 74 56 78 76 50 50 129 117 113 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 70 59 50 50 71 44 66 StMarylebone 70 81 88 78 64 66 53 64 47 59 74 78 100 56 71 65 56 56 Hampstead 105 96 73 53 61 84 47 65 48 74 70 52 59 44 57 65 67 41 St. Pancras 89 95 103 83 90 64 76 78 79 93 148 152 129 94 86 71 83 78 Islington 152 119 86 103 70 106 73 60 68 70 100 113 82 63 71 76 78 91 Stoke Newington 83 113 97 77 70 70 52 59 34 111 104 83 47 75 107 53 122 72 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 141 156 121 100 128 99 Holborn 52 89 79 61 66 61 104 102 46 70 104 87 53 50 57 71 67 55 Finsbury 118 82 130 81 86 112 170 163 93 74 107 100 76 94 100 118 89 106 City of London 59 130 60 49 51 74 71 60 68 89 96 161 65 106 50 47 78 90 Shoreditch 124 89 131 95 80 97 103 80 103 111 104 83 76 100 114 71 106 109 Bethnal Green 154 230 181 168 143 114 144 100 89 115 133 104 112 206 164 112 122 127 Stepney 106 132 112 123 157 150 128 93 89 107 104 113 106 169 150 118 133 127 Poplar 191 148 214 159 179 133 141 105 83 141 137 117 147 250 207 88 117 110 Southwark 71 72 116 113 86 106 102 151 207 141 100 113 100 87 107 112 111 77 Bermondsey 68 60 84 126 80 99 97 90 177 133 93 91 76 94 93 153 139 118 Lambeth 88 97 91 83 88 74 83 103 121 104 63 70 65 69 100 76 56 65 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 106 81 79 88 111 120 Wandsworth 74 83 84 79 60 51 100 114 99 74 74 135 124 100 93 118 128 123 Camberwell 69 65 67 112 140 180 154 102 156 130 122 113 82 63 64 76 83 85 Deptford 72 68 86 153 225 113 141 132 121 111 144 104 241 106 93 153 150 106 Greenwich 60 43 84 85 137 189 82 105 122 89 74 78 124 94 100 229 133 123 Lewisham 48 74 82 70 57 122 85 127 170 126 85 130 118 56 79 106 111 180 Woolwich 32 68 66 66 81 96 91 86 100 115 67 91 88 81 157 176 122 168 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Diphtheria—Age and sex distribution. 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 1908. At " all ages " the incidence of attack was, as in preceding years, greater on females than on males, while the incidence of death and the fatality were higher among the latter. In the age-groups adopted for the purposes of this table the greatest incidence of attack was upon both males and females of three years of age ; the greatest incidence of death was upon males of one and females of three years of age. The fatality was greatest among males and females under one year of age:— Diphtheria1—1908. Age-period. Males. Females. Notified Cases. Deaths. Case mortality per cent. Bates per 100,000 living. Notified Cases. Deaths. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 3,711 365 9.8 161 16 4,291 363 8.5 167 14 0— 130 32 24.6 220 54 109 34 31.2 186 58 l— 316 69 21.8 604 132 246 55 22.4 470 105 2— 379 61 16.1 716 115 325 52 16.0 617 99 3— 430 51 11.9 834 99 446 65 14.6 855 125 4— 408 46 11.3 809 91 428 27 6.3 853 54 5— 1,291 86 6.7 545 36 1,536 107 7.0 643 45 10— 374 13 3.5 168 6 515 14 2.7 226 6 15— 131 3 2.3 58 1 192 2 1.0 77 1 20— 93 1 1.1 40 0 190 3 1.6 68 1 25— 91 1 1.1 23 0 217 1 0.5 46 0 35— 52 — — 17 — 57 2 3.5 17 1 45— 9 1 11.1 4 0 19 - - 8 - 55 & upwards 7 1 14.3 3 0 11 1 9.1 4 0 1 See footnote (1), page 30. 35 The following tables have been prepared for the purpose of enabling the age incidence of notified cases of diphtheria in recent years to be compared with that of the cases in the period 1893-5. When the corrected figures of 1906-8 are compared with those of that period, it will be seen that the ages 5— and under have not shared in the decline to the same extent as the older ages, and this has been most marked at ages 4— and 5— in both males and females. Diphtheria. Case-rates per 100,000 living, at certain ages, 1893-1908. Males. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + All ages. 1893-5 295 840 933 1,170 1,114 675 278 159 114 93 44 24 13 264 1896-1900 268 849 1,091 1,349 1,370 792 298 142 94 59 28 13 7 277 1901-5 213 656 851 1,003 1,037 569 205 95 61 40 20 7 5 190 1906-8 202 642 703 905 873 552 179 67 45 29 18 6 4 169 Females. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + All ages. 1893-5 226 708 904 1,180 1,166 776 364 216 176 144 80 50 20 289 1896-1900 220 750 996 1,270 1,435 954 391 179 135 113 57 31 10 297 1901-5 146 557 763 941 1,076 692 257 109 85 63 33 15 6 195 1906-8 166 512 658 859 969 676 235 84 67 51 22 12 4 177 Comparative case-rates (1893-5=1,000 for each age). (These figures are corrected for difference in the age and sex constitution of the population, and the number of cases annually has been assumed to be constant). Males. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + 1893-5 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1000 1,000 1,000 1,000 1896-1900 853 954 1,101 1,082 1,158 1,104 1,018 866 801 618 621 533 504 1901-5 956 1,027 1,205 1,123 1,210 1,090 951 766 703 556 592 424 461 1906-8 988 1,116 1,102 1,121 1,139 1,191 944 633 588 461 620 395 435 Females. Period. 0- 1- 2- 3- 4- 5- 10- 15- 20- 25- 35- 45- 55 + 1893-5 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1896-1900 937 1,014 1,063 1,031 1,184 1,182 1,037 815 752 765 701 610 508 1901-5 937 1,100 1,197 1,106 1,280 1,241 976 698 673 611 588 431 422 1906-8 1,137 1,101 1,114 1,112 1,271 1,336 995 608 598 549 434 375 310 Diphtheria and Elementary Schools. In connection with the question of the reduction in the prevalence of the disease among persons of school age during the summer holiday when the schools are closed it has been thought well to include, as in previous reports, the following table. The summer holiday of the schools of the London County Council began on Thursday, the 23rd July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 24th August, i.e., at the beginning of the 35th week. If the number of cases in the four weeks preceding and the four weeks subsequent to the weeks most subject to holiday influence be compared, the following results are obtained for the age periods of 0—3, 3—13, and 13 years and upwards. 30 Diphtheria—Notified cases—1908. Period. Notified cases—Age periods. Increase or decrease per cent. 0—3. 3—13. 13 and upwards. 0—3. 3—13. 13 and upwards. Four weeks preceding weeks of holiday influence (28th to 31st) 74 308 85 — — — Four weeks of holiday influence (32nd to 35th) 93 305 86 +25.7 -1.0 +1.2 Four weeks following weeks of holiday influence (36th to 39th) 118 369 107 +26.9 +21.0 +24.4 The employment of bacteriological methods for administrative purposes continues to increase in London. Reports which supply this information, relating to 23 districts, show that in 8,229 bacteriological examinations, 1,667, or 20'3 per cent., gave positive results. Dr. Brown gives in his report an account of the procedure he has adopted in Bermondsey since the year 1902. Whenever a case of diphtheria is notified in that district, he invites other members of the family in which the notified case occurred, to come to the Town Hall for examination, so as to secure their examination about a week after the removal to hospital of the notified case and also after the return home of this case from the hospital. He thus examined 315 persons belonging to 136 families, and 13 of these persons he found to be harbouring diphtheria bacilli; four of these subsequently developed clinical symptoms of diphtheria. Again, Dr. Caldwell Smith states that when a succession of cases occur in schools in Wandsworth, measures are taken to swab the throats of all the children in the classroom in which cases have occurred. The homes of absentees are visited, and the throat of any child having a sore throat is swabbed. No child is allowed to resume attendance at school until found to be free from diphtheria bacilli. In Camberwell, it is the practice to examine bacteriologically all children who have been treated at home before they are allowed to return to school. The following table shows the number of cases from which material was examined in each of the 23 districts referred to:— Sanitary area. No. of specimens examined. No. found positive. Sanitary area. No. of specimens examined. No. found positive. Paddington 96 34 Bethnal Green 13 3 Fulham 313 109 Stepney 27 6 Chelsea 60 22 Poplar 225 80 Westminster, City of 138 33 Bermondsey 514 52 St. Marylebone 45 12 Lambeth 507 13 St. Pancras 122 46 Battersea 2,319 342 Islington 281 93 Wandsworth 467 162 Stoke Newington 109 49 Deptford 159 53 Hackney 208 74 Greenwich 1,285 196 Holborn 16 5 Lewisham 417 144 Finsbury 54 10 Woolwich 828 123 Shoreditch 26 6 In some of the reports, particular prevalences of diphtheria are discussed. Dr. Parkes refers to a special incidence of diphtheria on the children in three elementary schools in Chelsea, and to the recurrence of diphtheria in the Duke of York's School, where measures were adopted with prophylactic intent similar to those of the preceding year. Dr. Annis gives an account of a child in Greenwich whose parent allowed her to attend school after she had been told by a medical man that she was probably suffering from diphtheria, and while awaiting the result of bacteriological examination of material from her throat. Forty-nine children appear to have contracted " sore throat" from this child, and two of them were of a diphtheritic character. He also gives account of an outbreak of diphtheria in the Royal Hospital, Greenwich. In the case of a family from which a child had been removed to hospital on account of an attack of diphtheria, he found on the foot of a member of the family a sore from which he recovered diphtheria bacilli. Dr. Lennane gives a detailed account of outbreaks in two institutions in Battersea, the Wandsworth Infirmary and the Royal Masonic Institution for Girls; Dr. Wellesley Harris records that classes in five schools were closed in Lewisham on account of diphtheria prevalence among the pupils ; and Dr. Davies states that for the third year in succession there was an outbreak among the pupils of the Bostall-lane School in Woolwich, which continued in spite of resort DiagramXV. Whooping Cough. 87 to bacteriological examination and to the closure of the school for the Easter holidays. Dr. Priestley mentions the occurrence in the children's ward of a hospital in Lambeth of two cases of diphtheria, which were attributed to infection by the ward attendant who was found to be harbouring diphtheria bacilli. Of the cases occurring in Woolwich, the source of infection was noted by Dr. Davies to be in 56 cases other inmates in the house, in 30 cases schoolmates, in 14 neighbours and friends, in 6 return cases, and in 1 a general hospital. In Finsbury, where 130 actual cases occurred, Dr. Porter traced 22 cases to infection at home, 7 to infection at school, and 9 to infection elsewhere, in 3 instances the disease was possibly contracted from cats. Dr. Bryett states that in Shoreditch, where 210 cases were notified, 82 were attending school, 67 within a week of being certified, while some were actually suffering while at school and before their illness was recognised; 78 other cases occurred in houses from which children were attending school, although the actual patients were not school attendants, and in 28 cases there was antecedent sore throat in the house. Dr. Davies gives particulars of the day of illness on which medical aid was first obtained in 64 cases where this fact was noted. The first visit of a medical man took place in little more than a third of the cases on the first day, and in nearly one-third on a day subsequent to the second day. The extent to which multiple cases in houses occurred is mentioned in the reports relating to Paddington, Fulham and Holborn (in which districts there were respectively a total of 150, 400 and 50 cases notified). The figures given are as follows :— Paddington. Fulham. Holborn. Houses with 2 cases 8 28 1 „ 3 „ 3 5 1 4 „ 1 1 1 In these 49 houses, therefore, there were 113 cases, or 64 after the primary case, the subsequent cases being 10'7 per cent, of the 600 cases notified in these districts. Proportion of cases of diphtheria removed to hospital. It will be seen from diagram XIII. that the proportion of cases of diphtheria removed to the hospitals of the Metropolitan Asylums Board was about the same as in the preceding year. Whooping-cough. The deaths from whooping-cough in the Administrative County of London during the year 1890 (53 weeks) numbered 984, as compared with 1,786 in 1907 (52 weeks). The death-rates from this disease in 1908 and preceding periods have been as follows :— Whooping-cough. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-50 0.87 1902 0.401 1851-60 0.88 1903 0.351 1861-70 0.88 1904 0.321 1871-80 0.81 1905 0.321 1881-90 0.69 1906 0.261 1891-1900 0.501 1907 0.381 1901 0.351 1908 0.201 The following are the death.rates of children under five years of age. The steady fall of the death.rate during these neriods is consnicuous :— Whooping-cough—Mortality among children at ages 0-5. Period. Death-rate per 1,000 children living at ages 0-5. Period. Death-rate per 1,000 children living at ages 0-5. 1851-60 6.56 1903 3.162 1861-70 6.53 1904 2.912 1871-80 6.02 1905 2.872 1881-90 5.34 1906 2.332 1891-1900 4.212 1907 3.372 1901 3.132 1908 1.842 1902 3.562 The death-rate in each year since 1840 in relation to the mean of the period 1841-1908 is shown in diagram XV., while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891-1908 are shown in diagram VIII., page 25. 1 See footnote (1), page 8. 2 Including deaths of Londoners in the Metropolitan Workhouses, Hospitals, and Lunatic Asylums outside the County, but excluding those of non-Londoners in the London Fever Hospital, the West Ham Union Workhouse at Hackney, the Metropolitan Asylums Hospitals and the Middlesex County Asylum, within the County of London. 21322 F 38 It will be seen from the following table that in the decennium 1898-1907 the London whoopingcough death-rate was exceeded by the death-rates of Liverpool, Manchester, Birmingham, West Ham, Newcastle-on-Tyne and Salford, and in the year 1908 was lower than all except that of Bradford and Leicester. Whooping-cough—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.371 0.201 West Ham 0.47 0.26 Liverpool 0.47 0.45 Bradford 0.25 0.19 Manchester 0.43 0.33 Newcastle-on-Tyne 0.42 0.48 Birmingham 0.44 0.54 Hull 0.36 0.21 Leeds 0.36 0.28 Nottingham 0.32 0.23 Sheffield 0.36 0.53 Salford 0.49 0.42 Bristol 0.31 0.34 Leicester 0.27 0.13 The following table shows that the London whooping-cough death-rate was, in the decennium 1898-1907, higher than that of any of the undermentioned foreign towns, and in the year 1908, higher than that of all except Amsterdam, Copenhagen, and St. Petersburg. Whooping-cough—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.371 0.201 St. Petersburg 0.22 0.27 Paris 0.12 0.09 Berlin 0.26 0.19 Brussels 0.12 0.05 Vienna 0.09 0.09 Amsterdam 0.24 0.21 Rome 0.08 0.04 Copenhagen 0.33 0.37 New York 0.12 0.04 Stockholm 0.17 0.07 The following table shows the whooping-cough deaths and death-rates for the year 1908 and the death-rates for the period 1903-7 in the several metropolitan sanitary districts :— Whooping-cough—Death-rates in sanitary areas. Sanitary area. Deaths, 1908 (53 weeks). Death-rate per 1,000 personsliving. 1903-7. 1908. Paddington 11 0.25 0.07 Kensington 7 0.30 0.04 Hammersmith 19 0.30 0.15 Fulham 34 0.37 0.19 Chelsea 17 0.32 0.22 Westminster, City of 8 0.15 0.05 St. Marylebone 13 0.23 0.10 Hampstead 5 0.12 0.05 St. Pancras 69 0.34 0.29 Islington 55 0.32 0.16 Stoke Newington 6 0.29 0.11 Hackney 44 0.26 0.18 Holborn 8 0.29 0.14 Finsbury 25 0.45 0.26 London, City of 1 0.22 0.05 Shoreditch 24 0.62 0.20 Bethnal Green 42 0.42 0.32 Stepney 129 0.38 0.41 Poplar 73 0.44 0.42 Southwark 50 0.41 0.23 Bermondsey 22 0.39 0.17 Lambeth 50 0.32 0.15 Battersea 39 0.38 0.21 Wandsworth 62 0.29 0.21 Camberwell 54 0.32 0.19 Deptford 24 0.37 0.20 Greenwich 31 0.34 0.28 Lewisham 30 0.20 0.19 Woolwich 32 0.25 0.24 London 984 0.33 1 0.201 1 See footnote (1), page 8. Diagram XVI Typhus. 39 It will be seen from the foregoing table that in the period 1903-7 the highest whoopingcough death-rate obtained in Shoreditch (0.62), and the lowest in Hampstead (0.12); in the year 1008 Poplar (0.42) had the highest death-rate and Kensington (0.04) the lowest. The whooping-cough deathrates in each of the four quarters of the year 1908 were as follows: first quarter, 0.33; second quarter, 0.28 ; third quarter, 0.13 ; and fourth quarter, 0.07 per 1,000 persons living. The following table shows that when the London sanitary districts are grouped according to the proportion of the population living more than two in a room, in tenements of less than five rooms, the incidence of whooping-cough mortality progressively increases from the least to the most overcrowded groups of districts. Whooping-cough mortality and overcrowding,l 1901-8. Proportion of overcrowding in groups of sanitary areas. Whooping cough death-rates at ages 0—5 per 1,000 living. 1901-8. Under 7.5 per cent. 2.29 7.5 to 12.5 per cent. 2.75 12.5 to 20.0 per cent. 2.91 20.0 to 27.5 per cent. 3.18 Over 27.5 per cent. 3.31 As in the case of measles some of the annual reports show the number of cases of whooping-cough which became known to the medical officers of health in 1908, and the following figures are thus supplied:— Sanitary area. No. of cases. Sanitary area. No. of cases. Sanitary area. No. of cases. Paddington 170 Islington 385 Lambeth 311 Kensington 44 Hackney 357 Battersea 302 Hammersmith 156 Finsbury 160 Wandsworth 612 Chelsea 78 Shoreditch 1532 Lewisham 416 Westminster 62 Bermondsey 179 Woolwich 174 Typhus. There were no deaths from typhus registered in the Administrative County of London during the year 1908. The death-rates from this disease in successive periods have been as follows:— Typhus. Period. Death-rate per 1,000 persons living. 1871-80 .055 1881-90 .008 1891-1900 .0013 1901 .0013 1902 .0003 1903 .0013 1904 — 1905 — 1906 - 1907 - 1908 — In this table .000 indicates that the deaths were too few to give a rate of .0005 ; where — is inserted no death occurred. Only two cases of typhus are known to have occurred during 1908. The patients were a school boy, aged 14, and his sister, a few years older, employed as a tailoress, both resident in Fieldgate-mansions, Whitechapel. They were attacked about the same time, and the source of their infection was unknown. They were both removed to the Eastern Hospital, where they recovered. The death-rate in each period since 1868 in relation to the mean death-rate of the period 1869-1908 is shown in diagram XVI. 1 See footnote (1). page 18. 2 Excluded frcm school on account of whooping-cough infection. 3 See footnote ('), page 8, 21322 F 2 40 Enteric Fever. The number of cases of enteric fever notified in the Administrative County of London during 1908 (53 weeks) was 1,357, compared with 1,394 in the year 1907 (52 weeks). The deaths from this disease numbered 225 in 1903 (53 weeks), compared with 194 in 1907 (52 weeks). The case-rates and death-rates per 1,000 persons living and the case-mortality per cent, in 1908 and preceding periods were as follows :— Enteric Fever. Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case-mortality per cent. 1871-80 0.24 -2 -2 1881-90 0.19 -2 -2 1891-1900 0.141 0.8 17.4 1901 0.111 0.7 15.6 1902 0.121 0.7 15.8 1903 0.081 0.5 15.7 1904 0.061 0.4 15.1 1905 0.051 0.3 15.1 1906 0.061 0.3 16.3 1907 0.041 0.3 13.9 1908 0.051 0.3 16.6 The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1908 is shown on diagram XVII. The notified cases in each week of 1908 may be compared with the average weekly notifications of the period 1890-1908 on reference to diagram XVIII. The monthly case-rate and case-mortality in each of the years 1891-1908 in relation to the mean of the whole period is shown in diagram XIX. The following table shows the enteric fever cases, deaths, case-rates and death-rates for the year 1908, the case-rates for the decennium 1898-1907, and the death-rates for the period 1903-7 in the several sanitary districts— Enteric Fever—Case-rates and death-rates in sanitary areas. Sanitary area. Notified cases, 1908 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1908 (53 weeks). Death-rate per l,000 persons living. 1898-1907. 1908. 1903-7. 1908. Paddington 31 0.4 0.2 4 0.05 0.03 Kensington 42 0.4 0.2 5 0.04 0.03 Hammersmith 31 0.5 0.2 5 0.06 0.04 Fulham 39 0.5 0.2 10 0.07 0.06 Chelsea 17 0.4 0.2 5 0.03 0.07 Westminster, City of 41 0.5 0.2 6 0.05 0.03 St. Marylebone 34 0.5 0.3 6 0.04 0.05 Hampstead 25 0.4 0.3 5 0.03 0.05 St. Pancras 61 0.7 0.3 10 0.05 0.04 Islington 97 0.6 0.3 18 0.05 0.05 Stoke Newington 11 0.4 0.2 4 0.04 0.07 Hackney 66 0.8 0.3 7 0.11 0.03 Holborn 25 0.6 0.5 5 0.06 0.09 Finsbury 49 0.6 0.5 12 0.09 0.12 London, City of 7 0.9 0.4 — 0.05 — Shoreditch 105 0.7 0.9 11 0.06 0.09 Bethnal Green 83 0.8 0.6 13 0.07 0.10 Stepney 98 0.8 0.3 14 0.08 0.04 Poplar 61 0.9 0.3 14 0.07 0.08 Southwark 48 0.7 0.2 7 0.07 0.03 Bermondsey 58 0.8 0.4 12 0.07 0.09 Lambeth 66 0.5 0.2 8 0.05 0.02 Battersea 41 0.5 0.2 6 0.05 0.03 Wandsworth 61 0.4 0.2 7 0.05 0.02 Camberwell 36 0.4 0.1 7 0.05 0.02 Deptford 28 0.5 0.2 8 0.04 0.07 Greenwich 35 0.6 0.3 9 0.05 0.08 Lewisham 34 0.3 0.2 4 0.03 0.03 Woolwich 20 0.4 0.1 3 0.05 0.02 Port of London 7 London 1,357 0.6 0.3 225 0.061 0.051 1 See footnote (1), page 8. 2 The Infectious Disease (Notification) Act came into force in 1889. Diagram XVII Enteric Fever. Diagram XVIII Enteric Fever. ' Diagram XIX Enteric Fever. 41 It will be seen from the foregoing table that among the several sanitary areas in the period 1003-7 the enteric fever death-rate was highest in Hackney (0.11), and lowest in Chelsea, Hampstead and Lewisham (0 03); in the year 1908 Finsbury (0.12) had the highest enteric fever death-rate, while in the City of London there were no deaths. The death-rates from enteric fever in London, in each of the four quarters of the year 1908, were as follows : first quarter, 0 03 ; second quarter, 0-02 ; third quarter, 0-04 ; and fourth quarter, 0-09, per 1,000 persons living. Information is given in some of the reports concerning the numbers of persons attacked by enteric fever in 1908 who had eaten shell-fish at a time consistent with the hypothesis that it was the cause of illness. The districts referred to are Paddington, Fulham, Westminster, Hampstead, Stoke Newington, Holborn, Finsbury, Poplar, Lambeth, Battersea, Wandsworth, Camberwell, Greenwich and Woolwich. In these districts, after deduction of cases incorrectly diagnosed, some 454 cases of enteric fever are known to have occurred, and of these in 84 instances, or 18"5 per cent, of the cases, shell-fish had been thus consumed :— Shell-fish (not otherwise defined) 37 Oysters 21 Mussels 20 Winkles 4 Whelks 2 84 There is no information as to whether this proportion is in excess of the proportion of the population unattacked by enteric fever, which would be found on enquiry to have eaten shell-fish. In only one report is mention made of fried fish being eaten antecedent to an attack of enteric fever, and in the district to which the report relates there were only three such cases. Inasmuch as the London poor are large consumers of fried fish, it is not unlikely that absence of record rather than absence of occurrence may have been responsible for the conspicuously small number mentioned. Again, watercress, which has been thought by some to be responsible for occurrences of enteric fever, is mentioned in three reports in relation to seven total cases in these districts, and ice cream, clearly shown by Dr. George Turner to have caused a considerable outbreak of enteric fever in Deptford in 1892, is only mentioned in one report, and then in relation to four cases. It is probable that absence of record again plays a part here although there has undoubtedly been improvement in the conditions under which ice cream is made, effected by the administration of the provisions of the Council's General Powers Act of 1902 relating to the manufacture and sale of ice cream in London. A notable feature in the behaviour of enteric fever in London in recent years, has been the manifestation of localised prevalences occurring in poor populations and lasting often for a considerable number of weeks. There were two such prevalences in 1908, one in Bethnal Green the other in Shoreditch. The Bethnal Green prevalence occurred in the months of September and October. The cases in the Shoreditch prevalence extended over a longer period, which included those months, during which numerous cases occurred. Dr. Hamer was given by Dr. Bate the opportunity of investigating the Bethnal Green outbreak, and in Appendix I. will be found a report from him on this subject. In this report he also discusses the Shoreditch outbreak, the particulars of which were supplied to him by Dr. Bryett. It would appear that both Dr. Bate and Dr. Bryett consider the prevalences in their respective districts to be due in the main, if not altogether, to the influence of infection from person to person, while Dr. Hamer does not regard the observed facts as explicable on this basis, and sees reason for thinking that they must have been in great measure caused by infected food supply. In both districts the locality implicated was occupied by very poor persons living under the conditions which are usually observed in the homes of people of this class. It was found in Shoreditch, that in numerous instances there were multiple attacks in houses, i.e., two or three, or even more cases occurred in some of the houses, while in others only one case occurred. A point of considerable interest in the investigation of such occurrences is the extent to which enteric fever may be communicated from person to person. The view that enteric fever will spread by case-to-case infection is generally accepted, but the question needs careful consideration whether this can occur on the scale shown by the Shoreditch figures, if we are to regard the secondary cases occurring in houses as due entirely to infection from the first case, and, indeed, the so-called primary cases as also due to personal infection. The conditions which exist in the homes of persons of the class who suffered in Shoreditch are precisely those which would give opportunity for infection from person to person. On the other hand, persons attacked by enteric fever are removed from these houses as soon as the disease is recognised, and therefore are not exposing others to infection during the whole period of their illness. Mild and unrecognised cases no doubt remain, and these have to be thought of in estimating the amount of opportunity for case-to-case infection. In attempting to determine whether multiple cases occurring in houses are due to infection introduced into the house by an article of food, or to personal infection, or to both causes, the difficulty presents itself that the incubation period of the disease is variable, and often the beginnings of the illness are so indefinite in their manifestation that it is impossible to determine the date of attack with any precision. Hence an infected article of food supplied on a particular day may give rise 42 to cases of enteric fever, separated from each other by considerable intervals, which suggest dependence of these cases on each other, rather than on the actual cause. Again, an infected article of food may be operative on successive occasions, the cases resulting being distributed in such a way as to suggest infection from case to case. In these circumstances it is quite possible that an outbreak, suggestive, so far as time and place and distribution of cases is concerned, of being in the main due to case-to-case infection, may be actually due to infected food, infection from person to person playing a relatively small part in the total result. The conclusion which the investigator arrives at obviously depends in large degree upon his views on the infectivity of enteric fever. If he regards this quality as having large potentiality he is especially impressed by the occurrence of multiple attacks in houses which suggest case-to-case infection from a recognised case in the house, or, in its absence, of an unrecognised case in the house, or he may assume that the occasional visit to an infected house of a relation or a neighbour may suffice to account for the apparent spread of the disease from one house to another. If he regards this infectivity as having small potentiality he is especially impressed by the variability in the period of incubation, and by the difficulty in determining the date of manifestation of the beginning of the illness, considerations which make him think that cases with intervals between them of some magnitude may all have been infected at the same time. Appeal is usually made to the proportion of the persons attacked who have eaten particular articles of food, and here again the investigator who looks upon personal infection as the dominant factor, has a tendency to be satisfied that certainarticles of food usually thought of in this connection have not been consumed by a sufficient proportion of persons attacked to satisfy him that they have been operative, while the investigator who attaches relatively small importance to personal infection has a disposition to direct his inquiries to the consumption of articles of food which he thinks may be possibly operative, and to attach importance to some article of food which has been generally consumed by those attacked. The need for careful study of all local prevalences and for more precise knowledge of the part which personal infection may play in the dissemination of the disease is obvious. The following tables showing the London enteric fever case-rates and comparative case-rates at ages in successive periods are of interest and it will be seen that the amount of decline in the "all ages" case-rate has not been equally distributed at the various age-periods shown in the table:— Enteric fever.—Case-rates per 100,000 living, at certain ages, 1893-1908. Males. Period. 0- 5- 10- 15- 20- 25- 35- 45- 55+ All ages. 1893-5 40 101 161 149 138 114 73 45 20 95 1896-1900 36 107 148 150 138 121 71 40 20 95 1901-5 25 68 103 103 93 73 51 29 13 62 1906-8 12 38 45 49 43 43 38 22 10 34 Females. Period. 0- 5- 10- 15- 20- 25- 35- 45- 55+ All ages. 1893-5 35 89 111 99 93 81 52 29 18 68 1896-1900 31 92 116 104 92 78 54 32 11 68 1901-5 21 64 75 66 63 55 37 25 8 46 1906-8 11 34 45 35 35 35 24 16 6 27 Comparative case-rate (1893-5= 1,000 for each age). Males. Period. 0- 5- 10- 15- 20- 25- 35- 45- 55+ All ages. 1893-5 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1896-1900 904 1,066 920 1,005 1,000 1,059 983 893 1,031 1,000 1901-5 641 680 642 688 674 640 708 653 643 660 1906-8 293 378 282 325 312 372 523 498 531 359 43 Females. Period. 0- 5- 10- 15- 20- 25- 35- 45- 55 + All ages. 1893-5 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1896-1900 864 1,038 1,045 1,046 989 961 1,047 1,119 633 1,000 1901-5 582 720 671 664 680 681 717 881 467 676 1906-8 322 388 400 352 374 425 473 573 311 397 If the rates of the last period be compared with those of the first it is seen that among males the decline has been most conspicuous at ages 0-, 10-, 15-, and 20-, and among females at 0-, 15— and 20—. If the second period be compared with the first, ages 5-, 15-, 25- and 55+ among males, and ages 5-, 10-, 15-, 35- and 45- among females, show increase; the rates at "all ages" in these periods being identical. Enteric Fever.—Age and sex distribution. The following table shows the notified cases, deaths, case-rates, death-rates and fatality of enteric fever at the several ages and for each sex in London during the year 1908. The case-rate, death-rate, and fatality were at "all ages" higher among males than among females. In the age groups adopted for the purposes of this table the greatest incidence of attack was upon males aged 15-20 and upon females aged 10-15; the greatest incidence of death was upon males aged 35-45 and upon females aged 25-45. The fatality was greatest among males of 55 and upwards and females aged 45-55. Enteric Fever1—1908. Age-period. Males. Females. Notified Oases. Deaths. Casemor tality per cent. Rates per 100,000 living. Notified Cases. Deaths. Casemortality per cent. Rates per 100,000 living. Oases. Deaths. Cases. Deaths. All Ages 724 149 20.6 31 6 633 87 13.7 25 3 0- 1 4 14.3 11 2 1 4 11.1 14 2 1- 2 2 2- 5 4 3- 6 14 4- 14 15 5- 74 7 9.5 31 3 69 2 2.9 29 1 10- 93 11 11.8 42 5 82 7 8.5 36 3 15- 105 16 15.2 47 7 71 9 12.7 28 4 20- 81 13 16.0 35 6 90 10 11.1 32 4 25- 157 43 27.4 39 11 154 24 15.6 33 5 35- 118 35 29.7 39 12 81 18 22.2 24 5 45- 50 14 28.0 24 7 37 10 27.0 16 4 55 & upwards 18 6 33.3 9 3 13 3 23.1 5 1 Diarrhœa. The deaths in the Administrative County of London during 1908 (53 weeks) attributed to epidemic diarrhoea and infective enteritis numbered 1,577, while 1,081 deaths were attributed to diarrhoea and dysentery. The corresponding figures for 1907 (52 weeks), were 780 and 763 respectively. The age-distribution of the deaths in 1908 was as follows:— Diarrhoea—Deaths2 at the several age-periods—1908. Disease. Under 1 year. 1-5. 5-20. 20-40. 40-60. 60-80. 80 and upwards All ages. Epidemic diarrhoea, infective enteritis 1,241 302 11 3 7 10 3 1,577 Diarrhoea and dysentery 734 173 7 27 45 66 29 1,081 Total 1,975 475 18 30 52 76 32 2,658 1 See footnote (1), page 30. 2 See footnote (l), page 37, 44 No accurate comparison can be made of the deaths from epidemic diarrhoea for a long series of years in London; diagram XX, however, shows the death-rate from cholera, dysentery, and diarrhoea combined, in each year since 1840 in relation to the mean death-rate of the period 1841-1908. The following table shows that the London diarrhoea death-rate was in the decennium 18981907 lower than the death-rate of any of the undermentioned large English towns, except Bristol, Bradford and Newcastle-on-Tyne, and in 1908 was lower than that of any except Bristol, Newcastle-on-Tyne, and Leicester:— Diarrhœ—Death-rates per 1,000 persons living. Town. 1898-1907. 1908. Town. 1898-1907. 1908. London 0.771 0.531 West Ham 1.49 100 Liverpool 1.49 0.84 Bradford 0.65 065 Manchester 1.31 0.92 Newcastle-on-Tyne 0.69 0.46 Birmingham 1.22 0.80 Hull 1.38 1.36 Leeds 0.91 0.67 Nottingham 1.13 0.64 Sheffield 1.45 0.87 Salford 1.41 0.98 Bristol 0.56 0.34 Leicester 1.07 0.50 The deaths and death-rates from diarrhoea for the year 1908, and the death-rates for the period 1903-7 in each of the sanitary areas of London, are shown in the following table:— Diarrhoea—Death-rates in sanitary areas. Sanitary area. Deaths, 1908 (53 weeks). Death-rate per 1,000 persons living. 190.3-7. 1908. Paddington 52 0.60 0.34 Kensington 89 0.58 0.48 Hammersmith 74 0.75 0.59 Fulham 113 1.18 0.65 Chelsea 36 0.51 0.47 Westminster, City of 42 0.34 0.24 St. Marylebone 39 0.50 0.30 Hampstead 12 0.17 0.13 St. Pancras 88 0.52 0.37 Islington 112 0.50 0.32 Stoke Newington 19 0.42 0.35 Hackney 163 0.77 0.68 Holborn 23 0.51 0.42 Finsbury 95 0.93 0.97 London, City of 2 0.23 0.10 Shoreditch 117 1.28 1.00 Bethnal Green 102 0.94 0.77 Stepney 262 1.10 0.83 Poplar 155 1.20 0.89 Southwark 188 0.95 0.88 Bermondsey 109 1.04 0.84 Lambeth 141 0.70 0.43 Battersea 83 0.72 0.44 Wandsworth 104 0.61 0.35 Camberwell 126 0.63 0.44 Deptford 75 0.78 0.63 Greenwich 60 0.71 0.54 Lewisham 63 0.52 0.40 Woolwich 48 0.68 0.36 London 2,592 0.731 0.531 It will be seen from the foregoing table that the diarrhoea death-rate was in the period 1903-7 highest in Shoreditch (1.28), and lowest in Hampstead (0.17); in the year 1908, Shoreditch (1.00) had again the highest death-rate, the lowest obtaining in the City of London (0.10). The diarrhoea deathrates in London in each of the four quarters of the year 1908, were as follows: first quarter, 0.17; second quarter, 015 ; third quarter, 1*36 ; and fourth quarter, 0 46, per 1,000 persons living. (1) See footnote (1), page 8. Diagram XX Diarrhœa, Dysentery & Cholera. Mean Death-rate 1841-1908. 45 In a special report, Dr. Sidney Davies gives account of the results obtained by the voluntary notification of diarrhoea among infants in Woolwich in the months of July, August and September of the years 1905-8. During this period 844 cases were notified, and of these 115 died, or nearlv 14 per cent. The fatality was much greater among infants under three months of age, viz. 29 per cent., and diminished with increase of age. The fatality, moreover, was found to vary with prevalence, the disease being most fatal at the time of greatest] prevalence. Mortality from this disease, moreover, varied with temperature of the earth three feet below the surface. Diarrhœa prevalence appears to be determined by the rise of the earth temperature curve above a certain level, and, this prevalence once established, appears to continue irrespective of whether the temperature is subsequently maintained. In houses to which attention was directed by the notification of diarrhoea in an infant, older persons were found' also to be affected. An examination of the statistics obtained in the inquiry showed that while infants who were breast-fed suffered much less than those artificially fed, there was not much difference between the incidence of attack on children fed on cow's milk and those fed on condensed milk, except among the children fed on cow's milk at the Infants' Milk Depot, who suffered much less than other infants artificially fed. Dr. Davies says that there can be little doubt that the infection spreads from person to person in a family, and he thinks the distribution of the cases is consistent with the hypothesis that the disease is conveyed by flies. The dates of cases pointed to an incubation period of from two to seven days. As compared with London, the death-rate was slightly higher in Woolwich in the four years 1901-4, but much lower in the four years 1905-8, a result which Dr. Davies thinks is largely due to the steps which were able to be taken as the result of notification and also to the influence of the milk depot. Dr. Davies recommends that the system of notification should be continued and that the period of notification in each year should extend from June to October, inclusive. Erysipelas. The deaths from erysipelas in the Administrative County of London during 1908 (53 weeks) numbered 160, as compared with 189 in 1907 (52 weeks). The age-distribution of these deaths was as follows:— Erysipelas—Deaths1 at the several age-periods—1908. Under 1 Year. 1-5. 5-20. 20-40. 40-60. 60-80. 80 and upwards. All ages. 37 2 10 19 35 51 6 160 The number of cases notified and the number of deaths registered from this disease since 1890 have been as follows— Erysipelas. Year. Notified Cases. Case-rate per 1,000 persons living. Deaths.1 Death-rate per 1,000 persons living. 1891 4,764 1.13 214 0.05 1892 6,934 1.63 292 0.07 1893 9,700 2.26 424 0.10 1894 6,080 1.40 221 0.05 1895 5,660 1.30 179 0.04 1896 6,436 1.43 207 0.05 1897 5,794 1.31 184 0.04 1898 5,169 1.16 165 0.04 1899 5,606 1.25 213 0.05 1900 4,762 1.06 182 0.04 1901 4,604 1.02 171 0.04 1902 5,536 1.19 183 0.04 1903 4,372 0.95 183 0.04 1904 4,943 1.08 232 0.05 1905 4,972 1.06 226 0.05 1906 5,019 1.07 245 0.05 1907 4,497 0.95 189 0.04 1908 4,203 0.86 160 0.03 The number of cases of erysipelas notified and the case-rate for the year 1908, together with the case-rate in the decennium 1898-1907, in the several sanitary areas are shown in the following table:— 21322 1 See footnote (1), page 37. g 46 Erysipelas.— Case-rates in sanitary areas. Sanitary area. Notified Cases, 1908 (53 weeks). Case-rate per 1,000 persons living. 1898-1907. 1908. Paddington 105 1.0 0.7 Kensington 132 0.9 0.7 Hammersmith 69 1.0 0.5 Fulham 127 0.9 0.7 Chelsea 52 0.8 0.7 Westminster, City of 81 0.7 0.5 St. Marylebone 126 1.4 1.0 Hampstead 33 0.6 0.4 St. Pancras 158 1.1 0.7 Islington 236 0.9 0.7 Stoke Newington 25 0.8 0.5 Hackney 238 1.3 1.0 Holborn 46 1.3 0.8 Finsbury 95 1.3 1.0 London, City of 9 0.8 0.5 Shoreditch 127 1.4 1.1 Bethnal Green 246 1.9 1.8 Stepney 423 1.5 1.3 Poplar 191 1.2 1.1 Southwark 234 1.4 1.1 Bermondsey 168 1.4 1.3 Lambeth 225 0.9 0.7 Battersea 150 1.0 0.8 Wandsworth 209 1.0 0.7 Camberwell 233 1.1 0.8 Deptford 171 1.3 1.4 Greenwich 106 1.o 1.0 Lewisham 91 0.6 0.6 Woolwich 91 0.8 0.7 Port of London 6 London 4,203 1.1 0.9 The following table shows the age and sex distribution of the notified cases of erysipelas in 1908- Age-period. All Ages. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. Males 1,868 166 70 81 87 91 302 338 320 242 116 55 Females 2,335 179 72 90 137 131 317 401 410 315 178 105 Persons 4,203 345 142 171 224 222 619 739 730 557 294 160 The table shows, so far as the figures relating to notified cases of this disease can be trusted in this connection, that the number of females attacked largely exceeds the number of males attacked, and this is true, even when allowance is made for the excess of females iu the total population. Puerperal Fever. The deaths in the Administrative County of London during the year 1908 (53 weeks) attributed to puerperal fever1 numbered 137, as compared with 152 in 1907 (52 weeks). The number of cases notified and the number of deaths registered from this cause since the year 1890 have been as follows— Puerperal Fever.—Cases notified and deaths. Year. Notified cases. Deaths.2 1891 221 222 1892 337 313 1893 397 352 1894 253 210 1895 236 208 1896 277 225 1897 264 215 1898 247 184 1899 326 209 1900 237 169 1901 253 184 1902 311 201 1903 233 170 1904 273 198 1905 292 183 1906 298 187 1907 254 152 1908 228 137 1 Including deaths from puerperal septicæmia and puerperal pyaemia. 2 See footnote (1),page 37. 47 If these cases and deaths are considered in relation to the total population and total births the following- rates are obtained— Puerperal Fever.—Case-rates and death-rates. Year. Case-rate per 1,000 living. Case-rate per 1,000 births. Death-rate1 per 1,000 living. Death-rate' per 1,000 births. 1891 0.05 1.64 0.05 1.65 1892 0.08 2.55 0.07 237 1893 0.09 2.98 0.08 2.65 1894 0.06 1.92 0.05 1.60 1895 0.05 1.76 0.05 1.56 1896 0.06 2.04 0.05 1.66 1897 0.06 1.98 0.05 1.61 1898 0.05 1.86 0.04 1.39 1899 0.07 2.45 0.05 1.57 1900 0.05 1.81 0.04 1.29 1901 0.06 1.93 0.04 1.40 1902 0.07 2.34 0.04 1.51 1903 0.05 1.78 0.04 1.30 1904 0.06 2.11 0.04 1.53 1905 0.06 2.31 0.04 1.45 1906 0.06 2.39 0.04 1.50 1907 0.05 2.09 0.03 1.25 1908 0.05 1.86 0.03 1.11 It will be noted that the death-rate per 1,000 births in 1908 is the lowest recorded in the table. An account of puerperal fever occurring in the practice of midwives will be found on reference to the administration of the Midwives Act, 1902, see pp. 84, et seq. Influenza, Bronchitis and Pneumonia. The deaths attributed to influenza, which in 1907 numbered 967 (52 weeks), rose to 1,350 in 1908 (53 weeks). The deaths from bronchitis numbered 5,342 in 1908, as compared with 6,010 in 1907. In 1908 there were 6,751 deaths attributed to pneumonia, a decrease of 787 on the number occurring from the same cause in 1907. The deaths from these diseases since 1889 have been as follows:— Influenza, Bronchitis and Pneumonia. Year. Deaths1 from Influenza. Deaths1 from Bronchitis. Deaths 1 from Pneumonia. 1890 652 12,448 6,224 1891 2,336 13,136 6,915 1892 2,264 11,183 6,164 1893 1,526 10,413 7,198 1894 750 7,816 5,321 1895 2,156 10,633 5,989 1896 496 7,558 5,537 1897 671 7,408 5,053 1898 1,283 7,779 5,440 1899 1,817 9,195 6,666 1900 1,950 8,699 7,189 1901 664 7,317 6,121 1902 1,073 7,901 6,801 1903 644 5,240 5,826 1904 709 6,373 6,609 1905 689 6,049 6,965 1906 895 5,373 6,586 1907 967 6,010 7,538 1908 1,350 5,342 6,751 The distribution of deaths from influenza throughout the year for each of the years 1890 to 1908 is shown in the following table:— Influenza—Deaths' registered in London in four-weekly periods—1890-1908. Number of weeks. 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1-4 303 9 1,308 52 272 59 37 40 244 66 1,016 57 77 141 67 94 56 291 87 5-8 167 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 44 186 276 9-12 75 8 119 162 69 1,343 61 94 193 430 130 134 298 89 74 119 98 104 424 13-16 39 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 129 81 209 17-20 13 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 105 48 94 21-24 5 1,044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 40 41 36 25-28 6 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 21 25. 28 29-32 6 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 20 14 15 33-36 3 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 15 18 12 37-40 6 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 18 19 21 41-44 5 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 35 42 30 45-48 13 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 86 39 15 49-52 6 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 22S 59 57 1 See footnote (l), page 37. 2 The deaths occurring in the 53rd week of tho years 1890, 1896. 1902 and 1908 are excluded g 2 48 Phthisis. The deaths from phthisis in the Administrative County of London during 1908 (53 weeks) numbered 6,419, as compared with 6,654 in 1907 (52 weeks). The death-rates from this disease in successive periods have been as follows:— Phthisis. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1851-60 2.86 1903 1.551 1861-70 2.84 1904 1.621 1871-80 2.51 1905 1.421 1881-90 2.08 1906 1.441 1891-1900 1.79 1907 1.401 1901 1.661 1908 1.321 1902 1.601 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 1851-1908 (males and females) is shown in diagram XXI. The following table shows the crude phthisis death-rate corrected for differences in the age and sex constitution of the various sanitary districts. The factors for correction, also shown in the table, have been calculated by applying the 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 for London in the five years 1897-1901 Phthisis—Crude and corrected death-rates per 1,000 persons living, in the County of London and the several sanitary districts. Sanitary area. Standard deathrate.3 Factor for correction for age and sex distritribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1903-7. 1908. 1903-7. 1908. 1903-7. 1908. London 1.74 1.00000 1.49 1.32 1.49 1.32 1,000 1,000 Paddington 1.80 0.96659 1.09 1.01 1.05 0.98 709 741 Kensington 1.78 0.97419 1.23 0.98 1.20 0.95 806 725 Hammersmith 1.74 0.99600 1.29 1.26 1.28 1.25 865 953 Fulham 1.69 1.02786 1.27 1.14 1.31 1.17 878 890 Chelsea 1.83 0.95018 1.59 1.27 1.51 1.21 1,017 916 Westminster, City of 1.95 0.89205 1.50 1.23 1.34 1.10 900 833 St. Marylebone 1.85 0.93836 1.60 1.16 1.50 1.09 1,010 827 Hampstead 1.75 0.98862 0.75 0.78 0.74 0.77 499 586 St. Pancras 1.80 0.96551 1.74 1.51 1.68 1.46 1,131 1,107 Islington 1.75 0.99145 1.35 1.24 1.34 1.23 901 934 Stoke Newington 1.77 0.97914 1.25 1.07 1.22 1.05 824 796 Hackney 1.68 1.02969 1.26 1.22 1.30 1.26 873 954 Holborn 1.97 0.87894 2.76 2.11 2.43 1.85 1,632 1,408 Finsbury 1.72 1.01050 2.24 2.15 2.26 2.17 1,523 1,650 London, City of 1.89 0.91946 1.65 1.79 1.52 1.65 1,021 1,250 Shoreditch 1.66 1.04206 2.11 2.00 2.20 2.08 1,480 1,583 Bethnal Green 1.59 1.08984 2.09 1.61 2.28 1.75 1,533 1,332 Stepney 1.65 1.05281 1.84 1.56 1.94 1.64 1,304 1,247 Poplar 1.66 1.04772 1.58 1.34 1.66 1.40 1,115 1,066 Southwark 1.74 0.99829 2.20 1.88 2.20 1.88 1,478 1,425 Bermondsey 1.65 1.05026 1.91 1.89 2.01 1.98 1,350 1,507 Lambeth 1.75 0.99258 1.43 1.45 1.42 1.44 955 1,093 Battersea 1.69 1.02483 1.32 11.9 1.35 1.22 910 926 Wandsworth 1.72 1.01050 1.01 0.96 1.02 0.97 687 737 Camberwell 1.68 1.03522 1.27 1.12 1.31 1.16 885 880 Deptford 1.69 1.02969 1.32 1.16 1.36 1.19 915 907 Greenwich 1.67 1.04143 1.20 1.10 1.25 1.15 841 870 Lewisham 1.69 1.02543 0.87 0.85 0.89 0.87 600 662 Woolwich 1.70 1.01881 1.44 1.20 1.47 1.22 987 928 1 See footnote (1) page 2 The standard death-rate used in the calculation of the "factors for correction" has been calculated to more than the two places of decimals shown in the table. Diagram XXI Phthisis (Mortality). (The death-rates upon which this diaqram is based have been corrected for differences in the age constitution of the population.) Mean death - rate 1851-1908- 2.87 per1000 living. Mean death - rate 1851-!908-1.91 per 1000 living 49 It will be seen from the foregoing table (comparing the corrected death-rates) that among the several sanitary areas in the quinquennium 1903-7, Holborn (2.43) had the highest phthisis death-rate and Hampstead (0.74) the lowest; in the year 1908 Finsbury (2.17) had the highest death-rate, the lowest again obtaining in Hampstead (0.77). The death-rates from phthisis in each of the four quarters of the year 1908, were as follows: first quarter, 1.56; second quarter, 1.24; third quarter, 1.11; and fourth quarter, 13.5, per 1,000 persons living. The following table enables comparison to be made between the phthisis death-rates in the several sanitary areas for each of the years 1901-1908, inclusive. These death-rates are corrected for differences in the age and sex constitution of the various populations, and it will be seen that while there is a general tendency to decline in the death-rates, there is a considerable difference in the amount of decline in the rates of the different districts. To facilitate comparison the districts are arranged in the ascending order of their death-rates in the first year shown in the table, viz., 1901. Phthisis.—Corrected death-rates1 per 1,000 persons living (1901-1908). Sanitary area. 1901. 1.02. 1903. 1904. 1905. 1906. 1907. 1908. Hampstead 0.90 0.84 0.73 0.82 0.82 066 0.69 0.77 Lewisham 0.92 1.09 0.86 0.92 0.87 0.84 0.95 0.87 Paddington 1.06 1.01 1.02 1.16 0.93 1.08 1.05 0.98 Wandsworth 1.15 0.91 0.96 1.13 1.03 1.02 0.96 0.97 Greenwich 1.20 1.24 1.17 1.39 1.31 1.24 1.12 1.15 Deptford 1.22 1.15 1.39 1.46 1.26 1.32 1.38 1.19 Stoke Newington 1.32 1.23 1.20 1.68 1.30 1.02 0.92 1.05 Kensington 1.33 126 1.22 140 1.11 1.24 1.00 0.95 Hammersmith 1.41 1.42 1.46 1.37 1.16 1.24 1.20 1.25 Fulham 1.41 1.42 1.42 1.47 1.25 1.16 1.22 1.17 Battersea 1.49 1.34 1.32 1.46 137 1.31 1.28 1.22 Islington 1.50 1.49 1.39 1.54 1.25 1.22 1.31 1.23 Camberwell 1.53 1.56 1.26 1.42 1.25 130 1.36 1.16 Hackney 1.57 1.47 1.31 1.43 1.18 1.34 1.20 1.26 Chelsea 1.59 1.38 1.49 1.73 1.43 1.49 1.43 1.21 Lambeth 164 1.69 1.39 1.44 1.37 1.36 1.52 1.44 Westminster, City of .. 1.68 1.59 1.51 1.36 1.35 1.24 1.22 1.10 St. Marylebone 1.77 1.80 1.72 1.58 1.37 1.46 1.39 1.09 Woolwich 1.79 1.52 1.48 1.70 1.55 1.36 1.27 1.22 St. Pancras 1.80 1.82 176 1.82 1.47 1.75 1.60 1.46 Poplar 1.87 1.78 1.82 1.82 1.60 1.62 1.39 1.40 Bermondsey 1.88 1.97 1.83 2.23 1.88 211 1.97 1.98 London, City of 2.10 1.55 1.46 1.45 1.23 1.60 1.87 1.65 Stepney 2.20 2.00 2.21 2.23 1.81 1.81 1.64 1.64 Finsbury 2.21 2.30 2.30 2.42 2.04 2.20 2.35 2.17 Shoreditch 2.32 1.89 2.42 2.27 2.04 2.09 2.19 2.08 Bethnal Green 2.35 2.15 2.29 2.35 2.22 2.45 2.07 1.75 Holborn 2.47 2.65 2.76 2.51 2.50 2.08 2.27 1.85 Southwark 2.51 2.62 2.40 2.36 2.13 2.06 2.03 1.88 If the London rates of the priods 1901-4 and 1905-8 be compared, it is found that the rate has declined 13.2 per cent. The following table shows the number of deaths from phthisis at several age-periods in each o: be sanitary areas. Phthisis—Deaths1 at the several age-periods in sanitary areas.—1908 (366 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington 6 1 2 5 16 32 42 28 15 4 - - 151 Kensington 6 — 1 6 17 37 52 33 18 13 2 1 186 Hammersmith 3 2 4 7 18 28 31 28 19 11 1 - 152 Fulham 5 2 3 7 22 47 48 32 22 7 1 - 196 Chelsea 1 3 1 2 6 14 20 28 10 6 4 - 95 Westminster, City of 4 1 — 7 12 30 43 56 37 19 3 - 212 St. Marylebone 2 1 2 8 11 31 40 25 10 9 — - 139 Hampstead - 1 1 4 10 20 16 9 6 3 — - 70 St. Pancras 15 3 1 10 24 74 104 82 38 13 1 1 366 Islington 17 2 13 16 37 96 107 75 47 18 6 - 434 Stoke Newington 2 — 2 1 2 8 16 20 5 — — - 56 Hackney 10 4 2 17 33 64 56 52 36 15 1 - 290 1 See footnote (1) page 8. 50 Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All  Holborn 4 — — 3 4 18 26 26 20 6 1 — 108 Finsbury 9 1 1 4 19 44 53 33 27 16 1 — 208 London, City of — — — — 1 4 10 11 8 1 — — 35 Shoreditch 15 4 6 11 16 52 56 40 28 2 — — 230 Bethnal Green 7 2 2 11 20 46 45 45 20 7 2 — 207 Stepney 10 3 8 21 40 90 136 80 62 36 4 — 490 Poplar 10 — 4 11 28 54 57 39 25 9 2 — 239 Southwark 18 2 7 17 21 78 89 97 52 11 2 — 394 Bermondsey 18 3 5 19 24 51 50 45 19 6 1 — 241 Lambeth 30 5 4 17 33 96 84 96 57 30 4 — 456 Battersea 3 4 2 20 24 38 46 48 21 9 4 — 219 Wandsworth 4 1 3 19 36 65 67 29 39 10 3 — 276 Camberwell 13 4 2 14 35 78 75 46 28 8 2 1 306 Deptford 2 2 5 7 9 28 37 24 16 4 — — 134 Greenwich 4 — 2 5 14 26 32 20 13 4 3 — 123 Lewisham 3 — 1 8 13 42 31 18 11 7 — — 134 Woolwich 3 — 3 13 10 43 41 31 11 3 1 — 159 London 224 51 87 290 555 1334 1510 1196 720 287 49 3 6306 With decline of phthisis mortality, the age incidence of death is altering. If the rates of the five periods 1861-70, 1871-80, 1881-90, 1891-1900 and 1901-7 be compared with those of 1851-60, it is found, broadly speaking, that the decline in phthisis mortality among persons over fifteen has been most marked among females, while among persons under fifteen the decline is more nearly the same for the two sexes. This behaviour of the figures is consistent with the hypothesis that improvement in home conditions has been a material factor in the result, inasmuch as such conditions would be less operative upon males over fifteen than on females of that age, while their operation would affect more evenly both males and females under fifteen. The following table shows the mortality from phthisis in groups of London sanitary districts, arranged in respect to the proportion of their population living more than two in a room in tenements of less than five rooms. London, 1901-8. Phthisis death-rates in relation to overcrowding.1 Proportion of overcrowding in each group of sanitary areas. Crude phthisis death-rate per 1,000 persons living. Standard deathrate. Factor for correction for age and sex distribution. Corrected deathrate per 1,000 persons living. Corrected death-rate (London, 1,000). Under 7.5 per cent. 1.052 1.718 1.00991 1.062 712 7'5 to 1.5 per cent. 1.332 1.705 1.01761 1.355 908 12.5 to 20 per cent. 1.432 1.771 0.97969 1.403 940 20.0 to 27.5 per cent. 1.958 1.805 0.96124 1.882 1,261 Over 27.5 per cent. 1.979 1.651 1.05090 2.080 1,393 London 1.493 1.735 1.ooooo 1.493 1,000 Tables similar to the above have been published in several previous annual reports, and the close relationship existing between "social condition" as measured by "overcrowding" and phthisis mortality is conspicuous. It will be seen that in the group of most overcrowded districts the death rate from phthisis is approximately twice that in the group least overcrowded. A system of voluntary notification of cases of phthisis has been adopted in the majority of London sanitary districts. The districts in which this system of notification is in force and the number of notifications in 1908 is shown in the following table:— Sanitary area. No. of Cases. Sanitary area. No. of Cases. Kensington 229 Holborn 152 Hammersmith 118 Finsbury 220 Fulham 164 London, City of 49 Chelsea 63 Southwark 427 Westminster, City of 155 Bermondsey 134 St. Marylebone 172 Lambeth 373 Hampstead 30 Wandsworth 85 St. Pancras 249 Greenwich 107 Islington 109 Lewisham 57 Stoke Newington 17 Woolwich 154 Hackney 102 See footnote (1), page 18. 51 Thus the total number of cases notified in these districts was 3,166. During the year there occurred in these districts 4,330 deaths from phthisis, so that the notifications fell far short of the deaths resulting from this disease. In the remaining districts where the system of voluntary notification was not in operation the deaths numbered 1,976. These figures suffice to show how limited is as yet the practice of notification of cases of phthisis in London. There is, however, some hope that this practice will be extended through the operation of hospitals to which phthisical patients resort for treatment. Arrangements have been made by the Brompton Hospital for Consumption by which cases attending that hospital are, with the patients' consent, notified to the County Medical Officer of Health, who distributes the certificates of notification to the several medical officers of health in whose districts the patients are resident. The hospital, moreover, invites the medical officers of health to send for examination and treatment any other members of the patient's family who may be found to present symptoms of phthisis. St. Thomas's Hospital employs almoners who visit the homes of patients suffering from phthisis, with a view to giving advice and securing, as far as possible, the attendance at the hospital for treatment of other members of the family who may be affected. Phthisical patients attending Guy's Hospital are notified to the local medical officer of health. During the year I have communicated with other hospitals to which such patients resort with a view to the adoption of the system in operation at Brompton Hospital, a system which obviously is deserving of extension throughout London. So far as poor law cases are concerned, an Order of the Local Government Board requiring the notification of cases of phthisis in London occurring in poor law practices, which came into force on the 1st January, 1909, brings to the knowledge of the medical officers of health many of the cases occurring in that class of the community who most need his services. London, however, is but very imperfectly provided with the opportunities which are needed for utilising the knowledge thus gained. Phthisis mortality occurs especially among the poor, and measures for its reduction must largely include those which afford assistance, not only to the sufferer, but often to the families of invaded households. It is here that extension of philanthropic effort is greatly needed. The notification of phthisis without the ability to ameliorate the condition of the sufferer is not calculated to effect the main object in view. Thus the female sanitary inspectors of Kensington write: "It appears to us hopeless to expect any material benefit when the sufferer is compelled to five with others in one or two rooms, and the advice to sleep alone is a counsel of perfection very rarely capable of being followed." In a few districts (Battersea, Hampstead, St. Marylebone, Paddington, Stepney, Southwark and Westminster) voluntary health societies render useful aid, and indeed their services and the services in London generally of the Charity Organization Society and of Children's Care Committees deserve recognition, but it is a much wider development of the services which can thus be rendered in connection with the work of the medical officers of health that is needed. At the present time, when cases of pulmonary phthisis are brought to the knowledge of the medical officer of health, the home of the patient is visited, and advice is given as to the course which should be adopted in the invaded home. In a few districts the medical officers of health themselves undertake this work, but for the most part the visits are made by sanitary inspectors or by health visitors where these exist. Where there is a voluntary health society the case is handed over to it, but in many districts the notification is not followed by more than the giving of advice and the offer of sputum bottles and of disinfection. In Paddington, it deserves to be noted, a Dispensary for the Prevention of Consumption has been instituted, of which Dr. Reginald Dudfield thus writes:— "Not only will patients receive that advice, both medical and hygienic, which is necessary for the treatment of their disease and the prevention of the spread of infection, but they will be visited in their homes by doctor and nurse, who will instruct the patients how to give effect to the hygienic measures prescribed, and do their best to see that they are carried out. The dispensary system, however, requires the help of notification to achieve the best results." Dr. Dudfield's report also contains the following paragraph which shows what it is practicable to do in a district where voluntary notification has been adopted:— "After notification advice is given as to precautions to be observed, and as to the best method of living, etc. Frequent communications are addressed to the medical practitioners in charge of the patients, to learn what rules they desire their patients to adopt, and to ascertain whether the cases are in need of and suitable for treatment in sanatoria or country. In the last direction, the help of the Local Health Society and Committees of the Invalid Children's Aid Association and Charity Organisation Society has been sought. The Charity Organisation Society has given material relief in suitable cases. Twenty-one adult and twenty children patients were sent away to sanatoria or country through the co-operation of the agencies mentioned. In the majority of the cases the results were satisfactory, but certain patients refused to remain a sufficiently long time under treatment to obtain its full benefit. Records of all cases are in the possession of the Department." As stated in the last report, Dr. Bulstrode's inquiries on behalf of the Local Government Board have emphasized the need for early detection of and early treatment of the disease, and it is in this direction that improvement of London administration is especially needed. It is not claiming too much to say that there should be skilled enquiry as to the health of all members of invaded families, and provision for this is still wanting in London generally. That it is often impracticable for the medical officer of health, in view of his other duties, to undertake this work personally is obvious to those who are familiar with the duties which now devolve upon him. The institution of dispensaries will not only render useful service in the treatment of recognised cases, but will in some degree provide the necessary opportunity for early diagnosis, if the medical staff of such dispensaries act in effective co-operation with the medical officer of health. 52 A useful work is undertaken by sanitary authorities generally in London in giving opportunity for the examination of sputum from suspected cases of pulmonary phthisis. The annual reports relating to the following districts show the number of specimens examined and the results found. Thus:— Sanitary area. No. of specimens examined. No. found positive. Sanitary area. No. of specimens examined. No. found positive. Paddington 19 10 Shoreditch 6 1 Fulham 181 41 Bethnal Green 9 0 Westminster, City of 19 11 Stepney 59 18 St. Marylebone 71 21 Bermondsey 217 61 St. Pancras 46 9 Lambeth 163 42 Islington 205 69 Battersea 118 30 Stoke Newington 54 16 Wandsworth 72 21 Hackney 92 14 Greenwich 31 7 Holborn 9 4 Lewisham 86 36 Finsbury 21 3 Woolwich 175 54 Among the matters mentioned in the annual reports deserving of note are some figures given by the Medical Officer of Health of Paddington, concerning the average duration of cases of pulmonary phthisis from the time when the illness was first observed to the date of death. Dr. Dudfield found that in the case of males this period was 22.2 months and in the case of females 307 months, or 25.7 months for both sexes. The averages are based on records relating to 478 cases terminating fatally. Cancer. The deaths from cancer in the Administrative County of London during 1908 (366 days), numbered 4,628, as compared with 4,487 for the 365 days of 1907. The death-rates from this disease in successive periods have been as follows:— Cancer. Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1851-60 0.42 1903 0.961 1861-70 0.48 1904 0.921 1871-80 0.55 1905 0.931 1881-90 0.68 1906 0.981 1891-1900 0.85 1907 0.95l 1901 0.881 1908 0.961 1902 0.93l For the purpose of enabling the incidence of cancer on the several populations of the sanitary areas 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. These factors are shown in the following table, together with the death-rates for each sanitary area, corrected by their application. Owing to the changes of area in the sanitary districts of London caused by the London Government Act of 1899, the death-rates since 1900 are the only figures available for comparative purposes, but it can be seen from these figures that differences in the age and sex constitution of the population are partially responsible for the differences in the crude death-rates obtaining in the several districts. Cancer. Crude and corrected death-rates1 per 1,000 persons living in the County of London and the several sanitary districts. Sanitary area. Standard deathrate.2 Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected death-rate per 1,000 persons living. Comparative mortality figure (London 1,000). 1903-7. 1908. 1903-7. 1908. 1903-7. 1908. London 0.87 1.00000 0.94 0.96 0.94 0.96 1,000 1,000 Paddington 0.98 0.89478 1.11 1.24 0.99 1.11 1,052 1,153 Kensington 1.02 0.85622 1.04 1.04 0.89 089 943 925 Hammersmith 0.90 0.96811 1.04 0.98 1.01 0.95 1,066 986 Fulham 0.77 1.13828 0.86 0.69 0.98 0.79 1,037 816 Chelsea 1.03 0.84874 1.12 0.98 0.95 0.83 1,007 864 Westminster, City of 0.96 0.91348 1.02 1.18 093 1.08 987 1,120 St. Marylebone 0.99 0.88571 1.20 1.31 1.06 1.16 1.126 1,206 Hampstead 0.92 0.94816 0.97 0.97 0.92 0.92 974 956 ( Continued on next page). 1 See footnote (1), page 8. 2 See footnote (2), page 48. 53 Sanitary area. Standard deathrate.1 Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected death-rate per 1,000 persons living. Comparative mortality figure (London 1,000) 1903-7. 1908. 1903-7. 1908. 1903-7. 1908. St. Pancras 0.92 0.95229 1.00 1.23 0.95 1.17 1,009 1,217 Islington 0.90 0.96704 1.03 1.06 100 1.03 1,055 1,065 Stoke Newington 0.98 0.89387 1.08 126 0.97 1.13 1,023 1,170 Hackney 0.88 0.99341 0.86 0.96 0.85 0.95 905 991 Holborn 0.95 0.91924 0.97 0.93 0.89 0.85 944 888 Finsbury 0.84 1.04071 0.84 0.90 0.87 0.94 926 973 London, City of 1.06 0.82316 1.31 1.40 1.08 1.15 1,142 1,197 Shoreditch 0.79 1.10518 0.83 0.80 0.92 0.88 972 919 Bethnal Green 0.78 1.12077 0.87 0.87 0.98 0.98 1,033 1,013 Stepney 0.74 1.17976 0.78 074 092 087 975 907 Poplar 0.81 1.08327 0.78 0.85 0.84 0.92 895 957 Southwark 0.82 1.06350 0.94 0.87 100 0.93 1,059 961 Bermondsey 0.81 1.08462 0.88 087 0.95 0.94 1,011 981 Lambeth 0.92 0.95333 1.04 1.06 0.99 1.01 1,050 1,050 Battersea 0.79 1.10798 0.93 0.84 1.03 0.93 1,091 967 Wandsworth 088 0.99116 0.97 0.95 0 .96 0.94 1,018 978 Camberwell 0.87 1.00483 0.89 0.94 0.89 0.94 947 981 Deptford 0.81 1.07396 0.88 0.83 095 0.89 1,001 926 Greenwich 087 1.01064 0.82 0.88 0.83 0.89 878 924 Lewisham 0.92 0.95333 0.91 0.95 0.87 0.91 919 941 Woolwich 0.78 1.11933 0.82 0.72 0.92 0.81 972 837 It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1903-7 among the several sanitary areas the City of London (1.08) had the highest cancer death-rate and Greenwich (083) the lowest; in the year 1908 St. Pancras (1.17) had the highest, the lowest obtaining in Fulham (0.79). The following tables (a), (b), and (c) show the deaths during 1908 (366 days) in each of the sanitary districts from cancer at several age-periods under three headings, viz., sarcoma, carcinoma, and cancer, deaths classified under the last-named term being those for which the information given on the certificate of death was insufficient to further distinguish them for purposes of classification. (a) Sarcoma.—Deaths2 at the several age-periods in sanitary areas.—1908 (366 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Agesp Paddington — — — — 1 2 2 3 4 - - — 12 Kensington 2 — — 1 — — 1 4 2 - 1 - 11 Hammersmith 1 1 1 — - - 1 2 2 - - - 8 Fulham — 1 - - - 3 - 2 - - - - 6 Chelsea - - - - - 1 - - - - - - 1 Westminster, City of - - - 2 - - - 2 - - 2 - 6 St. Marylebone 1 — — 1 — 3 1 1 1 2 — - 10 Hampstead 1 — — — — 2 — 2 — 2 — - 7 St. Pancras — — — — 1 1 3 2 1 3 1 - 12 Islington 1 — — — 3 1 4 1 5 3 — - 18 Stoke Newington — — — — — 1 — 2 1 2 — - 6 Hackney 3 — — — 1 1 1 2 4 2 1 - 15 Holborn - - - - - - - - - - - - - Finsbury 1 - - - - - 1 — 1 2 — - 5 London, City of - - - - - - - - - - - - 1 Shoreditch 1 - - - - - 2 1 5 2 - - 11 Bethnal Green — 1 — - - 1 - 1 4 - 2 1 10 Stepney 1 - — — 1 3 2 1 1 2 — - 11 Poplar — — 1 — — 1 2 3 2 2 — - 11 Southwark 2 — 1 — 1 — 3 4 3 1 — - 15 Bermondsey 1 - — 2 — 2 2 2 — 2 — - 11 Lambeth 1 2 — 1 - 2 3 1 4 3 2 2 21 Battersea — - — 1 1 1 1 - 3 — 1 — 8 Wandsworth 1 2 1 - 1 1 5 3 3 2 1 1 21 Camberwell — — 1 1 - - 2 1 3 - - - 8 Deptford 1 - — - - - 1 1 — 3 1 — 7 Greenwich 1 1 — 1 — 1 — — 1 1 — 1 7 Lewisham 1 — 2 1 1 - - 1 1 — - - 7 Woolwich — — — — - 1 — 1 1 — 1 - 4 London 20 8 7 11 11 28 37 44 52 34 13 5 270 21322 1 See footnote (2), page 48. 2 See footnote (1), page 8. u 54 (b) Carcinoma,. Deaths1 at the several age-periods in sanitary areas.—1908 (366 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages. Paddington - - - - - 5 6 26 32 33 14 2 118 Kensington - - - - - 2 9 21 30 22 13 2 99 Hammersmith — — - - - 5 8 12 24 16 9 - 74 Fulham — — - - - - 8 23 20 14 7 2 74 Chelsea — — — — - 1 1 6 11 6 7 - 32 Westminster, City of — — — — 1 1 17 23 33 30 15 1 121 St. Marylebone — — — — - 1 7 19 25 22 10 4 88 Hampstead — — — — - 1 2 7 29 18 4 1 62 St. Pancras — — — — - 3 15 38 57 55 23 3 194 Islington — — — — 1 2 27 36 57 44 21 1 189 Stoke Newington — — — - - 5 10 11 9 4 1 40 Hackney — 1 — — - 1 6 37 25 29 12 - 111 Holborn — — — — - 3 6 12 10 2 - 33 Finsbury — — — — - 1 3 13 21 15 5 - 58 London, City of — — — — - 1 1 7 2 4 - 15 Shoreditch - — - - - 1 8 11 12 16 2 1 51 Bethnal Green - — — — - 1 4 14 13 13 7 2 54 Stepney - — — — - 4 16 39 36 39 9 1 144 Poplar - — — — 1 - 10 16 23 24 7 81 Southwark - — — — - 2 13 28 47 32 12 - 134 Bermondsey - — - — 2 7 16 19 23 10 - 77 Lambeth - — — — 5 14 60 68 55 20 3 225 Battersea - — — — - - 7 12 34 28 4 1 86 Wandsworth - — — 1 - 8 19 26 52 32 21 1 160 Camberwell - — — - - 3 18 26 37 38 17 2 141 Deptford - - - - - 3 6 16 19 25 3 - 72 Greenwich - — - - - 1 8 11 16 18 8 1 63 Lewisham - — - - 1 1 7 19 28 26 15 1 98 Woolwich - — — - - - 5 8 19 16 12 - 60 London - 1 — 1 6 52 260 580 817 710 297 30 2754 (c) Cancer (otherwise undistinguished).— Deaths1 at the several age-periods in sanitary areas.—1908 (366 days). Age-period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 and upwards All Ages.[/### Paddington - - - - - 2 5 14 19 13 5 - 58 Kensington — - - - - 2 10 15 23 23 7 1 81 Hammersmith — - - - 1 3 6 11 14 5 - 40 Fulham — - - - - - 2 8 10 14 2 2 38 Chelsea — - — 1 - - 4 3 15 12 6 - 41 Westminster, City of — - - - - - 3 17 21 22 12 - 75 St. Marylebone — 1 - - - 1 6 13 18 20 8 2 69 Hampstead — - - - - 1 5 - 8 6 1 - 21 St. Pancras — - — — — 4 10 14 23 19 14 3 87 Islington .. .. — - — - - - 13 28 49 37 30 6 163 Stoke Newington - - - - - 1 1 4 7 6 3 - 22 Hackney - - - - - 1 5 23 32 31 7 1 100 Holborn - - - - - 1 3 2 5 4 2 1 18 Finsbury .. - - - - - 3 2 3 8 7 1 - 24 London, City of - - - - - 1 - 3 4 2 1 - 11 Shoreditch - - - - - 1 3 4 12 7 3 - 30 Bethnal Green - - - - 1 2 3 9 20 11 4 - 50 Stepney - - - 1 — 5 10 15 19 23 4 - 77 Poplar 1 - — - 2 1 6 12 18 10 5 - 55 Southwark - - — - - 1 2 12 11 6 3 - 35 Bermondsey - - - - - 1 1 6 9 4 2 - 23 Lambeth - - - - 1 2 5 21 30 23 11 2 95 Battersea - - - - - - 1 12 18 18 9 2 60 Wandsworth - - - - - 1 6 14 36 22 12 5 96 Camberwell .. - - - - - 3 12 29 32 26 10 3 115 Deptford - - - - - 1 3 2 4 6 3 - 19 Greenwich - - - - - - 1 5 6 8 4 2 26 Lewisham - - - - 1 - 3 6 14 16 4 - 44 Woolwich - - — - - - 3 6 10 11 1 - 31 London 1 1 — 2 5 36 131 306 492 421 179 30 1604 1 See footnote (1),page 8. 55 The following table shows the proportional age-distribution of the deaths in London during 1908 (366 days) classified under the three headings— Cancer—Deaths1 at each age-period per 1,000 deaths at All Ages—1908 (366 days). Age-period. All ages. Under 35. 35- 45- 55- 65- 75- 85 and upward Sarcoma 1,000 315 137 163 193 126 48 18 Carcinoma 1,000 22 94 210 297 258 108 11 Cancer (not otherwise defined) 1,000 28 82 191 307 262 111 19 Total 1,000 41 92 201 294 252 106 14 In the report for the year 1907 a table was included showing the cancer death-rates in the period 1901-7 in areas presenting different degrees of overcrowding,2 the object being to compare the death-rates of populations differently circumstanced in respect of "social condition." The following table shows the corresponding death-rates for the period 1901-8:— London, 1901-8. Cancer death-rates1 in relation to overcrowding.2 Proportion of overcrowding in each group of sanitary areas. Crude cancer death-rate per 1,000 persons living. Standard deathrate. Factor for correction for age and sex distribution. Corrected death-rate per 1,000 persons living. Corrected death-rate (London, 1,000). Under 7.5 per cent. 0.931 0.883 0.99003 0.922 985 7.5 to 12.5 per cent. 0.923 0.864 1.01180 0.934 998 12.5 to 20 per cent. 0.984 0.921 0.94919 0.934 998 20- to 27.5 per cent. 1.012 0.904 0.96704 0.979 1,045 Over 27.5 per cent. 0.809 0.774 1.12946 0.914 976 London 0.936 0.874 1.ooooo 0.936 1,000 The figures shown in the table appear to indicate that there is no relation between cancer mortality and social condition as judged by overcrowding, and in this respect the behaviour of cancer differs altogether from that of phthisis (see page 50). Cerebro-spinal Fever. During 1908, 85 persons were certified to be suffering from Cerebro-spinal fever and 12 deaths were attributed to this diseases. The number of deaths in each year since 1901 has been as follows:— Deaths. Deaths. 1902 4 1906 4 1903 6 1907 25 1904 6 1908 12 1905 5 As stated in the last annual report, the larger number of deaths attributed to this cause in 1907 was probably an indirect effect of the Council making an Order requiring cases of this disease to be notified. The number of cases notified and the number of deaths were markedly lower in 1908 than in 1907. In 1907 the requirement of notification did not become operative until the 12th of March, and during the remainder of that year 135 cases were notified, or 50 more than in the whole of the year 1908. The age distribution of the 85 cases notified in 1908 was as follows:— Ages 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 13- 15 + Males 29 5 1 2 1 — 3 4 — — 1 1 1 Females 23 3 1 5 1 2 — 1 — — 1 — — 1 See footnote (1). page 8. 2 See footnote (l), page 18. 56 The distribution of the cases and deaths throughout the year was as follows:— Quarter ended Cases. Deaths. March 28th (13 weeks) 27 5 June 27th (13 weeks) 23 2 September 26th (13 weeks) 18 3 January 2nd (14 weeks) 17 2 A report by Dr. Wanklyn on Cerebro-spinal fever in London during 1908 is appended. (See Appendix II.) Anthrax. Five cases of anthrax are known to have occurred during the year, one of which proved fatal. Three persons attacked, all in Bermondsey, were employed in handling foreign hides at wharves in that district. All recovered. One case occurred in Shoreditch in the person of the wife of a caretaker employed at a horse-hair factory. This patient also recovered. The fifth case, which was fatal, was a domestic servant employed in Stoke Newington. The source of her infection could not be ascertained. Glanders. Six deaths are known to have occurred in London during the year. The first death was that of a horse-dealer who purchased worn-out horses with a view to selling them for utilisation as a source of food supply abroad. None of the horses in his possession were known to be glandered. The case was at first supposed to be one of influenza, then later of pneumonia and of typhoid fever. The existence of lumps under the skin and of a pustular rash was noted. On the day before his death the nature of the illness was recognised and the presence of the bacillus mallei was demonstrated. The second death was that of a horse-keeper. After the inquest the stud of 75 horses among which he had worked was tested, with the result that 11 reacted and were slaughtered. The man's illness commenced with pain in the shoulder, sores developed on the body and intramuscular abscesses were found. In the pus from one of the latter the bacillus mallei was detected. The third death was that of a carman owning four horses. One of these was found to be badly glandered. The man's illness was at first thought to have been caused by a blow and an abscess developed in the left shoulder. He was admitted to Guy's Hospital and intramuscular abscesses were found in the neighbourhood of the shoulder and elbow. Post-mortem the larynx was discovered to be affected. The fourth death was that of a horse-keeper who had worked in the stable above referred to (in connection with the second death) at which 11 glandered horses were found. The nature of the disease was diagnosed on his admittance to St. Bartholomew's Hospital. The fifth death was that of a man who had not been in any ascertainable way connected with horses. The case was considered at first to be one of influenza, then of rheumatic fever, then of septicaemia. The bacillus mallei was found in pus taken from the patient two days before his death. The sixth death was that of a coachman who lived in rooms over an empty stable. He was not known to have been in contact with glandered horses. He suffered from diarrhoea and developed a sore on his right arm and became delirious. A pustular rash appeared on his face. A diagnosis of glanders was made, but it was not confirmed bacteriologically. 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 1908 was 50.1 deg Fahrenheit, which is the average of the preceding 65 years. The rainfall during the year amounted to 23.78 inches, a decrease of 0 34: inches on the average of the preceding 65 years. The temperature and rainfall in each month of the year 1908 are shown in the following table:— Temperature and Rainfall—1908. Month. Temperature of the air. Departure of mean monthly temperature from average of preceding 65 years. Rain. Absolute maximum. Absolute minimum. Mean for the month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. January 54 18 36.3 -2.1 9 1.51 February 55 28 41.6 + 1.8 13 1.46 March 59 24 40.7 -1.8 17 2.22 April 62 28 44.3 -3.8 15 2.10 May 77 38 567 +2.9 15 1.53 June 82 42 60.4 +0.1 6 207 July 84 47 63.1 -0.6 12 3.66 August 83 47 60.7 -2.2 14 3.28 September 80 36 57.0 -1.2 12 122 October 79 33 54.5 +4.1 10 1.97 November 59 22 45.9 +2.5 12 0.76 December 54 12 39.4 -0.2 15 2.00 57 PART II. Dairies, Cowsheds and Milkshops. The County Council received during the year 229 applications for cowhouse licences, of which 225 were granted. The number of applications for licences received during the last fifteen years and the number granted are shown in the following table. It will be seen that the number of these premises in London is continually decreasing. No. of applications received. No. of premises for which licences were granted. 1894 456 446 1895 427 416 1896 405 393 1897 379 374 1898 357 354 1899 338 330 1900 323 321 1901 306 295 1902 294 291 1903 282 277 1904 266 259 1905 257 255 1906 244 240 1907 234 233 1908 229 225 In 1903 effort was made, in conjunction with the medical officers of health of London districts, to secure uniform statistical statement of the several proceedings of the sanitary authorities. 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 or from figures otherwise contained in their reports. The following table relating to cowsheds has been thus prepared:— Cowsheds. Sanitary area. Number of cowshed premises. Number of inspections by the sanitary authority, 1908. Number of prosecutions by sanitary authority, 1908. On register at end of 1907. Added in 1908. Removed in 1908. On register at end of 1908. Paddington 1 - - 1 3 - Kensington 1 - — 1 45 — Fulham 2 - — 2 15 — Chelsea 2 - — 2 42 - Westminster, City of 2 - — 2 56 - St. Marylebone 6 - — 6 58 — St. Pancras 9 - 2 7 155 — Islington 7 - — 7 81 — Stoke Newington 2 - — 2 41(a) — Hackney 21 - — 21 269 — Holborn 1 - — 1 52 — Finsbury 5 - — 5 - — Shoreditch 7 - - 7 77 — Bethnal Green 15 - - 15 63 — Stepney 38 - — 38 60 3 Poplar 15 - — 15 53 — Southwark 5 - — 5 58 — Bermondsey 7 - 1 6 38 — Lambeth 14 - — 14 — Battersea 3 - - 3 — — Wandsworth 13 - — 13 61 2 Camberwell 16 - 2 14 212(b) — Deptford 5 - 2 3 58 — Greenwich 4 - — 4 9 — Lewisham 15 - 1 14 153 - Woolwich 17 - - 17 78 — (a) Including milkshops. (b) Including dairies. 58 Milkshop premises. The following table shows the number of milkshop premises at the end of 1907 and 1908 in the several sanitary districts of London, the number of inspections and the proceedings taken. The table has been compiled from information contained in the annual reports:— Sanitary area. Number of premises. Number of inspections, 1908. Number of notices, 1908. Number of prosecutions, 1908. On register at end of 1907. Added in 1908. Removed in 1908. On register at end of 1908. Paddington 176 12 11 176 293 2 - Kensington 279 14 9 284 1,720 59 — Hammersmith 300 21 7 314 894 96 - Fulham 257 45 53 249 720 8 - Chelsea 126 2 9 119 150 9 - Westminster, City of 386 31 73 344 590 - 3 St. Marylebone 253 33 39 247 317 17 — Hampstead 114 4 5 113 416 15 1 St. Pancras - - - 413 1,140 - - Islington 532 41 — 573 3,303 493 1 Stoke Newington 53 - - - 41(a) — — Hackney 373 24 35 362 1,218 7 — Holborn 178 15 15 178 995 5 — Finsbury 259 29 45 243 286 50 — London, City of 606 48 42 612 - - - Shoreditch 284 24 16 292 3,513 18 2 Bethnal Green 346 3 7 342 1,163 62 — Stepney 1,037 64 131 970 2,828 34 2 Poplar 349 21 11 359 1,629 5 — Southwark 397 93 90 400 496 3 — Bermondsey 269 30 36 263 707 42 — Lambeth 523 21 — 544 - - - Battersea 254 39 52 241 615 48 — Wandsworth 364 37 34 367 874 59 1 Camberwell 599 41 24 616 1,443 — — Deptford 203 56 59 200 627 11 — Greenwich 210 17 17 210 390 30 — Lewisham 165 66 53 178 337 7 — Woolwich 143 31 40 134 308 10 - (a) Including cowsheds. In 1908 the London County Council obtained the sanction of Parliament to a provision contained in the General Powers Act of that year, authorising any sanitary authority to remove from the register of milk vendors, or to refuse to register the name of any person carrying on or proposing to carry on the business of a dairyman or purveyor of milk upon premises which, in the opinion of the sanitary authority are unsuitable for the sale of milk. The Act provides an appeal to a Court of Summary Jurisdiction. Tuberculosis of the udder in London cows. London County Council (General Powers) Act, 1904 (Part 7.). The Dairies, Cowsheds and Milkshops Order, 1899, provides that the milk from cows certified by a veterinary surgeon to be affected with tubercular disease of the udder, shall not be (a) mixed with other milk, or (b) sold or used for human food, or (c) sold or used for the food of swine without having first been boiled. In 1904, however, the Council obtained powers, as incorporated in the above-named Act, to remove any cow from any dairy, farm or cowshed in the County (elsewhere than in the City), if such cow is suspected to be suffering from tuberculosis of the udder, and if, upon slaughter, these suspicions are verified, a sum equal to three-quarters of the agreed value of the animal (not exceeding £22 10s.) is payable by the Council. If, however, the cow is proved to be free from tuberculosis of the udder, the full agreed value (not exceeding £30), together with a further sum of £1, is payable by the Council. 59 The cows in the London cowsheds have, since the date of the Dairies Order of 1899, been periodically inspected by the County Council's veterinary inspector, with a view to the detection of cows suffering from tubercular disease of the udder. During the year 1908 there were five inspections of all the cows in the London cowsheds, and the results of the veterinary inspector's examination are shown in the following table:— Examination of cows for tubercular disease of the udder—Summary of the reports of the Council's Veterinary Inspector for the year 1908. Details of Examination. 1st period, 11th Jan.— 15th March, 1908. 2nd period, 16th March— 26th May, 1908. 3rd period, 27th May— 31st July, 1908. 4th period, 1st August— 4th October, 1908. 5th period, 5th October— 5th Dec., 1908. Total number of cows examined 3,521 3,283 3,476 3,343 3,565 Affected with disease or defects of the udder 230 223 213 213 258 Affected with tubercular disease of the udder 3 3 2 5 3 Suspected cases of tubercular disease 2 1 — — - Subjects of acute mastitis 23 39 27 29 40 Affected with chronic induration of the udder 7 13 12 11 4 Atrophy of one or more quarters 141 117 123 127 142 Injuries, abscesses, simple eruptions, strictures and obliterations of milk ducts 16 27 22 18 32 Hypertrophied udders without induration 2 2 3 1 1 Giving milk of poor quality (dried-off cows) 36 21 24 22 36 The 16 cows suffering from tubercular disease of the udder were slaughtered, and the carcases destroyed, compensation being paid by the Council to the owners in accordance with the provisions of the London County Council (General Powers) Act of 1904. London County Council (General Powers) Act, 1907.—Part IV. Milk Supply (Tuberculosis). Part IV. of the 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, 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 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 provisions of this, part of the Act were consequently in force during six months of the year 1908. During the period under review, the method of procedure adopted was as follows: Samples were taken by the Council's inspectors from churns of milk consigned from the country to the various London railway termini, and submitted to the Lister Institute for bacteriological examination. In the case of those samples in respect to which the examination proved that there was evidence of the presence of tubercle bacilli, a clinical examination of the cows at the dairy farm from which the milk had been consigned was made by a veterinary inspector, appointed for the purpose under the Act. During the period under review 620 samples of milk were taken. The milk had been sent to London from the following counties: Bedfordshire, Berkshire, Buckinghamshire, Cambridgeshire, Cheshire, Derbyshire, Dorsetshire, Essex, Gloucestershire, Hampshire, Herefordshire, Hertfordshire, Huntingdonshire, Leicestershire, Norfolk, Northamptonshire, Oxfordshire, Rutlandshire, Somersetshire, Staffordshire, Surrey, Sussex, Suffolk, Warwickshire, Wiltshire and Worcestershire, and 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 Metropolitan and the London and North Western and South Western Railway Companies. The following table shows the number of samples taken during the period under review (1st July, 1908, to 16th January, 1909), the counties from which they were derived, and the results of the bacteriological examination at the Lister Institute. 60 County. No. of samples taken from churns for examination. Results of examination. No. of samples found 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 21 - 12 9 Berkshire 90 5 65 20 Buckinghamshire 45 2 32 12 Cambridgeshire 5 — 4 1 Cheshire 1 1 — — Derbyshire 75 11 50 15 Dorsetshire 2 2 — Essex 85 16 67 2 Gloucestershire 15 - 15 — Hampshire 35 5 28 2 Herefordshire 4 - 3 1 Hertfordshire 15 1 14 - Huntingdonshire 1 — 1 — Leicestershire 40 4 32 3 Norfolk 1 - 1 - Northamptonshire 23 - 13 10 Oxfordshire 49 - 44 4 Rutlandshire 1 1 - - Somersetshire 6 1 4 1 Staffordshire 14 2 11 1 Suffolk 15 3 12 — Surrey 1 1 — — Sussex 5 3 1 1 Warwickshire 11 1 8 2 Wiltshire 57 4 45 8 Worcestershire 3 - 3 — Total 620 61 467 92 This table shows that out of 528 completed examinations of samples taken from churns consigned to London. 61 Droved to be tuberculous, i.e.. 11.6 per cent. The following table shows the number of farms visited, the number of cows inspected and the number of cows certified to have tuberculosis of the udder during this period: County. No. of farms inspected. No. of cows inspected. No. of cows with tuberculous udders. Bedfordshire 1 20 - Berkshire 6 288 12 Buckinghamshire 6 178 2 Cheshire 1 36 1 Derbyshire 23 452 21 Essex 25 1,533 27 Hampshire 5 200 11 Hertfordshire 1 37 1 Leicestershire 4 106 5 Rutlandshire 2 20 — Somersetshire 19 254 11 Staffordshire 82 1,244 33 Suffolk 4 177 8 Surrey 1 87 6 Sussex 4 122 3 Warwickshire 2 64 2 Wiltshire 4 179 4 Totals 190 4,997 147 This table shows that 2.9 per cent. of the cows examined were found to have clinical symptoms of tuberculous disease of the udder. The supply of milk for human consumption from the cows thus affected was immediately stopped. The experience gained during 1908 shows the magnitude of the evil to be dealt with, and that it is possible, even under existing circumstances, to take steps which must eventually materially 61 reduce the amount of tuberculous milk supplied to London. The great need at the present time is, however, the systematic veterinary inspection of cows by the local authorities of the areas in which the dairy farms are situated, and the exclusion from the milk supply of the milk of cows suffering from tubercular disease of the udder or showing clinical signs of tubercular disease or giving tuberculous milk. In this connection it might be stated that provincial local authorities have generally shown willingness to co-operate with the Council in preventing the sale of milk from cows which the Council's veterinary inspector has certified to be suSering from tubercular disease of the udder, and in a few instances veterinary inspectors have been appointed by the local authorities for the enforcement of the provisions of the Dairies and Cowsheds Order of 1899. The adoption of this latter course by certain authorities, which is an indirect effect of the administration of the Council's powers, is one of the most hopeful results of the Council's Act of 1907. Offensive Businesses. In the year 1908 the County Council received 281 applications for licences for slaughter-houses and granted 273. The following table shows the number of applications received and the number of slaughter-houses licensed in recent years. It will be seen that the number of these premises is continually decreasing:— Slaughterhouses. 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 1901 384 381 1893 538 529 1902 371 362 1894 518 506 1903 350 346 1895 497 485 1904 338 333 1896 478 470 1905 322 318 1897 460 460 1906 310 308 1893 442 429 1907 301 294 1899 419 411 1908 281 273 1900 405 393 The number of slaughter-houses in each of the London sanitary areas and the frequency with which these slaughter-houses, in some of the districts, were inspected are shown in the following table — Sanitary area. Number of slaughterhouses. No. of inspections, 1908. No. of notices, 1908. Licensed at end of 1907. Licence lapsed or refused in 1908. Remaining at end of 1908. Paddington 7 - 7 582 - Kensington 12 1 11 227 — Hammersmith 9 — 9 117 17 Fulham 4 - 4 50 1 Chelsea 6 — 6 126 — Westminster, City of 1 1 — St. Marylebone 8 — 8 62 2 Hampstead 5 — 5 130 — St. Pancras 19 1 18 606 1 Islington 37 3 34 2,008 — Stoke Newington 7 2 5 110 3 Hackney 25 1 24 393 3 Holborn 1 — 1 11 1 Finsbury 3 - 3 - — London, City of1 7 — 7 Shoreditch 8 1 7 39 1 Bethnal Green 6 1 5 30 — Stepney 10 3 7 33 — Poplar 18 2 16 108 4 Southwark 6 — 6 78 — Bermondsey 2 — 2 31 1 Lambeth 24 — 24 Battersea 5 — 5 8 — Wandsworth 20 1 19 365 3 Camberwell 15 1 14 132 — Deptford 4 1 3 49 1 Greenwich 5 1 4 53 4 Lewisham 16 1 15 126 — Woolwich 11 — 11 56 4 1 The seven slaughter-houses in the City of London are not licensed by the London County Council. 21322 I 62 One application for the establishment anew of the business of a slaughterer of cattle in St. Pancras was granted but the premises were subsequently demolished. During the year the following authorised offensive businesses were discontinued : The business of a bone boiler, tallow melter and manure manufacturer in Poplar, the business of a soap boiler in Deptford, the business of a fat melter in Wandsworth, and the business of a gut scraper and cat-gut maker in Southwark. The number of authorised offensive businesses other than that of slaughterer of cattle in London, except those in the markets under the jurisdiction of the City Corporation, was at the end of the year as follows:— Fat melters 21 Tripe boilers 22 Glue and size manufacturers 5 Knackers 5 Fellmongers 6 Bone boilers 4 Manure manufacturer; 2 Soap boilers 12 Tallow melters 9 Gut manufacturers 3 89 In several instances more than one offensive business is carried on at the same premises, hence the number of premises used for the purpose of these businesses is smaller than the number of such businesses. The districts in which these premises are situated, the number of premises, and, for some districts, the number of inspections, are shown in the following table:— Premises used for scheduled offensive businesses. Sanitary area. No. on Register at end of 1908. No. of Inspections, 1908. Sanitary area. No. on Register at end of 1908. No. of Inspections, 1908. Kensington 1 3 Poplar 8 54 Hammersmith 4 52 Southwark 6 92 St. Marylebone 2 30 Bermondsey 12 73 St. Pancras 2 Lambeth 4 Islington 7 103 Battersea 2 2 Hackney 2 16 Wandsworth 5 272 Finsbury 1 Camberwell 4 Shoreditch 1 7 Deptford 3 33 Bethnal Green 1 4 Greenwich 2 Stepney 8 7 Woolwich 1 In 1907 the Council made new by-laws for the following offensive businesses (1): bone boiler, manure manufacturer and tallow melter, (2) soap boiler, (3) tripe boiler, (4) gut scraper and cat-gut maker or cat-gut manufacturer, (5) fat melter or fat extractor, (6) glue and size manufacturer, (7) knacker, (8) fellmonger, (9) dresser of fish skins; and, with the exception of the by-laws as to tripe boilers, these by-laws were confirmed by the Local Government Board on November 25th, 1907. A material point in which these by-laws differ from those which they supersede is the extension of the principle of the use of a "closed chamber" to all offensive processes and improvement in the method of ventilation of these chambers. Nuisances. Smoke nuisance. Some of the annual reports contain a list of the premises which came under observation through the discharge of black smoke from their chimneys, and among them electricity generating stations and laundries are frequently mentioned. Subsequent to the institution of proceedings in 1907 against the Underground Electric Railways of London Company, Limited, by the Chelsea Borough Council, marked improvement was observed in the amount of smoke discharged, although these proceedings were unsuccessful so far as the decision of the Court was concerned. Dr. Parkes reports that this improvement may be attributed "(1) to the new revolving wire-mesh screen inserted, at a cost of £2,500, into the adit conveying water of the Thames to the condenser pumps, which separates out the leaves and débris which formerly so often occasioned choking of the pumps and a consequent loss of vacuum; (2) to the more thorough regulation of the draught to the furnaces through the fire doors, which has now been carried out on improved principles ; and (3) to the use of coal of suitable quality, owing to favourable prices to the consumers being now current for such qualities of coal." These results, Dr. Parkes states, appear to be for the present satisfactory. Reduction in the amount of nuisance arising from black smoke is especially commented on by the medical officer of health of Paddington, who shows that in successive years since 1904 the amount has yearly decreased in that district. During the year the sanitary authorities had under consideration proposals of the Public Control Committee of the Council for amendment of the law relating to smoke nuisance. The need for extension of the powers of the sanitary authorities to enable them to deal with other than " black smoke appears to be generally recognised. 63 The following table, which is compiled 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. Sanitary Area. Observations and inspections. Nuisances and complaints. Intimations. Notices. Summonses. Paddington 28 (premises) 12 Kensington Hammersmith 21 (premises) 8 19 — Fulham 5 2 Chelsea — — - Westminster, City of 2,362 35 116 12 - St. Marylebone 340 Hampstead 8 St. Pancras 701 9 Islington 618 1 Stoke Newington 1 Hackney 1,480 46 2 1 Holborn 142 12 1 Finsbury 76 19 8 10 — London, City of 542 15 — Shoreditch 20 — — Bethnal Green 650 25 22 7 - Stepney 119 119 2 Poplar 92 62 46 5 Southwark 362 108 16 4 — Bermondsey 201 (chimneys) 37 — Lambeth 21 41 Battersea 42 21 1 — Wandsworth 90 1 Camberwell 82 Deptford 92 16 16 — Greenwich 364 16 1 Lewisham 182 12 1 — Woolwich 75 8 8 1 Nuisance from stable manure. The removal of stable manure is now effected by the owners of the manure, the sanitary authorities prescribing the frequency with which this should be done. A sanitary inspector may serve a notice on the owner of a particular accumulation of manure, requiring him to remove it, and this notice must be complied with within forty-eight hours. Further, the sanitary authority may employ scavengers, or contract with scavengers, for collecting and removing the manure from stables and cowhouses within their district, the occupiers of which signify their consent in writing to such removal. The removal of manure three times a week, or not less frequently than every forty-eight hours, is generally required by sanitary authorities, and much has been done to bring manure receptacles into compliance with the by-laws of the County Council, but improvement of existing conditions must depend upon the willingness of the sanitary authorities to institute a system of scavenging of manure similar to that adopted in respect of house refuse. Removal of house refuse. The by-laws made by the County Council requiring house refuse to be removed from all premises not less frequently than once in every week has effected a vast improvement in the scavenging of London. Thus, instead of the householder having to hail the dust cart in its course through the streets, a call is now required to be made at every house within the time prescribed by the by-law. Several annual reports show that the number of complaints of householders that their dust has not been removed is now comparatively very small. Moreover, some authorities have availed themselves of the powers given by the Council's by-laws relating to daily removal to require such removal in parts of their districts. The desirableness of more frequent removal than once a week is by degrees being recognized by sanitary authorities, especially where [houses are built in flats, or where blocks of artizans dwellings have been erected. Another circumstance, to which the medical officers of health of Paddington and St. Marylebone refer in their annual reports, is contributing to the need for the institution of a system of daily removal, viz., the larger use of gas fires, in which animal and vegetable matter cannot be burnt as in the ordinary coal fire. Facilities for institution of such a system have been given by the by-laws of the County Council which have led to the substitution of movable dust receptacles for the fixed brick dustbins, and by section 23 of the Council's General Powers Act, 1904, which empowers sanitary authorities to require the demolition of old and disused brick dustbins. These powers have been largely utilized, the annual reports showing year by year the number of movable receptacles provided and of fixed receptacles demolished. An important step has now been taken by the sanitary authority of Westminster, who have decided to extend to the whole area under their jurisdiction the system of daily removal which has hitherto been adopted in certain localities only. It may be anticipated that this action of the Westminster City Council will be farreaching in its effects, for it will demonstrate to the rest of London the advantages and practicability of daily removal. Under the by-laws of the County Council, when the sanitary authority decide to collect house refuse daily, occupiers of premises are required to place on the kerbstone or other convenient position, at times to be specified, a movable receptacle in which the dust has been 21322 I2 64 deposited. Thus a large amount of labour is saved to the scavenger, who is otherwise often obliged to (fetch [the dust] from a more distant or less accessible position. From the point of view of the improvement of health conditions in London, this system provides a distinct advance, and it is much to be desired that it will receive the cordial co-operation and support of the inhabitants. Nuisance from, flies. During the summer of 1908 further inquiry was undertaken with regard to nuisance from flies, on lines similar to those followed in 1907. As in the previous year, arrangements were made for fly papers to be exposed in suitable places in the neighbourhood of collections of house refuse, horse stable manure, cow manure, etc., and the flies thus caught were carefully counted and sorted into species. It is deserving of note that one of the depots which caused so much nuisance in 1907 was not used after June of 1908, and in correspondence with this it was found (judging by the results obtained at fifteen places of observation surrounding this centre) that there had been at least six million fewer flies in 1908 than in 1907, in houses within a radius of 200 yards from the depot. In 1907, as in 1908, the large part played by collections of horse manure in determining fly prevalence was abundantly apparent, andthe need for regulating the sanitary condition of stables was thus again emphasized. The flies caught during the year were classified into species, and in Dr. Hamer's report appended (Appendix III.) curves of seasonal prevalence of the three common species of house flies are exhibited. As regards the causal relation of house flies to summer diarrhoea, no final opinion can as yet be expressed. Other nuisances. The annual reports make mention of various nuisances which came under observation during the year. Nuisances from rag and bone shops are referred to in the reports relating to Paddington and Lambeth. Nuisances at the time of removal of fish offal, or failure to comply with the by-laws of the County Council as to the conditions to be observed in the removal of offensive matter were the subject of proceedings in several districts. In the report of the medical officer of health of St. Marylebone the subject of dust nuisance during the demolition of buildings is discussed, and it is stated that in Paris this nuisance is dealt with by spraying the building with water. Risk from the discharge of petrol into sewers is also mentioned in this report, and it is stated that it was pointed out to the occupiers of garages that the oils retained in petroleum interceptors should be baled up for return to oil refiners. To separate the oil from water the mixture should be put into a barrel standing on end and provided with two taps, one near the bottom and the other about a quarter of the way up, so that after settlement the oil may be drawn from the upper tap and the water from the lower. Nuisance from the discharge into sewers of gas washings in the making of petroleum gas is discussed in the report of the medical officer of health of the City, who points out that the nuisance which is due to sulphuretted hydrogen can be obviated in great degree by the addition of permanganate of potash to the washings. Nuisance from destructors in Tinworth-street and Shot Tower wharf is referred to by the medical officer of health of Lambeth, from a coke conveyor of the Gas Light and Coke Company by the medical officer of health of Battersea, from grinding of mica and from grain drying by the medical officer of health of Camberwell, and from the cleansing of cement bags by the medical officer of health of Greenwich. Nuisance from sewer ventilators is referred to in the reports relating to Westminster, Poplar, Battersea, Wandsworth, Greenwich and Woolwich, and floodings from sewers are mentioned in the reports relating to Poplar and Greenwich. The discharge of storm water from the Council's sewer into Battersea Creek was the subject of proceedings during the year. Housing of the Working Classes Act, 1890. No new schemes under this Act were made by the Council during 1908. The following is a summary of the proceedings during the year in respect of schemes previously made :— Proceedings under Part I. of the Act. Union-buildings scheme (Holborn).—In July the Housing of the Working Classes Committee reported the completion of a further portion of Laney-buildings, comprising tenements 27 to 62, providing accommodation for 168 persons in 16 tenements of three rooms, 16 tenements of two rooms, and 4 tenements of one room, and in October the Committee reported the completion of the final portion of these buildings, comprising tenements 63 to 71, providing accommodation for 54 persons in 4 tenements of four rooms, 1 tenement of three rooms and 4 tenements of four rooms. Buckridge and Kirkbybuildings on the same area are also completed. These buildings provide accommodation for 530 persons in 30 tenements of four rooms, 35 of three rooms and 20 of two rooms. The Council has displaced 1,402 persons from this area and has provided accommodation for 1,424. Proceedings under Part II. of the Act. Brantome-place and Prospect-terrace scheme—In July the Council approved plans submitted by the St. Pancras Borough Council for the erection on the Prospect-terrace area of six-storey buildings for the accommodation of 352 persons, including the provision of twelve bathrooms and a drying room and towel store in the basement of one of the blocks. The plans also showed accommodation for the caretaker, offices, waiting rooms, etc. Proceedings under Part III. of the Act. White Hart-lane estate.—In April the Council accepted a tender of £22,161 for the erection of 87 cottages on the second part of the Tower-gardens section of this estate. Norbury estate.—In October the Council accepted a tender of £11,673 for the erection of 63 cottages on the second part of Section B of this estate. Totter down-fields estate.—In October the Housing of the Working Classes Committee reported the completion of 17 cottages and two shops, the cottages providing accommodation for 170 persons 65 In all, accommodation for 5,362 persons in 767 tenements, together with four shops has been provided on this estate, and during the same month the Council approved an estimate of £107,393 for the erection on the third and final part of Section C of this estate of 10 cottages of five rooms, 108 of four rooms, 102 of three rooms and a box room, and 193 of three rooms, each cottage containing a scullery, and the usual offices. Proceedings of District Councils under Part III. of the Act. Chelsea.—The Borough Council of Chelsea approved plans for and accepted a tender of £14,688 for the erection of artizans' dwellings on a site the gift of Lord Cadogan. In connection with the erection of these buildings the County Council sanctioned a loan. Death-rates among persons resident in the Council's dwellings, 1908. 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 1908. The population thus dealt with comprised 25,235 persons, and the death-rate at "all ages," after correction for age and sex distribution, was 12.2 per 1,000 living, compared with 13.8 for London:— Cause of death. Death-rate per 1,000 living. Council's dwellings. London. All Causes—All Ages"" 12.2 13.8 ,, „ age 0—5 27.0 39.2 „ „ „ 5-20 2.3 2.2 „ „ ,, 20 and upwards 13.4 14.7 Diarrhœa 0.5 0.5 Principal epidemic diseases (excluding Diarrhœa) 0.8 0.8 Phthisis 1.2 1.3 Tuberculous diseases other than Phthisis 0.7 0.2 Bronchitis 1.2 1.1 Pneumonia 0.7 1.4 Proceedings in respect of houses represented under Part 11. of the Act as unfit for human habitation. The following tabular statement shows the proceedings of the district authorities concerning houses represented as unfit for human habitation, and in respect of which the Council has received copies of representations from 1st January to the 31st December, 1908:— Sanitary area. Total number of houses con- cerning which the Council has received information that representations have been made from the 1/1/08 to the 31/12/08. Number of houses dealt with by owners, without Magisterial intervention. Number of houses for which closing orders were granted. Number of houses for which dosing orders were refused. Number of houses represented but subsequently dealt with under Public Health (London) Act, 1891. Still closed. Demolished. Improved. Total. Still closed. Demolished. Improved. Total. Battersea - - - — — - - - - - - Bermondsey - - - - - - - - - - - Bethnal Green 3 - - 3 3 - - - - - - Camberwell - - - - — - - - - — — Chelsea - - - - - - - - - - — Deptford - - - - - - - - - - - Finsbury - - - - - - - - - - - Fulham - - - - - - - - - - - Greenwich - - - - - - - - - - - Hackney - - - - - - - - - - - Hammersmith - - - - - - - - - - - Hampstead - - - - - - - - - - - Holborn - - - - - - - - - - - Islington - - - - - - - - - - - Kensington - - - - - - - - - - - Lambeth - - - - - - - - - - - Lewisham - - - - - - - - - - - Paddington - - - - - - - - - - - Poplar - - - - - - - - - - - St. Marylebone - - - - - - - - - - - St. Pancras 2 2 - - 2 - - - - - - Shoreditch - - - - - - - - - - - Southwark - - - - - - - - - - - Stepney - - - - - - — — — - - Stoke Newington - - - - - - - - - - - Wandsworth - - - - - - - - - - - Westminster, City of - - - - - - - - - - - Woolwich 18 - 1 4 5 5 — 1 6 - 7 Total 23 2 1 7 10 5 - 1 6 - 7 66 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 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 1894:— Year. 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 deaths.† No. of cases of infectious disease. £ s. d. 1895 626 29,574 - - 16 12 37 6 0 51 99 1896 596 29,140 28,331 — 31 30 112 16 0 65 71 1897 581 28,718 26,121 — 31 30 92 11 0 59 48 1898 560 28,332 27,658 — 29 29 167 3 0 87 44 1899 544 28,448 28,229 1,162 25 22 183 9 0 96 54 1900 528 28,311 28,428 668 16 13 102 15 0 91 40 1901 514 28,037 35,225 2,133 16 15 96 3 0 102 166 1902 491 28,970 40,512 1,449 22 21 98 4 0 120 684 1903 470 28,893 33,402 4,790 6 6 26 11 0 98 53 1904 451 28,896 27,501 2,970 15 14 62 6 0 74 66 1905 413 27,571 28,158 1,565 21 16 77 3 0 53 14 1906 402 28,063 30,028 2,349 4 4 11 1 0 65 22 1907 395 28,651 33,630 2,307 3 3 12 9 0 81 27 1908 387 28,379 32,297 2,429 1 1 2 2 0 60 13 The number of cases of notifiable infectious disease reported in common lodging-houses was as follows:—Erysipelas, 6; scarlet fever, 4; diphtheria, 2; enteric fever, 1—total 13. The following table shows the total number of common lodging-houses, and the authorised accomodation for the different classes of lodgers in the several sanitary areas of London, other than that of the City, on 31st December, 1908.— Sanitary district. No. of houses. Authorised accommodation. Men. Women. Couples. Total. Battersea 8 157 78 23 281 Bermondsey 5 1,073 — — 1,073 Bethnal Green 14 712 — — 712 Camberwell 6 536 — — 536 Chelsea 9 337 52 — 389 Deptford 8 1,159 80 — 1,239 Finsbury 8 543 — — 543 Fulham 1 43 — — 43 Greenwich 4 157 — — 157 Hackney 6 401 — — 401 Hammersmith 9 466 — 4 474 Hampstead — — — — — Holborn 28 1,701 162 — 1,363 Islington 43 1,228 215 18 1,479 Kensington 24 431 272 — 703 Lambeth 7 693 — — 693 Lewisham 1 30 — — 30 Paddington 7 195 40 — 235 Poplar 9 1,143 — — 1,143 St. Marylebone 17 1,306 109 — 1,415 St. Pancras 10 727 109 — 836 Shoreditch 12 774 — — 774 Southwark 44 3,231 430 — 3,661 Stepney 56 5,440 694 180 6,494 Stoke Newington 1 37 — — 37 Wandsworth 10 185 5 20 230 Westminster, City of 17 2,300 75 — 2,375 Woolwich 23 519 44 — 563 London—excluding the City of London 387 25,524 2,365 245 28,379 t The number of deaths stated in the above table includes only the deaths actually occurring in common lodging-houses and a few deaths occurring in public institutions among persons of the common lodging-house class, which are brought to the knowledge of the inspectors in certain cases in which death is followed by an inquest. 67 Deaths 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 867; 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 (1907) and licensed common lodging-houses (1907 and 1908). Cause of death. Age 25 to 35. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 65 and upwards. London 1907. C.L.H. 1907. C.L.H. 1908. London, 1907. C.L.H. 1907. C.L.H. 1908. London, 1907. C.L.H. 1907. C.L.H. 1908. London, 1907. C.L.H. 1907. C.L.H. 1908. London, 1907. C.L.H. 1907. C.L.H, 1908 Phthisis 390 571 500 325 559 463 219 374 307 108 259 314 26 110 148 Other tubercular diseases 25 — 69 15 17 — 14 13 20 4 12 6 l 14 4 Alcoholism (including cirrhosis of the liver) 26 24 22 37 17 20 42 26 32 35 54 38 11 5 24 Urinary diseases 31 48 22 51 42 47 65 65 63 87 36 49 85 71 36 Violence 102 48 22 79 — 37 66 26 38 39 18 17 29 24 20 Cancer 26 — 22 54 17 47 121 65 38 160 72 43 95 81 76 Circulatory eases 98 71 46 129 119 131 167 103 189 224 169 155 252 152 152 eases Nervous diseases 36 - 46 37 34 47 32 6 20 41 24 39 44 43 52 Bronchitis 16 — 22 28 8 37 50 103 78 90 121 155 148 195 192 Pneumonia 91 143 207 106 111 114 98 168 130 90 139 110 70 110 52 Other causes 159 95 22 139 76 57 126 51 85 122 96 74 239 195 244 Total (all causes) 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Homeless persons. Efforts were made in 1904, 1905, and 1907 to ascertain the number of persons in the Metropolis who, being without homes, passed the night in the street, or on the staircases of tenement houses of which the street doors are left unfastened. On the night of 15th January, 1909, a similar investigation was made. The result on the last occasion differed but slightly from the results of the three previous investigations, and the statement made in 1905 that homeless persons were in the proportion of about 1 in every 2,000 of the population was practically upheld. It should, however, be mentioned that of 2,088 homeless persons found in 1909, charitable institutions provided shelter and food, but no bed, for 1,329 men, for a few hours during the night. It is interesting to note that the vacant beds in common lodging-houses on the night of 15th January, 1909, would have accommodated three times the number of persons found to be without lodging. A satisfactory feature of the inquiry was the diminution in the number of homeless women found. Appended to this report is a more detailed account of the results of this inquiry. (See appendix IV.) Seamen's Lodging-Houses. Under the provisions of section 214 of the Merchant Shipping Act, 1894, the Council has made by-laws for the regulation of houses accommodating seamen. These by-laws came into force on the 1st October, 1901. 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. No. of houses on register. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of Penalties and costs. No. of cases of infectious disease. tions. £ 8. d. 1902 97 1,665 2,842 - - - - - 1903 102 1,748 1,956 4 2 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 In the year 1908 proceedings before the magistrate were instituted in three instances, resulting in three convictions, the penalties amounting to £17 and £7 costs. The number of cases of notifiable infectious disease reported in seamen's lodging houses was six, all being cases of scarlet fever. The patients were children belonging to the families of three keepers. 68 On the 31st December, 1908, the total number of seamen's lodging-houses under supervision was 85, situated in the following metropolitan boroughs:— Metropolitan borough. Houses. Lodgers. Poplar 18 388 Stepney 66 1,157 Woolwich 1 26 Total 85 1,571 Licensing of Seamen's Lodging-Rouses. The only licensed seamen's lodging house in the county is the New German Sailors' Home, situate in Rich-street, West India Dock-road. This house accommodates 64 seamen lodgers. The Council has no power to compel keepers to apply for a licence, although it has power to grant licences on application by the keepers of such houses. The Council has been in communication with the Board of Trade as]to the desirableness of an Order being issued rendering obligatory the annual licensing of seamen's lodging-houses, and it is expected that such an order will be made during the coming year. Houses let in Lodgings. The power vested in sanitary authorities by section 94 of the Public Health Act for the regulation of houses let in lodgings is one of the most valuable of the powers conferred by that Act for maintaining the habitations of poor persons in wholesome condition. Upon the efficiency with which the by-laws made under that section are enforced depends in large degree the freedom of these houses from conditions of dirt and overcrowding. Experience of this administration increasingly shows its value, and indeed, in all areas in which the poor reside, its absolute necessity. In the following table will be found a statement of the number of houses in the several districts made subject to by-laws under this provision and, for a number of districts, the extent of supervision exercised over these houses so far as this can be judged by the number of inspections. It will be seen that the extent to which these houses are regulated in the several districts varies greatly, more so indeed, than can be explained by the differences in the character of the population, and, further, that the frequency of their inspection also varies, no information of the number of such inspections being forthcoming in respect of, some districts. These facts undoubtedly invite inquiry as to the efficiency of this branch of administration in the several sanitary areas. In my last report the position of the several sanitary authorities was stated in respect of amendment of the by-laws for houses let in lodgings consequent upon decisions of the High Court in 1904 in the cases of Stiles v. Galinski, and Nokes and Nokes v. the Mayor, Aldermen, and Councillors of Islington. There has since been no change in that position. Registered houses let in lodgings. Table showing the number of houses on the registers at the end of 1908, and other particulars. Sanitary area. Number of houses. No. of Inspections, 1908. No. of Notices, 1908. No. of Prosecutions. 1908. On register at end of 1907. Added in 1908. Removed in 1908. On register at end of 1908. Paddington 1,320 47 24 1,343 7,941 * 59 - † 3,387 36 Kensington 2,028 28 — 2,056 9,246 * 82 — t 1,184 7 Hammersmith 3,244 570 462 3,352 161 Fnlham 114 — — 114 — — — Chelsea 597 — 8 589 192 * 5 — † 136 — Westminster, City of 1,572 — 24 1,548 3,007 * 31 — † 349 7 St. Marylebone 758 — — 758 1,224 739 — Hampstead 315 — — 315 243 11 — St. Pancras 2,316 9 54 2,271 2,592 * 91 — † 1,427 Islington No register under new by laws. — — — 10,782 * 61 — † 1.218 5 Stoke Newington 243 138 Hackney 463 — — 463 410 283 — Holborn 686 — 5 681 1,436 * 17 — † 229 14 Continued on next page. 69 Sanitary area. Number of houses. No. of Inspections 1908. No. of Notices, 1908. No. of Prosecutions, 1908. On register at end of 1907. Added in 1908. Removed in 1908. On register at end of 1908. Finsbury 1,233 - 9 1,224 1,520 1,177 London, City of 304 — 10 294 † 350 - Shoreditch 272 14 - 286 345 18 - Bethnal Green 509 20 12 517 2,693 728 - Stepney 2,784 57 36 2,805 3,497 * 318 1 † 2,676 13 Poplar 1,020 22 1,010 2,351 Night 206 * 82 7 † 332 Southwark 1,255 — 8 1,247 2 Bermondsey 224 — — 224 896 * 6 † 62 Lambeth 372 — — 372 603 129 9 Battersea 123 - - 123 Wandsworth 229 39 1 267 705 * 17 - † 417 1 Camberwell 217 - — 217 1,456 * 12 - † 254 4 Deptford 269 — 269 — — Greenwich 13 10 — 23 † 10 — Lewisham 15 — — 15 162 * 7 — † 34 Woolwich 330 38 9 359 720 250 2 * For overcrowding. † For other conditions. The following information on this subject is contained in the annual reports of the medical officers of health:— Paddington.—"With the present exemptions, comparatively few houses can be added to the register, although many of the houses now exempt ought, it is believed, to be registered." An enumeration of the inhabitants made at the time of the annual cleansing gave 15,168 persons in 8,192 rooms, comprised in 4,902 tenements. The cases of overcrowding in 1908 numbered 300, as compared with 344 in 1907 and 412 in 1906. In many of the 300 cases the amount of overcrowding was but slight. In November it was found that there were 3,382 unoccupied rooms in streets occupied mainly by the working classes. The death-rate of the population in the "registered streets" was, in 1908, 23.5 per 1,000 and of that in the rest of the borough 10'8 per 1,000. Fulham.—"In the report for 1906 the attention of the Council was called to the unsatisfactory nature of the exemption clauses of the by-laws in respect of houses let in lodgings or occupied by members of more than one family, and further experience has shown that these clauses must be amended if any use is to be made of the by-laws, as at present many houses escape registration, which can only be dealt with satisfactorily in the interests alike of owners and occupiers, in this manner." St. Marylebone.—There are approximately 1,000 houses let in lodgings in the borough which require very constant supervision. The principal conditions receiving attention are dirt, vermin, insufficient water supply and overcrowding. Hampstead.—"The number of tenement houses in Hampstead that might with advantage be dealt with under the by-laws relating to houses let in lodgings is over 800, but hitherto the sanitary inspectors have been so much occupied with other work that it has been found impossible to keep anything like so large a number of houses under proper supervision; now that an additional lady inspector has been appointed it will be possible to make a considerable increase in the number of houses placed upon the register." St. Pancras.—The question of the amendment of the by-laws was the subject of a local inquiry by the Local Government Board during the year, the County Council having taken exception to the proposals relating to the basis of exemption of houses. The Local Government Board expressed the opinion that the borough council would do well to repeal the by-laws in question and to take into consideration the question of substituting a series based on the Board's present model with an exemption clause depending on rental limits similar to that contained in the model. The Board thought it might be advisable to divide the borough into two or more areas with different rental limits in different areas. Dr. Sykes reports that in due course exemption clauses will be submitted for the consideration of his committee. Stoke Newington.—"In the borough of Stoke Newington, more especially in the southern division, there is a considerable number of houses let in lodgings under circumstances and conditions which render it desirable, in the interest of personal and public health, that they should be registered and inspected at frequent intervals. Hitherto it has not been possible to make such a frequent inspection of the registered houses let in lodgings, as is called for in the health interests of those who occupy them. 21322 K 70 Battersea.—"In the borough of Battersea there is a number of houses let in lodgings under circumstances and conditions which render it desirable in the interests of public health that they should be registered and inspected at regular intervals. By the end of 1907,123 premises were on the register, and no additional houses were placed on the register during the year." Wandsworth.—"No difficulties have arisen during the year in carrying out these by-laws," and Dr. Caldwell Smith writes, "I am again able to report that all these premises have been kept in much better con dition since being placed on the register." Greenwich.—Dr. Annis writes, "Out of a number of such premises which has been reported to the Committee, it has been decided during 1908 to register 10, which together with 13 on the register at the end of 1907, gives a total of 23 premises on the register of houses let in lodgings at the end of the year. More recently, however, as a result of more pressing enquiries by the London County Council as to what this Council was doing in the matter, the Public Health Committee have directed that more houses of this class shall be placed on the register so that they may be inspected more regularly." Woolwich.—The female sanitary inspector reports, "Satisfactory results have been obtained from the continued supervision of the registered houses. Great improvement has been noticed in the state of the bedding, etc., in some of the houses. There has been less tendency to overcrowd the rooms, and efforts are made to separate the older children of different sexes." Water supply to tenement houses. In 1907 the Council obtained the sanction of Parliament to a provision which was included in the London County Council (General Powers) Act of that year and which empowers sanitary authorities to require a supply of water to the upper storeys of tenement houses. This provision came into force on the 1st January, 1908. The annual reports of medical officers of health show that considerable use of this provision has been already made in some districts Thus, information as to number of premises supplied with water as the result of the action of the sanitary authority under this provision and the number of cases in which it was found necessary to institute legal proceedings isgiven in respect of thefollowing boroughs :— No. of premises supplied. No. of legal proceedings. Paddington 421 — Westminster 281 6 St. Marylebone 21 1 Hampstead 24 — Islington 562 — Holborn 4031 — Finsbury 107 — Bethnal-green 36 — Southwark 286 8 Woolwich 25 — The medical officer of health of Stoke Newington reports that special attention has been given to all tenement houses in order to see that a water supply is provided on each floor in accordance with the provision of the Act. The medical officer of health of St. Pancras reports that the borough council resolved on the 29th July, 1908, that no action be taken in the matter. This decision of the St. Pancras Borough Council is in marked contrast to thatof the Borough Council of the neighbouring district of Islington, where it will be seen supplies were laid on to the upper floors of 562 tenement houses during the year. Mrs. Young, sanitary inspector of Islington, has noted the improvement effected in the cleanliness of home-workers' premises as the result of the exercise of these powers. (See page 76). Miss Middlebrook, sanitary inspector of Woolwich, thus writes of the administration of this power in connection with houses let in lodgings: "A water-supply on the upper floors, where occupied by a separate family, has been provided, as required by the London County Council (General Powers) Act. This encourages the lodgers to keep their rooms cleaner than they would if the water had to be carried some distance, instead of being close at hand. A strict supervision is maintained over negligent and dirty lodgers to prevent abuse where a separate water supply and sink are provided, to prevent the sink from becoming foul and nuisance arising." The Act makes no requirement that a sink should be provided in connection with the watersupply. This point was considered at the time the clause was drafted, and the fear was entertained that such a requirement might possibly lead to the use of the sink for the disposal of slop water and thus give rise to nuisance. The medical officer of health of Hampstead, however, states in his report that he has found the provision of a sink important and the borough council has been able to insist on such provision inasmuch as in those cases in which the owners refused to provide a sink the house appeared to be without a "sufficient drain "as required by Section 73 of the Metropolis Management Act, 1855. Experience will soon show whether it is desirable that the provision relating to requirement of water supply should be extended so as to include the provision of a sink in connection with the supply. Houses infested with Vermin. The powers contained in section 20 of the London County Council (General Powers) Act, 1904, are being increasingly used by sanitary authorities for the cleansing of premises infested with vermin. The annual reports supply the following information as to proceedings under this section in 1908 1 Number of notices served. In the case of Holborn it is stated that in the majority of instances the work was completed during the year. 71 Houses infested with vermin. Number of premises cleansed. Paddington 137 premises. Shoreditch 127 premises. Kensington 270 „ Bethnal Green 295 rooms. Hammersmith Stepney 929 „ Fulham 77 rooms. Poplar 213 „ Chelsea 236 „ Southwark 1,473 „ Westminster, City of 132 premises. Bermondsey St. Marylebone 53 „ Lambeth 51 persons and houses. Hampstead 9 rooms. Battersea 3 premises. St. Pancras 217 Wandsworth 84 Islington 115 premises. Camberwell 13 Stoke Newington Deptford 7 Hackney 121 „ Greenwich 5 Holborn 22 „ Lewisham 6 Finsbury 4 premises. Woolwich 183 rooms. London, City of In connection with the cleansing of the premises, numerous articles were cleansed under the powers given by section 19 of the Act. Revenue Act, 1903. Under section 11 of the Revenue Act, 1903, on the certificate of the medical officer of health that the house is so constructed as to afford suitable accommodation for each of the families or persons inhabiting it, with due provision for their sanitary requirements, there is exemption from or reduction of inhabited house duty, as follows:— (1) Where a house, so far as it is used as a dwelling house, is used for the sole purpose of providing separate dwellings— (a) The value of any dwelling in the house which is of an annual value below twenty pounds shall be excluded from the annual value of the house for the purposes of inhabited house duty; and (b) The rate of inhabited house duty, in respect of any dwelling in the house of an annual value of twenty pounds, but not exceeding forty pounds, shall be reduced to threepence; and (c) The rate of inhabited house duty, in respect of any dwelling in the house of an annual value exceeding forty pounds, but not exceeding sixty pounds, shall be reduced to sixpence. For the purposes of these provisions medical officers of health were called upon to certify numerous houses during the year, and in some instances the application was granted, in others it was refused, while in others, again, it was only granted after alterations had been made to meet the conditions necessary, before certification. The Act appears to be instrumental in ensuring a higher standard of dwelling accommodation than before The number of applications received and certificates granted during 1908 is shown in the following table:— Sanitary area. No. of houses for which applications for certificates were received during 1908. No. of tenements comprised therein. No. of tenements for which certificates were Granted. Refused. Deferred or withdrawn. Paddington 16 50 42 — 8 Kensington 9 143 110 — 33 Hammersmith 70 223 131 43 49 Fulham 298 627 199 224 204 Chelsea 11 48 14 34 — Westminster, City of 5 40 40 — — St. Marylebone 16 102 69 33 — Hampstead 11 57 4 7 46 St. Pancras 8 56 26 — 30 Islington 10 90 41 49 — Stoke Newington — — — — — Hackney 5 37 37 — — Holborn 14 229 229 — — Finsbury 3 60 56 4 — London, City of — - - — — Shoreditch — - - — — Bethnal Green 12 59 16 43 — Stepney 15 116 78 38 — Poplar Southwark 84* Bermondsey - - — — — Lambeth 115 363 113 250 — Battersea 40 129 - — 129† Wandsworth 92 203 156 22 25 Camberwell 25 105 15* 10* — Deptford 4 8 8 — — Greenwich - - - — — Lewisham 44 90 82 8 — Woolwich 1 — 1* — — 21322 Houses. † Includes applications refused. k 2 72 Among the reasons given for refusing or deferring the granting of certificates were non-compliance with requirements to provide anti-syphonage pipes to the water-closets or to amend sink-water pipes (St. Marylebone), absence of proper and sufficient water-supply and adequate washing accommodation (Poplar), premises unsuitable or insanitary (Bethnal-green), drain pipes not watertight or gas stoves not ventilated into the open air (Hampstead). Underground Rooms. The illegal occupation of underground rooms continues to occupy the attention of sanitary authorities of numerous districts in London. The medical officer of health of St. Marylebone reports that as a result of special inquiry and of a number of inspections by himself, he is of opinion that the large majority of the underground rooms in that borough are illegally occupied. He learns from medical practitioners of long experience in the locality that "rheumatism is exceedingly common amongst the children inhabiting underground rooms, and rickets only slightly less prevalent." "The consequences of rheumatism " Dr. Meredith Young writes," are manifested in heart-trouble before very long and this incapacitates sufferers from most forms of heavy physical work, which is usually the only kind of employment open to persons of this class." It has not been found practicable to deal with more of these rooms than those which are considerably below the standard required by the Public Health Act. A case of some importance came before the Courts during the year, of which the following account is given by Dr. McCleary, medical officer of health of Hampstead. "On 27th May, 1908, an important point in the law relating to underground rooms was decided in the Divisional Court on a case stated by the Hampstead Justices. The facts in this case were as follows:—The owner of a block of residential flats in the Town Ward was prosecuted by the Borough Council for allowing the caretaker to occupy three underground rooms that did not comply with the requirements of the Public Health (London) Act, 1891, the rooms being deficient in height, light, and ventilation, and in the provision of a proper area outside. Before the Justices, counsel for the defendant admitted that the rooms did not comply with the Act, but he took the technical point that the sanitary authority had known of the occupation for a period of more than six months, and therefore that by Jarvis's Act they were debarred from taking proceedings. The Justices upheld this view and dismissed the summons, but agreed to state a case. In the Divisional Court Mr. S. G. Turner appeared for the Council and Mr. W. Stewart for the respondent. The Lord Chief Justice, in his judgment, said that the real point in the case was this: Had the rooms been occupied at any time during the six months immediately preceding the issue of the summons? If so, an offence had been committed for which proceedings could be taken. In this case it was admitted that the rooms had been so occupied. The appeal, therefore, must be allowed with costs, and the case sent back to the Justices, Mr. Justice Darling added that Jarvis's Act limited the time during which proceedings could be taken to six months from the time when the matter arose. In this case the matter was continually arising. The six months' period was a moving period, and as each night passed a fresh offence arose on the front of the period, and one went off at the end." The number of underground rooms dealt with in 1908 in the several sanitary areas is shown in the following table:— Sanitary area. No. of rooms illegally occupied. No. of rooms closed. Sanitary area. No. of rooms illegally occupied. No. of rooms closed. Paddington 1 1 Shoreditch 5 5* Kensington 22 22 Bethnal Green — Hammersmith — — Stepney 78 27 Fulham 8 8 Poplar — — Chelsea 3 3 Southwark 1 1 Westminster, City of 40 Bermondsey — — St. Marylebone 127 127* Lambeth 21 21 Hampstead 54 3 Battersea 6 6 St. Pancras 87 Wandsworth — — Islington 47 47 Camberwell — — Stoke Newington 1 1* Deptford — — Hackney 3 1 Greenwich 8 8 Holborn 16 16 Lewisham — — Finsbury 11 11 Woolwich 1 1* London, City of - - Overcrowding. The annual reports show that the number of instances in which overcrowding was found was greater in 1908 than in 1907. The following table is compiled from information supplied by the medical officers of health in their annual reports. * Improved or dealt with. 73 Sanitary area. No. of dwellingrooms overcrowded. No. remedied. No. of prosecutions. Paddington 339 168† - Kensington 46 46 — Hammersmith — Fulham 60 60 - Chelsea 24 24 2 Westminster, City of 31 31 St. Marylebone 154 154 — Hampstead 9 9 — St. Pancras 181 181 Islington 131 131 - Stoke Newington 5 5 — Hackney 128 124 — Holborn 46 46 — Finsbury 125 125 — London, City of 17 17 Shoreditch 117 117 — Bethnal Green 163 154 Stepney 585 585 1 Poplar 156 156 — Southwark 426 426 Bermondsey 57 57 — Lambeth 31 31 — Battersea 88* 88 - Wandsworth 158 158 Camberwell 91 91 1 Deptford 25 25 - Greenwich 24 24 - Lewisham 39 39 - Woolwich 72 72 - * In Battersea 18 vans were also found to be overcrowded during the year. Summonses were taken out against the owners and convictions obtained. † In 171 cases no action was taken owing to the deficiency in air space being very slight. Factory and Workshop Act, 1901. The Factory and Workshop Act, 1901, requires every medical officer of health to report specifically on the administration in his district of those provisions of the Act the administration of which is imposed upon sanitary authorities, and a form of table has been prepared for the exhibition of those particulars which lend themselves to statistical statement. From this table and from other information contained in the annual reports of medical officers of health, the following summary table has been prepared:— 74 TABLE SHOWING PROCEEDINGS OF LONDON SANITARY Premises, Particulars, Class, &c. Paddington. Kensington. Hammersmith. Fulham. Chelsea. City of Westminster. St. Marylebone. Hampstead. St. Pancras. Islington. Stoke Newington. 1. Inspections. Factories (including factory laundries) 165 185 408 105 1 74 2 168 183 434 32 Workshops (including workshop laundries) 1,338 3,173 1,395 785 361 2,543 374 1,208 1,160 2,008 258 Workplaces (other than outworkers' premises) 50 311 678 350 72 2,252 378 698 209 1,620 9 Total (Inspections) 1,553 3,669 2,481 1,240 434 4,S69 754 2,074 1,552 4,062 299 2. Defects Found. Nuisances under the Public Health Acts. Want of cleanliness 33 213 83 93 10 834 34 32 83 719 61 Want of ventilation 7 31 2 4 — 189 — 3 - 12 — Overcrowding 7 12 — 3 — 58 5 8 — 8 — Want of drainage of floors — 5 4 5 — 66 — — — 72 5 Other nuisances 6 129 125 14 9 704 6 76 5 558 26 Sanitary accommodation Insufficient 2 32 5 7 2 22 — 4 11 12 1 Unsuitable 11 96 38 24 - 565 4 16 8 551 28 Not separate for sexes 1 6 2 2 — 140 5 4 3 10 - Offences under the Factory & Workshop Act. Illegal occupation of underground bakehouse (s. 101) - - - - - - - 1 - - - Breach of special sanitary requirements for bakehouses (ss. 97-100) — — 85 8 6 — 4 - 40 — — Other offences (excluding offences relating to outwork) — 2 - - - - - - 1 — — 67 526 344 160 27 2,578 58 144 151 1,942 111 Total (defects found) 3. Homework. Outworkers' Lists (s. 107). Received twice in the year from employers Number of Lists 122 120 42 26 64 649 150 142 38 698 26 Number of outworkers corresponding thereto 529 968 98 93 739 8,091 1,898 466 228 4,978 269 Received once in the year from employers Number of Lists 27 27 16 3 9 19 - 7 5 339 9 1 Number of outworkers corrosponding thereto 51 80 45 3 26 141 - 17 18 2,436 35 Number of addresses of outworkers received from other Councils 350 302 333 331 114 505 1,299 63 954 2,715 629 Number of addresses of outworkers forwarded to other Councils 316 832 86 45 580 3,321 1,347 412 137 1,431 151 Prosecutions Failing to keep lists - - - - - - - - - - - or permit inspection thereof Failing to send lists - - - - - - - - - - - Outworkers' Premises. Number of inspections of outworkers' premises 299 383 116 195 90 1,062 164 111 324 869 77 Outwork in unwholesome premises (s. 108) Instances - 13 9 3 3 371 - - 1 141 - Notices served - 13 9 3 3 456 - 1 79 - Prosecutions - - - - - - - - - - - Instances 24 17 - - - 249 - - 2 38 6 Outwork in infected premises (ss. 109, 110) Orders made (s. 110) - - - - - - - - - - - Prosecutions (ss. 109. 110) - - - - - - - - - - - 4. Registered Workshops. Workshops en the Register at the end of 1908. Bakehouses 64 95 55 69 38 84 78 35 179 244 27 Laundries 846 197 305 58 14 49 2,984 8 74 132 20 Other workshops 1,285 535 362 538 2,691 474 1,413 1,354 161 Total (number of workshops on the Register) 910 1,577 895 489 590 2,824 3,062 517 1,666 1,730 208 5. Other Matters. Matters notified to H.M. Inspector of Factories. Failure to affix abstract of the Factory and Workshop Act (s. 133) 5 85 - - 17 221 - 44 6 159 - Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts but not under the Factory and Workshop Act (s.6). Notified by H.M. Inspector 11 15 11 6 14 126 44 — 14 1 7 Reports (of action taken) sent to H.M. Inspector 8 12 11 6 12 126 18 - 14 1 - Other - 6 6 — 1 24 — — — — — Underground Bakehouses (s. 101) Certificates granted during 1908 - — — — — — — — — — — In use at the end of 1908 57 75 33 50 26 71 70 22 160 99 19 75 AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT, 1901. Hackney. Holborn. Finsbury. City of London. Shoreditch. Bethnal Green. Stepney. Poplar. Southwark. Bermondsey. Lambeth. Battersea. Wandsworth. Camberwell. Deptford; Greenwich. Lewisham. Woo with. 62 126 1,138 3,325 223 200 44 142 109 38 13 660 614 478 113 70 139 30 2,49 968 1,897 4,668 4,064 4,703 4,336 1,098 1,208 82 805 1,616 3,130 3,456 513 387 1,170 246 2,350 485 1,077 767 1,017 65 1,835 4,113 143 1,288 1,676 1,017 296 134 361 85 2,553 3,444 3,520 9,070 5,054 5,920 4,445 3,075 5,430 263 818 3,564 5,420 4,951 922 591 1,670 361 166 90 160 787 296 355 568 528 970 55 136 171 175 28 227 103 90 40 10 7 27 207 2 24 59 3 14 - 6 4 3 2 — 4 2 17 14 2 6 23 — — 32 2 18 - 13 2 9 — 2 — 7 6 8 — 3 — — — 1 — 47 13 — 3 1 4 — 13 2 - 95 64 552 1,652 73 264 188 377 1,064 79 634 209 281 103 78 30 62 33 4 4 34 30 6 8 33 3 22 9 — 3 7 4 — 11 2 14 90 71 243 2,520 51 210 23 2 4 28 303 76 114 51 64 15 35 3 12 21 101 14 6 26 1 — — 4 2 3 2 — 1 2 5 - - 2 - - - - - - - - - - - - - - - — 14 — — — — 30 — — 23 — 20 16 — — 8 29 — - - 76 - - - - - - 4 - - - - - - - - 390 264 1,124 5,320 442 867 960 916† 2,139† 211 1,096 490 609 194 371 185 231 95† 360 116 278 1,412 78 190 86 136 154 82 64 82 148 162 86 22 72 27 3,792 735 5,688 16,522 1,337 3,194 2,290 2,169 1,263 849 504 402 514 1,799 585 153 196 512 52 7 28 94 16 8 95 11 22 11 15 5 15 3 4 3 17 12 289 26 177 768 193 92 743 139 124 89 66 11 24 13 22 14 29 28 3,160 290 1,000 243 2,810 3,055 7,424 1,579 1,135 929 918 401 352 1,599 474 232 130 68 1,991 466 5,280 16,909 1,200 1,684 1,259 1,376 787 384 351 196 201 579 343 91 62 70 - - - - - - - - - - - - - - - - - - - - - - - - - 2 - 2 - - - - - - - - 768 188 104 214 2,577 5,900 5,455 2,638 1,100 1,483 575 729 381 1,194 383 245 276 220 - - - - 219 - 363 - - - - 44 40 24 - 14 - 11 — — — — 219 — 361 — — — — 49 31 — — 14 — 11 - - - - - - - - - - - - - - - - - - — — 1 — 17 — 176 40 13 - 6 7 22 — 6 — — — - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 111 29 62 28 69 87 180 66 108* 97 214* 83 160 174* 75 64 98 58* 93 11 27 2 30* 1,831 31 21 76* 40 232* 40 149 80* 11 21 76 19* 865* 988 2,032* 3,152 1,153* 2,599 363 2,677* 642 1,298* 387 683 903* 172 157 429 152* 1,069* 1,028 2,121* 3,182 1,252 1,918 2,810 450 2,861* 779 1,744* 510 992 1,157* 258 242 603 229* 39 19 55 57 - 46 40 29 5 1 37 44 46 17 5 4 23 3 30 12 28 19 33 42 93 4 6 2 8 1 5 4 — 1 8 2 14 15 28 19 9 42 73 4 6 2 8 — 5 1 — 1 6 — - 1 38 4 - - 20 5 17 - - - - - 44 - - - - - - - - - - - - - - - - - - - - - 50 24 38 23 43 27 58 29 41 32 72 31 48 66 28 17 22 23 * Includes workplaces. † Include* defects in outworkers' premises. 76 Comparison between some of the statistics for the years 1904-8 may conveniently be made thus:— 1904. 1905. 1906. 1907. 1908. Number of workshops on register 34,488 35,187 36,632 37,891 37,673 Number of inspections 84,600 86,071 79,526 81,171 84,058 Total number of defects found 18,922 19,023 19,407 22,071 22,012 Want of cleanliness 5,752 6,522 7,206 8,319 7,130 Want of ventilation 799 828 736 652 639 Overcrowding 413 347 461 295 237 Sanitary conveniences Insufficient 403 284 296 256 278 Unsuitable or defective 3,645 3,411 3,717 4,229 5,255 Not separate for sexes 308 239 251 388 376 The number of workshops on the register continues to increase year by year and there is very little variation in the number of instances in which it was found as the result of inspection that some condition required remedy. The need of the maintenance of sanitary supervision is therefore manifest. Reference to the number of inspections of workshop premises in the several sanitary districts shows that this number varies greatly. While in many districts the number of inspections has been equal to three times and in some four times the number of workshops, this number has in some districts fallen far short of the number of workshops and this has been notably the case in Chelsea, St. Marylebone, Bermondsey, and Lambeth. With respect to Bermondsey, the question of the sufficiency of the sanitary staff has been'under the consideration of the Local Government Board at the instance of the London County Council during the year. (See page 95.) Difficulty is still experienced in inducing employers to send in lists of outworkers during the year. Dr. Allan states that there are still many employers in Westminster who appear never to have heard that lists have to be sent in. It is a common experience in London that people are very prone to remain ignorant of laws, even those which especially affect the occupations in which they are engaged, a fact which militates against the rapid development of the administration of any new sanitary legislation in London. The lists, moreover, which are received apparently do not show the total number of persons who are employed as outworkers, for Miss Brown, Sanitary Inspector of Islington, states that some employers have commented on the fact that in February and August when the lists must be forwarded, they are not as a rule very busy, and that if lists are forwarded then, they do not represent the full complement of workers, as employees may be engaged later in the busy season. More complete knowledge of outworkers' premises will be gained when the recommendations of the Select Committee on Home Work are embodied in law. These recommendations are, inter alia,— "(a) That all Home Workers who are employed by other persons in producing or preparing articles for sale should be required to register their name, address, and class of work at, and receive a certificate of such registration from, the offices of the Local Authority, and that the keeping of accurate outworkers' lists by employers should be strictly enforced. "(b) That it should be an offence for any person to employ any Home Worker to produce or prepare any articles for sale by another person unless the worker produce a certificate of registration. "(c) That the provisions of Section 9 of the Public Health Act, 1875, with regard to factories and workshops which are not kept clean, or are ill-ventilated or overcrowded, should be extended to rooms in which Home Work is done, and power should be given to Sanitary and Factory Inspectors to inspect them and secure the enforcement of the law." The effect of inspection of homeworkers' premises is stated to lead to improved conditions and the provision relating to the supply of water to the upper floor of tenement houses contained in the Council's General Powers Act of 1907 is contributing to this result. Thus, Mrs. Young, Sanitary Inspector of Islington,writes:— "This section of the Act has proved useful in helping to better the conditions under which homework is carried on. The time and labour necessary to carry water from the basement to the top of a three-storey house is a matter of considerable importance and material cost to the homeworkers, with the result that in such cases, the use of water for all purposes has been reduced to a minimum. But where the domestic water supply has been carried upstairs in conformity with the Act, a marked improvement in the general cleanliness of the premises has followed." Inspection of outworkers' premises is necessarily leading to an improvement of the condition of dwellings generally. Thus Dr. King Warry reports that Miss Portlock, Sanitary Inspector of Hackney, found on inspecting 768 home-workers' premises that in 77 instances the workroom was a bedroom and kitchen, in 436 a kitchen, in 98 a bedroom, in 81 a living room, in 12 a scullery and in one instance a bathroom. In 63 instances only was the room solely used as a work room. Inspection of outworkers' premises is in practice not necessarily limited to the rooms occupied by them. The use as workshops of underground rooms is commented on in the report relating to Chelsea. Dr. Parkes urges that the use of underground rooms as workshops should be prohibited unless they comply with regulations to be made by the Secretary of State ; and he points out that if such regulations were in force architects, in designing new buildings for use as shops on the ground floor and residential flats on the upper floors, would cause the underground workroom to comply with the regulations, so that the shops and basements might be let at the full rental value. He indicates the regulations which he deems to be necessary and which would provide especially for the lighting and ventilation of the workrooms. Time might, he thinks, be given to the owners of existing underground workshops to bring them into compliance with the regulations. 77 Places where food is prepared for sale. The annual reports give information as to the administration of the powers conferred on sanitary authorities by the Council's General Powers Act of 1902 for controlling the conditions under which ice cream is prepared for sale. In one or two of the reports it is stated that as the result of administration of the provis?ons of this Act there has been considerable improvement in the conditions under which ice creams are manufactured. This trade is largely carried on by foreigners. In the City of London of 103 small confectioners making ice cream as many as 101 were foreigners. In the following table the numbers of these premises in the several sanitary areas, and other particulars, are shown. Ice cream premises. Sanitary area. Number of places. No. of inspections 1908. No. of notices, 1908. No. of prosecutions, 1908. On registor at end of 1907. Added in 1908. Removed in 1908. On register at end of 1908. Paddington 140 - 4 136 50 1 - Kensington 165 — — 165 265 43 — Hammersmith 200 30 3 227 476 37 1 Fulham 157 10 16 151 175 15 - Chelsea 39 - 1 38 19 1 - Westminster, City of 155 317 St. Marylebone 84 10 14 80 90 14 — Hampstead 78 6 8 76 133 3 — St. Pancras — — — 191 — — — Islington 230 — — 230 348 29 — Stoke Newington 36 38 Hackney 145 128 88 8 — Holborn 41 1 40 187 — — Finsbury 90 75 — London, City of 207 246 9 Shoreditch 84 12 6 90 200 17 — Bethnal Green 71 17 10 78 180 35 — Stepney 114 22 13 123 256 31 — Poplar 130 140 263 5 — Southwark 118 312 54 — Bermondsey 70 29 — 99 229 24 — Lambeth — — — — — — — Battersea 110 16 18 108 220 36 — Wandsworth 235 47 31 251 345 23 — Camberwell 238 13 35 216 494 17 — Deptford 121 26 19 128 207 7 — Greenwich 118 9 12 115 134 22 — Lewisham — — — — — — Woolwich 76 35 3 108 187 12 - The inspection of other premises where food is prepared for sale was continued during the year and this inspection is now part of the systematic work undertaken by the sanitary authorities. Such places are "workplaces" within the meaning of the Factory and Workshop Act, but except in the matter of sanitary conveniences, there were no powers applicable to these premises other than the general provisions of the Public Health (London) Act. With a view to the better control of the conditions under which food is prepared for sale, the Council obtained in 1908 the sanction of Parliament to provisions relating to this subject (See page 94). The annual reports show that there has been considerable inspection of such premises in some districts in London, restaurants, cook-shops, fried fish shops, butchers' shops, fish shops, greengrocers' and fruiterers' shops, tripe and sausage shops, etc., coming under supervision. Dr. Allan reports the conviction under the provisions of the Council's General Powers Act of a man in Westminster making sausages in the basement of a shop in which a quantity of unsound food was found; the floor and walls were dirty. and fluid was droDropping through the ceiling from a water-closet apartment above. The following table has been compiled from statements made in the annual reports, but in the absence of uniformity of statement, the figures relating to the various districts cannot be regarded as comparable and it is probable that the figures given, for some of the districts, inadequately represent the total number of premises used for the preparation and sale of food. 213122 L 78 Sanitary area. Premises used for the preparation and tale of food. Inspections. Sanitary area. Premises used for the preparation and sale of food. Inspections. Paddington 415 957 Shoreditch 243 Kensington 80 Bethnal Green 225 1,017 Hammersmith 135 Stepney 307 575 Fulham 93 250 Poplar 293 1,195 Chelsea 63 72 Southwark 326 1,121 Westminster, City of 1,033 4,700 Bermondsey 337 143 St. Marylebone 240 220 Lambeth 373 Hampstead 363 1,025 Battersea 251 1,288 St. Pancras 395 1,072 Wandsworth 485 586 Islington 685 800 Camberwell 198 447 Stoke Newington 25 Deptford 106 282 Hackney 25 118 Greenwich 124 167 Holborn 347 1,919 Lewisham 54 80 Finsbury 394 394 Woolwich 188 London, City of 839 1,000 Inspection of Food. The City Corporation has provided, in their Islington Market, new slaughter-houses for the use of butchers, and Dr. Collingridge recommends that opportunity should be given for the marking of meat which has been therein inspected. It is much to be desired that this opportunity should be given and that butchers will avail themselves of it. At the present time the purchaser of meat in London has no means of knowing whether it has been subjected to inspection. The amount of diseased and unwholesome meat seized or surrendered in the City markets was 1,283 tons 16 cwt.; of fish, 1,236 tons 12 cwt. in Billingsgate Market, and 7 tons 1 cwt. in the Central Markets; of different articles of food removed from the City wharves, 171 tons. In Finsbury, in which district are situated the so-called "extra-Corporation markets," 101 tons 14 cwt. of various articles of food, mostly meat, were seized or surrendered. In Islington the amount of food seized or surrendered was 5 tons 17 cwt., of which 2 tons comprised tinned foods. A considerable amount of food stuffs was seized or surrendered in Stepney. In this borough is situated the Spitalfields Market, where it was the practice of salesmen to offer fruit and vegetables for sale "subject to being sorted." The borough council called the attention of the salesmen to the provisions of the Public Health Act relating to unsound food, and invited them to assist the borough council by seeing that no unsound fruit or vegetables are disposed of for the purpose of human consumption. This action of the borough council, Dr. Thomas reports, had a good effect, a larger quantity of unsound fruit being surrendered than before. The methods of disposal of unsound food in this borough were revised during the year, canned meats being taken to Duke Shore Wharf and cut open and the contents thrown into a barge containing road sweepings and then taken to Sittingbourne and sold for manure. Canned foods of a liquid nature were spiked so that the contents of the tins ran out and condemned carcases of meat were burnt. There was improvement during the year of the inspection of meat killed in private slaughter-houses, and Dr. Thomas states that of 55 cows slaughtered in one slaughter-house, 37 were affected with localized tuberculosis and in two the udders were diseased. In Paddington, 4,505 lbs. of meat, fish, vegetables, etc., were condemned, and in addition 4,480 lbs. of vegetables and fruit were destroyed at the request of the Great Western Railway Company. In Southwark 53 tons of food stuffs were destroyed and 15 tons of damaged flour originally intended for human consumption were permitted to be used only for the manufacture of food for cattle. In Bethnal Green 2 tons 12 cwt. of food stuffs were seized or surrendered. In Bermondsey 127 tons of food stuffs were surrendered and various articles seized. In Westminster nearly 30 tons of food stuffs were surrendered and various articles seized, including 35 gallons of milk. In Shoreditch various articles of food were surrendered or seized, among those surrendered being 25,500 tongues in putrefactive condition, received from South America. The tongues were preserved in fluid containing boric acid which prevented the putrefactive odour being recognized until they had been cooked. The weight of articles of food seized or surrendered was 3 tons 16 cwt. in Hackney, and 1 ton 9 cwt. in Stoke Newington, and seizures and surrenders of quantities of food, the total weight of which is not shown, occurred in Battersea, Poplar, Lambeth, Greenwich, Fulham, Deptford, St. Pancras, Woolwich, Holborn, Wandsworth, St. Marylebone, Hampstead, Lewisham and Chelsea. The number of convictions in the several districts was, in the City, 4; Finsbury, 5; Islington, 11; Stepney, 3; Paddington, 4; Southwark, 2; Poplar, 2; Westminster, 4; Shoreditch, 2; Battersea, 4; Bethnal Green, 10; St. Pancras, 1; Holborn, 1; Wandsworth, 2; St. Marylebone, 3; Stoke Newington, 1. Regulations under the Public Health (Regulations as to Food) Act, 1907, made by the Local Government Board were issued during the year. The Regulations related to (a) unsound food and (b) foreign meat. The first series empowers a medical officer of health or other person appointed for the purpose to examine articles of food which have been landed in his district, and provides for the taking of samples of food and for the temporary detention of consignments pending examination of the samples. An article of food which in the opinion of the medical officer of health is unsound, or unwholesome, or unfit for human consumption, may be seized and application made to a Justice for an order of condemnation, or, by notice to the importer, the officer may require that until it has been examined the article 79 shall not be removed from the place specified in the notice, without the permission of the medical officer of health ; the Justice may make an order for its detention or disposal, if he is of opinion it is unfit for food. The second series (foreign meat) deals with three classes of meat. Class I. consists of foreign boneless meat which is imported in the form of scraps, trimmings or other pieces not sufficiently identifiable with definite parts of a carcase, and which has not before importation been made ready for human consumption in the form of sausage, or of other prepared or manufactured article of food; imported tripe, tongues or kidneys to which certain chemical preservatives have been applied; and several parts of a pig not prepared before importation as bacon or ham, and not contained in a package with an "official certificate." Class II. comprises foreign meat in the form of the entire carcase of the pig which has not before importation been salted, cured, pickled, dried, or smoked or otherwise prepared as bacon or ham, and is without the head in its natural state of attachment to the carcase, and is without the lymphatic glands about the throat and any other part of the carcase in their natural positions; and Class III. includes foreign meat which is in the form of several parts of the carcase of a pig, or of other edible parts of a pig which has not before importation been salted, cured, pickled, dried or smoked, or otherwise prepared as bacon or ham, which is not and does not comprise any foreign meat of Class I. and which is in a box, case, receptacle or packet with an "official certificate." Foreign meat unclassed consists of foreign meat other than that of the three classes mentioned. The Officer of Customs is required to detain for examination by the medical officer of health any foreign meat which appears to be of Class I. or Class II., and also of Class III. if he is of opinion that the meat of this class requires examination. Meat of Class I. is to be destroyed unless the importer re-exports it at his own expense, or furnishes proof that it is not intended for human consumption. With respect to meat of Class II., the carcases of pigs, not prepared as bacon or ham, which are imported without the lymphatic glands, and from which the head has been removed, are to be dealt with in the same way as meat of Class I. The medical officer of health is required to examine foreign meat which has been detained, and to give either a notice forbidding its removal for any purpose other than exportation, or a certificate that it may be removed, but he is not to give a certificate and must give a notice as regards foreign meat of Class I. or Class II., and also as regards foreign meat of Class III. or foreign unclassed meat, if it is, in his opinion, notwithstanding the "official certificate," diseased, unsound, unwholesome, or unfit for human consumption. The Local Government Board caused to be inserted in the London Gazette of the 22nd January, 1909, a notice containing a schedule of labels and marks declared to be admissible as " official certificates " in respect of foreign meat which consists of pork or other edible parts of the pig which has been subjected to inspection in Denmark, the Netherlands, the Dominion of Canada and New Zealand. For the purposes of inspection of food under these regulations, the consent of the Local Government Board has to be obtained for the appointment and payment of the persons to be employed. In connection therewith, the Board desire to be furnished with a statement showing the experience possessed by the proposed officer, and whether he has obtained any special qualification such as the certificate in regard to meat and food inspection of the Royal Sanitary Institute. The regulations authorise the Local Government Board by Order to co-ordinate the administration of sanitary authorities (port sanitary authorities and the sanitary authorities of districts abutting on the port) and local authorities (other sanitary authorities), and Orders for this purpose were issued at the end of the year. Disinfection. The principal alterations made in the arrangements for disinfection in London sanitary areas are the following:—Until 1908 the disinfection of infected articles from Stoke Newington had been carried out at the disinfecting station of the Hackney Borough Council. A disinfecting station has now been provided in Stoke Newington to which are taken infected articles from that district. At this station provision has also been made for the cleansing of verminous persons. A new disinfecting station having two Washington-Lyons apparatus and two boilers has been provided in Deptford. During the year, at the request of the Local Government Board, the Paddington Borough Council approached the Kensington Borough Council with a view to arrangements being made for joint use by the two authorities of the disinfecting station in Kensington, but no agreement had been made by the end of the year. The Kensington and the Battersea Borough Councils encourage poor persons to send their bedding to the disinfecting station in those boroughs, when disinfection is required, by lending to them bedding belonging to the borough council while their own is undergoing disinfection. Dr. Corbett reports that bedding was thus lent on 22 occasions in Kensington and Dr. Lennane on 331 occasions in Battersea during the year. Shelters. The following figures, which are taken from the annual reports, show the extent to which the shelters in several districts were used. No. of persons accommodated No. of persons accommodated. Chelsea 67 London, City of 19 Westminster, City of 2 Bethnal Green 27 St. Marylebone 14 Southwark 653 St. Pancras 31 Bermondsey 37 Islington 13 Battersea 28 Stoke Newington 2 Greenwich 1 family Hackney 87 Woolwich 3 Finsbury 9 21322 l 2 80 Owing largely to changes in the method of disinfection, shelters are used much less frequently than before, and in Greenwich the upper of two flats of the shelter has been let at a weekly rental. It is undoubtedly desirable that shelters should be maintained, even if their use is now less frequently needed than before. Shelters are especially useful for the isolation of " contacts they are now occasionally used for the accommodation of persons who have been exposed to the infection of small-pox, and who thus, if they subsequently develop this disease, do so under conditions which do not expose other persons to risk. In this respect they serve an exceedingly useful purpose, which may be of far-reaching influence. It will be seen from the above figures that the amount of use of shelters varies very much in different districts, a fact which is not fully explained by difference in the methods of disinfection. Referring to the small amount of use of the shelter in St. Marylebone, Dr. Meredith Young writes:—"The district inspectors have from time to time been reminded that it is their duty to enquire particularly into the manner in which those displaced from their homes during disinfection of premises intend to dispose of themselves during that time, and if they are not satisfied that they will be able to obtain lodgment without danger to the public health, they are to very strongly urge upon the people concerned the use of the shelter. It is feared that this instruction has not been as faithfully carried out as it might have been. The matter is, therefore, one which will require further and continued supervision." Mortuaries. During the year, the erection of a new mortuary was completed in Deptford. The mortuary stands on the same site as the coroner's court, disinfecting station and shelter. Two mortuary chambers are provided, one of which is used for the deposit of bodies of people who have died from infectious diseases, and with these chambers are a post-mortem room, waiting room, w.c.'s, etc. Plans for a new mortuary in Cottage-street, Poplar, have been approved ; and arrangements have been made by the Lambeth Borough Council for the construction of a mortuary on a small portion of a site in Romany-road, Norwood, which is being developed for use as a dust depot. The mortuary in Highstreet, Lambeth has been improved at a cost of nearly £1,500. The number of bodies received into the mortuaries of the several sanitary authorities during the year is shown in the following table :— Sanitary Area. Total number of bodies received into mortuary. Number of infectious bodies received into mortuary. Sanitary Area. Total number of bodies received into mortuary. Number of infectious bodies received into mortuary. Paddington 292 3 Shoreditch 367 6 Kensington 315 1 Bethaal Green 344 14 Hammersmith 244 Stepney 640 4 Fulham 178 5 Poplar 352 1 Chelsea 162 5 South wark 584 7 Westminster, City of 364 11 Bermondsey 230 3 St. Marylebone 414 5 Lambeth 382 2 Hampstead 78 — Battersea 259 12 St. Paneras 453 15 Wandsworth 204 2 Islington 563 3 Camberwell 321 4 Stoke Newington 40 — Deptford... 67 — Hackney 424 5 Greenwich 145 — Holborn 146 — Lewisham 130 3 Finebury 368 14 Woolwich 152 1 London. City of 194 — The number of bodies removed to mortuaries is nearly 12 per cent. of the total number of bodies of persons dying in London in 1908. The Cleansing of Persons. The demand for opportunity for the cleansing of persons from verminous conditions continues to increase in London. The extent of use of the accommodation provided for this purpose is shown in the following annual reports. Number of persons cleansed in 1908. Adults. Children. Persons Westminster, City of 5 23 Stoke Newington 65 St. Marylebone 11,304 5,244 Finsbury 9 St. Paneras 1,417 3,070 Poplar — 876 Islington 8 1,202 Camberwell 1,124 Hackney 225 519 Holborn 226 9 Stepney 58 64 Southwark 39 1,602 Bermondsey 69 1,398 Battersea 1,006 656 Wandsworth 12 29 Woolwich 101 161 81 In my last annual report, reference was made to the powers contained in the General Powers Act of 1907, for requiring the cleansing of school children and of the inmates of common lodging-houses. A similar provision relating to children is contained in Section 122 of the Children Act of 1908, which contains the following additional sub-section. "Where after the person or clothing of a child has been cleansed by a local education authority "under this section, the parent or guardian of, or other person liable to maintain, the child, allows "him to get into such a condition that it is again necessary to proceed under this section, the parent, "guardian, or other person shall, on summary conviction, be liable to a fine not exceeding ten. "shillings." Hence the duty of parents to keep their children free from a verminous condition is now recognised by law, and it may be hoped that the steady enforcement of the provisions of the Act, will finally effect the object in view. As yet, however, there is no penalty attaching to adults in common lodging-houses, who after being cleansed at the public expense, allow themselves again to become verminous, and indeed at the present time no adequate provision has been made in some districts under the Cleansing of Persons Act of 1897, for poor persons to free themselves from this condition, if they so desire. It may be anticipated, however, that recent legislation will have the effect of emphasising the importance of this provision, and that eventually this want will be met in all districts in London. In this connection it may be mentioned that the new disinfecting and cleansing station in Stoke Newington came into use during the year, and that it will meet the requirements of the inhabitants of that borough, who previously had to make use of the station provided in the neighbouring borough of Hackney. The question whether any indirect effect will result from the freeing of people from verminous condition can only be ascertained as the outcome of further knowledge and experience, but it is interesting to note that Dr. Sykes points out that since the establishment of the cleansing stations in St. Paneras and St. Marylebone "each of the boroughs shows a remarkable improvement in its position in regard to the prevalence of scarlet fever and diphtheria." In February, 1908, the Council sent to London sanitary authorities a letter asking for information as to the facilities which could be given by them for the cleansing of school children, and of adults living in common lodging-houses. This letter was as follows:— London County Council (General Powers) Act, 1907. "I am directed to draw attention to Sections 36 and 37 of the London County Council (General Powers) Act, 1907, with reference to the cleansing of verminous persons. It will be observed that Section 36 gives statutory power to the county medical officer, or any other person authorised by him (a) to examine the person and clothing of any child attending any school provided or maintained by the Council, to ascertain whether the person or clothing of such child is infested with vermin, or is in a foul or filthy condition; (b) to require the parent or other person responsible for such child to effect the cleansing of the person and clothing of the child within 24 hours of the notice to that effect, and (c) on default of such parent or other responsible person, to remove the child from the school and to cause the person and clothing of such child to be properly cleansed in suitable premises and with suitable appliances, and to detain there such child until such cleansing has been effected; and that Section 37 enables the medical officer or any other person authorised by him (a) to enter any lodging-house and examine the person and clothing of any person whom he has reason to suspect of being infested with vermin or in a foul or dirty condition; (b) to require such person to submit his person and clothing to be cleansed at specific suitable premises, within, 24 hours of notice of such requirement, and (c) on default of such person, to remove him to suitable premises for the purpose of effecting the cleansing and to detain him there until it has been effected. The Council believes that the Metropolitan Borough Council will agree that it is absolutely necessary that any arrangements made for carrying the Act into effect shall provide for dealing separately, not only with men and women, but also with boys and girls. The Council recognises that children in most cases belong to an entirely different class from that to which the adult person requiring cleansing belongs, and separate days or hours should be appointed for their reception, or particular rooms allocated to them, in order to avoid coming into contact with obviously undesirable adults. These are the more important points arising in connection with the new powers conferred upon the Council. Before making any definite arrangements to put the Act into force, it is necessary that the Council should obtain the fullest possible information as to the extent of the provision already existing; the method of disinfection of verminous clothing and of dealing with a verminous condition of the hair; the arrangements in regard to the supervision by the cleansing staff; and the facilities which the metropolitan borough council would be prepared to afford the Council in the matter. I am therefore to say, that the Council will bo obliged if the Metropolitan Borough Council will, at the earliest possible moment, favour the Council with information on the points just referred to, and will indicate also what facilities can be afforded to the Council in its administration of the sections of the Act in question." In the reports of the medical officers of health of the following districts, the subject is thus discussed. The medical officer of health of Fulham writes:— "The Borough Council of Fulham were advised by the medical officer of health that with respect to verminous persons from common lodging-houses, having regard to the fact that there is only one common lodging-house in Fulham, sufficient accommodation existed at the disinfecting station to deal with the few cases likely to arise, there being a bath there and a dressing-room, together with appliances for freeing the clothes from vermin. With regard to children, for whom separate arrangements must be made, the medical officer of health recommended that the necessary provision should be made at the shelter adjoining the disinfecting station, where the alterations and additions necessary for the work could be made at a cost of about £15, and that the services of a woman to bathe the children should bo engaged, to be paid either by borough council or London County Council. The borough council, however, decided to inform the County Council that they were willing to co-operate with them by cleansing verminous clothing and enforcing the provisions of Sections 19, 20, 21 and 24 of the London County Council (General Powers) Act, 1904, relating to verminous rooms, but that in their opinion the cleansing of verminous children should be undertaken by the parents of such children." 82 The medical officer of health of Chelsea reports :— "It would appear to be desirable to grant facilities at the Lots-road disinfecting station, for the cleansing of school children and the disinfection of their clothing; but it seems unnecessary to take such stops in the case of children affected by head vermin only, as these can be cured by appropriate measures to the heads of the children, which can be applied by the mothers, under the direction of the school nurse." The medical officer of health of Westminster states in this connection that the London County Council was informed that:— "The City Council have under consideration plans of a new disinfecting station in the south-western part of the City, and have included therein certain accommodation for dealing with this class of case; that the proposed station will be situated at the extreme end of the City boundary, and obviously could only be of use so far as children are concerned, to such as live in the neighbourhood; that the Council would be pleased to allow the officials of the London County Council who are dealing with this matter, to inspect the plans in order that they may see what it is proposed to do, with a view to seeing if the accommodation would be serviceable for the requirements of the County Council; that it is not thought desirable that children should be brought to the same place to be cleansed as persons from common lodging-houses; that the Council note that the County Council have to provide means for the cleansing of both classes of persons, and it is not thought that the proposed new station would be convenient for the use of the class of poison from common lodging-houses, which are mostly located in the St. John and Strand Wards of the City; that if the County Council desire to utilise the proposed new station, it might be available for school children in the neighbourhood; that the City Council might consider if they would retain, for the use of the County Council for the inmates of the common lodging-houses near by, the existing disinfecting station with the shelter at the Coroner's Court, Horseferry-road, which it was originally intended to remove, if the County Council think that it would be suitable for their requirements, but that it would not be desirable for school children to use these premises for cleansing purposes." The medical officer of health of Stepney states that "the Public Health Committee recommended the Council:— "(a) to inform the London County Council that this Council are of opinion that the execution of the provisions of the London County Council (General Powers) Act, 1907, should be undertaken by the London County Council and the cost spread over the whole metropolis; (b) to suggest to the London County Council that probably arrangements could be made with the several Boards of Guardians in the borough for dealing with the adults and children at the casual wards, the costs being defrayed out of the Metropolitan Common Poor Fund; (c) to inform the London County Council that this Council has no facilities to offer in connection with the carrying into effect of the section of the Act referred to, as the bathing accommodation at the shelter attached to the mortuary is required in connection with infectious diseases and for other purposes connected with the sanitary administration of the Borough." The medical officer of health of Poplar reports:— "There are four baths provided in connection with the shelter, at Bromley Depot, and adjacent to the disinfecting station, which are also used for persons making application under the Cleansing of Persons Act. The use of these baths, with all necessary materials, might, the Committee thought, be placed at the disposal of the London County Council for the purposes required, so far as such baths are not needed for the purposes for which they were provided. The public Health and Housing Committee were of opinion that school children requiring to be cleansed should be at ended to at these baths by the parents or by a person appointed by the London County Council. Clothing might at the same time be disinfected by the Borough Council's staff at the disinfecting station." In his annual report the medical officer of health of Lambeth refers to the expense which would be incurred by the Borough Council if they afforded facilities for the cleansing of children in Lambeth as proposed in the London County Council's letter, and he thus writes:— "To this suggestion, the Lambeth Council objected for the reason mentioned above, and having regard to the fact that the common lodging-houses and the public elementary schools are both under the jurisdiction and control of the County Council; and this objection was given to the County Council in writing on April 3rd, 1908, the limited accommodation at present at the disposal of the Borough Council for cleansing in connection with infectious diseases (at Wanless-road and Belvedere-road) being also pointed out." The medical officer of health of Deptford reports that at the new shelter "The two bathrooms can be used for the cleansing of verminous persons." The medical officer of health of Camberwell writes that "It will be remembered that this Council decided to allow the children whose heads had been found by the school nurse to be in a verminous condition, to use our disinfection station under the superintendence of our own officers. An amount has been expended on this work which really should be borne by the London County Council. If the work is to grow at the rate at which it has been doing during the last year, the present arrangements at the Peckham-parkroad Depot, which were originally intended for the voluntary cleansing of adults, will be found to be totally inadequate. As it is, it is worked with a certain amount of difficulty owing to the structural conditions, and to the lack of sufficient means for the heating of the bath water. At present the supply of this commodity has to be supplemented by one of the staff being employed to carry it over from the disinfecting machine, a procedure inadvisable and wasteful of time." The medical officer of Battersea refers to the increase in the numbers of persons attending the personal cleansing station, and thus writes :— "The growing popularity of the station has become embarrassing, the accommodation provided proving inadequate to cope with the work. The station is, in addition, unsuitable in other respects for the purpose, and the time has arrived when it is absolutely necessary to make other arrangements. The subject has been under the consideration of the Health Committee for some time. A considerable use has been made of the station by the children attending the public elementary schools, and the duty of enforcing the cleansing of these children devolves on the London County Council, as the education authority under the provisions of the Children Act, 1908. The Act which comes into force on the 1st April, 1909, empowers the London County Council for this purpose to make use of the apparatus, etc., of the local sanitary authority, on terms to be agreed on. The Committee have recommended the Council to approach the London County Council before extending the present station, with the object of ascertaining the extent to which they (the County Council) would be prepared to contribute to the expense of the station. This the Council resolved to do and negotiations are still pending." The medical officer of health of Hackney refers to the facilities which exist in Hackney for the cleansing of verminous persons and states that the Borough Council resolved:— "That the London County Council be informed that this Council is prepared to afford them the above facilities for the purpose of dealing with persons in a verminous condition, provided that this Council is not called upon to incur any additional expenditure thereby." 83 The London Equalisation of Rates Act, 1894. The Equalisation of Rates Act provides that the London County Council shall in each year form a fund equal to a rate of sixpence in the pound on the rateable value of London. The contribution from each parish to the fund is to be in proportion to its rateable value. The fund thus formed is to be distributed among the sanitary districts in proportion to their population. Where a sanitary district comprises two or more parishes, and the aggregate of the contributions from such parishes is less than the grant apportioned to the district, the difference shall be paid out of the fund to the sanitary authority of the district, and no payment towards any equalisation charge shall be required from any parish in the district. Subject to the above, when the contribution from a parish is less than the grant due, the difference shall be paid out of the fund to the sanitary authority of the district forming or comprising the parish ; and if it exceeds the grant to the parish, the Council shall, for the special purpose of meeting the excess, levy on the parish a county contribution as a separate item of the county rate. Every sum paid to a sanitary authority must be applied in defraying the expenses of the sanitary authority incurred under the Public Health (London) Act, 1891, and so far as not required for that purpose those incurred in respect of lighting, and so far as not required for that purpose those incurred in respect of streets, and where the sanitary district comprises two or more parishes the sum paid must be apportioned among such parishes in proportion to their population, and the amount apportioned to each parish credited to each parish in the reduction of the rate required from such parish towards the above-mentioned expenses. The sanitary authority is required to render annually to the Local Government Board a return showing the amount of the sum to be paid and the total expenses incurred in respect of the three subjects mentioned. If the Local Government Board, under section 101 of the Public Health (London) Act, are satisfied that the sanitary authority have been guilty of such default as in such section mentioned . and have made an order limiting a time for the performance of the duty of the authority, the London County Council shall, if directed by the Local Government Board, withhold the whole or any part of the payment of the sum due to such authority. The Act provides that for the purposes of the distribution of the fund an estimate of population on the 6th April in each year shall be made by the Registrar-General upon returns which the Local Government Board receive from the authority making the poor rate in each parish showing the total number of houses entered in the rate book of the parish. The following table shows the estimated population on the 6th April, 1908, and the amount of excess of contribution over grant, or of grant over contribution, in respect of each district for the year ended 31st March, 1909— Sanitary area. Estimated population, 6th April, 1908. Equalisation charge, being excess of contribution oyer grant for year ended 31st March, 1909. Net grant, being excess of grant over contribution for year ended 31st March, 1909. £ s. d. £ s. d. Paddington 145,251 3,775 5 5 — Kensington 184,411 16,771 7 6 — Hammersmith 120,459 — 7,707 14 - Fulham 157,547 — 14,227 9 10 Chelsea 71,557 6,317 4 4 — Westminster, City of 175,205 113,055 5 5 — St. Marylebone 124,391 19,625 15 4 — Hampstead 88,306 6,605 12 10 — St. Paneras 228,864 — 9,724 4 10 Islington 336,763 — 31,495 16 1 Stoke Newington 52,563 — 3,478 7 2 Hackney 219,423 — 20,649 2 - Holborn 53,888 13,686 - 9 — Finsbury 102,366 1,850 12 - — London, City of 25,076 129,348 13 - — Shoreditch 116,635 — 7,125 5 6 Bethnal-green 128,668 — 16,462 11 11 Stepney 286,910 — 29,708 14 8 Poplar 167,176 — 18,304 18 3 Southwark 197,754 — 13,577 18 2 Bermondsey 128,719 — 6,493 12 10 Lambeth 309,573 — 23,678 - 7 Battersea 172,940 — 13,932 19 - Wandsworth 318,603 — 23,336 10 4 Camberwell 269,193 — 28,864 - 2 Deptford 112,543 — 10,334 11 2 Greenwich 103,923 — 7,872 9 3 Lewisham 167,007 — 12,361 5 5 Woolwich 137,710 — 12,655 10 3 Inner Temple 127 607 13 2 — Middle Temple 104 347 11 8 - 84 Midwives Act, 1902. The number of midwives giving addresses in London whose names have been placed on the roll was 3,020, made up as follows :— (a) 1,824 in virtue of a certificate obtained by examination prior to the Midwives Act, 1902. (b) 1,011 in virtue of a certificate from the Central Midwives Board. (c) 185 in virtue of having been in practice for a year prior to the passing of the Act. After correcting for removals and deaths, where such had been reported, the number of certified midwives residing in London in 1908, was reduced to 2,690. Of these, 518 gave notice of their intention to practise during the year, including 32 midwives acting on specific occasions, but not practising regularly in London. The London midwives are classified as follows:— Not practising. Notifying intention to practise during 1908. Total. Class (a) 1,392 206 1,598 „ (b) 716 204 920 „ (c) 64 108 172 2,172 518 2,690 Many of the 204 midwives in class (b) who notified their intention to practise were newly qualified and were working for short periods at the institutions where they were trained, prior to taking up practice in other parts of England or going abroad. From the above figures it will be seen that less than 20 per cent. of the midwives residing in London are practising. The remainder for the most part act as monthly nurses under the direction of medical practitioners. Of the practising midwives, some 25 reside at, and work in connection with, lying-in hospitals or poor-law infirmaries, and are under the supervision of medical practitioners. Others living in their own homes attend patients on behalf of charitable institutions, which pay them fees for each case allotted to them, a few taking no other cases, while others are also engaged in independent private practice. The rest practise independently, or work in lying-in institutions not under direct medical supervision. Three practising midwives died, 12 gave up practice, and 27 removed from the county during the year. Inspection.—All practising midwives (except those working under the direction of a medical practitioner), are subject to supervision by the Council's officers to ascertain whether they are observing the rules of the Central Midwives Board as to cleanliness, the possession of the required apparatus and antiseptics, the keeping of case books and registers, and the sending of the various notices to the local supervising authority. The work of inspection was carried out by Miss L. S. Greig, M.B.,L.M., D.P.H., and Miss I. R. Shields, M.B., B.S. In May, Miss Greig resigned her appointment and the vacancy thus caused was filled in July by the appointment of Miss E. Macrory, M.B., Ch.B., L.M., D.P.H. In addition to routine inspection, inquiries are also made into cases of a septic nature, death of mother or child and inflammation of the eyes of infants. It has also been the practice of the inspectors to improve the knowledge of midwives required in the course of their work and to suggest methods for the better performance of their duties. The inspectors have also on several occasions accompanied midwives to confinements and on subsequent visits to their patients. Much useful information has thus been obtained as to the actual methods of work of midwives, especially in the cases of midwives who apply to the Central Midwives Board for approval to supervise the practical work of pupils intending to present themselves for examination. During the year 1,420 visits of inspection were made, including visits in special cases. In 779 cases the reports were satisfactory, in 143 cases unsatisfactory, in 421 the midwife was away from home when the inspector called, aud in 77 cases the midwife had ceased to practise or had removed to some other address. The 143 unsatisfactory reports referred to 106 midwives. 78 were reported to be unsatisfactory on one occasion only, 21 twice, 5 three times, and 2 four times. The improvement in the work of midwives which has been noted in successive years has continued. In most of the cases where the report was unfavourable, the midwife's attention was drawn by the inspector to the particular rule which she had failed to observe, and at a subsequent inspection the inspector was generally able to report favourably. In cases of a serious character, or of persistent neglect to observe the rules, the matter was reported to the Midwives Act Committee and a letter of caution was sent to the midwife. This course was adopted in 14 cases for the following reasons. Delay in advising medical assistance for inflammation of infant's eyes 4 Delay in advising medical assistance for weakly infant 4 Delay in advising medical assistance for mother, as required by rules 2 Failure to take temperature 3 Attending a patient without being disinfected after attendance upon a case of puerperal fever 1 14 85 In one case a midwife was cautioned by the Committee for leaving without medical assistance an infant suffering from inflammation of the eves. In four instances prima facie cases of malpractice, negligence or misconduct were found against certified midwives and particulars were reported to the Central Midwives Board. Nature of offence. Action taken by Central Midwives Board. Not taking antiseptic precautions and general ignorance Cautioned. Employing an uncertified substitute Cautioned. Not taking antiseptic precautions and general negligence Name removed from Roll. Neglect of patients and failure to take temperature Cautioned. The Council was asked by the Board to report in three months' time as to the conduct of the three midwives who were cautioned and also as to the practice of a midwife cautioned by them in the previous year (1907) In three out of the four cases, it has been possible to report that a marked improvement had taken place. The remaining case (the last in the above list) is still under consideration by the Board. During the year, a midwife whose name was removed from the roll in 1907, applied to the Board for restoration; reports as to this woman's practice showed that she was still unsatisfactory and the Board refused to restore her name to the roll. Some eight midwives were reported to be more or less illiterate, but their case books and registers are usually entered up by their relatives and the notices regularly sent in. Several midwives who showed themselves unacquainted with the use of the ordinary appliances or who were unable to make proper use of a clinical thermometer, received individual instruction from the Council's inspectors, and in some cases where there had been infringements of the rules owing to ignorance, the midwives were advised to attend a course at one of the Council's classes for midwives. There are 18 Jewish midwives who practice amongst the Jewish population in East London. The Jewish Board of Guardians assisted the Council by preparing a translation into Yiddish of the rules as to the duties of midwives, and copies of these rules were supplied to the Jewish midwives. Two Italian midwives attend women of their own nationaltiy in various parts of London. Fees charged by Midwives.—The fees charged by midwives vary in different localities from 5s. per case upwards, but as a general rule, a fee of 7s. 6d. (or 10s. if patient be a primipara) is expected Fees of 15s. and even up to £1 Is. have been paid to a midwife on rare occasions. The charities employing midwives pay 5s. or 6s. per case and provide the necessary drugs, registers of cases, etc. It is apparent from the number of cases attended by midwives as stated below, that only a small proportion of midwives can depend solely upon their practice for their livehhood, and many supplement their incomes by other means. A few keep lying-in homes and others are registered under the Infant Life Protection Act to take charge of nurse children. Some of those midwives who have an extensive practice are approved by the Central Midwives Board as qualified to give practical instruction to pupil midwives, and receive fees from the pupils for this instruction. The lying-in hospitals in London receive into their wards some 5,000 women annually and provide for attendance on about 19,000 in their own homes. The latter cases are conducted almost exclusively by midwives. Some of the hospitals pay the midwife a fee for each case, while others pay a fixed salary The patients are not as a rule expected to pay for the services rendered by the district midwives attached to hospitals, and in the case of institutions there is either free attendance or a nominal fee. Having regard to the provision made for the free attendance of labour cases in London, to the number of midwives practising in London, and to the fact a midwife can only attend normal cases and, if any abnormality occurs, medical help must be summoned and a medical man has to be paid in addition to the midwife, it is not surprising that many midwives find great difficulty in making a living. Lists of Births.—Midwives practising in London were asked in 1905 to send in lists of the births attended by them each week, forms and stamped envelopes for this purpose being supplied to them. A fair proportion of midwives agreed to comply with this request, and have continued to forward these lists to the Council, except in those boroughs where the Notification of Births Act has since been adopted. The medical officers of health of the boroughs in which the Notification of Births Act has been adopted, in forwarding lists of the births to the Council in accordance with the Act, indicate the cases delivered by midwives and the name of the midwife who attended. From the information obtained from these sources the following table giving some idea of the extent of practice of midwives has been compiled:— 1 midwife reported over 500 cases in the year. 4 midwives reported over 400 „ „ 9 „ „ from 300-400 „ „ 9 „ „ 250-300 „ 9 „ „ 200-250 „ 17 „ „ 150-200 „ 35 „ „ 100-150 „ 40 „ „ 50-100 „ 47 „ „ 20- 50 „ 106 „ „ less than 20 cases each in the year. 21322 M 86 Most of the midwives attending 300 or more cases in the year, have qualified assistants who work with them, and many of them are approved by the Central Midwives Board to supervise the practical work of pupils. The midwives of 15 institutions reported attending some 9,000 cases in patients' homes during the year. It is estimated that some 30,000 births are attended annually by midwives in London. Uncertified women.—During 1903-4, the Council's inspectors, in the course of their daily rounds, noted any cases of women having name-plates signifying that they were acting as midwives. Inquiries were made from various sources and the names of over 500 women in London who were practising midwifery were obtained. In April, 1904, a leaflet was issued by the Council calling attention to the provisions of the Midwives Act and giving information as to the course to be adopted to secure enrolment under the Act. This notice was sent to the women whose names had been obtained. From April 1904, until March 1905, an abstract of this leaflet was inserted from time to time in the daily papers and in such weekly papers as it was thought were most likely to be read by women practising midwifery. In this way an effort was made to inform every woman practising midwifery of the provisions of the Midwives Act, and to give every opportunity to her to secure enrolment. After March 1905, when it was impossible for any woman to become enrolled as a certified midwife except by examination, it was found that a small number of women had not availed themselves of the opportunity of securing the right to practice as "midwives," some from inability to pay the fee for enrolment, some who did not think their practice large enough to trouble about, and some through delaying too long. A list was prepared containing the names of any such persons and this list was amplified from time to time as fresh women were heard of. At the beginning of 1908, 119 names were on the list, and during the year, 20 additional names were added. The Council's inspectors have kept these uncertified women under observation and have reported from time to time details of their practice. In five cases infringements of the Act were found to have been committed by the women assuming the title of midwife. Cautionary letters were sent in all cases and four of the women ceased to use the title. In the remaining case, legal proceedings were instituted and a fine of £2 with £1 3s. costs was imposed by the magistrate. In the majority of cases, information as to uncertified women reaches the Council in the first instance from certified midwives who complain of the competition of women not subject to the rules of the Central Midwives Board. Of the 139 uncertified women reported to be practising as midwives, many were found to be monthly nurses who delivered a patient before the arrival of the medical practitioner engaged for the case, and others were found to be neighbours acting in an emergency. After deducting the number of these women, there remain only 40 uncertified persons who are known to practise more or less regularly. The number of cases attended by these women ranges from 1 or 2 in the year to 150 per annum in one particular instance. A total of 900 cases per annum is a fair estimate of the number of deliveries conducted by them. This number of cases would obviously not create a need for additional midwives when Section 1 (2) of the Act which practically terminates the employment of uncertified women comes into operation: indeed their work would be gladly undertaken by certified women who frequently complain that they now have not sufficient employment. Medical help notices.—The rules of the Central Midwives Board provide that in certain contingencies, which are set out in detail in the rules, the midwife must advise that medical assistance is required and whenaver this advice is given, notice of it must be given to the local supervising authority within 21 hours. Daring the year, 1908, 2,755 such notices were received. The figures for the previous years were 1905,1,113; 1906, 2,320; 1907, 2,533. The gradual increase in the figures during the last three years is no doubt in part due to a fuller understanding of the rules requiring such notices to be given and also to the fact that midwives are recognising better the necessity for calling medical assistance in cases where there is the slightest sign of danger to their patients. Notices of calling in medical assistance were sent in by 308 midwives. It thus appears that of 518 midwives who gave notice of intention to practice, 210 sent in no notices of advising that medical help was required. Some of these 210 midwives are working under medical supervision in hospitals and poor law institutions and are exempt from this rule, the majority, however, are those midwives who attend case3 only very rarely. 1 midwife sent in 98 notices 1 „ „ 85 „ 2 midwives sent in between 70-80 „ 2 „ „ 50-70 „ 5 „ „ 40-50 „ 8 „ „ 30-40 „ 15 „ „ 20-30 „ 43 „ ,, 10-20 „ 231 „ „ less than 10 „ The midwives who called in medical aid more than 20 times during the year were midwives with extensive practices. The reasons assigned by the midwives for advising medical assistance were as follows:— 8? Pregnancy— Abortion or miscarriage 34 Deformed pelvis 2 Growth on cervix 2 Ante partum hæmorrhage 86 Premature labour 11 Convulsions before labour 1 General health of patient 29 Varicose veins 28 193 % Lying-in— Abdominal swelling or tenderness 11 Excessive sickness 6 Offensive lochia 5 Rigor 13 Rise of temperature 165 Inflammation or swelling of breasts 15 Post partum haemorrhage 111 White leg 3 Phlebitis 3 Convulsions and eclampsia 16 Collapse and exhaustion 21 Mania 6 Other illness of patient 116 491 Labour— Presentations— Unable to make out presentation 19 Abnormal vertex 33 Difficult breech (including breech in primiparæ) 51 Knee 5 Face 23 Funis 39 Transverse 72 Placenta prævia 31 Twin birth 18 Triple birth 2 Prolapse of vagina or uterus 5 Prolonged labour (contracted pelvis, uterine inertia, etc.) 495 Retained and adherent placenta 186 Laceration of the perineum or injury to soft parts 246 Haemorrhage during labour 7 1232 Child— Injuries during birth 7 Asphyxia 50 Malformation or obvious deformity 54 Inflammation of the eyes 97 Jaundice 17 Cyanosis 13 Dangerous feebleness 390 Eruptions on skin 14 Convulsions 46 Bleeding from cord 6 Death of child 44 Still-birth 40 Other conditions in child 56 834 Infectious disease in patient's house 2 No reason stated 3 2,755 Estimating that 30,000 births are annually attended by midwives, it would appear that in 9.2 per cent. of these cases the midwife finds it necessary to summon medical assistance, in 6.4 per cent. on behalf of the mother, and in 2.8 per cent. on behalf of the child. It will be noticed that in nearly half the cases in which medical help for the child was advised, the reason assigned was dangerous feebleness. These cases are chiefly due to prematurity. Still-births.—During the year 228 midwives reported still-births in their practice, the number of still births being 666. The numbers in the previous years were 1905, 405; 1906, 574; 1907, 740. 1 midwife reported 12 cases 12 2 midwives reported 11 cases each 22 3 ,, ,, 10 ,, 30 3 9 „ 27 6 8 „ 48 8 „ „ 7 56 6 „ „ 6 36 12 „ „ 5 „ 60 26 „ „ 4 „ 104 34 „ „ 3 „ 102 42 „ „ 2 „ 84 85 „ „ 1 case 85 228 midwives reported 666 cases. If this number represents the total number of still-births in the practice of midwives it would mean that 2.2 per cent. of the cases attended by midwives in London were still-born. There are, however some cases in which the infant is born before the arrival of the midwife and found by her to be apparently dead. Unless evidence is forthcoming as to whether the child was born alive or dead a medical practitioner is summoned and the midwife usually reports the case as one of sending for medical assistance and not as a still-birth. The figures, which have kindly been furnished by the Secretary of the Royal Maternity Charity (an organisation which has district midwives working in all parts of London) show that of 2,423 births attended by their midwives, 60, or 2.5 per cent., were still-born. The form in which still births are notified provides for information as to (a) Sex of child. (b) Whether full term or premature (number of months). (c) Whether the child is macerated or not. (d) Presentation. 21322 M 2 88 The information under (a) showed that of 666 cases 356 still-born children were males, 305 were females, in three cases the sex was not stated, and in two the sex could not be determined. The following table shows the information under the headings (b) and (c) above. Condition of child. Total cases. Period of gestation. Fall term. 8 months. 7 months. 6 months. Under 6 months. Not stated. Macerated 393 156 88 92 43 11 3 Not macerated 266 165 32 30 27 9 3 No statement 7 2 1 — — — 4 Total 666 323 121 122 70 20 10 The presentations were as follows:— Vertex 406 Complicated vertex 41 Breech 94 Complicated breech 16 Footling 36 Transverse 7 Face or brow 2 Funis 16 Placenta prævia 1 Born before arrival, and presentation not known 38 Presentation not stated 9 Total 666 The following table shows the presentations of still-born infants of full term or 8 months gestation concerning which information as to maceration is given . Presentation, etc. Full term. 8 months' gestation. Macerated. Not macerated. Macerated. Not macerated. Vertex 124 82 71 16 Complicated vertex 6 9 3 3 Breech 11 39 8 8 Complicated breech 1 5 — 1 Footling 7 12 1 1 Transverse 1 1 1 — Face or brow — 1 — — Funis 1 7 — 1 Placenta prævia — 1 — — Born before arrival and presentation 4 7 3 2 not known — No statement 1 1 1 — 156 165 88 32 From this table it will be seen that of 244 macerated infants of 8 or more months' gestation only 20 presented by breech while of the 197 unmacerated there were breech presentations in 53. The following additional information concerning still-born infants was supplied in 51 cases. Infant, one of triplets 1 Infant, one of twins 17 Twin birth both still-born (5 instances) 10 Hydrocephalic head 5 Anacephalic head 2 Malformed head 5 White asphyxia 1 Cord broken before birth 1 Cord round neck 4 Spina bifida 1 Contracted pelvis 1 Illness of mother 3 51 89 Death of mother or child.—The rules of the Central Midwives Board provide that when the death of the mother or child occurs before the arrival of a medical practitioner the midwife in attendance must give notice to the Local Supervising Authority; 45 such notices were received, in two instances the mother and in 43 the infant died before medical assistance was obtained. The mother died from pulmonary embolism in one case and syncope from haemorrhage due to rupture of the uterus in the other case. Inquests.—Inquests are held in such cases as the above and also frequently in cases where a medical practitioner, though in attendance before death is unable to certify as to the cause of death. By the courtesy of the London coroners, notice is given to the Council's medical officer of inquests in eases where a midwife was in attendance on the deceased prior to death, and one of the Council's inspectors is thus enabled to be present to take notes of the evidence given. The inspector is frequently referred to on points arising as to the duties of the midwives under the rules. In this way, much useful information has been obtained as to the practice of midwives, which would not be elicited in the ordinary course of inspection. As the result of attendance at inquests on the deaths of mother or children, knowledge of uncertified wemen practising midwifery has been gained. During the year, 91 inquests were attended by the Council's inspectors and detailed reports made on the cases. In 10 cases the mother and in 81 the infant died. Of these 91 cases, 6 were among patients attended by uncertified women. In 3 cases the jury considered that there was lack of skill on the part of the midwife and in 7 instances expressed the opinion that medical assistance should have been sent for earlier. Attended by- Total. Deaths of mothers. Death of children. No blame attached. Want of skill. Delay in calling medical help. No blame attached. Want of skill. Delay in calling medical help. Certified midwives 85 9 1 — 69 — 6 Uncertified women 6 — — — 3 2 1 91 9 1 — 72 2 7 The cause of death was given as follows:— Mothers. Children. Syncope from haemorrhage 2 Weakness from prematurity 19 Septicaemia 1 Atelectasis 16 Pyœmia 1 Suffocation at birth 10 Puerperal peritonitis 1 Suffocation in bed with parent 10 Exhaustion from uterine inertia 1 Convulsions 7 Collapse 1 Cerebral hæmorrhage 4 Fatty degeneration of heart, syncope 1 Heart diseased or malformed 3 Pulmonary embolism 1 Cerebral embolism 1 Pneumonia 1 Catarrh of stomach or intestines 2 Bronchitis 1 Want of attention at birth (born before arrival of midwife) 3 Want of attention at birth (lack of skill) 1 Still-birth 4 10 81 In all cases where there was delay in sending for medical assistance, a letter of caution was addressed to the midwife concerned. Puerperal Fever.—During the year, 228 cases of puerperal fever were notified in London and the Registrar-General records 137 deaths from puerperal septic diseases. The term "puerperal septic disease" used by the Registrar-General includes puerperal septicaemia, sapræmia and pyœmia, as well as peritonitis and metritis occurring in connection with parturition. A more limited interpretation of puerperal fever appears to be adopted by some medical practitioners for the purposes of notification and of the 137 registered deaths from puerperal septic diseases, no less than 50 were not regarded by medical practitioners as puerperal fever, or at all events were not notified. In the table headed "causes of death" there is a column relating to the 50 deaths of unnotified cases. Of the 228 notified cases, 87 proved fatal, this gives a case mortality of 38.2 per cent. All cases of puerperal fever in which a midwife was in attendance on the patient, were investigated by the Council's inspectors, and full details of the illness obtained. For this purpose, early intimation of cases of puerperal fever is received from the Metropolitan Asylums Board, and by the courtesy of the several medical officers of health, I am able to ascertain by whom the delivery is conducted. A list of deaths from puerperal septic diseases is obtained each week from the General Register office. It has thus been possible to ascertain in each case whether a medical practitioner was in charge of the case, whether a midwife or uncertified woman conducted the delivery or whether the patient was confined in poor law institution or hospital; the results of the euciuiries are as follows :— 90 Delivery conducted by. Cases. Deaths. (a) Medical practitioners (including cases attended by hospital students and also cases in which though a medical practitioner was engaged the birth took place before his arrival) 158 75 (b) Certified midwives (including cases where birth took place before arrival) 51 15 (c) Uncertified women 7 4 (d) Confined in poor law institutions and hospitals 28 15 (e) Midwife and medical man (i.e., cases where a midwife was unable to deliver and called in a medical practitioner) 4 ( f ) Deaths in London of women confined elsewhere 8 8 (g) Miscarriages and abortions where no attendant was engaged 22 20 Total 278* 137 Causes of death in the 137 fatal cases:— Cause of death. Notified cases. Unnotified. delivered by midwives. Puerperal septicaemia 43 24 8 Puerperal septic absorption 3 — — Puerperal fever 11 — 2 Puerperal peritonitis 12 5 3 Peritoneal abscess — 1 — Septic pneumonia 3 1 1 Phlegmasia alba dolens 1 5 — Pyosalpinx — 1 — Puerperal parametritis — 2 — Puerperal endometritis 4 — — Erysipelas of leg following parturition — 1 — Phlebitis following parturition — 2 — Sloughing of rectum after labour — 1 — Sapræmia 3 3 1 Pyœmia 2 3 — Pelvic cellulitis 3 — — Necrosis of ileum after labour 1 — — Hyperpyrexia after miscarriage 1 1 Total 87 50 15 Concerning the 51 cases of puerperal fever occurring in the practice of midwives In addition to obtaining information from the midwife, the Council's inspector visits the medical practitioner who was afterwards called in to attend, during lying-in, a patient delivered by a midwife, and learns from him his opinion as to the nature of the case. The following table is based upon the information thus obtained. Diagnosis. Recovery cases. Fatal cases. Sapræmia 12 1 Septicæmia 17 10 Peritonitis — 3 Septic pneumonia 1 1 Puerperal mania 1 — Endometritis 1 — Pelvic cellulitis 1 — Septic thrombosis 1 — Severe laceration 1 — Perimetritis 1 — Total 36 15 * This figure includes the 228 notified cases of puerperal fever and 50 cases not so notified hut included by the Registrar-General in his total of deaths from puerperal septic diseases. 91 With regard to the 51 cases delivered by certified midwives, medical help was summoned in 38 instances on account of rise of temperature, either alone or in conjunction with other symptoms. In 8 instances the midwives state that no symptoms of puerperal fever were observed during the 10 days they attended on the patient, and in these cases medical help was summoned by the patient's friends on the 11th, 12th, 13th, 14th (twice), 15th, 18th and 20th days. The following table shows the day of the puerperium on which (a) the rise of temperature was first noted by the midwife (b) a medical practitioner was called in, (c) the case was notified as puerperal Eever, both as regards fatal and non-fatal cases, and (e) the death took place in fatal cases. Day of Confinement. 2nd day. 3rd day. 4th day. 5th day. 6th day. 7th day. 8th day. 9th day. 10th day. After 10th day. Total. Rise of temperature Recovery cases — 3 3 7 4 2 — 3 2 4 — 28 Fatal cases 1 — — 4 1 2 - — 2 — — 10 Medical Practioner called Recovery cases - 3 3 7 4 3 - 2 2 4 8 36 Fatal cases 1 3 — 2 3 2 — — 2 — 2 15 Notified as puerperal fever Recovery cases - — - 4 — 2 5 2 2 4 17 36 Fatal cases - 1 2 — — — 1 3 1 - 5 13* When death occurred in the fatal cases - 2 - - - 1 - - 1 2 9 15 Of the 9 cases where the patient died after the 10th day of the puerperium, two died on the 12th day, one each on the 14th, 16th, 18th, 19th, 22nd, 28th and 35th days. The age incidence of the cases of puerperal fever was as follows:— Total. Age. 15-20. 20-25. 25-30. 30-35. 35-40. 40-45. 45 and up. Recovery cases 141 4 43 33 29 23 8 1 Fatal cases 137 3 22 37 37 27 11 - The parity of women suffering from puerperal fever was ascertained as far as possible in the 51 cases attended by certified midwives and is shown in the following table. No. of cases. Recovered. Died. Primipara 7 6 1 2 Para 7 5 2 3 „ 4 2 2 4 „ 5 4 1 5 „ 4 1 3 6 „ 3 2 1 7 „ 3 3 — 8 „ 1 1 — 9 „ 3 2 1 10 or more para 5 4 1 Multipara (no definite statement) 5 3 2 No statement 4 3 1 Total 51 36 15 The following conditions were noted among the cases of puerperal fever delivered by certified midwives:— Laceration of the perineum in 4 cases. Adherent placenta in 3 cases. Retained pieces of placenta or membrane in 8 cases. Post partum haemorrhage in 2 cases. Abdominal pain or tenderness in 6 cases. Excessive sickness in 1 case. * Two fatal cases, one of septicaemia and one of pneumonia, were not notified as puerperal fever. 92 In six cases (two of them fatal) the birth had taken place before the midwife arrived. Six wives had two cases of puerperal fever each during the year. There were intervals of 3 months or more between the two cases in three instances, and the midwife in the meantime had attended and delivered several other patients, none of whom developed symptoms of puerperal fever. Two midwives delivered their second patient who suffered from puerperal fever before any symptoms of puerperal fever had been noticed in the first patient, and it is possible that infection may have been carried by the midwife from one case to the other. The usual antiseptic precautions were taken by one of the two midwives before she attended the second case. The other midwife states that she took antiseptic precautions before the delivery of the second patient, but this is open to doubt and her conduct of these cases and her general practice showed gross neglect. She was subsequently represented to the Central Midwives Board and her name was removed from the roll of midwives. The remaining midwife who had two cases in her practice delivered the first patient on the 1st day of the month and on the 6th called in medical assistance on account of rise of temperature; the doctor remained in charge of the case, and on the 7th the midwife ceased attending ; on the 9th she and her clothing and apparatus were disinfected and she resumed her work as a midwife and delivered two or three patients, none of whom developed symptoms of puerperal fever. On the 16th day of the month she delivered a patient who was notified on the 25th to be suffering from puerperal fever. Ophthalmia.—It is the duty of midwives to advise that medical assistance should be sought in any case of inflammation of the eyes, however slight, occurring in new-born infants. Notice of calling in medical assistance must be sent to the Local Supervising Authority. In this way cases of inflammation of the eyes are brought to notice. In October, 1907, special attention was drawn to the question, and from that time full enquiries have been made into each case by the Council's inspectors. During the last three months of 1907 there was a marked increase in the number of these notices, consequent upon the verbal directions given by the Council's inspectors, and in January, 1908, a circular letter was addressed to all practising midwives pointing out the importance of seeking medical assistance on the first appearance of any inflammation of the eyes. Ninety-seven such notices were received from midwives during the year, and in seven of these cases medical assistance, though advised by the midwife, was not obtained. These seven cases were all very slight and recovered completely. All the cases were investigated by the Council's inspector, who obtained from the midwife details of the antiseptic precautions taken by the midwife and visited the infant to see that it was receiving medical treatment. In twelve cases it has not been possible to learn the final result of the illness owing to the patient's removal and present address not being ascertainable. In one case an infant died before a cure was effected and in four there was impairment of vision. The remaining cases were completely cured. The cases were divided by the inspectors into three classes according to the duration of the discharge from the eyes. (a) Discharge from eyes lasting 10 days or less, 32. (b) Discharge from eyes lasting 10-30 days, 16. (c) Discharge from eyes lasting from 1-4 months, 46, Four cases occurred in which there was reason for thinking that infection from the newly-born infant took place, viz.:— (1) Mother developed swelling and redness of lids of one eye and a slight discharge from eyes. (2) Mother developed slight discharge from eyes lasting a few days. (3) Mother and another child (aged 3 years) developed conjunctivitis. (4) Mother developed conjunctivitis and discharge in the right eye. The midwives disinfected their hands after treating the children's eyes and adopted ordinary precautions such as burning the rags used for wiping the eyes. They also warned the mother to be careful. In several cases the midwife got the mother or some other person to attend to the child's eyes under her supervision so that she, the midwife, came in contact with the infection as little as possible. In no case did it appear that the midwife carried infection from one patient to another. Complete blindness did not result in a single instance, but impairment of vision occurred in the following four cases:— (a) Opacity 1/8 in. in diameter centrally placed in right cornea—some vision in right eye, left eye clear. In this case symptoms were observed on 6th day after birth, when a private practitioner was summoned. (b) Opacity nearly covering left cornea—right eye clear. In this case the symptoms were first observed on 3rd day after birth. On the 5th day a private practitioner was summoned, and on the 9th the infant was taken to an ophthalmic hospital. (c) Several opacities in both corneae, but as they are not central there is probably impairment of vision in both eyes, but not complete blindness. In this case symptoms were first observed on the 6th day after birth, when a private practitioner was summoned. (d) Right cornea practically covered with a large opacity, small opacity not central in left cornea. In this case symptoms were first observed on the 6th day after birth and a private practitioner was called in same day. The infant was subsequently taken to a hospital. 93 In cases a, b and d there was a history of vaginal discharge from the mother during pregnancy The treatment adopted by the midwife at birth in these cases was (a) eyes treated with boracic acid solution at birth; (b) eyes wiped with dry rag at birth and washed with 1 in 4,000 solution of corrosive sublimate half-hour later; (c) child born before arrival of midwife—eyes washed with boracic solution half-hour later; (d) eyes treated with 1 in 4,000 solution of corrosive sublimate at birth. In 13 cases medical assistance was not obtained by the midwife at the onset of the disease. In four of these a satisfactory explanation was given by the midwife, in four others the midwife was cautioned by the inspector, in one case she was cautioned verbally by the Midwives Act Committee and in the remaining four cases a letter of caution was addressed to the midwife. The antiseptics used by the midwives for treating the eyes at birth were perchloride of mercury (1 in 2,000 or weaker) in 51 cases, boracic acid (saturated solution) 34; lysolsolution, 1; cyllin solution, 1. In 21 cases the child was born before the arrival of the midwife, and consequently there was an interval between the birth and the treatment of the eyes ranging from 10 minutes to 1½ hours. A possible source of infection was ascertained in 34 cases. Soreness of the eyes of the mother or other member of the family existed in six cases. In 28 cases there was a history of [a vaginal discharge in the mother during pregnancy, and in three of these cases the discharge was admittedly gonorrhœal. In December the Midwives Act Committee invited Mr. E. Treacher Collins, F.R.C.S., of the Royal London Ophthalmic Hospital, Moorfields, and Mr. Malcolm M. McHardy, F.R.C.S. of the Royal Eye Hospital, Southwark, to assist the Committee with their advice as to the most efficient routine treatment to be adopted by midwives in order to prevent as far as possible the occurrence of ophthalmia in newly-born infants. As a result of the advice of Messrs. Treacher Collins and McHardy a leaflet was drawn up for distribution to practising midwives in London. Since then, however, the Central Midwives Board have had this subject under consideration and pending the amendment of the rules by the Board the issue of the leaflet has been postponed. Medical help for poor patients.—The difficulty of securing medical assistance when the patients are too poor to pay a fee has often been brought to notice, and midwives have asked for advice as to the course they should adopt in such cases. The arrangements made by the various Boards of Guardians in London were ascertained and a pamphlet giving this information was sent to every midwife giving notice of her intention to practise in London. This pamphlet shows that 14 Boards of Guardians are willing to consider a payment of a fee to any medical practitioner if the case be urgent, but four of these stipulate that in the first instance application must be made to the poor law medical officer. Twelve Boards of Guardians are willing to consider the payment of a fee to their own district medical officers called in by midwives in cases of emergency ; five Boards of Guardians had made no arrangements for dealing with these cases. It is obvious that unless the Boards of Guardians are willing to guarantee a reasonable fee to the medical practitioner called in and themselves recover the fee if it is subsequently found that the patient is in a position to pay, the requirements of the case will not be met. Scholarships.—In 1905 a scheme was started for awarding scholarships to students in midwifery. Up to the end of 1908, 26 students were elected as scholars. Of those elected 12 had completed their course of training and passed the examination of the Central Midwives Board, and of these 2 were acting as district midwives in connection with the extern department of a lying-in hospital, 2 were engaged in infirmaries, 2 filled temporary appointments, but were not subsequently able to obtain a practice, 1 was in private practice and 5 were not practising as midwives. There was very little demand for these scholarships and the difficulty of the scholars when qualified in obtaining work in London to comply with the conditions of the award led to the conclusion that the Council was not justified in continuing to make these awards.] Classes for midwives.—The Education Committee of the Council arranged courses of classes for the further instruction of midwives. The original intention was to afford an opportunity to midwives who had been in practice for a good many years to obtain further teaching in the theory of midwifery. These classes were instituted in 1905 and in subsequent years the numbers attending the classes increased and classes were arranged at additional centres. The classes were arranged for midwives and maternity nurses and there is reason to believe that practising midwives formed only a small proportion of those attending. A new scheme has now been arranged which provides separate courses for midwives and maternity nurses and reduces to four the number of centres where classes for midwives are held. Notification of Births Act, 1907. This Act provides for the notification within 36 hours to the medical officer of health of the occurrence of the birth of a child. It also provides, in the case of the County of London, that a list of the births notified each week to a medical officer shall be forwarded to the London County Council. A local authority may, with the consent of the Local Government Board, adopt the Act. In London 15 metropolitan boroughs and the City of London adopted the Act during 1908. The medical officers of health of these districts indicated on the lists sent to the Council the cases which were notified by midwives. For the purpose of comparison with the number of births given in the RegistrarGeneral's quarterly returns only the complete quarters during which the Act was in operation in each borough are taken into consideration. The following table shows (a) total births registered, (b) total births notified under the Act, (c) births notified by midwives under the Act. 21322 N 94 Sanitary district. Number of complete quarters of 1908 during which the Act was in operation. 1908. Births of living children during the complete quarters in which the Act was in operation. Still-born. (a) Registered by Registrars. (b) Notified under Notification of Births Act. (c) Notified under the Act by midwives. Notified under the Act. Notified by midwives under the Act. Battersea 3 qrs. 3,351 2,583 483 58 12 Bermondsey . 2 „ 2,082 1,652 270 22 4 City of London 3 „ 203 164 13 3 — Finsbury 3 „ 2,623 2,714* 315 52 5 Fulham 3 „ 3,457 j 2,713 1,293 73 31 Hampstead 3 „ 995 905 137 32 2 Holborn 3 „ 1,165 987 117 31 2 Islington 2 „ 4,203 3,106 1,016 109 24 Kensington 4 „ 3,427 1,794 921 61 25 Lambeth 2 „ 4,403 2,131 480 13 Paddington 2 „ 1,530 933 247 44 11 Poplar 3 „ 3,872 j 3,073 1,310 35 9 St. Marylebone 2 „ 2,037 1,607 293 17 6 St. Paneras 3 „ 4,138 2,839 879 106 23 Southwark 3 „ 4,660 4,207 1,857 92 48 Woolwich 3 „ 2,378 2,039 1,151 49 20 Total 44,524 33,447 10,782 797 222 From the above table it will be seen that 75 per cent. of the registered births are notified under the Act in the districts where this Act has been adopted. The proportion of still-births to total births notified under the Act is 2.4 per cent. In the absence of notification of 25 per cent. of the births occurring it is not possible to state whether this ratio is correct, but from information obtained in connection with the administration of the Midwives Act it would appear that a percentage of 2.5 is fairly accurate. Legislation. The principal Acts of Parliament passed in 1908 affecting public health administration in London were the following:— The Children Act, 1908.—(1) Gives powers to local education authorities for the cleansing of verminous children attending public elementary schools; (2) prohibits the sale of cigarettes and cigarette papers to children under sixteen years of age and includes other provisions for the prevention of smoking by children. The White Phosphorus Matches Prohibition Act, 1908.—This Act prohibits the manufacture and importation of white phosphorus matches from the 1st January, 1910, and also prohibits white phosphorus matches from being offered for sale from the 1st January, 1911. The application of these Acts is not limited to London. The London County Council (General Powers) Act, 1908—(1) Empowers sanitary authorities to refuse to register, or to remove from the register, the names of dairymen carrying on their business on unsuitable premises; (2) empowers sanitary authorities to appoint health visitors; empowers the Local Government Board to make regulations with regard to the mode of appointment, duties, salary and tenure of office of health visitors; and empowers the Council to make contribution towards the salaries of such officers; (3) empowers sanitary authorities to require proper provision for the cooking of food in tenement houses, other than those so used before the passing of the Act; (4) enacts regulations to be enforced by sanitary authorities for premises in which food is prepared or adapted for sale and for maintaining cleanliness in such premises and in persons so employed; (5) empowers the Council to make by-laws (to be enforced by sanitary authorities) with respect to the premises of a vendor of fried fish, a fish-curer, and a rag and bone dealer, and for regulating the conduct of businesses carried on therein. The Act provides that the City Corporation may make such by-laws for enforcement within the City. Water Supply. Dr. Houston, Director of Water Examinations, in his report to the Metropolitan Water Board, for the twelve months ended 31st March, 1909, reiterates conclusions already expressed by him with regard to "the great importance of active storage from the epidemiological point of view." From time to time, ever since he commenced in August, 1907, continuous and special study of the question of storage, he has emphasized the need of supplementing existing safeguards by more adequate provision * That more births are reported under the Act than are registered in this borough is due to the fact that some of the births in the City of London Lying-in Hospital, Finsbury, are registered in the district where the parents live, while under the Notification of Births Act the births would be notified from the hospital. • 95 of means for practising "judicious selection of raw water for waterworks purposes." The satisfactory quality of the Metropolitan water supply is judged, he says, by average results, and the worst results need to be brought "more closely into agreement with the best results." A first special "Research Report" appeared in May, 1908, in which Dr. Houston dealt with the vitality of the Typhoid Bacillus in samples of raw Thames, Lee and New River water. In practically all the experiments, 99.9 per cent. of the typhoid bacilli perished within one week. A second "Research Report," which appeared in October, 1908, gave the results of special search for the typhoid bacilli in samples of raw Thames, Lee and New River water. The results were negative, but Dr. Houston notes that " the value of the work depends largely on how far the negative evidence can be accepted, even in a relative sense, as conclusive." The medical officer of health of Woolwich refers to the quality of the water supplied by the Plumstead well of the Metropolitan Water Board. It was found that when the pumps were worked at a lower rate "the chlorine present in the water has been reduced from about 10 parts to 6 parts per 100,000." Dr. Davies mentions a suggestion which had been made that the excess of chlorine may possibly be due to water being drawn through from the river into the chalk by excessive pumping. Dr. Collingridge states that a considerable number of artesian wells have been recently sunk in the city and more are under construction, the object being to avoid the heavy charges for water supplied by the Metropolitan Water Board. Sanitary Inspectors and Health Visitors. During 1908 the Public Health Committee of the Council had under consideration the question whether the staff of sanitary inspectors was sufficient for the performance of the duties which devolved upon the borough council of Bermondsey. In 1906 the Council had caused inquiry to be made by its medical officer into this matter the medical officer of health of Bermondsey having repeatedly called attention to the need for the appointment of a female inspector for the inspection of workshops in which women are employed. The result of inquiry by the Council's medical officer was to show that for this and other purposes the staff of sanitary inspectors needed to be strengthened and after prolonged correspondence with the borough council, the Council resolved to represent to the Local Government Board that the borough council had failed to appoint a sufficient number of sanitary inspectors. Inquiry into the representation was made by Dr. Sweeting on behalf of the Local Government Board, and the Board made an Order requiring the borough council to appoint three additional inspectors. A health visitor was appointed by the Bermondsey borough council in January, 1909, for the purpose of utilizing the information obtained under the Notification of Births Act, that council having been urged by Dr. Sweeting to take this step. The Council also placed itself in communication with the Deptford borough council on the question of the sufficiency of the sanitary staff of that district, a vacancy created by the resignation of one of the sanitary inspectors not having been filled by the appointment of another inspector. As a result of this communication, an inspector was appointed by the borough council. The annual reports supply the following information as to appointments of additional sanitary inspectors and health visitors. In St. Marylebone two additional male inspectors were appointed and a temporary female inspector was employed to assist the female sanitary inspectors during four months of the year. An additional male sanitary inspector was appointed in Wandsworth, and an additional female sanitary inspector was appointed in Hampstead. In January, 1909, the borough council of Stoke Newington resolved to appoint a female sanitary inspector, and the borough council of Poplar appointed a health visitor in May, 1908. The Stepney borough council had under consideration, on the recommendation of their Public Health Committee, the question of the appointment of two health visitors, and, on the representation of the Stepney Council of Public Welfare, that of the appointment of a female sanitary inspector, but resolved not to make such appointments. The question of the appointment of a health visitor was considered by the Camberwell borough council, but no appointment was made. Education (Administrative Provisions) Act, 1907. In January, 1908, the Board of Education issued a schedule of essential points to be observed in the medical inspection of school children. On the 3rd November, the Council approved the appointment of five additional school nurses, two of them being primarily appointed for work arising under the Education (Administrative Provisions) Act; and on the 17th November the Council, for the purpose of this Act, approved a scheme for the employment of a medical staff as follows:—16 officers (to be known as school doctors), at a salary of £150 per year ; assistant school doctors, to be employed, 24 as from the 1st December, 1908, 24 as from the 1st September, 1909, and 24 as from the 1st September, 1910, each at a salary of £120 a year, and thereafter 24 to fill vacancies caused by retirement. The scheme provides that the holder of an appointment as school doctor or assistant school doctor shall not be eligible for reappointment as such after a total service of three years; that the vacancies occurring annually among the school doctors at salaries of £150 a year shall be filled by the promotion of assistant school doctors who are eligible for further service; and that casual vacancies arising in the staff of school doctors shall be temporarily filled until the ensuing 31st August by the temporary employment of past members of the staff. Appointments under this scheme were made in the following month. 21322 N 2 96 In May the Council, on the recommendation of the Education Committee, decided that, subject to the sanction of the Board of Education, open-air schools should be held from the 1st June to 31st October, 1908, at Birley-house, Forest Hill, grounds of Shrewsbury House, Shooter's Hill, and Montpelier House, Kentish Town. During the same month the Education Committee presented to the Council a report on the open-air school which had been carried on in Bostall Woods between the 22nd July and 19th October, 1907, and which Dr. Kerr and the Executive Officer had reported upon previously. Information inter alia as to the results obtained in the case of particular scholars in these schools will be found in Dr. Kerr's report, pages 71 et seq. (Appendix V.). An account of the medical work of the Education Committee during the 21 months ended 31 st December, 1908, is given in the same report. School attendance of children below the age of five years. In 1908 the Consultative Committee of the Board of Education reported upon the school attendance of children below the age of five. Various witnesses gave evidence before the Committee. The Committee recognised that the proper place for a child between three and five years of age is at home with its mother provided the home conditions are satisfactory, but under existing economic conditions the home surroundings of many are unsatisfactory, and the Committee consider that the best place for such children is a nursery school. The details of such nursery schools is described in the body of the report. Shirley F. Murphy, Medical Officer of Health. To the London County Council, November, 1909. 97 Medical Officers of Health of London Sanitary Areas, in 1908. Sanitary area. Medical officer of health. Battersea G. Q. Lennane, F.R.C.S. Bermondsey R. K. Brown, M.D. Bethnal Green G. P. Bate, M.D. Camberwell F. J. Stevens, M.D. Chelsea L. C. Parkes, M.D. City of London W. Collingridge, M.D. Deptford H. W. Roberts, M.RC.S. Finsbury C. Porter, M.D. Fulham J. C. Jackson, L.R.C.S. Greenwich E. G. Annis, M.R.C.S. Hackney J. K. Warry, M.D. Hammersmith N. C. Collier, L.R.C.P. Hampstead G. F. McCleary, M.D. Holborn W. A. Bond, M.D. Islington A. E. Harris, L.R.C.P. Kensington T. 0. Dudfield, M.D. Lambeth J. Priestley, M.D. Lewisham A. W. Harris, M.R.C.S. Paddington R. Dudfield, M.B. Poplar F. W. Alexander, L.R.C.P. St. Marylebone M. Young, M.D. St. Paneras J. F. J. Sykes, M.D. Shoreditch L. T. F. Bryett, M.D. South wark. G. B. Millson, L.R.C.P. Stepney D. L. Thomas, M.R.C.S. Stoke Newington H. R. Kenwood, M.B. Wandsworth P. C. Smith, M.D. Westminster, City of F. J. Allan, M.D. Woolwich S. Davies, M.D. APPENDIX I. 1 REPORT BY Dr. HAMER, MEDICAL OFFICER (GENERAL PURPOSES), ON LOCAL PREVALENCES OF ENTERIC FEVER IN BETHNAL GREEN AND SHOREDITCH DURING 1908. A local outbreak of enteric fever occurred in Bethnal Green during the months of September and October. After conference with Dr. Bate, the medical officer of health of Bethnal Green, and with the assistance of Mr. Henley, one of the sanitary inspectors, I made inquiry at the houses of the persons attacked and I later visited most of the patients after their removal to hospital. In summary of the conclusions ultimately reached it may be here at once stated that it appears to be clear that the outbreak was caused by infected food, and that while a hypothesis of shell fish (mussel) infection, which prima facie appeared a plausible one, is not in accord with the phenomena observed, a hypothesis of infection by fish must, on the other hand, having regard to all the circumstances, be looked upon as affording a possible explanation of the Bethnal Green prevalence. The special Shoreditch prevalence was more strictly limited in area, but not so limited in time as the Bethnal Green prevalence. Cases had already occurred in the affected area in Shoreditch early in the year (subsequent inquiry revealed the fact that there was some prevalence in the Bethnal Green area at this time also); but in the Shoreditch area cases continued to occur month by month until September and October, when Shoreditch and Bethnal Green were simultaneously involved. The fact that some of the Shoreditch cases were thus developed contemporaneously with those occurring in Bethnal Green led to conference with Dr. Bryett, the medical officer of health of Shoreditch, on the subject generally. Question necessarily arose as to whether the Shoreditch and the Bethnal Green cases were due to one common cause. Dr. Bryett has placed on record in his annual report the facts ascertained by him with regard to the Shoreditch cases. He says, "A large proportion of the cases certified were infected from previous cases in the borough," and he thus inclines to the view that the outbreak in his district was due in the main to direct infection from person to person. In the light of the facts of the Bethnal Green outbreak, it seems deserving of note, however, that there must remain at least a suspicion that infected food may have also played a not unimportant part in determining the Shoreditch prevalence, and to the reasons for entertaining this suspicion it will be well to refer after first giving a summary of the facts brought to light in Bethnal Green. The Bethnal Green Outbreak. The area affected.—With four exceptions all the cases, 36 in number, of enteric fever developed in Bethnal Green, from 1st September to 25th October, were notified in an area covering nearly one square mile, situated on either side of the eastern half of the Bethnal Green-road. The time relations of the outbreak.—In the 35th, 36th and 37th weeks of 1908 no cases of enteric fever were notified in the area above defined. In the following week, that ending 19th September two cases were notified (one of which proved not to be enteric fever); the cases notified in successive weeks from the 38th week onwards were as follows :— Week ended Saturday, Sept. 19, 38th week, 2 cases (one not enteric fever) ,, 26, 39th „ 2 ,, Oct. 3, 40th „ 6 ,, „ 10, 41st „ 1 „ 17, 42nd „ 5 „ „ 24, 43rd „ 2 „ „ 31, 44th ., 6 „ Nov. 7, 45th „ 5 „ „ 14, 46th „ 4 „ „ 21, 47th „ 1 „ 28, 48th „ — It may be assumed, having regard to the extent of prevalence of enteric fever in London at the time, that the area above defined was entitled to yield two or three cases of that disease per month. While, however, this figure was not reached in August or early September, nor again in the latter part of November and in December, it will be seen that from the 38th to the 46th week the number of cases was excessive, with the exception, perhaps, of the 41st week. This nine-week period must therefore be regarded as one of unusual incidence of the disease upon the area in question. If the dates of onset of illness (see table appended) be studied, there will be noted a tendency for the cases to occur in groups as follows :— 3 cases commenced within a day or two of September 6th. 5 „ „ ,, ,, „ 17th. 3 „ „ on October 6th. 5 „ „ „ 18th or 19th. It may have been that infection was introduced into this area on four separate occasions, but having regard to the variable incubation period of enteric fever, the facts as to dates of commencement of illness would fairly well accord with a smaller number of occasions on which infection was introduced—say, for example, (1) a first introduction about 6th September with associated development of symptoms in three cases almost immediately, and with later development of symptoms in some nine or ten other cases after an interval of a fortnight or rather longer; (2) a later introduction 21322 o 2 about 6th October, with early symptoms as before in some three cases, and later development of symptoms in seven or eight cases, with tendency again, as before, to grouping of some of these cases about a date approximately a fortnight later than 6th October. Possible causes of the outbreak. (1) Personal infection.—The fact that the outbreak was not an explosive one may be held to support a hypothesis that, after introduction of a few cases of enteric fever into the area, infection from case to case played a considerable part in promoting further spread of the disease. Against this supposition is the fact that for the most part the persons attacked (who lived, as has been noted, in an area covering nearly a square mile of ground) had no ascertainable relation or association with one another. In four instances there were multiple house invasions—three houses yielded two cases each, and one house four cases. It is impossible to be certain as to whether the cases in these houses were simultaneously infected, or whether the later sufferers were infected by theearlier ones. The balance of evidence seems to favour one, at any rate, of the groups of two cases, and the group of four cases, having received infection on one and the same date. In the other two households the two later cases may quite well, so far as dates of occurrence of symptoms are concerned, have been true secondary cases. No information pointing to any common source of infection outside London, such as visits to the seaside or to hop fields, could be elicited from inquiries made in the area and from the patients themselves, who were seen after their removal to hospital. (2) Water and food.—The geographical distribution of the cases does not admit of explanation on a hypothesis of contamination of a local water main. Milk, too, can be definitely excluded, as the source of milk supply to the cases was very varied. The extent of consumption of water-cress, ice-creams, mineral waters, shell-fish and fish was carefully considered. It soon became clear that as regards two articles only among those concerning which inquiry was made, namely, mussels and fish, could any serious question arise. The result of detailed inquiry showed that of the 28 patients concerned eight had almost certainly, seven had possibly partaken of mussels at about the time when infection must have been contracted, while 13 had not done so. In one instance, apart from the eight referred to (that of a woman) the patient had washed mussels and prepared them for her husband's consumption but had not eaten any herself. Her husband remained well; and it may be noted that in other instances also, among those above referred to, in which mussels had been eaten by a person who was later attacked by enteric fever, a number of persons had partaken of the same batch of mussels without ill results. With a view to ascertaining the normal percentage of mussel-eaters in the neighbourhood. Mr. Henley (sanitary inspector of Bethnal Green) made inquiry with regard to 67 families, taken at random, in the streets especially attacked, and found that 22 per cent. of the adults and 5 per cent. of the children, or about 15 per cent. of the entire population, had partaken of mussels at one time or another during August, September and October. Accepting these figures as a standard it would follow that out of 28 cases (16 adults and 12 children) it might have been anticipated as a matter of mere chance that some five or six would have eaten mussels. It may be pointed out that the inquiries in the case of the 28 patients attacked were not quite on all fours with those in the case of the 67 families. In the former case, in addition to making inquiries at the home, the patient himself or herself was, as a rule, seen and questioned in the hospital; while in the latter case particulars were obtained at the home alone, no special inquiry being made by a personal interview with each individual member of the families concerned. This is a point of much importance in dealing with an article of food like mussels. It is probable, in the light of the histories obtained from the patients in hospital, several of whom were able to give information which could not have been obtained from their friends, that a higher or lower figure might have been obtained, in the case of the unaffected families, if personal inquiry had been made in all instances, as was in fact done in the case of the actual patients. But the incidence of the disease upon mussel-eaters, viz., 9 or 10 out of 28, was not far removed from the incidence, 5 or 6 out of 28, which might a priori have been anticipated, having regard to the extent to which mussels were consumed in the district. In fact, the slight excess may be held to have been, mathematically speaking, within the limits of probable error. This analysis does not, therefore, attach any suspicion to mussels. Mussels may, indeed, be almost absolutely excluded as the source of infection, for it will be noted that at least 13, and possibly 20, of the 28 persons attacked, did not at any time eat mussels. Out of these 28 cases some 22 or more must, as has been seen, be taken as the number due to the special cause, operating in the area during September and October, the remaining cases being regarded as sporadic cases. Yet, even if all the mussel-eaters were included among the 22, the group would still include at least 7 and possibly 14 persons who had not eaten mussels. Turning now to the question of fish. A great deal of the fish consumed was obtained in the form of fried-fish, and on inquiry it was found that 24 of the patients had probably, while the remaining 4 may have possibly, partaken of fried-fish at or about the time when they must have been infected. Mr. Henley made inquiries, as he did in the case of mussels, with a view to obtaining a standard to apply with regard to fried-fish eating. He found that 77 per cent. of the adults and 46 per cent. of the children, or 63 per cent. of the whole population, had been in the habit of eating fried-fish during August, September and October. Hence out of the 28 persons attacked, it might be assumed that some 18 would be ascertained to be fried-fish eaters, had the question been one of mere chance coincidence. The number 24, found as a matter of fact to have eaten fried fish among the 28 sufferers, is 3 thus somewhat in excess of that which might have been expected as a matter of pure chance. No causal significance can be held to be implied by such a degree of excess, having in view the smallness of the numbers dealt with. It will be seen that only four persons can be classed as not having eaten fried-fish, and hence a hypothesis of infection by fried-fish cannot be at once dismissed from further consideration, for the four negative cases may, of course, have been instances of mere chance infection independent of the special cause operating in the district during September and October. It will be borne in mind that the area is entitled to show four, or indeed rather more than four, sporadic cases of enteric fever during these two months. If the four negative cases could be regarded as sporadic cases, all the remaining persons attacked in the area of special prevalence would have been fried-fish eaters. In other words, a fried-fish hypothesis is (so far as these figures go) adequate for explanation of the outbreak. It was not possible to demonstrate that cooked fish had been obtained from any single retail shop. Detailed information was obtained as regards the shops from which fried fish was purchased in the case of 18 of the patients. At least eight different shops were referred to, in one or another instance. The shop named by the largest number of sufferers was one from which six certainly, and possibly ten of the 18 had obtained fish. This shop is situated centrally within the area affected. As regards the remaining eight sufferers, one or two of them may quite exceptionally have obtained fish from this shop, but the fact must be accepted that this particular shop was not, at any rate, a recognised source of supply of these eight persons. Difficulties inseparable from investigations of this sort render it impracticable to make any more precise statement than this. The possibility was considered as to whether fish purchased in the uncooked condition had played a part in producing the special prevalence of enteric fever. This question will be further referred to in connection with the remarks to be made on the Shoreditch prevalence. Tabular statement giving certain particulars with regard to 28 cases referred to in the preceding report:— Date of notification. Date of onset. Sex. Age. Milk supply. Whether mussels consumed at or about time when disease was presumably contracted. If so, whence derived. Whether fried fish was consumed at or about time when disease was presumably contracted. If so, whence derived. Sept. 16 Sept. 2cent. M. 17 J. ? Yes from D. or elsewhere. „ 22 cent. „ 6cent. F. 16 R. No. Yes. N. or elsewhere. „ 23 cent. „ 17cent. F. 15 Cond. No. Yes. N. or elsewhere. „ 25 cent. „ 18cent. F. 37 W. Yes. Stall in main road Yes. D. twice a week. „ 27 cent. „ 16cent. M. 38 W. ? Yes. Not known. „ 28 cent. „ 7cent. F. 30 M. Yes. 3 or 4 weeks before illness. Yes. D. frequently. „ 28 cent. „ 5cent. M. 32 S. Yes. Yes. P. or elsewhere. „ 28 cent. „ 23cent. M. 45 w. No. Yes. Often. „ 29 cent. „ 16cent. M. 16 c. ? ? Oct. 6 cent. „ 29cent. M. 8 Cond. No. Yes. D. twice a week. „ 13 cent. „ 24cent. M. 11 Cond. No. Yes. B., or elsewhere. „ 13 cent. „ 17cent. F. 24 Cond. ? ? „ 14 cent. Oct. 6cent. M. 11 E. No. Yes. D. frequently. „ 17 cent. Sept. 27cent. M. 45 Cond. ? Yes. P. or elsewhere. ,, 17 cent. Oct. 3cent. M. 7 Cond. No. Yes. Various places. „ 20 cent. „ 6cent. M. 6 Cond. Yes. Yes. Landlord of house keeps a fried-fish shop. „ 26 cent. „ 19cent. M. 35 G. Yes. Yes. Various places. „ 17 cent. ? F. 32 J. No. Yes. Very frequently „ 26 cent. „ 18cent. M. 13 J. No. Yes. usually from P., cent. 27 cent. „ 18cent. F. 8 J. No. Yes. or R., possibly „ 27 cent. „ 19cent. F. 6 J. No. Yes. from D. „ 27 cent. ,, 6cent. F. 30 S. Yes. ? „ 29 cent. ,, 9 M. 9 D. No. Yes. S., and elsewhere. Nov. 1 cent. „ 19cent. F. 26 P. Yes. Yes. H. „ 3 cent. „ 23cent. M. 9 Cond. Yes. Yes. P., and elsewhere. „ 4 cent. „ 25cent. M. 32 F. ? ? „ 5 cent. - M. 9 ? 2 Yes (not known). „ 6 cent. „ 17cent. F. 7 H. & G. No. Yes. D., P. or B. The Shoreditch Outbreak. The particulars supplied in Dr. Bryett's report for 1908, show that while 101 cases occurred during the year in Shoreditch, nearly three-fourths of these were notified from one of the eight wards into which the borough is divided. A closer examination shows that by far the majority of the cases in this ward occurred in a limited area near its eastern border. In fact, more than half the total number of cases in Shoreditch were notified from six streets, or from a population of about one-fiftieth 21332 0 2 4 of the total population of the borough. Thus a population of between two and three thousand persons living in these six streets supplied as many cases during the year 1908 as did the whole of the rest of Shoreditch, with a population of some 113,000 persons. It should be noted, moreover, that the borough of Shoreditch is largely occupied by poor persons, and the character of the population of the specially affected area does not differ so markedly from that of the rest of the borough as to afford any adequate explanation of this very excessive incidence of enteric fever upon the implicated area. Dr. Bryett has demonstrated (see his Annual Report) certain curious relationships between the persons who were attacked in the special area—some of the children had played with other children previously attacked—in some instances sufferers were actually related to one another by blood or marriage—some of those attacked had shopped in the special area, or had marketed in the neighbourhood, or had visited there. These relationships, however, while they testify to the fact that the population specially attacked had many circumstances in common, cannot be regarded as finally demonstrating that direct case to case infection occurred in all instances. It might, indeed, be argued that relationships of a like sort would, provided close inquiry were made, be discovered in any area of similar character to the Shoreditch area, which chanced to be attacked to the same extent by enteric fever. In fact, an exclusive hypothesis of direct personal contact cannot be held to be sufficient explanation of the heavy incidence of the disease upon this area, unless it be assumed that the enteric fever prevailing therein manifested a special ability to spread by contact from person to person, either because of some peculiarity of the enteric fever germ of that area, or because the circumstances of the area itself were wholly exceptional. Dr. Bryett has referred to discovery of a number of unrecognised cases of the disease in the area, but, unless it be assumed that the enteric fever of the area was peculiar in its tendency to show itself in a masked form, this existence of unrecognised cases will not explain the remarkable incidence of the fever upon this area. Dr. Bryett made personal inquiry concerning all the cases of notified or suspected illness, and the fact that so many unrecognised cases were discovered may be held to testify to the thoroughness of his investigations rather than to any peculiarity of the disease as exhibited in Shoreditch. A further point against assuming that in Shoreditch personal contact played a predominant role is that in almost all instances the cases were removed, immediately they were discovered, to the Metropolitan Asylums Board's Hospitals. On the other hand, it might reasonably be contended that the relationships referred to, those of playmates, of marketing, visiting, etc., might all find explanation, apart altogether from the question of personal contact, on the hypothesis that the enteric fever in the area was due to an infected food supply. I discussed the matter on numerous occasions with Dr. Bryett and he made inquiries which led him, as did my own investigations in Bethnal Green, to the conclusion that a shell-fish hypothesis (and only mussels really came into question) would not explain the outbreak. Dr. Bryett also made inquiries as to fried-fish shops, again with a negative result. It seems, however, that in Shoreditch, and the same thing is true of Bethnal Green, fish and shell-fish are at certain times of the year habitually purchased from costermongers, who have barrows which either stand at a particular street corner or in some other prominent position, or else are wheeled about on a more or less defined "round" from street to street. As regards the Shoreditch area it has transpired that several such itinerant vendors of fish and shell-fish lived, during 1908, in houses in the six affected streets. Within the area is a common lodginghouse, and the information obtained with regard to the street traders was obtained in the first instance from lodgers in this house, and inquiries were then made into the particular facts ascertained by Mr. Jury, the chief inspector of common lodging-houses, and by Mr. Rowe and Mr. Shapley, inspectors in the public health department. Briefly it may be stated that in the household of a particular costermonger, whose home was situated just about the centre of the affected area, several cases of enteric fever occurred in the early months of 1908 (see Dr. Bryett's report—cases 7-10). The man himself died "from the effects of a fall" on March 20th. Dr. Bryett notes that" the stall was not kept on after his death"; but clearly the wants of his customers who lived in the immediate neighbourhood, were likely to be supplied by other vendors of fish and shell-fish and possibly by other costermongers, of whom there were two or three close by. A second costermonger carrying on a trade similar to that of the man who died, lived about a hundred yards away. This man sold " dabs " and shell-fish throughout the year until August, 1908, but not after that. A third costermonger, living in the same street as the man last named, had sold fish repeatedly during 1908, but he told me he did not "work the streets" which the first named costermonger had worked, nor did he know who did so after the death of the first-named costermonger. This third costermonger explained that, while most of the costermongers had regular rounds, if any costermonger had doubtful fish or shell-fish to dispose of, he would not be likely to sell them on his regular round, but elsewhere. He further entered into details as to the rounds worked by himself and by other costermongers in Bethnal Green. Mr. Rowe, moreover, obtained particulars concerning a number of the costermongers "working" the Shoreditch and Bethnal Green streets, but it was not found possible to determine that any one individual costermonger had supplied fish to consumers in the areas affected in Shoreditch and Bethnal Green. In view, however, of the facts elicited it is necessary to have regard to the possibility that infected fish, sold on some three or four separate occasions by a costermonger or costermongers, may explain the excessive incidence in 1908 of enteric fever upon these special areas in Bethnal Green and in Shoreditch. Such a hypothesis is capable of explaining the incidence of the disease upon the populations attacked. Moreover, so far as could be ascertained, no other food than cheap fish could by any possibility 5 be held accountable for a large proportion of the excessive number of cases occurring in the two special areas. Articles of food such as mussels, cockles, watercress and ice-cream, though in common use at one time or another, were not eaten in these areas at the several periods when the prevalences occurred. In Bethnal-green, it is true, the chief prevalence was in the mussel season; but, as has been pointed out, the inquiries made concerning mussel-eating make it clear that the majority of the sufferers were not infected by this article of food. In fact, consideration of a fish hypothesis and a mussel hypothesis, in relation to the circumstances of the Shoreditch and Bethnal-green outbreaks, shows that there is a point of agreement and an important point of difference in the two cases. If the percentage of mussel-eaters among sufferers from enteric fever be compared with the percentage of mussel-eaters in the population generally, there is fairly close correspondence. So again, if the percentage of fish-eaters among sufferers from enteric fever be compared with the percentage of fish-eaters in the population generally, there is no very marked discrepancy. But, on the other hand, while the percentages in the case of mussels are comparatively low, in the case of fish, the percentages are high. This method of comparing a population attacked with a control population results, therefore, in exclusion of mussels as the one and only cause of the special prevalences. While, on the other hand, it does not demonstrate that fish was almost exclusively at fault, it should be noted that it does not exclude this possibility. W. H. Hamer, Medical Officer (General Purposes). APPENDIX II. 1 APPENDIX II. CEREBROSPINAL FEVER IN LONDON DURING 1908. Happily there is little to record about this disease. There has been nothing approaching epidemic prevalence, and, among the reported cases, no evidence of infectiousness. The number of cases certified has been 85. Inquiries have been made into these by the respective city or borough medical officer of health, and 72 of the cases have been followed up by myself. The home of each patient has been visited, and particular attention has been paid to the question of how the disease might have been conveyed. The friends have been cross-examined as to possible channels of infection, and as to whether any other case of disease, of any kind, is known to have occurred in association, such as influenza, whooping cough, or phthisis. Inquiry has also been made into the duration of residence of the patient in the locality, whether, if an infant, he has been breast fed or not, whether pet animals have been kept, and whether there is any cause for the illness which gossip or information can suggest. In many cases the local medical attendants have been interviewed or written to, as well as the hospital staff who were in attendance on the case. In no single instance could any connection be traced between two cases: no case appears to have led up to any other, or to be derived from any other; no condition has been found to exist in any two or more cases which could be regarded as a common factor of causation. With the object of eliciting any possible infectious factor, inquiry was made into certified cases, whether they were subsequently verified or not. The same difficulty in verification was experienced as in dealing with the cases which occurred during the year 1907. In the notes on those cases is recorded the conflict of evidence which may arise between the pathologist and the bacteriologist, and the following cases which occurred during 1908 bear on the same subject. T. F. R., aged 9 months, had an illness of 14 days duration with cerebral symptoms and fatal termination; post mortem, the meninges contained purulent looking fluid; at the tip of each temporomaxillary lobe of the brain was a little creamy pus; there was thrombosis of vessels on the vertex, and an excess of fluid in the lateral ventricles; the cord appeared to be normal to the naked eye; the left middle ear contained some pus, but the drum was not perforated nor could any opening be found from the ear into the inside of the cranium, or any evidence of carious bone. Such is the post-mortem report of the naked eye conditions found. At once the question suggests itself as to whether the meningitis may not have been secondary to the pus in the left middle ear. But this reading of the case is considered to be negatived by the bacteriological report which states that the Diplococcus intracellvlaris meningitidis of Weichselbaum was found in the cerebrospinal fluid during life, and also after death in the fluid of the lateral ventricles. On this evidence, the case is classed as one of a specific infectious disease. Of a similar nature was the case T. S. I., 1 year old, who died after an illness of about 10 weeks with cerebral symptoms, and was found post-mortem to have purulent meningitis at the posterior base, and to have pus in both middle ears. In the cerebrospinal fluid the meningococcus was found. No doubt it may be held that in this case the pus in the middle ears was secondary to that in the meninges, and that in the first case the middle ear pus was merely that often found there in young children apparently otherwise healthy. No bacteriological examination appears to have been made of the aural pus in either of these cases. It would have been interesting if this had been done; and further, if it could be ascertained in what proportion of cerebrospinal fever cases there is any collection of pus in the middle ear; at present this organ is one which is not always examined post-mortem, or, if examined, its condition is not recorded. No excuse is needed for dwelling on the bacteriological method of identification of the disease, for that is the basis upon which its diagnosis ultimately rests. Bacteriology is considered capable of supplying an infallible test of its authenticity, but it is doubtful if this claim will always stand examination. In order to see plainly what the claim is, the report of Dr. Mervyn Gordon to the Medical Officer of the Local Government Board (February, 1907), may again be quoted. "Although this country has hitherto been remarkably free from epidemics of cerebrospinal meningitis, the disease obtains here sporadically; and this circumstance, coupled with the fact that epidemics of cerebrospinal meningitis have recently prevailed abroad, renders information concerning the characters of the special micrococcus associated with its product tion particularly desirable. Moreover, the presence within the human body of this microorganism has been found to constitute the surest test whereby cases of epidemic cerebrospinal meningitis can be detected. Its identification, therefore, becomes a matter of no little importance with reference to that early and accurate recognition of this disease upon which a successful system of prevention of the malady must in our present state of knowledge in great part, if not wholly, depend."—(Report of Dr. Mervyn Gordon to the Medical Officer of the Local Government Board, February, 1907.) Dr. Gordon reviews the discovery and general recognition of the organism concerned, viz.: the Diplococcus intracellvlaris meningitidis of Weichselbaum ; and says, "At the present day, therefore, it is generally admitted that the Diplococcus intracellular is of Weichselbaum, or as this microorganism is sometimes termed Micrococcus meningitidis cerebrospinalis, or more briefly the meningococcus, is certainly the chief, and apparently the sole, bacteriological factor in epidemic cerebrospinal meningitis." The identification of the meningococcus, he proceeds to say, is not a simple matter. There are numerous other micro-organisms which resemble it. Special methods and great care are 21322 P 2 requisite to identify it. He gives some—and the most important—of its distinguishing characteristics :— 1. Morphologically, it is a coccus, usually a diplococcus. 2. As to situation, it is chiefly intracellular, but this is not constant. 3. As regards stains, it is discoloured by Gram's method. 4. As regards cultural characters, Optimum development of the meningococcus occurs at 36°—37° C., and at 42° C. growth is arrested. " A character of first-rate importance from the differential point of view is the fact that the meningococcus will not grow at a temperature below 25° C." There are other distinguishing characteristics, viz.,its vitality, pathogenesis, agglutination and fermentation. But apart from these, if the micro-organisms does not fulfil tests 3 and 4 it cannot be considered to be the meningococcus ; for it may be one of the numerous other closely similar cocci. From Dr. Mervyn Gordon's description it will be seen how highly technical a proceeding is the identification of the distinguishing mark of cerebrospinal fever, and what a degree of skill and experience is necessary for the recovery of the true organism. With the view of ascertaining how far the methods recommended by him were carried out in the identification of cases certified during 1908, inquiry was made of several of the institutions from which notifications were received, as to the nature of the bacteriological inquiry commonly there in use for the identification of the meningococcus. These are set out below as follows, viz., Nos. A, B, C, D, E, F. A. D. 1. The organism a diplococcus. 1. The organism a diplococcus. 2. Intra- and extra-cellular. 2. Intra- or extra-cellular. 3. Gram-negative. 3. Gram-negative. 4. Growth on ascitic agar at 37° C. 4. Growth at 37° on agar smeared with rabbit's 5. No growth on ascitic agar at 22° C. blood. 6. Naked eye appearance of colonies taken into No further culture tests applied. Cases of menin- account. gitis returned as meningococcal on evidence fur- 7. With sugar media + ascitic fluid, meningococcus nished by above tests only. acidifies maltose, glucose, galactose, laevulose, not cane sugar, not lactose. The sugar test often not done, but considered to be of value. In cases of difficulty of diagnosis, the E. clinical features of the case are taken into con- 1. The organism a diplococcus. sideration. 2. Intra- or extra-cellular. 3. Gram-negative. B. No further bacteriological tests are applied. Evi- 1. The organism a diplococcus. dence furnished only by these tests warrants menin- 2. Intra- mainly, may also be extra-cellular. gitis being returned as meningococcal. 3. Gram-negative. 4. Grows on nasgar at 37° C. 5. Does not grow in broth—little in milk. 6. Naked eye appearances of colonies taken into F. account. 1. The organism a diplococcus. 7. The non-growth at 22° C. not considered to be 2. Intra- or extra-cellular. a necessary test. 3. Gram-negative. 8. The sugar test considered to be valueless. The examination of the organism is not carried Considered possible to diagnose cerebrospinal fever beyond this point; no cultural test is applied ; on bacteriological examination alone. in evidence furnished by these tests meningitis may be returned as meningococcal. C. 1. The organism a diplococcus. 2. Intra- or extra-cellular. 3. Gram-negative. 4. Growth on nasgar at 37° C. 5. No growth on nasgar at 22° C. 6. Naked eye appearance of colonies taken into account. The above points are taken into consideration in pronouncing on the presence or absence of the meningococcus. But Nos. 1, 2 and 3 would be considered sufficient, having regard to the clinical and other features of the case. It is evident that cases regarded by methods E and F as cerebrospinal fever, may be rejected by methods A and B. Yet all are recorded as genuine cases of the disease. A stronger illustration could scarcely be adduced for the necessity of a common standard of classification for cases of this disease. W. McC. Wanklyn. APPENDIX III. London County Council NUISANCE FROM FLIES. Report by the Medical Officer of Health, presenting further report by Dr. Hamer, Medical Officer (General Purposes) on the extent to which fly nuisance is produced in London by accumulations of offensive matter. (Ordered by the Public Health Committee to be printed, October, 1908.) During the summer of 1908 further investigations have been made with regard to " Nuisance from Flies," on lines similar to those followed in 1907, and the present report must be read with the report of that year. In 1908,141 places of observation surrounding nine sets of premises were chosen, as compared with 163 places of observation surrounding twelve sets of premises selected last year. For the most part the premises studied in 1908 have been either identical with or of a similar character to those watched in 1907. It is deserving of note, however, that one of the depots which caused so much nuisance last year was not used after June of the present year, and in correspondence with this it has been found (judging by the results obtained at fifteen places of observation surrounding this centre) that there have been at least six million fewer flies this year than last, in houses within a radius of 200 yards from the depot. Again, the disuse of a cowshed, which was a source of serious fly nuisance last year, has been followed by abatement of the nuisance in the neighbourhood of this shed. In 1908, as in 1907, the large part played by collections of horse manure in determining fly nuisance has been made abundantly apparent. The need of a power regulating the sanitary condition of stables; and, further, of strict exercise of the powers for requiring the removal of manure at sufficiently frequent intervals, and upon due precautions being taken with regard to such removal, has been long felt, but this need has been greatly emphasised now that it has become realised that the fly nuisance of cities is to so large an extent due to neglected conditions at stable premises. A number of interesting observations have been made in 1908 upon the different species of house flies. While the ordinary house fly, Musca domestica, is by far the mo3t common species, some thousands of specimens of Homalomyia canicularis (the smaller house fly) and Stomoxys calcitrans (a biting fly) have also been caught. It has been possible from the figures now available to construct a chart giving the curves of seasonal prevalence of these three species of flies. Musca domestica is found to be distinctly later in appearance, and also to remain until a later period of the year, than the other two species. Musca domestica preponderates so largely over other flies that the curve for this species practically corresponds with that for " total flies." The report also refers to the question of diarrhœa. No final decision can be given, but in the present state of knowledge it appears desirable to maintain a critical attitude as regards acceptance of the view that the fly acts as a carrier of the diarrhoea organism. Shirley F. Murphy, Medical Officer of Health. Dr. Hamer's Report. In continuation of fly observations of last year, a further series has been made throughout the summer of 1908. In 1907 twelve centres were selected and around them places of observation from six to twelve, and in some instances more in number, were chosen. The last-named places were, as a rule, the kitchens or living rooms of tenements occupied by poor people; and in these rooms fly papers were exposed for periods of two or three days,* and the average daily number of flies caught on the papers was thereupon determined (For details, see Report of 1907). In the summer of 1908 similar methods were adopted, though these were, as the result of the experience gained in 1907, in certain respects somewhat amplified and amended. For purposes of comparison, it may be noted in the first instance that The twelve centres of 1907 included — The nine centres of 1908 included— Four Depots, at three of which stable manure, Four Depots, at three of which stable house refuse, or both, were manipulated, manure, or house refuse, or both, were Two Stable premises, manipulated, A Cattle Market and two Cowhouse premises, Two Stable premises, Two Offensive trade premises, and A Cowshed, A jam factory. A Glue and Size Manufacturer's premises, and A jam factory. *It would have been more satisfactory to have exposed the papers for shorter periods, but the labour entailed made this impracticable. A paper which has been exposed for two days and on which a number of flies has been caught, is found to trap very few flies on the third day. Thus the records of flies caught are apt to show a drop on days when the "average daily number" is calculated from a three days' exposure of the paper, as compared with days on which it is calculated from a two days' exposure. 18484—2000—23.11.08 S.S./5974 2 In 1908, at three of the depots the Borough Councils or contractors concerned continued operations as in the preceding year. The use of the fourth depot was, however, discontinued after the end of June, no doubt in the main as the result of action taken by the Public Health Committee of the London County Council. Turning now to the stable premises—No. 6 of last year's report was again used as a centre , but in place of No. 5 of the same report a new stable centre was chosen. The observations made in 1907 at premises in the neighbourhood of the cattle market were not maintained in 1908. Thus centre No. 7 of last year disappears from the list. One of the cowhouse premises of 1907 (No. 9) has ceased to be used as a cowhouse; for various reasons it was, moreover, felt that there would be advantage in selecting a fresh cowhouse to take the place of No. 8. It will be seen, therefore, that in 1908 only one cowhouse was made a centre for observation. The two offensive trade premises of 1907 yielded, comparatively speaking, few flies, but having in view an object, to be later referred to, a new set of offensive trade premises was chosen as a centre for observation in 1908. The investigation of the question of fly prevalence in premises surrounding the jam factory was again undertaken, as in the previous year. Thus, nine centres in all were selected in 1908, and for purposes of reference it may be noted that— Centres 1, 2, 3, 4 and 6, have the same reference numbers in the two years. Centres 5, 7, and 8 are new centres not appearing in 1907 ; and centre 9 of 1908 is the same as the centre numbered 12 in 1907. As the twelve centres of 1907 were described in the report of that year, it is unnecessary to repeat these descriptions. It should be noted, however, that centre 2 was not used as a depot after the end of June, 1908, and in correspondence with this fact it will be observed that far fewer flies were secured on the papers hung in rooms surrounding this centre (see Diagrams 1907-8)—in fact, the abandonment of the use of the depot premises must be correlated with a diminution of nearly 100,000 in the number of flies, caught on papers exposed in the living rooms surrounding the depot during July, August, September and October. If it be assumed that the fifteen rooms in this centre in which fly papers were exposed may be taken as representing the average conditions in living rooms (as opposed to rooms used exclusively for sleeping purposes) within 200 yards of the depot, it would follow that during the past summer the number of flies has been less by something like six millions in this area than was the case in the previous summer of 1907. In this connection it may be here noted that the abandonment of use of one of the cowhouse premises (centre 9), in proximity to which much nuisance was experienced in 1907, led in 1908 to a remarkable diminution in the number of flies in the neighbourhood of this shed— a particular room in which thousands of flies were caught in 1907 being found to be almost entirely free from flies in 1908. If the observations of 1907 served no other purpose, they at least, by helping to bring about discontinuance of a serious source of nuisance, materially benefited the residents in the first of the localities in question. In order to complete the record of centres, a brief description of the three new centres chosen in 1908 is appended. No. 5. Stable premises.—This centre consists of a number of railway arches used for stabling horses by a firm of carmen. No. 7. Cowshed premises.—This cowshed is licensed for 16 cows. It is an old brick building with a loft for the storage of fodder. In the small yard adjoining, there is a milkstore, and there are also receptacles for grains and dung. The premises are within J mile of London Bridge, and they are surrounded by small houses, occupied by poor people, the neighbourhood being densely populated. No. 8. Offensive trade premises.—On these premises, which cover several acres of ground, the business of a manufacturer of glue and size is carried on. The neighbouring houses are for the most part occupied by poor persons. At the request of Dr. Copeman, F.R.S., Medical Inspector of the Local Government Board, flies were supplied to him by the Council's Inspectors, Messrs. Mernagh and Powell, for examination in connection with an enquiry on behalf of that Board in which he is engaged, and, again, at his request, special observation wa3 kept by Mr. Powell on houses in the neighbourhood of centre No. 8, with a view to determining the extreme distance to which a rare species of fly, found at the centre could be traced. Incidentally, a number of observations were made with "fly balloons," and in some instances these were placed out of doors instead of in living rooms. It was found that some species of flies were caught more easily in balloons than on fly papers, and, again, some flies were caught in larger numbers when the " balloon " was placed out of doors than when it was placed indoors. The general impression was created that out-of-door observations show a larger number of flies early in the season than do in-door observations.* Examination of fly papers on lines similar to those of last year was undertaken in the Council's Public Health Department, by Mr. Bates, and in his absence in September by Mr. Palmer, and certain results of interest have accrued from this work. These may be summarised as follows. 1.—As to the species of flies. As in 1907, more than nine-tenths of the flies caught were examples of the common house fly, Musca domestica. In Diagram I. (right-hand Inset), it will be noted that *Throughout the summer Mr. Powell caught, in four balloons, nearly 6,000 flies of which 24 per cent. wero Homalomyia canicularis, 15 per cent. were Calliphnra erythrocephala (the common bluebottle), and nearly 2 per cent. were Muscina (Cyrtoneura) stabulans; while on four fly papers exposed in similar positions 35,000 flies were caught of which 17 per cent. were Homalomyia canicularis, less than 1 per cent. were Calliphora erythrocephala and considerably less than 1 per cent. were Muscina (Cyrtoneura) stabulans. The difference in the percentages is particularly striking in the case of the bluebottles. 3 carves for "All flies and Musca" are plotted out to a scale which differs from that employed for" Other species." Study of this Diagram and of Diagram III. shows that Homalomyia canicularis has a seasonal curve which deviates notably from that of Musca domestica; indeed, while some 20 per cent. or more of the flies caught in June were specimens of Homalomyia canicularis, less than 1 per cent. of those caught in October belonged to that species. It will be seen on study of Diagram III. that a much larger percentage of Homalomyia was obtained in the case of certain centres, notably in that of centre 8, the glue and size factory. At this centre, moreover, specimens of an unusual species of fly were not infrequently encountered (see page 2 and Diagram III). At two of the centres considerable numbers of Stomoxys calcitrans were secured. At one of these centres (centre 7), a cowshed, vast numbers of this fly were found in the shed throughout the summer. At a cowshed near to the other centre in question (centre 6), a considerable, though much smaller, number of Stomoxys was caught. In the neighbourhood of two other centres, two single specimens of Stomoxys were encountered. In the cases of the two cowshed centres, Stomoxys calcitrans was found only in the sheds; no single specimen was obtained in a living room in the near neighbourhood of the sheds. It will be necessary to recur to this point later. No Stomoxys calcitrans was found in places of observation surrounding five of the nine centres. 2.—As to comparison, made last year, between centres where the influence of horse manure was very pronounced and the remaining centres. In 1907 there were four "stable centres" and eight "other centres." In 1908 there are four "stable centres" and five "other centres." In 1907 the curve for "stable centres" did not reach its maximum until the end of September, that for the other centres had already attained a maximum rather more than one month earlier. In 1908 the behaviour of the two curves up to the middle of August will be found to be similar to that in 1907 (provided, in making the comparison, the differing proportions of "stable centres" to "other centres" in the two years be allowed for). While in the later year, however, both curves show decline after that date, with a slight rise at the end of September, in the earlier year the "stable centres" do not show this decline, but the curve steadily ascends to its maximum at the end of September. There is correspondence in the two years in one respect, the curve showing average yield of flies per "stable centre" runs at a higher level, from mid August to the end of September, than does that showing the average number for the "other centres." In 1907, the "superadded wave" manifested in the curve giving totals for all centres, was thus due in the main to the maintained rise of the curve for the " stable centres," and it was suggested, inasmuch as the influence of stable manure had undoubtedly made itself felt at the " other centres " (though to less extent than at the " stable centres"), that, if the said influence could be entirely eliminated from the other centres, the "superadded wave" of late September would disappear from the "other centres" curve. In other words, there were two distinct seasonal curves—one for " other centres " having its maximum towards the end of August, and one for "stable centres" having its maximum rather more than one month later, just at the end of September. The latter wave was further attributed to the " breeding of batches of flies in horse manure, during the close of the summer and early autumn." The observations of 1908 raise the question as to the influence in this connection of the differing seasonal distributions of Homalomyia and Musca. Thus Homalomyia attained a maximum on August 7th (see Inset in Diagram I.), and then fell off, so that by the end of the month of August only a very small percentage of the flies caught belonged to this species. The maximum for Musca was not attained until August 14th, and further the decline of Musca was less marked during the latter part of August than that of Homalomyia. Thus it might be suggested that the differing seasonal curves of Musca and Homalomyia account for the slightly marked superadded wave of 1908 and the more marked superadded wave of 1907, and therefore account in some degree for the differing behaviour of the "stable centres" and "other centres" curves. The differing seasonal curves of the two species do not, however, wholly explain the want of correspondence in the " stable centres " and " other centres " curves. The numbers of Homalomyia are throughout much smaller than those of Musca, and, as a matter of fact, if Homalomyia be excluded from consideration altogether, and the numbers of Musca alone taken, the differences in the " stable centres " and " other centres " curves are still exhibited. Thus the " breeding of batches of flies " (and we may now go further and say of Musca domestica) " in horse manure during the close of the summer and early autumn " is no doubt in the main responsible for the differing behaviour of the curves for " stable centres " and " other centres " respectively. The part played by stables in determining fly prevalence is indeed one of paramount importance; and inasmuch as some stables are much more productive of nuisance than others, question arises as to whether efforts should not be made to secure uniformity both as regards compliance with a proper standard in respect to sanitary conditions and further as regards regular removal of manure. 3.—As to the mutual antipathy of the various species of house fly one to another. It was noted quite early in 1908, by one of the Council's inspectors, Mr. Tuck, that specimens of Homalomyia were, as a rule, present on a particular part of the paper, viz., at the lower margin. This inspector's practice had been to fold back a strip about J inch in breadth at the lower part of the paper and then to turn over the two corners (see Diagram IV). This expedient was adopted with a view to providing a means for catching " honey gum " which trickled down from the surface of the paper to its lower part, as otherwise the sticky gum was apt to fall upon floors, tables, etc., and cause annoyance. The lower § inch of fly paper exposed would under these circumstances be the back, not the front of the paper, and the surface would therefore not be a gummed one. Mr. Tuck, however, had further adopted a practice of again folding back this strip, so as to bring its ungummed surface into contact with the gum 4 on the paper, and of then releasing the portion folded back and allowing it to hang as before at the lower margin of the paper. It was upon the slightly gummed surface of the marginal strip that Homalomyia specimens were particularly apt to be found (see Diagram IV. The specimen of Homalomyia seen at the upper part of Fig. 1 in Diagram IV. was, no doubt, transferred from the lower strip, for the paper had apparently been folded over.) It was thought that possibly Homalomyia by preference alighted on a surface (the marginal strip) upon which there was but little gum; and again, the suggestion was made that possibly, while, Musca and Homalomyia both alighted upon the strip, Homalomyia alone was held there, but this, it will be noted, fails to explain the absence of Homalomyia from the rest of the fly paper. Yet again it was conjectured that Homalomyia had a habit of approaching from below upwards, and thus of alighting on the lowest part of the paper; and this contention was supported by the distribution of the two species of flies on a paper (see Diagram III., Fig. 3) having its gummed surface nearly horizontal, but with one half of that surface at a somewhat lower level than the other half. This last hypothesis was further supported by the fact that, in instances in which the special phenomemon was observed, the place in which the paper was exhibited was at a somewhat high level (in first-floor rooms, and in one case in a third-floor room). Mr. Powell, the inspector, who supplied the very remarkable paper shown in Diagram IV., Fig. 2, informs me that the room in question invariably supplied a large percentage of Homalomyia; that it was a dormitory occupied by 87 men; and that no food was prepared or consumed in it. The paper was not only at a high level (third floor), but it was further suspended 10 feet above the floor of the dormitory, and these facts help to explain the extraordinary distribution of flies upon it. Whatever the explanation of this curious phenomenon may be, it is clear that Homalomyia tends to alight on certain portions of the gummed papers which are comparatively free from Musca; and in corroboration of this, the fact may be noted that even in the earlier part of the year, when Homalomyia was specially in evidence, papers which yielded large numbers of Musca supplied comparatively small percentages of Homalomyia. More striking even than the behaviour of Homalomyia was that of Stomoxys, in relation to presence of Musca. Stomoxys calcitrans was found in large numbers at centre 7 and in smaller numbers at two other centres. But despite the vast numbers of this fly in the cowshed itself, at centre 7, no specimens of Stomoxys were secured at surrounding stations of observation in living rooms of houses. It was indeed remarkable to observe that although, during July and August for example, there were at times as many as 100,000 specimens of Stomoxys (this is, of course, an estimated number based upon the actual number found on a measured surface) in the cowshed, the papers exhibited in three living rooms situated within 10,10 and 20 yards of the shed yielded not a single specimen. The flies caught in these living rooms were almost exclusively Musca domestica. The sharpness of the line of demarcation between Stomoxys and Musca was observed on more than one occasion, when it was noted that up to, and even at the door of, the cowshed, Musca was plentiful and Stomoxys quite uncommon, or entirely absent; while, on the cows themselves, and within the shed generally, Stomoxys was the only fly found. A few specimens of Stomoxys were, however, seen in a shed used for dairying purposes, which adjoined the cowshed. The workers in this shed and in the adjoining house and those in the cowshed itself said they were never bitten by Stomoxys. This immunity was very striking, having in view the extent to which the flies collected on the fly papers were gorged with cow's blood. Although in the neighbourhood of these London cowsheds, Stomoxys did not enter houses, a different experience is obtained elsewhere. Thus, during August, I found Stomoxys calcitrans was plentiful in an isolated house in the country where there was no Musca. Stomoxys under these conditions entered living rooms freely, but did not alight on food or on human beings with the persistency of Musca; the fly showed a preference for sunny patches on the floor or on the window panes. The entire absence of Musca from the neighbourhood of this house seems worthy of note. I attempted to find specimens in the village half a mile away, but though Homalomyia was common enough there, I did not, in the course of a somewhat cursory examination, succeed in finding a specimen of Musca. 4. As to the mutilation of flies caught on the papers. During July and August many papers from various parts of London were found to present mutilated flies. In some instances the fly was decapitated, or the abdominal contents had been removed, a shell only, as it were, of abdomen remaining. On some of the papers a track of mutilated flies could be traced, so that clearly some fly-eating creature was responsible for the damage caused. Various suggestions were forthcoming in explanation of this phenomenon. First, that spiders were concerned. It was found by experiment that some spiders, and more particularly large spiders with strong legs, were able to walk without difficulty over " honey gum " papers on which there were many flies. If there were but few flies the spider could not as a rule traverse the paper. As a matter of fact, four spiders were trapped on fly papers exposed in the ordinary way. Other suggestions made were that various insects might have caused the mischief. This year, as last year, several bugs were found upon fly papers. It may be noted, moreover, that two wasps were caught. Further observations bearing upon the relation of flies to diarrhoea. At the outset, attention may be directed to two considerations, of which mention was not made in the report of 1907, and which, it may be thought, favour an hypothesis that flies serve as carriers of infection. It might in the first place be suggested, in view of the occurrence of the Homalomyia season at a period slightly earlier than the time of special prevalence of Musca, that if the seasonal curve 5 of the house-fly were dissected into its constituent parts (by separation of the flies into their three principal species—Musca, Homalomyia and Stomoxys), one or other of the three contributing curves, would be found to correspond even more closely with the diarrhoea curve than does the curve for "total flies." It may be noted, however, that the points to which attention was directed in last year's report,! as suggesting that the correspondence in the fly curve and diarrhoea curve is not quite of a kind which might be expected, supposing flies to stand in causal relationship to diarrhoea, remain practically unaffected by a substitution in the comparisons made of a curve for " Musca domestica " for that for " total flies." (See the right-hand Inset in Diagram I.) In the second place, Musca domestica is especially common in the poorer parts of towns, and it is, of course, among the poorer urban populations that diarrhoeal mortality is high. More precise information is desirable under this head, and the question is clearly one which deserves closer attention. It was pointed out, in the report of last year, that deaths from diarrhoea do not appear to occur, so far as the matter has been investigated, with greater frequency in populations living close to collections of stable manure, than in similar populations elsewhere. The experience of Dr. Harris, of Islington, was referred to last year, and I am now told by Dr. Porter, of Finsbury, that only four deaths occurred, in the summer of 1908, in a population of some 5,000 persons living in an area surrounding certain large stables (Centre No. 6, of this Report). In an area in Southwark, on the other hand (surrounding a cowshed, Centre No. 7), Dr. Millson, of Southwark, informs me, there were five deaths, in 1908, in a population of some 1,500 persons. The question of diarrhoea mortality, in dwellings near stables, has been discussed by Dr. Waldo in his Milroy lectures of 1900, by Dr. Niven in his annual reports, and by Dr. Sykes (" Public Health and Housing"). On the other hand, there are certain further arguments based upon study of the house fly and diarrhoea curves which seem to tell against belief in the causal relationship of flies to diarrhoea. For example, it is interesting to compare the two curves of 1908 with the corresponding curves of 1907. In the last-named year the culminating points of both curves were reached exceptionally late, and in one other respect the year was quite unique, inasmuch as the amount of diarrhoea was particularly small. The year 1908 has from both points of view been a more normal year. While, however, the deaths from diarrhoea were far more numerous in 1908 than in 1907 (during the eight weeks of maximum diarrhoeal mortality more than twice as many diarrhoea deaths occurred in the latter as in the former year), the number of flies was not correspondingly excessive; for in 1907 about 1,000,000 flies were collected at 163 stations, while in 1908 about 1,200,000 flies were collected at 141 stations. The figures, though very far from being conclusive, suggest that it would be well to ascertain whether the number of flies undergoes as marked fluctuation year by year as does the amount of fatal diarrhoea. This consideration, even if fully borne out by more complete enquiry, by no means, however, finally disposes of a fly-borne diarrhoea hypothesis, for (accepting for the purposes of argument this lastnamed hypothesis), the fluctuations of diarrhoea may be associated with variations in the amount of infective material, as well as in the numbers of the supposed carrier, the fly. Comparison of the curves for 1908 and 1907 brings to light, moreover, a striking fact regarding the behaviour of the fly and diarrhoea curves in the two years. From the middle of August to the end of the first week of October, 1907, the number of flies was practically stationary. Again, from September 4th to October 5th, 1908, the number of flies was also practically stationary. Further, judging by the total number of flies caught, in relation to the number of places of observation in 1907 and 1908, practically the same extent of prevalence of flies (in the parts of London concerned) was maintained during these two stationary periods of the two years in question. Yet during the stationary period of 1907 diarrhoea was steadily increasing, while during the stationary period of 1908 diarrhoea was steadily declining. In order to explain this phenomenon on the fly hypothesis, it becomes, therefore, as has been already surmised, necessary to assume that in determining variations in amount of diarrhoea, importance attaches not so much to the number of carriers of diarrhoea organisms, as to the extent of distribution of the organism itself. If this be admitted, however, it is (on the assumption that flies cause diarrhoea) clear that precise correspondence of the carrier curve, i.e. the fly curve, and the diarrhoea curve cannot be expected to occur. It may further be pointed out that, just as the various flowers, vegetables and fruits have their special times of appearing as the year goes by, so the flies and the diarrhoea may be expected to have a particular seasonal distribution. Thus, to take the case of fruits—strawberries, cherries, currants, raspberries, greengages, plums, pears, damsons, and blackberries, each in turn come into season throughout the summer months; the strawberries beginning in June and the blackberries, damsons and pears not having quite disappeared in October. If the figures of the " Market Returns," or those of the " Board of Trade Journal" giving the number of hundredweights of imported fruits, be used to plot out curves, it will be found that those appertaining, say, to currants and cherries, or those of plums and pears (see left-hand Inset in Diagram I.), show as close correspondence as the curves for diarrhoea and flies. Of course no one would infer that the cherries were caused by the currants, or the pears by the plums. The closeness of the correspondence in these instances therefore suggests caution as regards deducing causal relationship of flies to diarrhoea. In last year's report reference was made to the belief, formerly widely entertained, that prevalence of diarrhoea occurred during the period in which the earth temperature, at a depth of four feet below the surface, exceeded a particular height. It has been suggested, however, that this correspondence is, after all, a mere coincidence. Moreover, in 1907, the diarrhoea, judging by the four feet earth temperature curve, was several weeks behind time, and examination of the London figures for other years shows that the relation between diarrhoea and the temperature of the earth, four feet below the surface, is by no means so precise as it has been generally held to be. It is possible that the doubt, now widely 18181 B 6 entertained in this instance, may later be extended to the case of flies in relation to diarrhœa. At any rate, in the existing state of knowledge, too great insistence must not be laid upon the close correspondence of the two curves as being a proof that the one phenomenon is due to the other. In the absence of other evidence confirmatory of causal relationship, the fact of similarity of seasonal distribution in itself suggests reference to some one common cause, rather than appeal to an hypothesis that the one seasonal distribution is dependent upon the other. In a paper recently read before the Epidemiological Section of the Royal Society of Medicine, Dr. Owen H. Peters advanced the hypothesis that the seasonal rise of diseases such as diarrhœa and enteric fever stands in relation "to the cumulative effect of certain degrees of temperature extending over a certain time," that, in fact, a maturing or ripening process similar to that which occurs in the case of the harvest, and indeed in the vegetable world generally, is necessary. In the light of this theory, the periodicity manifested by the diarrhoea organism (whatever its nature may be) becomes all important as regards determining the season of diarrhoea prevalence. Dr. Peters notes,however, that, "since the relative conditions determine that the diarrhoea curve always falls within "the period of fly prevalence, it will be impossible by charts, etc. . . to show that epidemic diarrhoea is propagated without the help of flies." On the other hand, it may be argued' that, assuming the crop of diarrhoea organisms to be produced by a gradual ripening process, extending over weeks or months, it is still conceivable, inasmuch as the fly and diarrhoea seasons begin almost coincidently, that the fly may act as a carrier and thus play some part in favouring transmission of infection. Thus, to take a case which it might be suggested is a parallel one—the fertilisation of clover by humble bees. Suppose it to be surmised, in default of direct evidence, that bees fertilise the clover, because just at the time when the clover is ready to be fertilised the bees are busy in the fields. It might then be pointed out by some objector that the fertilisation of the clover must necessarily be preceded by certain processes of growth, having a definite seasonal periodicity and so on, and that the reason why the precise moment of arrival of the time, when the clover is ready to be fertilised, coincides with the time when bees are busily engaged in visiting flowers is that both seasonal periodicities are due to a common process of maturation—in fact, that no causal relationship between bees and the fertilisation of the clover has been established. So far as the hive bee is concerned, it appears that the more or less simultaneous occurrence of bee activity and clover fertilisation does not imply cause and effect relationship ; for, according to Darwin, the hive bee, which has a short proboscis, cannot lay the clover under contribution for honey, and it is only the humble bee, with its longer proboscis, which visits the clover and plays a part in bringing about the process of fertilisation.* Anyone who objected, therefore, to the argument of simultaneity, so far as clover fertilisation and humble bees are concerned, would be silenced by direct evidence that the humble bees fertilise the clover, and, similarly, if it should chance that evidence is ultimately adduced showing that flies transmit diarrhoea, those who are not now satisfied as to the claims of the fly-borne diarrhoea hypothesis will be compelled to admit its truth. W. H. Hamer, Medical Officer (General Purposes). *Darwin writes, "On the Origin of Species," chapter IV., "The tubes of the corollas of the common red and incarnate clovers (Trifolium pratense and incarnatum) do not, on a hasty glance, appear to differ in length; yet tho hive bee can easily suck the nectar out of the incarnate clover, but not out of the common red clover, which is visited by humble bees alone ; so that whole fields of tho red clover offer in vain an abundant supply of precious nectar to the hive bee. Thus it might be a great advantage to the hive bee to have a slightly longer or differently constructed proboscis. On the other hand, I have found by experiment that the fertility of clover depends on beas visiting and moving parts of the corollas, so as to push the pollen on to the stigmatic surface. Hence, again, if humble bees were to become rare in any country, it might be a great advantage to the red clover to have a shorter or mora deeply divided tube to its corolla, so that the hive bee could visit its flowers. Thus, I can understand how a flower and a bee might slowly become cent.cent. modified and adapted in the most perfect manner to each other." DIAGRAM 1. Diagram shewing the relation in point of tine between prevalence of flies, earth temperature, and diarrhœal martality in London, 1908. « j —f \ I * F*. vMill ( ~j 1 ,- ^ rr ,- 1 j ■A f\ ■ . v ■I U m i i/iJ/l DIAGRAM 2. Diagram shewing the average daily, number of flies collected oat successive intervals from June to October 1908 at stations surrounding the 9 selected centres. a / v DIAGRAM 3. Diagram shewing the proporation of each of four species to the total number of flies caught at the nine centres in successive weeks from July to October 1908. Sl». | ■v»'>' _»4$l awi _eaiex V J k ■ L_ !«*&. vtvt <.t\* .t»ir *v». w ■ » *_ |» » I L_ U&3- TtIi j&i _2S*» . -SiS?:-1 "•«" ■ I W_ I 1 ■ • ■ • * SAU . T ^ 515L, _S£>2> I _v5fi?r_ . ;b*m im. jm fVm Sit. .|Si we. _5>$e. ' •wft - >-••.. jesar I «»»- j Diagram 4. DIAGRAM shewing the anomalous distribution of Musca and Homalomyia on fly papers. •-Musca. x=Homalomyia. No. 1. Paper hung vertically in a first floor front No 2 Paper hung on ceiling joist 10 feet above room used as a living room floor in a third floor dormitory (87 beds) No. 3. Paper hung on ceiling, gummed side downwards. The paper sagged somewhat to the left of the centre line Nos. 4 and 5. These two papers were hung side by side In the same room as Papers Nos. 1 and 3. The turned up lower strip of the paper on the left waft gummed, that of the paper on the right was not. APPENDIX IV. London County Council. HOMELESS PERSONS. Report by the Medical Officer submitting the result of a census of homeless persons taken on the night of 15th January, 1909. Ordered by the Council to be printed, 16th February, 1909. In the following statement, I submit particulars of a census of homeless persons in London taken in accordance with the instruction of the Committee, on the night of Friday, the 15th January, and for the purposes of comparison I include the figures obtained when a like census was taken in January, 1904, February, 1905, and February, 1907. The following table enables the figures of 1909 to be compared with those of the previous years:— Number of Persons found Homeless at Night. Date. Men. Women. Children. Total. January, 1904 1,563 184 50 1,797 February, 1905 1,869 312 — 2,181 February, 1907 1,998 402 4 2,404 January, 1909 1,895 170 23 2,088* *Including 1,329 men accommodated for a few hours in shelters, but unprovided with beds (see text). In comparing these figures, it should be pointed out that in 1904 the area covered by the Council's officers who made the enumeration was somewhat smaller than that included in recent years, and, in the light of experience since gained, it is estimated that the number of homeless persons on that occasion might have been 2,000. It is, moreover, necessary to give some explanation of special conditions existing at the present time which affect the figures for 1909. These special conditions have arisen in the following way:— At the time of the census in 1905, the Salvation Army had instituted a system of feeding homeless persons at night at their shelters in Wych-street and Whitechapel-road. In 1907 this distribution of food was still being carried on though the applicants were fed on the Embankment instead of at the shelters. This year, however, the new method was tried of providing homeless persons between the hours of 12.30 a.m. and 3.30 a.m. with food and shelter in four institutions of the Salvation Army, where, however, no sleeping accommodation was provided for them. The Church Army, moreover, in connection with the use of tents in Aldwych, known as the King's Tents, where homeless men receive food and a ticket for a bed in a common lodging house in return for work at woodchopping, had leased a building in Millbank-street, Westminster, where the applicants for work were allowed to sit antecedent to performing their allotted task. The mode of admission in each case was by means of tickets distributed up to midnight on the Embankment. The Salvation Army and the Church Army thus provided shelter for 1,184 homeless persons on the night of the 15th January, while 145 persons were provided with similar accommodation in other institutions. If to this number the 759 persons found in the streets be added, the total number of homeless persons would be 2,088 a number comparable with the figures for previous years. It must be remembered, however, that several institutions in London provide beds free of charge, and the inmates of these institutions on the night in question, although of the homeless class, are not included among the 2,088 homeless persons referred to, in view of the fact that they were provided with sleeping accommodation. A table showing the free beds for persons of the class now being dealt with is included in the report. Again, I learn from the Church Army authorities that 638 tickets entitling the applicant to a bed for one night in a common lodging house were issued on Friday the 15th January, between the hours of 3 a.m. and midnight. All these tickets would be available for use the same night. It might be urged that the users of these tickets should be classed as homeless; in past years, however, it has been the practice only to include those persons as homeless who were unprovided with a bed on the particular night on which the enumeration was made, and the same course has been adopted this year. In any case the inclusion of these 638 men in the total of homeless persons would still give a number much smaller than in previous years if the corresponding figures for these years were similarly included, for the number of tickets distributed is certainly no greater than formerly, and in fact is less by nearly a thousand, than on the night of the census in February, 1905. It is impossible to state with any approach to accuracy, the number among the persons receiving the tickets from the Church Army who use them for the purpose for which they are intended, for I am informed that t he sale of these tickets is carried on to a considerable extent. Thus, a particular individual might perform his allotted task at woodchopping, which according to officers of the Army is valued at 2id.,in return for which he receives two meals and a ticket for a bed. This ticket, worth about 4d. or 5d., he has no difficulty in selling to any regular frequenter of the several common lodging houses at which the tickets are available. After disposing of the ticket for say twopence, the man may take his chance of another meal from the Salvation Army with three hours rest in the warmth of the shelter. 19483—2,000—4.3.09 S.S./7814 2 On the night of the last census (15th .January) there was heavy rain between 11 p.m. and ll.30 p.m. Afterwards although the weather was fine there was a very strong, cold wind. Having regard to these conditions it might be expected that a large number of persons would be found taking shelter on staircases or under arches, and it is somewhat surprising that only 49 men and 39 women were so found. In 1907 on a fine night, only 50 persons were found on staircases and under arches, while in 1904, when the night was wet, as many as 100 males and 68 females had thus found shelter. It will be noted that the number of homeless women found in 1909 is less than in 1907, and, further, that decrease is manifested in the number of women occupying either single beds or sharing "doubles" in the licensed common lodging houses. It does not appear that this decrease in the number of women is due to larger use being made of the free accommodation provided by philanthropic bodies, and it is an interesting fact that in the two homes instituted by the late Dr. Barnardo, the one at St. John's-place, Kensington, the other at Commercial-street, Whitechapel, into which are admitted, free of charge, women with children and girls under twenty years of age, the accommodation provided was in excess of the demand. Thus in the Kensington home, on the night in question there were only 6 females and 15 children although the house is licensed for 43 women, and in the Whitechapel home, where there are 71 beds there were only 22 women and 8 children. Indeed the wife of the deputy of the latter house stated that while the average number of inmates was about 40 the number had recently frequently fallen as low as 10. The number of persons found on the Embankment waiting for the distribution of tickets by the Salvation and Church Army officers was 1,350. Of these 600 received tickets from the Church Army and 640 received tickets from the Salvation Army, so that 110 men received no tickets. At a free shelter in Limehouse, however, 114 men received a meal of bread between midnight and 4 a.m., and this number may have included a number who were unable to obtain tickets on the Embankment. In comparing the number of homeless persons in the several years, it is desirable to have regard to the number of persons found in common lodging houses, shelters, and casual wards, as many persons frequenting these institutions may, upon occasion, find themselves among the homeless. On each occasion therefore of numbering the homeless, a census has been taken of the common lodging house population on the particular night, and by the courtesy of Mr J. S. Davy, C.B., of the Local Government Board I have been supplied with similar returns in respect of the casual wards. The following table shows the extent to which use was made of the authorised accommodation in licensed common lodging houses on the nights of the several censuses since and including 1904 :— Licensed Common Lodging Houses. Date. Authorised accommodation. Number of persons occupying beds. Men. Women. Couples. Total. Men. Women. Couples. Total. January, 1904 25,718 2,281 447 28,893 21,058 1,517 390 87 Children 23,442 February, 1905 25,671 2,450 422 28,965 21,055 1,578 357 34 Children 23,381 February, 1907 25,599 2,436½ 245 28,525 20,438 1,598 207 22,450 January, 1909 25,976 2,365 245 28,831 20,059 1,483 161 21,864 For the casual wards the corresponding figures are as follows:— Casual Wards. Date. Accommodation. How used. Men. Women. Women and children. Total. Men. Women. Children. Total. January, 1904 1,243 410 114 1,767 1,034 175 9 1,218 February, 1905 1,263 420 120 1,803 926 210 3 1,139 February,1907 - - - 1,882 - - - 1,137 January, 1909 1,241 444 122 1,807 1,001 184 3 1,188 The next table shows the common lodging house and casual ward accommodation, the extent of its use, and the number of homeless persons in each year. Date. Accommodation (persons). Persons. C.L.H. Cas. wards. Total. C.L.H. (Inmates.) Cas. wards. (Inmates.) Homeless. Total.* January, 1904 28,893 1,767 30,660 23,442 1,218 1,797 26,457 February, 1905 28,965 1,803 30,768 23,381 1,139 2,181 26,701 February, 1907 28,525 1,882 30,407 22,450 1,137 2,404 25,991 January, 1909 28,831 1,807 30,638 21,864 1,188 2,088 25,140 *These figures do not include the persons in the unlicensed homes and institutions referred to in table No. IV., and who might be regarded as belonging to the common lodging house class. 3 It will be seen from Table IV. that nearly 1,000 persons were provided with sleeping accommodation and food in shelters, not licensed as common lodging houses, belonging to philanthropic bodies. These persons have not been included among those of the poorest class shown in the preceding table, as the figures for each of the previous years in which enumeration were made are not available. The accommodation at the shelters and labour homes in question, however, is always fully used and it may safely be assumed that no great differences in the numbers of persons thus accommodated would be found if the figures for each of the years under review could be obtained. On the night of the 15th January some inquiry was made at the King's Tents, maintained in conjunction with the Church Army scheme of providing work and food for homeless men, as to the length of time the applicants for tickets had been in London, for it has been urged that the facilities offered for food and shelter attract men from the country. Of 158 men questioned, 55 stated they had been in London from one week to ten months, and of these 16 said they had been here only one month or less. This latter proportion is not so high as that obtained in 1905, when of 100 men questioned 30 admitted that they had come to London so recently as from one day to one month previously. A point noted at the time of this inquiry was the large proportion of young men and youths found among the homeless persons coming under observation. In my report on the results of the census made on February 1907, I commented on the facilities afforded in London for obtaining cheap or free food, and pointed out that at a philanthropic institu- tion in Shoreditch about 600 men were fed daily at a very small cost, a substantia] meal being provided for 2d. or 3d. a head. This institution also provides some 4,000 free meals each week. At the Church Army shelter in Millbank-street, the men are provided with a free meal of soup and bread on entering and another similar meal when they have completed their allotted task of woodchopping. The Salvation Army provides from 600 to 1,000 free meals of soup and bread each night, whilst in several of their shelters the payment of 4d. entitles a man to food and a bed. The London Congregational Union, moreover, at their shelter in Limehouse provide bread and the use of a bunk each night for 343 men free of charge and many others are here supplied with bread between midnight and 4 a.m. Other institutions provide free food, or food and shelter, and as I pointed out in my last report it would appear to be possible for a man to live so far as food is concerned at trifling cost to himself. The evidence obtained as the result of the several inquiries goes to show that there has been in recent years some diminution in the total figures giving the numbers of homeless persons and persons of the common lodginghouse class, that there is vacant clean accommodation available for all homeless persons at a trifling cost, and that for a limited number free accommodation and food is procurable. I have appended the following tables summarising the information obtained on the occasion of the last census. Table I. shows the number of homeless persons and their distribution in certain localities. Table II. shows the authorised accommodation in common lodging houses, the number of beds occupied, the number of beds vacant, and the number of persons who, for various reasons, were turned away. Table III. shows the free accommodation in shelters provided by philanthropic bodies and licensed by the Council, but does not include the beds in ordinary licensed common lodging houses occupied by persons on the night of the census whose accommodation was paid for by charitable organisations. Table IV. shows the accommodation in shelters not licensed as common lodging houses. Table V. shows details of the number of persons turned away from licensed common lodging houses, and the reason assigned for turning them away. (Sgd.) Shirley F. Murphy, Medical Officer of Health. 30th January, 1909. Table I. Number of Homeless Persons distributed according to Locality. Locality. Men. Women. Children. Embankment. Waiting for the distribution of tickets by officers of the Salvation Army and Church Army 1,350 — — Charing Cross, Shaftesbury-avenue, Holborn, City, Shoreditch 27 16 — Long-acre, Great Queen-street, Kingsway, Pinsbury, Broad-street, Bishopsgate 90 11 1 Millbank, Wardour-street, Soho, Long-acre, Chancery-lane, Ludgate-hill 193 38 21 King William-street, London-bridge, Thames-street, Dock-street, Aldgate 141 52 — Wheeler-street Arches, Booth-street Dwellings, Flower and Dean-street Arches and stairs 38 26 — Westminster Bridge, Vauxhall, Borough, New Kent-road, Peckham-rye 11 3 1 Knightsbridge, Edgware-road, Westbourne-grove, Notting-hill, Shepherd's Bush, Fulham Palace-road, Hammersmith 41 5 — Bermondsey, Southwark 12 11 — Totals 1,903 162 23 4 TABLE II. Common Lodging Houses. Sanitary district. No. of houses Accommodation. Census on 15th—16th Jan., 1909. No. of vacant beds on 15th—16th Jan., 1909. No. of persons turned away unable to pay, &c. Males. Females. Couples. Males. Females. Couples. Males. Females. Couples. Males. Females. Couples. Battersea 8 157 78 23 97 16 9 60 62 14 — — — Bermondsey 5 1,073 — — 821 — — 252 — — 4 — — Bethnal-green 14 712 — — 523 — — 189 — — 10 — — Camberwell 6 536 — — 523 — — 128 — — 7 — — Chelsea 9 337 52 — 254 36 — 83 16 — 3 3 — City of London 1 452 — — 442 — — 10 — — — — — Deptford 8 1,159 80 — 652 22 — 507 58 — 32 — — Finsbury 8 543 — — 414 — — 07 58 — 21 — — Fulham 1 43 — — 36 — — 7 — — 7 — — Greenwich 4 157 — — 102 — — 55 — — 1 — — Hackney 6 401 — — 254 — — 147 — — 6 — — Hammersmith 9 466 — 44 310 — 3 156 — 1 — — — Hampstead — — — — — — — — — — — — — Holborn 28 1,701 162 — 1,487 118 — 214 44 — 29 — — Islington 43 1,228 215 18 836 126 7 392 89 11 28 1 — Kensington 24 431 272 — 277 146 — 154 126 — — — — Lambeth 7 693 — — 626 — — 67 — — 9 — — Lewisham 1 30 — — 20 — — 10 — — — — — Paddington 7 195 40 — 136 26 — 59 14 — 5 — — Poplar 9 1,143 — — 599 — — 544 — — 46 — — St. Marylebone 17 1,306 109 — 1,127 75 — 179 34 — 19 2 — St. Pancras 10 727 109 — 597 44 — 130 65 — 8 7 — Shoreditch 12 774 — — 592 — — 182 — — 10 — — Southwark 44 3,231 430 — 2,372 273 — 859 157 — 44 — — Stepney 56 5,440 694 180 4,369 506 128 1,071 188 52 190 2 7 Stoke Newington 1 37 — — 35 — — 2 — — — — — Wandsworth 10 185 5½ 20 167 5½ 14 18 — 6 — — — Westminster 17 2,300 75 — 2,070 64 — 230 11 — 48 — — Woolwich 23 519 44 — 436 26 — 83 18 — 20 — — Totals 388 25,976 2,365½ 245 20,059 1,483½ 161 5,917 882 84 544 15 7 ½ 1 child. Note.—In addition to the figures given above there were in Rowton Houses on the same night 4,473 men and 635 vacant beds. TABLE III. Number of permanently Free Beds in premises licensed as Common Lodging Houses on the night of the 15th January, 1909. In other licensed Common Lodging Houses, some 600 or 700 beds occupied on that night were paid for by charitable institutions, chiefly by the Church Army. Premises. Free beds. For labour. Men. Women. Children. Men. Bermondsey. Salvation Army, Spa-road — — — 321 Bethnal-green. Holy Trinity Church, Old Nichol-street 21 — — — Church Army Labour, Warner-place — — — 71 Finsbury. Church Army Home, Banner-street — — — 132 Kensington. Bamardo's Home, St. John's-place — 6 15 — St. Pancras. Salvation Army Home, Argyle-square — — — 96 Stepney. Medland Hall 343 — 8 — 28, Betts-street — 6 — — Bamardo's Home, Commercial-street — 22 — — Salvation Army, Quaker-street — — — 202 Westminster. Ham Yard Hospice, Great Windmill-street 20 — — — 384 34 23 822 Unoccupied on night of census 4 47 — 33 5 TABLE IV. Number of Persons in Shelters, etc., not licensed as Common Lodging Houses. Sanitary district. Free beds. For labour. Men. Women. Children. Men. Bermondsey. (1) — 15 — — Holborn. (1) 34 17 — — (2) — 15 — — Southwork. (1) — 5 — — (2) — — — 171 Stepney. (1) 15 — — — (2) 139 107 28 — 188 159 28 171 There were on the same night in Church 245 men and 206 women. Army Labour Homes and Homes for Women. TABLE V. Common Lodging Houses. Number of Persons turned away and Cause—January, 1909, and February, 1905, compared. Reason. January, 1909. February, 1905. Increase + or Decrease — in 1909. Persons. Men. Women Couples. Total persons. Men. Women. Couples. Total persons. No money 479 11 — 490 670 64 4 742 — 252 House full 39 — — 39 198 1 6 211 — 172 Drunk 10 4 — 14 7 1 — 8 + 6 Too dirty 12 — 5 22 21 — — 21 + 1 Disorderly 3 — — 3 5 1 — 6 — 3 Too young 1 — — 1 — — — — + 1 Not getting up when called — — 2 4 — — — — + 4 Total 544 15 7 573 901 67 10 988 — 415 APPENDIX V. London County Council. REPORT OF THE MEDICAL OFFICER (EDUCATION) FOR THE 21 MONTHS ENDED 31st DECEMBER, 1908. This report to the Education Committee gives a review of twenty-one months instead of a year, but any statistics given show figures for the year ending 31st March, 1908, in order to be comparable with previous reports, and also the figures to the 31st December, 1908. The change has been made to accord with the regulations of the Board of Education Code and to bring London into line with the rest of the country, and with the Sanitary Authorities, whose annual reports are made up to the end of the calendar year. The period covered by this report has been marked by great activity in all matters concerning school hygiene and the physical care of children. There are in prospect further and wide-reaching changes and in the metamorphosis of elementary education, which is even now in process, it will be very necessary to have a clear idea of what education is, what the duties of an education authority should be, and where the limits of those duties should lie. The doctrines which guide our work, and, indeed, all educational work, must be sharply realised, clearly defined, and understood, otherwise a labyrinth of legislative enactments or a tangle of overlapping authorities will cause trouble and confusion in the future. During the plastic period of development of the nervous system each individual acquires a stock of experiences of value during the rest of life. The information and knowledge derived through reading, writing, and the other conventions of civilized life form an addendum to the great mass of experience accumulated by the mere process of living, and it is this addendum of a formal or artificial nature which it is to the common interest to impart to each individual, if necessary, at the cost of the State. During this plastic period, which in England is mainly the first sixteen years of life, the desires and needs of the growing organism of the child are essentially different from those of the adult and must always be separately considered and have special provision. The whole State provision for aiding the growth and development of the child from the time it ceases to be entirely dependent upon its parents until it attains puberty—a period roughly embraced between three and sixteen years of age—now constitutes this formal education. The only scientific doctrine to follow as a guide for legislation is that any public supervision of, or provision for, the growth and development, that is, the general care of children should be under the control of the education authority. The recognition of this unifying principle will simplify laws and avoid endless overlapping and complications in practice. Any attempt to separate duties or functions by artificial definitions is bound to result in enhanced cost of working, unnecessary friction, duplication and possibly even actual failure. Hitherto in our work it has, for practical purposes, been attempted "to render unto Caesar the things that are Caesar's," by regarding all that concerns the child in school as under the control of the education authority, and all that concerns it beyond the school as being under the control of other (local) authorities, but in practice there is often lack of co-ordination, and sometimes differences of standard, which occasionally give rise to results that are most grievous. In regard to cleanliness of the person (see p. 34), any efforts to fully effect this throughout the schools have been frustrated in many parts of the Metropolis by lack of provision for effecting cleansing. Again, for children excluded from school as suspicious, during the prevalence of diphtheria, several Sanitary Authorities have refused to test the conditions existing in such suspicious children in their districts, holding that this is a matter for the Education Authority, who, from their standpoint, simply exclude the children until the risk of infectiousness is deemed to be past, leaving the sanitary authority to deal as they please with suspicious cases in their own districts. Probably the majority of children refused admission to the special schools of the Council, as being for educational purposes imbecile, are later on either refused care by the Guardians of the Poor or transference to any suitable institution on the ground that they are not "imbecile." This question of the care of idiots and imbeciles forms a very good instance of confusion. There is no authority having the statutory duty of caring for imbecile or idiot children who are not paupers. The poorer classes have no institutions open to them except those under the Poor Law. A child excluded from the special schools as imbecile by the educational officers is generally refused help by the Guardians, but if this body accepts its care, then the parents, even if they pay the whole cost of maintenance at such an institution as Darenth, are thereby pauperised. The light shed in the last few years on the problems of ordinary education from the study in our schools of feeble-minded and partially defective children would to a large extent have been lost if these had not been under the educational authorities. The least costly and most practical solution appears to be, that any public provision for protecting and aiding growth and development of children during the years of school life—three to sixteen years of age—should be entirely committed to the education authority. This would allow such matters as the feeding, teaching, cleansing, medical treatment or social protection of school children, when these duties become a public care, to be administered by the one authority, and by bringing all the various problems into a correct relation and perspective would also effect considerable financial economy. On the other hand, transient conditions in which the child bears the same social relations as any other individual, as for instance when affected with typhoid or scarlet fever, or when guilty of a crime, would still come under the same provision by the sanitary authority or police respectively as at present. Fortunately this is the line taken by all the recent legislation in matters concerning children. 20261 A 2 4 PROVISION FOR MEDICAL INSPECTION. In November, 1889, the late School Board for London decided to appoint a medical officer, to give his whole time, at a salary of £400 a year, to report on candidates for permanent offices and generally to advise the Board on any matters on which his special medical knowledge might be useful. The medical officer was appointed, with a junior clerk to do his clerical work, but the condition that the whole time should be given was abrogated. Consequent on the passing of the Elementary Education (Blind and Deaf) Act, 1893, the Board, in 1898, appointed temporarily two doctors to give half time for the purpose of examining children alleged to be defective. One of these was a woman who also had the duty of examining female candidates for permanent employment. The chief work of the department was the medical examination of candidates for permanent offices, the supervision to some extent of infectious diseases in the school and the medical examination of defective children. In 1902 the staff consisted of the medical officer, two medical examiners giving half-time services, and four clerical assistants, when the medical department was reorganised. The present medical officer succeeded Dr. Smith; eight oculists were appointed to give 200 school sessions each to testing the children's vision, and a ringworm nurse who had been working under the supervision of the School Management Committee was transferred to this department. Two half-time assistants were appointed for work in connection with the Special Schools, and shortly afterwards an additional half-time assistant for a special measles enquiry projected by the medical officer. It was almost at once found that a laboratory was required; this was provided, and Dr. C. J. Thomas was made a full-time assistant; six of the oculists were reappointed, but their duties were now tacitly extended to include a great deal more than mere vision testing, and later five additional nurses were appointed. The whole work of the department was by this time organised so that systematic records of all observations were established, and many enquiries could be commenced. The field of work taken by the department was the investigation of all conditions affecting or tending to affect the health of those working in the schools. The First Annual Report of the medical officer was published in April, 1903. During the following year a cleansing scheme for the schools was established; a complete report of the visual conditions of the children obtained; the method of bacteriological control of diphtheria established; the measles enquiry extended; the whole of the children in the Special Schools generally reviewed; and enquiries commenced to elucidate the conditions of congenital aphasia, which have thrown so great a light on school work. The London County Council took over the Educational work in May 1904, but the non-provided schools did not then come under medical inspection. During 1903-4, work had so rapidly extended that it could not be systematically carried out for want of staff, and what had been done showed the serious conditions existing in various directions. A scheme was therefore prepared for dealing with the general condition of the scholars ; the prevention of diffusion of infections; the promotion of cleanliness, which is the basis of all hygiene ; the hygiene of school work; and the sanitary conditions of school buildings. To carry out this work, one permanent half-time assistant and 20 quarter-time temporary assistants were appointed in place of the six oculists. For dealing with ringworm and securing personal cleanliness in the schools a superintendent and 26 additional nurses were added to the staff. It was then possible to do more work, and the method of the measles enquiry was extended to the whole of London; the Favus School was opened, and new regulations for the further control of diphtheria established. In January, 1906, a complete system of medical supervision was extended to all the non-provided schools, and large numbers of children who should have been in special schools were discovered ; the rolls of the special schools increased from 7,056 to 8,892, and, with the closer grip of the work now required, the staff had to be increased by the addition of four quarter-time medical officers. During the same time medical work had also been extending in other directions; for instance, before any scholarship was awarded the candidate was medically examined, and the need of this is shown by about a quarter of them being referred in order to have some medical treatment. The secondary schools, pupil teachers' centres and training colleges are also under regular inspection, although this work has not yet been put on a permanent basis. Card records are kept of children from the time, at the age of eleven, they enter as scholars until, from the training college, they pass on to the teaching staff The department is now worked in four sections : (1) The examination of candidates for employment in schools, scholarship candidates, scholars in secondary and trade schools, and students in the pupil teachers' centres and training colleges. (2) Medical inspection of schools, including the detailed examination of many children, vision testing, the general physique, school conditions—such as lighting, heating, ventilation, sanitation, furnishing, educational work such as timetables, play, exercise, out of school conditions, and the hygiene of reading, writing, manual work and so on, dealing also with the work and health of the teachers. (3) Prophylactic measures of cleanliness and disease prevention, co-operating with managers and Care Committees in respect to cleanliness and personal hygiene; and with the medical officers of health and sanitary authorities in respect to infectious and other diseases; for the protection of children and teachers without undue interruption of educational work. (4) Special school work—Examining under the various Education Acts children nominated by the school doctors, teachers, managers and others, with a view to admission to special schools and periodically examining children already in these schools. The special schools include schools for the mentally or phvsically defective, the blind or deaf, and similar institutions. The Council is also in touch with various Custodial Institutions and establishments for care of industrial, truant, crippled, epileptic, morally defective and various other classes of cases. 5 The medical staff at the end of 1908 numbers 52. The permanent staff, including the Medical Officer (Education), one assistant medical officer giving whole time, two assistants giving half time, and eight assistants giving quarter time—of whom three are women. The statutory medical inspection of elementary school children is carried out by a temporary staff of 16 school doctors, each in charge of a district, and having one or more assistant school doctors, of whom there are 24. It has been decided to increase the staff by the addition of 16 assistant school doctors in the summer and another 16 in 1910, so that ultimately there will be 72 members of this temporary staff giving quarter-time. Each of the temporary staff serves for a period of three years. The school nursing staff consists of a superintendent, two assistants, and 51 school nurses; they undertake the oversight of personal hygiene in both elementary and secondary schools. Routine Inspection.—In the routine medical inspection the head teachers are asked to place on a form the names of all children known to them as presenting any abnormality (except vision). The school doctor, after giving due notice, visits the school and sees the children selected by the teacher and especially notes any cases presenting defects of hearing, brain, speech, limbs or nutrition, and a card is left with the teacher for each child requiring treatment. The doctor then goes over the school and notes any defects in regard to the general arrangement of the building( environment, etc.); general condition of the school (window and artificial lighting, heating, ventilation, building, sanitation, desks and seating); general condition of the children (physique, teeth, nutrition, etc.); the hygiene of school work (hours of work, modes of work, reading, writing, drawing, manual work, recreation, exercise); and any other matters which affect the health of the teachers and children and the physiological development of the latter. Should the doctor discover any child who, in his opinion, should be medically examined with a view to being admitted to a special school, the teacher is asked to fill up and forward a nomination form to the head office. The teacher has an opportunity of discussing with the doctor any matters affecting the health of the school. Vision.—The vision of all the children is tested once in 12 months, one half of the schools in April and the other half in September. The preliminary test is done by the teacher, and the names of all children in standards I., II., III. and IV. whose vision is 6/18 or worse, and children in standard V. and above whose vision is 6/12 or worse, are placed on a form provided for the purpose. When the doctor visits the school be tests the vision of the children returned as defective and gives the teacher a red or green card according to the amount of defect found, for each child who should seek advice. These cards are distributed to the children a few at a time so as not to cause inconvenience to the hospital authorities. The teacher notes in the attendance register the number (6, 9, 12, 18, etc.), expressing the visual acuity, against the name of the child. Medical Register.—A medical register is now kept at each school in which the doctor notes any school conditions which are detrimental to the health and well-being of the teachers and children, and enters the name of any child where conditions exist such as discharging ears, very defective vision, etc., where managers could assist in obtaining relief. When the examination has been completed, the doctor's report is forwarded to the head office, where the conditions are noted and any matters requiring attention are dealt with. The following summary is compiled from these reports:— 1st April, 1907, to 31st March, 1908:— Conditions Found. Schools Departments. Number on Roll. Numbers examined. Returned by Teachers. Vision.* Hearing. Speech. P.D. M.D. Non-Provided Schools 243 43,457 3,397 384 256 175 527 280 Council Schools 609 227,292 17,803 1,995 2,002 1,314 3,965 1,470 Total 852 270,749 21,200 2,379 2,258 1,489 4,492 1,750 Treatment Suggested. Schools. Requiring treatment urgently. Requiring transfer to special school. Vision.* Hearing. Speech. P.D. M.D. Vision.* Hearing. Speech. P.D. M.D. Non-Provided Schools 309 245 116 437 137 1 1 — 12 142 Council Schools 1,520 1,563 693 2,543 683 8 8 1 78 478 Total 1,829 1,808 809 2,979 820 9 9 1 90 620 * Apart from vision testing, for which see p. 54. 6 Children were also selected individually from their classes, and reported on as follows :— Schools. External diseases of the eye. Throat or nose affections. Ear disease. Excessive "dirt." Other defects. Non-Provided Schools 532 467 185 25 248 Council Schools 2,002 3,086 1,064 119 1,595 Total 2,534 3,553 1,249 144 1,843 1st April to 31st December, 1908:— Conditions Found. Schools. Departments. Number on Roll. Numbers examined. Returned by Teachers. Vision.* Hearing. Speech. P.D. M.D. Non-Provided Schools 70 11,991 1,137 116 73 78 116 36 Council Schools 276 100,694 28,085 1,106 806 789 1,670 620 Total 346 112,685 29,222 1,222 879 867 1,786 656 Treatment Suggested. Schools. Requiring treatment urgently. Requiring transfer to special school. Vision.* Hearing. Speech. P.D. M.D. Vision.* Hearing. Speech. P.D. M.D. Non-Provided Schools 62 51 44 59 14 2 4 2 1 13 Gouncil Schools 894 605 538 884 182 — 6 — 7 122 Total 956 656 582 943 196 2 10 2 8 135 * Apart from vision testing, for which see p. 54. Children were also selected individually from their classes, and reported on as follows :— Schools. External diseases of the eye. Throat or nose affections. Ear disease. Excessive dirt." Other defects. Non-Provided Schools 214 113 62 10 127 Council Schools 1,274 1,886 387 152 743 Total 1,488 1,999 449 162 870 Conditions of the schoolrooms.—Although often far from what is desirable, the hygienic conditions of the schoolrooms are being gradually improved, and many conditions drawn attention to have been ameliorated, but, on the other hand, many defects repeatedly noted still exist. The conditions recoded may stated in the bordest terms as follows: 1st April, 1907, to 31st March, 1908:— Schools. Lighting. Ventilation. Heating. Sanitation. Furniture. Non-Provided Schools Good 57 49 57 54 42 Fair 10 10 6 7 7 Bad 21 14 9 8 26 Council Schools Good 191 164 144 127 138 Fair 16 10 14 10 14 Bad 52 29 21 13 10 7 1st April to 31st December, 1908:— Schools. Lighting. Ventilation. Heating. Sanitation. Furniture. Non-Provided Schools Good 18 8 8 6 8 Fair 3 2 1 4 — Bad ... 4 3 — 1 9 Council Schools Good 237 114 113 119 114 Fair 23 16 6 9 1 Bad 33 18 9 4 15 There is a remarkable difference in the state of cleanliness of schoolrooms. Of course, a dark and antiquated schoolroom in a dirty neighbourhood can never have the appearance of a newer suburban building, but the cleanliness should be much more under the control of the teachers, and they should be more responsible than they seem to be in this matter. Education (Administrative Provisions) Act, 1907.—Since the passing of this Act the whole aspect of medical inspection in elementary schools has changed. This change has not been so noticeable in London, as many of the requirements both of the Act and Board of Education circulars had been carried out for several years. For the present it is intended to continue the routine medical inspection, but, in addition, 80 schools have been selected where all children admitted since 1st August, 1908, and those expected to leave before 31st July, 1909, will be examined. In one half of these schools the examination will be conducted with full details in accordance with the Board of Education schedule, and in the other half the work will be carried out on a somewhat simplified scheme, as regards the clerical records. Where rooms are available the examinations will be conducted on the school premises, but in others it may be necessary to draft the children to centres. The parents will be invited to attend. A school nurse will assist the doctor and the class teacher will also be present in order to obtain as much information as possible about his pupils. Only experience can show how far the nurse and teacher respectively are necessary. It will be necessary later to prepare a pamphlet on the teachers' part in medical inspection, but it is expected that they will take a very real interest in this work as a great part of its value is lost if they do not benefit by the knowledge gained. The teacher's duty is not merely to teach but to educate, and for this purpose they should make themselves acquainted with the capacities and physical qualities of their pupils. Many teachers have a praiseworthy knowledge of their charges, but all of them ought to be able to note quite as well as the doctor or nurse the height, weight, visual acuity, hardness of hearing, want of clothes or personal cleanliness of their pupils, and it is of the greatest importance to their work as educators that they should be accustomed to see and note these things for themselves. This detailed medical inspection should not mean any serious disturbance of school work, as a large number of children would not be absent from any particular class at one time. EXAMINATION OP CANDIDATES. First Examination.—Head, assistant and pupil teachers, training college students, scholarship candidates, instructors and schoolkeepers employed in the schools are medically examined in this department before commencing work. It has been possible by the use of a better system of records to reduce the numbers of examinations to 7,138 this year against 7,998 last year. There were 2,149 head and assistant teachers, 1,195 pupil-teachers, 3,019 scholarship candidates, 649 training college students and 126 instructors and schoolkeepers examined. References.—In addition to the " first " examinations, 664 references were dealt with. These references relate to the leave to be granted to employees absent owing to personal illness ; to teachers returning to duty after extended leave of absence—(a) owing to personal illness, (b) in order to visit educational institutions abroad, (c) to study for degrees, and (d) married women under No. 93 of the regulations with regard to the education service. In some cases, reports were required in regard to the salaries of teachers for periods of absence owing to illnesses alleged to have been contracted at schools, and also as to whether the conduct of employees had impaired their efficiency. The number of references for the year under review compared with those for the preceding year shows an increase of 129, or 24 per cent. Scholarship Candidates.—Over 3,000 scholarship candidates at various ages from eleven to thirty were examined. The chief groups are the junior scholars and the probationer scholars. The others are returned as a heterogeneous group of special scholars. It may be noted that by the card index of these cases the medical history of individual cases is now being carried forward systematically through a long series of years. Junior County Scholars.—The main regulations as to these are that the head teachers of elementary schools in London are required to fill up nomination forms for the general examination for junior county scholarships for all boys and girls attending their schools, who (a) will be not less than eleven and not more than twelve years of age on 31st July, and (b) who are working at the time of examination in the sixth or a higher standard in the case of boys, and in the fifth or a higher 8 standard in the case of girls. Head teachers are at liberty to nominate any other candidates qualified by age whom they consider as likely to attain the scholarship standard. The Medical Officer (Education) is required to certify that the scholar is in a fit state physically to take advantage of the scholarship. The results of medical examination are shown in the following table:— Age. Number examined. Number of examinations. Pit. Vaccination. Referred back. Rejected. Not vaccinated. No marks. Cleanliness,- Throat. Teeth. Vision; Sundry. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 10 104 129 81 17 — — 5 10 9 — — 173 245 111 21 3 24 6 28 12 3 3 11 618 704 480 66 9 6 22 68 47 7 3 971 1,281 577 95 10 171 49 151 73 9 6 12 2 2 2 — — — — — — — — 1 2 - - - 1 1 - - - - Total B. 724 835 563 83 9 6 27 78 56 7 3 G. 1,145 1,528 688 116 13 196 56 179 85 12 9 Grand Total 1,869 2,363 1,251 199 22 202 83 257 141 19 12 The medical examination practically gives the defects of the brightest children of the age group about eleven years old. As they must in any case remain in school until fourteen years of age, the rejections are very few. Most useful work is, however, done by making it a condition that all defects that are remediable shall be treated before the children are allowed to take up their scholarships. The Council thus possesses a powerful lever for the amelioration of physical defect,which, however, is applicable to the brightest children only, and 161 boys out of the 724, or 22 per cent., and 457 of the 1.145 girls, or 40 per cent., were induced to have the necessary attention to removable conditions which impaired their efficiency; advice as to mode of life, incipient disease and other conditions was given to many more. In the 724 boys, want of cleanliness was only noted in 11, six being referred back on this account; teeth required urgent treatment in 78, over 10 per cent.; spectacles were required in 56 cases and 48 others were already wearing glasses, making a total of 14 per cent. having visual defect serious enough to require optical aid. Mouth breathing, enlarged tonsils and other defects of the throat were noted in 39, of whom 27 were referred back for treatment; 14 had subnormal hearing, nearly 2 per cent. Other conditions noted were anæmia 19, heart disease in 7, deformity of chest or spine 12 (8 being rickety), bronchitis 4, chronic skin disease 4, defective articulation 2, enlarged glands 3, alopecia 2, ringworm 1, congenital malformations 4. Three rejections were due to progressive myopia, defective vision due to opacities not aided by spectacles, and active phthisis. In the 1,145 girls, want of cleanliness, chiefly in the hair, was noted in 221 or 20 per cent., and 196 referred back on this account. Teeth required special attention in 179 or 16 per cent., and decay of teeth was often noted as co-existing with uncleanliness in other directions; spectacles were required by 85, and were already being worn by 70 more, making 14 per cent. with serious defect of vision; the proportion being identical with that among the boys. Unhealthy conditions of the throat were noted in 160, or 14 per cent., and treatment required in 56 cases. Hearing was distinctly defective in 34, or 3 per cent., 131 were recorded as anaemic, or 11.4 per cent., a much greater proportion than amongst the boys; this and unhealthy throat conditions being alike probably due to the greater confinement to the house in the case of girls. Other conditions noted were heart disease 14, spinal curvatures 64, over 5 per cent., enlarged cervical glands 16, chorea 1, chronic skin disease 1, ringworm 3, scabies 1, defective articulation 13. Amongst the referred cases, the following serve as types:— I. R., aged 11.4—Anaemic, adenoid facies, hearing much impaired, bone conduction better than aerial, both membrana tympani perforated; slight lateral curvature of the spine; unfit for teacher but fit for scholarship. M. P., aged 11.9—Head verminous, teeth dirty, systolic murmur at heart apex. Mother warned about heart. Not intended for teacher. I. V., aged 11.7—Systolic murmur at apex of heart; often suffers from pains in limbs. Fit for scholarship, but unfit for teacher. L. M., aged 11.8—Narrow chest, mouth breather, hearing defective, adenoids. Report in a month. Treated at hospital and now fit. The nine rejections were candidates with the following conditions—Tubercle (lungs 1, glands 4); chronic bronchitis with heart disease 1, deafness 2, defective speech 1. Infectious Diseases.—An account of previous illnesses is asked for in the history form filled in by each candidate. If omitted, it has not been insisted on, but a sufficient number have given details, which are as follows:— 9 Total. Number of Measles Whooping Diptheria. Scarlet Fever Chicken-pox. Mumps "Childish Responses Cough. Ailments.” Boys—. 724 606 536 267 36 81 171 24 10 Girls— 1,145 1,002 893 484 65 173 325 51 17 It might have been suggested that the bright children would have suffered less than the average from infectious diseases, but the above table shows that this is not so. This tendency had been noted in relation to normal as compared with mentally defective children in a return published in the Annual Report for 1906, p. 42. It has often been shown that measles does not tend to spread in the upper departments of schools owing to the high proportion of children who have already suffered, and here we find 90 per cent. of those who replied have bad measles. Amongst boys the percentage who have suffered from scarlatina is eleven, which agrees very closely with the protection rate for the age group which was worked out by Dr. Stevenson in last year's Annual Report, page 41. Girls suffered still more heavily, to the extent of 15 per cent. This difference, as I showed some twelve years ago, emphasises the importance of out of school conditions. Probationer Scholars.—The standard of health to be expected from these is higher than in the case of the junior scholars, as from these the pupil-teachers are to be recruited and they will ultimately have to pass a medical examination under the Superannuation Rules. According to the regulations, probationer scholarships are open to candidates of not less than fourteen and not more than 16 years of age on 31st July. Only those candidates are eligible whose parents enter into an undertaking that they intend the candidates, unless awarded intermediate county scholarships, to become pupil-teachers if accepted, and after being pupil-teachers to proceed to a training college with the view of becoming teachers in public elementary schools. These candidates, therefore, fall within the group 14—16. The results of the examination are:— Age. Number examined. Number of examinations. Fit. Vaccination. Referred back. Rejected. Unvaccinated. No marks. Cleanliness. Throat. Teeth. Vision. Sundry. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 12 — — — — — — - - — — — 1 2 - - - 1 1 - - - - 13 10 10 9 1 - - - 1 - - - 16 20 7 1 — — 1 6 2 — — 14 157 178 116 10 1 2 4 16 19 - 2 324 380 212 13 3 24 10 59 27 1 6 15 78 87 53 6 - 1 2 16 7 - 2 211 246 141 12 — 17 4 27 10 — 4 Total B. 245 275 178 17 1 3 6 33 26 - 4 G. 552 648 360 26 3 42 16 92 39 1 10 Grand Total 797 923 538 43 4 45 22 125 65 1 14 In the 245 boys 4 were reported and 3 referred back as unclean; teeth caused 33, and vision 26 references, but 10 more already wore glasses, making a percentage of 14.7 requiring optical aid. Unhealthy throats were noted in 9 cases, of which 6 were referred back. Other defects noted were defective hearing 2, articulation 2, deformities 3, anaemia 3, heart disease 2, enlarged glands 1. The 4 cases rejected were:—for high myopia 1, stammering 1, indescribable condition of filthiness 1, and 1 with enlarged tonsils, caries of teeth, poor vision with squint and stammering. In the 552 girls, want of cleanliness was reported in 52 cases and 42 were referred back on this account. Teeth required treatment in 92 or 17 per cent. Spectacles were required in 39 cases and already worn in 64 others, making 19 per cent. requiring such aid. In 36 cases throat conditions were unsatisfactory, and treatment had to be insisted upon in 16. There was anæmia in 39 cases and deformity in 26. Other defects were heart troubles 9, sub-normal hearing 6, goitre 3, defective articulation 3. The 10 rejected cases were:—for defective vision 2, profound anæmia 1, stammering and anaemia 1, deafness 1, uncleanliness 1, and heart disease 4. Two with heart disease were returned as fit to hold scholarships but not to pass as teachers. Vaccination.—Owing to the regulations of the Board of Education with regard to the fitness of teachers, it has hitherto been necessary in all scholarship candidates to make enquiries as to vaccination. This year amongst the junior scholars, 221 out of 1,869 had never been vaccinated; this 20261 B 10 gives a percentage of 11.8. A much lower proportion of probationer scholars was unvaccinated, namely, 47 out of 797, or 5.9 per cent. This indicates an increase in the proportion of unvaccinated children born in the year 1896 over those born in 1892. The following table has been compiled from our records "Condition of Vaccination":— Year of Birth. Number Examined. Unvaccinated. Percentage Unvaccinated. 1890 853 40 4.6 1891 1,251 80 6.4 1892 797 47 5.9 1894 1,758 102 5.2 1895 2,052 201 10.2 1896 1,869 221 11.8 The increase in unvaccinated children born in the years 1895 and 1896 may perhaps be connected with the aoitation which preceded the establishment of the conscientious objector. Special Scholars.—The heterogeneous mass grouped under this head have not always the same standard of examination:— Age. Number examined. Number of examinations. Fit. Vaccination. Referred back. Rejected. Unvaccinated. No marks. Cleanliness. Throat. Teeth. Vision. Sundry. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B G. B. G. B. G. B. G. 12 19 21 17 2 - - — 1 — — — - - - - — — — — — — 13 11 14 7 1 — — 2 1 1 — — 2 2 2 - - - — - - — — 14 45 52 29 - 1 - 4 8 2 - 2 66 80 36 4 - 8 2 17 5 — 1 15 69 73 47 3 3 ? 5 1 4 39 44 30 2 - 3 1 4 1 - 1 16 36 39 31 2 - - — 3 - — 7 7 6 1 1 - — — 1 — — Over 16 27 32 17 1 - — — 1 9 - — 39 39 36 - - - - 1 - - 2 Totals — B. 200 231 148 9 1 — 9 15 21 1 6 G. 153 172 110 7 1 11 3 22 7 — 4 Grand Totals 353 403 258 16 2 11 12 37 28 1 10 Among the special scholars there were :— Cripples (age 13—15).—Eleven boys were examined; 3 were cases of hip disease, 1 of amputation for hip disease, 2 spinal caries, 1 with tuberculous ankle and 2 with infantile palsy. One boy was rejected as it was found that the hip disease, from which he was suffering, had entirely disappeared. Ten girls were examined; 4 had tuberculous knees, 2 curvature of the spine, 1 hip disease, 1 club foot, 1 congenital amputation; 1 girl with heart disease was rejected on account of her unfavourable chances of life. Blind (age 14—16).—9 boys and 4 girls; these cases were mostly the result of ophthalmia neonatorum. Deaf (age 14—16).—Boys, 4 ; girls, 6. Boy Artificers for the Royal Navy (age 15); 19 candidates were examined; 6 were rejected, 5 on account of trifling visual defect and 1, who had passed as a trade scholar, on account of defective physique. Trade and Technical Scholars (age 14—15).—71 boys were examined; referred back on account of teeth 10, vision 6, throat 6, hearing 2. Two mercantile marine scholarship candidates were rejected on account of vision. 79 girls were examined ; noted or referred for want of cleanliness 12, teeth 25, vision 13, throat 5, heart 3, hearing 2, deformities 3, anaemia 11. Intermediate County Scholars (age 15—16).—44 boys were examined; noted or referred for want of cleanliness 1, teeth 3, vision 19, throat 4, anaemia 1, heart 1. 13 girls were examined; referred for teeth 1, vision 3. Senior County Scholars (age 18—22).—27 men were examined; referred for teeth 1, defective vision 16, deformities 2, heart 1. 15 women were examined; referred for teeth 1, defective vision 5. Midwifery Scholarships.—14 women at ages from 24 to 36 years were examined and 2 were rejected on account, respectively, of suppurating gums and general unsuitability. 11 1st April to 31st December. There were 866 head and assistant teachers, 1,260 pupil teachers, 2,848 scholarship candidates, 526 training college students and 107 instructors and the schoolkeepers examined. References.-509 references were dealt with, an increase of 31, or 6.5 per cent., when compared with the number for the corresponding period of the previous year. Scholarship Candidates.—The examination of candidates for scholarships for the year 1908 has resulted in a few being absolutely rejected, but a large number were referred back for medical or other treatment and ultimately passed. There is still a considerable number of children of very poor physique being passed as scholars. Junior Scholars.—Candidates for junior county scholarships were noted as follows:— Number examined. Number of examinations. Fit. Vaccination. Referred back. Rejected. Age. Unvaccinated. No. marks. Want of cleanliness. Throat. Teeth. Vision. Sundry (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 10 145 176 98 19 8 6 6 21 19 - - 176 237 93 28 2 27 12 51 19 - 3 11 626 764 414 73 6 16 28 101 89 4 - 854 1230 407 112 12 176 65 256 71 21 - 12 4 2 3 — — - — - - - 1 — — — — — — — — — — 1 Totals— B. 775 942 515 92 14 22 34 122 108 4 1 G. 1030 1467 500 140 14 203 77 307 90 21 4 Grand Totals 1,805 2,409 1,015 232 28 225 111 429 198 25 5 Several candidates were passed who would have been rejected as pupil-teachers. A number of cases were seen several times before being finally passed; 171 (boys, 30; girls, 141) were referred back for two defects, and 20 (boys, 2; girls, 18) for three defects. The total number of cases referred back was 790 (boys, 260; girls, 530), the percentage of the number referred back for more than one defect on the total number referred back being 24.2 (boys, 12.3 per cent.; girls, 30 per cent.). It should, however, be noted that of the cases accepted 1 girl had enlarged tonsils with speech affected; another girl had a pronounced lateral curvature, 2 boys had organic heart disease compensated; 3 boys had slight deafness arising from middle ear disease; 2 boys had hernia; another boy had high myopia; and of 5 other girls, 1 had lateral curvature with anaemia, the second organic heart disease compensated, the third organic heart disease, the fourth cardiac hypertrophy and old lung mischief, and the fifth was a delicate type with lateral curvature. Probationer Scholars.—Probationer scholarships are awarded to enable candidates to ultimately become elementary school teachers. They were noted as follows:— Age. Number examined. Number of examinations. Fit. Vaccination. Referred back. Rejected. Unvaccinated. No marks. Want of cleanliness. Throat. Teeth. Vision. Heart Sundry (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B G. B. G. B. G. 12 1 2 — — — — — — 1 — — — - — - - - - — — — — — — 13 24 28 18 1 1 1 - 3 4 — — — 16 25 4 - 5 3 6 6 - - — 14 121 146 73 9 1 1 5 9 20 — 1 — 144 192 54 10 - 19 10 54 19 — 4 1 15 68 87 40 3 — 2 3 18 10 — — 1 174 228 74 12 1 27 8 70 15 — 1 3 16 1 1 1 — - - - - - - - - — — — — — — — — — — — - Totals 215 264 132 13 2 4 8 30 35 — 1 1 334 445 132 22 1 51 21 130 40 — 5 4 Grand Totals 549 709 264 35 3 55 29 160 75 — 6 5 20261 12 The foregoing table does not, however, express to the full the amount of defects found; in the cases referred back only the chief defect is recorded, but of these 63 (boys, 16; girls, 47) were for two defects and 11 (boy, 1; girls, 10) for three defects, the percentage of the number of cases referred back for more than one defect on the total number of referred cases being 25.9 (boys, 20.2 per cent.; girls, 28.3 per cent.). In the case of probationer scholars, the examination has to be somewhat stricter than with junior scholars. Articulation which was hopelessly bad was a cause of rejection. On the other hand several doubtful cases, including the following, were passed after the parents had been made thoroughly alive as to the defects of their children and the need of remedy ; for instance, of 8 girls, 2 had lateral curvature, 2 had middle ear disease, 1 had severe anaemia, another had hernia, spinal curvature and defective vision, the seventh had heart disease (double mitral murmur), and the eighth recent bronchitis. One boy was accepted who had slightly dilated heart. Special Scholars.—Special scholarships include domestic economy, gardening, trade, technical, blind, deaf, cripple, and boy artificers for the Royal Navy. They were noted as follows— Age. Number examined. Number of examinations. Fit. Vaccination. Referred back. Rejected. Unvaccinated. No marks. Want of Throat. Teeth. Vision. Heart. Sundry. (1) (2) (3) (4) (5) (6) ness. (7) (8) (9) (10) (11) (12) (13) B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. B. G. 11 2 3 1 — - - - - 1 - — - — — — — - - - - — - — - 12 16 16 13 3 — — — 3 — - — - — — — — — - - — — - — - 13 31 35 23 2 - - 3 3 2 - - - 1 1 1 - - - - - - - - - 14 62 74 46 4 1 - 5 8 4 - 1 1 112 152 58 4 2 18 5 30 12 - — - 15 65 74 41 7 1 - 2 5 7 - — 6 63 74 44 5 - 3 3 8 3 - 2 4 16 54 58 40 4 — 1 — 7 5 - — 1 23 25 20 — 1 — 1 1 1 - — — Over 16 41 42 36 1 - - - 3 2 - 1 — 24 25 19 — — — — 3 1 - — — Totals 271 302 200 21 2 1 10 29 21 - 2 8 223 277 142 9 3 21 9 42 17 — 2 4 Grand Totals 494 579 342 30 5 22 19 71 38 — 4 12 Of the 151 cases referred back 20 (boys, 6; girls, 14) were for two defects and 1 (girl) for three defects, the percentage of the number of cases referred back for more than one defect on the total number of referred cases being 13.9 (boys 8.6 per cent.; girls, 18.5 per cent.). It may be noted that one of the cases accepted for the gardening scholarships had high myopia (-14 dioptres) and that one of the blind scholars was also deaf. Seven boy artificers for the Royal Navy had to be rejected for comparatively trivial defects. Visits to Schools and Homes.—The average number of visits to schools and homes recorded separately each week by officers of this department is as follows:— 1st April, 1907, to 31st March, 1908:— Special Schools. Ordinary Schools. Domiciliary and Special enquiries. Medical Officer and assistants 21 60 14 Thirty-two nurses and superintendent 301 143.3 1st April to 31st December, 1908:— Special Schools. Ordinary Schools. Domiciliary and Special enquiries. Medical Officer and assistants 29 51 10 Thirty-two nurses and superintendent 310.6 140.5 13 Each of the schools for physically defective children is visited at least once a month, and each of the residential schools once in three months by the Medical Officer. The visits to ordinary schools have been at irregular intervals. Arrangements have now been made for a nurse to visit each school at least once a month. TRAINING COLLEGES, PUPIL TEACHERS' CENTRES AND SECONDARY SCHOOLS. During the half-year ending 31st March, 1908, the colleges, centres, and secondary schools have been visited, and a large number of the students carefully examined, a card register being established. With regard to the physical defects noted below:— Institutions. Numbers. DEFECTS. Number of Visits. Number on Roll. Number examined. Throats. Backs. Lungs. Heart. Glands. Anaemia. Malnutrition Teeth-defective. Lack of Cleanliness. Ears. Speech. Vision. Round. Curvature. Training Colleges. Avery-hill 25 320 320 9 59 30 - 12 — 76 29 119 3 7 15 80 Clapham Day 1½ 160 160 1 24 10 - 15 — 37 2 62 2 2 1 32 Greystoke-place 24½ 149 228 3 30 24 - 4 — 49 11 82 3 4 2 57 London Day 41 143 140 16 12 9 1 2 1 17 3 66 1 1 3 35 Islington Day 250 253 17 14 13 1 7 1 37 17 121 2 — 4 54 P. T. Centres. Battersea 6½ 206 99 4 26 3 - 1 — 14 5 42 1 1 3 24 Chelsea 8½ 256 165 1 39 15 1? - 1 33 12 56 - 1 7 50 Deptford 10 220 118 2 27 8 - 1 — 25 12 42 — 2 4 34 Hackney 9 175 178 22 53 29 2 3 1 23 4 86 10 2 2 31 Mile End 6 128 110 9 20 10 — — — 8 3 54 4 1 - 20 Stepney 6 125 103 8 28 10 — 2 — 22 8 46 4 3 - 20 Woolwich 7½ 150 85 3 8 6 — 2 — 15 9 35 2 3 4 19 Secondary Schools. Eltham 14 140 121 10 34 20 1? 3 3 15 22 31 3 4 14 30 Fulham 19½ 256 247 28 51 32 — 5 7 22 21 71 9 10 25 68 Hackney 20 220 265 77 52 42 1? 8 17 45 37 131 52 10 4 40 Kentish Town 26 309 309 51 45 48 — 9 — 50 35 137 9 5 4 59 Kingsland 20 245 244 61 45 54 — 15 5 37 18 107 31 13 4 44 Manor Mount 11 120 115 5 23 14 — 4 1 24 12 3 36 3 10 11 Paddington 17 143 145 28 29 10 — 11 3 21 20 78 17 4 7 28 Peckham 29 240 265 21 59 33 — 3 4 46 15 78 29 7 18 70 St. Pancras 7 80 79 15 19 7 1? 2 2 9 7 34 9 5 - 13 Southwark 17 135 164 30 25 33 — 5 1 24 28 68 22 3 1 38 Stockwell 19½ 293 321 18 55 43 — 18 7 45 11 123 18 13 6 123 Sydenham 16 150 158 12 24 24 — 2 4 21 16 41 9 8 5 49 Wandsworth 5 89 78 29 22 9 - 1 1 6 10 39 9 2 — 20 Lungs.—Three students were rejected for phthisis. Backs.—The women doctors called attention to the carrying of heavy books as a factor in causing round backs or curvature in those thus predisposed. The contents of book bags were found sometimes to weigh 7 or 8 pounds. The provision of additional lockers at school is recommended; this is especially wanted in schools like Paddington and St. Pancras, which are also used for evening classes. Hearts.—About half of the students noted with defect of the heart showed actual organic disease. In each case games or exercises were regulated as required. Personal hygiene.—In spite of strenuous efforts on the part of the mistresses, a large percentage of the pupils still show a want of cleanliness. In many cases lectures dealing specially with personal hygiene have been given by the teachers in consequence of the medical examinations. Teeth.—All cases presenting caries were noted, and the percentage appears large. There is a very decided improvement in the routine use of the toothbrush. At the Peckham school the headmistress has arranged with a dentist to attend systematically to the teeth of the children owing to the difficulty of obtaining suitable treatment. General remarks.—It would be a good plan if the general supervision of health, as well as the organisation of games and exercises, were definitely committed to the drill mistresses. In some of the schools, notably Hackney, Kentish Town and Paddington, the sanitary arrangements are very defective. On re-examining the girls it is found that a very considerable number have taken steps to remedy defects, and often with gratifying results. It is found to be very difficult to make the girls realise the need for a sufficiency of sleep. This is the case in the schools, but particularly in the Pupil Teachers' Centres, where there is little attempt to limit the time spent on homework. 14 EXAMINATION OP INFANTS. The following tables show the result of the routine examination of 221 infants of 3, 4, and 5 years of age, representing the new children admitted to several infant departments in Islington schools of average type. Each child was examined by Mr. Cecil Rowntree, as fully as is possible without removing the clothes except in special cases. The general nutrition, the condition of the teeth, excessive dirt, etc., were noted in each case, and any departure from the normal, however slight, was recorded. 111 boys and 110 girls were examined with the following results: Of the total number (221) only 115 could be regarded as absolutely normal, while 46 per cent, of the boys and 38 per cent. of the girls had some definite defect of a nature that could be classified. The remaining 12 were noted as being below "par," either physically or mentally, but showed no actual lesion. The following table shows the above figures in full: Infanta. Age 3. Age 4. Age 5. Totals. Sex M. F. M. F. M. F. M. F. Number examined 33 31 48 35 30 44 111 110 Normal 15 21 20 16 19 24 54 61 Below par 1 1 3 3 1 3 5 7 Definite defect 17 9 25 16 10 17 52 42 The next table shows an analysis of the various defects arranged so as to show the sex and age: Infants. Age 3. Age 4. Age 5. Totals. Sex M. F. M. F. M. F. Number examined 33 31 48 35 30 44 221 Definite defect 17 9 25 16 10 17 94 Teeth, average of tota 4.8 4.8 3.7 4.3 3.7 4.1 - Naso-pharyngeal cases 10 2 10 6 7 10 45 Arched palate alone — — 2 1 - 3 6 Cervical glands 4 3 6 - 3 4 21 Tuberculous glands — — — — 1 1 2 Deafness 2 — — 3 — 2 7 Otorrhæa 2 — — 1 - - 3 Impetigo 2 4 6 1 1 1 15 Speech very defective — — 1 — — — 1 External eye diseases 2 — — 2 2 1 7 Squint — — — — — 1 1 Rickets 2 1 3 3 — — 9 Varioella 1 - - - - - 1 Congenital abnormalities — - - 1 1 1 3 Cervical Glands.—Of the 21 cases of enlarged cervical glands tuberculosis was the cause in 2, enlarged tonsils and adenoids in 10, very bad teeth in 3, and in the remaining 5 no special cause could be discovered. The largest number of defects is constituted by what may be termed the naso-pharyngeal cases, those suffering from tonsils or adenoids, nasal obstruction or mouth-breathing. These were 20 per cent. of the total number examined and 47 per cent. of those with defect. The incidence of naso-pharyngeal conditions was 30 per cent. higher in the boys than in the girls, but the numbers dealt with are too small to warrant deductions. It was in these children that the greatest number of defects was discovered, some of the cases presenting two, three, or even more lesions—usually more or less co-related. For instance, some of them were mouth-breathers, with deviated nasal septum, tonsils and adenoids, septic mouths, and were suffering from deafness, otorrhœa, impetigo and blepharitis; this with possibly the addition of a squint is by no means an overdrawn picture of cases frequently met with. The figures given in these tables do not reveal the full importance of naso-pharyngeal defect, as it is in later childhood that the gravest consequences of this condition show themselves, viz., the deafness, otorrhoea, dental caries and other conditions which are known to be intimately associated with it. For example, only seven cases of deafness were detected, three of whom had otorrhoea ; a percentage far below what would be found if the same children were re-examined a few years later. Teeth.—A study of the condition of the teeth in these cases reveals no new fact, but confirms what has already been pointed out on previous occasions— (1) The increasing amount of caries from three years of age and onwards; (2) The fact that girls have slightly better teeth than boys. The cervical glands were markedly enlarged in 20 cases, the enlargement was in nearly every case either associated with carious teeth or with naso-pharyngeal conditions. Impetigo was met with in 15 children, but hardly calls for special note beyond the fact that it appears much more common in infants than in older children. Eyes. —Systematic examination of the eyes from the point of view of acuity of vision was not carried out, but systematic vision testing of children between the ages of six and seven just before their transfer to the more exacting visual conditions in the boys' and girls' departments, would be of great 15 value and would in all probability diminish the large number of cases of astigmatism and myopia at present met with in older children. It is extremely rare to find an infant, who has been provided with spectacles ; in the infants' department of a fairly good class school with a roll of 350 only one child wa3 found wearing glasses. The above figures do not fully represent the amount of disease present in children of the age under consideration, as many who would have been classed among the defectives have escaped observation owing to absence on account of "delicacy" or some more definite defect. On the other hand, included among what may appear an excessive number of defectives, are many in which the defect was very trivial, such as impetigo, or in which medical treatment could do but little as in the case of old rickets, mental defect, and physical inferiority, the results of improper feeding, defective hygienic surroundings and the environment that goes to complete the picture of poverty, dirt and misery. ENLARGED GLANDS. The lymphatic glands about the head and neck, which guard the various entrances to the body, are of interest as they show the effects of any invasion. In the debilitated they become chronically inflamed and may pass into diseased conditions. The causes so far as they could be ascertained have been investigated by Miss A. M. Roberts who examined 750 boys and 750 girls distributed evenly in the Council's schools. She has unfortunately not made a return of their ages. 750 Boys. 750 Girls. Conditions noted. Numbers. Percentages. Numbers. Percentages. With cervical adenitis 36 4.8 44 5.8 With palpable glands 196 26.1 451 60.1 With enlarged superficial cervical glands 83 11.0 389 51.8 With upper deep cervical. 192 25.6 288 38.4 With submaxillary 3 0.4 12 1.6 With submental — — 2 0.3 With suboccipital 1 0.1 2 0.3 Enlarged glands without much caries 24 3.2 106 14.1 Enlarged glands with much dental caries 208 27.6 389 51.8 Decayed teeth without enlarged glands 375 50.0 99 13.2 Well marked caries of teeth 583 77.0 488 65.0 Three or more than three carious 296 39.3 258 34.4 " Stopped" teeth 2 0.3 — — Enlarged tonsils and adenoids 82 10.9 132 17.6 Skin affections of face or scalp 22 2.9 65 8.6 Recent or actual verminous heads 5 0.7 381 50.8 In some cases of enlarged glands the cause is tubercle, but in many there is an irritant acting before the tubercular infection, some cause such as the irritation of pediculi, the catarrhal changes induced by enlarged tonsils or adenoids, carious teeth or eczematous conditions of the face, blepharitis, conjunctivitis and other contagions of low infective power. From the table it is seen that the number of cases among the girls is more than double that of the boys, partly from the healthier tone from more energetic exercises among the boys and partly from the less frequent pediculous irritation of the scalp. Whilst 50 per cent. of the boys had decayed teeth without enlarged glands, this occurred in only 13 per cent. of the girls, evidence of the large part pediculi play in causing such irritation. Where tubercle effects a lodgment in such chronically inflamed glands there is always risk of its progress, so that the brain, lungs, or peritoneum may ultimately become affected. The result of this enquiry shows the extreme importance of the cleanliness which we are trying to effect in the schools, and the necessity for treatment of carious teeth and of chronically enlarged tonsils or adenoids. Among the 1,500 children only 2 had had conservative treatment of the teeth. Some figures are also given on p. 14 relating to the condition of the lymphatic glands in very young children. ADENOIDS. Early in 1908 the managers of certain schools being anxious to follow up any cases requiring treatment in the matter of enlarged tonsils, adenoids or obstructed breathing, Mr. Yearsley undertook the selection of such cases at Walton-street, Marlborough-road and Cook's-ground schools. At Walton-street the number on the roll was 119 mixed, and 114 infants. Of these. 84 were selected for detailed examination and 19 of the mixed and 41 infants were returned as suffering from enlarged tonsils and adenoids, or adenoids alone. There were 10 infants and 11 from the mixed department requiring immediate treatment. At Marlborough-road senior and junior mixed departments with a roll of 827, 231 were selected, 94 having adenoids with or without enlarged tonsils, and 40 probably adenoids; immediate treatment was required by 32. The infants' department had 303 examined, 105 being judged as having adenoids and 26 probably; the number requiring immediate treatment was 34. At Cook's-ground every child was examined: of the 274 infants, 60 had adenoids and 32 probably ; of the 297 girls, 81 had adenoids and probably; 30 others; and of the 317 boys, 77 had adenoids and 22 probably. 14 girls, 1 boy, and 2 infants had had adenoids removed during the two preceding years, and 40 girls, 15 boys, and 22 infants required immediate treatment. 16 The sum of these three representative schools is— Number on rolls. Number selected for detailed examination. Of these number normal. With adenoids and large tonsils. Large tonsils only. Mouthbreathers. Partial Mouthbreathers. Nasal. Adenoid. Tonsils, Nasal. Adenoid. 2,251 1,500 822 663 75 28 186 1 10 55 About seven per cent. (164 out of 2,251) of these children were in a condition suggesting the advisability of surgical operation. The figures themselves give little of the impression conveyed by reading the individual notes, of the mass of educational inefficiency which they represent. Inattentiveness, dullness, backwardness, spurious mental defect, varying deafness, coughs, bronchial irritability, recurring colds, these are the regular accompaniments of most of the cases of obstructed nasal breathing, and are so frequently mistaken for signs of early phthisis that one lady medical inspector in another part of the country has recently attempted to show that some 14 or 15 per cent. of the elementary school children in that district are consumptive. UNDERFED CHILDREN. The question of underfed children is one of great interest and importance, and one with which the medical inspector is immediately concerned. The aspect of the question which is of the greatest importance from his point of view is the detection of the cases, for it will often happen that he will be called upon to give an opinion as to whether a particular child is underfed or not. The detection of an underfed child is by no means so easy and straightforward a matter as at first sight might appear. In point of fact there is no certain criterion of these cases. Underfed children are usually undersized, they are always pale and anspmic, they take no interest in their surroundings, they look hopeless and forlorn. But so do many children whose fathers are in regular work, whose mothers are not drunkards, who perhaps are well clothed and have sound boots—the most certain stamp of the relatively well-to-do, and who when asked what they have had for dinner will describe meals of Gargantuan proportions. The explanation of these cases is probably not insufficiency, but unsuitability of food. What is ill-nutrition.—An attempt was made to standardise the criteria of nutrition in some way, but it was found impossible. Physical measurements.—The body weight in relation to height appears to be a quantitative measure which, however, was found not to furnish any very definite proportion below which it would be possible to say a child was ill-nourished. Variation of stature may be a racial quality, or the results of old troubles as rickets, so that it cannot be taken as an expression of existing conditions in the individual. Anæmia.—The presence and amount of anæmia is sometimes most difficult to assess, the fair complexioned children often appearing much more anaemic than they really are. In the open-air schools Tallquist's colorimetric method was used, but not in this enquiry. The condition may be due to so many other causes that it cannot be taken as an index of nutrition, although when well established it is no doubt also a cause of malnutrition. General appearance.—The general appearance to a practised eye sums up many slight signs, the looseness and smoothness of the skin, the firmness of the flesh, the amount of subcutaneous fat, the indications of lowered nutrition in eruptions, slight inflammation of eyelids, roughness of the hair and so on. This may lead to incorrect estimation, for instance, the anxious expression and temporary pallor of a neurotic child may lead to a much lower estimate of nutrition than is correct. Such estimates, too, appear often at fault when checked by physical measurements. Without any indication of actual disease one child in a family may appear miserably nourished whilst another is in most excellent and robust condition. The alteration in facial expression is perhaps the most marked effect of the improved nutrition effected by open-air schools. The animal spirits and vitality of ordinary children are not only lacking, there is often listlessness in the poorly nourished, but tbis is not usually capable of being inspected and recorded by the doctor. The personal equation of the examiner will always have considerable influence so that too close comparisons of the work of different doctors should be avoided. How children are fed.—The children of the poor, and not necessarily the very poor, never have fresh vegetables, rarely have fresh milk and never in adequate quantity; good eggs are unknown to them, in fact they appear to live largely upon bread, tea, and either beef or mutton broth with an occasional meal of bacon or frozen meat. It is partly the result of carelessness, partly of ignorance, and largely owing to the fact that the mothers often have far more to do than they can manage. Two or three small children to look after and often, in addition, washing or other work to do, leave but little time or opportunity for the preparation of food of suitable nature. From careful school enquiries the usual breakfast of most children seems to consist of tea with bread and butter. Such cheap and wholesome foods as porridge, dripping, milk, etc., appear to be almost entirely neglected. A further point of considerable importance in regard to the feeding of children where a meal is only given four or five times a week, is the nature of the dietary. If poverty is the cause of want of feeding, then the child is probably supplied quite sufficiently with the ch2aper starchy foods, and the costlier fats and proteids are what is required. No diets for helping underfed children are likely 17 to be satisfactory unless there is excess of proteids and fats over the starchy food. Judged by this standard most diets supplied by public funds are probably wanting in value for the children, however useful they might be as a single meal for a normal individual. Dr. L. Haden Guest in discussing the question of feeding of children found the same difficulties of assessment. He suggests, in judging of whether a child requires to be specially fed at school, that two standards (i.) the social circumstances of the parents, and (ii.) the physiological condition of the child must both be used, but notes that in children in obvious need of feeding from their physiological appearance the parents circumstances were often good and vice versa. Malnutrition in school children may arise from a formidable list of causes, chief among which are: 1. Insufficient building up of the tissues due to deficiency of food either in quantity or in quality (improper food); it may be due to want of assimilation from bad teeth, hurried meals, indigestible food, or excess of liquid with meals, particularly alcoholic liquids or strong tea or coffee. Smoking may come in. Or there may be defects in the lymphatic system, particularly sub-acute or chronic tubercular conditions. There may be deficiency in oxidation, from the quality of the air breathed (although probably the results of this are very indirect) from actual deficiency of air entering the lungs owing to nasal obstruction or adenoids, or to defects of the chest (rickets, bad postures, tight clothing); or there may be defective oxidation from circulatory defect in the blood, from mechanical defect of the heart, from anaemia, or of the lymph stagnating from want of exercise. 2. Excessive breaking down of the tissues may occur in many nervous conditions, particularly in the irritable and neurotic children who fail to get sufficient sleep, or are constantly irritated by vermin; after febrile illnesses, or due to actual overwork and the effects of chronic fatigue. Late hours are probably a very powerful factor. 3. There are also conditions of arrested or delayed development of a congenital nature. When a child is handled in school many of these causes are suspected, and it is difficult to apportion their effects. Enquiries are very difficult, as generally neither the children nor their parents seem capable of giving accurate and definite statements about such matters as health or feeding. It seems quite impossible to distinguish between bad feeding, improper feeding and bad home conditions, in the cases where there is nothing organically wrong with the children. Removal for the greater part of the waking hours to a fresh environment, as in the open-air schools has an undoubted benefit to most, but in the children examined and classed as badly nourished the medical inspectors have always refrained from assigning deficiency of food as the main cause. The girls seemed to show the effects of want most. During the first half of June, 1908, over 10,000 children were medically examined in accordance with the following scheme:— "To inspect the children in the schools named paying particular attention to their nutrition and the prevalence of anæmia. It will be sufficient to return them for:— Nutrition as— Ansæmia as— Excellent (1) Normal N. Very good (2) Pale P. Good (3) Very Pale V.P. Fair (4) Bad (5) In cases of children who are marked (5) you might make an attempt to ascertain whether their want of nutrition is due to underfeeding; other home conditions (e.g., want of sleep); or the results of ill-health from various diseases. Average samples should be taken from each department (boys, girls, and infants), preferably taking whole classes. These children were definitely classed as regards nutrition, and the presence or absence of anæmia. There are no definite standards, and in the classification it was evident that the personal equation of the examiner played considerable part, but at the same time the total result may be taken as representing a fair average judgment. The results may be represented thus : Nature of district of schools. Numbers recorded. Nutrition. Colour. Excellent. Very Good. Good. Fair. Bad. Normal. Pale. Very pale. Good schools 3,583 1,126 1,130 897 389 41 3,019 536 28 Medium schools 4,475 1,443 1,211 1,195 525 101 3,579 725 171 Poor schools 2,907 96 394 1,057 1,054 306 1,786 936 185 Totals 10,965 2,665 2,735 3,149 1,968 448 8,384 2,197 384 Put into percentages these numbers are :— Good schools 3,583 31.4 31.5 25.0 10.9 1.1 84.3 14.9 0.8 Medium schools 4,475 32.2 27.0 26.7 11.8 2.2 80.0 16.2 3.8 Poor schools 2,907 3.3 13.5 36.3 36.3 10.5 61.4 32.2 6.3 20261 18 The percentages of bad nutrition and of very pale children in each group of schools should be remarked. It is at once evident that although there is no direct connection between anaemia and bad nutrition, both conditions are commonest in the poorer schools. Ill-nutrition is related largely to want of employment and consequent privation. It is also related in other cases largely to bad housing; to want of sleep and large families. Anaemia seems to be also intimately associated with the presence of adenoids, enlarged tonsils, and other diseased conditions. Regarding the schools, as a whole, these three conditions seem to have about equal effects, but to be principally evidenced as want of food in the poorer, want of sleep and proper domestic hygiene in the medium schools, and want of exercise and effects of debilitating disease in the better class schools. Good schools.—The parents are generally in continuous work and housing is good. The general standard of health and nutrition may be said to be surprisingly good. It was in regard to one of these that Sir John Gorst wrote to the newspapers about this time, complaining of the impression made by the condition of the children. The report of the medical officer for the school was: "These children are in very good condition and well cared for. 96 per cent. of the girls are very clean in external appearance, and 146 out of 410 have provided themselves with special canvas shoes for drill." Medium schools.—Here housing begins to be evident. There is generally want of near open spaces and a tendency to overcrowding, so that want of sleep is common. The following is a type : "This is a good school in a very poor neighbourhood. On making a tour of the district the doctor noted that the children excluded from school were in a shocking condition, a great contrast to those attending regularly. They do not appear to have any treatment in most cases, and are kept in a horribly filthy condition, not at all conducive to a cure. Any old rags seem sufficient to clothe these unfortunate, excluded children when they do not come under the eye of an authority." Poor schools.—The housing conditions are generally very poor, families are often large and the larger the family the less rent can be aflorded. There is also unemployment always facing the father, and malnutrition is evident in some of these schools. A well-known school in the North of London is described as a type— "Extreme poverty so that there is hardly a child up to the average Islington standard. Most of the men are unskilled workers often out of employ. Nearly every child requires feeding in the winter months. Bread and milk has been most successful. The teachers say they notice the deterioration after a fortnight's holiday. The children of widows are, as has been noted before, generally better than the others. Intemperance is difficult to assess but it is common to find that beer is fetched twice a day. In the 43 cases marked ill-nutrition, actual existing disease accounted for 10. In 29 cases serious home conditions of poverty and underfeeding existed; 11, father out of work; 3, father in hospital, prison or deserted; 1, both parents blind; 3, drink seemed the cause. In these 29 families, 10 had 6 or more children. Medically speaking, inspection here is accompanied by but little benefit as the parents are of the class who pay no attention to messages conveyed to them from the school, and have neither the time, the money nor the inclination to take the children to the hospital." A more detailed enquiry was made at Laxon-street and Sirdar-road schools, by Drs. Squire and Sikes; there were 685 boys and 725 girls, a total of 1,410 children. Sirdar-road, Notting Dale, is one of the poorest schools of London, in the midst of a migratory, criminal and thoroughly degenerate and poverty stricken population. Laxon-street is also in a very poor district. Lack of employment, improvidence and drink are exceedingly common in both districts. Conditions found.—Sirdar-road children. Heights and weights. Using as a standard the figures obtained from the measurement of 6,122 children in " poor schools " Group A. of last years' report, and comparing with them the actual measurements made at Sirdar-road and also measurements of what the Standard weight would be if corrected for height of the children at Sirdar-road, it is found that the figures are similar above 9 years of age ; below 9, the Sirdar-road children are very deficient in weight compared with the " poorer schools " ; at 13 and 14 they are as good if not better. The actual ficures are :— Boys. Girls. Age last . birthday Description. Nos. Heights. Weights. Nos. Heights. Weights. (cm.) (kg.) (cm.) (kg.) 7 Standard 139 115.8 22.18 181 115.7 2130 Sirdar-road 51 112.4 20.90 26 112.7 20.15 Standard corrected — — 21.50 — — 20.74 8 Standard 460 119.5 23.76 494 119.2 22.52 Sirdar-road 46 116.0 21.76 50 114.9 21.07 Standard corrected — — 23.06 — — 21.70 9 Standard 563 124.7 25.49 540 123.5 24.55 Sirdar-road 50 120.8 23.74 57 121.0 23.99 Standard corrected — — 24.69 — — 24.06 10 Standard 436 129.1 27.56 546 128.8 26.83 Sirdar-road 51 127.5 26.54 54 127.3 26.57 Standard corrected — — 27.21 — — 26.52 11 Standard 440 133.4 28.61 449 133.5 29.44 Sirdar-road 52 133.3 29.23 49 131.1 27.84 Standard corrected — — 29.58 — — 28.90 12 Standard 506 137.3 32.06 420 139.3 33.10 Sirdar-road 67 136.0 32.00 49 136.2 31.68 Standard corrected — — 31.21 — — 32.36 13 Standard 438 141.9 34.86 410 144.8 36.81 Sirdar-road 58 140.5 34.96 45 143.1 37.06 Standard corrected — — 34.51 — - 36.36 19 Physical measurements at Laxon-street and Sirdar-road in relation to the estimation of nutrition are given combined as there was no material variation between the two weights of boys at these schools. Weights of the boys in different groups were averaged as follows: Age last birthday. Nutrition. Standard average of 10,000 London boys, Annual Report, 1906. Excellent. Very good. Good. Fair. Bad. 7 22.8 21.2 22.2 20.7 20.4 22.8 8 25.8 24.1 22.6 22.8 21.6 24.4 9 26.9 27.9 25.6 24.2 22.8 26.4 10 30.5 28.4 27.4 26.3 26.7 28.7 11 31.0 29.7 29.9 28.3 31.4 31.2 12 38.2 32.6 32.5 31.8 22.7 34.4 13 36.4 35.6 36.6 35.0 32.5 37.7 Anæmia which is so prevalent in towns, and which the open-air does so much to remedy, was present in a considerable number at all ages. Age last birthday 7 8 9 10 11 12 13 Totals. Colour of blood. B. G. B. G. B. G. B. G. B. G. B. G. B. G. Sirdar-road. Normal 34 22 29 32 27 40 32 39 31 37 35 30 41 30 459 Pale 15 4 17 18 19 17 16 12 21 12 19 19 17 14 220 Very pale 2 0 0 0 4 0 3 3 0 0 2 0 0 1 15 Laxon-street. Normal 20 19 23 23 34 19 23 26 25 14 25 13 24 17 305 Pale 22 27 31 32 19 23 26 33 20 23 8 27 15 26 332 Very pale - 7 2 8 2 5 4 7 1 10 1 7 - 1 55 Nutrition.—This is the estimate of nutrition made on the child's general appearance. Its value has already been discussed. It is to be noted that the excess of bad nutrition appeared among the girls. Age last birthday 7 8 9 10 11 12 13 B. G. B. G. B. G. B. G. B. G. B. G. B. G. Totals. State of Nutrition. Sirdar-road. Excellent — — — — 1 — 1 - - - - - - - 2 Very good 3 2 2 1 1 1 2 — 2 1 3 2 4 1 25 Good 27 8 20 11 23 19 24 15 20 15 26 13 23 15 259 Fair 21 13 20 29 23 35 22 29 30 29 25 29 29 27 361 Bad - 3 4 9 2 2 2 10 - 4 2 5 2 2 47 Laxon-street. Excellent 3 2 2 1 6 3 1 — 8 — 3 3 7 6 45 Very good 9 14 10 16 15 12 12 13 9 11 13 8 8 13 163 Good 12 23 23 24 20 20 18 36 15 24 11 22 10 14 262 Fair 12 9 15 14 9 10 13 10 10 9 6 11 11 9 148 Bad 6 5 16 8 5 2 9 7 4 3 1 3 3 2 74 The relation between nutrition and anaemia can be seen in this general table of the children at Laxon-street. Nutrition. Anæmia. Normal. Pale. Very Pale. Excellent 47 2 — Very good 137 31 — Good 110 144 17 Fair 17 116 18 Bad 5 46 26 20261 C2 20 The condition of the teeth was noted as similar to other elementary schools. The cleanliness and sufficiency of the clothing were expressed as one quality representing social condition—about a quarter were very good, a half average, and the remaining quarter only fair as regards clothing. Only 5 per cent. were bad in this respect. Nearly all the clothing is second hand or more remote still. It would be an advantage if pawnbrokers were compelled to disinfect all clothing to be sold secondhand. This last enquiry was conducted in the autumn when many of the children had just returned from " hopping " and probably were in better condition than at any other time of the year. In a paper recently published, Dr. Gastpar,* the Medical Officer of Schools in Stuttgart, shows that among some 8,0001 Wurtemburg children examined in the last four years, the difficulties of classification for statistical purposes according to nutrition were so great that he abandoned individual classification for classification in groups. Some of his results are of such interest that they have been extracted in tabular form showing percentages of those seen. Chest troubles. Actual . Abnormal Nutritional condition. numbers spinal England glands. Adenoids. heart noted. curvature. Not Judged to be sounds. tubercular. tubercular. Good 1,984 1.0 0.5 16.7 3.8 — 2.6 Without anæmia 2,625 3.5 2.6 21.1 14.4 0.07 14.6 Average With anaemia 1,385 5.0 5.3 22.5 20.8 0.5 22.0 Without anæmia 1,045 9.2 10.0 23.3 30.0 0.7 17.8 Poor With anæmia 998 10.3 12.5 26.2 44.1 2.8 26.3 Totals 8,037 4.7 4.7 21.2 18.6 0.6 14.8 * Zeits f. Schulgesundheitspflege 1908. 11. These figures, perhaps, give excessive percentages of defect judged by our English standards but they express in figures the enormous importance as a national duty of bringing up every case of poor nutrition to at least the average standard and this is sufficient excuse for their introduction. It was noted both by Dr. Squire and Dr. Sikes that children are often sleepy and scarcely fit for school work after a full meal. Dr. Guest notes this as occurring for a few weeks and being succeeded by improved tone. It is probable that it is more marked the more debilitated the child is, and must be taken as an indication of the child having been in a condition in which schooling was being wasted and feeding required. From these observations at Sirdar-road and Laxon-street as well as the previous wider enquiry, it seems that there will always be a certain number of children who require more food than they get at home but that provision of school meals, although important and even necessary, is only a small part of what is required towards completely combating ill-nutrition prevalent among children attending school, and a similar opinion is held by all the members of the medical staff who have made special enquiries on this matter. SCHOOL EXCURSIONS. A few vacation schools are held each year with good results to the children of some of the poorest districts. There has, however, been opened up to education authorities through the recognition by the Board of Education as school attendance under article 44 of the Elementary Schools Code of school journeyings involving residence outside the county, opportunities for practical education by bringing town children into direct contact with fuller and fresher experiences of nature than most of them have the chance of enjoying. One or two headmasters have made such journeys very great educational events in their pupils' lives and from the view of health and physique there is everything to commend this new extension of school work. Arrangements should be made for all children going on such expeditions to be seen by the school doctor at least two months previously. In the case of the excursion to the Isle of Wight 51 boys were examined previously by Dr. Riviere, two being excluded on account of well marked mitral disease of the heart. In addition 7 boys showed some cardiac dilatation. This was slight except in one case (A) a boy of a nervous, restless type, whose heart was considerably dilated (dulness 1 inch to right of sternum and outside left nipple line). He was advised not to go, but on his own doctor's permission, he was sent with restrictions. Another boy (B) appeared to have some chronic kidney trouble with hypertrophy in addition to dilatation. A third (C) showed some incoordination of movement suggesting the early onset of chorea, his heart was of poor tone, but hardly dilated, he was sent with restrictions. The others had just sufficient dilatation to be noteworthy. Two days after the boys returned from their journey great improvement in health appeared in all who had been previously noted as sound, and no cardiac dilatation appeared in any. Of the 7 noted with dilatation previously 3 showed a distinct increase. Their general health was either worse or not improved. The average sound boys then got much benefit from their expedition and no heart dilation resulted, whereas of the seven boys with weak and somewhat overdone hearts, three were distinctly worse, one was not improved, and one was probably saved by having been restricted, the only two who were not worse were boys who had been very anaemic. It is evident that with boys of these ages prolonged exercise must be avoided if they show any signs of being fagged, and that a considerable period of rest must be allowed in each period of twelve hours. 21 MEDICAL TREATMENT. In the introduction to the Report for 1906 it was stated that " the question of rigid adhesion to the policy of completely excluding any medical treatment from the work of the Educational Branch of the Public Health Department may have to be very carefully considered," and various examples were given later of types of cases where a public medical service would be of the greatest utility. In the introduction to the Report of the following year it was stated " a point has now been reached as to whether the greater part of the medical inspection shall remain fruitless, or whether the Council shall take steps which will justify its later interference to see that its younger dependents have a fair chance of properly benefiting by the education offered. Treatment as a public duty will have to be considered in respect to certain educational matters, such as visual troubles, discharging ears, ringworm and the care of the teeth, in which neither the private practitioner nor the hospitals can give any hope of either providing sufficient or satisfactory relief for most of the cases requiring it." A special Sub-Committee on the Medical Treatment of School Children was appointed in July, 1907, and included thirteen representatives of the Council and eight representatives of outside' interests, such as the chief medical bodies, hospitals and charities. It has, by collecting information and taking evidence, been able to present a clear and definite picture of the conditions existing and requiring remedy. The reference to the Sub-Committee was as follows:— (i.) What is the existing provision for the medical treatment of school children. (ii.) To what extent can this provision be rendered more available by the action (a) of the hospitals, (b) of the Council ? (iii.) What additional provision, if any, is desirable ? (iv.) How should this provision be supplied ? The report and appendices presented to the Education Committee on 8th December, 1908, extended to forty pages. The substance is given using the actual words of the Sub-Committee as far as possible. It was found that the cases requiring public attention could be conveniently taken under the heads of teeth, vision, ringworm, suppurating ears, general debility and tuberculosis. During the past six years great and increasing attention has been devoted to the questions of school hygiene in London. The education authority began with the mere intention of preserving its scholars from the grosser forms of infection, and of selecting from the ordinary school those children who needed special instruction. Step by step, however, dealing with one subject after another, and gradually increasing its staff, the Council has elaborated a system of school inspection. This system is admittedly still incomplete, and different matters receive varying degrees of attention. The vision of all children, for instance, is tested with substantial thoroughness, while their teeth have only been examined in a few instances. As, however, the Council gradually extended the field of its operations, the same result became apparent in one department after another. It was found that medical inspection created a demand for medical attendance, and that that demand did not produce a corresponding supply. It can now be shown in full detail that the health of many children is impaired, temporarily or permanently, for want of medical treatment. It can also be shown that, in a considerable proportion of cases, medical treatment is practically unattainable. A large proportion found to require treatment do not obtain it. The reasons for this neglect are partly the ignorance or apathy of the parents, and partly the real difficulty in the case of the poor in obtaining medical attendance. The waits at the out-patients' department are usually long, two visits are generally required, and it is of course impossible to examine children unattended by an adult. The parent has consequently to spend two half-days in procuring a prescription for the child, and this, especially where the mothers work, is sometimes an impossibility. Though the proportion of those who sought advice was not great, the actual numbers who attended the hospital were largely increased, so much so that the hospitals found themselves seriously overburdened by the numbers of children Who attended. Some issued notices respecting the number of children to be seen. The London Hospital, for instance, issued a notice directing children under 12 to attend on Wednesdays only, and limited the number of those seen to 15. The Great Northern Hospital were unable to make provision for more than 10 children per week. St. George's Hospital wrote to point out that "the examination of these children prevents many patients who require more urgent treatment from being seen by the ophthalmic surgeon." The Victoria Hospital for Children complained of the "large batches of children who attend at the outpatients' department on Wednesday afternoons." The secretary of the Royal London Ophthalmic Hospital called the attention of the Council to the "great inconvenience caused by the attendance of school children at this hospital on Saturdays." "This difficulty," he added, "is now becoming very acute." Mr. Sydney Holland wrote on the 21st December, 1906, complaining that " 24 children turned up at the London Hospital on Saturday last," and in another letter stated "on January 12th our oculist had 50 cases sent to him of children to be seen for refraction only. All our arrangements are made for him to finish his work at one o'clock. . . . He was working till three and then had these 50 cases to see. It is really intolerable." It is clear, therefore, with regard to the eyes of the children that the resources of the hospitals have been seriously strained, while on the other hand, many children with defective vision are compelled either to injure their sight, or to lose in great part the benefits of education. Teeth.—From the strong and unanimous evidence before the Committee it is clear that the teeth of the children in the London schools are in an extremely unsatisfactory state. They have no doubt that this state of affairs is mainly due to neglect in proper feeding and other matters during infancy and childhood. The attention of parents should be drawn to the question and valuable preventative work could be done through the schools. At the same time, it does not appear that sufficient 22 provision exists either for conservative treatment or even for extraction in London. They are convinced that the existing provision is wholly inadequate, and, unless additional facilities are provided, it is not possible for large numbers of children to obtain proper dental treatment. Vision.—It is computed that about 60,000 children in the schools suffer from defective vision. It appears that the hospitals can only deal with a small proportion of these cases. The work required is mainly determining errors of refraction. This is tedious and without great professional interest, while the number of cases involved is a serious strain on the hospitals. The Council has continually received complaints from the hospitals on this point. At the same time, the bulk of the children seen by the Council's oculists do not so far as can be judged, obtain advice. In consequence, the money spent by the Council on the inspection of children is, to a great extent, wasted. They think that additional provision is desirable for dealing with the large number of children suffering from defective vision who under present conditions, can only obtain knowledge of what they need without any means of procuring it. Ringworm.—Ringworm is common all over London. The children affected are often away from school for several months, and occasionally even for years. The effect upon the school attendance is serious, equal to a loss of grant amounting to £5,654 per annum. The Committee think that additional provision is desirable if this disease is to be effectively dealt with. They do not think that more should be done with regard to the treatment of school children suffering from favus. The treatment given in the favus school may be considered as satisfactory. Suppurating Ears and Adenoids.—It seems that the hospitals are sufficiently able to deal with the cases requiring operations. It is different, however, with those cases of discharging ears which require prolonged treatment. This condition not only lessens the capacity of children to benefit by instruction, but is extremely dangerous. Cases of middle ear disease would need careful examination by a surgeon and then, in the majority of cases, frequent cleansing by nurses. There is great difficulty in carrying out such a course of treatment as part of the ordinary out-patients' department of a hospital. The Committee think that it is desirable that additional provision should be made for such cases, and cannot resist the conclusion that in many instances such treatment would preserve life or save hearing. General Debility.—General debility is often due to the poverty of the parents, and many diseases, such as defective vision, carious teeth, suppurating ears and adenoids, dirt and other circumstances, incidental to slum life are contributory causes of debility. In the large majority of cases a stay in a home intermediate between the hospital and the special school provides the only prospect of real recovery. Tuberculosis.—When occurring sub-acutely in internal organs, might be provided for in residential institutions where open air life could be secured, and in which a limited and graded curriculum would be beneficial. When tuberculosis attacks bones or joints it should be similarly treated, unless the condition is removed for the time from the education authority owing to the necessity for surgical operation. The Sub-Committee believe that the general impression left on the minds of the Education Committee will be that the existing provision of hospitals and other institutions as now organised is generally inadequate; while in regard to particular diseases such as dental cases, errors of refraction, ringworm and suppurating ears, little more than is done at present can be expected from the hospitals, and other institutions with their existing resources and organisation. Finally the Sub-Committee answered the questions of their reference as follows:— Summary and Recommendations. (Questions i. to iii.) In answer to the first three questions addressed to us— (i.) What is the existing provision for the medical treatment of school children ? Such facilities as exist for the medical treatment of school children are provided by hospitals, dispensaries, infirmaries, etc., and the general practitioner. (ii.) To what extent can this provision be rendered more available by the action (a) of the hospitals, (b) of the Council ? Many of the above-mentioned institutions with their existing accommodation can do no more so far as the treatment of the cases indicated is concerned. Some could do more if assisted from public funds; others could do no more whether assisted or not. (iii.) What additional provision, if any, is desirable ? We think that, generally, sufficient accommodation exists to deal with the graver cases that require operative treatment. On the other hand, as regards the more ordinary ailments of children a large amount of routine work is necessary, the provision for which is inadequate and in many parts of the county non-existent. Our findings with regard to teeth, vision, ringworm, favus, suppurating ears and adenoids, debility, and tuberculosis are as follows— (a) Teeth. (1) That, in the opinion of this Sub-Committee, there is a prevalence of dental caries among children attending public elementary schools, and that the existing accommodation in the hospitals and dispensaries for even simple dental examination and treatment is wholly inadequate. (2) That, in the opinion of the Sub-Committee, it is desirable that provision should be made for simple dental treatment of school children. (3) That it is desirable that instruction in the hygiene of the teeth should be given to school children and to their parents or guardians. (4) That it is desirable that the daily use of the tooth-brush by children in their homes be encouraged. (5) That it is desirable that from time to time children be examined as to the cleaning of their teeth. 23 (b) Vision. (1) That a large number of children are suffering from defective vision. (2) That both their ability to profit by school instruction and, in many cases, their physical health, are prejudicially affected. (3) That neglect or delay in treatment may be attended by chronic or permanent disability. (4) That, owing to the large number of cases, the existing provisions for their examination and treatment are inadequate; and further, that the delay and loss of time suffered by parents seeking, often from a distance, hospital treatment for the children affected frequently result in the children not being treated at all. (5) That the existing accommodation in the hospitals and dispensaries for such treatment is inadequate. (6) That all cases treated should be re-examined every other year. (7) That additional provision is desirable for the treatment in the vicinity of the school of all children suffering from errors of refraction. (c) Ringworm. (1) That, owing to this obnoxious and contagious disease, many children, estimated at 2,950 annually in regular attendance, are prevented from attending school, and expose others to infection at home. (2) That the cure of the disease by lotions and ointments is a process occupying many months, or, in some cases even several years, the patient being meanwhile prevented from attending an ordinary school, and remaining a source of infection. (3) That the disease is now capable of being cured rapidly by X-ray treatment, the child ceasing at once to be a source of infection and able to resume school on the re-growth of its hair. (4) That, owing to the fact that X-ray treatment is provided only at a few hospitals, where its use is greatly in demand for a variety of adult and other diseases, the treatment is available only to a very limited extent for ringworm cases. (5) That the delay and loss of time suffered by parents seeking, often from a distance, treatment for the children affected frequently results in unwillingness to submit the child for treatment, the child meantime remaining a source of infection. (6) That by means of the X-ray treatment, the disease can be practically stamped out, thus rendering unnecessary the present schools specially maintained for children suffering from it. (7) That provision is desirable for the treatment of the disease by X-rays at a fixed centre or centres. (8) That power shall be given to compel the attendance of children for treatment immediately on discovery of the disease. (d) Favus. (1) That the present special treatment of cases of favus disease should be continued. (e) Suppurating ears; adenoids. (1) That cases of suppurating or discharging ears are greatly prevalent amongst children, about 1 per cent., or 7,500 children being thus afflicted, more especially those in insanitary surroundings. (2) That neglect of the complaint frequently results in deafness or defective hearing, and sometimes in consequences dangerous to health, or even life; in most cases the child being more or less disqualified from profiting by the school instruction. (3) That the cure of such cases involves skilled syringing of the ears daily as well as dressings. (4) That such treatment cannot in most cases be given at the child's home, and cannot be undertaken by the hospitals, even if the parents were able and willing to take the child there for treatment. (5) That provision is desirable for the proper treatment of suppurating ears in the immediate vicinity of the school. (6) That any cases requiring operation or treatment other than as above described, and all cases of enlarged tonsils or adenoids calling for operation, should be referred to hospital or private treatment. (f) Debilitated children. (1) That a considerable number of children living in insanitary conditions are so debilitated as to be unable fully to profit by instruction in school, or attend without further deterioration. (2) That such children especially succumb to tubercular infection as well as other diseases. (3) That it is desirable that further provision be made of schools on the lines of the existing open-air day schools at which debilitated children could be admitted by the local education authority for short periods. (g) Tuberculosis. (1) That tubercular disease with its consequences disqualifies children, if able to attend school, from taking due advantage of school instruction. (2) That many cases discharged after treatment from hospital, and other cases not treated in hospital or convalescent home, require rest and sanitary surroundings for their effective and permanent cure. (3) That the disease could, in a large number of cases, be arrested or cured if such means were provided for its treatment in the earliest stages, and that it is of the first importance that it should be so treated. (4) That children in whom tubercular disease of the bones or joints is detected should be sent to their private practitioner or to hospitals for treatment. In answer to the Fourth Question— (iv.) How should this provision be supplied ? It would appear that the children attending the elementary schools maintained by the Council, who require medical treatment, may be divided into three classes— Class 1. Those requiring care in an institution and out-door life, i.e. (a) debilitated children; (6) children convalescent from tuberculosis treated surgically ; (c) children suffering from subacute or early tubercular disease. Class 2. Those requiring operative and in-patient treatment. Class 3. Those who can be promptly and adequately dealt with in suitably equipped rooms, e.g., children suffering from teeth defects and simple diseases, eye defects and simple diseases, skin diseases (chiefly parasitic, e.g., ringworm, scabies, pediculosis, etc.), ear defects and simple diseases. 24 The provision requisite for each of these classes must now be considered in detail. Class 1.—As already stated a large number of the children in this class can only be effectively treated by segregation in institutions intermediate between the hospital and the special schools situated in the country, but in order adequately to provide for these children whose physical debilitation and deterioration constitutes a grave national danger a number of residential schools will be necessary. Class 2.—The relatively small number of children belonging to this class will leave or be excluded from school and be referred for treatment at home by private practitioners, or for in patient or operative hospital treatment. Class 3.—In this class are collected the very large mass of cases revealed by medical inspection, namely, physical deficiencies, which can be readily and economically treated if dealt with together at suitable centres conveniently situated in regard to the schools. Two distinct propositions have been considered by the Committee— (1) That the Council should make arrangements with the existing hospitals and dispensaries. (2) That the Council should establish school surgeries or clinics at which treatment should be provided by its own medical officers. Both propositions are alike in that the cost of dealing with the deficiencies enumerated above is to be provided out of the education rate. (1) Efficiency—The Committee find that the hospitals in the metropolitan area not only are concentrated in those areas in which there are fewest schools but, further, that the spatial accommodation in their buildings is in many cases inadequate or cannot be extended. The Committee find that at the present time the dispensaries in the metropolis are few in number, are not as a rule situated conveniently for the schools, or provided with suitable or adequate accommodation, and finally that in various large areas (e.g., one district in S.E. London, with a population of over 300,000) there are no dispensaries. We are informed that neither the provident dispensaries nor the friendly societies at present deal with the greatest and most difficult part of the problem, namely, the treatment of the teeth, eyes, suppurating ears, and other conditions which require continuous and skilled care and attention. Such cases were, we were told, dealt with by obtaining hospital "letters" for the patients. Treatment through any dispensaries must either be given at the residence of the medical practitioners who are dispensary officers, or on premises specially provided. If the first system, which we are informed is the present ordinary practice, is adopted, and if the parents are further required to accompany their children, not only will it be difficult to secure premises sufficiently suitable to be approved by the Board of Education, but a serious waste of time and wages, involving constant difficulty and friction, must result, and would probably militate very seriously against the children receiving the treatment they would require. If new and specially equipped premises are to be provided for the dispensaries, the cost must be borne by the Council, and is not likely to be less than that which would be entailed by the provision of similar premises under the direction of the Council itself. It is clear, therefore, that the hospitals and provident dispensaries of the metropolis cannot adequately provide the treatment required, and even if such service were attempted, the efficiency, i.e., the time and care given to children at any of the charitable or provident institutions referred to where both adults and children attend, would be less than that provided in a school surgery or clinic designed and equipped for the special needs of the school children. The treatment in such a school clinic would be furnished by school medical officers under the immediate direction of the Council. (2) Economy.—Although the question of payment to existing institutions is necessarily surpassed by the considerations just detailed, it must receive further discussion. Such payment would, as a rule, cover two sources of expenditure; the cost of accommodation and equipment on the one hand, and on the other the cost of skilled attendance. The Committee has not received any estimate of such expenditure and therefore cannot institute accurate comparisons, but payments to institutions and departments founded for other purposes probably would not offer such return as money expended in the maintenance of a school surgery or clinic arranged and reserved for the direct purpose of treating the defects of the children referred. It must also be evident that the indefinite series of payments to a large number of separate institutions and the endless adjustments and assessments of payments to the medical staffs of these institutions involved by such a system can only result in inextricable financial confusion and possibly extravagance, whereas the administration of school clinics by the education authority can be financed with accuracy and economy. The proposal that the State should subsidise from public funds charitable medical institutions in order to create a claim on the benefits of such hospitals or dispensaries for children or persons under State authority, educational or poor law, raises a new and serious question of principle. The representative meeting of the British Medical Association has already fully considered this question and is resisting the proposal on the ground that any State medical service must be adequately organised, must be administered on a systematic basis, and must be clearly distinguished from work undertaken for charitable motives. Recommendations. (а) That, as the existing provision of private and hospital practice sufficiently meets the requirements in the case of children requiring operative and in-patient treatment (who are thus removed from the direct purview of the educational authority), no further steps be taken in respect of this class. (b) That the Oouncil should establish school clinics at suitable centres in the metropolis for the medical treatment of the defects included in class 3. 25 A Minority Report was also submitted in reference to Question IV., as to the means which should be adopted for the supply of certain additional provision necessary for the medical treatment of school children— The two simplest methods are— 1. To set up school clinics working under the immediate management and supervision of the local education authority. 2. To utilise existing types of institutions, giving, if necessary, financial assistance. It can be argued that the institution of school clinics would be simple and elastic. If the treatment of children of school age were an entirely new problem demanding consideration for the first time, much might be said for placing their health and education under the same authority, however keenly we might feel, as some of us do, that medical treatment is not in principle a strictly educational duty and should not be cast on the education rate. The need for providing treatment for children has, however, engaged public attention and has called into existence various types of institutions whose special function is to provide that treatment. We are confronted, therefore, by the accomplished fact that the ground is to some extent already covered and must consider whether the existing provision can be utilised as far as it goes and extended to meet the need. We must remember that, as part of their daily routine, existing institutions can do and are doing, so far as their present resources permit, a great deal of the work which the local education authority would do if it set up clinics. In many cases the necessary appliances and accommodation are already provided, though at present the existing provision is inadequate. We understand that at certain times even this provision is unused, but might be more fully utilised by arrangement, especially if funds were forthcoming to provide additional staff. In this way part of the expenditure on buildings would be saved which would otherwise be inevitable, and even if it were necessary to help an institution to extend its accommodation, the room thus provided would be available for the general use of the institution when not required for children. Again, the section of the Act which gives the local education authority the power under which any proposed action would be taken, contains a special proviso " that in any exercise of powers under this section the local education authority may encourage and assist the establishment or continuance of voluntary agencies and associate with itself representatives of voluntary associations for the purpose." This proviso clearly contemplates that the course we recommend was one which a local education authority would do well to adopt, otherwise it is difficult to see why Parliament should have inserted words to this effect. In short, the Act and circular explaining it evidently contemplate in the first place an attempt to use and extend existing institutions, a view in which we concur. It must not be forgotten that existing institutions can deal with persons during their entire life, while medical treatment provided by local education authorities in that capacity would only be available to persons during their school career. An education authority could only treat between the ages of three and, say, fifteen, and has no power over a child during the first three critical years of its life, when greatest harm is usually done. Under our proposals a person would be treated all his life long, whether of school age or not, at the type of institution which exists simply to supply such treatment. If the Council were to set up clinics a person would be treated, say, at a hospital from birth to three, from three to fifteen at a school clinic, and from fifteen onward at a hospital again. We have had before us the secretary of the Provident Medical Dispensaries Association, who described to us the work of his society. The object of his society was to provide through the general practitioners medical treatment for ordinary ailments of the working classes, and he assured us that an effort would at once be made to open medical clubs or dispensaries where they might be w anted, if the Council gave any encouragement. Should the Council choose to use its power to treat, we think that the various hospitals, etc., should be approached and asked what they would be prepared to do, if necessary, in return for financial aid. In spite, therefore, of the attractiveness at first sight of the system of school clinics, we think it would be unwise (by setting up, at the cost of the education rate and under the immediate management of the local education authority, a number of what would in fact be children's hospitals) to add another type of institution providing medical treatment to those already existing, unless and until such institutions have proved incapable of the extension and co-ordination necessary to meet any given need. They recommended that to supply the additional provision for the medical treatment of school children, which has been found desirable, the Council should utilise existing types of institutions, giving financial help, if necessary, and receiving special facilities in return for any grant of public money. The Education Committee on the 16th December, 1908, resolved :— (а) That, as the existing provision of private and hospital practice sufficiently meets the requirements in the case of children requiring operative and in-patient treatment (who are thus removed from the direct purview of the educational authority), no further steps be taken in respect of this class. (б) That to supply the additional provision for the medical treatment of school children which has been found desirable, the Gouncil should utilise existing types of institutions, giving financial help, if necessary, and receiving special facilities in return for any grant of public money, but that in districts where no suitable institution exists, and where within a reasonable time it shall have been found impossible to make the necessary provision by an extension of existing institutions, the Council should consider whether in default of other means it shall make the provision itself. DEVELOPMENT OF ARTICULATION. A short account was given in the last Annual Report of the development of capacity for articulating consonantal sounds. Some 650 children had been carefully tested with 227 test sounds embracing 21 single, 75 double and 13 triple consonantal sounds. It was shown that the development of articulatory capacity is not uniform, but by fits and starts and at different ages in the two sexes. Dr. Ernest Jones has continued his enquiry analysing the development of each group of sounds and the nature of the mistakes made. The investigations on consonantal sounds would be valueless unless neighbouring sounds were also stated. These neighbouring sounds have an exceedingly great influence on the enunciation of the sounds tested. This is true not only of neighbouring sounds but also of comparatively distant ones. For instance, three children can pronounce the "th" sound in the word " think " for every two who canjpronounce it in the word "thin." In general, a sharp terminal sound increases the facility with which the initial sound can be produced. Two investigators using different test words might thus easily arrive at quite different conclusions. The word pronounced immediately before the test word also exerts a considerable influence on the accuracy of the word in question. The effect of the contiguous vowel is important but has not been followed up. Replacements of consonants.—In studying the character of mispronounced words replacements have been especially noted. 20261 D 26 (a) In the 450 children from which the replacements were noted in 227 test words each three replacements far exceed in frequency any of the others, viz., Th by F, Th by V, and Ng by N. (1) Th was replaced by F 772 times by the boys and 590 times by the girls. It occurred most often in Thl in intermediate positions, in initial Thr and terminal Tht. (2) Th was replaced by V 253 times by the boys and 130 times by the girls. This occurred most often in terminal Thed and The. (3) Ng was replaced by N 108 times by the boys and 110 times by the girls, almost always in terminal Ng. This sound is more deficient among the girls than most of the others, when considered with respect to its deficiency among the boys. It is, however, more deficient among the girls from indistinctness rather than actual replacement. (b) Replacement of sibilants by a peculiar slushing sound of X. This occurred more often with S among the boys, and with Z among the girls. This replacement of sibilants is 17 times more frequent among boys than girls. Sh is very frequently replaced by S in Shr. (c) Exchange of anterior and posterior palate Unguals, replacement by the latter being 13 times as common as the reverse. (d) Interchange of nasals and trilled sounds:— (i.) Replacement of Ng by N, referred to above. (ii.) Replacement of M by N, chiefly in the terminal Them and Zm. (iii.) Replacement of N by L, chiefly in intermediate sounds. (iv.) Replacement of L by R. (e) Interchange of labials and labiodentals. V is replaced occasionally by B in intermediate positions. These are the five main types of replacements noted in the order of their frequency. The voiceless sounds are more often replaced than voiced ones, and the interchange of voiceless and voiced sounds is very rare. Relation of Nasal Obstruction to Articulatory Defect.—When testing the children the nasal obstruction was noted in 700 cases by estimating its amount purely from the facial attributes characteristic of the condition. Five arbitrarily chosen classes were used, distinguished as none, slight, some, considerable and bad. Of these children 469 had quite normal speech and 231 speech defects. Stammering existed in 69, of whom 49 had " normal" articulatory powers, and 29 were defective. Normal children numbered 254 boys and 215 girls. Nasal defects (estimated). Nil. Slight. Some. Considerable. Bad. Totals. Numbers of children— Boys 41 122 64 24 3 254 Girls 35 94 62 23 1 215 Percentages— Boys 162 48.0 25.3 9.5 1.2 100 Girls 162 43.7 28.7 169 0.4 100 Average number of marks gained for articulation (possible, 1,000)— Boys 985.2 972.1 974.0 967.2 972.9 - Girls 983.5 981.3 979.2 9795 941.2 - If these classes are divided into groups according to the marks obtained for articulatory capacity, the total possible being 1,000, the following table is obtained:— Degree of nasal obstruction. Boys. Girls. Less than 970 marks. 970. 995 marks. 996. 1,000 marks. Total in class. Less than 970 970. 995 marks. 996. 1,000 marks. Total in class. Actual numbers observed— Nil 8 13 20 41 7 12 16 35 Slight 29 42 51 122 22 39 33 94 Some 18 30 16 64 19 26 17 62 Considerable 12 8 4 24 7 10 6 23 Bad 2 - 1 3 1 - - 1 Percentages of total in class — Nil 19.5 30.2 48.8 100 20.0 34.3 45.4 100 Slight 238 34.4 41.8 100 234 41.5 35. 1 100 Some 28.1 46.9 25.0 100 30.6 41.9 27.1 100 Gonsiderable 50.0 33.3 16.7 100 30.4 43.5 26.9 100 27 The bad class is left out of further consideration as the numbers are so small. Taking the four different classes of obstruction in the boys, it is to be noted that of the " nil" obstruction nearly a half get high marks and less than a fifth are in the low mark group. At the other end of the obstruction scale, where it is "considerable," the reverse holds, and there is a uniform change in each class, so that the correlation with the degree of nasal obstruction and the percentage of cases is very close. The same relations, although not so striking, are noticeable among the girls. If the table is set out as percentages of each mark group, it is found that the relations in each group of boys and girls remain sensibly the same, so that it is evident that the factor of nasal obstruction is the only one coming in, as the incidence of nasal obstruction and total marking shows no perceptible difference in the two sexes. Abnormal Speech.—These 231 children numbered 132 boys and 99 girls, the actual numbers in each class being:— Degree of nasal obstruction. Nil. Slight. Some. Considerable. Bad. Totals. Numbers of children— Boya 15 34 40 26 17 132 Girls 10 25 29 22 15 99 Percentages of totals. Boys 113 25.7 30.3 19.7 12.9 100 Girls 10.1 25.2 29.2 22.2 13.1 100 Average marks for articulation(possible, 1,000)— Boys 879.9 868.8 882.2 868.6 921.4 - Girls 7815 890 3 824.9 828.6 895.4 - Although the numbers are comparatively small, the incidence of nasal obstruction is similar in both sexes, but there is no relation whatever between the degree of obstruction and average of marks obtained. In both sexes the class of most obstruction gets highest marks, and in the girls the class of least obstruction obtains the lowest marks. Analysing the results as before the same conclusion is reached :— Degree of nasal obsrtuction. Boys. Girls. Less than 970 marks. 970995 marks. 9961,000 marks. Total in class. Less than 970 marks. 970995 marks. 9961,000 marks. Total in class. Numbers— Nil 5 5 5 15 4 5 1 10 Slight 12 9 13 34 7 10 8 25 Some 10 16 14 40 10 11 8 29 Considerable 9 13 4 26 4 10 8 22 Bad 2 9 6 17 4 5 4 13 Percentages of total in each class— Nil 33.3 33.3 33.3 - 40.0 50.0 10.0 - Slight 35.3 26.5 38.2 - 28.0 40.0 32.0 Some 25.0 40.0 35.0 - 34.5 37.9 27.6 - Considerable 34.6 50.0 15.4 - 18.2 45.5 36.4 - Bad 11.8 52.9 35.3 - 30.8 38.5 30.8 - The absence of any order or progression is quite evident. The conclusions drawn from this enquiry are that the consonantal articulatory capacity is inversely related to nasal obstruction in normal children and more decidedly so in the case of boys than girls. The incidence of obstruction being equal in the two sexes, it appears that a given degree of obstruction produces, either through deafness or in other ways, more harmful effect on the articulatory capacity of boys than of girls. On the other hand , with abnormal cases who present gross defects in the consonantal articulatory capacity, no correlation whatever can be traced in either sex between the degree of nasal obstruction and the extent to which this capacity is impaired. Possibly some slight correlation might be found if a much larger number of cases could be taken but the factor is evidently unimportant and submerged by others. 20261 D 2 28 NEEDLEWORK. It is possible to get most beautiful specimens of patching done by children as young as five years of age, but it is not wise. The immature eye of a young child is quite capable of working efficiently in accommodating itself to vision for all objects over a foot distant, but the rate of increase of accommodative effort increases out of all proportion as objects are brought nearer to the eye. The child generally sacrifices clear vision to a bigger image not so clear, and tends to work on fine objects at 4 to 6 inches distance. The ultimate results to vision in many cases are serious and the nervous strain great. The nerve groupings which are concerned with finger work are so immature that children in the infant department, at six or seven years of age, can only use the muscles concerned clumsily, and with immense strain to themselves and more remotely to the teachers also. Knowing the physiological importance of these facts, the following articles were inserted in the London County Council School Management Code, 1904 :— 110d. ii. It is exceedingly important that the children should be prevented, as far as is possible, from acquiring the bad habit of working with a short distance from eye to work. In no case should any child be permitted to occupy itself with work nearer to the eye than a foot distance. iii. In infants' departments, in girls' when sewing, in boys' writing or doing fine drawing or painting, children often bring their eyes down closely to their work, enduring cramped chests, round backs, and much eye strain. During such work teachers should pay especial attention to prevent these habits, and endeavour to secure observance of a proper working distance. 147. v. Teachers of girls and infants' departments are instructed to study the eyesight of children when doing needlework, by seeing that they have sufficient light, and by strictly adhering to the Government Regulations. In 1905 it was reported by the Council's officers that this article (i.e., 110(d) of the Code) was practically ignored in nearly all our schools. Dr. Louisa Woodcock has therefore investigated sewing as actually taught in thirteen schools, including some with a considerable alien population, and has endeavoured to discover the relations of such needlework to visual defect and nerve strain. Sewing was abolished in infants' schools in 1905 for all children below standard I., that is below the age of six, but is still taught between six and seven. Especial attention has, therefore, been paid to these children. The method of investigation was first simply to note children at work, without in any way criticising, and later to endeavour to find out the kind of work aimed at, and the reason for it. In 100 children, standards I. to IV. and aged from 6 to 10, doing either sewing or knitting, 84 per cent. held their work at from 4 to 6 inches distance or nearer, and the 16 per cent. who had a better working distance were mostly knitting. Knitting, with one exception, was held further off than sewing; the exception was a girl of seven wearing glasses, who from habit held her knitting 3 inches away, although she could work equally well at a greater distance. No child worked at the distance of 12 inches recommended in the Code. The children seemed to find it less effort to hold the work near. No instructions as to eye distance are usually given by the teachers, although some trouble is taken about this matter in regard to reading. The rule is for sewing to be held very closely, knitting nearly double the distance, whilst reading is done at three or four times the distance of sewing; and often when the reading is held nearer it is found that it can be done equally well further off. For instance a girl in standard III. whose sewing was held 2½ to 3 inches off and who had already had a red warning card in regard to defective vision, read her book at 6 to 7 inches, but when asked to hold it at 13 inches read equally well. The evidences of strain which Miss Woodcock noted as commonest are :— (i.) A bad position of the body, the work usually being pressed closely to the chest to obtain a point d'appui, entailing a stooping posture, and rounded and high shoulders. Sometimes this point is attained by fixing some other part of the body, by fixing the head, or by resting the elbows on the desk, or pressing the knees up against desk edge, and so on. (ii.) Squinting, which shows itself where the child keeps up its accommodation and the convergence overacts. It is temporary but means eye strain which may be a preliminary to changes ending in myopia. (iii.) Corrugated forehead, overaction of the frontal muscles forming horizontal creases, knitting of the eyebrows. (iv.) Twisting of the body and neck, the head being held sideways from incoordinate action of muscles of the two sides. (v.) Grimacing. The mouth often open, due to muscular relaxation and " habit spasm " of the face. There is also muscular spasm due to over action in the efforts to control the finger movements. It is only when these actions are excessive and long continued that they can be classed as indicating injurious strain. On all points there are abundant instances of the effects of the work, but single typical cases will be quoted as illustrative of the effects noted. In a standard I. class of 28 in a girls' school, ages 6 and 7, the children were hemming with a needle No. 7 about 10 stitches to the inch in a poorly-lighted room. A few minutes after beginning work 10 were squinting, especially when threading the needle, 11 were knitting the eyebrows, 2 standing up to sew; and 6 stopped working. Halfway through the hour only 4 children did not present nervous effects, and at the end of the hour only 1. In standard II. of the same school, average age about 8, half the class knitting, and the other half (20) sewing, of whom 16 were working in a bad position and 9 squinting. In the higher standards the girls tend naturally to hold their work at a reasonable distance, perhaps a third of the number working quite satisfactorily. It is in standards I. and II. that nervous overstrain and awkward postures are so apparent, and from the length of these children's arms, 10 29 inches eye work distance should be quite comfortable for them. In one school where 24 girls were hemming in the same room as 34 boys, all being about 7 years of age, only 1 boy was frowning whilst 17 girls were doing so. These girls had had six previous lessons in hemming, including four of drill, so that this was the second lesson in hemming a specimen. Each specimen had been inked in red and black dots by the teacher, about six stitches to the inch to ensure regularity of stitch. The wasteful expenditure of nervous and muscular energy displayed by these children, and the clumsiness of the hands of all the 24 was most striking. 21 held their hands close to their chest wall entailing bent head, and chin sunk in chest, raised shoulders, or heads held sideways and bodies twisted; 3 were squinting and only 1 held her work at a reasonable distance. B 5 7 8 Actual sizes. A—Coarse threader for learning. B—Darning needle with wool tied in. 5, 7 and 8—Sizes of needles from infants' departments, Standard I. The threading of needles is a very difficult task for many. The needles size 7 and 8 (are about 3.3 cm. or 11/8 inch long) have very small eyes (.6 mm. by '25 mm.). The difficulties of the young children are increased by their needles becoming constantly unthreaded. Two lessons are usually devoted to learning to thread needles. Watching 40 children of standard I., age about 7, many of them held the needle about 3 or 4 inches off, and 1 tried for half an hour unsuccessfully; the teacher stated that this child had spent the whole of the previous lesson in unsuccessful attempts. In a standard I. 39 were present and the light was not good, the windows having double-ribbed and wired glass. 15 of the class were frowning, 10 were threading their needles and the notes made were:— (a) Two are squinting. (b) N.R. (vision=6/24) spent 25 minutes in trying to thread a needle, frowning, with twisted limbs, she was continually letting the needle fall, and spent most of the lesson time under the desk. (c) T.S., according to the teacher, slightly defective mentally, did not succeed in spite of all her attempts in 30 minutes. (d) E.N. (vision=6/9) sighs heavily, she sits in the front row in a bad light, and cannot thread her needle in five minutes. (e) J.E. (vision=6/36) holds her needle 4£ inches from the eye, opens her mouth all the time in the effort, succeeded after ten minutes. It was noted too that the children occasionally suck the needles instead of the end of the cotton, and some suck their thimbles; as these thimbles are used promiscuously they will have to be remembered if sore throats should be prevalent. On the other hand, in a standard I. where the children are dull, backward and of the truanting class, aged 9 and 10, and in standard II., aged 11 and 12, where they had been taught hemming on coarse canvas with a large-eyed rug needle, most of them threaded a small-eyed needle for the first time quickly, although the younger children again held the needles 3, 4 or 5 inches off the eye. Headaches from eye work are rare in the elementary schools. They are almost unknown as ocular headaches, being chiefly associated with home conditions of debility and want of ventilation and in children generally with nasal obstruction from adenoids, but in connection with needlework lessons, headaches do occur and children crying with headaches are almost peculiar to the needlework lesson. The Learning Of Sewing.—Standard I.—Hemming; oversewing (specimens), plain knitting, strips of cotton with two steel or wooden needles. Making articles for use—Hemming handkerchiefs (for sale), dusters, bean bags (for a game), pillowslips. The materials on requisition are coarse canvas unbleached calico, white calico (Horrocks), cotton (red blue or green). A child in standard 0 of a junior mixed department is taught first to thread a coarse needle or threader (about two lessons). She then learns a thimble drill in four parts, after this a needle drill which is different in the case of knitting, hemming and oversewing. One may hear these drills chanted over for ten minutes at the beginning of a lesson, the children making the fine movements without using cotton. The drills make an adult realise how complicated these fine, and in later years automatic, movements really are. In answer to an enquiry about a class of 64 7-year old girls the 30 mistress wrote that on testing the needlework class after seven lessons, including three preliminary lessons, no child could really work a hemming exercise, holding needle and work quite correctly, and that several further lessons would be necessary. Mr. Cecil Rowntree finds the sewing drill in universal disfavour. It appears a laborious unattractive and clumsy method of aiming at a result probably to be attained by much simpler methods. One headmistress stated, and probably it is not uncommon, that she teaches the children sewing first and the sewing drill afterwards. Actual size. 0 (Aet. 12)—The gusset has 46 stitches to the inch. D (Aet. 7-8)—Hemming specimen with 13 stitches below and 25 above. E, F—Backstitching, unnecessary and hurtful, threads counted. In some schools the children of standard I. made six stitches to the inch, in others ten, but the specimens kept for exhibition average about fourteen. Too much stress is laid on regularity. It is impossible for a teacher to obtain regularity, and to attend to ensuring the proper working distance in a large class. The first will come without teaching, but the last, if neglected, means the establishment of the most harmful of school habits. As regards the time given to the respective exercises in needlework, the working of specimens bulks greatest. In one school it was stated to take three-quarters of the whole time devoted to needlework. In a year in the higher standards, each child makes one garment for sale. They do not necessarily in all schools make even one, but they always have five or six specimens of each stitch required. These specimens are thus considered an end in themselves, instead of a means to an end, and attain a much more surprising standard of excellence than the work in the garments. Far too many are worked in order to attain a uniform standard of excellence. It is painful to the eyes to examine some specimens where there are 40 to 50 stitches to the inch. The Counting of Threads.—In the London County Council Code, 1905, p. 77, it is stated :— "Counting of threads should never be practised. This habit is not merely dangerous to the sight of the children it is also inconsistent with the use of needlework as a hand and eye training." In spite of this prohibition, darning and herring-bone stitch are taught on canvas, by this unnecessary and eye straining method. A class of 59 (standards III. and IV.) girls being taught herringbone stitch on a large frame containing squares of knotted tape, was taueht to recite— Count down four, Count along four, Take up two. At the corner— turn needle up turn frame round turn canvas round. and although later in practice it may not be done on flannel in this way, yet many specimens of flannel herring-bone work can be found strongly reminiscent of the "count down four" formula. Darning also is taught on canvas by counting stitches, so that although the method is supposed to be abandoned as soon as the process is learned, on examining a darned specimen there can be little doubt that the work is done by the thread. Fine work, such as the cross cut or the hedge tear is generally done by counting threads. This class of work is done by matching colour and texture with marvellous perfection in France, " Stoppage " ; but the effects on the eyes of the workers are notorious. The 31 question of contrast and colour which is so trying to the "stoppeuse" has to be considered here. The dazzling white canvas should be condemned. Working in red wool on white canvas is very trying to astigmatic or hypermetropic children, who form the majority, and should also be prohibited. Actual size. Darning with coloured wool on white canvas ; very dazzling work. The red colours which are so irritating should no longer be issued, and coloured cottons and wools be restricted to blues and greens. From October to March no needlew ork should be allowed after 3 p.m. and during November 15 to February 15 no needlework should be allowed in the afternoons at all. Artificial light in school is practically always insufficient for this work. Dr. Woodcock summarises her observations by stating that it is unscientific to teach fine stitches on fine materials to children of 6 or 7 years of age, since the practice of such stitches not only causes considerable eye strain, but also general nervous overstrain. Hemming and over-sewing should not be taught before the age of 9 or 10 years. If the weaving and knotting as practised by the children of New York schools is condemned on technical grounds, then coarse stitches, not more than four to the inch should be taught with a large rug needle into which the thread may be tied, on soft, coarse pervious material, but not canvas. This requirement should be made universal in the standards I. of all schools. Canvas should be prohibited, and also dots and lines to facilitate regularity or technical excellence. Counting of threads as an aid to teaching should also be forbidden. Technical excellence will be produced by rapidity rather than accuracy of work, and need not be regarded in earlier school work. A correct working distance must be insisted on or the work stopped. Technical excellence is at present striven for without regard to hygiene. SCHOOL DUST. Dust arises in school from wear and tear of floors, furniture, and materials, such as crayons, chalks, or wool, used in teaching. The greater part is introduced from outside, either upon the persons of the children and others attending the school or with the unfiltered air which blows through windows and other ventilating apertures. Much material is carried in on the shoes of the children, but from enquiries and observations in naturally and artificially ventilated schools it appears that about as much dust is carried in by the air as is taken in by the children. Samples of the dust taken from the tops of cupboards in schools show, when examined microscopically, soot, chalk, and other amorphous materials, bits of woody fibre, hair, and wool, and always epidermic scales derived from the skin of the children. Grown upon suitable media colonies of the common organisms (e.g., staphylococcus epidermidis albus) of the human skin have been cultivated. The organic contents of school dust show that it may be a source of specific disease. The more complete the removal of dust the healthier the school building must be. The taint of fermenting organic material can be distinguished first thing in the morning in most schools where the windows have been kept closed during the night. Air borne.—The amount of dust collected in mechanically ventilated schools is only about onehalf of that found in those naturally ventilated, although from the fact that hot-air deposits dust on colder surfaces this dust often appears as discolouration of the wall at the hot air inlets. The air entry in these mechanically ventilated rooms is usually preceded by filtration. It is impossible to filter the air entering naturally ventilated rooms, but more attention should be given to the state of the inlets; the apertures and passages often contain long standing collections of dirt. The more modern Tobins Tubes have doors at the bottom opposite the inlet openings which permit of ready cleansing, but where there are galleries it is sometimes impossible to obtain access to these tubes; some of the inlets are also protected by fixed gratings which render their cleansing impracticable. 32 Personal Introduction.—The danger of specific contamination will be minimised by greater attention to personal cleanliness and the more extended use of baths. Although the removal of dirty foot-gear is not practicable, more attention should be given to the removal of dirt from the shoes before entering school. The habit of scraping and wiping the feet upon entry to a building is so important that the habit should be inculcated in all children. In the Council's schools a sunk scraper is generally provided at the entrance door. The use of mats is decidedly advantageous, both in conjunction with the scraper at the door where the bulk of the dirt is removed, and also at the entry to the hall after mounting the stairs. Daily cleansing.—Damp saw-dust is used as far as possible. A sackful of saw-dust costs one shilling, and in a medium-sized school lasts about three weeks. Occasionally a school is found where dry sweeping is done, but this is unsatisfactory, as the effect upon the health of the cleaners is bad, and a large proportion of the dust is distributed through the air and left to settle on the desks and tables. It is uncommon to find sweeping being done with the windows closed, but in some schools, owing to the difficulty in getting rooms warm, the windows are kept closed. The use of wet sawdust in sweeping halls leaves nothing to be desired, and probably no better method could be adopted. It is, however, impossible to sweep the portions of the class-rooms occupied by dual desks, as the time and labour allowed is too small to allow for the sawdust being removed from between and beneath the feet of the desks, and as the desks cannot be moved a certain amount of dry sweeping is practically universal. The use of frequently damped brooms is probably the best solution and lightly spraying with a garden syringe with a fine rose would be of great service; the provision of such apparatus in each school would render routine disinfection of classrooms with formalin at times of infectious outbreaks an easy matter. After sweeping with or without sawdust it is the general practice to close the windows and wipe all the furniture with cloths damped with paraffin. This is excellent, though the practice of waiting until the disturbed dust has settled is better. Much dust accumulates upon the tops of cupboards and ledges out of reach, and the fermenting material left undisturbed in these situations contributes largely to the unpleasant bouquet noticed when there is insufficient ventilation. It would be a great advantage if the tops of cupboards were made smooth and polished and slightly sloped, as it is impossible to clean them when left uneven. All ledges should be sloped outwards and downwards from the wall, and there should be no horizontal surfaces out of reach. The picture mouldings are generally veritable dust traps and extremely unhygienic. The older iron rail standing clear of the wall is greatly to be preferred. School Dust and. Disinfectants.—The specific function of disinfectants is asserted to be in connection with infectious diseases, the zymotic fevers especially. All our enquiries here and most of the teaching of recent years go to show that out-of-school conditions are far more powerful means of disseminating these diseases, and that the school plays a comparatively secondary role. The infection is from the children themselves, not from doors and cupboards, desks or floors; these means are trivial; it is the undetected or mild cases or carriers continuing to attend that accounts for school spread of disease when it exists. It is little use disinfecting a school room if the clothes and persons of the infective children cannot also be disinfected. The method of searching for the infective focus and removing it must always be the chief line of resisting the spread of infective diseases. "With these facts in mind, the value of routine disinfection as applied to school rooms sinks to insignificance compared with its value in such a focus as a sick room after the patient has been removed. The cost of disinfection will always be very great, and as the cost of the disinfectant is probably ninetenths of the whole, it is obvious that as a commercial interest routine disinfection in relation to educational buildings is likely to be pushed as energetically as ventilating expedients were once urged on an ignorant public ; although the value seems to be in little doubt the actual results to be obtained by routine disinfection might be worth a trial, using disinfection in one group of schools and omitting it in a control group. Dustless Oils.—Far more efficacious from the dust point of view would be the use of oils as floor dressings. In many commercial houses and banks these oils are found very useful. They appear to have been unsuccessful when tried in some elementary schools, but at the Stockwell Secondary School for the past year the use of this method has been very satisfactory. The usual routine in the hall, for instance, is 9 a.m. assembly, 9.30-12.10 drill, 12.40 dinner. After this it is swept. 1.30-2, on wet days, dancing, 2 drill. The drill mistress formerly suffered much from irritable throats, due probably to dust. This has disappeared since the floors were oiled. There is less dust now on the food and during meals, and dancing has only been practicable during the past year. The decorations of the room seem fresher than those of the adjoining school decorated at the same time. There are no complaints. Dresses are not dirtied or discoloured, and there is a considerable economy in labour. Considering the extensive use of these dust fixing oils (Staubbindende Oele) in German Schools it would be well worth trying an experiment on a considerable scale. SCHOOL NURSES. There are thirty-two school nurses with a superintendent. With such a small number for the whole of London there must be no vague generalities or filmy suggestions as to what the school nurse should do. Her work is educational and designed to promote the efficiency of the school in certain definite ways. She does not in any sense act instead of the parents, she does not bind up cut fingers, put ointment on chilblains or attend to minor ailments and trivial accidents. Such work at present is mere shortsighted waste of time. The nurse examines children regularly to detect conditions of uncleanliness and disease, and also does what little is possible in the way of home visitation to stimulate the parents to obtain relief for objectionable conditions The work to be done in schools of populous districts is 33 so continuous and so strenuous that no one but a school-nurse giving her whole time to the work should ever be considered, and except for country districts nurses under voluntary societies or associations should be out of the question. The nurse's work falls into four main groups, some of which have not yet been fully developed, for reasons to be discussed later. These groups are — inspection of heads for presence of lice (pediculi capitis); inspection of clothes and bodies for vermin (pediculi vestimentorum) the detection and control of ringworm ; assisting the teacher with the nurse's knowledge and experience, in sundry small questions that occasionally arise either in carrying out the medical officer's orders, or in suggesting temporary procedure in cases of suspected outbreaks of infectious or contagious diseases, scabies, ophthalmia, offensive discharges and so on. She can also often give temporary help to the teacher in many small and doubtful points about school hygiene, such as open windows, damp feet or clothes. Fault is found occasionally with the nurses but the complaint that they do not visit the schools often enough comes in a hundred times more frequently than all other complaints put together. Sentimental complaints about want of privacy in examining children are occasionally made, but they are quite unreasonable. Anything like privacy in such work would, by doubling the time taken, also double the cost of the work, not only for the nurses but also for the doctors. Cases which are at all likely to require such private examination are exceptional and must always be left to the discretion of the nurse or doctor by any reasonable parent. Children can only have their heads inspected by taking them in large numbers. Where a case of suspected ringworm, or even so-called scurfiness of the head is seen the child is put aside and examined after the others. The nurse uses careful measures for asepsis after each of such suspected children. She is provided with permanganate of potassium, with corrosive sublimate for a stronger disinfectant. She has also a powerful lens, and forceps for manipulation of ringworm cases, and spirit lamp sterilizer for her metal instruments. Complaints against the nurses usually come from parents whose pride has been wounded by the receipt of a notice about vermin. Although in such cases the child is generally cleansed there is sometimes opposition. Even secondary school pupils take up that attitude, and occasionally training college students referred to me have argued that their heads were clean enough and a few nits counted for nothing. The nurses work is often the first step towards dispelling a cloud of ignorance; the fact is brought home that cleanliness and the physical condition of the child are as important to the Education Authority as the training of the mind, and there is a moral training in the lessons of self respect and courage, the perseverance to effect cleansing in a home where often all is against it, and in the teaching that cleanliness is within the reach of those who strive for it. The superintendent has now organised the service so that no school shall be left unvisited more than seven weeks, but for a really efficient service every school should be visited at least once a week, this would require sixty-five additional nurses. In addition to this routine visit there are, of course, very many more visits paid to different individual schools, but by arranging a fixed hour for the routine visit the teacher can prepare for the nurse and arrange for out of school cases to be present. This saves time and causes little disturbance of the school work. The numerous requests from secondary school mistresses for nurses visits is also increasing the work in this direction. Each nurse sends in a weekly report of schools visited; numbers examined; numbers noted and details of any special cases. She also makes a formal report to the superintendent at the office, viva voce, once a month. Originally there was opposition on the part of some teachers to the work of the nurses; this has almost ceased. As in all other matters of medical inspection the teachers in the majority of schools have come to take the greatest interest in the work of the visiting nurse, and identify themselves with her aims. This aid and active co-operation is a necessity. If the nurse does not get such help, difficulties with parents soon arise which do not occur in schools where there are strong, sympathetic and discreet head teachers. There are no regulations yet as to the nursing costume and the Council school nurses do not wear any regular uniform. Such a distinctive dress should be provided, because it is important that the school nurse should be recognisable by all as a regular officer of the Authority. Parents should learn that it is no use to attempt evasion of regulations by moving children from school to school, as the school nurses attend all schools. It also ensures suitable washable clothes being worn by the nurses in school. Again, parents respect the uniforms of the nurses whom they see in hospitals and infirmaries, and as the Council's nurses visit many places where they would be liable to insult in an ordinary dress, a Council nurse's uniform would protect them in any locality. 1st APRIL TO 31st DECEMBER, 1908. There are now 51 school nurses with a Superintendent and two Assistant Superintendents. The districts have been re-arranged and each nurse has now an average of about 13,000 children under supervision. In order to ensure efficiency arrangements have been made for each school to be visited at least once a month. This is effected by devoting the morning of each day to the inspection of a separate school and the afternoon to dealing with the most unclean schools. Three days' notice is given to the Head Teachers of the Nurses' intended visits in order that they may arrange for any special cases, upon which advice is wanted, to be present. PERSONAL HYGIENE. Elementary Schools.—The cleansing of children from vermin is accomplished by bringing pressure to bear on their parents. Heads.—In regard to unclean heads the cleansing scheme has been carried out in 124 schools, with the following results 20261 E 34 « . White Red Proposed. Excluded _ , .. ' 0 _ cards cards by nurse for Departments. children Clean. Verminous. Firgt Final for prosecu. examine . notice. warning, exclusion. tion. Boys 26,838 25,714 1,124 802 240 94 49 Girls 29,768 20,554 9,214 7,146 3,896 2,027 1,402 Infants 30,759 26,032 4,727 4,010 1,879 830 555 Mixed 3,937 3,180 757 697 364 249 158 Special 883 645 238 208 122 75 64 Totals 92,185 76,125 16,060 12,863 6,501 3,275 2,228 The parents of 81 children were prosecuted and fines imposed varying from Is. 6d. to 12s. These statistics cannot be compared with previous years as the standard of cleanliness has been raised to such an extent that comparisons would be quite misleading ; there is not now the same need to apply the scheme to whole schools as there was four or five years ago. Considerable modifications have been effected with a view of avoiding disturbance of school work. The great improvement in cleanliness is shown by the high standard to which the nurses now work. Formerly only cases with actual sores or vermin were reported ; now children with nits alone are held to be unclean. The allegations that children are mostly infected in school cannot be true to any extent as in every district the condition of the children is always worse after the holidays. It is of great importance to get nurses of the right sort. A kind, tactful, yet firm character in an intelligent and refined nurse manages to conduct a cleansing scheme in even a large school, with very few, sometimes no exclusions, for prosecution. This cleansing scheme has been thoroughly effective. Bodies and Clothes.—The action of the school nurses has been almost entirely directed to effecting cleansing of heads, but it is now necessary to extend this care to the bodies and clothes of the children. The numbers are much larger than was supposed. Some 19,900 cases are known to the nurses. The revelation of the state of these children often causes astonishment and disgust in the teachers, who, whatever they may have suspected, could scarcely examine the children as the nurses do. The Superintendent of Nurses examined some classes carefully with a view of ascertaining the prevalence. She found in one school 12 out of 55 boys in one class, 10 out of 60 girls, and eight out of 54 infants had verminous clothes ; in another school 43 boys out of 135 had verminous clothes. These proportions are fortunately characteristic only of the dirtier schools, but of these there are very many. That such conditions are tolerated gives an idea of the conditions of the homes. The homes are often so dirty, so dark and wanting in the means of cleansing, that it would have been pure injustice to exclude such children and prosecute the parents. The powers suggested originally, to exclude such children and demand their cleansing by the sanitary authorities, were not obtained. The Clauses of the L.C.C. General Powers Act of 1907 have proved impracticable and as the matter is still under consideration, nothing further has been done except in the districts where the Borough Councils provide facilities for bathing such children. The Municipal Cleansing Stations provided for verminous persons are inadequate to the needs of London. They are chiefly for the class of tramps and street walkers who frequent common lodging houses. The buildings are often used also as disinfecting stations or to provide accommodation for persons temporarily turned out whilst disinfection of the house after scarlatina and other such diseases is being done. The buildings too are generally situated in remote or otherwise undesirable localities. There are very many grave risks which would be incurred through allowing or The parents of 255 children were prosecuted and fines varying from Is. 6d. to 20s. imposed. From 1st April to 31st December, 1908, the scheme was carried out at 32 schools with the following results:— Departments. No. of children examined Clean. Verminous White Cards First. notice. Red Cards Final warning. Proposed by nurse for exclusion. Excluded for prosecution. Boys 6,143 5,859 284 276 91 37 16 Girls 7,556 4,568 2,988 2,592 1,417 758 601 Infants 8,357 6,741 1,616 1,534 808 437 287 Mixed 1,534 1,153 381 359 195 114 71 Special 259 160 99 1 99 60 32 13 Totals 23,849 18,481 5,368 4,860 2,571 1,378 988 35 encouraging children, particularly little girls, to visit these places, and the objections of the parents would always be a reasonable and paramount obstacle in the way of such stations being utilised for the cleansing of children from the elementary schools. The child infected with vermin is of a totally different class to the verminous adult. The one is capable of being trained and educated to be a cleanly and self-respecting citizen, the other is lost in these respects and only to be treated as a nuisance requiring mitigation so as to be tolerable. In St. Pancras an enlightened policy has been followed in the provision of separate arrangements for children. On the other hand, in Southwark there is illustrated another and effective way of dealing with this nuisance of verminous clothes. The Superintendent of School Nurses reports that:— "The St. Pancras children make great use of the baths, and the teachers speak very highly of the improvement of the children in school, both as regards their health and their attention to their work. It is certainly remarkable to see what a difference can be made in the aspect of a child by such a weekly cleansing bath and clothes free from vermin—the skin and colour improved, brighter eyes and a more intelligent look, and a disappearance of the horrid fidgetting, the result of irritation. There is no question of the popularity of such a bath with the children ; often it is their first acquaintance with the joys of immersion in hot water, and the feeling of well-being that the use of it with soap brings about. About a hundred children attended these baths weekly, but unfortunately many of these relapsed into the same dirty state directly they ceased coming to the baths, showing the great need we have for stronger measures in dealing with the homes. There is one district in London in which the co-operation of the Medical Officer of Health has proved invaluable, that is, Southwark. It has been enough here to send the child once to the cleansing station; the child's name and address are sent to the Town Hall, a Sanitary Inspector visits, and has the house cleansed and the bedding stoved. The nuisance of all this upset has so brought the need of cleanliness home to the parents, that the effect remains for a long time, and perhaps never is it required to send the child again to the cleansing station. The parents have a great horror of the arrival of the sanitary van being seen by the neighbours and can be made to do a great deal to prevent it." The Children Act, 1908, gives power to the Education Authority to examine and cleanse these children in default of the parents. The cleansing of children being an entirely separate problem from the cleansing of adults, there pan be no objection to its being done by the Education Authority, and it is a further step in the direction of trusting all public duties concerning the regular care of the child as a child entirely to the one authority which looks after his general physical and mental development. The cleansing of bodies and clothes when undertaken by the Education Authority will have to be done by treating the very bad cases first. The cleansing stations should be on a comparatively modest scale, as it is to be expected that the demand for their service will diminish in the course of a few years. A cheap method of rapidly sterilising and drying clothes, in 15 to 20 minutes, is highly desirable, but not yet attainable. It would probably much simplify arrangements and considerably reduce expenditure. Cleansing Of Clothes.—An attempt was made to find out how far the use of sterilising apparatus would aid in destroying the offensive animals. To be effective the apparatus should be cheap, easily worked and not liable to get out of order, or cause dangerous risks. The clothes should be sterilised and fit for wear within the half hour. Dr. Brincker has made some experiments in this direction. A zinc-lined cupboard was constructed in which formalin vapour could be diffused by a lamp, to which the clothes were exposed, but although half an hour's exposure to formalin vapour in varying strengths up to twelve times that usually recommended, and so strong that the operator could hardly face it, no effect was produced on the pediculi; even when exposed to it in test tubes they were quite lively three days later. A steam apparatus in use at the Favus School was also experimented with and with steam at 100 deg. C., in twenty minutes both pediculi and nits were completely destroyed. If there were means of cleansing clothes easily it would then be possible to insist on children attending school free from body vermin, their re-appearance on any child who had been cleansed being sufficient reason for the sanitary authorities insisting on complete disinfection of the house from which the child comes. The fact that formalin fails so completely, however, with pediculi is worthy of note in reference to houses as well as the clothes. Secondary Schools.—The medical examination in secondary schools revealed an unsatisfactory state of personal hygiene among the pupils and the following scheme has now been adopted to deal with this condition :— The nurse visits the school, examines the pupils and supplies the head mistress with a copy of the following card for each case where the personal hygiene is found to be unsatisfactory:— Obverse. M.0.9. LONDON COUNTY COUNCIL. PRIVATE NOTICE. Your attention is called to the unsatisfactory condition of this pupil's hair. She should return to school on the . The nurse will see her again, when it is hoped 'hat the condition will be remedied. Head mistress. Date 20261 E2 36 Reverse. DIRECTIONS FOR CLEANSING A small-tooth comb should be used daily. All nits should be removed from the hair. The use of sassafras oil is strongly recommended. "When the pupil returns she is re-examined and if the condition has not been remedied she is again excluded and a copy of one of the following circular letters is sent to the parent:— (A.) Secondary School. When the nurse visited the above School on the inst., your daughter's ( ) head was found to be in an unsatisfactory state. Although a notice was forwarded on the inst., calling your attention to this matter, the condition has been allowed to persist. I have now to inform you that unless the condition complained of is remedied and the child returns to school free from the signs of infection on I shall have no alternative but to recommend her exclusion from school. (B.) Secondary School. When the nurse visited the above school on the inst., your daughter's ( ) head was found to be in an unsatisfactory state. Although a notice was forwarded on the inst., calling your attention to this matter, the condition has been allowed to persist. I have now to inform you that unless the condition complained of is remedied and the child returns to school free from the signs of infection on I shall have no alternative but to recommend the termination of the scholarship. If the pupil does not return to school on the date given, or returns in an unsatisfactory condition, the case is reported to Committee with a view to permanent exclusion in the case of fee-paying students and to the withdrawal of the scholarship in the case of scholarship holders. RINGWORM. In the first report to the School Board for London which I made in 1903, it was stated that: " The selection of children whose efficiency in school is damaged by dirt, parasites, chronic diseases of ears, or impaired visual acuity, is just beginning. The treatment of all these matters is tedious, has to be thorough, but is a routine of the most monotonous and uninteresting description. The burden at present falls on the hospitals, and they have not yet adapted themselves to it. Whether even with time they can ever efficiently discharge this public duty is at least doubtful." Ringworm was one of the diseases considered by the Special Sub-Committee on the treatment of children, and their recommendations will be found on page 23. It is the chief trouble the nurses have to deal with as considerable numbers of children are out of school for long periods. It is one of the diseases for which the hospitals fail, and the provision of medical treatment is required, a disease soon to become comparatively rare when public remedy is provided. Troubles constantly arise on medical certificates, some of which are given even in face of the knowledge communicated by letter that ringworm has been found microscopically. The number of doubtful cases submitted by the nurses for microscopical examination was:— Insufficient Number of Found to be Found material Year. specimens forms of to be for observation examined. ringworm. favus. found. accurate observation. judgment. Year ending 31st March, 1908 2,175 1,705 25 347 58 40 1st April to 31st December,1908 2,751 2,212 32 423 47 37 In 151 cases, medical certificates had been given that the children were free from disease or fit to attend school, but in 144 cases ringworm was found, in 3 cases favus was found, and only in 4 cases was the distinctive organism not found. In the second period, April to December, 1908, medical certificates were given in 127 cases where specimens were submitted, and in 119 cases ringworm was found ; and only in 8 was no fungus found. There were also medical certificates furnished in 5 cases stating that the children were suffering, but on examination these were found to be free and re-admitted to school. In one case where ringworm was found no appearance of the disease could be seen when the child was examined shortly after at the head office. In some of the cases the clinical appearances were such that we had grave doubts as to the bona fide nature of the certificate. It wa3 pointed out in a previous report that the loss of grant from ringworm ran into many thousands 37 of pounds yearly and would continue until public provision for the free treatment of this disease is made. This is the only way of satisfactorily dealing with it as a school matter. This disease is one which might easily be disseminated by careless handling, and for that reason minute precautions are taken by the nurses after handling such cases. On the other hand a single case sometimes remains in a family without spreading for some unexplained reason, and adults are free from risk of infection. A case of chronic ringworm has recently been found which had been in a large residential school for months without any other child being affected, and yet usually in a residential school the chance admission of one unobserved case means a rapid development of several cases. FAVUS. The Favus School opened at Osborne-place in June, 1906, has been sanitarily a great and encouraging success, mainly owing to the time and care expended on it by the late Dr. Bertram Abrahams. He set up as his ideal the complete extirpation of the disease in the East End and established by patient enquiry and testing the success of the school routine which is the most successful purely medical treatment we are acquainted with. He lived long enough to see his rlesire brought well in view by the inauguration of electrical treatment which will enormously shorten the period of treatment required for cure. During the year 28 children have left, and 23 have been admitted, 76 remaining on the roll. The accommodation has been reduced to 55. The ages of the children admitted were:— Ages J 5 6 j7 8 9 10 11 12 Numbers 2 2 7 4 2 3 2 1 =23 And the duration of the disease in these children, so far as could be ascertained, was:— Duration in years 1 2 3 4 5 6 7 8 9 Numbers 4 4 4 2 5 1 1 1 1 =23 Of these 23 admitted, 12 had already been under treatment at the London Hospital and 9 elsewhere, but only 1 child had materially benefited, and that child has now removed from the district. It was certified free from fungus before removal. Two had not had any previous treatment. Of the 28 who left, 19 were cured, 1 was over the age limit and six removed from London. One was taken oft the roll on account of long and serious illness due to rheumatic fever and its sequelaj. Of the 76 children on the roll, at the end of the year (31.3.08), 13 came from the Jews' Free School, 8 from Myrdlestreet, 6 from Chicksand-street, 4 each from Baker-street and Commercial-street, and 29 from 16 other neighbouring schools, whilst 12 had never been in school. The ages of these 76 children are :— Age 5 6 7 8 9 10 11 12 13 14 15 Numbers 2 2 10 5 7 7 11 12 10 9 1 =76 And the duration of the disease has been such that many have had it the greater part of their lives. Duration in years 1 2 3 4 5 6 7 8 9 10 11 12 14 I Numbers 4 9 12 9 12 4 2 4 13 8 2 I 6 1 =76 The earlier difficulty of getting reliable information as to the family prevalence of favus has at last been surmounted by the patient enquiries of the nurse, who now can speak to many of the mothers in their own language. She has obtained full accounts of 54 families; in 42 the father was foreign born, and 47 the mother was foreign born; in 4 the parents were English born, but some of the grandparents were Portuguese; in 41 families more than one of the members were affected. Several of these families have had all the children attending the favus school cured. In 7 of the cases the disease was attributed to infection at the ordinary school. In many families one or both parents were stated to have suffered earlier and recovered, and the history shows a considerable proportion of recoveries about puberty, this practically is the case in the allied disease of ringworm. It is noteworthy that in 19 cases the children were affected on their arrival from Russia; in one case all six members of the family were affected. 38 It has been established that the risk of re-infection in the school is almost negligible. Dust taken from various parts of the school repeatedly failed to give any favus cultures, although they were easily obtained from hairs or scales direct from the children's heads. A table of the results of treatment published in the last Annual Report showed how ineffective various measures for the relief of favus seemed to be. The fault could not be said to depend on either the hospital or the medical men, as a great deal has to be left to the parents. Ignorance, apathy or mere laziness, lead to neglect, and the fungus retains its hold especially in the deeper parts of the skin around the hairs. No case was therefore regarded as cured in which repeated microscopic investigation of hair stumps failed to detect the fungus unless it had remained clear for three months. The sanitary routine of the school is now applied to each of the children. Children on admission to the school are generally found in all degrees of uncleanness. The scalp is covered with yellowish, crusted dimpled patches, sometimes purulent, but more generally with sticky honeylike secretion. The purulent cases occasionally have a faint odour, otherwise the characteristic mousy odour mentioned in the text books is but rarely noticed. The hair is cut very short once a week with clippers. The head is then washed with plenty of soft soap; a knitted headflannel and towel is used, and each is marked with the child's name. After use the towel and flannel are placed in disinfectant solution and all the head-flannels are boiled in the evening after being used. If there are many scabs when the child is admitted the head is poulticed each morning with Unseed and a small proportion of cyllin, about one part in 200 of the water used for the poultice. The heads are also washed daily. When poulticing is not required a compress of perchloride of mercury solution, one in 250, with glycerin one in 10 or 12 or a compress of cyllin solution is used. The cyllin solution may be increased in strength till in some cases the pure solution is painted on. The cyllin is merely used as a convenient disinfectant, no doubt many other similar materials would be equally applicable and equally effective. All the children have the patches treated daily with white precipitate ointment, one in three, after washing, and before going home. This is continued till no fungus can be detected in the stumps when all treatment is withdrawn and the case kept under observation. At the end of three months, without recurrence it is pronounced cured and discharged. The routine is kept up during the holidays. During the past year 19 cases have been discharged after the severe test of watching three months for recurrence. These recoveries appear due to the treatment of this routine as worked out by Dr. Abrahams. But many cases somewhat improved still remain and the results, although brilliant for favus treatment, seem meagre compared with the toil expended by the nurse. In order to handle this disease more effectively, it has been decided to practise epilation by the Roentgen rays. A room has been set apart for a bath-room for cleansing the clothes of children, and for medical treatment with the X-rays. An electrical apparatus for the production of Roentgen rays is worked by current from the electric lighting mains. The special electrical apparatus comprises an induction coil giving a 12-inch spark and a Watson's mercury turbine break or interrupter; the dielectric being coal gas, a current of which is brought into contact with the mercury when in action. The primary current from the main is adjusted as required by the resistance of a graduated rheostat; the secondary current from the induction coil passing through a vacuum tube gives origin to the X-rays. This tube is supported by an arrangement capable of adjustment to any position and carrying a shield so that the child patient can sit comfortably during the operation, instead of being in a constrained position. The shield protects the patient's body from the rays and also to a certain extent protects the operator. This protection has recently been increased. The technique is similar to that used in the Paris ringworm schools except that the shield allows the whole head to be done in six exposures instead of twelve as in Paris. The areas not under treatment are protected by sheet lead, the parts under treatment being exposed by windows cut in the lead. Both the primary current from the main passing through the coil and the secondary current going through the vacuum tube are carefully measured and from these the necessary dose of rays can be estimated. As these factors might vary, a control check is used in observing the chemical change in a pastille of platinocyanide of barium. This changes from a standard green tint to a standard orange colour during the time the scalp receives the necessary exposure, varying from 16 to 19 minutes. The action of the rays results in the hair being shed in from two to three weeks after the exposure. In the case of ringworm, essentially a disease of the hair, the fungus is generally carried oft by this epilation. In the case of favus, however, the hair follicles also contain spores and act as foci of disease, so that the case has to be carefully watched and any re-appearance of the disease immediately treated. We may now look forward to practically abolishing the disease within a comparatively short time so far as its interference with school is concerned. When the school was started it was resolved only to keep cases till they were cured or reached the age of 14. In several cases the parents made no effort to aid the school care, some even opposed it and children were taken away at 14 still suffering and in two cases known the boys went to assist at barbers' shops. This has now been remedied by the Council allowing children uncured to be retained till 16. It is highly improbable that any child will ever be so retained as the parents at once have realised that they must assist if their child is to be ready to leave at 14. During the year 1908 the school had been conducted entirely on the lines already indicated. Since May the electric installation has been at work, and during the last six months has been under the superintendence of Dr. H. G. Critchlev. The work for the year ending 31st December, 1908, may be summarised as follows :— In the bath-room an "Equifex" vermin destroyer has been fixed. While the children are being bathed their clothes are exposed to current steam at 100°C. in the chamber of the Equifex vermin destroyer for 15 minutes, and to dry hot air (for drying the clothes) for frve minutes, 20 minutes in all. Current steam at 100°C. has proved to be effectual in killing body lice, fleas, bugs, and is also capable of destroying the nits of body lice which are very resistant. 39 At 1st January, 1908, there were 78 children on the roll and only four were admitted daring the year. Two were discharged as cured during the first quarter, seven during the second quarter, 13 during the third quarter, and 30 at the end of the year : of these, 26 were cured by the X-rays, the installation having only been working since July. At the close of the year there were 30 remaining on the roll, and several of these are to be detained only a few weeks for further observation to make sure that an effective and permanent cure has been obtained. SICKNESS, ETC., IN CLASS. In one Boys' Department the District Inspector made the following report:— Boys.—In the sixth standard no less than 34 boys out of 56 have suffered with some more or less serious physical infirmity during the year. In fact the condition of the class would point to the necessity not merely for the medical inspection of the boys, but of careful advice and treatment. On further enquiry the inspector added that he did not infer that these boys were any worse than those in other parts of the school; their class master is a little more observant of and interested in their condition. It is worth putting this teacher's notes on record as an example of conditions, which will in a few years time probably be almost unbelievable, and also as an example of a teacher's fine interpretation of duty, although in about one third of the cases the parents could not be stimulated to take any action. G.B. —Abscess on buttock, so that he could not sit. Ringworm, absence 8th January to July, 1908. Alb. G.—Aaenoios and enlarged tonsils. Eight visits to hospital. Alf. G.—Deafness, adenoids suspected. No action. S. C.—" Scattered Homes " boy. Defective vision, spectacles supplied by the Guardians. Aural discharge detected in school. Attended by medical officer to Guardians, then out-patient at London Hospital. Left—over age. S. da C.—Tonsils operated on at London Hospital, December, 1907. G. D.—Tonsils removed at Gt. Ormond Street, November, 1907. Suffered St. Vitus dance. Wears glasses for visual defect. G. P.—Epileptic fits all school life ; less frequent this year. R. P.—Deafness. No action taken by parents, just left. B. R.—Defective vision. Absent under hospital, November, 1907—March, 1908. G. R.—Defective vision. Glasses supplied and worn till he left. A. S.—Defective vision. Both parents seen. No action. N. S.—Defective vision. Parents written to, father just died. No action. H. T.—Defective vision. Parents written to and seen. No action taken. Since left for Sir John Cass' School. P. W.—Tonsils removed, 23rd December, 1907. A. W.—Defective vision. No action taken by parents. I. Z.—Deafness after diphtheria. Speech affected. W. G.—Out-patient at London Hospital with urinary trouble. W. E.—Defective vision. Glasses supplied and worn. E. B.—Defective vision. Glasses supplied and worn. C. E.—Defective vision. Glasses supplied and worn. G. R.—Polypus in nose recurring. Has been removed nine times. J. M.—Deafness in left ear detected in February. Attended London Hospital. Operated for adenoids March, 1908. G. B.—Tubercular glands in neck, Autumn, 1907. R. W.—Severely cut about head by father with bottle. Attended hospital three weeks in January. Father had given him a black eye previously. J. A.—Absent twelve weeks with pneumonia. A. B.—Absent four weeks with pneumonia. S. T.—-Speech affected by cleft palate. Examined by doctor, February. H. B.—Injury to knee in climbing wall, receiving no attention. Message to parents. Taken to London Hospital. Absent six weeks. A. G.—Defective vision. No action taken. T. A.—Defective vision when tested. FACIAL ERYSIPELAS IN A CLASS. On 21st March a letter was received from the head teacher of the Girls' Department at New Park Road stating that there had been three cases of erysipelas in standard VI. The first case, A. S., occurred on February 19th. Her nose was " swollen and extremely red and shiny." Tt was diagnosed as erysipelas by a medical man. She was out of school for a month, returning on 16th March, and was examined there on April 8th; she was noted as undersized, poorly nourished and poorly clad, evidently convalescent from a serious illness which tbere was no reason to doubt was correctly diagnosed. The second case, M.C., occurred on March 12th, three weeks after the first case and before her return to school. Her face under the right eye became swollen, red and painful. She was sent home and treated by applications of flour. She was seen in school on March 26th, as a well clad refined and delicate girl. Some swelling still remained as a bagginess under the right eye and the whole history was quite consonant with a slight attack of erysipelas. The third case, A.M., ceased attendance on March 16th ; she had no contact with either of the previous two ; but stated that M. C.'s face was exactly like hers at the start. Her mother on April 8th gave a very definite history of erysipelas which started in a small spot under the left eye ; the nose and eyes becoming red and swollen, and then it spread down the neck with watery blisters that hung in bags. On examination she was healthy and well grow n. The face was still somewhat swollen and there was no doubt that she had had erysipelas. 40 The classroom was thoroughly disinfected on March 27th, but in spite of this two further cases occurred. The fourth case, A. B., was absent from April 2nd to 6th. The inflammation started under the left eye where the skin was swollen and red. The head teacher sent her to a local practitioner who diagnosed an infectious process. Seen on April 8th she was an undersized and ill-nourished child. There was a small punctured point, covered with a scab, below the left eye but no longer any inflammation. The fifth case, M. W., ceased attending on April 3rd. The inflammation commenced under the right eye and spread across the nose to the face. Seen on April 8th with " St. Anthony's fire " she had erysipelatous inflammation of the skin of the face including nose and cheeks, which were red and swollen with a definite margin, and here and there little vesicles especially about a linear scratch under the right eye where the inflammation is said to have started. She was well developed and nourished, and at the time when seen was extremely ill and suffering with bronchitis. She had sat immediately in front of A. B., who had become ill the previous day. The spread of erysipelas through a class in this manner is a rarity that may almost be described as unique. The origin of the inflammation in at least three cases from a scratch below the eye, and in the same position in the other two is suggestive of factitious production, but the fact that the cases did not originate at once but at intervals, and that none of the children were particular friends is against this. Two of the children were exceptionally sensible, intelligent and truthful, and denied all but the possibility of an unnoticed and accidental scratch. The classroom was at the top of the building and had been used as an art room, having shadow curtains which could be rolled upwards, out of deep and dusty troughs, which it was impossible to clean, and which were therefore removed. INFECTIOUS DISEASES. Notifiable diseases.—During the past year, London has suffered from a more than usually severe prevalence of scarlet fever and diphtheria, the former especially showing a marked increase as compared with the previous year. For the last five years, the number of scarlet fever cases has been steadily rising, and the figures for this year justify the opinion expressed in last year's annual report, that the crest of the upward wave of epidemic prevalence has been reached. There is reason to think that the incidence of this disease will now begin to diminish. Scarlet fever and diphtheria are the only notifiable infectious diseases which to any material extent affect school children and special reference is made to these diseases on pages 47-54. Non Notifiable diseases.—The principal non-notifiable diseases which affect school children are measles, mumps, whooping cough, chicken pox, ringworm, ophthalmia or blight, and scabies. With the exception of measles and whooping cough, these diseases although seriously affecting attendance at school, are not dangerous to life. Among children's diseases, measles claims the heaviest deathroll, due largely to ignorance on the part of parents. Charts.—The actual rise and fall of scarlet fever (Diagrams D, F) and diphtheria (Diagrams E, G) each week, and the percentage of deviation above or below the weekly mean, are shown in the diagrams. All cases notified by the school teachers are allocated in the various weeks in which they occur; accurate comparison between the curve representing all persons and that representing elementary school children is thus ensured. The measles chart (H) represents the comparative prevalence of the disease during the past t.hrp.p. vp.a.rs. The following table shows the numbers of cases of scarlet fever, diphtheria and measles that have been notified during the past three years:— Disease. Year. Total number notified. Weekly mean. All ages. Children attending public elementary schools. All ages. Children attending public elementary schools. 1905-6 19,892 7,400 382 142 1906-7 20,741 8,716 399 168 Scarlet Fever 1907-8 27,077 12,990 521 250 1905-6 6,553 1,977 126 38 1906-7 7,987 2,645 153 51 Diphtheria 1907-8 8,817 3,227 170 63 1905-6 Non notifiable 22,157 — 426 1906-7 Non notifiable 19,065 — 367 Measles 1907-8 Non notifiable 23,762 — 457 ALL PERSONS CHILDREN ATTENDING PUBLIC 1907 ELEMENTARY SCHOOLS 1908 E ALL PERSONS CHILDREN ATTENDING PUBLIC Martin.Hood StLarki ijLith,London.W.C F G H 41 The table given below shows the average number per week of elementary school children suffering from scarlet fever and diphtheria in relation to the average number of all persons suffering from these diseases during the past three years. The ratio is expressed as a percentage. Disease. 1905-6. 1906-7. 1907-8. Average per week. Average per week. Average per week. All Persons. School Children. Percentage. All Persons. School Children. Percentage. All Persons. School Children. Percentage. Scarlet fever 382 142 37% 399 168 42.1% 521 250 48% Diphtheria 126 38 30% 153 51 33% 170 63 37% The apparent increase in incidence upon school children is to a large extent to be explained by more complete notification on the part of the teachers, especially those in non-provided schools. School closure.—The numbers of schools under special investigation for the three most dangerous diseases affecting school children during the year were as follows:— Diphtheria—Provided 133 Non-provided 31 Scarlet Fever—Provided 3191 422 Non-provided 103 Measles—Provided 412 Non-provided 174 586 The numbers of schools or classes closed for the various diseases are given below in tabular form. The closures on account of measles have been more numerous than last year, but the larger number of closures is not the direct outcome of the increased prevalence of the disease. School closure in outbreaks of measles is undertaken purely as a preventive measure, since we have proved it to be futile to take this step as a means of checking an outbreak when once measles is established in school; it is therefore only carried out on the first appearance of the disease in a classroom. Several considerations are to be weighed before closing a room at this stage. For instance, notification by the teachers must be definite and prompt; the proportion of children protected by previous attack must be known; the age of the children and the existence or progress of the disease in other parts of the school should also be considered. Even when carried out successfully, closure in London only postpones an attack for a few months, and is of little value except when applied to babies' rooms. In scarlet fever outbreaks, closure is seldom applied, individual inspection and exclusion of suspicious cases being found to be of much greater utility in controlling the disease. This subject is dealt with fully on pages 47-53. Diphtheria is controlled by means of bacteriological investigation, and the exclusion and notification of children found to be harbouring bacilli. School closure, except under exceptional circumstances, may mean loss of control of dangerous cases. Department. DISEASES. Diphtheria. Scarlet Fever. Measles. Measles and Scarlet Fever. Diphtheria, Measles, Whooping Cough, Chicken Pox. Scarlet Fever, Measles, Whooping Cough, Chicken Pox. Measles, Whooping Cough, Chicken Pox. Number under Observation. Clasrsooms Closed. Departments j Closed. Number under Observation. Classrooms Closed. Departments Closed. Number under Observation. j Classrooms Closed. Departments Closed. Classrooms Closed. Departments Closed. Classrooms Closed. Departments Closed. Classrooms Closed. Departments Closed. Classrooms Closed. Departments Closed. Boys— Provided 18 — 1 76 1 1 – – – – – – – – – – – Non-provided 4 – 1 8 – – – – – – – – – – – – – Girls— Provided 28 – 1 123 9 1 – – – – – – – – – – – Non-provided 5 — 1 35 – – – – – – – – – – – – – Mixed- Provided 6 — – 30 3 1 – – – – – – – – – – – Non-provided 2 — — 20 – – – – – – – – – – – – – Infants— Provided 100 4 1 255 16 5 411 58 9 – 1 – 1 – – – – Non-provided 24 – 1 80 — 1 174 17 5 – 1 — — — 1 — 1 20261 f 42 Of the above 142 closures, 122 were carried out by this department, usually after consultation with the local authorities. The following 20 closures were carried out by local sanitary authorities acting alone— Lewisham Diphtheria 4 classrooms. Scarlet Fever 1 department. 1 classroom. Measles 3 departments. 10 classrooms. Bermondsey Scarlet Fever 1 classroom. In the case of measles, the disease for which class closure is most frequently required, the numbers of classrooms and departments closed in infants schools were distributed through the year as follows:— Year , j 1907. 1908. Month April. May. June. July. Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Classrooms. P. 6 7 14 1 — 2 2 — 2 10 13 1 N.P. — 3 2 1 — 1 — — — 3 — 7 Departments. N.P. — 1 2 — — — 1 — — 2 2 1 N.P. 1 1 — 1 — — — 1 — — 1 — Schools affected. P. 5 8 9 1 — 2 3 — 2 9 10 2 N.P. 1 4 2 2 — 1 — 1 — 2 1 5 Miscellaneous Closures.—Gideon-road. Several rooms were flooded in consequence of heavy rains, and one department was closed for two weeks. The boys' and girls' departments were closed for three days. Neckinger-road.—The whole school was closed on account of the verminous state of the school furniture and walls. St. Peter's, Greenwich.—The girls' department was closed by the managers on the advice of "medical authorities," owing to the presence of scarlet fever. Closures for Disinfection.—The following closures were carried out for the purpose of disinfection only, but in no case did the period extend beyond one and a half days. Scarlet Fever.—Three infants' departments; three infants' classrooms; one girls' classroom; one non-provided school. Scarlet Fever and Diphtheria.—One infants' classroom. Measles.—One infants' department (non-provided). 1st APRIL TO 31st DECEMBER, 1908. Charts.—The diagrams illustrating the rise and fall of scarlet fever (I, K) and diphtheria (J, L) for the nine months ended 31st December, 1908, show a marked decrease in the incidence of these two diseases; we are able to report in each disease a marked diminution in the weekly mean; compared with the corresponding nine months of the previous year, the decrease in the case of scarlet fever is still more pronounced. Period. Weekly mean. Scarlet fever. Diphtheria. All persons. Public elementary school children. All persons. Public elementary school children. Whole year ended 31st March, 1908 521 250 170 63 Nine months ended 31st December, 1907 552 265 170 63 Nine months ended 31st December, 1908 413 196 140 52 During the nine months 14,547 cases of measles were reported. The weekly mean was 373, representing a decrease of 134 cases per week over the corresponding nine months of the previous year. The numbers of schools under observation during the nine months for diphtheria, scarlet fever and measles were as follows 1 ALL PERSONS CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS 1908 J 1908 ALL PERSONS CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS ■ 'N V MEAN NOTIFICATIONS MEAN NOTIFICATIONS 196 per week 413 per week i MEAN NOTIFICATIONS MEAN NOTIFICATIONS 52 per week 140 per week - t, «wr ^ 43 Diphtheria—Provided 77 Non-provided 11 88 Scarlet Fever—Provided 240 Non-provided 64 304 Measles—Provided 334 Non-provided 115 449 School Closures.—The following table shows the number of closures during the nine months and also the number of departments under observation for the various diseases:— Departments. DISEASE. Diphtheria. Scarlet Fever. Measles. Measles and Whooping Cough. Number under Observation. Classrooms Closed. Departments Closed. Number under Observation. Classrooms Closed. Departments Closed. Number under Observation. Classrooms Closed Departments Closed. Classrooms Closed. Departments Closed. Boys'— Provided 17 – 1 71 – – – – – – – Non-provided 3 — — 11 — — — — — — — Girls'— Provided 9 — 1 97 5 — — — — – – Non-provided 5 — — 21 – – – – – – – Mixed– Provided 5 2 — 23 2 — — — — – – Non-provided — — — 8 — — — — — — — Infants'— Provided 63 1 2 198 7 – 334 55 3 – 1 Non-provided 7 — – 51 – 1 115 18 2 – – Recently a new policy of excluding only "unprotected" children, i.e., children who have not had measles, has been systematically adopted, and the following table represents the numbers of classrooms and departments affected thereby. It will be seen from this table that in some cases all children under five years of age were excluded from certain departments and classrooms, but in five of these cases the exclusion was ordered by the Lewisham Borough Council:— "Unprotected" children excluded. Children under five years of age. Classrooms. Departments. Classrooms. Departments. Provided 102 3 (Children under five years of age.) 2 5 Non-provided 21 1 1 2 In the case of measles, the disease for which most frequent class closure is required, the numbers of classrooms and departments closed in infants schools were distributed through the nine months as follows:— 1908. Month April. May. June. July. Aug. Sept. Oct. Nov. Dec. Classrooms– Provided 5 4 9 13 – 5 12 6 1 Non-provided 1 6 2 2 — — 4 2 1 Departments— Provided — 1 — — — 1 — 1 — Non-provided — 1 — 1 — — — — — Schools affected– Provided 4 5 9 10 – 5 11 7 1 Non-provided 1 7 2 3 – — 4 2 1 20261 F2 44 The exclusions of "unprotected" children were distributed throughout the nine months as follows :—■ 1908. Month April. May. June. July. Aug. Sept. Oct. Nov. Dec. Classrooms— Provided — 5 2 3 — — 7 30 55 Non-provided — 2 – – – — 1 5 13 Departments— Provided – – – 3 (children under 5 years) – – – – – Non-provided – – – – – – 1 – – Schools affected- Provided — 4 1 6. — — 6 21 38 Non-provided — 2 — — — — 2 5 9 Miscellaneous Closures.—Pocock-street Cookery Centre. Closed for one session by instructress in consequence of a case of scarlet fever. Wesleyan Practising School.—The boys', girls' and infants' departments were closed on the recommendation of the local Medical Officer of Health for 10 days before the Easter holidays, in consequence of the depletion of the teaching staff by reason of an outbreak of German measles among the teachers at the Training College in connection with the school. Disinfection Requiring Closure for Short Periods.— Broomsleigh-street School (Infants). One room closed for one session—scarlet fever. Hawley-crescent (Girls').—One room closed for one day—scarlet fever. Moberly (Infants,).—One room closed for two days—scarlet fever. "Stanley" (Infants').—One room closed for one session—scarlet fever and diphtheria. St. Andrew's, Streatham.—Infants' department closed by order of the local sanitary authority for three sessions—measles. St. Mary Magdalene (R.C.), Brockley.—Infants' classroom closed for one session. Case of scarlatinal desquamation. Victory-'place (Girls').—One room closed by order of local Sanitary Authority for one session— scarlet fever. Wood-street (Infants').—Two rooms closed for one day—scarlet fever. MEASLES. The first special enquiry which I proposed to the late School Board for London has now been conducted for a period of five years in the district of Woolwich by Dr. C. J. Thomas in co-operation with Dr. Davies, the Medical Officer of Health, and may be said to have revolutionised our ideas, as it has given much valuable information in regard to the distribution and methods of treating measles outbreaks in the schools. It has resulted in a great saving in school attendance and has incidentally shown also that the measles death rate may be minimised. By means of advice cards there has been accomplished a gradual education of the parents to a sense of their responsibility and to the seriousness of the disease. The principles deduced from this enquiry seemed of sufficient weight and importance to justify their application to the whole of London, and the Council therefore resolved on 28th January, 1908, that the rules of this system should be adopted in all the infants' departments of the public elementary schools in the metropolitan area. They have also been recommended generally by the Local Government Board. Instructions have been given to all the head teachers of infants' departments and the new methods are now in operation. The following procedure has been adopted. The infants' head teacher makes enquiry as to the measles history of each scholar on the roll, and of every child newly admitted to the department. If a child has already had measles, this is recorded in the attendance register by the letter M; if the child is not known to have suffered, this is noted by the letter O. Should a child with a negative measles history contract the disease before leaving the infants' department, a suitable alteration is made in the register. The record thus established serves to show at any time the proportion of children protected by previous attack to those who are unprotected and liable to attack when exposed to infection, and it is upon this knowledge that any action is based. Immediately a case of measles occurs in the department, a copy of the following dark red card is distributed to each of the unprotected children in the classroom in which the patient was attending:— 45 OBVERSE. [M.O.19 A.] LONDON COUNTY COUNCIL. Notice to From The Parent or Guardian of The Head Teacher (Infants' Dept). School. As a case of measles has occurred among the scholars in the class which your child attends, it is possible that may have contracted the disease. As it requires about twelve days for measles to develop after infection, you are requested to pay particular regard to the state of your child's health, during the NEXT THREE WEEKS, and upon the slightest sign of illness to abstain from sending to school. Date Signature. REVERSE. NOTE. Measles may be a very serious illness in young children, and many die from it. The early symptoms are those of a cold, which may be at first slight; there is generally running at the eyes and nose, sneezing and possibly cough. Many children lose their lives because parents allow them to go out of the house, thinking that the indisposition is only a slight cold, when it is really measles. The case is then reported to the Medical Officer (Education) with particulars as to the numbers of protected to unprotected children in the room. The measles returns from all schools are reviewed daily at the Head Office, and when, in the opinion of the doctor, closure of a classroom would tend to check the spread of the disease, instructions are given to the head teacher, who immediately sends home the children in the affected classroom, after distributing the following light green card of warning to parents:— OBVERSE. [M.O. 19.] LONDON COUNTY COUNCIL. Notice to From The Parent or Guardian of The Head Teacher (Infants' Dept.), School. As a case of measles has occurred among the scholars in the class which your child attends, it has been decided to close the class till Measles is an infectious disease. You are therefore cautioned, in the event of your child showing any signs of this disease, to keep from contact with other children or from exposure in public places until a fortnight shall have elapsed after exposure to infection. A child who appears only to have a slight cold may have contracted measles and be dangerous to others. Any child who has contracted measles must not resume school attendance for one month. Date Signature. REVERSE. NOTE. Measles may be a very serious illness in young children, and many die from it. The early symptoms are those of a cold, which may be at first slight; there is generally running at the eyes and nose, sneezing and possibly cough. Many children lose their lives because parents allow them to go out of the house, thinking that the indisposition is only a slight cold, when it is really measles. It is expected that the widespread circulation of these cards will rouse parents to greater vigilance, and that the detention at home and isolation of children immediately the symptoms show themselves will reduce to a minimum the risks of infection being conveyed into school from outside sources. The increased watchfulness on the part of the teachers, and prompt exclusion of suspected children, will also reduce the chanccs of the diffusion of the infection in school. Some apprehension is expressed by head teachers in regard to the possibility of the red cards throwing parents into a state of panic and leading to interference with attendance by temporary withdrawal of many of the children. These apprehensions do not appear to be justified in actual practice, and the increase in frank confidence between school authorities and parents can only tend to greater trustfulness ultimately. The parent has a right to know if his child has been exposed to the risk of contagion, and we would fail in our duty if this information were suppressed through the indirect action of the Board of Education's regulations in the supposed interest of school attendance. It must be 46 remembered that these red cards are only sent when there has been a case of measles in a classroom, and then only to the homes of children who have been exposed to infection, and who have not previously suffered. The information received from the teacher is set out on the form of analysis for each school. To take a concrete example, the occurrence of four cases of measles in three classrooms at Atley-road came to light on 2nd June. The knowledge that only 18 per cent. of the children had not already had measles showed that it was safe to assume that no spread would take place and that therefore no action was necessary. ATLEY-ROAD SCHOOL—INFANTS' DEPARTMENT. Classroom. Age. Date of Analysis, 2.6.08. Date of Analysis. (Completion of Outbreak.) Oases. Last Attendance. Total. Cases. Last Attendance. Total. C. 5 1 13.5 2 1 9.6 3 53—Measles. 11—0. 1 26.5 B 56—Measles. 12—0. 5 1 22.5 1 1 10.7 2 D. 58—Measles. 16—0. 4 1 26.5 1 2 29.5 3 Analysis sheet of measles outbreak at Atley-road—No exclusions. At Leipsic-road on 20th May it became apparent from the analysis sheet below that the children under five were threatened with an outbreak of measles since 34 per cent., 24 out of 69, had not previously suffered. The unprotected children were therefore excluded for a short time. LEIPSIC-ROAD SCHOOL—INFANTS' DEPARTMENT. Classroom. Age. Date of Analysis, 20.5.08. Date of Analysis, (Completion of Outbreak.) Cases. Last Attendance. Total. Cases. Last Attendance. Total. B 4.5 1 6.5 6 1 15.5 9 45—Measles. 2 14.5 2 18.5 24—0. 2 15.5 1 18.5 Unprotected children in this room excludeduntil 1.6.08–notified. D. 5 1 14.5 3 42—Measles. 1 15.5 9—0. 1 26.5 D. 7 – – – 3 9.6 4 54—Measles. 1 10.6 10—0. Analysis sheet of measles outbreak at Leipsic-road—Unprotected children in Room B excluded for 12 days. Unfortunately, when closure takes place, all subsequent events pass out of knowledge, and the control of the outbreak by home visiting and advice on the part of the local medical officer of health ceases. School remains the one channel of information concerning measles, and in absence of school attendance the control over the death rate which knowledge gives is lost. At St. George's-row School, Westminster, on the other hand, it was known on 16th May that a case had occurred in the babies' room, but as the particulars with regard to previous history were not forthcoming, no action could justifiably be taken; had it been certain that a large proportion of the children were unprotected, closure of Class B until the end of the month would have saved the occurrence of some of the second crop and also have prevented the spread to other less susceptible classes. 47 ST. GEORGE'S-ROW SCHOOL—INFANTS' DEPARTMENT. Classroom. Age. Date of Analysis, 16.5.08. Date of Analysis, 28.5.08. Date of Analysis, 11.6.08. Date of Analysis. (Completion of Outbreak.) Cases. Last attendance. Total. Gases. Last attendance. Total. Cases. Last attendance. Total. Cases. Last attendance. Total. G 3.4 1 12.5 1 2 25.5 3 1 13.5 18 1 25.5 27 2 14.5 1 28.5 1 21.5 1 29.5 2 23.5 1 3.6 2 25.5 1 4.6 2 27.5 10.6 1 1.6 1 17.6 2 2.6 1 22.6 2 5.6 D 6 1 2.6 1 — — 1 B 5 – – – – – – 4 5.6 4 1 5.6 13 1 10.6 1 16.6 1 22.6 1 25.6 1 26.6 1 29.6 2 6.7 A 5 – – – – – – – – 1 12.6 4 1 17.6 ' 2 19.6 Hall 5 – – – – – – – – – 1 4.6 4 1 10.6 1 11.6 1 26.6 Analysis sheet of measles outbreak at St. George's-row.—Insufficient knowledge of the conditions prevented closure in time to stop extension. SCARLET FEVER. Whilst the enquiries into the natural history of measles and also of diphtheria have furnished important and practical means of dealing with these diseases and effected a great diminution in unnecessary loss of school attendance, scarlatina has not furnished the return which it is hoped will yet be obtained. We have ascertained that the peeling stage of scarlet fever is of little importance as regards infectivity and also that a high proportion of people escape the disease. The manner of outbreak in school, each case usually in a different class, and the difficulty of tracing direct effects of cases, point to the want of immunity in certain individuals as the most important factor in the appearance of any case. What the nature of this immunity in the general population is, and its absence in particular cases, will have to be traced later. School, we can say, is not the most important factor in scarlatinal dissemination. The enquiry which was being made by Dr. Stevenson, who has now become County Medical Officer for Schools in Somersetshire, has been continued by Dr. Hogarth. With the co-operation of the Medical Officers of Health in Battersea, Hampstead, Finsbury and Paddington, detailed enquiries are being carried out in those districts, as well as in certain other groups of schools when opportunity offers. The notification forms from head teachers of all schools are considered daily, and when more than one or two cases occur in a department, the returns are set out on an analysis sheet for the school, and a watch is kept on the distribution of any future cases. 48 Department. Date of analysis. CLASSROOM. Notes. B C1 C2 D Age. Cases. Date of last attendance. Age. Cases. Date of last attendance. Age. Cases. Date of last attendance. Age. Cases. Date of last attendance. Infants' 9.5 7.8 *1 7.5 5 †1 1.5 4.5 *1 7.5 5.6 †1 1.5 *1 1.5 *Same family. † Do. Note.—This table shows that five cases (affecting only two families) have occurred in one department in a week without any suggestion of a school outbreak. No further cases occurred. E C B G A Infants' 23.6 5.6 1 2.6 7 1 15.6 7 1 16.6 4 1 11.5 6 1 19.6 1 226 Note.—These six cases are well distributed throughout a department of 400 children, and point to several sources of infection, probably outside the school. Such an outbreak requires investigation, but there is nothing to suggest school closure or any cause for alarm. The connection between cases is considered and, if necessary, a special visit to the school is made for further enquiries. But, without regarding epidemics, information is also obtained by following up series of consecutive cases. In these investigations the school work is supplemented by further enquiries out of school made by the Medical Officers of Health. Methods Of Infection.—Scarlet fever spread in schools appears to be through close personal contact with:— A previously known case either in its early or later stages. A mild unrecognised case, not excluded from school. An apparently simple sore throat, without other symptoms. Rarely a carrier case not suffering. Sometimes it is impossible to differentiate between the last three varieties of infector. The incubation period is usually three to five days, but appears to vary between 12 hours and three weeks and sometimes possibly longer. Slight sanitary defects in the school and its surroundings, bad drains, smells, unsatisfactory w.c.'s and water supplies, however unhygienic in themselves, are not primary causes of scarlet fever in London schools, and must not be suffered to lead us astray from the real channels. Infected books, pencils or drinking cups, cannot account for more than an infinitesimal number of the cases. Origin of outbreak is traced by the following method:— (a) The registers must be examined for at least a month previously to see if any child has returned to school after scarlatina or after exclusion for infection in the home. All such cases should be carefully investigated, the parents, if necessary, being seen. It does not suffice to rely on the teacher's memory for these details. (b) The names of all other absentee children must be written down with their absences in chronological order. Absence for a single day, especially Friday or Monday, may be sufficient for mild scarlatina. Enquiries should be made from the child, the class teacher, the returns of the attendance officer and the head teacher. All cases should be regarded as suspicious until proved innocent. (c) In the classes in the various standards, questions as to sore throats may be asked from the children generally, or as to their knowledge of anyone with sore throats for a considerable time back, to some fixed date such as Easter, etc. (d) Having exhausted the enquiries from registers and teachers, the seats of all suspicious and affected children should be noted, also other associations, on the way to or from school, for instance. (e) The mixing in classrooms for particular lessons or hours has also to be enquired into and the possibility of contact with previous cases in other rooms or departments. These enquiries, even if there be seven or eight cases in a department, can easily be conducted in a school session. Without them, any more superficial examination, such as the examination of the children class by class for signs of desquamation or of aural or nasal suppuration is for practical or scientific purposes comparatively useless. Nor is it fair to exclude the school as a probable or possible source of infection till such an enquiry has been made. 49 20261 Table III. CLASSROOM INFECTION. Method of analysing cases of Scarlet Fever and Sore Throat with a view to discovering the source of infection. Case. Age. Diagnosis. Dates. Symptoms in school. Dates. Last attendance. First absence. Onset. Notification. Return to school. Remarks. 1. C. h. 8 "Sore throat" 8.1.07 8.1.07 8.1 Headache – 28.1.07 Infected during holidays. Attended by doctor. 2. F. G 8 "Sore throat" – 7.1.07 2.1 None 16.1.07 Infected during holidays. Probably a mild case of scarlet fever and on return to school (16.1.07) infected 3, 4 and 7 with scarlet fever and 5 and 6 with sore throats, with all of whom she was "great friends." 3. i. M 9 Scarlet fever 18.1.07 21.1.07 17.1 17th, absent, headache 18th, heavy, poorly 22.1.07 8.4.07 Both these cases showed symptoms in school and may possibly have infected 5, 6 and 7. 4. L.C. 9 Scarlet fever 18.1.07 21.1.07 18.1 Poorly—vomited outside 22.1.07 29.4.07 5. W. l. 8 "Slight tonsilitis" 18.1.07 21.1.07 20.1 None — 29.1.07 Attended by doctor. 6. H. L. 7 "Sore throat" 22.1.07 23.1.07 23.1 None — 11.2.07 Came to school with 2, 4.2.07. Slight peeling of one thumb. 7. D.C 8 Scarlet fever 23.1.07 24.1.07 23.1 Poorly, headache 26.1.07 15.4.07 Probably infected by 2. 8. e. l 9 Scarlet fever 1.2.07 4.2.07 2.2 None 13.2.07 — Infected by 7 after 10 days' interval or by mild cases 1 or 5 on their return. 9. G. F 8 "Bad throat" 19.2.07 20.2.07 19.2 None — 25.2.07 Infected by 6 on her return to school. 10. L. K. 8 Scarlet fever 22.2.07 25.2.07 24.2 None 25.2.07 — Drill partner of 6. Infected by her on return. G 50 Prevention of Spread Of the Disease.—The information obtained in the above enquiry is useful to prevent further spread. The general procedure may be stated thus:— Ascertain from teacher or children whether any notified cases showed any symptoms in school or playground, e.g., languor, drowsiness, headache, sore throat or vomiting. If not, there is little likelihood of further cases from school infection. If symptoms were observed, note the names of those sitting next or those who accompanied the child to or from school. They should be watched for symptoms as suspects. Exclude all children with sore throat whether scarlatinal symptoms are present or not. Train the teachers not to re-admit any child to school after absence for indisposition until the parents have afforded a satisfactory reason for the absence. Any child absent for sore throat should not be re-admitted except on medical authority. Examine all suspects for peeling hands and for nasal or aural discharges and exclude from the playgrounds as well as school all contacts and those suffering from sore throats. This enquiry, if carefully conducted, does not give rise to scare or alarm, and affords the teachers a practical insight into a very important matter. Mode of Spread of Scarlatina.—Illustrative cases of the behaviour of scarlatina are afforded from enquiries at Broomsleigh-street School, where, although there had been no cases for several months, a small outbreak began early in 1908, shortly after the Christmas holidays. Twenty cases occurred closely associated, whilst three fresh cases which could not be traced to school arose in the Easter holiday and one in the summer term, making 24. Many of these cases could not be traced to the school. A large proportion of the infected children came from three streets immediately adjoining the school and partially isolated in the form of a cul-de-sac by the railway. Several were undoubtedly infected out of school as the result of non-isolation of mild cases. Nine cases, however, occurred in one classroom of infants, aged five to six years. Fourteen other children who had not had scarlatina were closely associated and exposed to the risk without presenting any symptoms of disease. A tenth isolated case occurred in this room, three months later, from home infection. Scarlatina and sore throat. "Portland," Sept., 1908. Shows how two sisters gave rise to two series of cases. The continuous circles are notified cases of scarlatina, dotted circles probable cases not notified. The symptoms noticed in school are given, and intervals between cases. 51 in another class. The origin of the infectious sore throat was not clear, but may have been from "out of school" association with a girl excluded on account of infection at home who subsequently developed scarlet fever herself. In the case of each sister the girls sitting next in class were infected with scarlatina. The second sister attended school for two days with her throat "wrapped up." None of the secondary cases showed any symptoms in school or gave rise to further cases. An example of a different method of spread may be given from Chequer-street School, where 27 cases occurred between April and the end of the year. The origin of the first case could not be detected. There was no source of infection found in school. Seven further cases occurred in the summer term, but no single case could be traced to school infection. Four cases occurred in one block of Peabody-buildings in two families, another in the next block was contracted during a six weeks' absence, and the seventh was also an "out of school" case. A number of "out of school" cases affecting children above or below school age living in the same blocks were probably links. During the Michaelmas term 20 cases occurred. The connection with the previous cases was not at school but extended over the holiday period by means of "out of school" cases. Seven of these were in five rooms of the girls' department, two in two rooms of the boys', and 11 in five rooms in the infants'. The only suspicion of school spread was four in one room of the infants', but they were spread over three months. Possibly only two of these twenty were secondary in school, but even there the probability seemed more to be the home contact. Fourteen of the cases came from the same, or neighbouring, blocks of buildings, whilst the only remaining one was either infected in school as a secondary case or imported from a neighbouring borough This explanation, even as it stands, of home and street contact, seems more reasonable than the hypothetical infection in school, especially as after the careful kind of investigation detailed above no mild cases were detected and practically no sore throats, nor were any missed cases revealed later. Further, twelve different foci are needed to account for cases in twelve separate classrooms in three separate departments and no secondary cases resulting. On the other hand, a continuous series of cases at short intervals in neighbouring blocks of buildings favour the out of school dissemination. It is to be remembered also that out of school there is no knowledge of, or control over, the cases of sore throat which so often disseminate scarlatina. Missed cases, or carriers which revive infection, of the type which Newsholme described as chronic scarlatina, may cause trouble. In a small non-provided girls' and infants' school in Hampstead there were four cases last summer. The first was an isolated case and was infected from a resident in the same street. The others were three sisters attending three different classrooms. No secondary cases occurred. In the Michaelmas term in the infants' classes three further cases occurred. One of the previous cases had a period of indisposition after return to school and apparently affected two others, and one suspicious case. During her absence no further case occurred, but they broke out again five weeks later. Several were affected with sore throats and four children who were sitting together appeared to have been mild cases of scarlet fever. After their exclusion no further cases occurred. Among the girls the outbreak was confined to two classes. The first was possibly infected by one of the infant cases, but apparently gave rise to no secondary case in school. A fortnight later in a girl with a sore throat the diagnosis was missed until three weeks later her sister developed scarlatina. This girl meanwhile infected a friend at school, and probably also another girl in the same room. Three Weeks later three suspicious cases were discovered, and these gave rise to two others. All these children were sitting together. After their exclusion there were no further cases. Of the 15 cases in this whole outbreak 12 showed no signs of illness in school. Only one of the three others, and that a missed case with a doctor in attendance, gave rise to secondary cases. The secondary cases were almost certainly due to mild cases thought at the time to have sore throat only. The real significance of these cases would not have been discovered had there been no school enquiry on the spot. If the school or classroom had been simply closed the result might have been an extensive outbreak of scarlet fever in the neighbourhood. Closure for Scarlatina.—closure of a school or department for scarlet fever as it is now met with may be relegated to the list of crude and unscientific measures. Closure of one or two classrooms, though seldom justifiable, may be resorted to when school visitation and investigation is not possible. Ill-considered measures of closure signify failure to detect the sources of spread, unrecognised cases possibly continuing to spread disease unchecked out of school. Such cases under a watchful teacher and medical observation would soon be detected. Class closure should still be used experimentally at least in infant schools where enquiries are difficult on account of the youth of the children, and their frequent absences for trivial complaints. In any case, unless careful enquiry has been made, it is impossible to decide whether cessation of an outbreak is due to closure or to other and natural causes. For instance, at Betts Street School, where closure of the youngest class was resorted to, it is highly probable that the disease had already come to its natural end, nor, on the other hand, did the disease spread in two other rooms (B and E) where closure was not applied, though parallel conditions prevailed. This may be seen in the following table:— 20261 G2 52 Department. Date of Analysis. CLASSROOM. B C E Age. Cases. Date of last attendance. Remarks. Age. Cases. Date of last attendance. Remarks. Age. Cases. Date of last attendance. Remarks. Infants' 25.9 4.5 L.C. 17.9 Sick in 3.4 L.F. 16.9 Appeared well 5.6 C.J. 8.9 Peculiar Betts- 3.10 afternoon, but taken ill colour in street 7.10 sent home. dinner time. face. 8.10 17.10 R.V. 21.9 Excluded, — J.C. 21.9 Present p.m. — J.S. 5.10 No illness 25.10 infection in Face streaky in school. 28.10 house, 7-14 as if it had Sept. Had been struck. cough. — J.G. 13.10 Not ill in school. S.D. 25.9 Not ill in school. E.P. 13.10 Not ill in CLOSED, 25.9--5.10. school. C.C. 1.10 Not ill in *R.S. 25.9 During closure school. *D.S. 25.9 — J.W. 17.9 Did not return (Notified 8.10) after closure of room. No illness in school. — M.M. 20.10 No illness in school. * Same family. Instructions to Teachers in Scarlatinal Outbreaks.—A circular is now sent out as soon as a school come3 under observation for scarlatina, asking the head teachers to pay special attention to the care of the children in the classroom in which any child, who subsequently develops scarlatina, has shown any indisposition whilst at school, or where two case3 have occurred within a period of three weeks. They are asked to enter on a list of absentees the names of all children absent for one day or more through illness or indisposition, and also all excluded for scarlet fever in the house, with dates of last attendance, nature of indisposition and date of return to school. The teacher is directed to make special enquiries about any case of sore throat. The names of children absent from other causes than illness (weather, no boots, holiday, etc.) are entered on another side of the absentee sheet. "Where the teacher does not carry out these requests thoroughly, or is perhaps not reliable, and frequent visits by the Medical Officer are out of the question, closure of an infected room may in some cases be desirable. Such was the case recently in one classroom in an infants' school. Two cases occurred in the Easter term; one of these on return in the summer proved an almost certain source of infection, though no signs of aural or nasal discharge or of any catarrh could be discovered. Four of this child's associates contracted the disease within five days of his return to school; one was his playmate out of school. The infecting child was then isolated and there was no need to close the room. No further cases occurred in this room for three weeks, but scarlet fever was very prevalent in the district. Next, five children failed almost contemporaneously within three days. Four of them, however, lived in the same street—the street in which two of the previous cases had occurred, and one of them was secondary to her younger brother, and all were probably contracted out of school. Of these six cases in the same street four of the affected families lived within three doors of each other and in these houses there were several other secondary cases, so that the school source of infection is at least open to doubt, even though in the present case a larger number of cases than usual occurred in one classroom. Of this second series of cases, four were notified and removed to hospital at once, but one returned after the Whitsun holidays, contrary to definite routine instructions, having been absent for several days previously with sore throat. On his return he infected three children and one suspicious case within two days. Then he was discovered and notified. If the classroom had been closed he would not have been discovered, and the Medical Officer of Health would have been without useful information. Again, there was a lull for ten days, but scarlet fever still prevailed in the district. Then a fresh case occurred in the same classroom (source not traced—possibly out of school). The child showed symptoms of indisposition in school and infected two cases at intervals of two and nine days respectively. After another interval a fresh source of infection arose (probably not at school, as this room was under medical supervision almost daily), and gave rise to three secondary cases. The room was closed for disinfection on two days, but this served to allay the anxieties of the teachers rather than to have any deterrent effect on the outbreak. It is difficult to say, even after the event, whether closure of this room at any period of the outbreak would have served any useful purpose, but 53 it is equally certain that one series of cases could have been prevented if our routine instructions had been faithfully carried out, whereas on the other hand closure of the room would have allowed an unrecognised case to wander at large and to infect a number of other children out of school. Scarlatinal infection seldom spreads through a classroom, but when such is the case local investigation affords useful information. On October 1st four cases of scarlet fever were reported from one classroom in the boys' department at Wordsworth-road School. The cases had all occurred during the preceding eight days. A common source of infection seemed probable and an investigation was held on the spot. The first case possibly originated from a boy who was suffering from a mild attack of scarlet fever (thought to be measles at home). This boy had just returned to school, but was only actually in attendance for less than one hour before being excluded by the head master; so this source of infection may be questioned. At all events the first notified case of scarlet fever occurred two days later and almost certainly infected three other cases sitting in neighbouring desks. It was anticipated that with the discovery and removal of the primary source of infection the outbreak would cease, as only one of the secondary cases had shown symptoms of indisposition in the school. This proved to be the case. As a result of the investigation two other cases appeared to be suspicious and were excluded and the local Medical Officer of Health was informed. Two other boys suffering from slight sore throats were also excluded. The only other notified case of scarlet fever occurred two days after the re-admission of the boy thought to be suffering from measles. They sat next to one another in class and the measles case subsequently peeled in a manner leaving little doubt as to its scarlatinal nature. With this case the outbreak appeared to end. But as a result of careful enquiries on the part of the head master and assistant teacher it has been possible to obtain further detailed information as to the real and insidious nature of the scarlatinal spread. In addition to the unrecognised case of scarlet fever already referred to as measles, there were three other obviously missed cases—boys who were absent for 10, 14 and 20 days respectively suffering from sore throat, headache, vomiting and subsequent peeling, etc., and five slight sore throats absent 2, 5, 10, 12 and 12 days respectively, some of which were associated with vomiting and fever, others merely with headache. It is to be observed that in this outbreak no further " return " cases occurred. In this classroom, which consisted of 41 boys, aged 9 to 11 years, 7 had previously suffered from scarlet fever, which is an equivalent to an immunity of 17 per cent.—an unusually high percentage for this age period. After the outbreak had ceased, the apparent immunity was increased to almost 30 per cent. The real immunity, however—that is to say, including the missed cases and the slight sore throats—should be represented as just over 50 per cent. No wonder, then, that such a large proportion of the adult population is apparently immune to scarlet fever. At least two of the boys, closely associated with scarlet fever cases, but not taking the disease, were found on enquiry to be protected by previous attacks. The following diagram illustrates the seats occupied by all the boys in the class—the arrows indicate the probable direction of the spread, though it is difficult to ascertain how the slight sore throats infected each other. School scarlatina, showing notified cases, missed cases, slight sore throats and order of incidence in the classroom, dates of absence and return. Wordsworth-road (B.) school. DIPHTHERIA. In the last Annual Report the possibility was pointed out that after some years of diminished incidence of diphtheria in London the cycle of increased prevalence would probably recur. The figures for the present year bear this out. It may be that the disease is on the upward slope of such a curve 54 From 1893 to 1901 the amount of diphtheria was above the mean ; from 1902 to 1905 there was a time of much decreased prevalence. The years 1905-6 and 1906-7 showed an increasing prevalence, although the weekly notifications are still below the mean of the years from 1892 onwards. During the past year the increase has been maintained. The figures for the past three years and nine months are as follows:— Total number notified. Weekly mean. All ages. School children. All ages. School children. 1905-6 6,553 1,977 126 38 1906-7 7,987 2,645 153 51 1907-8 8,817 3,227 170 63 1908 (9 months from 1st April) 5,477 2,026 140 52 The notifications of school children are taken as the cases notified to the school teachers by the medical officers of health. There is undoubtedly much leakage, especially due to the failure of many voluntary (non-provided) schools, owing to want of sufficient acquaintance with the Council's rules. This is rectifying itself as shown by the percentage of school children to the whole, viz., 30 per cent., 33 per cent., 37 per cent., and 37 per cent. for these periods respectively. It must, however, be remembered that with increased prevalence the proportion of children at school ages suffering, compared with sufferers at all ages, tends to increase. During the year 133 provided and 31 non-provided, 164 schools in all, were under special observation for diphtheria. Routine inspections of children's throats were necessary in 45 school outbreaks, 770 cultures were bacteriologically tested and the outbreaks were traced to carriers, of whom 75 were found. Between March 31st and the end of the year 1,780 cultures were taken at 55 visits to schools and the Klebs-Loeffler bacillus found in 93 cases. Up to March 31st two boys' departments were closed, two girls' and two infants' and in addition four classrooms were closed for short periods, while between March 31st and December 3lst four departments were closed, one boys' one girls' and two infants', and in addition two classrooms in a junior mixed department, and one in an infants' department. In view of the increasing prevalence of diphtheria it will be necessary to use all possible resources in dealing with the disease. The Council's regulation by which all sore throats are notified to the medical officers of health by teachers when diphtheria is prevalent in a district, and the children refused admittance until a certificate of freedom from infection is produced based upon bacteriological examination, is likely to be of the utmost value where local arrangements exist for free bacteriological diagnosis. From the school point of view the greatest danger of spread arises from these mild undetected cases. The maintenance of expensive isolation hospitals, and the universal provision and carrying out of disinfection in notified cases alone are no longer to be considered adequate protective measures. Unless facilities exist for the detection of mild carrier cases preventive measures are largely wasted. Although in practically every large provincial centre of population in this country such provision has been made, it is not yet available in many of the London boroughs. Unless the whole of the local sanitary authorities see their way to making such provisions it is to be feared that London may suffer more severely than is necessary during the coming positive wave which seems almost inevitable in the next few years. Facial Eruptions in Diphtheria Carriers.—Attention has been drawn to the presence of facial eruptions of herpetic or impetiginous nature in diphtheria contacts. Twice the Klebs-Loeffler bacillus has been found in such conditions. In one case a boy of five at Hawley-crescent School was found with sores upon his face. The scab of one of these sores was lifted and a culture taken from the resulting raw surface. The growth gave vigorous colonies of Klebs Loeffler bacilli which were submitted to virulence tests at the Lister Institute by Dr. Arkwright, who found that they were fully virulent. In another case at Elizabeth-street a culture of diphtheria bacilli was obtained from what appeared to be a single patch of impetigo upon the cheek of a school girl. In both instances there were found diphtheria bacilli also in the nasal discharges and in the throats. VISION. The Vision Testing Of School Children—Full details of this have been given in previous reports. The children are tested, using both eyes, from a distance of 6 metres. Standard Snellen Test Types are used, and the teachers record the vision in the attendance registers. All children who do not attain V.=6/18, or above Standard V.=6/12, are put on a list which is forwarded to the Head Office. These children are reviewed later by the medical officer and green cards of warning or red cards in more urgent cases are forwarded to the parents. The teacher makes what school arrangements are possible and the worst cases are very carefully noted and if necessary exhaustively examined with respect to any need for special training as blind or semi-blind. 55 A Special School at Boundary-lane has been opened for cases of high myopia and it will be used to give education to these children in such a way that their eyes may be spared during the period of growth. The first year's experience in the working of this school will be necessary before it is worth reporting at length on the subject. The public provision for treatment of eye defects is referred to on page 23. Nothing has yet been finally decided in regard to the public treatment for all the mass of eye defects. An experimental school clinic on a small scale is being privately worked at Bow. It has not been established long enough to have made any report. Dr. Hugh Thompson, who was formerly on the medical staff of the School Board for London, has been conducting an ophthalmic clinic for school children in Woolwich since May 1907. The whole of the organising work is done by the ladies of the Invalid Children's Aid Associaation, on whose premises the children selected by them are seen during 2½- or 3 hours once a week. In this way, Dr. Thompson had treated 456 children up to the end of 1908; of these 316 were refraction cases needing spectacles, 54 were cases of conjunctivitis or troubles of the lids, independent of refractive error, 25 of corneal affection needing active treatment. The rest were of various kinds, some trivial, some on the other hand so grave as to be too late for any effectual treatment, most of the latter are the cases of corneal opacities due to old phlyctenular keratitis, and so often alluded to in previous reports as cases neglected and trivial in themselves yet resulting in lifelong injury. A few were cases out of the common, and a few required hospital treatment. The refraction cases were examined under atropine in a specially fitted room, and an optician attended to provide the spectacles prescribed which cost from two to four shillings according to the complexity of the prescription. The collection of spectacle money from the parents is part of the work of the organising ladies. The co-operation of the district nurses has also been invaluable. As regards hospital treatment, Woolwich is peculiarly unfavourably situated, but arrangements have been made so that all cases requiring admission are taken in either at Guy's or the Western Ophthalmic Hospital, and in this way all unnecessary journeyings to and from the middle of London have been avoided. Results of Vision Test—1st April, 1907, to 31st March, 1908 :— Standard. Dept. Provided Schools. Non-Provided Schools. Number Returned as bad Vision by the Advice Cards given. Number on Registers Returned as Bad Vision by the Advice Cards given. on Registers Teachers Oculists. Ordinary Green. Urgent Red. Teachers Oculists Ordinary Green. Urgent Red. I. Boys 17,394 1,544 1,144 738 278 6,857 650 496 306 136 Girls 16,952 2,042 1,193 757 296 6,453 691 531 299 153 Mixed 7,434 636 478 300 113 2,689 277 214 115 72 II. Boys 27,780 2,221 1,735 1,032 458 8,009 663 554 329 162 Girls 27,093 3,170 1,936 1,194 526 8,810 878 728 389 242 Mixed 9,046 673 540 310 128 3,358 279 234 148 67 Boys 28,487 1,999 1,589 982 419 8,201 619 545 334 163 III. Girls 28,886 3,234 2,128 1,195 600 8,913 858 692 391 240 Mixed 6,445 459 378 203 89 2,992 263 217 119 76 Boys 27,559 1,835 1,439 884 360 7.603 591 512 257 178 IV. Girls 27,501 2,947 1,905 1,116 511 8,322 822 680 376 222 Mixed 5,947 386 307 144 74 2,747 233 188 120 55 Boys 24,819 3,145 2,075 1,345 359 6,929 1,017 770 523 166 V. Girls 23,511 4,215 2,540 1,570 472 7,188 1,396 969 607 239 Mixed 5,088 573 423 238 54 2,340 354 261 179 34 Boys 18,949 2,021 1,299 838 203 5,081 715 510 336 84 VI. Girls 17,374 2,696 1,567 971 255 4,989 866 614 382 143 Mixed 4,385 405 258 149 36 1,645 238 162 120 24 Boys 14,252 1,182 738 440 127 3,642 425 330 183 93 VII. Girls 12,410 1,415 747 456 101 3,132 416 300 176 56 Mixed 3,379 301 194 100 22 1,135 119 93 55 25 Higher Boys 720 93 60 38 14 — — — — — elementary Girls 517 95 54 5 — — — — — — Mixed 585 38 36 23 3 — — — — — Special Schools Mixed 5,597 1,159 752 433 165 — — — — — Boys 159,960 14,040 10,079 6,297 2,218 46,322 4,680 1 3,717 2,268 982 Totals Girls 154,244 19,814 12,097 7,264 2,761 47,807 5,927 4,514 2,616 1,295 Mixed 47,906 4,630 3,366 1,900 684 16,906 1,763 1,369 856 353 56 Provided Schools. Non-Provided Schools. Totals. Percentages. per cent. per cent. Number on Registers 362,110 lOO'OO 111,035 lOO'OO 473,145 lOO'OO Returned as defective by the— Teachers 38,484 10.63 12,370 12.24 50,854 10.75 Oculists 25,542 7.05 9,600 9.50 35,142 7.43 Advice cards given— Ordinary green 15,461 4.27 5,740 5.68 21,201 4.48 Drgent red 5,673 1.56 2,630 2.60 8,303 1.75 Total cards 21,134 5.83 8,370 8.28 29,504 6.24 1st April to 31st December, 1908:— Standard. Dept. Provided Schools. Non-Provided Schools. Number on registers Returned as bad Vision by the Advice cards given. Number on registers Returned as bad Vision by the Advice cards given. Teachers Oculists. Ordinary green. Urgent red. Teachers Oculists. Ordinary green. Urgent red. 14,079 1,113 815 527 183 512 38 29 17 12 I. Girls 13,187 1,342 907 634 187 577 40 30 21 7 Mixed 5,971 555 359 214 82 321 17 10 7 3 Boys 23,539 1,670 1,343 888 293 598 35 29 19 10 II. Girls 23,057 2,023 1,496 1,013 301 828 44 37 19 18 Mixed 7,578 512 376 231 89 297 19 17 10 5 Boys 23,416 1,642 1,331 846 314 783 33 27 21 6 III. Girls 23,507 2,123 1,621 1,024 389 823 48 40 25 15 Mixed 6,089 390 308 182 73 209 14 11 8 3 Boys 23,169 1,539 1,195 782 248 699 34 31 19 12 IV. Girls 23,409 2,002 1,501 899 377 905 78 48 34 15 Mixed 4,932 336 247 155 47 191 19 12 11 4 Boys 20,724 2,544 1,716 1,154 249 706 79 66 51 15 V. Girls 20,879 3,130 2,019 1,313 293 732 134 106 82 24 Mixed 4,565 601 379 238 75 154 21 18 17 1 Boys 15,669 1,606 997 640 150 502 36 28 23 3 VI. Girls 14,402 2,058 1,308 821 177 610 79 63 51 12 Mixed 3,746 420 254 180 38 130 15 12 9 3 Boys 12,715 1,058 613 392 97 387 40 21 16 – Girls 10,355 971 565 362 69 359 43 32 28 4 Mixed 3,254 254 156 92 22 76 5 3 3 – Higher Elementary B. & G. 4,774 566 408 253 58 — — — — — Boys 133,311 11,172 8,010 5,229 1,534 4,187 295 231 166 58 Totals Girls 128,796 13,649 9,417 6,066 1,793 4,834 466 356 260 95 Mixed 36,135 3,068 2,079 1,292 426 1,378 110 83 65 19 H. E. 4,774 566 408 253 58 – – – – – Provided • Schools. Non-Provided Schools. Total. Percentage. per cent. per cent. Number on registers 303,016 100.00 10,399 100.00 313,415 100.00 Returned as defective by the— Teachers 28,455 9.39 871 8.37 29,326 9.36 Oculists 19,914 6.57 670 6.44 20,584 6.58 Advice cards given— Ordinary green 12,840 4.23 491 4.72 13.331 4.25 Urgent red 3,811 1.26 172 1.65 3,983 1.27 Total cards 16,651 5.49 663 6.37 17,314 5.52 57 Nature of the Eye Defects Found.—In London it has scarcely been possible to go beyond the determination of proportions of children at various ages with defective visual acuity. The general ideas of ophthalmic surgeons as regards school effects on the eyes are mainly based on the work of Continental specialists, and there the factors of race, habits, and diet have not been as much insisted on as the fact of myopia increasing with age and scholastic attainments. The condition is one which is bound to increase with age, and probably selection has as much to do with its increase during school and college life as any direct effects of education. Whether the scholastic work is mainly the accompaniment rather than the cause of myopia; why the high myopes are most frequently girls; what part debilitated conditions during the growing period plays; and how many of the myopes would have become myopic in any case it is almost a confession of heresy to enquire. For educational purposes it would be exceedingly useful to know what eyes are likely to tend to myopia. Hypermetropia, the eyeball with a short optical axis, is the normal condition in the young child and the wild man. The tendency of the eyeball is to stretch, so that its optical axis becomes longer, and if it stretches beyond a certain point that is the focus of the lens and refractive arrangements, myopia or an over lengthened condition of the eyeball exists. Certain eyes develope irregularly, their section would not be circular but elliptical, and they cannot focus a point clearly, they are astigmatic, and it is this condition of astigmatism which perhaps chiefly recruits the army of myopes. If so, then every effort should be made to save such eyes in early life. Dr. Hugh Thompson attempted by means of glasses to ascertain the distribution of the various defects when he was acting as oculist under the School Board for London. He was well aware of the limitations of the method, but it was the only one applicable in his daily school work. He found that among 1,732 children, who had bad subnormal vision, out of a total class register of 24,099 children, the errors of hypermetropia, hypermetropic astigmatism, mixed astigmatism, and myopia with myopic astigmatism were in about equal proportion, and the myopia appeared to increase in the higher standards at the expense of the astigmatism. Any method to be completely satisfactory should embrace all the children, and probably if means of readily and completely examining the refraction of school children's eyes existed the question would soon be settled. Mr. Bishop Harman has taken all the school children seen by him at the Belgrave and Middlesex Hospitals. The children attending the Belgrave live in the neighbourhood and attend the neighbouring schools. They are a different class from those attending the Middlesex. In the neighbourhood of this Hospital there is a large alien colony, and the schools also are of a very different class. The whole region is overcrowded. These children numbered 1,100—482 at the Belgrave and 618 at the Middlesex. Their refraction was worked out after the eyes had been kept under atropine for a week. The real refraction, corrected for infinity, was stated. Cases due to injury or corneal ulceration were omitted. The results were: Hypermetropia. Hypermetropic Astigmatism Mixed Astigmatism. Myopia. Myopic Astigmatism. Odd eyes. Total. Numbers 468 315 78 102 115 22 1100 Percentage 42.5 28.6 7.1 9.3 10.4 2 100 No explanation of this classification is needed, except of odd eyes, which means that one is hypermetropic and the other myopic. The mixed astigmatism is counted here with the myopes. Of every 100 children, less than 29 were myopic, but these children with bad defect of vision only represent at most 10 per cent. of the school children, so that myopia can be considered as not exceeding 3 per cent.; and as the tests catch all the myopes but miss hypermetropes who can accommodate sufficiently the proportion of myopia will be even less than that given. The sex incidence of refractive error is very interesting. Girls account for nearly 78 per cent. of the cases, and in the general school returns 75 per cent. of the children with poor or bad vision are girls. The approximation of the sex incidence in the two groups at school and at hospital is very close:— Sex. Hypermetropia. Hypermetropic Astigmatism. Mixed Astigmatism. Myopia. Myopic Astigmatism. Odd eyes. Total. Boys 482— Number 201 136 34 50 52 9 482 Percentage 41.7 28.2 7.0 10.4 10.5 2.0 100 Girls, 618— Number 267 179 44 52 63 13 618 Percentage 43.2 29.0 7.1 8.4 10.2 2.1 100 The causes for this divergence in visual acuity in the sexes seem purely social. There is no evidence that the eyes of boys and girls differ in growth. Whatever common eye conditions are investigated a similar incidence is found, i.e. more girls than boys affected, and in each case a social influence 20261 H 58 has seemed the most constant factor. Possibly the boys play in the open-air whilst the girls are confined more to the house, and the boys doing no needlework have an advantage, for their accommodation muscles are in a better state of tone on account of their outdoor life, and at the same time less fatigued by school work, than is the case with the girls. This suggests that fine work, needlework particularly, should be reduced to a minimum in schools and that should a girl excel in fine sewing she should be medically examined lest she be a myope. The social surroundings of the patients attending the Belgrave are better than those at the Middlesex, although both groups are equally poor. If anything the Middlesex patients are better fed for they include many Jews who feed their children well:— Hypermetropia. Hypermetropic Astigmatism. Mixed Astigmatism. Myopia Myopic Astigmatism. Odd eyes. Total. Belgrave Hospital— Numbers 226 146 33 35 38 4 482 Percentage 46.7 30.3 6.8 7.3 7.9 0.8 100 Middlesex Hospital— Numbers 242 169 45 67 77 18 618 Percentage 39.1 27.2 7.3 10.8 12.4 2.9 100 Some of the differences in this table are due to the children falling off about 11 at the Belgrave, but the racial factor comes in at the Middlesex. Last year the causes of defect in the vision of children attending a school in the neighbourhood of the Middlesex Hospital had to be enquired into on account of a report of H.M.I. Large numbers of these children were alien immigrants; they are seen both in school and at hospital, and the examination of their eyes shows a very heavy incidence of astigmatism, and particularly myopic astigmatism. In an examination of the incidence of refraction cases at one of the Moorfields Clinics Mr. Harman found the proportion of aliens reached 35 per cent., as compared with natives 26'6. Myopia has been shown by many observers to increase in frequency and degree with age. The Hospital returns show this and also what kind of eyes become myopic. Mr. Harman's returns of 618 children seen at the Middlesex Hospital. H—Hypermetropia. HA—Hypermetropic astigmatism. M—All varieties of myopia. Considering in this chart the poor vision due to hypermetropia (H), there is a slow rise in the cases from 28 to 33 per cent. This slow increase is what naturally occurs from the hypermetropia compensated in childhood becoming more evident as accommodation decreases with age. This slow increase in hypermetropia affords evidence of the accuracy of the chart. The curves of hypermetropic astigmatism (H. A.) and of myopia (M) may be considered together, and are seen to run parallel till school work has become the chief thing in the child's life, when they diverge, myopia increasing steadily and astigmatism decreasing pari passu. The child with bad vision due to astigmatism attempts to facilitate the 59 perception of objects by bringing them closer to the eye, increasing the visual angle, and getting a greater stimulus to the retina. Everyone does this daily and it does no harm so long as the act is not unduly prolonged. It necessitates convergence of the eyes and it is to the pressure of the muscles causing convergence that the injurious effects are ascribed. The pressure tends to cause bulging of the globe, and with the slightest abnormality in shape myopia may start. Once this has commenced a vicious circle is established. The myopia necessitates a closer approximation of objects, this a greater convergence and pressure and then more myopic stretching. The examination of the vision returns points to a very fair condition of the eyes of London children, especially compared with returns collected in German-reading countries. The greater proportion of cases of poor vision are due to natural conditions of hypermetropia and hypermetropic astigmatism. They are congenital conditions. The incidence of what may be termed manufactured bad vision, myopia, and its associated astigmatism forms from a quarter to a third of the cases, and as these represent less than a tenth of the children, less than 3 per cent. are myopic. SPECIAL SCHOOLS. Mentally Defectives.—During the routine inspection of the Special Schools for mentally defectives a card was filled up for each case seen, to afford data for a special investigation into the mental capacity of the brighter children with a view of ascertaining whether an intermediate class is desirable in which special teaching should be given to children who, although unfit at present for the elementary school are not in reality feeble-minded, and also of reporting on the number of children at present in the schools for Mentally Defective Children who are unlikely ever to improve, either in a mental or manual capacity. These are matters of opinion in which the personal equation plays a considerable part. It has taken a very long time to obtain the information. The following card was drawn up and the particulars of each child examined at the schools recorded:— Name of child. Date of birth. School attended. How long has the child been in a special school ? Would it do better in an "intermediate" school? State whether likely to improve materially either mentally or manually. State whether likely to be able to earn its own living. State whether likely to be able to contribute materially to its own support State whether it will be able to do anything after leaving school. Nearly five thousand children were examined. The records may be analysed as follows:— Boys. Girls. Total. Cards filled up 2,826 1,954 4,780 Not completed, too early to give an opinion 26 23 49 Unclassified, defective, etc. 10 5 15 Total 2,862 1,982 4,844 1908—BOYS. Age. Better in an intermediate school. Likely to materially improve. Able to earn own living. Able to contribute to own support. Able to do anything after leaving. Total. Yes. No. Yes. No. Yes. No. 6 – 2 1 1 – 1 1 – 2 7 1 23 15 9 15 3 3 3 24 8 20 184 147 57 139 46 4 15 204 9 57 370 331 96 322 63 19 23 427 10 78 478 398 158 386 115 33 22 556 11 103 381 361 123 348 98 26 12 484 12 102 322 315 109 307 66 26 25 424 13 86 245 265 66 261 43 9 18 331 14 47 176 161 62 165 32 18 8 223 15 18 88 79 27 73 22 4 7 106 16 8 37 28 17 29 11 4 1 45 Total 520 2,306 2,101 725 2,045 500 147 134 2,826 20261 H2 60 1908—GIRLS. Age. Better in an intermediate school. Likely to materially improve. Able to earn own living. Able to contribute to own support. Able to do anything after leaving Total. Yes. No. Yes. No. Yes. No. 6 – 1 1 – 1 – – – 1 7 – 16 6 10 11 3 – 2 16 8 15 108 97 26 80 29 7 7 123 9 30 237 196 71 171 59 19 18 267 10 60 289 246 103 239 74 21 15 349 11 83 247 243 87 233 74 14 9 330 12 80 249 240 89 248 57 17 7 329 13 44 194 155 83 160 49 20 9 238 14 35 130 107 58 106 42 9 8 165 15 23 76 59 40 62 18 10 9 99 16 4 33 17 20 18 11 5 3 37 Total 374 1,580 1,367 587 1,329 416 122 87 1,954 In dealing with these figures the very uncertain nature of the units must be remembered and an allowance of perhaps 10 per cent, on any number made either way for what may be termed errors of observation. Taking the total numbers at all ages there are:— 1908. Better in an intermediate school. Likely to materially improve. Able to earn own living. Able to contribute to own support. Able to do anything after leaving. Totals. Yes. No. Yes. No. Yes. No. Numbers. Boys 520 2,306 2,101 725 2,045 500 147 134 2,826 Girls 374 1,580 1,367 587 1,329 416 122 87 1,954 Totals 894 3,886 3,468 1,312 3,374 916 269 221 4,780 Percentage. Boys 18 82 74 26 72 18 5 5 59 Girls 19 81 70 30 68 22 6 4 41 Totals 19 81 73 27 71 19 5 5 100 In this table one fifth are noted as likely to be suitable for intermediate schools, three-quarters as likely to materially improve, only 10 per cent. unfit to earn their own living, and twice this number as able to contribute towards their own support. These figures seem to err on the side of optimism. In the First Report to the School Board (page 22) on the examination of about 500 children in the special schools, the judgment as to future capacity of these children was that roughly one third would be capable of materially contributing to their own livelihood after leaving; one third would partially contribute, but required an after care association of some kind to keep watch over them, whilst the remaining third should not be allowed to mix with the general community, and ought to receive some kind of permanent custodial treatment. In this last investigation, however, the returns of children over 12 according to their ability to work is given as:— Children aged 12 or more in special schools, 1908. Able to earn own living. Able to contribute towards support. Able to do anything after leaving school". Yes. No. 1,129 Boys 835 174 61 59 868 Girls 594 177 61 36 1,997 Total. Number 1,429 351 122 95 Percentages 71 18 11 61 In a paragraph on the prospects of children in special schools the Royal Commissioners reported:— "The result would thus appear to be that from 5 to 10 per cent. of the children are moved into the ordinary schools and do well. Of the class below them, some 45 per cent. at most' do manual work well and are of fair intelligence as regards ordinary matters of life,' and they are considered capable of earning their own living altogether or to a material extent. The third class, about 50 per cent. of the whole, are 10 per cent. of them 'fit only for a custodial home,' and about 40 per cent. capable of doing a certain amount of work under supervision. These figures, however, and the others which we have quoted above from various sources, should probably be subjected to some reduction." The only real difference between this estimate and ours, is that about 10 to 15 per cent figure in our estimate as able to earn their own living, which the Commissioners assign to the lower grade of only able to partially support themselves, is possibly due to the form in which the questions were put. Special Class of Children who do not improve.—The children who are pupils of special schools for the mentally defective are defined by section 1 (a) of the Elementary Education (Defective and Epileptic Children) Act, 1899, as being those who, not being imbecile, and not being merely dull and backward, are defective, that is to say, children who by reason of mental or physical defect are incapable of receiving proper benefit from the instruction in the ordinary public elementary schools, but are not incapable, by reason of such defect, of receiving benefit from instruction in such special classes or schools as are in this Act mentioned. It is very difficult to say how far a child who is not imbecile, is yet incapable of receiving benefit. The following are notes of certain children formerly in the Leo-street Special school:— 1.—When examined in October, 1903, this boy's articulation was very defective. June, 1904, he was unintelligible, had no idea of calculation and had made practically no improvement. June, 1905, he was doing nothing, was in the lowest grade, constantly smiling. June, 1906, his mechanical work was not better than the three R.'s. March, 1907, he could not count beyond four, hopeless intellectually. January, 1908, he could count up to 10. He is now 12 years of age and his speech is unintelligible to strangers. 2.—This girl was examined in January, 1903. She could not articulate plainly, was said to be quick at housework, but educationally "nil." Said she had two fingers, three heads, but one nose. In September, 1904, she could not step in line. Was of the poorest mental stuff in the centre, was malodorous. June, 1905, very unintelligent. June, 1906,, a very low type of intellect not making any improvement in any subject. Was absent at each subsequent visit of the doctor. Reported as making practically no advance. 3.—This girl was examined in September, 1904. She was a tiny, undergrown little girl who knew nothing. In June, 1905, she was aged 10, had only two teeth in the top jaw, her mental capacity was nil; has had operation for tubercular bone. Now over 12 years of age; has to be frequently sent home owing to verminous condition. 4.—This boy was examined in June, 1904, when 8½. Very weak-minded, no power of calculation. June, 1906, power of grasping any point so limited that he will not be equal to an infant within 3 or 4 years. Manual work bad. January, 1908, no advance mentally; now aged 12. 5.—This boy was examined in January, 1905. A defective-looking boy. Said his age was 12; it was only 9. Could not write figure 3. June, 1906, knew a few monosyllables in book. March, 1907, articulation very poor, improvement slight. January, 1908; now 12 years old and his mental capacity shows no advance. In April, 1908, these cases were submitted to the Special Schools Sub-Committee as, although they could not be certified as incapable of being educated, yet they had made practically no advance in knowledge for many months. The Council ultimately decided in June to exclude these children, as they were apparently incapable, by reason of their defect, of receiving benefit from the instruction given in the school; and further that particulars of the cases should be sent to the Local Government Board and to the Board of Education for their observations. The Local Government Board replied that they had no jurisdiction in regard to children not chargeable to the Poor Rates. The first of the cases was subsequently readmitted on the request of his parents, but later, after careful consideration, excluded on a medical certificate as ineducable. As he is not a pauper he will now run the streets uncontrolled. Moral Defectives and Permanent Custodial Treatment.—The necessity for compulsory powers of detention in custodial schools till 16, and later for the rest of life, of certain moral defectives is a most pressing matter. For instance just as we find incases of pure word-blindness a defect of a particular region of the brain, sometimes as a hereditary failing which may occur in children normal in other respects, or combined with any amount of other defect, from mere dulness to low grade mental defect, imbecility, or idiocy, so cases are found of morally defective children, who vary in mental capacity from some cases which are exceedingly clever in other respects, to children who are so bad as to be classed as imbecile. Very commonly through such individuals being on what might be considered as a lower scale of mental development than normal the emotions are much more developed relatively than the intellectual qualities which give restraint, so that they are exceedingly plausible in speech, and have a peculiarly attractive gift of adapting themselves, smiles or tears being available with equal ease according to their environment. There are great differences in the way the defect is manifested. It is almost impossible yet to classify them, but a provisional arrangement might be made into (a) Passive (b) Active. (a) Passive cases (only passive trouble in school conduct). i. Children who have irregular but recurrent outbursts showing moral defect in slight degrees amounting to uncontrollable bad temper; often with a complete heedlessness of all correction or advice, and very often a tendency to roam or wander away. These cases are probably of an epileptic nature and require detention and are to be regarded as cases of disease. ii. Children who seem merely not to be amenable to discipline. This is a large class and I think a very large proportion would be taught habits of obedience by regular and inflexible corporal punishment. Most of them are subjects for industrial training later on, but they often present other defects, e.g., wordblindness. 62 (b) Active cases (active troubles to the teachers). i. Children who are only differentiated from the first of the class above by their violence and destructiveness in their outbursts of rage almost unprovoked at times and quite irregular. For the greater part of their time such children are inoffensive, sometimes clever, often dull, stupid or even sullen, but in a rage behave as uncontrollable lunatics. They are, however, comparatively rare. ii. Murderous tendencies from pure cruelty. Quarrelling, pinching, biting others. Infliction of cruelty on young children or killing of animals. In particular cases these children are very objectionable in school. Manslaughter has been committed by children of innocent, pleasant, and in one case almost angelic appearance. There is every grade of mental attainment among these children afflicted with this lust of cruelty. iii. Interference with the opposite sex shows itself in boys, but most objectionably in girls. There is every grade from the natural attraction of the sexes to the most flagrant and offensive behaviour requiring the attention of the police. Here again, mental capacity may vary from children who are quite normal in school work to those who are low grade mental defectives. This particular type of girl is most difficult to deal with. It is of vital importance to place them in residential schools and separate them from other children of the same age, because though numerically few, they constitute a most vicious element, a leaven of evil among the girls with whom they are compelled to mix. It is principally for the sake of others that this policy is proposed. In the case of the low grade girl it seems a pressing question, whether with her defects and her tendencies, she is not likely to become a mother in an exceedingly short time, and this is very probable. There is also the other question that very many of these children live in bad homes, and in some cases may be expected not to be shielded, if they are not even abetted by their friends. The question of saving the last class of children from what is called moral contamination is hardly worth consideration. Apart from their bad school influence the case of the low grade girl with strongly marked sexual tendencies can scarcely be separated from the case of any other defective child. Many of them are good looking apparently healthy children, but all are likely in early adult life, within a comparatively short range of time, to propagate their defects, some classes perhaps earlier than the others, but for this particular reason there is hardly any ultimate benefit from segregating one class more than the others. Any segregation is therefore really on account of mental defect, not on account of purely moral defect; otherwise the Standard VII. girl with immoral tendencies would also want segregation, which no one would propose. Moral defect, as pointed out, may exist with comparatively good mental development, and there is no suggestion of segregating such individuals although they may be just as likely as others to add to the unsociable elements of the future population. It might also be suggested that in this particular class with very strong desires and passions for the other sex, exclusion from the satisfaction of these desires and passions by segregation would be an injustice which they have not deserved. A much more humane and scientific idea than mere segregation and more economical to the State would be to deprive such individuals of the objectionable powers and capacities, at the same time relieving them of the passions and desires, before the time at which these develop. Report of the Royal Commission.—The long awaited Report of the Royal Commission on the Feeble Minded was issued in July. The Commissioners propose that all the feeble minded, of whatever age or degree, shall be under the care of a Board of Control. They also recommend that a register of feeble minded children should be formed, the names being supplied voluntarily by parents or guardians, or as a statutory duty by officials of all kinds public and private. The number of non-pauper children in London in 1908 who might have been expected to come on such a register would be:— Mentally defective under the Act of 1899. Day Res. Epileptic. Day Res. Mentally defective and also blind, or deaf, or physically defective. Imbecile. Totals. (a) Probably not certifiable under the recommendation of the Royal Commission. (b) Certifiable under the recommendation of the Royal Commission. Children under the School Authority— (1) Under instruction 6,267 55 82 23 130 †36 ‡4,215 2,378 (2) Not under instruction §237 191 120 627 ‡158 1,017 Total 6,559 296 250 663 ‡4,373 3,395 Children provided for by the Metropolitan Asylums Board. *182 — — 450 — 632 * The above is incomplete as a return of all " mentally defective "London children—(i.) On account of some who should probably be included, not having been certified; (ii.) because some who might be classified as mentally defective, etc., are in workhouses, infirmaries, poor law schools or institutions. § Waiting list. † Reported as under instruction of some kind, though not in Council schools. ‡ Two-thirds of the mentally defective children passed for admission to special schools under the Act of 1899. 63 The Commissioners think it would be possible also by this single authority to establish such arrangements as would render the duplication or triplication or conflict of medical certificates impossible. They recommend observation centres for purposes of scientific study and diagnosis in difficult cases, and that the education authorities should establish intermediate schools or classes for dull and backward children. All these are matters upon which reports in similar terms have already been made to the Council or late School Board. The Commissioners also recommend that all mentally defective children should be taken from the care of the Board of Education and placed under the Board of Control. Such proposals would lead to great difficulties in practice which may be mentioned here. There is no hard and fast line between the borderlands of normal mental conditions and feeblemindedness, and to say that a doubtful case must pass under the authority of the Board of Control with all that implies would in very many cases be a great injustice which would be successfully resisted in the Courts. It is almost impossible to make anything like a correct diagnosis at early ages; even in the infant department the diagnosis of feeblemindedness, if attempted, would be wrong in a large proportion of cases. The proposals of the Commissioners would lead to a double set of medical officials invading the schools. The school doctors associated with the sanitary service, and an entirely different set with different training and experience, e.g., the doctors under the Board of Control associated with lunacy. The same officials could not serve in a double capacity, on account of the quite different work in other respects required from them. There would be frequent conflict of opinion and certificates. As has been elsewhere pointed out the tendency of legislation has been in accordance with the doctrine that any interference on the part of the State, through the local authority or otherwise, with a child between the ages of 3 and 16 is interference for the purpose of promoting the development of the child, mental, moral or physical, and that whatever may be the mental condition of the child, such promotion comes fairly within the scope of education. SPECIAL SCHOOLS EXAMINATIONS. Under the provisions of the Blind and Deaf Children Act, 1893, and the Defective and Epileptic Children Act, 1899, there have been 6,602 children examined with the following results:— Month. 1907-8. Number of examinations. Numbers Examined.' Passed for Mentally defective. Physically defective. Mentally and physically defective. Blind. Deaf. Residential school. Industrial school. Elemen tary school. Imbecile. Invalids and Epileptics. April 37 429 132 62 1 – 7 1 – 115 11 100 May 41 497 147 68 2 1 10 1 1 153 10 104 June 43 648 180 86 — 6 6 2 2 192 11 163 July 38 526 132 67 1 5 3 1 — 166 15 136 September 44 537 137 97 — 4 10 4 — 151 12 122 October 45 697 177 117 — 12 15 2 1 178 15 180 November 48 746 199 111 — 5 18 2 1 211 22 177 December 37 541 139 76 — 6 2 3 1 145 13 156 January 48 613 156 77 — 1 5 1 1 203 13 156 February 48 638 192 92 — 8 14 2 1 184 12 133 March 51 730 205 94 — 3 6 3 — 262 17 140 Total 480 6,602 1,796 947 4 51 96 22 8 1,960 151 1,567 1903-4 170 2,531 1,046 372 – 30 32 – – 702 119 230 1904-5 339 5,048 1,761 776 — 61 60 – — 1,216 148 1,026 1905-6 415 5,554 1,838 819 — 57 114 – — 1,504 163 1,059 1906-7 464 6,573 1,868 1,017 3 51 129 25 18 1,830 181 1,451 1907-8 480 6,602 1,796 947 4 51 96 22 8 1,960 151 1,567 Last year + or— + 16 + 29 —72 —70 +1 – —33 —3 —10 + 130 —30 + 116 From 1st April to December 31st 1908, 4,982 children have been examined with the following results:— Month. Passed for Number of examinations. Numbers Examined. Mentally defective. Physically defective. Mentally and physically defective. Mentally defective and deaf. Mentally defective and blind. Blind and deaf. Blind. Deaf. Industrial school. Elementary school. Imbecile. Invalids and Epileptics. April 32 427 90 77 — l — — 9 8 3 144 8 87 May 54 721 188 131 — 2 — — 11 10 3 247 14 115 June 46 634 159 113 — 1 1 — 8 5 — 201 13 133 July 37 486 132 101 — — — — 6 4 6 137 8 92 August 3 33 7 4 — — — — — — 3 8 1 10 September 54 717 154 128 — — — — 9 17 1 206 20 182 October 48 675 192 103 1 — — — 11 8 1 198 15 144 November 50 706 198 118 — — — 1 9 10 3 191 19 157 December 41 583 185 77 — 1 — — 1 6 3 160 10 140 Total 365 4,982 1,305 854 1 5 l 1 64 68 23 1,492 108 1,060 64 Examinations at the Head Office.—There are many appeals from the examinations which are held locally, or cases referred for further examination or enquiry by the medical officers. For several years, therefore, a school clinic in the form suggested in Circular 596 of the Board of Education, has been carried on at the head office on Thursday mornings. It is not for treatment but "for the further and more scientific examination of cases," and in the majority of those seen a final disposal educationally is possible. By this means parents, teachers, superintendents and the various officials concerned can confer, and a decisive medical opinion can be given. In many cases magistrates now refer cases for such examination and opinion and in many others legal proceedings on the part of the authority are avoided. Notes are kept on a card index, and one case may be followed up and seen several times at considerable intervals. About 1,700 cards have been analysed, and the cases, which are about 4 per cent. of all submitted for medical examination with a view to special educational treatment, have been disposed of as follows:— Boys. Girls. Total. Numbers of children examined 833 839 1,672 Fit for elementary school under certain conditions. Visual defects 77 118 195 Aural defects 22 30 52 Other defects 18 36 54 Unfit for elementary school. Invalids— Visual 46 93 139 Aural 2 11 13 Other defects 20 23 43 Visual defects (Blind schools)— Blind 114 136 350 Partial vision 4 4 8 High myopia 14 37 51 Aural defects (Deaf schools)— Total deafness 60 67 127 Partial deafness 72 65 137 Partial deafness, not noted 81 74 155 Word deafness 2 1 3 Physical defects 38 9 47 Epileptics 30 13 43 Mentally defective 68 38 106 Imbecile 20 8 28 Combined defects— Mental and deaf 33 21 54 Mental and blind 20 17 37 Deaf and blind 1 6 7 Triple defects 3 8 11 Residential (custodial) 88 24 112 Under the heading of combined defects cases only are included where two or more defects come in to such an extent that the educational disposal of the child is affected. Inherited syphilis plays a considerable part in these cases. Such cases were headed as:— Boy 10—Interstitial keratitis, nearly blind, very deaf, and with arthritis of knee joints. Boy 11—Mentally defective, epileptic, corneal nebulæ, semiblind. Girl 8—Interstitial keratitis, nearly blind, quite deaf, supposed also mentally defective. Girl 8—Very deaf, very blind, unsteady on feet. Girl 12—One eye, deformities, great weakness of muscles, deaf. Girl 5—Corneal nebulae, deaf, mentally defect, pareses from old hemiplegia. Girl 7—Deaf mute, paralysed in left hand. Girl 6—No hearing, practically blind, hip disease and crutches. Boy 11—Blind from optic atrophy, very deaf, with chronic rhinitis, some paresis, mind almost a blank. A considerable proportion presented other defeets than the main one considered, which however did not actually affect educational treatment; thus in the 555 children with aural defects as the chief point, there were 72 who presented visual defects in interstitial keratitis, choroiditis, conjunctivitis blepharitis, corneal ulcers, opacities or leucomata, and in no less than five only one eye remained. The combination of deafmutism with imbecility appears frequently among aliens from Russia. One particular family was noteworthy, as the parents were Jews and cousins, and three cousins in Russia were deafmutes; and of their own children two were deaf, one was an imbecile cripple at Darenth, and the one presented was a girl of six who was mentally defective and deaf. 65 The children sent to residential custodial institutions (reformatories, industrial schools, truant schools, Acre Lane or Sandwell Hall), who are seen at the head office, come chiefly from the remand home, where some doubt as to their mental condition has been raised. Most of them present considerable degrees of physiological variation in their mental capacity. Wordblindness is very frequent among them, also moral imbecility, the lack of self-control in social relationships from want of power to form clear conceptions of conventional behaviour. Notes from the cards give some idea of the origin and previous environment of these children. Boy 9—Thief, truant, absolutely fearless, but nervous and twitching; a brother and sister died young of fits, a brother is on a training ship; on the father's side, the father himself now steady, has twice attempted suicide, his brother attempted suicide, another brother dying of softening of the brain and sister imbecile, a cousin imbecile, and another cousin with brain trouble. Boy 8—Tiny boy of fair and angelic appearance, but moral imbecile of most hopeless and wicked kind, has attempted to drown a child, he never needs to be told twice to do a thing, and never asks a question. Boy 13—Standard four. Uncontrollable temper if anything crosses him, throws food about, smashes windows, language awful; threw baby across the room. Boy 7—Illegitimate son of a prostitute who is in prison, he has cleft palate, harelip, low mental condition and poor physique. Boy 10—Much sharper than he appears, very artful, probably drowned his companion. Boy 12—Hairy pleasant faced impish-looking arab, appears three years younger, two sisters mentally defective and brother in industrial school. Boy 9—Four people to get him here, extremely cruel to children and animals; killed a cat with his hands. Boy 9—Healthy appearance; sets fire to place; grandfather in asylum, brother in Darenth, other brothers in industrial schools. Boy 13—Father abstainer, mother died of drink, all six children in industrial schools. Of the 28 cases adjudged imbecile, the subsequent disposal, from enquiries made six months later was:— Boys. Girls. Total. In institutions 5 3 8 Living with parents or guardians 6 5 11 Living with a friend and attending an extra-metropolitan elementary school. 1 — 1 Guardians arranging for institution 1 — 1 Attending special schools 2 — 2 Not traced 5 — 5 20 8 28 The number of imbeciles known at any time as unsuitable for school is about 500 to 600. A careful enumeration gave on March 31st, 1907: Age last birthday 5 6 7 8 9 10 11 12 13 14 15 Numbers 595 39 43 76 72 72 86 62 72 36 28 9 An analysis of the ophthalmic troubles which gave rise to difficulties, and had to be thoroughly examined at the office, may also be of interest. They were as follows:- Admitted to elementary school. Invalided. Blind and mental defect. Blind. Totals. Disease. B. G. B. G. B. G. B. G. B. G. All children. Ophthalmia neonatorum Congenital syphilis— — 2 1 — 3 4 27 28 31 34 65 Interstitial keratitis, iritis 5 9 8 16 3 4 5 7 21 36 57 Uveal and optic atrophy — — — — 3 2 9 10 12 12 24 Uveal and optic disease, other causes. 3 5 3 — 5 — 6 4 17 9 26 Retinitis pigmentosa — — 1 — 2 — 2 3 5 3 8 Sympathetic ophthalmitis — — 1 1 — — 4 2 6 3 8 Loss of or injury to an eye 2 4 — 1 — — — — 2 6 7 20261 1 66 Admitted to elementary school. Invalided. Blind and mental defect. Blind. Totals. Disease. B. G. B. G. B. G. B. G. B. G. All children. Purulent ophthalmia— Smallpox — — — — — — — 1 — 1 Measles — — — — — — 2 4 2 4 1 Diphtheria — — — — — — — 1 — 1 Unknown 1 4 — — — — 6 7 7 11 26 Trachoma 1 1 4 10 — — 1 — 6 11 17 Phlyctenular keratitis 31 44 12 37 2 2 9 4 54 87 141 Blepharitis and conjunctivitis (chronic) 6 10 2 6 — — — — 8 16 24 Simple error of refraction 13 12 6 7 — — — — 19 19 38 Myopia— Under 10D 7 11 3 9 1 2 4 14 15 36 1 Over 10D — — 2 4 — — 10 23 12 27 90 Squints 3 7 _ _ _ _ __ 3 7 10 Congenital defects— Cataract 4 7 3 1 — — 12 14 19 21 40 Malformations 1 2 — — — 1 10 12 11 15 26 Albinism— — — — — — 1 1 1 1 2 Cerebral troubles — — — — 1 2 4 — 5 2 7 Hemeralopia — — — — — — 2 1 2 1 3 Malignant disease — — — 1 — — — — — 1 1 — — — — — — — — 257 363 620 WORD DEAFNESS. Cases are now diagnosed from time to time as being congenital word deafness. The condition is a rare one—indeed it is just 10 years since the first case was described by me, and most cases hitherto recorded have been noted among our London children by Dr. Thomas. In certain children, usually with general mental defect, words heard act in a kind of reflex way, and are immediately reproduced as a parrot speech (echolalia). The mechanism of hearing and production is perfect, but the structures concerned in understanding the words heard are wanting. In the ordinary mentally defective child this is always taken as indicating considerable and grave mental defect, showing want of development of the higher auditory speech centres. The memories of words are stored in the brain in various ways, but spoken words are heard by the ear: are seen by lip-reading; can be felt by motor speech, and understood by first repeating the words. The ordinary method of learning word heard is by development of a centre, the higher auditory (word) centre. Where this fails speech may be learnt by the visual (lip-reading) centre becoming specially educated, or by the motor (spoken) word centre developing. The highest intellectual centres for understanding words can be reached through any of these routes. Word deafness then may be associated with general mental defect or in rare cases may be isolated, the rest of the brain being normal, the word centre alone impaired. Besides this variety, a few children are seen from time to time where obscure hysterical or psychical causes seem to have interfered with normal speech evolution. In one case, apparently of a functional nature, and originating in a fright, a boy of nine who had not spoken for years was made to count numbers in an audible voice at the first examination by simple suggestion strongly maintained. Some of the doubtful cases seen at the Head Office have been followed up in the deaf schools, by careful testing early this year by Dr. E. Jones. He thinks these cases have been too much assimilated in their mechanism to word blindness, to which they do not bear resemblance. He does not credit the "word hearing centre" hypothesis, although even if it is wrong, it was this hypothesis which by analogy led to deduction from the earlier observed word blindness, and to the search for and discovery of this much rarer condition of congenital word deafness. In addition to the mentally defective there are clinically a number of cases which fulfil the simple definition of persons able to hear, but unable to understand what they hear. Of two children with the same degree of deafness one may understand the meaning of words heard much better than the other. This may be due to a congenital weakness of the hypothetical auditory word centre, or to some psychical inhibition due to infantile psychasthenia, hysteria, or congenital debility. In these last cases the defect is only apparent. The words are heard, registered in the memory, and even subconsciously understood, and all that is lacking is conscious apprehension of the meaning, as happens when a person under strong emotion cannot take in the meaning of words addressed to them. If such a psychical cause arises early in life, after this has begun to act not only is there continuous amnesia for the meanings of words heard, but the case also may differ from that in an adult in that there is no further formation of a conscious vocabulary with any meaning attached. The child therefore is in many respects like a mentally defective one, and such cases have often, or perhaps generally, been neglected as imbecile. The profound secondary consequences of speech, or of want of speech, from the educational point of view are not always realised, but become quite comprehensible from this point of view. There is probably a close relation between deafness and word deafness, in that most cases, though not all, show some deafness. The analysis of this apparent deafness is very difficult. How 67 far it is secondary to the want of brain development or lack of aural functioning cannot yet be determined, but it is not universally present. The type of speech for instance in Case V. below, was like that of case VI., the speech of a semi-deaf child, and not like the consonantal defects found in a child with speech defects in the ordinary school. Dr. J ones found that amongst normal school children the enunciatory capacity varied with the degree of nasal obstruction, and therefore presumably with the deafness, whereas among children with marked speech defects this was in no sense so. Thus it would appear that grave speech defects in the elementary schools do not depend mainly on hearing defects, and show a different type from the cases due to congenital (weakness of the word centre) word deafness, which in part is allied to the cases associated with hearing defect. Psychical Deafness.—Illustrative case notes are here given from suspected cases which have been followed up during the past year. I.—C.H.S., No. 7671, boy aged 8, Dcccmber, 1907; attending M.D. School:— Other five children normal, except eldest rather backward. Natural development till 3½. Great fright from being put into cold bath as punishment. Could not be brought near a bath for two years after without evincing the greatest terror. After this date he began to gradually lose his speech, was absolute in six months, and continued so for three years. In the past year began to slowly regain some small phrases—" No, I won't," "Leave me alone," "I'll tell daddie," were quoted. Talks to infant sister, 2½, lalling in infantile speech to her. Hums tunes correctly. Terrified of his shadow. Sometimes cannot be got to take food for watching the door lest someone enters. Follows mother about at home. Terrified of nurses since adenoid operation 3 years ago. No fits of temper. With loss of speech apparently lost all power of understanding and merely stared when addressed, regaining this pari passu with speech. Will clear table or answer the door. He is exceedingly timid and nervous and requires great patience to win any trust. Unquestionably he understands his mother's narrative, following it with interest. His hearing is normal; he matches colours but cannot read and count. Now has infantile speech—" mifs " for " miss," " Tardie " for "Charlie," " peddy " for " penny," like the infant sister. In school the boy is regarded as deaf mute and mentally deficient. He has made no progress and the teachers are unable to get into communication with him. He sits apathetically motionless. Ten months later Dr. Thomas reports, " He is clearly a case of motor aphasia, the cause being psychical or hysterical." II.—L.D., No. 21,432, girl, aged 10, December, 1907:— Family history negative. Mother regards her as quite normal, except for lack of speech, and the fact that she cannot learn at school. She has used short phrases at homo. She is clean and tidy and has always been quite normal in this respect. Well formed child, very timid, hears whisper well, performs simple requests. No speech could be elicited nor any complicated requests such as counting. A case of motor aphasia in which, however, the evidence is not clear that the troubles are secondary to psychical disturbance. III.—D.B., (see Fig. below), girl, aged 11, February, 1908; Deaf School:— Two brothers and three sisters normal. Three years in centre. Three-years in Deaf school. On admission had only vowel hearing and could reproduce no words. Apart from hearing and speech, normal, and more intelligent in work than a deaf child of her age. Frightened and nervous. Relies apparently on lip-reading, but hears whisper at 5 feet, obeying "Pick up your glove," uttered behind her back ; is, however, very uncertain and doubtful about all commands. Spontaneous speech slipshod and indistinct, but reproduced speech quite clear. Using test words and comparing results with lip-reading to those when only hearing is allowed, there was always a tendency to replace "sh" by "s" much more marked with lip-reading, d and g and n and 1 are often mistaken too. Case III. D.B. M—Motor speech centre. LA, L,A—Lower auditory centres. A—The undeveloped weak auditory speech centre. LV, LV — Lower visual centres. LR—Lip-reading centre. I—The seat of consciousness diagrammatically represented. Eye, LV, LR, L—The most direct route to the understanding of speech (lip-reading). Ear, LA, M, L—The preferred route to the understanding by the ear. Ear, LA, A, L—The normal route from the ear to understanding; in this case weak or absent. Ear, LA, M, speech—Echolalia. 20261 12 68 This has been classed as a case of congenital word deafness, but differs from typical cases in the extent to which commands are understood when heard, in spite of the influences impelling the child to rely upon sight. Dr. Thomas, who examined her in November, 1908, reports on the striking difference between heard speech which is merely repeated (echolalia) and seen speech (lip-reading) which is immediately answered rationally; for instance:— Query : What is the time ? (By ear only). Answer: What is the time. (Mumbled without intelligence.) Query : What is the time ? (Lip-read.) Answer: (Immediately looking at the clock.) Three o'clock. Query : What is your father doing ? (Lip-read.) Answer : Gone to work. Query: What is your mother doing? (By ear only.) Answer : What is your mother doing ? (Echolalic.) In this case the word deafness prevents the higher word centre being effective, and the child can only repeat words heard without comprehending their meaning, but she has now learned to understand by lip-reading. But on further examination many interesting points come out:— (By ear)—Q. What is the number of your house ? A. What is the number of my house ? (But no attempt to reply to the question.) (By ear)—Q. How many brothers and sisters have you ? A. How many brothers and sisters have 1 ? (But no sign of answering the question.) (By eye)—Q. What is your sister's name ? A. Bertha. The alteration in the pronouns marks an advance on mere echolalia. This substitution of the correct pronoun is especially taught in deaf schools. On further examination it was found that after she had repeated (echolalia) a question, if interrogated by lip-reading without the question being put again, she could answer it, thus— (By ear)—Q. What is the number of your house ? A. What is the number of my house. (By eye)—Q. Well! tell me. A. Forty. Again— (By ear)—Q. How far away do you live ? A. How far away do / live. Teacher (by eye) —Q. Weil! tell him. A. Not very far away. The child was evidently using some subconscious action. The motor centre being roused by echolalia, by directing attention to this the meaning of the phrase is perceived. Telling the child not to repeat the question but to think of it, and answer— (By ear)—Q. What is your brother's name ? A. What is my brother's name ?—Willie. (By ear)—Q. Wrhen is your birthday, Dorothy ? A. When is my birthday, Dorothy ?—December thirtieth (By ear)—Q. When do you say your birthday was ? A. When do you say my birthday was'—December thirtieth. ( By ear)—Q. Do you like cake ? A. Do I like cake?—Yes. The child was now given to understand that she was on no account to repeat the question, but to think carefully of what she heard. She found great difficulty in doing this, but after pondering some time a correct answer was obtained without the echolalic motor response being evoked aloud. It was evident that considerable restraint had to be exercised to prevent this, and every now and again, in spite of instructions, the echolalia recurs to words heard but never to words seen. In January, 1909, she answers ordinary speech correctly even with her back to the speaker, but if a whisper is used she at once reverts to the echolalic answers, showing that the auditory centre is still not completely controlled. In this girl's case no language was acquired until lip-reading was established, and the quickest and most direct route to her consciousness is by this centre. Questions heard are repeated by echolalia, but now she corrects her pronouns subconsciously. If special attention is directed to the motor response to questions heard understanding can be attained and a correct answer given. With great effort, heard phrases are understood without motor response being interposed, but not easily, often with error and often forcing the motor response in spite of attempted inhibition. Evidently the auditory centre is very weak, and it is difficult on any other hypothesis to explain this case. IV.—M.B., No. 15,152, girl, aged 7, January, 1908 ; Deaf School. A.B. (below), her brother:— Did not speak before admission to centre 13 months ago ; has made slight progress in lip-reading since. Resembles brother in general condition. Hearing present but defective ; watch at 5 cm. No spontaneous speech; defective understanding and somewhat unintelligent; hardly any power of speech reproduction. Examined by Dr. Thomas 10 months later, she had made great progress, but in spite of her intelligence, it is still difficult to communicate owing to want of language. She has a strained puzzled expression, but gives great attention. She hears conversational tones and repeats by echolalia without comprehension. Will often name a thing shown, although she cannot recognise the word when spoken. The incidence of defect is on the word hearing centre, and she is in exactly the same position as her brother was at her age. 69 V.—A.B., No. 9,615, boy, aged 12, January, 1908 ; Deaf School:— Brother normal. Sister of 7, defective in similar way (No. 15,152 above). Never spoke till admitted to centre 13 months ago ; since then has been taught lip-reading and made considerable progress. Hearing defective, conversational tones at 12 feet, but understanding of words is exceedingly defective compared to hearing. Defects in consonantal combinations—s, z, n, 1, being worst —are much greater than in a "speech defect" child in an ordinary school whose enunciation corresponds to that of this boy. When only allowed to hear, the capacity of reproduction was much reduced. He has been classed as congenital word deafness, but it is difficult to judge how far actual deafness and how far lack of understanding account for the ultimate result. This boy is, 10 months later, at Anerley, doing well. VI.—A.H., No. 10,197, girl, aged 12, January, 1908 ; Deaf School:— Very little speech on admission ; considerable progress since then. More intelligent in studies than most deaf children. Spoke a little (?) before attack of whooping cough at age of three. Spontaneous speech intelligible, hearing greatly reduced ; watch on contact. She clutches at whole words and either gets them completely or not at all. Guessing is very great. Strangeness of a word enormously increases her difficulties; she gets the "n" clearly in "pen," but fails with it in "gun." Lip-reads perfectly, except for some difficult combinations, Nd, Fn, Dn, Gl, Gn. With sound only easily makes mistakes. She is semi-deaf, a typical lip-reader, making mistakes in G and N, the most difficult consonants to see, but some mistakes are those never made by a pure lip-reader, e.g., Fr for Thr, and Sk for Sp. She therefore depends partly on hearing, or else on the memory of sounds heard before she became deaf. Examined later at the Elementary School to which she was returned, it was found that the whole trouble was semi-deafness or hardness of hearing, and that there was now no difficulty in understanding all she could hear. PHYSICALLY DEFECTIVE SCHOOLS. The special schools for physically defective children are intended for the education of those children who, owing to chronic disease or crippling deformity, are unable or unfit to mix with healthy children in the ordinary schools. These children have often lost much schooling owing to prolonged illness, and require to be rendered capable of earning their own living by means of some skilled trade, and it is often considered advisable that they should remain at the special school up to the age of 16 even though their disease is cured, provided that the instruction they obtain by so remaining is likely to enable them to earn their own living. Children should not be sent to the P.D. centres simply because they are backward owing to previous ill health, nor on account of malnutrition the result of poverty or want of care, although the temptation on the doctor's part to procure some help for these cases that he knows will otherwise drift downwards is always very great. As a result of his careful examination, Mr. Elmslic defines the children who can be considered as proper subjects for these physically defective schools as:— 1. Those with tuberculous disease of the bones and joints, and most of these should be retained in the centres even when the disease is quite or apparently cured, because it may relapse even after several years' quiescence, or the deformity left may render it desirable to prepare the child for special skilled work. 2. Paralysed children. 3. Children with various deformities of the trunk or limbs if (a) the deformity is sufficient to render them unable to mix with healthy children. (b) the deformity is increasing. (c) they are under treatment requiring some observation, e.g., by the school nurse. (d) if orthopaedic instruments have been worn which are liable to injury. 4. Certain children with heart disease. 5. Children convalescent from or liable to recurring attacks of chorea. 6. Certain rare chronic cases, e.g., chronic rheumatism, asthma, chronic bronchitis, exophthalmic goitre, haemophilia, and so on. 7. Exceptionally, certain children who are semi-blind or semi-deaf. 8. Cases admitted on probation, who have doubtful defects and illnesses of various kinds, and including some whose mental status is indeterminate. The children who should be considered as not suitable for admission are those with 1. Trivial deformities. 2. Deformity or paralysis accompanied by evident mental defect. 3. Rapidly increasing paralysis (pseudo-hypertrophic). 4. Hernia. 5. Epilepsy, except occasional cases with vetit mal. 6. Lupus and other chronic skin diseases. 7. Children who are objectionable from offensive discharges or habits, or from dirt. 8. Nervous, delicate children and those said to suffer from fits, anaemia, adenoids, etc., but who present no real evidence of disease. 9. Mentally defective children including cretins. Physically Defective Children—There are now 29 Physically Defective Schools with 2,410 children on the roll. Three of these are held at hospitals (Royal National Orthopaedic Hospital, Alexandra Hospital and the Home for Incurables, Hampstead), where chronic cases are treated. Mr. R. C. Elmslie, who has been paying special attention to the physically defective children, has now completed the card index of each child. An analysis of 1,050 cases was given in the last Report with a discussion of the 70 chief groups. The table of physical defects in 2,141 crippled and invalid children shews the proportions in which the various diseases exist in our school population. The reason for the retention of the majority of these children in such centres is evident. A child with tuberculous disease of the hip, with severe paralysis or with a heart lesion is not fit either to walk any considerable distance to school, or to mix with healthy children. Unless he is educated at a special centre he will probably not be educated at all. Certain of these cases might be dealt with more fully than was possible in previous reports. S-pastic paralysis.—Twenty per cent. of these cases are also mentally defective. Owing, however, to the difficulty of getting them to and from school it is impossible to send them to special schools for the mentally defective. The majority of these children will repay education, and it should be clearly understood that the existence of paralysis due to a brain lesion is not inconsistent with a high mental ability. One boy with hemiplegia had not only reached the sixth standard in his ordinary work at 16, but was also able to do excellent designing with his left hand, his right being useless. Progressive paralysis.—Ten of these children (nine boys and one girl) were cases of pseudohypertrophic muscular atrophy. It has been necessary to exclude three of these during the past year owing to the steady progress of the disease having extended to a complete loss of the power of walking. When once the diagnosis is fully established there is no public benefit to be obtained from the education of these children, although no doubt for a time they are interested and their burden lightened by school and its events. The remaining cases were of Friedreich's Ataxia, one of the peroneal type of muscular atrophy, and one of doubtful nature. Congenital syphilis.—This widespread and destructive disease is fortunately only represented by extremely small numbers in these special schools. The bone lesions due to congenital disease do not show up before 11 or 12, and are rare and progress slowly, so that they do not interfere much with school life. It is in respect to other organs like the eye, ear, and brain that damage is marked educationally. Chorea.—Recurring attacks of chorea are responsible for serious loss of attendance. Children affected in this way are better for a year or two at an invalid school where they are kept quieter and are under more strict observation. It is found by experience that children who have suffered from repeated attacks whilst at the ordinary school can attend an invalid school regularly and remain apparently quite well. Phthisis.—The number of cases is extremely small, and in several the vague history and absence of physical signs make the actual diagnosis very doubtful. Those children who have actual signs or expectoration have to be excluded, but the numbers thus excluded are small. The cry of abundant phthisis in our elementary schools has no foundation in facts. Mentally defective.—The six mentally defective children were all admitted for observation, and eventually transferred to a centre for mentally defectives. There are, however, many children showing some mental defects in addition to their physical defects. In them the difficulty of transport necessitates their retention as physically defective. Children with trivial dejects.—These include convalescents from acute illnesses and operations, delicate, weakly anaemic children, in whom no defined disease is diagnosed; nervous children, children in whom chronic ill health is also the cause of backwardness and great irregularity of attendance. Many of these are admitted for observation only. Owing to the small classes, the presence of the school nurse and the frequent attendance of a medical officer, it is soon possible to place each child and ascribe its backwardness or irregularity to the proper cause. The majority of such cases only remain about a year and then return to the ordinary school. The delicate, anaemic and nervous children often improve greatly whilst attending the invalid school. Table of 2,141 children in schools for the Physically Defective.—The table is given in eight main groups, and these again, where necessary, are shown in subdivisions. Where a child suffers from two diseases or defects the second entry is enclosed in a bracket. Boys. Girls. Total. Boys. Girls. I. Tubercular diseases of the bones and joints. - - - 467 396 Spine 183+ (1) 140+ (1) 325 - - Hip 198 +(8) 178+(7) 391 - - Knee 78 + (12) 59+(10) 159 - - Ankle and tarsus 5+(7) 12+(5) 29 - - Elbow l + (2) l + (4) 8 - - Various 2+(2) 6+(2) 12 - - II. Infantile paralyses 130+(3) 122+(3) 258 130 122 III. Spastic paralyses - - - 64 67 Hemiplegia 32 27+(2) 61 - - Paraplegia 21 21 42 - - Diplegia 11 19 30 - - IV. Pseudohypertrophic muscular atrophy and other progressive paralyses. 13 2 15 13 2 V. Various deformities - - - 168 167 Congenital dislocation of the hip 10 29+ (1) 40 - - Congenital talipes equino varus 20 8 + (1) 29 - - Congenital amputations or deformities 4 + (l) 9 14 - - 71  Boys. Girls.; Total. Boys. Girls. V. Various deformities. Rickets 25+(l) 34 60 - - Results of septic bone or joint disease 21+ (7) 17 45 - - Amputations 52 20 72 - - Infantile coxa vara 1 11 12 - - Scoliosis 3+(8) 15+(8) 34 - - Malunited fractures 5+(l) - 6 - - Scarring from burns 3 - 3 - - Hernia 2+(2) 2 6 - - Congenital syphilitic lesions - 3+(l) 4 - - Kyphosis - 3 3 - - Various 22 16 38 - - VI. Heart disease 120+ (1) 148 +(2) 271 120 148 VII. Various other chronic diseases - - - 71 71 Chorea, active, or recent 14+ (1) 27+(4) 46 - - Slight epilepsy of various kinds 16+(4) 19+(6) 45 - =- Phthisis 8+ (11) 10+ (1) 30 - - Haemophilia 7 - 7 - - Chronic bronchitis, asthma, etc. 7 5 12 - - Exophthalmic goitre, convulsive tic, etc. 19 10 29 - - VIII. Sundry other diseases and defects - - - 56 79 Eye diseases 0 6 12 - - Ear diseases 5 5 10 - - Mental defects 3 3 6 - - Various slight defects, convalescents and those admitted under observation. 42 65 107 - - 1,089 1,052 Grand total - - - 2,141 OPEN-AIR SCHOOLS. There has now been time to obtain experience of four open air schools. The first school at Bostall "Woods was opened during July-October 1907, and the three schools at Montpelier House, Birley House and Shrewsbury House were opened during June-October 1908. Bostall Woods school was about nine miles east of London Bridge and a mile and a half south of the river, just on the boundary of the county. A mile and a half south-west of this is Shooter's Hill, on the top of which is Shrewsbury House. Montpelier House is an old-fashioned low storied house in about two and a half acres of ground, three miles due north of Trafalgar Square, whilst Birley House adjoins the Horniman's Museum, four and a half miles south from the Tower. In each case the soil is stiff clay which did not dry readily after rain, except 'on the high and exposed area at Shrewsbury House; otherwise there was abundance of room, plenty of trees and grass, and the sites suited admirably. Method of Selection of Children.—The class of children wanted for these schools are those who through poverty, neglect, heredity or certain chronic conditions are unfit for the ordinary strain of school life. With very many the natural powers of growth may be expected to assert themselves if the conditions are favourably adjusted even for a relatively short time. This can be done by bringing the child under easier conditions. In the open air school the whole burden of life is lightened by the regular rest and daily sleep, the systematic feeding, the stimulating effect of the open air, and the reduced pressure in regard to merely academic work. The selection of these children has hitherto been a weak point in the medical arrangements, chiefly owing to the fact that only a short time has been available for this purpose. Certain schools presenting relative accessibility whether by foot or electric tram, were selected and the head teachers were asked to nominate children to be submitted to the medical officer. These children were examined at centres. For the Bostall Woods School 272 children were nominated from 51 schools in Woolwich, Greenwich, Plumstead and Deptford, and 149 selected (68 boys and 81 girls) as most likely to benefit. After considering their relative accessibility to the school, 49 boys and 64 girls were admitted. Both at these examinations and those for the other schools, many robust children were found, who, from statements of parents or for other reasons were supposed by the teachers to be in delicate health. The supposed diagnosis of weak heart was often given with absolutely healthy children, and of consumption in children who merely had adenoids. The ailments among the children admitted at Bostall W oods are representative; they were as follows:— Palpably enlarged cervical glands 63 Pallor sufficiently great to indicate considerable anæmia 47 Enlarged tonsils 27 Adenoids (nasal obstruction) 7 Heart disease 6 Lungs—Phthisis early 1 Bronchiectasis 1 72 Slight lung symptoms, clearing up and probably due to adenoids 4 Enlarged glands in chest 4 Chorea (St. Vitus dance) 2 Bone diseases—Old cervical caries of spine 1 Old necrosis 2 Lateral curvature 1 Eye diseases-Corneal ulcers and blepharitis 4 Thirteen children showed marked signs of tubercular diathesis, one of hydrocephalus, one of congenital syphilis, and four evidence of damage through infantile rickets. Every child benefited physically by attendance at the school; the general improvement was greater than could have been anticipated, and in some instances was remarkable. The children admitted were suffering in the main from debilitating conditions which arise from city life. The commonest ailments were anaemia, enlarged cervical glands, adenoids and hypertrophied tonsils. Many of the children were said to be " consumptive," but this meant that they suffered from adenoid growths and enlarged tonsils. The improvement amongst those with active disease who happened to be admitted was very gratifying, and this experience should remove any hesitation in dealing with such cases in future if the opportunity arises. The children were drawn from all social grades usually attending elementary schools. Some trouble was caused by verminous conditions, and a few children were withdrawn by parents who would not take the necessary steps to free them from this condition. The clothing, though in some cases poor, was generally sufficient. This year the same method of selection was adopted. 453 children were submitted by the head teachers, 417 examined by the doctors, and 234 admitted to the schools. The roll averaged about 80 at each school. The reasons of a medical nature for the rejection were that the child was not likely to benefit, or was likely to come to harm from the school. Cases of tubercular knee, epilepsy, corneal ulceration, chronic heart disease, rheumatism, and mediastinal tumour were amongst those rejected. The equipment of these schools was in some instances rather primitive, and the sanitary arrangements of a rather makeshift nature. Whilst at Montpelier House and Birley House there was an old mansion with spacious rooms, and conveniences of water and drainage, these were lacking at Bostall Woods, except water, and at Shrewsbury House, which depended on Plum Lane School as its feeding base and for the supply of water. The weather was excellent, but in a wet summer, owing to the clay sites, the schools would have been very bad. During a few days of excessive heat in July, 1908, there was at all the schools a general loss of weight, over and above weight of clothes. As shelters in the three schools in 1908 Doecker sheds were used from which one side had been removed. These gave a floor space of about 50 by 15 feet, a portion at the end being separated off as a storeroom where necessary. The actual school work amounted to about four hours a day, with one and a half hours of organised play and manual training in the form of gardening, laundry work, basket making, cane weaving, plasticine work and needlework. Feeding.—Three meals were given daily: breakfast at 9 a.m. of porridge ad libitum, sugar, and a half-pint of milk. Dinner at 1 p.m., 4 ounces of meat or 5½ ounces of fish, 6 ounces of potatoes and a quantity of vegetables, followed by 6 ounces of pudding. On one day a week the meat was replaced by a large plate of lentil or pea soup and bread. Tea at 5 p.m. was a half-pint of milk, weak tea or chocolate, with bread and butter or dripping, followed by bread and jam or cake. A few children were also given milk in the middle of the morning. To avoid monotony in the feeding arrangements, called for a good deal of care on the part of the school nurse. Daily rest and sleep.—The rest of from one and a half to two hours daily after dinner was very essential. Some of the children slept like logs, but the sleepers were in a minority. They rested and dozed in deck chairs in the sun or shadow as they preferred, but it was evident that these chairs could be considerably improved. During the summer days many children preferred to wrap themselves in their rugs and lie on the ground. Even in the autumn the children did not appear to feel cold from sleeping in the open. Some further enquiries as to the night sleep of these children would be useful; it was generally stated that they slept better in spite of the afternoon rest. The absence of long hours of sitting and the constant stimulation of lymphatic circulation by movement soon made itself evident in improved tone in the children's appearance. They were kept under regular medical observation. The nurse recorded weights and heights in alternate weeks, and the doctor at his frequent visits made notes of the physical condition, especial attention being given to anaemia, which was checked by Tallquist's method of estimating haemoglobin, by testing the colour of a drop of blood taken up in white blotting paper against standard tints. The state of nutrition, the teeth, cervical glands, tonsils, presence of adenoids were watched. Careful chest examinations were made as regards heart and lung conditions, and some of the children were kept under very close observation by repeated examinations. Medical treatment generally was not undertaken. Dr. Alice Johnson endeavoured to correct some spinal curvatures at Birley House by special exercises, and the nurses were also directed to syringe discharging ears, but no medical remedies were administered. A noteworthy circumstance was the evident systemic depression resulting from the slightest operations. Several children were taken by their parents to have treatment of teeth or to have operations for adenoids, and in most cases there was for some days a distinct effect, which in many showed itself as an arrest in the rate of increase of weight, and in a few as a loss of weight going on for a week or two. 73 Notes on some of the children at Bostall Woods who received most benefit. Celia M., set. 9 7/12. Height 112 cm., deficiency 12.5. Weight 16.8 kilos., deficiency 7.8. Weight in tenth week 19.6 kilos. Increase in weight 2.8 kilos. Percentage increase in weight 16 .6. Condition upon admission—Nutrition 2 (5 being maximum mark). Teeth 3 (5 maximum mark). Tonsils enlarged, glands enlarged. Heart and lungs normal. Very pale and thin. Joseph W., set. 10. Height 119 cm., deficiency 10.5. Weight 20.7 kilos., deficiency 10.5. July 25th. Back, cervical caries of the spine. Heart and lungs normal. Tonsils enlarged, glands slightly enlarged. Nutrition 2. Teeth 3. August 8th. Tumbled off car in alighting, and cut his head. Stitched up at infirmary. August 9th. Amount of hœmoglobin 60 per cent. August 27th. Is looking better, more colour, eats well. September 26th. Amount of hæmoglobin 75 per cent. Weight in tenth week 22 kilos. Increase 1.2 kilos. Increase per cent. of body weight 57. Herbert S., set. 10. Height 125 cm., deficiency 9.5. Weight 24.1 kilos., deficiency, 6.1. August 13th. Polypus of ear lately removed. No discharge now. Nutrition 3. Teeth 3. Glands palpable. Pale. Tubercular type. Phthisis present left lung. Hæmogloblin 75 per cent. August 27th. No expectoration. September 26th. Hæmoglobin 80 per cent. Weight at tenth week 261 kilos. Actual increase 2 kilos. Increase per cent. of body weight 8.3. David McD., set. 10. Height 119 cm., deficiency 9.5. Weight 20.5 kilos., deficiency 61. August 8th. Nutrition 3. Teeth 3. Glands and tonsils enlarged. Chest normal. Hæmoglobin 65 per cent. September 26th. Hæmoglobin 80 per cent. Weight at tenth week 21.6 kilos. Actual increase 1.1 kilos. Increase per cent. 5.3. 20261 K 74 Ethel A., set. 8. Height 113 cm., deficiency 5. Weight 18.6 kilos., deficiency 4.5. August 2nd. Nutrition 3. Teeth 3. Tonsils and glands enlarged. Old rickets. Pigeon chest. August 8th. Haemoglobin 80 per cent. September 26th. Haemoglobin 80 per cent. Weight in tenth week 20.9 kilos. Increase 2.3 kilos. Increase per cent. of body weight l2.3. Ethel T., set. 10. Height 126 cm. (normal). Weight 25.7 kilos. (normal), Chorea three years ago. July 29th. Pale. Has had chorea for three weeks. Heart normal. Nutrition 3. Teeth 2. Tonsils enlarged. August 2nd Slight improvement. Heart normal. August 9th. Hæmoglobin 75 per cent. Movements less. Heart slightly enlarged. Murmur at apex. Recommended to rest whole time in school. August 13th. Still a murmur at heart. Rests all day. August 27th. Ditto. Movements lessening. September 6th. Murmur of heart less pronounced. September 17th. Heart improving. Movements gone. September 26th. Hæmoglobin 80 per cent. Weight in tenth week 27.3 kilos. Increase 16 kilos. (6.2 per cent.). Gertrude P., set. 10. Height 122 cm., deficiency 8. Weight 216 kilos., deficiency 5.7. July 29th. Club fingers. Said to have chronic bronchitis. Nutrition 3. Teeth 3. Tonsils and glands slightly enlarged. Left lung much disease -bronchiectasis. August 6th. Hæmoglobin 80 per cent. August 27th. Haemoglobin 85 per cent. Weight in tenth week 23.3 kilos. Increase 1.7 (7.8 per cent.). Kathleen M., set. 11. Height 141 cm., excess over average 6. Weight 31.1, excess 1.3. August 2nd. Nutrition 4. Teeth 3. Glands not enlarged ; looks fairly well but anaemic. August 6th. Haemoglobin 75 per cent. August 27th. Looks quite well. September 27th. Hæmoglobin 80 per cent. Weight in tenth week 36.2 kilos. Increase 51 (16.4 per cent.). Any absence for a few days was generally accompanied by distinct loss of weight, and there was loss of weight, to be discussed later, on finally leaving the open-air for the ordinary schools. The cardiac conditions of debilitated children are worth careful study, and at Shrewsbury House, which stands about 320 feet above the level of the districts from which the children came, some fears were expressed lest the steep ascent might tell on the children. The work was, however, eased by the stop at Plum-lane (215 feet) for breakfast. Dr. Theodore Fisher examined the cardiac condition of these children carefully on several occasions. Of the boys, 14 had some abnormality, but none had definite organic disease. Eighteen girls had abnormalities, and another with chronic lung disease appeared to have chronic heart trouble also. In about half of the cases the signs disappeared whilst in attendance at the school. The medical notes may be summarised in the following paragraph:— The actual abnormalities found among the 35 boys were, four with localised systolic murmurs at the apex but nothing further to suggest organic disease, one disappeared whilst under observation. Two had basic systolic murmurs, one of which disappeared; in six the diastolic sound sometimes called false reduplication of the second sound was heard at the apex; in three this disappeared ; in two there was reduplication of the second sound at the base of so marked a character that it was worth noting, and in one this disappeared. Among the 44 girls, in two who had suffered from chorea there was possibly but not certainly mitral disease, but a definite diagnosis would be impossible before several more months; no change was detected in them whilst under observation ; 13 had basal systolic hæmic murmurs ; in three these disappeared. On the other hand, in a few of the most anaemic no cardiac abnormalities could be detected; in two there was also a systolic murmur at the apex ; in two a diastolic sound sound at the apex was the abnormality, and it cleared up in one case. At Montpelier House, Dr. Clive Rivere noted five boys with some cardiac dilatation at the first examination; in all it increased under the strain of school life, and restrictions became necessary. With one boy it appeared to be aggravated by an operation for adenoids, and he was greatly hampered by it during his stay at the school. The admission of strong or robust children among debilitated or weakly ones in an open-air school should be avoided, as although they themselves derive great benefit, they set an example of strenuous living to the weakly ones which is actually harmful Similar conditions have been found in boys going on school excursions (page 20). 75 Physical Measurements. — The heights of the children at admission are shown a various ages (last birthday) for boys and girls in the four schools, and totalled, and also compare with the average derived from London schools. Last birthday. Shrewsbury House. Bostall Woods. Birley House. Montpelier. House. All open-air schools London elementary schools. Age. B. G. B. G. B. G. B. G. B. G. B. G. 7 - - 107.5 1140 118.0 114.0 12.15 - 115.2 114.0 116.0 115.4 7 8 118.6 115.7 118.8 120.1 120.7 128.5 119.8 116.7 119.5 118.6 120.5 120.2 8 9 124.3 121.4 125.0 121.4 126.6 120.7 119.8 122.8 123.1 121.8 125.2 124.7 9 10 133.0 128.0 121.3 129.8 119.7 132.0 124.6 129.7 124.3 130.0 129.8 129.9 10 11 130.1 136.2 138.2 132.7 137.3 134.6 131.3 134.3 134.5 134.1 134.3 135.0 11 12 139.7 133.4 138.0 134.7 144.9 139.7 132.4 137.0 137.8 137.0 138.7 140.6 12 13 138.5 144.2 136.0 143.7 134.5 142.8 140.0 139.2 137.0 142.0 143.1 146.8 13 Table showing heights of children in centimetres admitted to each open-air school, to all the open-air schools, and also for Council schools generally. Thin lines showing weights of children on admission to open-air schools. Thick lines showing standard weights of 20,000 boys and girls in ordinary Council schools. The alterations in weight were taken to afford a better indication of improved nutrition. The weighing was done in the afternoons after the rest hours. During the very hot weather a loss of weight was apparent in many children over and above what lighter clothes could account for. The school at Bostall Woods was only open 13 weeks, whilst the others were open 21 weeks. For the tabular statement, the first weighings were taken, the last weighing, and the number of weeks interval between them to get a weekly rate of change in the weight. This has been averaged and expressed as a percentage of the body weight at entrance to the school. The same has been done for the children in the London Elementary Schools, from whom standards were obtained some years ago. It may be of interest to reproduce the figures here, as they were obtained graphically from the charts already published. Table showing rates of growth in weight in kilograms reckoned on weight at middle of year of age for 20,000 children in Council schools. London, 1906. BOYS. GIRLS. Year of age. Weight to middle of year observed. Rate of increase annually. Percentage of body weight at middle of year. Weight to middle of year. Annual rate of increase of weight. Percentage increase of body weight weekly. 7 22.02 1.4 .122 21.2 1.6 145 8 23.47 1.7 .139 22.92 1.9 .160 9 25.46 2.1 .159 25.00 2.2 .156 10 27.59 2.3 .164 27.16 2.45 .173 11 29.95 2.3 .147 29.87 3.0 .192 12 32.46 3.1 .183 33.32 3.9 .225 13 36.40 3.3 .174 37.71 4.25 .217 14 39.23 4.0 .196 41.80 4.7 .216 20261 k 2 76 Table showing the weights in kilograms at various ages and percentage weekly increase in weight of the children at each open-air school, and all together compared with Council schools generally. Sex Age last birthday. Average weight at entrance. Percentage average weekly increase on the body weight. Shrewsbury House. Bostall Woods. Birley House. Montpelier House. All open-air schools—total. London Council schools. Shrewsbury House. Bostall Wcods. Birley House. Montpelier House. All open-air schools—total. London Council schools. Boys 7 - 18.3 21.3 21.8 20.0 22.02 - .567 .535 .230 .525 .122 8 22.7 23.5 21.9 22.1 22.8 23.47 .294 .442 .581 .458 .426 .139 9 24.0 24.6 24.3 22.2 23.8 25.46 .354 .426 .447 .302 .367 .159 10 28.8 22.8 21.9 25.8 24.6 27.59 .243 .696 .697 .356 .464 .164 11 26.8 29.6 29.5 27.1 28.4 29.95 .317 .506 .358 .402 .371 .147 12 31.9 31.4 31.6 26.5 29.9 32.46 .335 .391 .386 .414 .388 .183 13 32.6 30.0 30.7 32.3 31.5 36.40 .224 .333 .456 .396 .311 .174 14 - - - 33.2 33.2 39.23 - - - - - .196 Girls 7 - 20.1 21.0 - 20.4 21.2 - .769 .428 - .600 .145 8 20.4 22.6 24.2 20.6 21.5 22.92 .431 .628 .665 .378 .482 .160 9 22.9 22.6 23.7 23.2 23.0 25.00 .349 .728 .586 .508 .509 .156 10 25.2 25.8 27.0 25.4 25.9 27.16 .373 .751 .486 .563 .526 .173 11 27.8 26.7 28.8 28.0 27.8 29.87 .348 .813 .408 .543 .490 .192 12 27.8 28.5 31.6 27.3 28.7 33.32 .468 .616 .532 .468 .549 .225 13 31.5 33.4 32.3 31.7 32.2 37.71 .426 .726 .594 .482 .540 .217 14 - - - 37.0 37.0 41.80 - - - 563 - .216 The enormous gain in weight is not a permanent increase, and is lost on ceasing to attend the school, with its rest and feeding. Many of the children from Shrewsbury House were reweighed on 12th December, and those from Birley House on 16th January, 1909, practically six months from the entrance to the school. The gain in weight can be set out whilst in the school, and also the gain remaining roughly six months after entrance to the school, and compared approximately with the gain of the standard children in that time. The girls retained the weight gained well; the boys fell back considerably but were still above the average, although they started below it. Table showing weights in kilograms, gain in weight whilst in open-air school, and gain about six months after admission, as compared with Council schools generally. Age last birthday. Birley House. Shrewsbury House. London Average. Weight on admission. Gain in weight on leaving. Gain in weight 6 months after admission. Weight on admission. Gain in weight on leaving. Gain in weight 6 months after admission. Weight at middle of year. Gain in weight 6 months later. Boys— 8 21.7 3.0 1.2 23.4 1.4 .4 23.5 .9 9 24.2 2.1 .8 25.3 1.9 1.3 25.5 1.0 10 23.1 2.2 1.6 28.8 1.4 .7 27.6 1.2 11 29.6 2.1 2.4 26.7 1.8 1.3 29.9 1.2 12 32.3 2.4 1.4 31.9 2.2 1.8 32.5 1.7 13 29.4 3.2 2.1 32.6 3.5 1.3 36.4 1.2 Girls— 8 242 3.2 2.8 20.3 1.8 1.5 22.9 .9 9 23.7 2.9 1.6 22.9 1.6 1.3 25.0 1.1 10 27. 6 2.6 1.6 25.6 1.8 1.8 27.2 1.2 11 27.9 2.8 2.1 28.0 2.1 1.5 29.9 1.5 12 31.9 3.5 2.7 27.6 2.8 1.9 33.3 1.9 13 32.3 3.6 2.8 31.5 2.8 2.5 37.7 2.1 At Montpelier House the final weighings of the children were made at the end of February, 1909, and are therefore not tabulated with the others. The standard children are shown compared, and in this school there appears to be a considerable gain retained. 77 Table showing weights in kilograms, gain in weight whilst in open-air school, and gain nine months after admission, as compared with standard children. Age last birthday. Montpelier House. Standard London council school children. Weight on admission. Gain in weight on leaving 21 weeks later. Gain in weight 9 months after admission. Weight in middle of year of age. Gain in weight 9 months later. Boys— 8 25.7 1.8 1.7 23.47 1.4 9 23.0 1.2 1.8 25.46 1.6 10 26.9 1.8 1.8 27.59 1.6 11 27.2 2.3 1.8 29.95 2.1 12 27.9 2.3 2.0 32.46 2.6 13 - - - 3640 2.4 Girls— 8 20.8 1.5 1.8 22.92 1.5 9 22.7 2.0 1.7 25.00 1.7 10 25.1 3.0 2.8 27.16 2.0 11 27.6 3.3 4.0 29.87 2.6 12 25.4 1.9 2.8 33.32 3.0 13 32.3 2.2 3.4 37.71 3.3 Haemoglobin Estimations.- The haemoglobin estimates show definitely that the pallor, which was one of the symptoms which weighed in the selection of children, was the result of considerable anæmia; the boys were more deficient in haemoglobin than the girls, the greatest deficiency being amongst the ten-year-old boys, who were also of such poor physique, deficiency in haemoglobin amounting to 28.4 per cent. The average amount of haemoglobin (100 being taken as normal) in boys was 74, and amongst girls 756, while the actual average increase of haemoglobin amongst boys in six weeks was 4, whilst amongst girls it was 4.75. These estimations are of great value, as whilst weighings show the quantity of increased nutrition, the percentage of haemoglobin to the normal shows the quality of the gain. At Bostall Woods the interval between the estimations was six weeks ; at the other three schools the interval was 16 to 19 weeks, and the increase was greater. In the following account all the numbers relating to haemoglobin refer to Tallquist's scale, in which 100 is taken as the normal. There were great divergencies between the individual schools at the first estimation, varying from 65 among girls at Birley House to 79 amongst boys at Montpelier House. The final estimations, however, were so close (from 82.5 amongst boys at Shrewsbury House to 87 amongst boys at Montpelier House) as to show less than 5 variation in the different groups, this being quite within the margin of unavoidable error. The least average gain (8) was found amongst the boys at Montpelier House, who were best at the outset, and the girls at Shrewsbury House; the highest average gain (23) was amongst girls at Birley House, who were worst at the outset. Table showing percentage of hæmoglobin (normal 100) in open-air school children. School. Number. Hæmoglobin average. Average increase per cent. Number showing decrease. Number stationary. Numbers showing improvement. Admission, June. When school closed, October. Below 10. 10 to 20. 20 and upwards. Montpelier House— Boys 35 79 87 8 2 1 14 16 2 Girls 40 76 86 10 1 1 13 22 3 Shrewsbury House— Boys 33 74 82.5 85 - 1 11 21 - Girls 40 75 83 8 - 2 14 24 - Birley House— Boys 36 68 88 20 - 1 - 7 28 Girls 46 65 88 23 - - - 11 35 Total 230 - - - 3 6 52 101 68 78 Three children showed a decrease in hæmoglobin. G.P., aged 9½, at Montpelier House, fell from 90 on admission to 85. He was a confirmed mouth breather, necessitating an operation for adenoids whilst at the school, which doubtless led to loss of blood; his tendency to mouth breathing was not entirely removed; the operation in addition led to temporary loss of weight, which was more than made up during his subsequent attendance. A.G., aged 11½, fell from 100 hæmoglobin to 90 ; he was the subject of severe heart disease and attended very badly. E.S., aged 11½, fell from 85 to 80 ; she, however, had teeth extracted three days before the first estimation, and suffered considerable bleeding from the gums. Six children remained stationary, 52 children increased up to 10, 102 increased from 10 to 20, and 68 increased 20 and upwards. The Birley House children showed a very great amount of anaemia at entrance ; they came from central and overcrowded parts of Lambeth, and Camberwell, and the improvement made was so great that at the closure of the school their condition was equal to that of the children in the other schools. In a few cases the anaemia was very profound, but nevertheless responded readily to the healthy conditions of open-air life. D.H., aged 9, on admission was in a very bloodless condition, the hæmoglobin estimate being only 30 on the 15th June, the heart was dilated and loud anæmic bruits were heard at each cardiac valve ; on the 26th June the hæmoglobin was again only 30 ; on the 2nd July it had risen to 40, on the 10th July to 60, on the 17th August to 70, on the 31st August to 80, and on 13th October it was 90, the heart was back to its normal size and all the murmurs had disappeared. ,, A.H., aged10¾, on admission was noted to be thin, anæmic and weedy. On the 15th June there was chronic bronchitis noted and the hæmoglobin estimate 60; on the 3rd July hæmoglobin 80 and very little cough ; on the 13th October hæmoglobin 90 and the bronchitis had entirely disappeared. In several other cases at this school an increase of 30 in the haemoglobin estimate was charted, and in each the improvement was accompanied by the disappearance of all the other concomitant signs and symptoms of anaemia. These cases show how greatly open-air schools are likely to benefit the children in the more densely populated areas where slums are unbroken by open spaces. The difficulty in their provision is that of transport. Notes on some of the children who received benefit generally. J.B., girl (Montpelier House), aged 10½. Height on admission 141 c.m., excess 11 c.m. Weight on admission 29'3 kilo., excess 2 kilo. Hæmoglobin 75. Condition on admission (2.7.08): Bodily—thin, overgrown, dilated heart, tonsils and adenoids; mental—very slow and resentful. Weight on leaving, 33'8 kilo. Percentage increase in body weight, 15. Increase in hæmoglobin 10. Condition on leaving (24.10.08): Bodily—Looks much improved, heart normal, still needs attention to tonsils and adenoids ; mental—temper much improved, has begun to make progress. I.H., girl (Montpelier House), aged 11. Height on admission 126 cm., deficiency 5'5 c.m. Weight on admission 21.9 kilo, deficiency 5'6 kilo. Hæmoglobin 75. Condition on admission (2.7.08): Bodily—poorly nourished, small, seven carious teeth; mental—backward, not good tempered, resentful. Weight on leaving 24'9 kilo. Percentage increase in weight 13.7. Increase in hæmoglobin 15. Condition on leaving (24.10.08): Bodily—great improvement in appearance, teeth not done; mental—has gained much self-respect, a better environment would make her a really good girl. G.J., boy (Montpelier House), aged 12½. Height on admission 137 cm., deficiency 2 cm. Weight on admission 27'9 kilo., deficiency 5.1 kilo. Condition on admisson (29.6.08): Bodily—hæmoglobin 75 ; thin, mouth breather, enlarged tonsils, three carious teeth, lateral curvature mentally—indifferent, incapable of making an effort, no ambition. Weight on leaving 30'7 kilo. Percentage increase in body weight 10. (Lost weight in eighth week owing to operation upon tonsils.) Gondition on leaving (26.10.08): Bodily—has done well, increase in hæmoglobin 15, better nourished and can use nose properly ; mental—at first took no part in games, gradually induced to do so, was chosen by boys to be captain, has won a creditable place in the. school, home life is very bad and cheerless. E.S., girl (Montpelier House), aged 8½. Height on admission 117 c.m., deficiency 3 c.m. Weight on admission 20'6 kilo., deficiency 3 kilo. Hæmoglobin 60. Condition on admission (27.6.08): Thin, pale, six carious teeth, backward, cannot read nor calculate. Weight on leaving 22 8 kilo. Percentage increase in body weight 10.5. In crease in hæmoglobin 25. Condition on leaving (26.10.08): Looks greatly improved, teeth not treated, reading much improved, more interested in lessons. M.S., girl (Montpelier House), aged 9½. Height on admission 117 cm., deficiency 7'5 c.m. Weight on admission 20'8 kilo., deficiency 4 kilo. Hæmoglobin 60. Mentally, on admission (27.6.08), backward, very dull, inattentive. Weight on leaving 23.9 kilo. Percentage increase in body weight 10. Increase in hæmoglobin 20. Mental condition on leaving (30.10.08), work much improved, much more attentive. E.S., girl (Montpelier House), aged 10¼. Height on admission 140 cm., excess 9 cm. Weight on admission 27.4 kilo., deficiency .35 kilo. Hæmoglobin 80. Condition on admission (15.7.08): Thin and delicate, some suspicion of phthisis in lungs; Mentally—restless and hysterical. Weight on leaving 31.2 kilo. Percentage increase in body weight 14. Increase in hæmoglobin 5. Condition on leaving (24.10.08): Looks much better in colour and stoutness, great improvement; Mentally—has greatly improved in temper and lost her sulkiness. W.H., boy (Birley House), aged 10½. Height on admission 120 cm., deficiency 8'5 cm. Weight on admission 18.2 kilo., deficiency 8'8 kilo. Condition on admission : Very thin, heart and lungs normal, back muscles weak ; Chest—rickety deformities. Hæmoglobin 80. Weight on leaving 24'9 kilo. Percentage increase in bodyweight 27. Increase in hæmoglobin 10. Gondition on leaving—Much improved. F.G., boy (Birley House), aged 9½. Height on admission 135 cm., excess 10 cm. Weight on admission 27 kilo., excess 1 kilo. Hæmoglobin 70. Weight on leaving 31 kilo. Percentage increase in bodyweight 15. Increase in hæmoglobin 10. E.G., boy (Birley House), aged 8. Height on admission 111 cm., deficiency 7 cm. Weight on admission 19.7 kilo., deficiency 2'8 kilo. Hæmoglobin 60. Pale, thin and debilitated, cervical glands enlarged. Weight on leaving 25.5 kilo. Percentage increase in bodyweight 29. Increase in hæmoglobin 20, glands much smaller. M.L., girl (Birley House) aged 8¾. Height on admission 135 cm., excess 13.5 cm. Weight on admission 27'2 kilo, excess 3.7 kilo. Hæmoglobin on admission 70. Ansemic, slight chorea. Weight on leaving 30 9. Percentage increase in bodyweight 13.5. Increase in hæmoglobin 10. Chorea disappeared. 79 1 C.U., girl (Birley House), aged 13. Height on admission 145 cm., normal for age. Weight on admission 30.6 kilo., deficiency from normal weight 6'5 kilo. Haemoglobin on admission 70. Condition on admission : Anæmio child, enlarged tonsils. Weight on leaving 36 kilos., deficiency from normal 1.5 kilo. Percentage increase in bodyweight at 1.6. Increase in hæmoglobin 20. G., girl (Birley House), aged 13. Height on admission 145 cm., normal. Weight on admission 34'6 kilo, deficiency 2'5 kilo. Haemoglobin on admission 70. Condition on admission: Anaemic and debilitated. Weight on leaving 39.8., excess of normal 2.3 kilo Percentage increase in bodyweight 15. Increase in haemoglobin 10. D.C., girl (Birley House), aged 12¼. Height on admission 136 cm., normal Weight on admission 33'8 kilo., excess 1.3 kilo Haemoglobin on admission 50. Condition on admission: Anaemia, dilated heart, hæmic murmurs Weight on leaving 37.7 kilo. Percentage increase in bodyweight 10.5. Increase in haemoglobin 40. On leaving, heart normal size and in good health. E.R., girl (Birley House), aged 12½. Height on admission 127 cm., deficiency from normal 9 cm. Weight on admission 22.2 kilo., deficiency from normal 10.3 kilo. Haemoglobin on admission 70. Condition on admission: Anaemic, old rickets. Weight on leaving 26'5 kilo Percentage increase in weight 19'9. Increase in haemoglobin 20 B.J., girl (Birley House), aged 9¾. Height on admission 125 cm., normal. Weight on admission 27.9 kilo., excess 2.6 kilo. Haemoglobin 70. Weight on leaving 33.2. Percentage increase in bodyweight 19. Increase in hæmoglobin 30. JAMES KERR, Medical Officer (Education). March, 1909. *