43/3 i^tc TO- London County Council. ANNUAL REPORT OF THE COUNCIL, 1913. VOL. III PUBLIC HEALTH (INCLUDING THE REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER, MAIN DRAINAGE; HOUSING OF THE WORKING CLASSES). Printed for THE LONDON COUNTY COUNCIL. by odhams limited. And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, Ltd., 2 and 4, Great Smith-street, Victoria-street. Westminster, S.W., Agents for the sale of the. publications of the London County Council. 23610 C. 310b CONTENTS. Chapter XXXII. page. Public Health Reports—Report of the County Medical Officer of Health and School Medical Officer for the year 1913—Part I. (Vital Statistics and Administration). Introduction 1 A—Vital Statistics.—Population—Marriages—Births—Deaths—Infantile mortality—Principal epidemic diseases—Smallpox and vaccination—Measles—Scarlet fever—Diphtheria—Whooping-cough—Typhus—Typhoid fever—Diarrhœa and enteritis—Erysipelas—Puerperal feverInfluenza, bronchitis and pneumonia—Phthisis—Cancer—Cerebro-spinal fever—Anterior poliomyelitis—Anthrax—Glanders—Leprosy—Cholera and Plague—Meteorology B—Administration.—Dairies, cowsheds and milkshops—Offensive businesses—Nuisances—Housing of the Working Classes—Underground rooms—Overcrowding—Houses let in lodgings—Death rates in Council's dwellings—Common lodging houses—Seamen's lodging houses—Cleansing of Persons Act, 1897, etc.—Vermin inquiry—Water supply to tenement houses—Revenue Act, 1903—Factory and Workshop Act—Places where food is prepared for sale—Inspection of food—Shelters—Mortuaries—Homeless persons—National Insurance Act, 1911 (Treatment of Tuberculosis)—Health visitors—Water supply—Inspection of theatres, music halls, ctc.—Rag Flock Act, 1911—Midwives Act—Work of the chemical and analytical branch of the Public Health Department 54 Chapter XXXII.(a). Public Health Reports (continued)—Special reports submitted during 1913 by the Medical Officer of Health 87 I.—Census of homeless persons, taken on the night of the 14th February, 1913. II.—Census of homeless persons, taken on the night of 24th October, 1913. Chapter XXXIII. Public He \lth Reports (continued)—Report of the County Medical Officer of Health and School Medical Officer for the year 1913—Part II. (Education). Introductory Note.— Medical inspection and treatment-—" Following up "—Government grant."— Infectious diseases—Personal hygiene scheme—Special reports of school doctors 101 Medical Inspection 108 Medical Treatment—Adjustments in the scheme- —Hospital treatment centres—Dental treatment 135 " Following-up " Re-Inspection Co-operation between School Attendance Officers and the Public Health Department 149 Malnutrition 150 Medical Inspection of Feeding-Centres155 Detection of Early Cases of Tuberculosis156 Exercises for Children Suffering from Physical Defects158 Open-Air Schools— Birley House—Shooter's Hill 109 Playground Classes 173 School Journeys Undertaken during 1913 175 Instruction in Hygiene in Upper Standards of Elementary Schools 182 Teaching of Infant Care 182 Teaching of Sex Hygiene 183 Personal Hygiene—Inspection—Verminous heads—Verminous persons and clothing—Scabies— Children's Country Holiday Fund 183 Flea Prevalence, 1909-13 187 Examination of Candidates—For the permanent service—Teachers and county scholars 188 ii. page, Medical Inspection—(Training colleges, secondary and trade schools) 191 Residential Institutions—Industrial schools—places of detention 193 Infectious Diseases—Scarlet fever—Diphtheria—Measles—Whooping cough—Exclusions from school—Places of detention—Residential, industrial and special schools—Ringworm and favus 195 Schools for Defective Children.—Mentally defective—Physically defective—Deaf and partially deaf—Blind, partially blind and myope 207 Condition of School Buildings 222 Chapter XXXIV. Public Health—Powers and duties—Tuberculosis—Milk—Homeless persons—Common Lodging Houses—Seamen's Lodging Houses—Nuisances—Offensive businesses— Appeal Committee—Midwives—Lying-in Homes—Infant Life Protection—Employment of Children—Diseases of Animals 224 Chapter XXXV. Main Drainage 231 Chapter XXXVI. Housing op the Working Classes 235 Chapter XXXVII. Housing Accounts and Statistics.—Memorandum by the Comptroller (Mr. H. E. Haward) submitting Housing Accounts for the year ending 31st March, 1914—Memorandum by the Housing Manager (Mr. S. G. Burgess), submitting Housing Statistics for the year ended 31st March, 1914 241 Appendixes. I.— Classification of children as to clothing, nutrition, cleanliness and teeth iii. II.—Medical inspection of school children—summary of results (whole county) vii. III.—Medical inspection of school children—results of inspection of entrants, boys and girls (London boroughs) viii. IV.—Medical inspection of school children—results of inspection of boys and girls born in 1905 (London boroughs) ix. V.—Medical inspection of school children—results of inspection of boys and girls born in 1901 (London boroughs) x. VI.—Hospitals and centres at which medical treatment is provided for elementary school children ; and the annual provision made xi. VII.—Re-inspection (first) 1913 xii. VIII.—Re-inspection (first) 1913—Council scheme ailments only xiii. IX.—Re-inspection (second) 1913 xv. X.—Re-inspeotion (second), 1913—Council scheme ailments only XI.—Re-inspections, 1913—final position of all defects xviii. XII.—Re-inspections, 1913—final position of Council scheme defects only xix. XIII.—Re-inspections—results of first re-inspections for the four terms for which figures are available xx. XIV.—Re-inspections—results of second re-inspections for the three terms of 1913 xx. XV.—Re-inspections—final position of all defects—percentage treated xxi. XVI.—Number of candidates examined for the permanent service And the conditions found xxii. XVII.—Number of scholarship candidates examined and the conditions found xxiii. XVIII.—Candidates examined for the teaching profession and the conditions found XIX.—Scholars—Defects noted on medical examination xxv. XX.—Proceedings of sanitary authorities under the Factory and Workshop Act xxvii. iii. page XXI.—Housing accounts— A.—Housing of the Working Classes Act, 1890 xxix. B.—Dwellings under Improvement Acts xxxix. C.—Dwellings under the Housing of the Working Classes Act, 1890, and Improvement Acts combined xlv. D.—Details of Revenue Account— I.—Housing of the Working Classes Act, 1890 .. .. .. xlvii. II.—Dwellings under Improvement Acts .. .. .. .. .. xlix. E.—Percentages on gross rental of the several items of Income and Expenditure in respect of dwellings in D li. F.—Summary of Financial Results— I.—Housing of the Working Classes Act, 1890 liii. II.—Dwellings under Improvement Acts lv. G.—Details of Repairs and Renewals Account lvii. H.—Contributions from and to rates lvii. J.—Capital expenditure on Clearance Schemes under the Housing of the Working Classes Act, 1890 Iviii. K.—Commercial and Housing Values of sites for Working-class Dwellings lix. XXII.—Statutes under which dwellings under Improvement Acts have been erected lx. V XXIII.—Housing Statistics— A.—Number of tenements in the Council's working-class dwellings lxi. B.—Accommodation in the Council's working-class dwellings lxiii. C.—Rents charged in the Council's working-class dwellings Ixix. D.—Accommodation provided and gross rent per annum on 31st March, 1892, and each subsequent year lxxi. E.—Number of persons re-housed (improvement and clearance schemes) lxxi. F.—Lettings effected, tenants transferred or who vacated, 1913-1914 lxxii. G.—Percentage of total outgoings on rent receivable for the last five years lxxiii. H.—Population of the Council's dwellings according to a census taken in March, 1914 Ixxiv. J.—Cases of infectious disease removed from the Council's dwellings, 1913-1914 Ixxv. K.—Births and deaths in the Council's dwellings, 1913-1914 lxxvi. I.Occupations of the Council's tenants lxxvii. Diagrams. facing page Part I. Diagram A.—Marriages, 1851-1913 6 B.—Births, 1851-1913 6 „ C.—Deaths (all causes), 1841-1913 10 „ D.—Infantile Mortality, 1858-1913 13 „ E.—Smallpox (mortality), 1841-1913 18 „ F.—Measles (mortality), 1841-1913 21 „ G.—Measles and Whooping-cough (monthly deaths), 1891-1913 21 „ H.—Scarlet Fever (mortality), 1859-1913 23 „ I.—Scarlet Fever (admissions to hospitals of Metropolitan Asylums Board, percent, of total notified cases in London), 1890-1913 23 „ J.—Scarlet Fever (monthly notified cases and case-mortality), 1891-191323 „ K.—Diphtheria and Croup (mortality), 1859-1913 25 „ L.—Diphtheria (admissions to hospitals of Metropolitan Asylums Board, per cent, of total notified cases in London), 1890-1913 25 „ M.—Diphtheria (monthly notified cases and case-mortality), 1891-1913 25 „ N.—Whooping-cough (mortality), 1841-1913 28 „ O.—Typhus (mortality), 1869-1913 29 „ P.—Enteric Fever (mortality), 1869-1913 31 „ Q.—Enteric Fever (weekly notified cases, 1913, and 1890-1913) 31 iv. facing page Diagram R.—Enteric Fever (monthly notified cases and case-mortality), 1891-1913 .. .. 31 „ S.—Diarrhoea and Enteritis (deaths under 2 years of age per 1,000 births, 1862-1913) 36 „ T.—Phthisis (mortality—males and females), 1851-1913 41 ,, U.—Tuberculosis (death rates in age groups, England and Wales, Ireland, United States and Prussia) .. .. .. .. .. .. .. .. .. 42 ,, V.—Cancer (death-rates in age groups, England and Wales, Ireland, United States and Prussia) .. .. .. .. .. .. .. .. .. .. 46 „ W.—Vermin (seasonal prevalence of three kinds), 1909-191370 Part II. „ A.—Mirror writing—Specimens of handwriting by a child of 9 years of age in Standard I. 120 „ B.—Mirror writing—Examples of right and left hand writing .. 121 ,, E.—Seasonal prevalence of fleas compared with weekly notifications of scarlet fever and diphtheria, 1909-1913 188 „ F.—Scarlet Fever (weekly notifications), 1913 196 „ G.—Diphtheria (weekly notifications), 1913 197 „ H.—Measles (deaths, notified cases and estimated cases), 1907-13, in weekly periods 199 ,, I.—Genealogy of mentally defective children 209 * Maps. C.—Map showing the hospitals and centres at which medical treatment is provided for elementary school children 139 D.—Area served by cleansing stations 185 K.—Distribution of mentally and physically defective children in each electoral area 216 London County Council. ANNUAL REPORT OF THE COUNCIL, 1913. CHAPTER XXXII. report of county medical officer of health and school medical OFFICER (Dr. W. H. Hamer) for the year 1913. Part I.—General. Introduction. The population of the County of London in the middle of the year 1913, as estimated by the Registrar-General, was 4,518,191 persons. The loss of population resulting from outward movement in recent years, which was commented upon in last year's report, is referred to in greater detail this year on page 2. The marriage rate fell slightly, to 183, but with the exception of the rate for 1912, is the highest since 1899. The birth rate was the same as in 1912, namely 24.5, and thus for the first time in ten years no decline is recorded. This fact might be attributed to the effect of certain provisions in the National Insurance Act, but it is worthy of note that a similar pause in the decline of the birth rate in 1913, is observed in certain of the foreign capital towns, such as Paris, Amsterdam and Stockholm. In England and Wales, as a whole, the birth rate increased from 23 8 in 1912 to 23 9 in 1913. The death rate, which was 13.6 in 1912, increased to 14 2 owing to the higher infantile mortality, which rose from 91 to 105. The death rate was nevertheless below the average of the decennium 19011910, and as compared with that period the lower rate of 1913, resulted in a gain of 7,847 lives, or 387,897 years of life. The death rates from the principal epidemic diseases, namely, measles, whooping cough, scarlet fever, diphtheria and typhoid fever showed marked decrease on the average of the preceding five years. There were no deaths from smallpox or typhus. Eight cases of typhus, or suspected typhus, were reported during the year, and are described in detail on page 30 ; certain of them are of special interest as illustrating the difficulty sometimes experienced in determining whether a case is in point of fact one of typhus or of typhoid fever. In last year's report reference was made to experience gained in the campaign against typhoid fever in South-west Germany in recent years ; in the present report a discussion will be found at page 31, of the very important researches of Dr. Houston, Director of Water Examinations, Metropolitan Water Board, concerning the possibility of detecting organisms resembling the typhoid bacillus in raw river water. An increase occurred in the number of cases of scarlet fever, diphtheria and erysipelas, notified during the year, while on the other hand, the number of cases of smallpox, typhoid fever and puerperal fever declined. In some sixteen instances more than one case of puerperal fever occurred in the practice of the same midwife, and the results of investigation into these multiple cases are given in detail at page 39. The phthisis death rate was 130 per 1,000 living, as compared with 135 in 1912. The extent to which London residents suffering from phthisis die outside the area of Greater London is discussed at page 41. The age incidence of tuberculosis mortality in England and Wales is compared with that in Ireland, Prussia, and the registration area of the United States (see diagram U), and the results of an analysis of the figures relating to differences in age-incidence observed in the countries named will be found at page 42. The notification of all forms of tuberculosis became compulsory on the 1st February, 1913, and the resulting data for the County of London as a whole are exhibited and discussed at page 47. One case of human glanders was notified in 1913 and references were found in medical literature to certain other suspected cases ; details relating to these cases are given on pages 51 to 53. In the administrative section of the report a continued decrease has to be recorded in the number of premises requiring to be annually licensed by the Council, including cowsheds, slaughterhouses, offensive trade premises and common lodging houses. Seamen's lodging houses show a slight increase, though there are now only half as many as were in use prior to licensing powers being obtained. A considerable amount of work under the Housing, Town Planning Act, has been done throughout London, especially under the Inspection Regulations. Generally, the defects found have been remedied under the Public Health (London) Act, but owing to the absence of particulars in some of the reports it is impossible to tabulate in a complete form the results of the action taken. In one or two of the reports, too, no information is given as to the work carried out under the regulations made under Section 94 of the Public Health (London) Act, relating to houses let in lodgings. Many of the reports of medical officers of health contain references to the cleansing of verminous persons, houses, and clothing, and it is evident that this important work is receiving an increasing amount of attention. Facing page 70 is included a diagram showing the seasonal prevalence of three kinds of vermin during the five years in which observations with regard to this point have been made. The five years' record shows that distinct improvement has been brought about. Two censuses of homeless persons were made during the year—in February and late October. The figures on both occasions show a large reduction on those previously obtained, and indeed the number of persons enumerated in February last year (649) was less than one-quarter of the number reported in 23610 B 2 Annual Report of the London County Council, 1913. February, 1910 (2,747), when the maximum number was recorded. It should be noted, moreover, that the reduction in the number of homeless persons has been accompanied by a reduction in the numbers of inmates of common lodging houses and casual wards to the extent of more than 1,000 persons since 1910. Both reports have been reprinted in Chapter XXXII.A of this report. On pages 74 to 76 there is reference to the preliminary arrangements made for the treatment of tuberculosis under the National Insurance Act. The complete scheme was only in draft at the end of the year and the action taken subsequently does not come within the period covered by this report. Details of the work carried out under the Midwives Act, 1902, will be found on pages 78 to 85. Towards the end of the year the Council transferred the work of the chemical department to the public health department, together with the staff, excepting that portion engaged exclusively upon gas testing and photography. Details of the work performed by this branch of the department will be found on pages 85 to 86, A.—Vital Statistics. Population. The census populations of London boroughs in 1901 and 1911 and the mid-year population in 1913, as estimated by the Registrar-General, are shown in the following table :— Metropolitan borough. Census Population 1st April, 1901. Census Population 3rd April, 1911. Estimated Population (middle of year 1913). Metropolitan borough. Census Population 1st April, 1901. Census Population 3rd April, 1911. Estimated Population (middle of year 1913). Paddington 143,976 142,551 142,210 Shoreditch 118,637 111,390 109,654 Kensington 176,628 172,317 171,284 Bethnal Green 129,680 128,183 127,824 Hammersmith 112,239 121,521 123,745 Stepney 298,600 279,804 275,300 Fulham 137,289 153,284 157,117 Poplar 168,822 162,442 160,913 Chelsea 73,842 66,385 64,598 Southwark 206,180 191,907 188,487 Westminster, City of 183,011 160,261 154,810 Bermondsey 130,760 125,903 124,739 St. Marylebone 133,301 118,160 114,532 Lambeth 301,895 298,058 297,139 Hampstead 81,942 85,495 86,346 Battersea 168,907 167,743 167,464 St. Pancras 235,317 218,387 214,330 Wandsworth 231,922 311,360 330,395 Islington 334,991 327,403 325,585 Camberwell 259,339 261,328 261,805 Stoke Newington .. 51,247 50,659 50,518 Deptford 110,398 109,496 109,280 Hackney 219,110 222,533 223,353 Greenwich 95,770 95,968 96,015 Holbom 59,405 49,357 46,949 Lewisham 127,495 160,834 168,822 Finsbury 101,463 87,923 84,679 Woolwich 117,178 121,376 122,382 London, City of 26,923 19,657 17,916 London 4,536,267 4,521,685 4,518,191 Movement of the London population in recent years. Movement of the London population in recent years.— The marked change in the age-constitution of the London population during the past twenty years was commented upon in the second London life-table (see Appendix III., Annual Report of County Medical Officer, 1912, p. 106), where it is suggested that the change is due mainly to the outward movement of the population over the county boundary, and, so far as the earlier ages are concerned, to the diminution in the birthrate since the eighties. Local migration is, however, the more important factor, since variations in the number of births are largely the result of the local movement of population. As a standard by number of births are largely the resu t of the local movement of pop ulation. As a standard by which to measure the effect of local migration upon the age-constitution of the population, the changes during the last twenty years in England and Wales as a whole may be taken ; and the figures for this area are compared with those for London in the following table, which shows the increase (+) or decrease (—) in the population at age-groups in the two areas in the twenty years intervening between the census of 1891 and that of 1911. Males. Females. London. England and Wales. London. England and Wales. 0— — 15,608 + 161,051 — 20,389 +139,842 5— — 10,854 + 153,923 — 11,383 + 147,695 10— — 8,074 + 136,773 — 8,117 + 139,348 15— — 4,939 + 189,720 — 8,107 + 196,036 20— — 3,879 +255,306 + 2,392 +274,000 25— + 28,721 +742,645 + 46,951 +835,862 35— + 46,861 +725,431 + 58,639 +791,644 45— + 40,231 +502,544 + 44,628 +528,851 55— + 32,516 +315,032 + 30,225 +326,350 65— + 17,641 +157,868 + 19,972 +212,637 75 + + 5,467 + 44,914 + 10,156 + 90,495 Report of the County Medical Office—General. 3 These figures relate to the County of London as a whole, but London is divided by the Thames into two areas in which the character of the local movement is altogether different. London north of the Thames was in 1891 already so largely built upon that the steadily increasing population could not be accommodated within the county boundary; and, as a consequence, there has been since then a continual movement of population from northern London into the adjacent counties of Middlesex and Essex. On the south side of the Thames, however, there was in 1891 so large a proportion of the area undeveloped that the outward extension has not overflowed the county boundary during the period in Question to anything like the same extent as on the north side. The figures for the county deserve, therefore, to be shown for these two areas separately, and are as follows :— Age-group. Males. Females. London. North of the Thames. London. South of the Thames. London. North of the Thames. London. South of the Thames. 0— —19,196 + 3,588 —23,435 + 3,046 5— —16,205 + 5,351 —16,954 + 5,571 10— —14,479 + 6,405 —14,648 + 6,531 15— —12,410 + 7,471 —14,560 + 6,453 20— —10,693 + 6,814 — 7,968 + 10,360 25— + 14 +28,707 +11,386 +35,565 35— + 12,832 +34,029 +21,005 +37,634 45— + 14,943 +25,288 +17,381 +27,247 55— + 13,707 + 18,809 +10,829 +19,396 65— + 7,747 + 9,894 + 7,740 + 12,232 75 + + 2,314 + 3,153 + 4,199 + 5,957 The changes north of the Thames are in marked contrast to those in the southern area, the figures for the latter being, as would be expected for the reasons mentioned above, much more similar in character to those for England and Wales. If, however, there be added to the northern area those extra-London districts into which the outward movement has chiefly taken place, namely the registration county of Middlesex and the districts of West Ham, Epping and Romford in Essex, a grouped northern population is obtained which exhibits changes generally comparable with those in England and Wales:— Age-group. Males. Females. 0— +31,110 + 24,803 5— +31,899 + 30,584 10— +29,216 + 30,431 15— +29,374 + 30,648 20— +25,391 + 39,096 25— +86,422 +114,925 35— +91,526 +108,900 45— +67,533 + 76,205 55— +44,757 + 46,507 65— +22,884 + 28,985 75— + 7,091 + 13,072 The figures given above exhibit approximately the relation between the balance of inward and outward movement in London and in England and Wales respectively. If the population which had moved into London in the period under consideration had been similar in age-constitution and equal in number to that lost, the resulting changes in London would have been almost identical with those shown in England and Wales. The section of the general population, however, which would be most affected by the absence of additional accommodation within the northern area of London would naturally consist of families of increasing size, i.e., the families of younger married persons ; and it is evident from the northern figures that the balance of movement has in fact resulted in loss of the younger population, the loss being progressively less with advancing age. It is, moreover, evident from the figures shown for London north of the Thames, that at ages 20-45, and more especially 25-35, there is a very considerable difference between the sexes in the balance of inward and outward movement, the males at this age having only increased by 14 while the females have increased by 11,386. The explanation is that London attracts females of this age in greater degree than males. This fact is clearly apparent from the diagram at page 110 of last year's Annual Report, which shows that at about this age the female population in London is more greatly in excess of the male population than at any other period of life ; and from figures given in volume vii. of the 1911 census (pp. 1 and 13), it is seen that while in England and Wales the number of females aged 24-25 exceeded the males of the same age by 12.1 per cent., the corresponding excess in London was 24.7 per cent. 23610 2 4 Annual Report of the London County Council, 1913. The conclusions thus arrived at from consideration of the changes in age-constitution of the London population in the twenty years 1891 to 1911 are in general agreement with the census of birth places of the population as recorded in 1911. The following figures, abstracted from volume ix. of places of the population as recorded in 1911. The following figures, abstracted from volume ix. ofracted from volume ix. of the 1911 census (pp. xxv. and xxvi.), show the age-constitution per 1,000 males and per 1,000 females of persons (i.) enumerated in London born elsewhere (immigrants) and (ii.) born in London enumerated elsewhere (emigrants) : Age-group. Maids. Females. Immigrants. Emigrants. Immigrants. Emigrants. 0— 185 311 165 265 20— 92 91 98 88 25— 204 197 216 203 35— 189 174 184 180 45— 152 115 146 124 55— 101 68 98 77 65— 58 33 64 45 75 + 19 11 29 18 All ages . 1,000 1,000 1,000 1,000 It is unfortunate that the age-group 0-20 has not been further subdivided; it would naturally be expected that among the 185 per 1,000 of male immigrants there would be a greater proportion of males aged 15-20 than among the 311 per 1,000 males emigrating from London, and thus the disproportion between the percentage of children added by the immigrant population would be even more marked than the aggregate age-group 0-20 shows. The same remark would apply in even greater degree to females, in view of the considerable influx of domestic servants aged 15-20. In the same volume of the census, the proportion of foreign-born population in London is shown (table 3, p. 136). North of the Thames there were 151,459 foreign-born inhabitants as compared with 22,574 south of the Thames, The northern area, therefore, receives the greater proportion of foreigners, 22,574 south of the Thames, The northern area, therefore, receives the greater proportion of foreigners, and as this area is practically built over, the immigrant foreigners must almost necessarily displace the native population, as will be seen from the following table :— Birth-place. North of the Thames. South of the Thames, Per cent. Per cent. London 66.6 70.7 Elsewhere in U.K. and Colonies 27.8 28.1 Foreign countries 5.6 1.2 The age-constitution of the foreign-bom population of London per 1,000 of each sex deduced from figures given on page 251 of the same census volume is as follows:— Age-group. Foreign immigrants. Males. Females. 0— 140 153 20— 144 131 25— 277 269 35— 200 197 45— 128 129 55— 67 72 65— 33 36 75 + 11 13 All ages 1,000 1,000 If these figures be compared with those for all immigrants, given above, it will be noticed that while the males and females of each age-group are fairly balanced there is a relatively marked deficiency in children and persons over 45, compensated for by the excess in the number at wage-earning ages. Report of the County Medical Officer—General. 5 Alien immigration.—In 1913 there was a considerable increase in the number of foreigners settling in London as compared with the previous year, the alien passengers landed in the Port of London from European and Mediterranean ports being 5,450 as against 3,726 in 1912. The increase is mainly among the Russian immigrants, who numbered 3,569, as compared with 2,145 in 1912, an increase of nearly 70 per cent. There was, however, in 1913 a renewed activity in the general movement from Russia, the recorded number of Russian immigrants into the United States of America being about 80 per cent, greater than in 1912 ; and it does not, therefore, appear that the increase in Russian immigrants to London is due to any special local cause. The proportion of immigrants of British nationality refused admission, or deported after admission, to the Colonies or the United States, varies considerably ; on an average of the five years 1909-1913 there were 2.1 per cent, rejected by the United States, 0.4 per cent, by Canada, 0.06 per cent, by Cape Colony, and 0.04 per cent, by Australasia. More than half those rejected by the United States were described as paupers or likely to become a public charge. Disease and defective mental condition caused the rejection of 0.28 per cent, by the United States, 0.17 per cent, by Canada, and 0.04 per cent, by Australasia. Alien immigration Natural Increase.—The following table shows the mean annual rate of " natural increase " of the population per 1,000 living in certain periods from 1886 to 1913 :— With a view to a proper understanding of this table it may be well here to state that the observed rate of increase in the population is dependent upon two causes (i) the difference between the numbers of births and deaths described as "natural increase," and (ii) the difference in the numbers of emigrants and immigrants generally referred to as " the balance of passenger movement." The rate of natural increase, therefore, is the rate that would obtain in a population whose numbers are undisturbed by migration. Period. Annual birth-rates per 1,000 living. Annual death-rates per 1,000 living. Annual rate of natural increase per 1,000 living. London. Greater London. (a) England and Wales. London. Greater London. (a) England and Wales. London. Greater London. (a) England and Wales. 1886-1890 1891-1895 1896-1900 1901-1905 1906-1910 1906 1907 1908 1909 1910 1911 1912 1913 32.106 30.766 29.666 28.556 26.526 27.656 26.896 26.716 25.836 25.546 24.786 24.486 24.536 31.97 30.46 29.31 28.57 26.28 27.52 26.75 26.53 25.58 25.02 24.42 23.84 23.90 31.44 30.48 29.27 28.15 26.22 27.17 26.40 26.70 25.78 25.04 24.37 23.82 23.88 19.69c 19.82c 18.51c 16.41c 14.88c 15.75c 15.34c 14.64c 14.99c 13.69c 15.04c 13.55c 14.16c 18.68 18.49 17.23 15.14 13.72 14.66 14.18 13.56 13.76 12.44 13.83 12.25 12.79 18.89 18.71 17.69 16.03 14.68 15.44 15.07 14.78 14.60 13.49 14.60 13.29 13.68 12.41 10.94 11.15 12.14 11.64 11.90 11.55 12.07 10.84 11.85 9.74 10.93 10.37 13.29 11.97 12.08 13.43 12.56 12.86 12.57 12.97, 11.82 12.58 10.59 11.59 11.11 12.55 11.77 11.58 12.12 11.54 11.73 11.33 11.92 11.18 11.55 9.77 10.53 10.20 Natural increase of the population. The following table enables comparison to be made of the rates of "natural increase" of the London population with those of the principal towns of England in the period 1908-12, and in the year 1913. Town. 1908-12. 1913. Town. 1908-12. 1913. London in (b c) 10.4 (b c) Bradford 46 4-7 Greater London 11-9 (a) 11-1 (a) Hull 135 133 Liverpool 11-9 12-1 Newcastle-on-Tyne 12-9 121 ' Manchester 10-2 10-4 Nottingham 10-0 8-6 Birmingham 125 12-6 Stoke-on-Trent 14-5 12-8 Sheffield 13 7 12-4 Portsmouth 121 12-2 Leeds 91 8-1 Salford 111 10-9 Bristol 9-2 9-8 Leicester 101 9-3 West Ham 155 16-5 Hates of natural increase in large English towns. (a), (b and (c) see footnotes next page. Rates of natural increase in foreign towns. 6 Annual Report of the London County Council, 1913. The factors affecting the rates of natural increase in the different localities probably tend more to vitiate accurate comparison when the populations concerned are of different nationalities, and this should be borne in mind in connection with the following table showing the rate of increase in London and certain foreign towns (d) :— Town. 1908-12 1913. Town. 190S-12. 1913. London 11.1 (bc) 10.4 [b c) Stockholm 8.9 8.0 Paris 0.6 1.5 Petrograd 3.8 4.3 Brussels 2.9 3.9 Berlin 6.5 5.5 Amsterdam 11.0 12.0 Vienna 4.5 1.6 Copenhagen 11.5 10.4 New York 11.5 11.7 It will be noticed that the excess of births over deaths in 1913 is above the average of the preceding five years in Paris, Brussels, Amsterdam, Petrograd and New York. These rates can only be regarded as approximate, and in making comparison of one town with another it should be borne in mind that full correction for births and deaths in institutions might considerably modify the rates of some of the towns. Marriagerates— London. Marriages. The number of marriages in the Administrative County of London in 1913, was 41,379 (365 days) giving an annual rate of 18.3 persons married per 1,000 living. The marriage-rate in successive periods has been as follows— Period. Marriage-rate per 1,000 persons living. Period Marriage-rate per 1,000 persons living. 1851-1860 20.6 1904 17.5 1861-1870 20.3 1905 17.5 1871-1880 19.1 1906 17.9 1881-1890 17.6 1907 17.9 1891-1900 17.8 1908 16.9 1901-1910 17.5 1909 16.9 1910 17.3 1901 17.7 1911 17.8 1902 18.0 1912 18.6 1903 17.8 1913 18.3 The accompanying diagram (A) shows the marriage-rate in each year since 1850, in relation to the mean marriage-rate of the period 1851-1913. It will be seen that in recent years the highest marriage-rates were attained in 1882, 1891 and 1898 ; the rate then fell to a minimum of 16'9 in 1908 and 1909 (the point previously touched in 1887 and 1888) and has since shown recovery to 18 6 in 1912 and 18 3 in 1913. marriages of minors. In the year 1913 among males 3.3 per cent, married were under 21 years of age, and among females 11.8 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 (а) Greater London is the administrative area of the Metropolitan and City police. (б) For the purposes of these rates the births in the principal lying-in institutions have been distributed to the district to which they belong. (c) These death-rates are fully corrected for institutions, 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. Since the year 1910, the deaths have been further corrected by the inclusion of non-institutional deaths of London residents occurring in the outer Ring of Greater London. (d) All rates in this report relating to foreign towns are calculated upon figures published by the Registrar- General. Diagram A. Marriages. (LONDON) Diagram B. Births. (LONDON) Report of the County Medical Officer—General. 7 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, but there is some indication of a pause in the decline :— Period. Marriages of minors per cent, of total marriages. Loudon. England and Wales. Males. Females. Males. Females. 1851-1860 2.8 11.9 5.7 18.0 1861.1870 3.6 14.6 6.8 20.4 1871.1880 4.7 16.9 8.0 22.0 1881.1890 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 13.0 4.4 14.7 1906 3.5 12.9 4.3 14.6 1907 3.2 11.8 4.1 14.2 1908 2.9 11.3 4.0 14.0 1909 3.1 11.1 4.0 13.7 1910 2.9 10.8 3.8 13.3 1911 3.1 10.9 3.9 13.3 1912 3.1 11.2 3.9 13.5 Births. The number of births in the Administrative County of London in 1913 (53 weeks) was 112,637, giving a birth-rate of 24.5 per 1,000 persons living per annum. The birth-rate in successive periods has been as follows:— Period. Birth-rate per 1,000 persons living. Period. Birth-rate per 1.000 persons living. 1851-1860 33.6a 1904 28.56 1861-1870 35.4a 1905 27.96 1871-1880 35.4a 1906 27.66 1881-1890 33.2 1907 26.96 1891-1900 30.26 1908 26.76 1901-1910 27.56 1909 25.86 1910 25.56 1901 28.96 1911 24.86 1902 28.76 1912 24.56 1903 28.83 1913 24.56 Birth-rates— London. The corresponding figures for England and Wales, which show a decline generally similar to that noted in London, are as follows :— Period. Birth-rate per 1,000 persons living. Period. Birth-rate per 1,000 persons living. 1851.1860 34.la 1904 28.0 1861-1870 35.2a 1905 27.3 1871-1880 35.4a 1906 27.2 1881-1890 32.4 1907 26.5 1891-1900 29.9 1908 26.7 1901-1910 27.2 1909 25.8 1910 25.1 1901 28.5 1911 24.4 1902 28.5 1912 23.8 1903 28.5 1913 23.9 Birth-rates— England and Wales. The following table enables comparison to be made of the birth-rate in London and Greater Birth-rates London with that of the chief towns of England ; it should be borne in mind, however, that the London in large figures alone are fully corrected (i.e., by the exclusion of births within the County to mothers not usually towns. (a) The registration of births was not male compulsory until the beginning of 1875 ; before that year many births were probably unregistered. (b) See footnote (b), page 6. 8 Annual Report of the London County Council, 1913. resident in London). Were similar correction made in other towns considerable modification of the rates shown might result. Town. 1908-12. 1913. Town. 1908.12. 1913. London 25.5a 24.5a Bradford 19.4 19.7 Greater London 25.1 23.9 Hull 29.2 28.0 Liverpool 31.0 30.0 Newcastle-on-Tyne 28.5 27.1 Manchester 27.3 25.9 Nottingham 25.4 22.7 Birmingham 28.3 27.3 Stoke-on-Trent 32.6 31.4 Sheffield 29.0 28.2 Portsmouth 25.5 24.4 Leeds 24.6 23.6 Salford 28.4 26.7 Bristol 23.0 22.5 Leicester 23.5 22.6 West Ham 30.4 310 Birth-rates in foreign towns It will be seen from the following table that the decrease in birth-rate apparent in London is shared by all the chief foreign capitals; but that the London birth-rate compares not unfavourably with that of many of the largest of these capital towns. There is considerable difference in practice a; to the registration and allocation of births occurring in the several towns, and the rates shown must therefore, be regarded as affording material for only approximate comparison. Town. 1908-12. 1913. Town. 1908-12. 1913. London 25.5 24.5 Stockholm 23.0 21.1 Paris 17.3 17.4 Petrograd 27.8 25.7 Brussels 16.8 15.9 Berlin .. 21.5 19 2 Amsterdam 23.4 23.4 Vienna .. 20.9 17.1 Copenhagen 26.3 24.1 New York 27.1 25. 7 Birth rates in London sanitary districts. The diagram (B) facing page 6 shows the London birth-rate in each year since 1850, in relation to the mean birth-rate of the period 1851-1913. In connection with this diagram it should be noted that the registration of births was not made compulsory until the beginning of 1875 ; before that year many births were probably unregistered. From the year 1885 onwards the number of births has been corrected as far as possible by the exclusion of those which occurred in the chief lying-in institutions in cases where the mother resided outside the Countv of London. The following table shows the birth-rate in the several sanitary districts per 1,000 persons living in the period 1908-12 and in the year 1913:— Metropolitan borough. Births, 1913 (53 weeks). (a) Birth-rate per 1,000 persons living. (a) 1908-12. 1913. Paddington 3,055 21.9 21.1 Kensington 3,357 19.3 19.3 Hammersmith.. 3,043 24.8 24.2 Fulham 4,302 28.4 26.9 Chelsea 1,257 20.4 19.1 Westminster, City of 2,227 15.9 14.2 St. Marylebone 2,221 20.9 19.1 Hampstead 1,326 15.5 15.1 St. Pancras 5,512 25.6 25.3 Islington 8,357 25.4 25.3 Stoke Newington 1.144 20.4 22.3 Hackney 5,522 24.0 24.3 Holborn 798 19.5 16.7 Finsbufy 2,547 31.2 29.6 London, City of 167 12.1 9.2 Shoreditch 3,513 32.2 31.5 Bethnal Green 3,998 32.0 30.8 Stepney 8,187 32.7 29.3 Poplar 5,230 31.7 32.0 Southwark 5,936 30.3 31.0 Bermondsey 3,896 31.8 30.7 Lambeth. 7,233 24.9 23.9 Battersea 4,239 26 4 24.9 Wandsworth 6,840 22.8 20.4 Camberwell 6,671 25.3 25.1 Deptford 3,103 27.6 27.9 Greenwich 2,541 25.5 26.0 Lewisham 3,522 21.9 20.5 Woolwich 2,893 23.9 23.3 London 112,637 25.4 24.5 It will be seen from the above table that the birth-rates of the several sanitary districts vary greatly, ranging, when the rates for the year 1913 are compared, from 9.2 in the City of London, to 32.0 in Poplar. (a) See footnote (b), page 6, Report of the County Medical Officer—General. 9 Under the Notification of Births Act, 1907, the London County Council receives particulars Notification of the births which have been notified to the medical officers of health of the several sanitary of births, districts in London, and from the information thus recpived the following table has been prepared :— Metropolitan borough. Total births notified (corrected lor institutions). Stillbirths (corrected). Births less still-births (corrected). Births registered (corrected). Excess of registered over notified births (corrected). Paddington 3,120 74 3,046 3,055 + 9 Kensington 3,129 95 3,034 3,357 + 323 Hammersmith 2,590 46 2,544 3,043 + 499 Fulham 3,505 124 3,381 4,302 + 921 Chelsea 1,055 28 1,027 1,257 + 230 Westminster, City of 1,615 41 1,574 2,227 + 653 St. Marylebone 2,342 75 2,267 2,221 — 46 Hampstead 1,292 25 1,267 1,326 + 59 St. Pancras 5,158 144 5,014 5,512 + 498 Islington 7,589 210 7,379 8,357 + 978 Stoke Newington 995 25 970 1,144 + 174 Hackney 5,710 144 5,566 5,522 — 44 Holborn 751 27 724 798 + 74 Finsbury 2,772 46 2,726 2,547 — 179 London, City of 149 5 144 167 + 23 Shoreditch 3,298 72 3,226 3,513 + 287 Bethnal Green 3,932 109 3,823 3,998 + 175 Stepney 8,250 254 7,996 8,187 + 191 Poplar 4,871 107 * 4,764 5,230 + 466 Southwark 6,140 161 5,979 5,936 — 43 Bermondsey 3,739 54 3,685 3,896 + 211 Lambeth 6,912 205 6,707 7,233 + 526 Battersea 3,722 72 3,650 4,239 + 589 Wandsworth 4,774 114 4,660 6,840 + 2,180 Camberwel 5,897 151 5,746 6,671 + 925 Deptford 3,112 66 3,046 3,103 + 57 Greenwich 2,634 51 2,583 2,541 — 42 Lewisham 3,577 96 3,481 3,522 + 41 Woolwich 2,784 77 2,707 2.893 + 186 London 105,414 2,698 102,716 112,637 + 9,921 The number and percentage of still-births and of multiple births notified in 1913 (uncorrected for institutions) is shown in the following table :— Metropolitan borough. Total births notified. Still-births. centage still born. Multiple births. Percentage of mothers delivered of more than one child at a birth. Twins. Triplets. Total born. Cases. Stillborn. Cases. Stillborn. One- both. One. Two. Three Paddington 2,890 64 2.21 47 2 1 — — — — 94 1-65 Kensington 3,129 95 3.00 34 5 — — — — — 68 109 Hammersmith 2,515 42 1.67 14 3 — — — — — 28 0-56 Fulham 3,422 121 3.53 25 10 15 — — — 50 0-73 Chelsea 1,019 25 2.45 13 1 1 — 26 1-29 Westminster, City of 1,481 37 2.50 15 2 — — — — — 30 102 St. Marylebone 3,823 146 3.81 57 4 4 3 1 — — 123 1-59 Hampstead 1,243 24 1.93 15 1 1 — — — — 30 .1-22 St. Pancras 4,733 135 2.85 41 6 1 1 — — — 85 0-90 Islington 7,283 197 2.70 82 9 4 3 1 — — 173 1-18 Stoke Newington 982 23 2.34 12 1 — — — 24 1-24 Hackney 5,710 144 2.52 73 8 4 _ — — 146 1-29 Holborn 809 25 3.09 11 1 1 — 22 1-38 Finsbury 3,307 58 1.75 48 3 1 1 — — — 99 1-50 London, City of 363 19 5.23 2 1 — — — — — 4 0-55 Shoreditch 3,119 66 2.11 17 4 1 2 40 061 Bethnal Green 3,854 108 2.80 45 5 2 — 96 1-23 Stepney 8,483 254 2.99 118 8 5 — — — 236 1-41 Poplar 4,746 106 2.23 72 3 — — — — — 144 1-54 Southwark 6,140 161 2.62 75 7 1 — 153 1-25 Bermondsey 3,730 54 1.45 40 2 4 1 — — — 83 111 Lambeth 7,256 216 2.97 101 7 1 2 l — 208 1-44 Battersea 3,729 77 2.06 35 1 1 70 0-95 Wandsworth 4,732 108 2.28 53 3 1 1 109 115 Camberwell 5,897 151 2.56 89 5 1 — 181 1-55 Deptford 3,105 66 2.12 34 4 — — — 68 111 Greenwich 2,631 51 1.94 24 1 2 48 0-92 Lewisham 3,570 95 2.66 38 3 76 1-07 Woolwich 2,783 77 2.78 27 - 1 — 54 0-98 London 106,484 2,745 2 58 1,257 106 50 18 3 — — 2,568 121 Still-births and multiple births in 1913. 23610 0 10 Annual Report of the London County Council, 1913. Death-rates all causes Deaths. The number of deaths in the Administrative County of London in 1913 (53 weeks) was 65,030 giving an annual death rate of 14.2 per 1,000 of the estimated population. The death-rate in successive periods has been as follows :— Period. Death-rate (All Causes) per 1,000 persons living. Period. Death-rate (All Causes) per l,000persons living. 1841-1850 24.8 1904 16.5a 1851-1860 23.7 1905 15.6a 1861-1870 24.4 1906 15.8a 1871-1880 22.5 1907 15.3a 1881-1890 20.3 1908 14.6a 1891-1900 19.2a 1909 15.0a 1901-1910 l5.7a 1910 13.7a 1901 17.2a 1911 15.0a 1902 17.4a 1912 13.6a 1903 15.4a 1913 14.2a The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1913 is shown in diagram (C). ihe 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 1911. 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 1912. Town. Estimated Population (middle of 1913). Crude death-rate per 1,000 persons living. Death-rate per 1,000 persons living (corrected for age and sex distribution). Comparative mortality figure. 1908-12. 1913. 1908-1H. 1913. 1913. England & Wales 36,919,339 1415 13-68 13-85 13.39 9.46 London 4,518,191 14.38 14.16 14.38 14.16 1,000 Liverpool 756,553 19.11 17.94 19.73 18.52 1,308 Manchester 730,976 17.13 15.56 18.50 16.80 1,186 Birmingham 859,644 15.81 14.71 16.50 15.35 1,084 Sheffield 471,662 15.38 15.74 16.18 16.56 1,169 Leeds 457,295 15.48 15.41 16.40 16.33 1,153 Bristol 361,362 13.74 12.68 13.51 12.47 881 West Ham 294,223 14-8J 14-50 15-28 14-88 1,051 Bradford 290,540 14-85 14-94 15-67 15-76 1,113 Hull 287,032 15-61 14-77 15-70 14-85 1,049 Newcastle-on-Tyne 271,295 15-59 1505 16-41 15-84 1,119 Nottingham 264,735 15-47 1414 15-61 14-27 1,008 Stoke-on-Trent 239,284 18'06 18-65 19-26 19-89 1,405 Portsmouth 241,256 13-39 12-23 13-24 12-09 854 Salford 233,849 17-35 15*99 18-61 16-94 1,196 Leicester 280,970 13-39 13-33 13-77 13-71 968 Death-rates in large English towns. London had therefore (comparing the corrected death-rates) both in the quinquennium 19081912 and in the year 1913 a lower death-rate than any of these towns except Bristol, Portsmouth, and Leicester. The following table enables comparison to be made of the crude death-rate of London with that of several foreign towns :— Town. 1908-12. 1913. Town. 1908-12. 1913 London 14.4a 14.2 Stockholm 141 131 Greater London 13.2 12.8 Petrograd 24.0 21-4 Paris 17.0 15.9 Berlin 15-0 13-7 Brussels 13.9 12.0 Vienna 16-4 15-5 Amsterdam 12.4 11.4 New York 15-6 140 Copenhagen 14.8 13.7 Death-rates in foreign towns. (a) See footnote (c), page 6. Diagram C. Deaths (all Causes) (LONDON) Report of the County Medical Officer—General. 11 It will be seen from the foregoing table that in the quinquennium 1908-12 the London death-rate was exceeded by the death-rates of Paris, Copenhagen, Petrograd, Berlin, Vienna, and New York, and in 1913 was only exceeded by that of Paris, Petrograd and Vienna. The following table shows the mean death-rates obtaining in London at the several age-groups and for each sex in the decennium 1901-1910 and in the year 1913. Age-group. Males. Females. Mean deathrate 1901-1910. Death-rate 1913. Difference per cent. Mean deathratel901-1910. Death-rate 1913. Difference per cent. 0— 53.61 40.73 —24.03 45.71 33.85 —25.95 5— 3.47 3.24 — 6.63 3.48 2.88 —17.24 10— 1.99 1.97 — 1.01 2.04 2.08 + 1.96 15— 2.88 2.93 + 1.74 2.40 2.48 + 3.33 20— 3.81 3.41 —10.50 2.77 2.51 — 9.39 25— 5.72 5.22 — 8.74 4.19 3.53 —15.75 35— 10.97 9.88 — 9.94 8.12 6.85 —15.64 45— 19.37 18.72 — 3.36 13.93 13.12 — 5.81 55— 35.00 34.56 — 1.26 25.90 24.35 — 5.98 65— 69.10 69.32 + 0.32 54.62 53.11 — 2.76 75— 140.88 150.41 + 6.76 119.76 121.60 + 1.54 85 + 290.54 284.69 — 2.01 258.54 250.41 — 3.14 All ages 16-98 15-72 —7 42 14 34 13 00 —9.34 Death-ratea in London— age and sex distribution. It will be seen from this table that the rate of mortality in 1913 was lower than that of the period 1901-1910 at each age-period of life and for each sex, except among males aged 15-20, 65-75 and 75-85, and among females aged 10-20 and 75-85. Fluctuations of mortality. 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 those age-groups to which the deaths relate. The following table shows the results thus obtained from table, which has been newly calculated on the basis of the mortality in the years 1901appendix III., p. 105, Annual Report of County Medical Officer, 1912.) Age-group. Mean future lifetime, 1901-1910. Age-group. Mean future lifetime, 1901-1910. Males. Females. Males. Females. Years. Years. Years. Years. 0— 54.43 58.24 35— 25.90 29.04 5- 52.88 56.72 45— 19.18 21.72 10— 48.47 52.38 55— 13.34 15.16 15— 44.02 47.93 65— 8.60 9.70 20— 39.72 43.52 75— 5.15 5.74 25— 33.52 37.06 85 + 2.93 3.22 In the following table the number of deaths occurring in the year 1913 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 1901-1910 been maintained in that year. The number of lives thus shown to have been gained in 1913 is also given, 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 the preceding table to the number of lives gained at each age-group :— Age-greup. Deaths calculated according to mean death-rates of 1901-1910. Deaths occurring in the year 1913. Gain (+) or loss (—) of lives in the year 1913, by fluctuations of mortality. (+) or loss (—) of " life capital" in the year 1913 by fluctuations of mortality. Males. 0— 12,565 9,547 + 3,018 + 164,270 5— .749 699 + 50 + 2,644 10— 396 392 + 4 + 194 15— 556 565 — 9 — 396 20— 727 650 + 77 + 3,058 25— 2,078 1,897 + 181 + 6,067 35— 3,222 2,901 + 321 + 8,314 45— 4,142 4,004 + 138 + 2^647 55— 4,604 4,547 + 57 + 760 65— 4,712 4,727 — 15 — 129 75— 2,655 2,835 — 180 — 927 85 and upwards .. 651 638 + 13 + 38 All Ages—Males .. 37,057 33,402 + 3,655 + 186,540 23610 c 2 12 Annual Report of the London County Council, 1913. Age-group. Deaths calculated according to mean death-rates of 1901-1910. Deaths occurring in the year 1913. Gain ( +) or loss (—) of lives in the year 1913, by fluctuations of mortality. Gain ( +) or loss (—) of " life capital " in the year 1913 by fluctuations of mortality. Females. 0— 10,635 7,877 + 2,758 + 160,626 5— 757 627 + 130 + 7,374 10— 414 422 — 8 — 419 15— 509 526 — 17 — 815 20— 658 596 + 62 + 2,698 25— 1,810 1,525 + 285 + 10,562 35— 2,703 2,279 + 424 + 12,313 45— 3,353 3,157 + 196 + 4,257 55— 3,974 3,736 + 238 + 3,608 65— 5,054 4,914 + 140 + 1,358 75— 4,008 4,069 — 61 — 350 85 and upwards .. 1,425 1,380 + 45 + 145 All Ages—Females 35,300 31,108 + 4,192 + 201,357 Total—Persons 72,357 64.510 + 7,847 + 387,897 It will be seen from the preceding table that during the year 1913, compared with the decennium 1901-1910, there has been a saving of 7,847 lives, representing a gain to the community of 387,897 vears of " life-capital." Death-rates in LondoD boroughs. ihe 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 1913, and for the period 1908-12 (a). Area. Factor for correction for age and sex distribution. Crude death-rate per 1,000 persons living. Corrected deathrate per 1,000 persons living. Corrected comparative mortality figure (London, 1,000). 1908-12. 1913. 1908-12. 1913. 1908-12. 1913. England and Wales 0.9790 14.2 13.7 13.9 13.4 965 944 London 1 0000 14.4 14 2 14.4 14. 2 1,000 1,000 Paddington 0.9941 130 13.4 12.9 13.4 896 944 Kensington 0.9957 13.4 13.7 13.3 13.6 924 958 Hammersmith 0.9884 14.2 13.9 14.0 13.8 972 972 Fulham 1.0340 13.6 12.5 14.1 12.9 979 908 Chelsea 0.9513 15.2 13.9 14.5 13.2 1,007 930 Westminster, City of 1.0540 12.6 12.7 13.3 13.3 924 937 St. Marvlebone 1.0198 14.5 140 14.7 14.3 1,021 1,007 Hampstead 1.0572 9.7 10.7. 10.2 11.3 708 796 St. Pancras 0.9971 15.3 15.2 15.3 15.2 1,062 1,070 Islington 0.9749 14.4 15.1 14.0 14.8 972 1,042 Stoke Newington 0.9512 12.4 13.6 11.8 12.9 819 908 Hackney 1.0066 13.3 13.4 13.4 13.5 931 951 Holborn 1.0034 16*1 14.6 16.1 14.7 1,118 1,035 Finsbury 0.9887 19.4 18.3 19.2 18.1 1,333 1,275 London, City of 1.0419 150 15.2 15.7 15.8 1,090 1,113 Shoreditch 1.0331 18.4 18.6 19.1 19.2 1,326 1,352 Bethnal Green 1.0397 16.7 15.4 17.4 161 1,208 1,134 Stepney 1.0433 16.5 14.9 17.2 15.6 1,194 1,099 Poplar 0.9898 170 16.3 16.8 161 1,167 1,134 South wark 1.0060 17.6 17.4 17.7 17.6 1,229 1,239 Bermondsey 0.9976 18.1 17.9 181 17.8 1,257 1,254 Lambeth 0.9804 14.3 14.3 14.0 14.0 972 986 Battersea 1.0098 13.4 13.9 13.5 14.0 937 986 Wandsworth 1.0045 111 10.6 11.2 10.6 778 746 Camberwell 0.9883 13.7 13.7 13.5 13.6 937 958 Deptford 0.9879 14.7 15.3 14.5 15.2 1,007 1,070 Greenwich 0.9837 140 14.2 13.7 14.0 951 986 Lewisham 0.9826 10.7 10.6 10.6 10.4 736 732 Woolwich 1.0249 12.3 12.6 12.6 13.0 875 915 It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1908.12, Finsbury (19.2) had the highest rate and Hampstead (10.2) the lowest, and in the year 1913 Shoreditch (19.2) had the highest, and Lewisham (10.4) the lowest. The death-rates in each of the four quarters of the year 1913 were as follows: first quarter 17.5; second quarter, 13.3; third quarter, 11.8 ; and fourth quarter, 14.1 per 1,000 persons living. (a) All death-rates in this report relating to metropolitan boroughs are fully corrected for institutions. Cf. footnote (c), page 6. Diagram D. Infantile Mortality (Deaths under one year of age per 1,000 birth) (london) 13 Re-port of the County Medical Officer—General. Infant Mortality. Deaths of infants per 1,000 births. The deaths of children under one year of age in the Administrative County of London during 1913 (53 weeks) numbered 11,869, being in the proportion of 105 per 1,000 births The proportion in successive periods has been as follows:— Period. Deaths under one year of age per 1,000 births. Period. Deaths under one year of age per 1,000 births. 1841-1850 157a 1904 145b 1851-1860 155a 1905 130b 1861-1870 162a 1906 131b 1871-1880 158a 1907 116b 1881-1890 152 1908 113b 1891-1900 159b 1909 108b 1901-1910 126b 1910 103b 1901 148b 1911 129b 1902 140b 1912 91b 1903 130b 1913 105b The accompanying diagram (D) shows the infant mortality in each year since 1857 in relation to the mean infant mortality of the period 1858-1913, and also the infant mortality in each year after exclusion of the deaths from premature birth, which cause of death would in all probability be affected in greater degree than the deaths under any other heading by the more complete registration of recent years. Infant mortality in large English towns. The following table enables comparison to be made of the infant mortality in London and other large English towns. Town. 1908-12. 1913. Town. 1908-12. 1913 London 109b 105B Bradford 125 127 Greater London 103 98 Hull 130 128 Liverpool 141 131 Newcastle-on-Tyne 123 121 Manchester 138 127 Nottingham 140 130 Birmingham 137 129 Stoke-on-Trent 163 170 Sheffield 126 128 Portsmouth 101 90 Leeds 130 134 Salford 140 136 Bristol 112 96 Leicester 125 120 West Ham 120 107 London had therefore in the period 1908-12 a lower infant mortality than any of these towns except Portsmouth. In 1913 the London rate was below that of all except Bristol and Portsmouth. It should, howeyer, be pointed out that the comparative rates given in the above table, which shows the deaths of infants under one year of age per 1,000 births, are not fully corrected for births in institutions except with regard to the rates for the Administrative County of London, as shown in heavier type. The figures, therefore, to this extent, are not strictly comparable. Deaths and death rates of infants in London boroughs. The following table shows the deaths of infants under one year of age and the number of these deaths per 1,000 births in each of the sanitary districts of the County of London for the period 1908-12 and for the year 1913 (b):— Metropolitan borough. Deaths under one year of age, 1913 (53 weeks). DO Deaths under one year of age per 1,000 births. 1908-12. 1913. Paddington 305 105 100 Kensington 375 112 112 Hammersmith 314 115 103 Fulham 414 110 96 Chelsea 113 99 90 Westminster, City of 213 94 96 St. Marylebone 202 100 91 Hampstead 97 69 73 St. Pancras 508 102 92 Islington 894 102 107 Stoke Newington 94 82 82 Hackney 549 103 99 Holbom 83 103 104 Finsbury 352 131 138 (Continued on next page.) (a) See footnote (a), page 7. (b) See footnotes (b) and (c), page 6. 14 Annual Report of the London County Council, 1913. Metropolitan borough. Deaths under one year of age, 1913 (53 weeks). Deaths under one year of age per 1,000 deaths. 1908-12. 1913. London, City of 16 93 96 Shoreditch 546 144 155 Bethnal Green 470 126 118 Stepney 916 122 112 Poplar 586 127 112 Southwark 682 124 115 Bermondsey 513 135 132 Lambeth 736 103 102 Battersea 469 104 111 Wandsworth 603 92 88 Camberwell 708 98 106 Deptford 347 115 112 Greenwich 262 108 103 Lewisham 273 83 78 Woolwich 229 86 79 London 11,869 109 105 It will be seen from the foregoing table that in the period 1908-12 and in the year 1913 Shoreditch (144 and 155 respectively) had the highest infant death-rates and Hampstead (69 and 73 respectively) had the lowest. The deaths under one year of age per 1,000 births, during each of the four quarters of the year, were as follows:—First quarter 117; second quarter 81; third quarter 106; fourth quarter 116. The reports of Medical Officers of Health of the several sanitary districts of the Administrative County for the year 1913 contain tables prepared in accordance with the instructions of the Local Government Board giving the number of deaths, from all causes and certain specified causes, of infants at different age-periods in the first year of life. From the information thus supplied, the following table has been compiled, showing the figures for London as a whole for the 53 weeks of Causes of death of infants under one year of age. 1913. It will be seen that the total deaths here shown differ slightly from the total in the preceding table derived from the annual summary of the Kegistrar-General. Cause of death. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 0-3 Months. 3-6 Months. 6-9 Months. 9-12 Months. Total Deaths under one year. Common Infectious Diseases— Small-pox – – – – – – – – – – Chicken-pox – – – – – – – 2 1 3 Measles – 1 2 1 4 6 22 98 197 323 Scarlet Fever – – – – – – 1 5 2 8 Diphtheria and Croup – 1 2 – 3 4 4 13 29 50 Whooping-cough – – – 11 15 63 69 96 108 336 Diarrhœal Diseases— Diarrhœa, all forms 3 6 13 18 40 280 397 290 214 1,181 Enteritis (not tuberculous) 6 15 24 19 64 344 405 299 181 1,229 Gastritis, Gastro-intestinal Catarrh 2 5 4 4 15 54 22 11 8 95 Wasting Diseases— Premature Birth 1,306 199 129 85 1,719 1,896 35 5 2 1,938 Congenital Malformations 171 57 23 18 269 356 35 17 13 421 Atelectasis 172 16 12 6 200 214 2 – – 216 Injury at Birth 100 9 2 – 111 114 – – – 114 Want of Breast-milk 291 98 106 70 565 972 345 99 64 1,480 Atrophy, Debility, Marasmus Tuberculous Diseases— Tuberculous Meningitis 1 – – 1 2 10 32 49 49 140 Abdominal Tuberculosis – – – – – 17 30 23 24 94 Other Tuberculous Diseases – – 1 – 1 19 28 28 29 104 Erysipelas 1 2 3 2 8 21 4 4 1 30 Syphilis 11 12 13 12 48 130 35 13 10 188 Rickets – – – – – – 8 10 13 31 Meningitis (not Tuberculous) 2 – 3 3 8 18 37 47 32 134 Convulsions 88 38 36 21 183 261 72 55 34 422 Bronchitis 9 24 45 48 126 358 211 149 122 840 Laryngitis – – – 1 1 2 2 3 2 9 Pneumonia 13 32 26 38 109 386 334 351 401 1,472 Suffocation, overlaying 52 7 10 14 83 208 61 15 5 289 Other causes 145 45 37 28 255 384 127 116 84 711 Total (All Causes) 2,373 567 495 400 3,835 6,117 2,318 1,798 1,625 11,858 15 Report of the County Medical Officer—General. Causes of death. Comparison may be made between tbe number of deaths from the several causes in the above Causes of table with those of the seven antecedent years by reference to the following table:— Cause of death. 1905. 52 weeks. 1906. 52 weeks. 1907. 52 weeks. 1908. 53 weeks. 1909. 52 weeks. 1910. 52 weeks. 1911. 52 weeks. 1912. 52 weeks. 1913. 53 weeks. Deaths in 1913 in excess or defect of the corrected averageforl905-12. Diminution in 1913. Excess in 1913. Small-pox 1 – – – – Chicken-pox 3 3 5 3 10 4 5 3 3 1 – Measles 389 420 400 333 503 391 531 371 323 75 – Scarlet Fever 34 18 35 24 20 10 6 10 8 10 – Diphtheria and Croup 52 59 53 67 60 30 '53 49 50 – – Whooping Cough 623 502 746 469 524 602 424 429 336 176 – Diarrhœa 3,423 4,468 1,790 2,709 1,849 1,536 4,443 1,230 2,505 27 – Enteritis (not tuberculous) Gastritis, Gastro-intestinal Catarrh Premature Birth 2,423 2,208 2,299 2,197 2,122 2,086 1,970 1,976 1,938 112 – Congenital Malformation 547 613 645 705 667 657 472 397 421 – 36 Atelectasis 175 175 216 Injury at birth 99 113 117 110 113 108 123 112 114 – 7 Want of Breast-milk 2,281 2,130 1,922 1,843 1,825 1,682 1,738 1,384 1,480 271 – Atrophy, Debility, Marasmus Tuberculous Meningitis 273 241 239 259 203 179 211 162 140 69 – Abdominal Tuberculosis 192 225 153 168 145 129 99 78 94 46 – Other Tuberculous Diseases 284 246 264 255 188 142 148 126 104 90 – Erysipelas 64 50 52 35 48 32 26 20 30 9 – Syphilis 271 233 226 229 216 186 172 172 188 13 – Rickets 79 67 58 51 45 54 38 24 31 18 – Meningitis (not tuberculous) 300 302 210 246 170 174 183 125 134 67 – Convulsions 803 660 603 520 495 475 428 374 422 91 – Bronchitis 1,276 1,043 1,284 982 960 843 847 710 840 98 – Laryngitis 25 23 15 18 15 13 17 13 9 7 – Pneumonia 1,490 1,335 1,629 1,431 1,334 1,442 1,334 1,186 1,472 – 145 Suffocation, overlaying 462 417 421 417 322 321 261 301 289 56 – Other causes 1,004 1,009 979 885 852 751 804 693 711 114 – Total 16,397 16,385 14,145 13,956 12,686 11,847 14,509 10,120 11,858 Net diminution 1,162 Number of births 125,939 124,880 121,408 122,898 116,559 115,190 111,738 110,358 112,637 Deaths of infants at certain age periods. The total deaths among children under one year of age from "all causes" at certain age periods in 1913 may be compared with similar figures included in the Annual Reports for preceding years as follows:— Year. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 0-3 Months. 3-6 Months. 6-9 Months. 9-12 Months. Total Deaths under one year. 1905 2,886 808 667 564 4,925 8,132 3,227 2,665 2,373 16,397 1906 2,683 707 722 545 4,657 7,764 3,439 2,736 2,446 16,385 1907 2,758 760 676 533 4,727 7,504 2,580 2,087 1,974 14,145 1908 2,645 651 631 485 4,412 7,189 2,736 2,097 1,934 13,956 1909 2,535 612 540 471 4,158 6,564 2,352 1,910 1,860 12,688 1910 2,465 598 500 451 4,014 6,230 2,148 1,795 1,674 11,847 1911 2,374 617 571 503 4,068 6,669 3,035 2,485 2,320 14,509 1912 2,353 564 462 383 3,762 5,641 1,764 1;382 1,333 10,120 1913 2,373 567 495 400 3,835 6,117 2,318 1,798 1,625 11,858 16 Annual Report of the London County Council, 1913. The following table has been prepared to show approximately the death-rates in age-periods per 1,000 living at the beginning of each period:– Year. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 0-3 Months. 3-6 Months. 6-9 Months. 9-12 Months. Total under one year. (a) 1905 22.9 6.6 5.5 4.6 39.1 64.6 27.4 23.3 21.2 130.2 1906 21.5 5.8 5.9 4.5 37.3 62.2 29.4 24.1 22.0 131.2 1907 22.7 6.4 5.7 4.5 38.9 61.8 22.7 18.7 18.1 116.5 1908 21.5 5.4 5.3 4.1 35.9 58.5 23.6 18.6 17.4 113.6 1909 21.7 5.4 4.8 4.2 35.7 56.3 21.4 17.7 17.6 108.8 1910 21.4 5.3 4.5 4.0 34.8 54.1 19.7 16.8 15.9 102.8 1911 21.2 5.6 5.3 4.7 36.4 59.7 28.9 24.4 23.3 129.8 1912 21.3 5.2 4.3 3.6 34.1 51.1 16.8 13.4 13.1 91.7 1913 21.1 5.1 4.5 3.7 34.0 54.3 21.8 17.3 15.9 105.3 With a vie.w to comparing the rates of mortality from the several groups of diseases, per 1,000 born, in the years 1905-13 the following table has been prepared:– Year. All causes. (a) Measles. Whoopingcough. Diarrhoeal diseases. Wasting diseases. Tuberculous diseases. Meningitis and convulsions. Bronchitis. Pneumonia. Other causes. 1905 130.2 31 4.9 27.2 42.5 6.0 8.8 10.1 11.8 15.8 1906 131.2 3.4 4.0 35.8 40.5 5.7 7.7 8.4 10.7 15.0 1907 116.5 3.3 6.2 14.7 41.0 5.4 6.7 10.6 13.4 15.2 1908 113.6 2.7 3.8 22.0 39.5 5.6 6.2 8.0 11.7 14.1 1909 108.8 4.3 4.5 15.9 40.6 4.6 5.7 8.2 11.4 13.6 1910 102.8 3.4 5.2 13.3 39.4 3.9 5.6 7.3 12.5 12.2 1911 129.8 4.7 3.8 39.7 40.1 4.1 5.5 7.6 11.9 12.4 1912 91.7 3.4 3.9 11.2 36.6 3.3 4.5 6.4 10.8 11.6 1913 1053 2.9 3.0 22.2 37.0 3.0 4.9 7.5 13.1 11.7 Deaths of infants in London boroughs. The following table shows the age-distribution of the deaths under one year of age in the several sanitary districts of London:— [####]Metropolitan borough. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 0-3 Months. 3-6 Months. (i-9 Months. 9-12 Months. Total under 1 Year Paddington 62 10 15 8 95 162 61 44 38 305 Kensington 81 15 14 14 124 174 73 66 58 371 Hammersmith 68 11 13 9 101 163 52 50 49 314 Fulham 108 23 19 14 164 228 90 52 42 412 Chelsea 30 6 6 4 46 62 21 21 8 112 Westminster, Gity of 50 12 8 9 79 123 44 18 28 213 St. Marylebone 56 13 5 7 81 119 30 28 18 195 Hampstead 28 6 4 2 40 59 18 9 5 91 St. Pancras 120 25 28 17 190 284 102 70 56 512 Islington 195 49 47 29 320 507 178 111 102 898 Stoke Newington 26 1 5 5 37 62 9 9 11 91 Hackney 100 26 24 17 167 275 108 87 79 549 Holborn 19 5 4 3 31 45 15 5 15 80 Finsbury 54 14 21 11 100 166 76 55 51 348 London, City of 4 2 – 1 7 11 2 1 2 16 Shoreditch 76 23 24 8 131 242 105 99 84 530 Bethnal Green 68 19 20 14 121 201 113 94 62 470 Stepney 161 41 38 33 273 435 191 157 134 917 Poplar 111 31 22 29 193 308 103 95 82 588 Southwark 124 22 30 15 191 353 114 118 97 682 Bermondsey 77 14 19 10 120 216 113 83 93 505 Lambeth 144 34 22 31 231 370 159 106 98 733 Battersea 96 30 14 18 158 240 85 77 70 472 Wandsworth 150 35 23 20 228 339 110 78 78 605 Camberwell 135 46 21 34 236 374 138 112 114 738 Deptford 60 8 11 15 94 169 78 49 54 350 Greenwich 52 16 13 7 88 135 54 39 35 263 Lewisham 60 18 14 5 97 156 47 28 38 269 Woolwich 58 12 11 11 92 139 29 37 24 229 London 2,373 567 495 400 3,835 6,117 2,318 1,798 1,625 11,858 17 Report of the County Medical Officer—General. Infant mortality and "social condition. With a view to the consideration of the effect of " social condition (a)" 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 infant mortality obtaining for groups of districts can be compared:– 0 Infant mortality in relation to "social condition"—1913. Age-period. Group of boroughs in order of "social condition." I. II. III. IV. V. Under 1 week 18.3 22.0 21.3 21.7 19.7 1-2 weeks 5.2 4.6 5.4 4.9 5.0 2-3 „ 3.6 4.2 4.0 4.3 5.5 3-4 „ 1.6 3.2 3.8 3.8 3.4 Under 1 month 28.7 34.0 34.5 34.7 33.6 0-3 months 45.1 51.7 54.5 55.1 56.9 3-6 13.3 18.2 20.0 19.3 27.0 6 9 7.6 13.6 14.6 16.0 22.0 9-12 „ 9.0 13.2 13.6 13.6 19.2 0-12 months 75.0 96.7 102.7 104.0 125.1 The foregoing table shews that there is a marked difference in the mortality among children under one year of age when the extreme 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 is observable. This will be better appreciated by reference to the following table, in which the mortality of the group of districts of relatively highest "social condition" is taken as 100:— Number of group of boroughs in order of "social condition." Comparative mortality—Group I. taken as 100. Children aged 0-3 months. Children aged 3-6 months. Children aged 6-9 months. Children aged 9-12 months. Children under 1 year. 1905-12. 1913. 1905-12. 1913. 1905-12. 1913. 1905-12. 1913. 1905-12. 1913. I. 100 100 100 100 100 100 100 100 100 100 II. 115 115 128 136 142 179 160 148 126 129 III. 120 121 133 150 149 193 171 151 132 137 IV. 125 122 144 144 165 211 185 152 140 139 V. 132 126 176 202 196 291 232 213 159 167 The figures for the period 1905-12 show that in each successive trimester of the first year of life the difference in the mortality obtaining for the several groups of districts becomes generally more pronounced. The figures for 1913 are in general agreement with those for the period 1905-12. 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, and enteric fever during 1913 (53 weeks) was 3,103, giving an annual death-rate of 0-68 per 1,000 persons living. (a) The standard adopted throughout this report for determining the " social condition " of a borough is the percentage of all children between the ages of 5 and 14 scheduled in the borough by the Council for education purposes in the years 1905-7. The scheduling of children for this purpose is conducted annually by the Council, and the question whether or not a child is to be scheduled depends upon various circumstances which, taken together, form a general measure of " social condition." The County has been divided into five groups of different grades of " social condition." Group I. contains all boroughs in which less than 82 per cent, of the children aged 5—14 were schedulod ; Group II., 82 to 87 per cent.; Group III., 87 to 92_per cent.; Group IV.. 92 to 97 per cent.: Group V ; 97 per cent, and over. 23610 D 18 Annual Report of the London County Council, 1913. Deaths from epidemic diseases in in London boroughs. The following table shows the deaths from the principal epidemic diseases (excluding pyrexia, typhus, diarrhoea and enteritis), and the death-rates per 1,000 persons living in each of the sanitary districts of the County in 1913, and the death-rates for the period 1908-12:— Metropolitan borough. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. Paddington 117 0.66 0.81 Kensington 126 0.65 0.72 Hammersmith 113 0.89 0.90 Fulham 102 1.00 0.64 Chelsea 28 0.72 0.43 Westminster, City of 47 0.43 0.30 St. Marylebone 64 0.72 0.55 Hampstead 40 0.42 0.46 St. Pancras 100 0.93 0.46 Islington 224 0.91 0.68 Stoke Newington 26 0.55 0.51 Hackney 117 0.73 0.52 Holborn 20 0.71 0.42 Finsbury 74 1.61 0.86 London, City of 6 0.30 0.33 Shoreditch 99 1.61 0.89 Bethnal Green 113 1.37 0.87 Stepney 162 1.36 0.58 Poplar 158 1.53 0.97 Southwark 179 1.26 0.93 Bermondsey 161 1.57 1.27 Lambeth 205 0.81 0.68 Battersea 154 0.92 0.90 Wandsworth 171 0.68 0.51 Camberwell 158 0.77 0.59 Deptford 118 1.01 1.06 Greenwich 80 0.91 0.82 Lewisham 96 0.54 0.56 Woolwich 45 0.64 0.36 London 3,103 0.92 0.68 It will be seen from the foregoing table that the death-rate from these diseases in the period 1908-12 was highest in Finsbury and Shoreditch (1.61) and lowest in the City of London (0.30), and in 1913 was highest in Bermondsey (1.27) and lowest in the City of Westminster (0.30). The deathrates from these diseases during each of the four quarters of the year were as follows : First quarter, 1.19 ; second quarter, 0.87; third quarter, 0.35; and fourth quarter, 0.32 per 1,000 persons living. Smallpox and Vaccination. Smallpox death-rates in London. The death-rates from smallpox in successive periods have been as follows:— d. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-1850 0.402 1904 0.006a 1851-1860 0.280 1905 0.002a 1861-1870 0.276 1906 – 1871-1880 0.457 1907 – 1881-1890 0.142 1908 – 1891 -1900 0.009a 1909 0.000a 1901 1910 0.035a 1910 – 1911 0.002a 1901 0.051a 1912 0.000 1902 0.285a 1913 1903 0.003a The smallpox death-rate in each ear since 1840 in relation to the mean death-rate during the period 1841-1913 is shown in diagram (E). (a) See footnote (c), page 6. Diagram E. Smallpox. (london) 19 Report of the County Medical Officer—General. 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:— Year. Cases of smallpox 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 1.683 1903 416 0.091 1904 489 0.107 1905 74 0.016 1906 31 0.007 1907 8 0.002 1908 4 0.001 1909 21 0.005 1910 7 0.002 1911 72 0.016 1912 6 0.001 1913 4 0.001 Smallpox— notified cases and case rates. It will be seen from the following table that in the quinquennium 1908-12 and in the year 1913 none of the under-mentioned towns had an appreciable death-rate from small-pox. Town. 1908-12. 1913. Town. 1908-12. 1913. London 0.00a - Bradford - - Greater London 0.00 - Hull 0.00 - Liverpool — 0.00 Newcastle-on-Tyne 0.00 - Manchester 0.00 - Nottingham 0.00 - Birmingham 0.00 - Stoke-on-Trent - - Sheffield 0.00 - Portsmouth - - Leeds — - Salford - - Bristol 0.01 - Leicester - - West Ham — — Smallpox death-rates in large English towns. The following table shows that, of the undermentioned towns, Petrograd alone had an appreciable death-rate from smallpox during the last six years:— Town. 1908-12. 1913. Town. 1908-12. 1913. London 0.00a - Stockholm - 0.01 Paris 0.00 0.00 Petrograd 0.13 0.02 Brussels 0.00 0.00 Berlin 0.00 - Amsterdam - - Vienna - - Copenhagen - - New York 0.00 - Smallpox death-rates in foreign towns. Of the four cases notified in London, one case only proved to be true small-pox, in the other cases the diagnosis was not confirmed. Smallpox in London. During the year suspicion as to the existence of smallpox was raised in 20 cases which came under the notice of medical officers of health, and Dr. Wanklyn or Dr. Brincker consulted with the medical practitioner and the borough medical officer of health with regard to the diagnosis in most of the cases. In only one instance was the diagnosis of smallpox confirmed. This case was that of a woman, aged 34, who was removed from premises in Poplar frequented by seamen. The source of infection was not known. So far as could be ascertained there were 10 contacts, who were kept under observation, and full particulars were circulated among the metropolitan borough councils and other authorities concerned. The patient was subsequently discharged from the hospital cured. Among the remaining cases, 10 proved to be chickenpox. (a) See footnote (c), page 6. 23610 D 2 20 Annual Report of the London County Council, 1913. Vaccination returns. The following table shows the proportion of children born in London in each year who were not finally accounted for in respect of vaccination. Year Children not finally accounted for (including cases postponed) per cent. of total births. Year. Children not finally accounted fo (including cases postponed) per cent. of total births. 1872 8.8 1893 18.2 1873 8.7 1894 20.6 1874 8.8 1895 24.9 1875 9.3 1896 26.4 1876 6.5 1897 29.1 1877 7.1 1898 33.0 1878 7.1 1899 27.7 1879 7.8 1900 25.8 1880 7.0 1901 24.1 1881 5.7 1902 21.3 1882 6.6 1903 20.7 1883 6.5 1904 19.1 1884 6.8 1905 18.9 1885 7.0 1906 21.2 1886 7.8 1907 22.7 1887 9.0 1908 21.5 1888 10.3 1909 20.6 1889 11.6 1910 20.5 1890 13.9 1911 20.8 1891 16.4 1912 20.9 1892 18.4 The percentage of children born who were exempted by "conscientious objection" certificate; in and since the year 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; 1907, 3.1; 1908, 7.3; 1909, 10.1; 1910, 13.6; 1911, 15.8; 1912, 20.0. Number of children unaccounted for as regards vaccination per cent. of total births. 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:— Metropolitan Union. 1898. 1899. 1900. 1901. 1902. 1903. 1904. 1905. 1906. 1907. 1908. 1909. 1910. 1911. 1912. Bermondsey 32.5 23.6 21.8 18.0 17.5 16.3 16.6 15.7 17.2 18.0 18.1 20.0 22.3 23.3 25.7 Bethnal Green 67.0 48.2 49.2 52.2 44.1 44.9 42.8 42.0 48.3 55.1 56.8 50.6 56.8 66.7 55.9 Camberwell 41.2 29.7 23.0 20.0 .21.4 21.8 23.6 23.4 26.8 34.0 37.3 40.5 45.3 48.3 51.6 Chelsea 17.3 14.9 16.0 13.4 14.9 13.9 10.0 8.9 13.0 14.3 16.9 19.8 19.3 20.0 25.9 Fulham 15.4 12.6 13.7 12.0 11.8 12.7 11.5 10.8 14.6 18.1 19.3 21.8 23.5 25.2 29.5 George's, St., Hanover-sq. 11.1 9.0 7.1 5.8 7.5 5.1 4.9 4.4 4.3 7.2 8.4 10.3 11.8 13.2 16.4 George, St., inthe-East 34.6 35.0 33.5 30.6 29.7 27.7 15.7 17.3 16.8 17.7 15.6 18.3 19.6 21.2 25.4 Giles, St., and St. George 32.5 33.0 33.6 30.7 27.1 24.9 17.9 20.4 20.8 28.1 26.9 31.5 30.8 29.4 34.4 Greenwich 17.2 14.2 13.8 12.6 11.1 11.1 10.4 9.7 9.8 13.1 16.5 19.1 21.4 25.1 31.6 Hackney 49.0 38.6 40.4 38.5 26.1 25.5 26.9 28.2 36.8 33.2 34.4 39.0 43.8 49.1 56.6 Hammersmith 13.8 11.7 9.1 8.3 9.4 7.2 7.4 8.0 10.1 13.1 18.8 19.2 22.1 24.5 33.5 Hampstead 15.4 10.3 11.0 10.0 9.2 9.5 9.2 9.2 10.4 12.3 15.1 17.0 22.5 25.2 28.4 Holborn 43.8 31.8 28.5 27.6 23.2 20.7 20.4 20.6 24.5 26.7 29.3 31.8 34.2 39.1 46.5 Islington 31.1 29.2 26.2 21.6 17.7 17.0 15.9 17.5 18.2 21.2 25.2 27.1 30.8 34.2 42.9 Kensington 13.5 10.2 9.2 9.0 7.2 6.6 6.6 5.5 7.2 8.0 9.4 11.0 13.8 15.4 19.6 Lambeth 30.6 25.2 20.6 22.2 20.4 21.0 16.9 17.3 19.6 23.4 27.8 32.6 34.6 38.1 43.3 Lewisham 27.8 22.6 20.7 15.7 13.5 15.4 14.0 13.8 16.2 21.4 26.3 29.4 33.9 38.1 41.0 London,City of 25.4 18.3 14.2 11.3 11.3 11.8 13.0 15.3 16.8 17.5 18.2 18.2 22.0 33.2 38.8 Marylebone,St. 18.0 20.9 17.7 14.6 12.5 10.8 10.4 10.8 12.1 12.7 12.9 14.5 15.7 16.2 17.2 Mile End Old Town 68.9 69.9 68.0 66.1 58.8 59.8 47.3 47.1 48.4 52.3 53.9 51.8 51.1 53.4 54.8 Paddington 14.7 14.6 13.5 11.0 10.1 11.7 12.7 13.3 13.3 15.5 16.2 15.7 20.1 20.2 22.4 Pancras, St. 36.7 36.1 32.9 32.8 26.2 25.3 23.1 22.1 26.0 31.1 31.1 36.8 41.9 45.6 47.4 Poplar 63.6 50.1 49.0 49.1 44.2 46.9 45.4 45.3 49.3 53.9 55.1 53.3 57.6 56.5 62.1 Shoreditch 68.8 52.4 53.0 44.7 36.4 36.6 34.8 36.7 33.3 33.3 39.2 42.4 47.0 48.6 55.8 Southwark 32.6 30.3 27.6 26.8 25.4 24.9 24.3 24.2 28.4 31.1 32.0 34.3 37.0 39.4 46.0 Stepney 48.6 46.9 44.4 44.3 37.2 35.8 32.9 32.9 32.9 38.1 50.6 51.3 56.6 58.8 64.1 Strand 25.2 19.7 19.2 16.1 19.0 18.6 15.0 11.8 11.7 14.2 24.9 21.4 26.3 28.7 29.3 Wandsworth 32.2 25.1 23.0 20.5 19.2 17.2 16.3 14.8 18.0 22.8 28.2 30.1 34.5 34.0 39.3 Westminster 17.4 14.8 12.2 13.3 13.4 12.1 11.0 8.2 9.4 10.1 12.5 13.4 17.2 16.5 20.1 Whitechapel 11.8 14.5 13.1 10.5 9.5 10.1 9.1 10.6 11.5 14.1 17.1 15.9 18.8 19.9 20.2 Woolwich 10.2 8.3 7.5 9.8 9.7 7.1 7.2 6.6 9.3 15.0 23.2 23.9 28.8 28.9 32.8 London 34.4 28.7 26.8 25. 22. 21.7 20. 20. 22. 25. 28. 30. 34. 36.6 41. The above table shows increase since 1905 in the proportion of children born who are remaining unvaccinated. Diagram F. Measles. ( london) / Diagram G. Measles & Whooping-Cough (Deaths 1891—1913.) — (LONDON) » 21 w Report of the County Medical Officer—General. Measles. The deaths from measles in the Administrative County of London during 1913 (53 weeks) numhered 1,570, as compared with 1,799 in 1912 weeks). The death-rates from this disease per 1,000 persons living in 1913 and preceding periods have been as follows:— Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-1850 0.62 1904 0.50a 1851-1860 0.53 1905 0.38a 1861-1870 0.58 1906 0.42a 1871-1880 0.51 1907 0.40a 1881-1890 0.64 1908 0.33a 1891-1900 0.58a 1909 0.51a 1901-1910 0.44a 1910 0.44a 1911 0.57a 1901 0.43a 1912 0.40a 1902 0.51a 1913 0.34a 1903 0.45a Measles death-rates in London Inasmuch as the birth-rate has not been constant during these periods and the proportion of population in the early years of life has probably diminished in recent years, the death-rate of children under five years of age has also been worked out. The following table shows the death-rate from measles of children at this age in successive periods:— Period. Death-rate per 1,000 children living at ages 0—5. Period. Death-rate per 1,000 children living at ages 0—5. 1851-1860 3.89 1904 4.49a 1861-1870 4.18 1905 3.38a 1871-1880 3.65 1906 3.83a 1881-1890 4.74 1907 3.58a 1891-1900 4.82a 1908 3.00a 1901-1910 3.92a 1909 4.73a 1910 4.00a 1901 3.71a 1911 5.18a 1902 4.49a 1912 3.68a 1903 4.02a 1913 3.08a Mortality among children at ages 0-5. The death-rate in each year since 1840 in relation to the mean death-rate of the period 1841-1913, calculated on the population at all ages, is shown in diagram (F). The monthly deaths from measles in relation to the mean of the period 1891-1913 is shown in diagram (G). The following table shows the deaths from measles, in 1913 (53 weeks) and the death-rates it 1908-12 and 1913 in each of the sanitary districts of the County:— Metropolitan borough. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. Paddington 55 0.31 0.38 Kensington 84 0.31 0.48 Hammersmith 47 0.38 0.37 Fulham 50 0.44 0.31 Chelsea 18 0.32 0.27 Westminster, City of 22 0.16 0.14 St. Marylebone 33 0.32 0.28 Hampstead 21 0.14 0.24 St. Pancras 41 0.45 0.19 Islington 107 0.44 0.32 Stoke Newington 11 0.25 0.21 Hackney 68 0.33 0.30 Holborn 10 0.31 0.21 Deaths and death-rates from measles in Loudon boroughs. (Continued on next page.) (a) See footnote (c), page 6. 22 Annual Report of the London County Council, 1913. Metropolitan borough. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. Finsbury 30 0.90 0.35 London, City of — 0.12 - Shoreditch 52 0.91 0.47 Bethnal Green 62 0.72 0.48 Stepney 95 0.76 0.34 Poplar 69 0.76 0.42 Southwark 105 0.71 0.55 Bermondsey 90 0.96 0.71 Lambeth 99 0.36 0.33 Battersea 93 0.45 0.55 Wandsworth 116 0.31 0.35 Camberwell 68 0.37 0.26 Deptford 50 0.47 0.45 Greenwich 40 0.36 0.41 Lewisham 25 0.12 0.15 Woolwich 9 0.24 0.07 London 1,570 0.45 0.34 In the distribution of measles mortality throughout the year 1913, the highest death-rate obtained in Bermondsey (0.71) and the lowest in Woolwich (0.07), exclusive of the City of London, where no death occurred. For the period of 1908-12, Bermondsey (0.96) had the highest measles deathrate, and the City of London and Lewisham (0.12) the lowest. The death-rates for this disease in London in each of the four quarters of the year 1913 were as follows: first quarter, 0.75; second quarter, 0.49; third quarter, 0.11; and fourth quarter, 0.04 per 1,000 persons living. There was no exceptional prevalence of measles during the year 1913. London sanitary authorities continue to devote much time and attention to this disease, and it is a common practice to visit the homes of the patients to urge the importance of medical care. Leaflets as to the care of the patient ate issued and disinfection is carried out. 3,400 cases were admitted to the hospitals of the Metropolitan Asylums Board under the Local Government Board Order of the 30th May, 1911. The mortality rate among these cases was 12.6 per cent., as compared with 9.6 per cent. among 4,314 cases received during 1912. The rate for males was 13.4 per cent. and that for females 11.8 per cent. Measles death-rates in large English towns. If the London measles death-rate be compared with that of the following large English towns, it will be seen that in the quinquennium 1908-12, the London death-rate was exceeded by the death-rates of Liverpool, Manchester, Birmingham, Sheffield, West Ham, and Salford, and in the year 1913 exceeded all except Liverpool, Manchester, Birmingham, Sheffield, Stoke-on-Trent and Salford. Town. 1908-12. 1913. Town. 1908-12. 1913. London 0 .45a 0.34a Bradford 0.21 0.12 Greater London 0.38 0.31 Hull 0.37 0.04 Liverpool 0.63 0.41 Newcastle-on-Tyne 0.39 0.23 Manchester 0.55 0.36 Nottingham 0.37 0.07 Birmingham 0.48 0.45 Stoke-on-Trent 0.45 0.96 Sheffield 0.71 0.78 Portsmouth 0.27 0.10 Leeds 0.30 0.23 Salford 0.68 0.54 Bristol 0.30 0.13 Leicester 0.41 0.15 West Ham 0.71 0.22 Scarlet Fever. The cases of scarlet fever notified in the Administrative County of London during 1913 (53 weeks) numbered 17,552, compared with 11,312 in 1912 (52 weeks). The number of deaths registered from this cause was 188 in the year 1913 (53 weeks), compared with 159 in 1912 (52 weeks). (a) See footnote (c), page 6. Diagram H. Scarlet Fever. (london) D i a g r a m l. Scarlet Fever. Number of admissions to Hospitals of the Metropolitan Asylums Board per cent of total casts notified in London. 1890-1913. Diagram J. Scarlet/Fever. (london) 23 Report of the County Medical Officer—General. The scarlet fever case-rates, death-rates and case-mortality for 1913 and preceding periods are shown in the following table:— Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Casemortality per cent. 1861-1870 1.13 — a — a 1871-1880 0.60 — a — a 1881-1890 0.33 — a — a 1891-1900 0.19b 4.8 3.8 1901-1910 0.10b 3.9 2.7 1901 0.13b 4.1 3.2 1902 0.12b 4.0 3.1 1903 0.08b 2.8 2.9 1904 0.08b 3.0 2.7 1905 0.12b 4.3 2.8 1906 0.12b 4.5 2.6 1907 0.14b 5.7 2.5 1908 0.12b 4.8 2.5 1909 0.08b 3.8 2.2 1910 0.05b 2.3 2.0 1911 0.04b 2.3 1.6 1912 0.04b 2.5 1.4 1913 0.04b 3.8 1.1 Scarlet fever death-rates. The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591913 will be seen on reference to diagram (H). The monthly case-rate and case mortality in each of the years 1891-1913 in relation to the mean of the whole period is shown in diagram (J). It will be seen from the following table that in the period 1908-12 the London scarlet fever death rate was exceeded by that of Liverpool, Manchester, Birmingham, Sheffield, West Ham, Newcastleon-Tyne, Stoke-on-Trent, Portsmouth, and Salford. In 1913 it was exceeded by all except Leeds, Bristol, Bradford, Hull, Stoke-on-Trent and Leicester. Town. 1908-12. 1913. Town. 1908-12. 1913. London 0.076 0.046 Bradford 0.05 0.03 Greater London 0.06 0.0 Hull 0.03 0.01 Liverpool 0.22 0.08 Newcastle-on-Tyne 0.08 0.08 Manchester 0.13 0.13 Nottingham 0.05 0.06 Birmingham 0.16 0.21 Stoke-on-Trent 0.17 0.02 Sheffield 0.08 0.16 Portsmouth 0.09 0.08 Leeds 007 0.03 Salford 0.18 0.13 Bristol 0.04 0.02 Leicester 0.07 0.03 West Ham 0.10 0.06 Scarlet fever death-rates in large English towns. The following table shows the scarlet fever cases, deaths, case-rates, and death-rates for the year 1913 and the case-rates and death-rates for the period 1908-12 in the several sanitary districts. Metropolitan borough. Notified cases, 1913 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. 1908-12. 1913. Paddington 487 2.89 3.37 7 0.06 0.05 Kensington 558 1.93 3.21 3 0.03 0.02 Hammersmith 537 2.80 4.27 7 0.06 0.06 Fulham 767 3.05 4.80 3 0.06 0.02 Chelsea 206 2.59 3.14 3 0.05 0.05 Westminster, City of 379 2.41 2.41 7 0.04 0.04 St. Marylebone 417 2.79 3.58 10 0.08 0.09 Hampstead 208 2.15 2.37 4 0.03 0.05 St. Pancras 565 3.13 2.59 6 0.06 0.03 Islington 1,315 3.07 3.97 17 0.06 0.05 Stoke Newington 109 2.31 2.12 1 0.05 0.02 Hackney 821 3.22 3.62 11 0.06 0.05 Holborn 132 2.36 2.77 - 0.05 — Finsbury 274 2.58 3.18 4 0.09 0.05 London, City of 47 1.66 2.58 1 0.02 0.05 Shoreditch 354 2.76 3.18 3 0.09 0.03 Bethnal Green 411 3.64 3.16 3 0.13 0.02 Stepney 820 3.79 2.93 8 0.08 0.03 Poplar 754 3.88 4.61 12 0.10 0.07 Southwark 880 2.86 4.59 11 0.06 0.06 Scarlet Fever in London boroughs. Continued on next page. (a) The Infectious Disease (Notification) Act came into force in 1889. (b) See footnote (c), page 6. 24 Annual Report of the London County Council, 1913. Metropolitan borough. Notified cases, 1913 (53 weeks). Case rate per 1,000 persons living. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. 1908-12. 1913. Bermondsey 731 3.45 5.77 4 0.11 0.03 Lambeth 1,397 3.27 4.63 14 0.07 0.05 Battersea 949 3.79 5.58 7 0.06 0.04 Wandsworth 1,007 3.02 3.00 11 0.04 0.03 Camberwell 1,155 2.94 4.34 13 0.05 0.05 Deptford 625 3.96 5.63 3 0.06 0.03 Greenwich 330 3.61 3.38 2 0.06 0.02 Lewisham 670 3.69 3.90 5 0.06 0.03 Woolwich 645 5.18 5.19 8 0.08 0.06 Port of London 2 London 17,552 3.16 3.82 188 0.07 0.04 The notified cases of scarlet fever show an increase of 6,240 over the number notified in 1912, due mainly to an increased autumnal prevalence. The disease, however, continues to be mild in type and the mortality rate is comparatively low. The high incidence of attack is not restricted to London, but has been observed in Birmingham, South Shields, and other large towns. Dr. Millson says that in Southwark he has observed that increased scarlet fever prevalence generally occurs in cycles of five years. The outbreak at the end of 1913 followed on a period of comparative quiescence lasting for seven years, and Dr. Millson has examined his notifications with a view to learning if the average age of the patients attacked has increased. He finds that this is not the case in Southwark, and concludes that if a child escapes scarlet fever up to the age of five years it stands a very fair chance of escaping altogetner. This question is deserving of more extended study than it has yet received. In Wandsworth special attention is directed to visiting the homes of child patients who, after recovering, moreover, are examined by the medical officer of health before they return to school. 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 1913. It will be seen that at "all ages" the case-rate was highest among females, while the fatality was higher among males. Scarlet fever cases aud deaths by age and sex, London. In the age-groups adopted for the purposes of this table, the greatest incidence of attack was upon males aged 4-5 years, and females aged 5-10 years; the greatest incidence of death was upon males aged 1-2 and females aged 2-4; and the fatality was highest among males aged 0-1 and females aged 1-2 years. Age-period. Males. Females. Notified cases. 53 weeks. Deaths. 365 days. Casemortality per cent. Rates per 100,000 living. Notified cases. 53 weeks. Deaths. 365 days. Casemortality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages 7,936 101 1.3 367 5 9,616 84 0.9 395 4 0— 74 8 11.0 148 16 79 1 1.3 161 2 1— 266 24 9.2 581 53 233 11 4.8 515 25 2— 443 17 3.9 915 36 448 14 3.2 937 30 3— 634 14 2.2 1,333 30 655 14 2.2 1,368 30 4— 741 6 0.8 1,591 13 791 8 1.0 1,703 18 5— 3,459 23 0.7 1,577 11 4,187 22 0.5 1,894 10 10— 1,419 3 0.2 702 2 1,956 8 0.4 949 4 15— 456 2 0.4 232 1 514 2 0.4 238 1 20— 190 1 0.5 98 1 304 - - 126 - 25— 180 2 0.1 49 1 339 3 0.1 77 1 35— 63 1 1.6 21 0 68 - - 20 - 45— 8 - - 4 - 29 1 3.5 12 0 55 & upwards 3 - - 1 — 13 - - 4 - It will be seen from diagram (I) that the proportion of cases of scarlet fever admitted to the hospitals of the Metropolitan Asylums Board was somewhat smaller than in the preceding year. Scarlet fever —diagnosis not confirmed. Cases certified to be those of scarlet fever and admitted into the hospitals of the Metropolitan Asylums Board in which the diagnosis was not subsequently confirmed, constituted in successive years the following percentage of the total cases admitted:— Year. Percentage. Tear. Percentage. 1901 5.6 1908 5.8 1902 4.7 1909 6.9 1903 6.4 1910 9.5 1904 6.7 1911 8.7 1905 5.4 1912 6.4 1906 4.9 1913 6.0 1907 6.8 Diagram K. Diphtheria. (LONDON) Diagram L. Diphtheria. Number of admissions to Hospitals of the Metropolitan Asylums Board per cent of total cases notified in London. 1890-1913 Diagram M. —— Diphtheria.- (LONDON) 25 Report of the County Medical Officer—General. Diphtheria. The cases of diphtheria (including membranous croup) notified in the Administrative County of London in 1913 (53 weeks) numbered 7,654, compared with 7,101 in 1912 (52 weeks). The number of deaths was 431 in 1913 (53 weeks), compared with 452 in 1912 (52 weeks). It should be borne in mind that the case-rate and case-mortality may be affected by variations in the extent of use of bacteriological methods of diagnosis, the effect of which is to increase the number of clinically mild cases of the disease notified. Diphtheria death-rates in London. The diphtheria case-rates, death-rates, and case-mortality in 1913, and preceding periods, are shown in the following table:- Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case-mortality per cent. 1861-1870 0.18 -a -a 1871-1880 0.12 -a -a 1881-1890 0.26 -a -a 1891-1900 0.49b 2.6 18.8 1901-1910 0.17b 1.8 9.3 1901 0.29b 2.7 10.9 1902 0.25b 2.3 10.8 1903 0.166 1.7 9.6 1904 0.16b 1.6 10.0 1905 0.12b 1.4 8.4 1906 0.15b 1.8 8.6 1907 0.17b 1.9 8.9 1908 0.16b 1.7 9.0 1909 0.13b 1.5 9.1 1910 0.10b 1.2 7.9 1911 0.14b 1.6 8.3 1912 0.10b 1.6 6.4 1913 0.09b 1.7 5.6 The death-rate in each year since 1858 in relation to the mean death-rate of the period 1859— 1913 is shown for diphtheria and also for diphtheria and croup combined in diagram (K). The monthly case-rate and case-mortality in each of the years 1891-1913 in relation to the mean of the period is shown in diagram (M). Diphtheria death-rates in large English owns. 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 quinquennium 1908-12 the London rate was exceeded by that of all except Sheffield, Nottingham and Leicester, and in 1913 was exceeded by the rates of all except Bristol and Leicester. Town. 1908-12. 1913. Town. 1908-12. 1913. London 0.12b 0.09b Bradford 0.16 0.18 Greater London 0.13 0.09 Hull 0.15 0.11 Liverpool 0.15 0.10 Newcastle-on-Tyne 0.15 0.11 Manchester 0.15 0.13 Nottingham 0.11 0.14 Birmingham 0.15 0.19 Stoke-on-Trent 0.31 0.38 Sheffield 0.09 0.12 Portsmouth 0.32 0.35 Leeds 0.19 0.18 Salford 0.32 0.13 Bristol 0.14 0.08 Leicester 0.07 0.08 West Ham 0.16 0.10 Diphtheria cases, deaths and deathrates in London boroughs. The following table shows the diphtheria cases, deaths, case-rates, and death-rates for the year 1913, and the case-rates and death-rates for the period 1908-12, in the several sanitary districts:- Metropolitan borough. Notified Cases, 1913 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. 1908-12. 1913. Paddington 304 1.23 2.10 12 0.07 0.08 Kensington 145 1.12 0.83 6 0.10 0.03 Hammersmith 138 1.54 1.10 12 0.16 0.10 Fulham 270 2.00 1.69 14 0.17 0.09 Chelsea 61 1.47 0.93 1 0.12 0.02 Westminster, City of 192 1.07 1.22 8 0.09 0.05 (Continued, on next page) (a) The Infectious Disease (Notification) Act came into force in 1889. 23610 (b) See footnote (c) page 6. E 26 Annual Report of the London County Council, 1913. Metropolitan borough. Notified Cases, 1913 (53 weeks) Case-rate per 1,000 persons living. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. 1908-12. 1913. St. Marylebone 130 1.08 1.12 6 0.08 0.05 Hampstead 128 1.11 1.46 3 0.11 0.03 St. Pancras 438 1.69 2.01 16 0.12 0.07. Islington 551 1.55 1.66 34 0.13 0.10 Stoke Newington 84 1.10 1.64 6 0.03 0.12 Hackney 331 1.26 1.46 11 0.09 0.05 Holborn 60 1.26 1.26 4 0.09 0.08 Finsbury 107 1.81 1.24 9 0.18 0.10 London, City of 30 1.07 1.65 1 0.04 0.05 Shoreditch 185 1.50 1.66 14 0.16 0.13 Bethnal Green 223 1.66 1.72 10 0.15 0.08 Stepney 471 1.79 1.68 22 0.15 0.08 Poplar 345 1.52 2.11 34 0.17 0.21 Southwark 327 1.43 1.71 19 0.16 0.10 Bermondsey 243 1.79 1.92 17 0.13 0.13 Lambeth 408 1.20 1.35 37 0.13 0.12 Battersea 288 1.59 1.69 20 0.11 0.12 Wandsworth 447 1.43 1.33 16 0.08 0.05 Camberwell 403 1.31 1.51 18 0.12 0.07 Deptford 245 1.58 2.21 17 0.11 0.15 Greenwich 267 2.34 2.74 12 0.14 0.12 Lewisham 431 2.35 2.51 35 0.18 0.20 Woolwich 402 2.42 3.23 17 0.14 0.14 Port of London — — — — — — London 7,654 1.53 1.67 4.31 0.12 0.09 Diphtheria cases and deaths by age and sex -London. It will be seen from the foregoing table that in the period 1908-12 the diphtheria death-rate was highest in Finsbury and Lewisham (0.18) and lowest in Stoke Newington (0.03); in the year 1913, Poplar (0.21) had the highest death-rate, and Chelsea (0.02) the lowest. The diphtheria death-rates in London in each of the four quarters of the year 1913 were as follows : first quarter, 0.10 ; second quarter, 0.09 ; third quarter, 0.06 ; and fourth quarter, 0.11. 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 1913. At " all ages " the fatality was higher among males, while the incidence of attack was slightly higher among females. In the age-groups adopted for the purposes of this table the greatest incidence of attack was upon males and females aged 4-5 years. The greatest incidence of death was upon males and females aged 1-2 years, and the fatality was greatest among males and females under 2 years of age. Age-period. Males. Females. Notified Cases, 53 weeks. Deaths, 365 days. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. Notified Cases, 53 weeks. Deaths, 365 days. Case mortality per cent. Rates per 100,000 living. Cases. Deaths. All Ages 3,445 209 6.2 160 10 4,209 219 5.3 173 9 0- 113 19 17.1 226 39 100 28 28.5 204 58 1- 195 33 17.2 426 73 199 36 18.4 439 81 2- 294 29 10.0 607 61 255 24 9.6 533 51 3- 350 33 9.6 736 71 360 26 7.3 752 55 4— 390 26 6.8 838 57 354 23 6.6 762 50 5— 1,263 62 5.0 576 29 1,553 69 4.5 702 32 10— 429 4 0.9 212 2 587 10 1.7 285 5 15— 168 — — 86 — 261 1 0.4 121 0 20— 81 — — 42 — 195 — — 81 — 25— 94 2 2.2 25 1 223 — — 51 - 35— 36 - — 12 — 83 1 1.2 25 0 45— 22 — — 10 — 21 — — 9 - 55 & upwards 10 1 10.2 4 0 18 1 5.6 6 0 The attack rate for diphtheria was somewhat higher in 1913 than in 1912, especially as regards females. The case mortality was lower than in the earlier year, and this, too, was most marked in the case of females. 5,475 cases, or nearly 72 per cent. of the notified cases, were removed to hospitals of 27 Report of the County. Medical Officer—General. the Metropolitan Asylums Board, and the mortality rates among these cases have therefore great influence in determining the rates as a whole. In the Board's report for 1913 the following statement occurs: "It has been suggested that the decline in the mortality rate which followed the introduction of the antitoxin serum treatment of diphtheria might largely be accounted for by the inclusion of numbers of cases which were certified after the bacteriological test only. Therefore such cases have been shown separately in Table 1. It is very satisfactory to find that, notwithstanding the exclusion of the bacteriological cases from the above Table V., the death-rate, calculated on the admissions, for last year was 65, the lowest on record, as compared with a rate of 30 per cent. before the introduction of antitoxin, and it was 2.4 below the average rate for the preceding ten years."Reference to Table I. in the Board's report shows that of the 5,475 cases admitted, only 399 are designated "Diphtheria (bacteriological)." Obviously, this number does not represent the proportion of cases with very mild symptoms or no symptoms at all, now notified, which would not have been notified twenty years ago. The method of exclusion of cases recorded as " Diphtheria (bacteriological) " fails to take adequate account of the pronounced alteration of view as regards diagnosis which has been brought about in recent years. Curiously enough, although diphtheria is as a rule more fatal to males than to females, among the cases under two years of age admitted to the fever hospitals in 1913, the mortality rate as shown in the Board's Table V. was for males 13.5 per cent. whilst for females it was nearlv 23 per cent. Diphtheria case rates, London boroughs. To enable the variations in diphtheria prevalence in the several sanitary districts to be more clearly appreciated, the following table has been prepared. This table shows the comparative case-rates of each district in each of the years 1891-1913 inclusive, i.e., the case-rates of each district are shown in relation to the London case-rate of the same year, the London rate being taken as 100. The figures for the years 1901-9 differ from those given in previous reports owing to the revision of the population estimates on the basis of the results of the 1911 census. Metropolitan borough. Diphtheria.-Comparative case-rate (London case-rate taken as 100). 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 Paddington 104 77 73 117 74 66 91 98 68 44 88 65 61 63 47 72 61 59 87 69 73 114 126 Kensington 78 60 68 63 86 70 67 49 51 74 53 54 60 67 52 57 74 78 69 74 78 67 50 Hammersmith 195 164 87 72 77 67 49 58 58 85 75 68 85 111 146 134 94 97 108 112 99 91 66 Fulham 61 58 78 126 139 99 109 145 135 178 175 130 122 132 139 156 212 152 145 139 125 95 101 Chelsea 138 110 83 107 143 184 107 79 61 74 54 77 80 54 51 130 118 117 98 102 77 87 56 Westminster, City of 58 91 57 53 61 53 59 67 50 59 52 67 61 52 48 69 44 64 93 76 56 65 73 St. Marylebone 70 81 88 78 64 66 53 64 47 59 73 76 103 58 72 63 53 55 63 88 70 82 67 Hampstead 105 96 73 53 61 84 47 65 48 74 70 50 61 43 55 67 69 43 38 49 108 119 88 St. Pancras 89 95 103 83 90 64 76 78 79 93 149 152 132 95 88 69 80 78 98 99 119 162 121 Islington 152 119 86 103 70 106 73 60 68 70 102 112 81 66 74 75 75 91 89 119 111 101 100 Stoke Newington 83 113 97 77 70 70 52 59 34 111 105 82 46 75 110 52 120 72 37 86 95 69 98 Hackney 131 147 135 108 93 89 122 152 106 107 167 139 145 163 122 99 127 99 81 70 86 72 87 Holborn 52 89 79 61 66 61 104 102 46 70 105 86 53 51 58 69 62 54 62 74 106 18 75 Finsbury 118 82 130 81 86 112 170 163 93 74 110 101 77 94 103 118 86 105 125 139 124 106 75 London, City of 59 130 60 49 51 74 71 60 68 89 95 158 63 102 47 44 65 76 62 82 72 58 99 Shoreditch 124 89 131 95 80 97 103 80 103 111 103 84 77 101 110 71 101 105 112 96 96 80 100 Bethnal Green 154 230 181 168 143 114 144 100 89 115 133 105 110 206 165 110 116 122 97 117 96 109 103 Stepney 106 132 112 123 157 150 128 93 89 107 106 111 108 176 154 118 135 131 139 118 113 83 101 Poplar 191 148 214 159 179 133 141 105 83 141 137 118 149 252 207 85 113 109 88 88 107 100 127 Southwark 71 72 116 113 86 106 102 151 207 141 101 111 102 88 106 114 110 78 89 121 94 95 102 Bermondsey 68 60 84 126 80 99 97 90 177 133 94 92 79 94 91 147 129 112 105 137 124 111 115 Lambeth 88 97 91 83 88 74 83 103 121 104 65 68 67 68 105 79 56 65 86 90 83 72 81 Battersea 144 123 132 122 97 81 125 178 116 70 59 74 109 85 80 92 110 123 116 111 81 88 102 Wandsworth 74 83 84 79 60 51 100 114 99 74 76 132 125 98 92 114 117 115 84 77 100 85 80 Camberwell 69 65 67 112 140 180 154 102 156 130 125 113 82 65 66 77 80 86 97 86 82 77 91 Deptford 72 68 86 153 225 113 141 132 121 111 144 103 243 111 94 156 150 107 121 98 92 98 132 Greenwich 60 43 84 85 137 189 82 105 122 89 73 81 127 100 107 240 138 132 115 144 203 168 164 Lewisham 48 74 82 70 57 122 85 127 170 126 87 129 121 59 77 101 105 176 170 117 130 168 151 Woolwich 32 68 66 66 81 96 91 86 100 115 69 91 91 85 161 182 120 173 150 117 119 22! 194 London 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Cases notified as diphtheria and admitted into the hospitals of the Metropolitan Asylums Board but in which the diagnosis was not subsequently confirmed, constituted the following percentage of total cases admitted in successive years Year. Percentage. Year. Percentage. 1901 12.8 1908 18.1 1902 13.5 1909 16.8 1903 14.7 1910 14.2 1904 161 1911 13.5 1905 18.0 1912 13.8 1906 15.5 1913 16.6 1907 17.0 Diphtheria -diagnosis not confirmed. 23610 E 2 28 Annual Report of the London, County Council, 1913. Whooping-cough. The deaths from whooping-cough in the Administrative County of London during the year 1913 (53 weeks) numbered 800, as compared with 970 in 1912 (52 weeks). Whooping coughdeath-rates. The death-rates from this disease in 1913 and preceding periods have been as follows :— Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1841-1850 0.87 1904 0.33a 1851-1860 0.88 1905 0.33a 1861-1870 0.88 1906 0.27a 1871-1880 0.81 1907 0.40a 1881-1890 0.69 1908 0.21a 1891-1900 0.50a 1909 0.28a 1901-1910 0.32a 1910 0.30a 1901 0.35a 1911 0.23a 1902 0.41a 1912 0.21a 1903 0.36a 1913 0.17a whoopingcough death rateschildren 0-5 years. The following table shows the death-rates from whooping-cough in London per 1,000 children living at ages 0-5 years. The rates are shown for each decennium from 1851 and for the several years from 1901 to 1913. Period. Death-rate per 1,000 children living at ages 0-5. Period. Death-rate per 1,000 children living at ages 0-5. 1851-1860 6.56 1904 3.01b 1861-1870 6.53 1905 3.01b 1871-1880 6.02 1906 2.47b 1881-1890 5.34 1907 3.64b 1891-1900 4.21b 1908 2.00b 1901-1910 2.95b 1909 2.56b 1910 2.836 1901 3.14b 1911 2.15a 1902 3.64b 1912 2.02a 1903 3.23b 1913 1.63a The death-rate in each year since 1840 in relation to the mean of the period 1841-1913 is shown in diagram (N), while the deaths in each month since 1890 in relation to the mean monthly deaths of the period 1891-1913 are shown in diagram (G), facing page 21. Whoopingcough deathrates in large English towns. It will be seen from the following table that in the quinquennium 1908-12 the London whoopingcough death-rate was exceeded by that of all the undermentioned towns except Bradford, Hull, Nottingham, Portsmouth and Leicester; while in the year 1913 it exceeded that of Sheffield, Bristol, Bradford, Nottingham, Portsmouth and Leicester. Town. 1908-12. 1913. Town. 1908-12. 1913. London 0.25a 0.17a Bradford 0.18 0.07 Greater London 0.23 0.15 Hull 0.22 0.27 Liverpool 0.41 0.31 Newcastle-on-Tyne 0.34 0.34 Manchester 0.34 0.19 Nottingham 0.23 0.16 Birmingham 0.37 0.19 Stoke-on-Trent 0.32 0.49 Sheffield 0.33 0.14 Portsmouth 0.20 0.07 Leeds 0.26 0.20 Salford 0.36 0.17 Bristol 0.26 0.14 Leicester 0.20 0.05 West Ham 0.38 0.18 (a) See footnote (c), page 6. (6) 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. Diagram N. -Whooping Cough.- (LONDON) Diagram 0. -Typhus.- (LONDON) 29 Report of the County Medical Officer-General. Whooping Cough in London boroughs The following table shows the whooping-cough deaths and death-rates for the year 1913 and the death-rates for the period 1908-12 in the several sanitary districts :- Metropolitan borough. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. Paddington 37 0.20 0.26 Kensington 29 0.18 0.17 Hammersmith 47 0.24 0.37 Fulham 27 0.28 0.17 Chelsea 5 0.20 0.08 Westminster, City of 7 0.11 0.04 St. Marylebone 10 0.22 0.09 Hampstead 11 0.10 0.13 St. Pancras 31 0.27 0.14 Islington 61 0.24 0.18 Stoke Newington 6 0.19 0.12 Hackney 23 0.22 0.10 Holborn 6 0.20 0.13 Finsbury 31 0.37 0.36 London, City of 2 0.09 0.11 Shoreditch 29 0.39 0.26 Bethnal Green 34 0.31 0.26 Stepney 26 0.32 0.09 Poplar 38 0.43 0.23 Southwark 38 0.29 0.20 Bermondsey 47 0.33 0.37 Lambeth 47 0.21 0.16 Battersea 28 0.27 0.16 Wandsworth 23 0.22 0.07 Camberwell 54 0.21 0.20 Deptford 46 0.33 0.41 Greenwich 24 0.32 0.25 Lewisham 23 0.15 0.13 Woolwich 10 0.17 0.08 London 800 0.25 0.17 It will be seen from the foregoing table that in the period 1908-12 the highest whooping-cough death-rate was that of Poplar (0.43), and the lowest was that of the City of London (0.09); in the year 1913, Deptford (0.41) had the highest death-rate and Westminster (0.04) the lowest. The whooping-cough death-rates in London in each of the four quarters of the year 1913 were as follows: first quarter, 0.27; second quarter, 0.23; third quarter, 0.11; and the fourth quarter, 0.10. Typhus death rates, London, Typhus. There were no deaths from typhus in the Administrative County of London during the year 1913. The death-rates from this disease in successive periods have been as follows:- Period. Death-rate per 1,000 persons living. 1871-1880 .055 1881-1890 .008 1891-1900 .001a 1901-1910 .000a 1901 .001a 1902 - 1903 .001a 1904 - 1905 - 1906 - 1907 - 1908 - 1909 _ . 1910 - 1911 - 1912 - 1913 - (a) See footnote (c), page 6. 30 Annual Report of the London County Council, 1913. Eight cases of typhus or suspected typhus were reported during the year. Six of these cases (1 to 6) form one group and all occurred in one four-roomed house situated in the Borough of Stepney. The following is a history of the cases:- Case No. 1.—J. F. W., aged 30, a street vendor of vinegar, was taken ill on Sunday, 11th March, about mid-day. He was attended at home and on 25th March, when he was admitted to the Mile End Infirmary, his temperature was 102.5 deg. and rales and rhonchi were heard in both lungs. There was no sign of disease in the abdomen. His bowels were quite regular and there was no diarrhœa. On 27th March the right lower lobe of the lung was solid. On 3rd April his chest was quite clear. He was discharged on 15th April. The diagnosis-made was one of pneumonia. Case No. 2.—A. M. W., aged 21, wife of No. (1), was taken ill on 5th April. On 9th April she was admitted to the Mile End Infirmary. On admission her temperature was 102.6 deg. She had a rash on her right arm with scattered spots elsewhere. There were no signs of disease in her lungs, heart or abdomen. The tongue was furred and the urine albuminous. On 12th April she was dull mentally, her legs were drawn up and she vomited after taking milk ; after this date she improved. She was discharged from the infirmary about the end of May. Her temperature chart is very suggestive of enteric fever. In the opinion of the medical attendant she suffered from enteric fever, but the case has not been notified as the medical superintendent of the infirmary did not so regard it. Case No. 3.-On 11th April, J. B., aged 47, the father of No. (2), a painter, was taken ill and he was admitted to the Mile End Infirmary on 16th April. On admission his temperature was 103 deg. and he complained of pains all over his stomach, but there was no vomiting. He had flea bites on his legs. His blood was examined and gave a negative Widal reaction on 17th April, but was positive on 24th April. There was no tenderness or rigidity over the abdomen and the spleen was not palpably enlarged. He became gradually worse and on 27th April the pulse was very weak and he became delirious. He died on 29th April and on the same day the case was notified by the medical superintendent of the infirmary. Case No. 4.-F. M. B., aged 7, was taken ill on 4th May and notified to be suffering from enteric fever on 7th May. She was removed to the South Eastern Fever Hospital on the same day. She was notified to be suffering from typhus fever on 19th May. Case No. 5.-M. B., aged 17, was notified on 16th May to be suffering from typhoid fever. She had been removed to the fever hospital late the previous evening—14th May—having been notified as enteric fever. She had been ill since 11th May. On 17th May she was reported as suffering from typhus fever and not enteric fever. Case No. 6.—K. B., visitor to the house, fell ill about 11th May. Admitted to Metropolitan Hospital on 19th May. Removed to Eastern Hospital on 27th May. The case was diagnosed as typhus on 28th May. The source of infection in this group of cases could not be traced, and even now there appears to be doubt as to whether the illness at this house.was typhoid fever or typhus fever, so great was the difficulty which was experienced in determining whether the individual cases were, clinically speaking, cases of typhus or typhoid fever. In all probability the disease from which the patients suffered was really one and the same in all instances, and that being so, great interest must be attached to the considerable divergence of view as to the diagnosis. There were two other cases, one in Bermondsey and one in Southwark, neither of which had any connection with the Stepney cases. They were as follows:- Case No. 7.—A. S., aged 39, a labourer. The patient had been ill since 11th August and before that date he had diarrhoea. There was a rash on the 14th and he was certified as suffering from enteric fever. He was subsequently notified as suffering from typhus and removed to the Eastern Fever Hospital on 21st August. On 25th August the temperature was down, there was a purplish rash on the legs (suspicious of typhus) and arms, while the trunk was more or less clear. Case No. 8.—H. L., aged 20, a tin solderer. The. onset was sudden on 11th May. On the 21st vomiting and shivering occurred, and a rash on the arms developed on the 23rd. The patient was admitted to the South Eastern Hospital on, the 24th. By next day the rash had become universal except on the forehead and circumoral region. There ensued violent delirium and convulsions; the eyes were suffused ; the tongue was furred and dry ; fauces normal; some cough ; respirations 44 ; pulse 140 ; temperature 103 deg. ; rhonchi in lungs. The following day the patient was a little better ; mind clear ; tongue moist; slight deafness. Diagnosed as typhus. Typhoid Fever. The number of cases of typhoid fever notified in the Administrative County of London during 1913 (53 weeks) was 758, compared with 704 in the year 1912 (52 weeks). The deaths from this disease numbered 114 in 1913 (53 weeks), compared with 117 in 1912 (52 weeks). Diagram P. - Enteric Fever.- (LONDON) Diagram Q. -Enteric Fever.- Notified Cases. (LONDON) Diagram R. - Enteric Fever.- (LONDON) Report of the County Medical Officer—General. 31 The case-rates and death-rates per 1,000 persons living and the case-mortality per cent. in 1913 and preceding periods were as follows:- Period. Death-rate per 1,000 persons living. Case-rate per 1,000 persons living. Case-mortality per cent. 1871-1880 0.24 -a -a 1881-1890 0.19 -a -a 1891-1900 0.14b 0.8 17.4 1901-1910 0.06b 0.4 15.3 1901 0.11b 0.7 15.6 1902 0.12b 0.7 15.8 1903 0.08b 0.5 15.7 1904 0.06b 0.4 15.1 1905 0.05b 0.3 15.1 1906 0.06b 0.4 16.3 1907 0.04b 0.3 13.9 1908 0.05b 0.3 16.6 1909 0.03b 0.2 14.0 1910 0.04b 0.3 15.3 1911 0.03b 0.2 14.1 1912 0.03b 0.2 16.6 1913 0.02b 0.2 15.0 Typhoid fever death-rates and caserates, London. The death-rate in each year since 1868 in relation to the mean death-rate of the period 1869-1913 is shown in diagram (P). The notified cases in each week of 1913 may be compared with the average weekly notifications of the period 1890-1913 on reference to diagram (Q). The monthly case-rate and case-mortality in each of the years 1891-1913 in relation to the mean of the whole period is shown in diagram (R). Last year reference was made to the comprehensive report, which appeared in 1912, giving an account of the experience gained in the campaign against typhoid fever instituted by Robert Koch in South-West Germany in 1904. The point of view therein illustrated and defended in great detail was one which had been elaborated as the result of the eight years' subsequent examination by German bacteriologists of Koch's hypothesis. Koch held that typhoid fever was due to an organism, the natural habitat of which is the human body, and he and his followers were led to assume that typhoid fever can be stamped out by the institution of sufficiently stringent measures directed against the typhoid bacillus whenever and wherever it is found directly associated with the healthy or diseased human body. Some of the difficulties arising out of these assumptions were considered in last year's report. During 1913 an important report appeared which throws some very interesting side lights upon Koch's hypothesis and upon the general question of the aetiology of typhoid fever. In his 10th Report on Research Work, Dr. A. C. Houston, Director of Water Examinations, Metropolitan Water Board, attacks once more, and in greater detail than he has done hitherto, a problem which has been for some years engaging his special attention. Dr. Houston has made many attempts to isolate the typhoid bacillus from raw Thames water. Save in two instances he has been unsuccessful, but he has realised from the first the limitations of the method of examination which has been employed. The bacteriologist is faced with the task of endeavouring to pick out the typhoid bacillus from among vast numbers of other organisms, of endeavouring in fact to discover the needle in the bundle of hay ; or, rather, it might be said of predicting how many needles may be expected to be present in an almost unlimited number of haystacks. Thus, as the outcome of much labour he is only able ultimately to assert, under the strict conditions of limitation necessarily observed, that in the small number of bundles of hay examined with the particular object in view, he has only twice found what appeared to be a needle. Dr. Houston has employed two somewhat diverse methods of arriving at his results and the general conclusions are given on page 11 of his report. It transpires that neglecting the two apparently positive results, it may be inferred that the typhoid bacillus will not be found in 9 c.c. of raw river water, judging by one of the methods employed, or in 17 c.c. of raw river water, judging by the other method. The quality in this particular connection of filtered water is assumed to be 1,000 times more satisfactory than that of raw water, and hence absence of the typhoid bacillus may be generally inferred from samples of 9,000 c.c. or 17,000 c.c. of filtered water, i.e., from 10 to 20 litres, or say, 15 to 30 pints of such water. Dr. Houston (pp. 6 and 7 of his Research Report) discusses two problems: "Whether typhoid bacilli reach the consumer singly or in clumps, and whether one or a number are necessary to start the infective process," problems which, he says, " are of extreme interest to epidemiologists." He states that, assuming a customary draught of water to be half a pint, we have to "face the circumstance that although the typhoid bacillus may not be present in 9047 c.c, it may yet be present in,say, 9152 c.c., so that on the average we may ingest it once out of every 32 draughts." He adds, " If a single typhoid bacillus ingested with a draught of water can conceivably infect with typhoid fever a susceptible individual, this would be a serious matter, but if, as seems more probable, a number are always or usually required to start the infective process and they are present as ' individuals ' and not as ' clumps' and are equally distributed throughout the filtered water, infection might seldom, if ever, take place." (a) The Infectious Disease (Notification) Act, came into force in 1889. (b) See footnote (c), page 6. 32 Annual Report of the London County Council, 1913. During 1913 the low level of typhoid fever prevalence now maintained for several years was again observed and, indeed, as remarked in last year's report, in 1909, 1912 and 1913 there was practically no autumnal increase at all. There are reasons for thinking that at any rate the large majority of the cases of typhoid fever which occurred in London in those years, have been due to causes other than the consumption of drinking water ; and yet if the number of times each individual must be assumed to swallow single bacilli in the course of a year be multiplied by the figure representing the population of London (four and a half millions), it transpires that the total number of instances in which it cannot be reasonably inferred that the bacillus has not been consumed by Londoners amounts to several millions. But here, in addition to the question of dosage, it is necessary to bear in mind the fact that although Dr. Houston has only happened to light upon two single bacilli indistinguishable from typhoid bacilli, further examination may conceivably result in his coming across samples which contain not merely a single typhoid bacillus, but a large number of such bacilli. It should be realised that the total bulk of water examined, in the course of the detailed investigations described in the Research Report, is almost infinitesimally small in comparison with the amount of water consumed annually by the London population. Apparently these examinations have related in all to only 29,470 selected colonies from 257 separate raw river water samples (see Ninth Research Report, p. 6) or to a total amount of not more than some twenty or thirty gallons of water. The sum of all the samples thus represents a proportion of only one to many million parts of the total amount of water actually supplied in London during the period in which Dr. Houston's examinations were made. To illustrate the danger of drawing conclusions from the data thus available, a case which may perhaps be regarded as more or less parallel may be considered. Two or three hundred children bear some such a like small proportion, to the child population of the world, as that above referred to. No one would suggest that if examinationof 250 children, taken more or less at random throughout the world, showed only two children presenting the rash of smallpox, it could reasonably be inferred that smallpox was a negligible quantity at the present time so far as the child population on the earth is concerned. There is, moreover, the consideration that in the case of samples of water the limitations of the method of examination used are admittedly very great, so that it would have to be assumed, in the more or less parallel case of the examination of the school children, that while only two cases of smallpox were detected, there might have been in actual fact many others. This consideration further emphasises the need for caution in interpreting the bacteriological results just referred to. There is a further point which should be mentioned. In Table 5 of the Tenth Research Report there are two columns f and g, and a third column h, which gives figures corresponding to the ratios f/g. The averages of the numbers in columns f and g are given, but the average of the ratios in column h is obtained by dividing the average of the figures in column f by the average of the figures in column g. Such a method of calculating an average would be legitimate if it were desired, say, to ascertain the mean death-rate of a number of different communities. If, for example, twelve towns were selected with widely varying death-rates and populations, the true mean death-rate per unit of population of total deaths in the twelve towns,/total population of the twelve towns, but if the group of towns would be rightly expressed by the ratio on the other hand it were desired to ascertain the chance of death in a period of one year of an individual residing for one month of the year in each of the twelve towns consecutively, this chance would be equal to the arithmetical average of the annual death-rates per unit of the towns in question, and would be independent of the size of the populations concerned. Thus, if it be assumed that the annual death-rates per unit of each of the towns is a, b, c, d . . . l respectively then the chance of death in one month to an individual residing in the first town for that period would be a/12, in the second b/12, etc., and his chance of death in the twelve months would be a+b+c...+1/12. Having regard to the fact that the latter instance is analogous to the case discussed by Dr. Houston it would appear that the use of the arithmetical mean of the ratios f/g would have been preferable to the use of the average upon which his deductions are based, for it is especially necessary to note that the variation of one of the individual ratios in column h from the "average," depends in large measure on the time of the year at which the sample is taken. Thus in Table 3 the figures for August and September are 185 and 640 and those for February and March 70,400 and 117,333, the average being 1,214. It is not a little remarkable that the figures in the last column of this table present so marked a seasonal variation ; in August the degree of pollution of the filtered river water (as measured by the particular test employed) was six or seven hundred times as great as in March and, if a seasonal curve of pollution be constructed, it will be found that the water is much less polluted in the winter and spring and becomes more polluted in the late summer and early autumn ; the period of maximum pollution, it may be observed, precedes by some six or eight weeks the time when typhoid fever is wont to be specially prevalent. It should be noted, however, that it is pointed out (p. 10) that the bad results obtained in August are " probably due, in part at all events, to a slight multiplication of bacteria which can grow in bilesalt-agar, but which are only very doubtfully related to sewage contamination " ; and again, " the bilesalt-agar test is an excellent one, but like all other tests it has its limitations," and . . any bacteriologist of experiene will agree that under certain conditions, which do not readily lend themselves to definition, Report of the County Medical Officer—General. 33 we may occasionally have a relatively high bile-salt-agar count when the evidence is against the water being seriously if at all polluted." In so far, on the other hand, as the bile-salt agar test is to be trusted, and in so far as reliance is to be placed on the kind of impurity observed as a measure of risk, the results show that during August and September, the danger incurred is far higher than at other time If due allowance is made for period of storage before consumption of the water and for period of incubation of the disease, this finding might even be held by an enthusiastic " water theorist" to be suggestive, for the maximum prevalence of typhoid fever is apt to occur about six or eight weeks after the period of maximum impurity. These considerations make it clear that it is not safe to rely upon averages taken over a whole year. It cannot reasonably be assumed, because absence of the typhoid bacillus can be inferred from 9 c.c. or 17 c.c. (see Table 4 already referred to), when a whole year is taken into account, that the absence of a typhoid bacillus can be inferred from these amounts of water at times shortly preceding the period of special typhoid prevalence. It is, in point of fact, possible that, at such times, absence of the typhoid bacillus from far smaller amounts of water only can safely be inferred. The points raised by Dr. Houston's inquiries are both interesting and suggestive, but clearly the most striking result of his investigations is the demonstration in the water examined of bacilli indistinguishable from typhoid bacilli. He speaks of them, it is true (on p. 6 of his Report) as the two " query typhoid " microbes, but, he adds, " If they had been isolated from the blood or excretions of a patient suffering from typhoid fever they would, I think, have been classed as typhoid bacilli, as the matter stands all that can be said is that they were practically indistinguishable, according to my tests, from this microbe." It is interesting to contrast this cautious attitude of mind with the much more positive conclusions bacteriologists were prepared to draw as recently as nine years ago from, bacteriologically speaking, somewhat similar findings. Just after the outbreak of typhoid fever in Lincoln in 1905, the official report on the outbreak records that " search was made for the bacillus typhosus in the water of the public supply ; and from a sample taken from one of the sources of this supply on February 1st, a microorganism was recovered which resembled the bacillus typhosus in all essential respects. A similar micro-organism which was regarded as possibly being the bacillus typhosus,somewhat altered in character by sojourn in the water, was isolated from a sample of sediment taken from the ' pure water tank ' which receives the water after filtration at the waterworks on February 11th." The evidence, apart from that furnished by bacteriological inquiry, afforded "ground for presumption that the public water supply of the Corporation of Lincoln was concerned in the dissemination of the fever." The two positive bacteriological findings were, however, held to determine the matter at Lincoln. It may be argued, of course, that at Lincoln there was an outburst, in London the typhoid fever incidence was scattered both in place and in time. In other words the results of the bacteriological examination must be weighed with the other evidence, but when it is realised that Dr. Houston evidently attaches no great importance to his two positive results the conclusion follows that if these results can be almost dismissed from consideration in London, too great significance must not be attached to similar findings elsewhere. In the last nine or ten years a good deal of time has been devoted in Germany, in America and in this country to examination of organisms isolated from public water supplies presenting greater or less resemblance to typhoid bacilli. The odd thing has been that in several cases in which it has been declared that the typhoid organism had been isolated, the water was doing no harm, e.g., in a case reported in Germany by Beck and Ohlmuller and in that of the Belfast water supplly in 1907. The suspected cultures from Belfast were exhaustively reported upon by Drs. Houston and Gordon, who concluded that implicit reliance could not be placed upon the agglutination test and they added that they could not associate a microbe causally with disease in man "even though a certain number of the tests beside the agglutination test may lend support to the hypothesis of pathogenicity." Dr. Houston's more recent and very elaborate study of Thames water carries the matter, a step further for he has now demonstrated on two separate occasions the presence of microbes indistinguishable by his most rigorous tests from the typhoid bacillus, and as this result has been obtained by examination of only two or three dozen gallons of raw water, it is clear that the entire London water supply may at times contain large numbers of such bacilli. And yet no one is disposed to suggest that London drinking water seriously contributes to the amount of typhoid fever in London. But over and above the two positive findings there stands out plainly the consideration of far greater significance, that proper regard must be paid to the limitations of bacteriology in dealing with this question, Dr. Houston's reports have brought home to all who have studied them the fact that failure to demonstrate the presence of the typhoid bacillus in a particular specimen of water does not necessarily justify the conclusion that the bacillus is not there. In point of fact the inference that is forced upon the mind is practically similar to that which must be drawn from the German work referred to in last year's report. When study of bacillus carriers was first undertaken it was thought that the existence of the bacillus carrying propensity must necessarily mean infection of those with whom the bacillus carrier came into contact. In last year's report some of the difficulties which have to be encountered by the upholder of this hypothesis were enumerated and discussed. Similarly it has been assumed that the presence of a bacillus indistinguishable from the typhoid bacillus in a public water supply necessarily implies grave danger, but here again the results do not bear out the surmise. Those who accept the contact theory are compelled to resort to the view that the carrier's bacilli do not always cause harm, but only do so on the rare occasions (in the life of many carriers, at any rate, such occasions never occur) when the carrier becomes effective. Similarly, study of the bacteriology of water compels the bacteriologist, who maintains that the bacillus typhosus is the causal organism of typhoid fever, to assume either that something must be conjoined with this 23610 F 34 Annual Report of the London County Council, 1913. bacillus if it is to be " effective," or alternatively, that no final deductions can be drawn from the presence of single bacilli, and that insistence must be laid upon the question of dosage. These most laborious and thorough inquiries of Dr. Houston will necessarily tend to confirm many students of this difficult question in the view that presence of the typhoid bacillus is not the same thing as potential infectivity; the close association of typhoid bacilli with typhoid fever in man lends strong support to Koch's doctrine that the human body is par excellence the manufactory of typhoid bacilli, but the evidence laboriously collected by Koch's followers with a view to demonstrating how the typhoid bacillus obtains access to the body and sets up typhoid fever rather tends to supply the rival theory that it is typhoid fever which leads to development of the typhoid bacillus in the human subject. Dr. Houston, approaching the problem from quite a different standpoint, also obtains results which most readily find explanation on the hypothesis that the bacillus should be looked upon as effect rather than cause. Dr. Houston, five years ago, in his Third Research Report (p. 18), in giving a carefully considered opinion as to the value of storage, referred to certain " qualifying considerations," and among these was the fact that "epidemiologists are displaying a not new but aggravated tendency to question the integrity of the reputed causal agents of certain waterborne diseases. Some, indeed, go so far as to consider that the typhoid bacillus and cholera vibrio may, in a causal sense, come to share the inglorious fate, in this respect, of the hog cholera bacillus." Dr. Houston's own work in the last five years, from one point of view, rather tends further to aggravate the tendency mentioned. Demonstration of the presence in two instances, and the consequent presumption of the presence in considerable numbers of bacilli indisinguishable from typhoid bacilli in drinking water, which epidemiologically considered has during recent years not fallen under suspicion, once more raises question as to the significance to be attached to the presence of such bacilli. Twenty years ago importance was attached to the argument that the bacilli as known in the laboratory could not survive a run down a river like the Tees. Dr. Barry, in giving evidence before the Water Commission (1892-93), said : " If it is found that what is called the specific bacillus of typhoid fever will not live under particular circumstances, as has seemed to be shown by laboratory experiments then I think that possibly the true bacterium has not been found." Now, thanks to improvements in bacteriological technique, the pendulum has swung the other way, and Dr. Houston finds no dearth but an embarras de richesses. Thus, as has already been pointed out elsewhere (Trans. Roy. Soc. of Med. 1906-07): "During the last fifteen years a new difficulty (has) arisen inasmuch as it has been ascertained that large communities can with impunity be supplied with polluted river water for periods of some years, without manifest injury, provided certain precautions are adopted, and these it would seem are not of a kind which necessarily precludes the bacillus from obtaining access to household supplies." The experience of the last seven years goes to confirm the view expressed in 1907. The difficulty now is not to explain how the bacillus can survive, but why bacilli which survive do not cause mischief. The suspicion necessarily arises as to whether it may not be necessary to look elsewhere than to these bacilli for the cause of typhoid fever. If, for the sake of argument, it could be assumed that the causa causans of typhoid fever is stopped by a sand filter, the close correlation between the carrying into effect of improvements in the treatment of raw river water and diminution of water-borne typhoid might in part be explained and it would then be no longer difficult to understand Dr. Houston's results. Typhoid fever in London boroughs. The following table shows the typhoid fever cases, deaths, case-rates and death-rates for the year 1913, and the case-rates and death-rates for the period 1908-12 in the several sanitary districts- Metropolitan borough. Notified cases, 1913 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. 1908-12. 1913. Paddington 25 0.21 0.17 6 0.03 0.04 Kensington 28 0.19 0.16 4 0.03 0.02 Hammersmith 13 0.19 0.10 - 0.04 — Fulham 34 0.21 0.21 8 0.04 0.05 Chelsea 7 0.18 0.11 1 0.03 0.02 Westminster, City of 29 0.20 0.18 3 0.03 0.02 St. Marylebone 19 0.18 0.16 5 0.03 0.04 Hampstead 15 0.20 0.17 1 0.04 0.01 St. Pancras 41 0.25 0.19 6 0.03 0.03 Islington 50 0.24 0.15 5 0.04 0.02 Stoke Newington 9 0.16 0.18 2 0.03 0.04 Hackney 39 0.24 0.17 4 0.03 0.02 Holborn 7 0.35 0.15 - 0.06 - Finsbury 15 0.40 0.17 — 0.06 — London, City of 6 0.25 0.33 2 0.03 0.1l Shoreditch 15 0.43 0.13 1 0.05 0.01 Bethnal Green 23 0.44 0.18 4 0.06 0.03 Stepney 68 0.30 0.24 11 0.04 0.04 Poplar 40 0.34 0.24 5 0.07 0.03 Southwark 39 0.23 0.20 6 0.03 0.03 Bermondsey 27 0.30 0.21 3 0.04 0.02 Continued on next page. 35 Report of the County Medical Officer—General. 35 Metropolitan Borough. Notified. cases, 1913 (53 weeks). Case-rate per 1,000 persons living. Deaths, 1913 (53 weeks). Death-rate per 1,000 persons living. 1908-12. 1913. 1908-12. 1913. Lambeth 39 0.21 0.13 8 0.04 0.03 Battersea 20 0.23 0.12 6 0.03 0.04 Wandsworth 52 0.20 0.15 5 0.03 0.01 Camberwell 23 0.17 0.09 5 0.02 0.02 Deptford 17 0.19 0.15 2 0.04 0.02 Greenwich 8 0.22 0.08 2 0.04 0.02 Lewisham 34 0.18 0.20 8 0.03 0.05 Woolwich 14 0.13 0.11 1 0.01 0.01 Port of London 2 London 758 0.24 0.16 114 0.04 0.02 It will be seen that among the several sanitary districts in the period 1908-12 the typhoid fever death-rate was highest in Poplar (0.07), and lowest in Woolwich (0.01); in the year 1913 the City of London (0.11) had the highest typhoid fever death-rate, while four districts had a death-rate of 0.01 only and in Hammersmith, Holborn and Finsbury there were no deaths. The death-rates from typhoid fever in London in each of the four quarters of the year 1913 were as follows : first quarter, 0.03 ; second quarter, 0.02 ; third quarter, 0.02 ; and fourth quarter, 0.03. The following table shows the notified cases, deaths, case-rates, death-rates and fatality of typhoid fever at the several ages and for each sex in London during the year 1913. The case-rate. death-rate and fatality were, at " all ages," higher among males than among females. Typhoid fever cases and deaths by age and sex, London. 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 females aged 10-15; the greatest incidence of death was upon males aged 35-55 and females 35-45; and the fatality was greatest among males aged 45-55 and females over 55 years of age. Age-period. Males. Females. Notified Cases. 53 weeks. Deaths. 365 days. Casemor tality per cent. Rates per 100,000 living. Notified Cases. 53 weeks. Deaths. 365 days. Casemor tality per cent. Rates per 100,000 living. Cases. Deaths. Cases. Deaths. All Ages- 393 63 16.3 18 3 365 51 14.2 15 2 0- 2 - 1 - 1— — - 1 1 2- 4 - — 5 2 2 1 16.1 8 1 3— 2 — 6 - 4— 4 - 9 1 5— 58 6 10.5 26 3 32 — — 14 — 10— 51 4 8.0 25 2 45 5 11.3 22 2 15— 59 4 6.9 30 2 40 4 10.1 19 2 20— 48 7 14.8 25 4 50 6 12.2 21 3 25— 68 11 16.4 18 3 86 14 16.5 20 3 35— 53 15 28.8 18 5 59 12 20.7 17 4 45— 28 11 39.9 13 5 22 3 13.9 9 1 55 & upwards 16 5 31.7 7 2 12 4 33.8 4 1 Cases certified to be typhoid fever admitted into the hospitals of the Metropolitan Asylums Board, but in which the diagnosis was not subsequently confirmed, constituted the following percentage of total cases admitted in successive years:- Year. Percentage. Year. Percentage. 1900 18.3 1907 29.1 1901 25.4 1908 28.1 1902 21.2 1909 37.9 1903 24.2 1910 24.8 1904 26.3 1911 34.2 1905 29.7 1912 40.8 1906 25.2 1913 40.4 Typhoid feverdiagnosis not confirmed. Diarrhœa and Enteritis. The deaths at all ages from diarrhoea and enteritis in the administrative County of London during 1913 (53 weeks) numbered 3,598, as compared with 1,774 in 1912. Of the total of 3,598 deaths 2,528 occurred during the first year of life, and 570 in the second year. In each quarter the deaths numbered 376, 365, 687 and 1,170 respectively. 23610 - F2 36 Annual Report of the London County Council, 1913. In diagram (S) the death-rate from diarrhoea and enteritis among infants under two years of age in each year since 1861 is shown in relation to the mean death-rate for the period 1862-1913. Diarrhœa and Enteritis deaths and death-rates in large English towns. The following table shows that the London death-rate in 1913 from diarrhoea and enteritis among infants under two years of age per 1,000 births was lower than the death-rate of all the undermentioned large English towns, except Bristol, Newcastle-on-Tyne and Portsmouth. Town. Deaths. Death-rate per 1,000 births. Town. Deaths. Death-rate per 1,000 births. London 3,098a 27.50a Bradford 169 29.12 Greater London 4,361 24.22 Hull 337 41.22 Liverpool 881 38.15 Newcastle-on-Tyne 126 16.85 Manchester 621 32.22 Nottingham 201 32.90 Birmingham 843 35.31 Stoke-on-Trent 293 38.33 Sheffield 412 30.49 Portsmouth 112 18.70 Leeds 331 30.24 Salford 197 31.09 Bristol 156 18.88 Leicester 152 28.61 West Ham 351 37.82 Diarrhœa deaths in London boroughs. The deaths and death-rates from diarrhoea and enteritis among infants under two years of age for the year 1913 in each of the sanitary districts of London, are shown in the following table:- Metropolitan borough. Deaths 1913 (53 weeks). Death-rate 1913 per 1,000 births. Paddington 71 23.24 Kensington 80 23.83 Hammersmith 64 21.03 Fulham 98 22.78 Chelsea 24 19.09 Westminster, City of 52 23.35 St. Marylebone 37 16.66 Hampstead 18 13.57 St. Pancras 114 20.68 Islington 221 26.44 Stoke Newington 16 13.99 Hackney 141 25.53 Holborn 15 18.80 Finsbury 97 38.08 London, City of 2 11.98 Shoreditch 207 58.92 Bethnal Green 151 37.77 Stepney 287 35.06 Poplar 159 30.40 South wark 182 30.66 Bermondsey 165 42.35 Lambeth 202 27.93 Battersea 125 29.49 Wandsworth 148 21.64 Camberwell 179 26.83 Deptford 93 29.97 Greenwich 52 20.46 Lewisham 50 14.20 Woolwich 48 16.59 London 3,098 27.50 It will be seen from the foregoing table that the death-rate in 1913 from diarrhœa and enteritis per 1,000 births was highest in Shoreditch (58.92) and lowest in the City of London (11.98). The deathrates in London in each of the four quarters of the year 1913 were as follows: first quarter, 10.40; second quarter, 9.73; third quarter, 54.62; and fourth quarter, 37.37. Erysipelas. The deaths(a) from erysipelas in the Administrative County of London during 1913 (53 weeks) numbered 131 as compared with 152 in 1912 (52 weeks). ErysipelasAge distribution of deaths, London. The age-distribution of these deaths was as follows:- Under 1 Year. 1— 5— 10— 15— 20— 25— 35— 45— 55— 65— 75 + All ages. 28 6 1 — 1 4 9 8 20 18 25 11 131 (a) See footnote (c), page 6. Diagram S. -Diarrhœa & Enteritis. (Deaths under two years of age per 1,000 births) (LONDON) 37 Report of the County Medical Officer—General. Erysipelas cases and deaths. The number of cases notified and the number of deaths registered from this disease since 189C have been as follows:- Year. Notified Cases. Case-rate per 1,000 persons living. Deaths. (a) 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 1.20 183 0.04 1903 4,372 0.97 183 0.04 1904 4,943 1.09 232 0.05 1905 4,972 1.10 226 0.05 1906 5,019 1.11 245 0.05 1907 4,497 1.00 189 0.04 1908 4,203 0.91 160 0.03 1909 4,192 0.93 180 0.04 1910 3,982 0.88 133 0.03 1911 4,845 1.07 202b 0.04b 1912 4,098 0.91 152b 0.03b 1913 4,148 0.90 131b 0.03b Erysipelas case-rates in London boroughs. The number of cases of erysipelas notified and the case-rate for the year 1913, together with the case-rate for the period 1908-12, in the several sanitary districts are shown in the following table :— Metropolitan borough. Notified Cases, 1913 (53 weeks). Case-rate per 1,000 persons living. 1908-12. 1913. Paddington 112 0.76 0.77 Kensington 112 0.75 0.64 Hammersmith 101 0.68 0.80 Fulham 121 0.77 0.76 Chelsea 35 0.58 0.53 Westminster, City of 75 0.52 0.48 St. Marylebone 78 0.96 0.67 Hampstead 33 0.44 0.38 St. Pancras 215 0.81 0.99 Islington 228 0.69 0.69 Stoke Newington 35 0.62 0.68 Hackney 184 1.20 0.81 Holborn 29 0.85 0.61 Finsbury 125 1.71 1.45 London, City of 8 0.62 0.44 Shoreditch 159 1.26 1.43 Bethnal Green 265 1.59 2.04 Stepney 364 1.51 1.30 Poplar 173 1.20 1.06 Southwark 260 1.33 1.36 Bermondsey 130 1.19 1.03 Lambeth 219 0.72 0.73 Battersea 123 0.92 0.72 Wandsworth 206 0.65 0.61 Camberwell 257 0.88 0.97 Deptford 232 1.58 2.09 Greenwich 112 1.08 1.15 Lewisham 84 0.59 0.49 Woolwich 72 0.75 0.58 Port of London 1 London 4,148 0.94 0.90 (a) See footnote (b), page 28. (b) See footnote (c), page 6. 38 Annual Report of the London County Council, 1913. Erysipelas cases by age and sex, London, The following table shows the age and sex distribution of the notified cases of erysipelas in 1913— Sex. Under 1 year. 1- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75 and upwards. All Ages. Males 66 85 75 66 101 109 244 367 398 224 152 52 1,939 Females 61 95 84 87 172 128 258 360 404 294 190 76 2,209 Persons 127 180 159 153 273 237 502 727 802 518 342 128 4,148 The table shows that the number of females exceeds the number of males attacked, and it should be noted that the attack rate among females is higher, even when allowance is made for the excess of females in the total population. Puerperal Fever. The deaths(a) in the Administrative County of London during the year 1913 (53 weeks) attributed to puerperal fever(b) numbered 139, as compared with 159 in 1912 (52 weeks) and 142 in 1911 (52 weeks). Puerperal fever cases and deaths, London, The number of cases notified and the number of deaths registered from this cause since the year 1890 have been as follows- Year. Notified cases. Deaths.(c) 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 1909 287 180 1910 292 161 1911 302 142a 1912 380 159a 1913 349 139a Puerperal fever caserates and death-rates, London, If these cases and deaths are considered in relation to the total population and total births the following rates are obtained— Year. Case-rate per 1,000 living. Case-rate per 1,000 births. Death-rate (c) per 1,000 living. Death-rate (c) per 1,000 births. 1891-1895 0.07 2.17 0.06 1.97 1896-1900 0.06 2.03 0.05 1.50 1901-1905 0.06 2.10 0.04 1.44 1906-1910 0.06 2.27 0.04 1.36 1891 0.05 1.64 0.05 1.65 1892 0.08 2.55 0.07 2.37 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 1.94 0.04 1.41 1902 0.07 2.35 0.04 1.52 1903 0.05 1.79 0.04 1.30 1904 0.06 2.12 0.04 1.54 1905 0.06 2.32 0.04 1.45 1906 0.07 2.39 0.04 1.50 (Continued on next page.) (a) See footnote (c), page 6. (b) Including deaths from puerperal septicaemia and puerperal pyaemia. (c) See footnote (b), page 28. 39 Report of the County Medical Officer—General. Year. Case-rate per 1,000 living. Case-rate per 1,000 births. Death-rate (a) per 1,000 living. Death-rate (a) per 1,000 births. 1907 0.06 2.09 0.03 1.25 1908 0.05 1.86 0.03 1.11 1909 0.06 2.46 0.04 1.54 1910 0.06 2.53 0.04 1.40 1911 0.07 2.70 0.03b 1.27b 1912 0.08 3.44 0.04b 1.44b 1913 0.08 3.10 0.03b 1.23b Some interest attaches to the account of cases of puerperal fever occurring in the practice of midwives. During the year 1913 two midwives had three cases of puerperal fever in their respective practices and 14 had two cases each. The circumstances of these cases were as follows:— A. had a case in June which developed on the third day of the puerperium. The midwife was disinfected and resumed practice. In August she had another case and was again disinfected. Both these cases recovered. Towards the end of October she had a third case which terminated fatally. From the past history of this case it is probable that some latent tubal trouble was present. B. had a case in April, which terminated fatally. She was disinfected and resumed work. Another fatal case occurred in her practice in July when she was again disinfected. There was a third case in her practice during November, but in this instance the patient recovered. C. had a case in April and was disinfected. The second case in her practice occurred in September and both patients recovered. D. delivered a patient on 23rd April and continued in attendance until 30th April, when the husband called in a doctor, who found patient with a high temperature and delirious. Case was notified on 1st May and midwife was informed by doctor of notification. She had conducted another delivery on 30th April and continued in attendance without disinfection until 10th May. The patient in this case contracted puerperal fever and was notified on 4th June. The facts were in due course brought to the notice of the Central Midwives Board, and the Board removed the name of the midwife from the roll. Both patients recovered. E. had a case on 24th April which was delivered for her by another midwife. Patient's condition was never satisfactory owing to domestic trouble and on the fourteenth day she had a rise in temperature and was removed to the infirmary. The second case of puerperal fever in this midwife's practice occurred on 5th May. Both patients recovered and in neither instance could any blame be attributed to the midwife. P. had a case in October and after disinfection resumed work. The se'cond case occurred in December. Neither case was fatal. G. had a case in her practice which was notified on 3rd March. The midwife was disinfected and resumed work. The second case occurred in a patient who was confined on the 24th March ; temperature rose on the third day. The nurse in attendance upon this patient was at the time suffering from a poisoned hand and arm. This case terminated fatally, but the first patient recovered. H. had a case in May and attended another urgent call after she had been informed by the doctor who had been called to the first case that he intended to notify it; she was accordingly cautioned. The second case occurred in July and there appeared to be no connection between it and the first case. Both patients recovered. I. had a case in January and another in April. No connection could be discovered between the two cases ; both patients recovered. J. had two cases, one in July and one in August, between which no connection could be traced. Recovery ensued in each case. K. had two cases in November, one of which terminated fatally. She was disinfected and six other patients on whom she was in attendance all did well. L. had two cases, one in March and one in June. Both patients recovered. M. had a case on 4th May at which she was assisted by a pupil who a few weeks previously had accompanied another midwife from the institution to a case which was eventually notified. The pupil had, however, been thoroughly disinfected. The second case in this midwife's practice occurred on 80th May and was visited by her on account of patient's condition until the thirteenth day of the puerperium when the temperature was found to be 101.2 deg. and medical aid was obtained. N. had a case in July and another in December. Both patients recovered. O. had a case in October and another in November. As this midwife appeared to be neglecting her patients the case was reported to the Central Midwives Board. P. had two cases in February, but there was apparently no connection between them. Influenza, Bronchitis and Pneumonia. The deaths (b) attributed to influenza, which in 1912 numbered 534 (52 weeks), rose to 863 in 1913 (53 weeks). The deaths from bronchitis numbered 5,792 in 1913, as compared with 5,479 in 1912. In 1913 there were 5,887 deaths attributed to pneumonia, as compared with 5,337 in 1912. (a) See footDote (6), page 28. (b) See footnote (c), page 6. 40 Influenza, bronchitis and pneumonia death-rates, London. Annual Report of the London County Council, 1913. The deaths and death-rates from these diseases since 1889 have been as follows:— Year. Influenza (a). Bronchitis (a). Pneumonia (a). Deaths. Deathrate. Deaths. Deathrate. Deaths. Deathrate. 1890 652 0.15 12,448 2.93 6,224 1.46 1891 2,336 0.55 13,136 3.12 6,915 1.64 1892 2,264 0.53 11,183 2.63 6,164 1.45 1893 1,526 0.35 10,413 2.42 7,198 1.67 1894 750 0.17 7,816 1.80 5,321 1.23 1895 2,156 0.49 10,633 2.43 5,989 1.37 1896 496 0.11 7,558 1.68 5,537 1.23 1897 671 0.15 7,408 1.67 5,053 1.14 1898 1,283 0.29 7,779 1.74 5,440 1.22 1899 1,817 0.41 9,195 2.05 6,666 1.49 1900 1,950 0.43 8,699 1.93 7,189 1.60 1901 664 0.15 7,317 1.62 6,121 1.35 1902 1,073 0.23 7,901 1.71 6,801 1.47 1903 644 0.14 5,240 1.15 5,826 1.28 1904 709 0.16 6,373 1.40 6,609 1.45 1905 689 0.15 6,049 1.33 6,965 1.53 1906 895 0.20 5,373 1.18 6,586 1.45 1907 967 0.21 6,010 1.32 7,538 1.66 1908 1,350 0.29 5,342 1.15 6,751 1.46 1909 1,216 0.27 6,128 1.35 7,591 1.68 1910 723 0.16 5,043 1.12 6,729 1.49 ' 1911 4966 0.11b 5,203b 1.15b 5,618b 1.25b 1912 5346 0.12b 5,479b 1.22b 5,337b 1.18b 1913 8636 0.19b 5,792b 1.26b 5,887b 1.28b Influenza— seasonal distribution, The distribution of deaths (a) from influenza throughout the year(c) for each of the years 1891 to 1913 is shown in the following table No. of weeks. 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 (b) 1912 (b) 1913 (b) 1— 4 9 1308 52 272 59 37 40 244 66 1016 57 77 141 67 94 56 291 87 61 112 61 56 66 5— 8 7 637 96 96 164 58 55 368 259 298 75 224 103 62 119 44 186 276 90 151 77 101 106 9—12 8 119 162 69 1343 61 94 193 430 130 134 298 89 74 119 98 104 424 430 98 57 67 183 13—16 29 42 180 56 257 50 121 140 302 172 102 89 54 62 75 129 81 209 257 64 51 32 164 17—20 770 33 125 32 106 50 96 61 121 105 81 58 46 40 56 105 48 94 85 41 39 46 90 21—24 1044 22 72 27 35 33 54 51 82 57 30 35 37 21 38 40 41 36 46 16 15 22 30 25—28 242 15 49 19 28 17 26 25 42 16 21 20 25 17 16 21 25 28 34 11 11 9 16 29—32 51 7 23 17 14 15 18 27 27 12 18 7 18 5 4 20 14 15 15 9 10 14 8 33—36 32 9 23 20 17 10 13 10 11 11 11 16 6 9 11 15 18 12 10 17 6 15 12 37—40 13 6 18 14 15 12 19 17 19 15 12 13 17 24 22 18 19 21 15 29 17 16 22 41—44 15 20 28 29 22 27 29 46 55 17 23 35 13 92 39 35 42 30 31 25 40 48 32 45—48 35 18 152 41 47 56 35 49 61 55 44 65 44 98 44 86 39 45 56 75 46 39 54 49—52 81 28 546 58 49 56 71 52 342 46 56 99 51 138 52 228 59 57 86 75 66 70 57 Phthisis death-rates, London, 1851.1913. Phthisis. The London deaths from phthisis, including acute miliary tuberculosis (6), during 1913 (53 weeks) numbered 5,981, as compared with 6,069 in 1912 (52 weeks). The death-rates from this disease in successive periods have been as follows:— Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 persons living. 1851-1860 2.86 1904 1.67b 1861-1870 2.84 1905 1.45b 1871-1880 2.51 1906 1.50b 1881-1890 2.08 1907 1.46b 1891-1900 1.79b 1908 1.39b 1901-1910 1.49b 1909 1.40b 1910 1.25b 1901 1.65b 1911 1.35bd 1902 1.61b 1912 1.35bd 1903 1.57b 1913 1.30bd Since the year 1910 the deaths from phthisis belonging to the London population have been more completely ascertained than in previous years (see footnote (c), page 6); and further the deaths (a) See footnote (6), page 28. (b) See footnote (c), page 6. (c) The deaths occurring in the 53rd week of the years 1890, 1896, 1902, 1908 and 1913, which are not shown, numbered 1, 14, 37, 16 and 22 respectively. (d) Including miliary tuberculosis. Report of the County Medical Officer—General. from phthisis include deaths from miliary tuberculosis, which previously had been included under general tuberculosis. These two circumstances in conjunction disturb the continuity of the phthisis death-rates shown above, but it is unfortunately not possible to determine with any certainty from the published figures of the Registrar-General whether, or to what extent, the increase in the deathrate in 1911 denotes an actual increase in the mortality in that year over 1910. The more accurate local distribution of deaths would not, however, affect the rate for England and Wales as a whole; and from the fact that the increase shown in this rate (exclusive of miliary tuberculosis), in 1911 over 1910, in the Annual Report of the Registrar-General for 1911 (see p. 35) amounted to 4.6 per cent., it is reasonable to suppose that there was a corresponding actual increase in mortality in London. The increase due to the addition of miliary tuberculosis to phthisis in England and Wales is found from the same source (p. 156) to be 2 3 per cent. The phthisis death-rate since 1850 (corrected for differences in the age constitution of the population) in relation to the mean death-rate of the period 1851-1913 (males and females) is shown in diagram (T). This diagram shows the marked decline of phthisis mortality in both sexes since about 1865, the greater incidence of such mortality on males than on females, and the fact that until recent years the decline has been more manifest among females than males. The following table shows the crude phthisis death-rates, and the rates corrected for differences in the age and sex constitution of the populations of the various sanitary districts. 41 Phthisis death-rates in London boroughs. The factors for correction, also shown in the table, have been calculated by applying the 1911 census population, at each age and for each sex, of each of the London sanitary districts, to the death-rates, at each age and for each sex, obtaining in England and Wales during the decennium 1901-1910:— Metropolitan borough. Factor for correction for age and sex distribution. Crude death-rate. Corrected death-rate. Comparative mortality figure. (London 1,000.) 1908-12. 1913. 1908-12. 1913. 1908-12. 1913. London 0.9628 1.34 1.30 1.29 1.25 1,000 1,000 Paddington 0.9198 1.04 1.09 0.96 1.00 7.39 800 Kensington 0.9217 0.98 1.08 0.90 1.00 699 800 Hammersmith 0.9510 1.23 1.20 1.16 1.14 900 912 Fulham 0.9779 1.32 1.31 1.29 1.28 997 1,024 Chelsea 0.9151 1.40 1.23 1.28 1.13 992 904 Westminster, City of 0.8422 1.24 1.31 1.04 1.10 805 880 St. Marylebone 0.8932 1.28 1.36 1.15 1.21 887 968 Hampstead 0.9021 0.68 0.57 0.61 0.51 474 408 St. Pancras 0.9322 1.58 1.50 1.47 1.40 1,139 1,120 Islington 0.9573 1.29 1.33 1.23 1.27 954 1,016 Stoke Newington 0.9329 1.00 0.93 0.93 0.87 717 696 Hackney 0.9730 1.31 1.15 1.27 1.12 983 896 Holborn 0.8577 2.11 1.87 1.81 1.60 1,400 1,280 Finsbury 0.9976 2.05 2.01 2.04 2.01 1,577 1,608 London, City of 0.8219 1.65 1.48 1.35 1.22 1,046 976 Shoreditch 1.0270 1.85 1.79 1.90 1.84 1,470 1,472 Bethnal Green 1.0436 1.59 1.55 1.66 1.62 1,284 1,296 Stepney 1.0282 1.69 1.68 1.74 1.73 1,346 1,384 Poplar 1.0222 1.42 1.46 1.45 1.49 1,117 1,192 Southwark 0.9786 1.89 1.85 1.85 1.81 1,428 1,448 Bermondsey 1.0123 1.79 1.61 1.82 1.63 1,405 1,304 Lambeth 0.9548 1.42 1.29 1.36 1.23 1,048 984 Battersea 0.9829 1.26 1.13 1.24 1.11 960 888 Wandsworth 0.9627 0.91 0.86 0.87 0.83 672 664 Camberwell 0.9902 1.27 1.15 1.26 1.14 974 912 Deptford 0.9820 1.30 1.30 1.28 1.28 986 1,024 Greenwich 1.0040 1.22 1.17 1.23 1.17 949 936 Lewisham 0.9693 0.72 0.74 0.70 0.72 541 576 Woolwich 0.9781 1.23 1.50 1.20 1.47 930 1,176 It will be seen from the foregoing table (comparing the corrected death-rates) that among the several sanitary districts, in the quinquennium 1908.12 and in the year 1913, Finsbury, (2.04 and 2.01 respectively) had the highest phthisis death-rate and Hampstead (0.61 and 0.51 respectively) the lowest. The death-rates from phthisis in London in each of the four quarters of the year 1913 were as follows: first quarter, 1.55; second quarter, 1.27; third quarter, 1.07; and fourth quarter, 1.32. The figures upon which the above table is based, so far as the years since 1910 are concerned, are those given in the Annual Summaries of the Registrar-General, which represent the deaths of Londoners occurring within the Greater London area. The Registrar-General since 1911 has supplied corrected figures which purport to give the deaths of London residents occurring in the whole of England and Wales. The effect of this more exact allocation of deaths, will be seen from the following table, 23610 c 12 Annual Report of the London County Council, 1913. which indicates the percentage by which the death-rates, as given in the Summaries for the three years 1911-1913, are increased in the more accurate annual report figures for the same period. Metropolitan Borough. Increase in death- rates per cent. Metropolitan Borough. Increase in death- rates percent. Metropolitan Borough, Increase in death- rates per cent. Paddington 2.6 Stoke Newington 6.1 Bermondsey 1.6 Kensington 3.6 Hackney 2.3 Lambeth 3.1 Hammersmith 1.9 Holborn 2.4 Battersea 3.5 Fulham 4.1 Finsbury 0.8 Wandsworth 4.5 Chelsea 2.3 London, City of 2.1 Camberwell 2.5 Westminster, City of 4.8 Shoreditch 0.9 Deptford 3.5 St. Marylebone 4.6 Bethnal Green 1.8 Greenwich 1.4 Hampstead 9.6 Stepney 1.5 Lewisham 6.7 St. Pancras 2.0 Poplar 3.0 Woolwich 1.1 Islington 1.5 Southwark 2.6 London County 2.7 A point of considerable interest in connection with the influence exerted by movement of population upon the phthisis death-rate, is thus brought to light for it transpires that in areas of better social class the percentage increase in the death-rate is greater, i.e., a greater number of London residents of the better class die away from Greater London than of the poorer classes, the figures being as follows:— Number of group of boroughs in order of "social condition," (o) Increase in group deathrate per cent. I. 6.7 II. 3.4 III. 2.7 IV. 2.8 V. 1.4 Phthisis— Mortality and "social condition." The following table shows the mortality from phthisis during the year 1913 in groups of London sanitary districts, arranged in order of "social condition." Number of group of boroughs in order of " social condition." Crude phthisis death-rate per 1,000 persons living. (6) Corrected death-rate per 1,000 persons living. (b) Corrected death-rate (London, 1,000). I. 0.73 0.69 547 II. 1.04 0.98 778 III. 1.25 1.18 944 IV 1.45 1.42 1,129 v. 1.70 1.74 1,389 London 1.30 1.25 1,000 Age-incidence of Tuberculosis mortality in England and Wales, Prussia, the United States registration area and Ireland. The diagram (U) facing this page shows the mortality at ages from all forms of tuberculosis in England and Wales, Prussia, the registration area of the United States and Ireland for 1911 and some previous census years. It will be noted that the curves of age-incidence in the four nationalities represented have some points in common, there being evident in all a decrease in mortality up to about the tenth year, followed by an increase more or less continuous until between the thirtieth and sixtieth year. There are, however, some very striking differences, especially between the English and Irish and Prussian curves after the thirty-fifth year. It is for instance remarkable that while in England and Wales the maximum mortality among males in 1881 was at about the fortieth year (becoming thereafter later and later until in 1911 it is at about the fiftieth year), in Prussia there was a remarkably heavy incidence on later ages, with a maximum in the age period 60-70, a phenomenon which has become markedly less in each decennium, and, indeed, an opposite change to that in England and Wales is in some degree discernible, the Prussian maximum since 1881 having tended to fall if anything earlier in life. It thus appears that the Prussian knd English mortalities are approaching a similar age-incidence, since the result of the changes noted is to bring the age-incidence curves in the two countries in 1911 into far greater similarity than they exhibited thirty years before. A preliminary consideration, which may have had some small influence, may perhaps be referred to, namely, the fact that at the higher ages the mortality from other causes than tuberculosis is somewhat greater in Prussia than in England. Thus the death-rate from all causes among males aged between 50 and 60 in England and Wales in 1911 was 20.6 per 1,000 living of that age, and 2.5 per 1,000 died of tuberculosis. In Prussia the corresponding figures were 21.4 and 2.9 respectively. It has been found in London that among the more prosperous sections of the community, the deaths from phthisis (a) See footnote (a), page 17. (b) See footnote (c), page 6. Report of the County Medical Officer—General. 43 at the higher ages form a relatively smaller proportion of the deaths from all causes than in the poorer populations. If the greater mortality from all causes at higher ages in Prussia is to be regarded as indicating that the marked improvement in economic conditions in Prussia only dates from thirty or forty years ago, it might suffice to explain, in some measure, why the phthisis death rate at the higher ages still compares unfavourably with that of England and Wales. The rates for 1911 are given in the following table. Age group. Death-rate per 1,000 living in each age-group in 1911. England and Wales. Prussia. All causes. Tuberculosis. Tuberculosis per cent of all causes. All causes. Tuberculosis. Tuberculosis per cent. of all causes. Males. 30— 6.3 2.1 33 6.2 1.9 31 40— 10.8 2.4 22 11.0 2.3 21 50— 20.6 2.5 12 21.4 2.9 13 60— 43.0 2.1 5 44.5 3.0 7 70— 94.4 1.1 1 99.1 2.0 2 Females. 30— 5.2 1.5 29 6.3 2.0 32 40— 8.5 1.4 16 8.1 1.6 20 50— 15.8 1.1 7 15.2 1.6 11 60— 33.0 1.0 3 36.6 1.9 5 70— 78.7 0.6 1 89.9 1.5 2 The table clearly shows that with increasing age the death-rate from tuberculosis contributes more largely towards increasing the death-rate from all causes in Prussia than in England and Wales. It must, however, be borne in mind, in this connection, that other influences may be operative here; in particular the influence of migration, and of varying practices in connection with nomenclature of disease (to both of which reference will almost immediately be made) need to be kept in view. It will be observed that while both the English and Prussian curves show well-defined maxima of incidence at about the fortieth, and at about the sixty-fifth year respectively, the American curve has two periods of high incidence at about the fortieth and seventieth years. Perhaps this may be in part accounted for by the fact that a considerable proportion (nearly 10 per cent.) of the population of America is of German origin. It may be assumed, therefore, that German influence has been markedly exerted in the United States, and the traditions and training of practitioners of German oiigin, who have migrated to America, may have played an appreciable part in determining the fact that the United States curve is, as it were, a blend of the curves of England and Wales and Prussia. It may be added that in Wisconsin, with 24 per cent. of its population of German origin, the buckling of the mortality curve of age-incidence of tuberculosis is particularly marked. A little consideration will make it clear that one of the most conspicuous aberrations of the German curve from that of the other countries dealt with, is in all probability due in the main to the influence of fashion in nomenclature. The excessive rates from tuberculosis at the higher ages in Prussia cannot in fact be held to betoken any peculiar natural phenomenon, for if the death-rates at ages, from all respiratory diseases plus tuberculosis, in Prussia and in England and Wales, be compared, it will be found that there is almost precise correspondence. This fact suggests that the notable differences observed in death-rates at higher ages in the case of tuberculosis alone must be due to some, so to speak, artificial transference of disease from one heading to another. This view is confirmed when it is found that bronchitis is a far more frequent cause of death, at these same higher ages, in England and Wales than it is in Prussia, and in point of fact the excess in tuberculosis at these ages in Prussia is broadly speaking equivalent to the defect in bronchitis. Thus it would appear that much of the disease called tuberculosis forty years ago in Prussia would have been called bronchitis in England and Wales, and though this divergence of view has tended to disappear to some extent as years have gone by, it still remains a phenomenon to be reckoned with. Since the discovery of the tubercle bacillus there has been modification of the views held with regard to tuberculosis in both countries ; but there has apparently been more considerable change of view in Prussia than in England and Wales. That this should be so will be readily understood if reference be made to teaching which had a marked influence upon German opinion fifty years ago. Professor Felix von Niemeyer, of Tubingen was wont to insist that "pulmonary tuberculosis "did not necessarily originate as the result of "specific new growth" (Laennec's dogma, so Niemeyer termed it); but that it might develop" out of acute or chronic pneumonia, take its rise from a bronchial haemorrhage, or from a neglected or protracted cold." Niemeyer held that" a bronchitis out of which phthisis is developed might primarily be a genuine cold and, further, " hat in very many cases there is not a single tubercle found in phthisical lungs." Again, Niemeyer wrote " ost phthisical patients have no tubercles in the beginning, but many of them become tuberculous in the course of the disease"—thus " tuberculosis is in most cases a secondary disease"—and he declared that in the cases in which tuberculosis had been developed in the course of phthisis, treatment was "indeed impotent." It is not possible here to discuss the issues raised by Niemeyer as against Laennec,but it may be pointed out thatNiemeyer's contentions commanded much attention and greatly influenced opinion. Practitioners who were exhorted to remember that a 23610 g 2 44 Annual Report of the London County Council, 1913. "trifling bronchial catarrh occurring in an individual with a 'phthisical habitus' should bo looked upon as a dangerous enemy and treated with the utmost care"; or, who had been insistently taught that a protracted bronchial catarrh frequently leads to consumption," and told that "physical signs which hitherto have been considered characteristic of pulmonary tuborculosis gain a different meaning for those who have left Laennec's standpoint," would doubtless be more inclined than practitioners who did not accept the new German view, to include cases of pneumonia and bronchitis (as they would have been termed in England) among their cases of pulmonary tuberculosis. There can thus be practically no doubt that in the main the striking divergence of type of the Prussian curve from those of England and Wales and Ireland is due to differing views as to nomenclature in the various countries concerned, and this is confirmed by the fact that in the United States, in which country both the differing views find expression, the resulting type of curve is intermediate between, and presents in itself the peculiarities of both, the divergent types. Here again, as Murchison remarked fifty or more years ago, we have to look for explanation of divergencies of type to "the mental revolutions of practitioners rather than to the actual revolutions of disease." The differences existing in Prussia and in England have tended to disappear with time, but that fashion still plays a part in determining allocation of tuberculosis deaths, more particularly at higher ages, will be realised on referring to the figures given by the Registrar-General in his Annual Report for 1912, at page 600, where an analysis is presented of all the deaths from tuberculosis in that year, showing the frequency with which complications with other diseases were met with in different age-periods. Taking those complications only which might alone have been fatal it will be found that the percentage of deaths in which such complications were certified to exist was as follows:— Percentage of total deaths Age-group, from Tuberculosis in which complications wore certified, 0— 15 5— 16 15— 10 25— 1 5 45— 12 65— 16 All ages 10 Thus, in the highest age-group complications are especially common. A further point of interest in this connection was pointed out by Dr. Dudfield in his annual report for 1912; he notes that it is a common thing to find that among persons notified as being tuberculous and subsequently dying, no reference whatever is made to the existence of tuberculosis on the death certificate. Probably no group of causes of death is less satisfactory to deal with from the point of view of international comparison than that of diseases of the respiratory system, including pulmonary tuberculosis. The disease which initiated the trend of events resulting in death may be certified, for instance, as acute bronchitis, but the bronchitic condition itself may have been consequent upon phthisis in an early stage, the presence of which might never come to light except in the relatively few cases where post-mortem examination is made. The same remark applies to deaths from pneumonia and bronchopneumonia. It may be added that while there is as already noted, so considerable a difference between the death-rates from bronchitis in America and England, the English rate being greatly in excess, on the other hand the American pneumonia death-rate exceeds the English, and this doubtless in part explains why it is that on comparing the total death-rates of the two countries from respiratory diseases, including phthisis, it is found that they do not greatly differ. It is not possible to say precisely how far the excess of bronchitis in this country may be actual and caused by unfavourable climatic conditions, but unquestionably it is largely a matter of diagnosis. The influence of general health conditions and of varying practices as regards terminology having now been considered it remains to discuss a third factor having influence upon the curves giving phthisis deaths at ages. It is obvious that any movement of population to or from a country must affect its death-rate. Such influence as is thus exerted may be expected, moreover, to be especially marked in the case of mortality rates from diseases which are not rapidly fatal, for in acute disease there is less likely to be movement away from the country of origin and also less likely to be return to that country in the event of a serious illness being developed in the new home of the emigrant. The influence in question may perhaps especially be looked for in the case of phthisis, for the reason that removal from the country of origin to some more favourable climate, has been freely advocated in phthisis from the time of the Greek physicians onwards, and has especially been insisted upon since the middle of the last century; while during the last fifty or sixty years the facilities for such removal have greatly increased; moreover, it needs to be remembered that in the case of phthisis the disease is often of so protracted a character that it is quite possible for sufferers from it to return home to die. In England and Wales, Ireland and Germany the movement of population, during the last halfcentury, has been especially large. In the absence of complete records of actual inward and outward 45 Report of the County Medical Officer—General. movement the figures giving the difference between the growth of population in the intercensal period and the excess of births over deaths in the same period may in the first instance be referred to. They are as follows:— Loss (—) or gain (+) by balance of emigration and immigration. Period. England and Wales. Ireland, Germany. 1871—1880 —164,000 —661,000 —701,000 1881—1890 —601,000 —738,000 —1,301,000 1891—1900 —68,000 —464,000 —354,000 These figures only relate to net gain or loss. Some indication of the extent of emigration from particular European countries may be obtained from the following statement as to the nationality of the majority of immigrants into the United States given in " Immigration," by Henry Pratt Fairchild:— Native country of Immigrants Percentage of total immigrants. 1861-70. 1871-80. 1881-90. 1891-1900. 1901-10. Austria-Hungary 0.3 2.6 6.7 16.0 24.4 German Empire 35.0 25.5 28.0 14.0 3.9 Italy, Sicily and Sardinia 0.5 2.0 5.9 18.0 23.3 Russia and Finland 0.2 1.9 4.4 14.0 18.2 England 38.0 15.6 12.0 6.0 4.4 Ireland 15.5 12.0 10.0 3.9 This statement clearly indicates that the very large volume of emigration from Europe to America has been drawn in quite differing degrees from various sources during the period under review. Thus, the percentages for Germany, England and Ireland overwhelmingly preponderate over those for the other three countries in the decade 1861—70, and migration from Germany was maintained at a high level in the two succeeding decades ; but in recent decades the countries in the above table formerly showing low percentages now present high percentages and vice versa. It is important to bear in mind in connection with phthisis rates, that it is not merely the numbers giving the balance of emigration and immigration, and not merely the total figures giving emigration and immigration (so far as these can be obtained), to which attention should be directed. One country may give largely of its best and retain generally speaking, its feebler and more diseased units, while another may send away its poorer population and its phthisics in large numbers and only very exceptionally part with those who are more resistant to disease. Generally speaking, countries which are passing through a period of prosperity tend to shed the less vigorous and successful units of population, while countries suffering from privation and disturbed conditions are likely, on the other hand, to lose their more energetic and capable citizens or country folk. Another point of importance is the fact that in different countries not only the nature of the stimulus to emigration, but the opportunities open to the emigrant may vary considerably. Thus, in the case of Germany some 90 per cent. of the emigrant population, during the three decades when there was a considerable exodus from the country, went to the United States of America and they consisted largely of capable and energetic country people ; the same comment has been made regarding the population emigrating from Ireland during those decades. On the other hand the existence of rapidly growing British colonies furnished an open field for emigrants from this country, but while many of the emigrants were of vigorous type, numbers of sickly persons were included among them; for until comparatively recent years no restrictions as regards physical fitness were placed upon those entering the Colonies and, as a matter of fact, in the last half-century large numbers of persons with early phthisis have proceeded from this country to Australia, New Zealand, South Africa, Canada and other British possessions. The remarkable development of facilities of travel and the closely waged competition between emigration agencies has led to notable extension in the particular field of enterprise concerned with the "lifting" of masses of population. The extent of operation of the disturbing influence of emigration upon the phthisis death-rate has been dealt with in some detail elsewhere (Trans. Roy. Soc. Med. 1912-13), and it has been shown how markedly the phthisis death-rates of English registration districts are affected by movement of population. An especially curious point is the effect produced on the rates at certain ages by the return of consumptives to their homes in the country to die ; this phenomenon is much more marked in females than in males; the rate at higher ages in males in the towns, on the other hand, may be in part explained by the tendency manifested by men, who are incapable of earning a living in the country, to tramp up to the town. The same facts are illustrated on a larger scale when the male and female death rates in the urban and rural areas of the country as a whole are examined. On turning from the statistics of registration areas to those of entire European countries, the teaching of the figures is more difficult to understand, but there are clear indications of differences between prosperous countries 46 Annual Report of the London Count)/ Council, 1913. and countries in which conditions have been less favourable, in the matter of phthisis death rates ; thus in Europe, England and Germany show great reduction and this began earlier in England than in Germany; Ireland, Norway and Hungary show actual increase ; other countries occupy an intermediate position. Examination of the curves for England and Wales, Prussia, the United States and Ireland in the light of the foregoing observations, may now be made. All four curves present a slight protuberance corresponding to the age 20-25 males and 15-20 or 20-25 females; it is possible that this may be in part produced by movement of population, which would be especially likely to cause disturbance in the figures at the age period when emigration is specially high, and the likelihood of movement of sick persons outward, or, on the other hand, of dying persons to their original homes, would be particularly manifested. The curves for all the countries show that males suffer more than females, but if examination be instituted into the decrease in mortality in the ten years 1901-1911 (as measured by the area between the outline for 1901 and that for 1911) it will be seen that while in England and Prussia the total decline in incidence upon males exceeds that upon females, the reverse is found to hold in America, where, moreover, decrease in male incidence falls short of that among males both in Prussia and England. It may be that there is here reason for suspecting that in numerous instances, more particularly among the male emigrants to the United States, there have been included persons suffering from early phthisis and the precautions recently insisted upon with regard to medical examination on landing may thus find some justification. Conclusions, however, on this point so far as the American figures are concerned, must be regarded with some reserve, as the "Registration Area" of 1901 has been since extended, and consequently the rates are not strictly comparable. (The Registration Area in 1911 comprised some threefourths of the total population of the United States.) In the more recent years there is a marked tendency for the curves in both sexes to approximate to a more or less common type. In the earlier years, on the other hand, the differences of type are very marked. This is probably due in large measure, as already indicated, to other causes than the influence of movement of population, but this factor has doubtless also made itself felt in various ways. At one extreme stands the Irish curve with its highest incidence at 20-25 or 25-35; at the other extreme the Prussian curve with its maximum at 60-70. The England and Wales curve shows in the earlier years greater similarity to the Irish type, but in the later years it and the Prussian curve more nearly approximate to one another. Now, it is particularly interesting to note that if the England and Wales figures be dissected, by separating out the urban and rural counties from each other, the rural counties conform fairly closely to the Irish type while the urban conform more closely to that of Prussia. It would seem then, on the whole, that the following conclusions may be drawn:— 1. In the case of Ireland (and in less marked degree the phenomenon is apparent in the rural counties of England and Wales) there is specially noteworthy incidence upon young adults; this may be in part due to the fact that the more vigorous units of population have been removed; leaving behind a population which is less resistant to disease, and in part due to return to the original home when fatal illness develops of a certain number of those who had emigrated. 2. In the case of England and Wales the exceptionally favourable rates as compared with the other countries are no doubt in part attributable to the unique facilities which have existed for enabling those affected by early phthisis to go abroad, with the result that the deaths when they have ultimately occurred have not prejudically affected the death rates recorded in this country. Conversely, the United States curves, particularly those of males, may have been, to some small extent, prejudicially affected by addition of such deaths. In Germany and to a less marked extent in England and Wales, the growth of the sanatorium movement has doubtless led to a certain number of patients who might otherwise have gone abroad remaining to be treated at home. The extent of the influence thus exerted can scarcely have been as yet such as to appreciably affect the curve in this country at any rate. As regards Germany there seems at no time to have been so great a tendency, as has existed undoubtedly in this country during the last half century, for consumptives to go abroad. 3. The very heavy rates at the higher ages in Prussia and the rise in the incidence rates at the highest ages in the United States are doubtless due in the main to peculiarities of fashion in nomenclature which have already been fully discussed. It may, however, be here noted that the type in both these curves is rather suggestive of the urban as distinguished from the rural curve of England and Wales, and it may be that the high degrees of urbanisation in Prussia and in the United States registration area have not been altogether without influence in this connection. The outstanding lesson to be drawn from this examination of age-incidence of tuberculosis in different countries is, it may now be urged, that emphasis should be placed upon the very variable connotation of the expression tuberculosis at different times and in different countries. The huge contrasts presented by the German and English curves, in corresponding years, seem to be in large degree thus explained, and it cannot be doubted that variations in tuberculosis mortality, in one and the same county at different times, are also in very large degree similarly accounted for. With a view to seeing whether any further light would be thrown upon the tuberculosis curves, examination of the similar curves for cancer has been made. In Diagram V Batch3-1412 the incidence of cancer mortality in England and Wales, Prussia, the United States Registration Area and Ireland is shown. Incidentally it may be noted that the fall at the highest ages (70 and upwards) in Prussia is probably in the main due to the higher percentage of cases returned as "altersschwache" (or senile debility) at these ages, while the falling away of the curve for 1911 in the case of the highest ages in Ireland is probably in the main a result of disturbance in the statements as to age resulting from the introduction of old age pensions. The broad deductions, however, to be drawn from the cancer curves are first, that cancer can have caused but little interference with the types of tuberculosis curves which have Report of the County Medical Officer—General. 47 been studied, and second, there should be noted the heavy incidence of cancer at the special cancerages (40-60) in Prussia as compared with the other countries. As in the case of tuberculosis this represents in all probability not a natural but an artificial difference, and if that be so it is important to recognise in the case of cancer as in that of tuberculosis how variable are the connotations of this word as used in different places and at different times. During the year 1911 the system of compulsory notification of pulmonary tuberculosis was completed and it was in operation during the whole of 1912. This scheme was begun on the 1st January, 1909, as the result of the Public Health (Tuberculosis) Regulations, 1908, issued by the Local Government Board on the 18th December of that year. These regulations provided for the notification of cases of pulmonary tuberculosis by Medical Officers of Poor Law Institutions, District Medical Officers, Superintending Officers of Poor Law Institutions and Relieving Officers. The respective duties of these officers in connection with notification are prescribed in Articles IV to VIII of the Regulations. Further Regulations were made on 22nd March, 1911, extending the system of notification to cases occurring among the in-patients or out-patients at hospitals, or other similar institutions for the treatment of the sick, which are supported wholly or partially otherwise than by the contributions of the patients (or of their relatives or guardians) and otherwise than from rates and taxes. These Regulations are described as the Public Health (Tuberculosis in Hospitals) Regulations, and came into force on 1st May, 1911. A further stage in the system of notification of pulmonary tuberculosis was reached by the issue of the Local Government Board Order of the 15th November, 1911. This Order provided that from the 1st January, 1912, every Medical Practitioner should notify within 48 hours every case of pulmonary tuberculosis occurring in the course of his public or of his private practice, but it relieved the medical practitioner of the duty of notifying a case which had to his knowledge already been notified to the proper authority. The Order was not a consolidating Order but supplemented and to some degree extended the Poor Law and Hospital Regulations. These three orders were consolidated, and extended to apply to all forms of tuberculosis, by a new order of the Local Government Board dated 19th December, 1912, which came into force on 1st February, 1913. Under this order the Council has made the following summary return of cases of tuberculosis notified in the County of London during the eleven months of 1913 in which the regulations under the new order were in operation. Form of Tuberculosis notified. Sex. Notifications on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, infra.) 0— 1— 5— 10— 15— 20— 25— 35— 45— 55— 65 + Age not stated. Total. Pulmonary Tuberculosis M. 26 209 655 561 654 980 2,173 2,349 1,671 815 221 3 10,317 F. 14 210 662 604 707 1,045 2,142 1,615 954 430 192 4 8,579 " Other " Tuberculosis M. 111 651 896 511 287 160 226 171 80 44 27 2 3,166 F. 95 454 682 472 272 217 248 114 82 34 31 — 2,701 All forms of Tuberculosis M. 137 860 1,551 1,072 941 1,140 2,399 2,520 1,751 859 248 5 13,483 F. 109 664 1,344 1,076 979 1,262 2,390 1,729 1,036 464 223 4 11,280 Form of Tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through madical inspection in elementary schools.) Notifications on Form C. (Secondary notifications from institutions receiving cases). 0— 5— 10— 15 + Total. Poor-law. Other. Pulmonary Tuberculosis M. 8 96 57 — 161 2,890 1,120 F. 7 82 71 1 161 1,073 752 " Other" Tuberculosis... M. 10 156 162 9 337 256 100 F. 4 111 114 3 232 124 112 All forms of Tuberculosis M. 18 252 219 9 498 3,146 1,220 F. 11 193 185 4 393 1,197 864 48 Annual Report of the London County Council, 1913. In classifying the returns of notifications received from the borough councils for the purpose of this summary, care has been taken to follow as far as possible the International List of Causes of Death, adopted by the Registrar-General in 1911; and the notifications should therefore be comparable with the death in London from "pulmonary," and from " other tuberculosis," respectively. Assuming the total number of notifications received in 1913 to afford a fair criterion of the ageincidence of the disease, general comparison may reasonably be made of this incidence with the agedistribution of the London deaths, say, in 1911 and 1912; there is, in the light of past experience, no reason for thinking that the age-distribution of the deaths in so large a population varies in any great degree from year to year. Since, however, the female population outnumbers the male at all ages except infancy, the figures must first be adjusted to allow for the varying excess of females in order to enable a comparison to be made of the age incidence of attack and death in the two sexes. This correction having been made, the incidence of attack and mortality per 1,000 cases and deaths at all ages, is as follows:— Agegroup. Pulmonary Tuberculosis. Other Tuberculosis. All Tuberculosis. Cases. Deaths. Cases. Deaths. Cases. Deaths. M. F. M. F. M. F. M. F. M. F. M. F. 0— 20 27 30 45 208 188 545 568 64 67 117 167 5— 63 85 9 17 288 270 120 151 116 132 28 49 10— 53 77 9 34 186 200 74 49 84 108 19 37 15— 60 81 34 73 88 94 50 48 67 84 37 67 20— 102 120 82 97 54 74 33 27 91 108 74 80 25— 216 245 202 220 73 85 52 41 182 205 177 178 35— 222 185 240 227 53 39 35 37 183 148 205 183 45— 157 109 193 151 25 28 38 24 126 89 167 122 55— 80 49 130 80 14 12 28 19 64 40 113 66 65 + 27 22 71 56 11 10 25 36 23 19 63 51 All ages 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 It will be seen that of 1,000 cases of pulmonary tuberculosis at all ages, 298 occur at ages below 25 years among males while among females there would be 390 cases; and similarly of 1,000 deaths at all ages, among males 164 Would be under 25 years of age as against 266 among females. There is no corresponding divergence in age-incidence observable in " other tuberculosis." The males attacked at all ages exceed the females by 37 per cent. and the deaths by 86 per cent. The lower death-rate for phthisis among females is thus due both to less susceptibility to definite attack and to a greater power of resisting the inroads of the disease when established. While the above table serves to show the difference in age-distribution of 1,000 cases and deaths in the two sexes throughout life, the following table gives the relative incidence of disease and death on the two sexes at each age-period:— Age-group. Pulmonary tuberculosis among females. (Males=100) Other tuberculosis among females. (Males=100). All tuberculosis among females. (Males—100). Cases. Deaths. Cases. Deaths. Cases. Deaths. 0— 96 81 72 84 78 83 5— 98 99 75 102 85 101 10— 107 213 85 53 96 112 15— 98 104 85 77 94 106 20— 86 63 109 64 89 63 25— 83 58 92 64 84 59 35— 61 51 59 87 61 52 45— 51 42 91 52 53 42 55— 45 33 67 55 46 34 65 + 59 42 77 115 61 47 All ages 73 54 80 81 75 58 The only age at which the case-rate of pulmonary tuberculosis among females exceeds that among males is between 10 and 15 years, the excess being, however, only 7 per cent. The deaths among females at this age, however, exceed the male deaths by 113 per cent. The abnormally high fatality among females at this age cannot be entirely accounted for by the increased incidence of disease; it may perhaps be due to a want of power to resist the progress of the disease. It has been suggested Report of the County Medical Officer—General. 49 that the want of resisting power at this age is the result of changes at puberty; it is worthy of note, however, that this factor does not appear to operate in the case of forms of tuberculosis other than pulmonary, for the figures at this age-period show actually a smaller incidence and fatality of other tuberculosis among females than among males. It is possible that changes in respiratory movement which affect males and females in differing degrees at this period of life may have some influence. It has been observed that at this age the base of the lung is relatively more frequently attacked among females, and it has been suggested that the unnatural constriction which results from the wearing of stays may account for this fact. The restriction in the amount of active outdoor life among girls of this age, due to domestic work, cannot, moreover, be entirely left out of account. Cancer. The deaths from cancer (a), in the Administrative County of London during 1913 (53 weeks), numbered 5,206. as compared with 5,007 for the 52 weeks of 1912. Cancer death-rates, London, 1851-1913. The death-rates from this disease in successive periods have been as follows:— Period. Death-rate per 1,000 persons living. Period. Death-rate per 1,000 per sons living. 1851-1860 0.42 1904 0.94a 1861-1870 0.48 1905 0.96a 1871-1880 0.55 1906 l.01a 1881-1890 0.68 1907 0.99a 1891-1900 0.85a 1908 1.02a 1901-191 0.98a 1909 1.04a 1910 l.03a 1901 0.88a 1911 1.05a 1902 0.93a 1912 1.11a 1903 0.98a 1913 1.13a For the purpose of enabling the incidence of cancer on the several populations of the sanitary districts to be more precisely stated, factors have been calculated for correcting the death-rates, as far as possible, for differences in the age and sex constitution of the several populations concerned. These factors are shown in the following table, together with the death-rates for each sanitary district, corrected by their application.(b) Metropolitan borough. 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). 1908-12. 1913. 1908-12. 1913. 1908-12. 1913.[/##3] London 0.9634 1.06 1.16 1.02 1.12 1,000 1,000 Paddington 0.8542 1.19 1.31 1.02 1.12 998 1,000 Kensington 0.8117 1.18 1.13 0.96 0.92 943 821 Hammersmith 0.9363 1.05 1.22 0.98 1.14 965 1,018 Fulham 1.0723 0.97 1.13 1.04 1.21 1,019 1,080 Chelsea 0.8018 1.33 1.38 1.07 1.11 1,043 991 Westminster, City of 0.8484 1.26 1.46 1.07 1.24 1,049 1,107 St. Marylebone 0.8556 1.33 1.45 1.14 1.24 1,115 1,107 Hampstead 0.8657 1.08 .116 0.93 1.00 920 893 St. Pancras 0.9362 1.23 1.39 1.15 1.30 1,125 1,161 Islington 0.9163 1.11 1.25 1.02 1.15 996 1,027 Stoke Newington 0.8235 1.22 1.52 1.00 1.25 986 1,116 Hackney 0.9594 1.01 1.15 0.97 1.10 947 982 Holborn 0.8425 1.18 1.04 0.99 0.88 994 786 Finsbury 0.9977 0.94 1.02 0.94 1.02 918 911 London, City of 0.78S3 1.33 1.56 1.05 1.23 1,027 1,098 Shoreditch 1.1342 0.83 0.73 0.94 0.83 922 741 Bethnal Green 1.1866 0.94 1.03 1.12 1.22 1,094 1,089 Stepney 1.2037 0.82 0.88 099 1.06 971 946 Poplar 1.0747 0.94 1.00 1.01 1.07 994 955 Southwark 1.0335 1.03 1.15 1.06 1.19 1,045 1,062 Bermondsey 1.0744 1.07 1.15 1.15 1.24 1,133 1,107 Lambeth 0.9193 1.18 1.29 1.08 1.19 1,068 1,062 Battersea 1.0112 0.99 1.11 1.00 1.12 986 1,000 Wandsworth 0.9552 0.99 1.06 0.95 1.01 931 902 Camberwell 0.9688 1.03 1.10 1.00 1.07 984 955 Deptford 0.9963 1.02 1.14 1.02 1.14 1,000 1,018 Greenwich 0.9895 0.92 1.49 0.91 1.47 898 1,312 Lewisham 0.9223 1.05 1.17 0.97 1.08 945 964 Woolwich 1.0321 0.94 1.01 0.97 1.04 955 929 Cancer death.rates in London boroughs. (a) See footnote (c), page 6. (b) The deaths upon which these rates are calculated, so far as the years 1911 to 1913 are concerned, are the deaths in England and Wales which have been allocated by the Registrar.General to London. Prior to 1911, the correction was limited to the Greater London area. ii 50 Annual Report of the London County Council, 1913. It will be seen from the foregoing table (comparing the corrected death-rates) that in the quinquennium 1908-12 among the several sanitary districts, Bermondsey (1.15) had the highest cancer deathrate, and Greenwich (0.91) the lowest; in the year 1913, Greenwich (1.47) had the highest, the lowest obtaining in Shoreditch (0.83). In the report for the year 1909 a table was included showing the cancer death-rates in the period 1901-9 in areas presenting different degrees of overcrowding, the object being to compare the deathrates of populations differently circumstanced in respect of "social condition." The figures for 1913 show that there is no relation between cancer mortality and social condition, whether measured by the degree of overcrowding or by the percentage of children scheduled for compulsory education, and in this respect the behaviour of cancer differs altogether from that of phthisis (see page 42). Reference may here be made to diagram (V) showing the age incidence of cancer among populations of different nationality, and to the discussion of the diagram on page 46. Cerebrospinal Fever. During 1913, 92 persons were certified to be suffering from cerebro-spinal fever and 6 deaths were attributed to this disease. The number of deaths in the London population registered in each year since 1901 has been as follows:— Deaths.(a) Deaths. (a) 1902 4 1908 12 1903 6 1909 15 1904 6 1910 10 1905 5 1911 9 1906 4 1912 4 1907 25 1913 6 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 requirement of notification did not become operative until the 12th of March, 1907, and during the remainder of that year 135 cases were notified, or 50 more than in the whole of the year 1908. In 1909 there were 111 notified cases, 115 in 1910, 101 in 1911 and 105 in 1912. In February, 1912, the Council made the disease permanently notifiable. The age distribution of the 92 cases notified in 1913 was as follows:— Sex. Cerebro-spinal fever—Age distribution of notified cases, 1913. 0- 1- 2- 3- 4- 0- 6- 7- 8- 9- 10- 13- 15 + All ages. Males 15 5 4 — 4 6 2 2 1 2 4 3 6 54 Females 10 8 2 2 2 2 — 1 — — 2 2 7 38 Persons 25 13 6 2 6 8 2 3 1 2 6 5 13 92 Of the 92 cases notified, in 34 the final diagnosis confirmed the original diagnosis, in 30 the original diagnosis was reversed, and in the remaining 28 no additional evidence was forthcoming. Of the 34 cases verified on final diagnosis a post mortem examination was made in respect of 4 and bacteriological evidence was obtained in 8; the nature of the latter evidence was usually not fully stated, and, as the examinations were made by different bacteriologists, there were in all probability different standards as to what might be considered as bacteriological proof of the disease. Anterior poliomyelitis. The Order making the disease notifiable became operative on 1st September, 1911, and during the remainder of that year 66 cases were notified. During 1913(53 weeks), 145 persons were certified to be suffering from anterior poliomyelitis as compared with 132 persons in 1912 (52 weeks). The age distribution of the 145 cases notified during 1913 was as follows:— Sex. 0- 1- 2- 3- 4- 5- 6- 7 - 8- 9- 10- 13- 15 + All ages. Males 3 21 22 9 3 2 3 — 1 1 2 — 3 70 Females 6 20 11 12 6 2 3 2 1 2 3 1 6 75 Persons 9 41 33 21 9 4 6 2 2 3 5 1 9 145 Of the 145 cases notified the diagnosis was confirmed in 61 instances. In 3 cases the original diagnosis was reversed, and in 81 cases no further evidence was available. (a) See footnote (c), page 6. Report of the Count;/ Medical Officer—General. 51 Anthrax. Human anthrax was made a notifiable disease under the Public Health (London) Act, 1891, by order of the Council as from 26th April, 1909. The following is a return of the number of cases notified from that date:— 1909 9 1910 6 1911 e 1912 2 Three cases of anthrax in man were notified in 1913. It will be seen, therefore, that very few cases of this disease among human beings occur in London. The Home Secretary has appointed a committee to inquire into the dangers of infection from this disease in the processes of sorting, willeying, washing, combing and carding wool, goat hair and camel hair, and in the processes incidental thereto, with a view to considering whether something more can be done to minimise the risk. The Committee had not reported at the end of the year. Glanders. The introduction of mechanical traction has resulted in a large reduction in the number of horses kept in London, particularly in the case of large owners, both for private and commercial purposes, and there has been a corresponding reduction in the number of cases of equine glanders reported under the Glanders and Farcy Orders. The following figures indicate the number of cases notified in London from 1901 to 1913 inclusive:— 1901 1,828 1908 1,730 1902 1,604 1909 1,272 1903 1,915 1910 597 1904 1,869 1911 281 1905 1,387 1912 172 1906 1,382 1913 288 1907 1,365 Glanders in man was made a notifiable disease under the Public Health (London) Act, 1891, by order of the Council on 6th April, 1909 (p. 926). This Order came into operation on 26th April, 1909. Between that date and March, 1910, only six cases were notified under the Order and the diagnosis was confirmed in only two cases. The results of an investigation respecting glanders conducted by Dr. J. M. Bernstein and Dr. W. H. Hamer were given in the Annual Report of the Council for 1910*, and particulars of the known cases of human glanders which had been reported from 1893 to 1911, 49 in number, including the above-mentioned six cases, were set out in an appendix to the report. Among the conclusions drawn from the inquiry were these—that equine glanders is more prevalent in stables where only few horses are kept, that in such cases the "horses, often badly fed and overworked, and so offering little resistance to infection, are still liable to constitute a serious source of infection, both to other horses and to man," and that "the men who own these horses would be, and in fact are, if they suspect themselves to be suffering from any infectious disease, very loth to draw attention to themselves and interfere with their freedom." The inquiry further indicated that in the majority of the cases of alleged glanders in human beings which were investigated the patients had had direct contact with horses, but that there were several cases in which no evidence of such contact was obtainable. It was found that there were varying clinical symptoms in the cases investigated and that difficulty of diagnosis was experienced even after bacteriological examinations had been made. The only case of glanders in man which was notified in 1913 should now be added to the list given in the report for the year 1910. The case occurred in Deptford and the subjoined information has been extracted from the annual report of the medical officer of health for the borough:— "S. O. B., 17 years, of Lewisham High-road. The patient was removed to St. John's Hospital where he died. Bacteriological examination confirmed the diagnosis. It was found impossible to trace the source of infection." The occurrence of this case led to elicitation of the fact that three suspected cases of glanders had been under treatment in the hospital in which the man S. O. B. died. The particulars relating to these cases afford further illustration of the difficulties of diagnosis already referred to ; the following summary is given of these cases, which were described in "The Lancet," by Drs. H. M. M. Woodward and K. B. Clarke in December, 1913 (p. 1696):— Case 1.—The patient, aged 19, a sailor, who had been ill for three days, was admitted for pyrexia and complaining of a deep-seated pain in the right epigastric region. There was nothing of importance in his previous history, and as far as can be ascertained, he had nothing to do with horses. As the patient had complained of some pain after micturition, a catheter was passed and material was planted out on all the ordinary media. In twenty-four hours there grew colonies of staphylococci and of a gram-negative bacillus which it is stated proved on further investigation to be the bacillus mallei. Later there appeared over the chest, back and face an eruption simulating small-pox. After being delirious for several nights, the patient gradually passed into a state of coma and died eleven days after admission. " At the autopsy * Annual Report of the Council, 1910, Vol. iii., pp. 109-114. 23610 h 2 52 Annual Report of the London County Council, 1913. scattered abscesses were found in both lungs, the base of the right lung being chiefly affected. A large retroperitoneal abscess was discovered on the anterior aspect of the sacrum. Cultures from both these situations yielded a growth of the bacillus mallei." Case 2.—The patient, a mechanic aged 43, was admitted for acute rheumatism. His work did not bring him in contact with horses and he did not live near any stables. He was taken ill a few days before admission with an acute pain in the right ankle joint. A small abscess formed and was opened on the outer aspect of the right leg ; other joints became involved, particularly the knee joint, right shoulder and left ankle. Inflammatory foci appeared on various parts of the body, but slowly disappeared without suppuration. No definite diagnosis up to this date had been made though several possibilities had been suggested. At various times the case was thought to be one of acute rheumatism, acute gout, and then phthisis, and later a diagnosis of gonorrhœal pyaemia was suggested. Blood was taken from a vein, but remained sterile on all the media. Pus taken from the wound on the right leg contained streptococcus pyogenes. Smears taken from the urethra showed the presence of gonococci. The patient rapidly lost ground; an abscess formed on the right leg and was opened, a quantity of pus escaping. In this a gram-negative bacillus was found which proved on further investigation to be the bacillus mallei. Five weeks after admission a papule appeared on the left side of the neck which soon became vesicular and in thirty-eight hours the whole face was covered with pustules and the eyelids were very cedematous, the condition simulating small pox. The bacillus mallei was also found in these pustules. The patient died six weeks after admission." Case 3.—The patient, aged 14, was admitted as being a possible case of cerebro-spinal meningitis. From inquiries made it was discovered that the patient a fortnight before he became ill had been looking after a horse which was suffering from ulcers, and that a dog which was kept in the same stables had died from an unknown disease. At the autopsy, "the brain and medulla were normal and only in the cerebellum a small patch of grey-greenish viscous pus was found. Cultures from all the various organs were taken and also from the pus in the cerebellum. Most of the cultures remained sterile; some showed post-mortem bacteria. The cultures from the pus in the cerebellum grew the bacillus mallei." In addition to the foregoing, an interesting account of the experiences of a veterinary surgeon of the Indian Civil Veterinary Department, Mr. S. H. Gaiger, who underwent forty-five operations for glanders, including twenty-seven under a general anaesthetic, appeared during the year. The account is given in an article published in the Journal of Comparative Pathology and Therapeutics in September, 1913. The following is a synopsis of Mr. Gaiger's statement:— In March, 1911, he was at work on an obscure case of disease in an Arab pony in India, which he ultimately proved by bacteriological means to be glanders. After he had been at work on the case for about a week Mr. Gaiger became ill during the night of 3rd March with severe headache and a temperature of 102 deg. F. There appeared to be no reason to connect his illness with his laboratory work. On 5th March he felt acute pain between the diaphragm and liver, it appeared that the peritoneal surfaces were inflamed. This pain ceased to be acute in a few days. It was the first internal symptom and he considers that it pointed to the bacillary infection having taken place through the alimentary canal. Mr. Gaiger asserts that infection did not take place by accidental inoculation and no lesions of the respiratory tract have ever been observed. For about three weeks from the date of the onset of his illness he had intermittent fever and the case was diagnosed as malaria and was treated accordingly. Pain in the intercostal muscles on the right side was then felt and suggested pleurisy, but careful medical examination revealed nothing and the pain became less acute in a few days and in due course both peritoneal and pleural pains completely and finally disappeared. The first external lesion was observed on his left hand on 25th March when a very painful deep-seated swelling appeared. The swelling became hard and painful, necessitating the use of morphia for three nights. Afterwards an incision was made, but no pus had accumulated. Later, pus was extracted and a culture taken from the wound gave a growth which was said to be a bacillus " most like glanders, but yet showed differences." Two inflamed places later appeared on the forearm on the course of one of the lymphatics and frequent operations were performed on the hand and the lesions on the forearm. Cultures from one of the abscesses on the forearm were incubated at the Veterinary College Laboratory. After twenty-four hours no growth was visible, but after forty-eight hours the growth was luxuriant and Mr. Gaiger was struck by the resemblance to glanders cultures. Cultivation on potato was "diagnostic." One tube of the culture was sent to a Research Institute and they named the bacillus "53 A " and made a vaccine, but only five doses were used at very irregular intervals and this treatment was not given a fair trial. It is stated to have had no apparent effect on the course of the disease. On 14th June the case was diagnosed as tuberculous caries of the second metacarpal and an X-ray photo of the hand was taken showing changes in the metacarpal which could be seen by comparison with the sound metacarpals. Part of the shaft of the metacarpal was removed and Mr. Gaiger, in the light of after experience, considers that this operation was a mistake and was the indirect cause of the loss of his whole arm six months later. He states " that his whole experience shows that the bacillus mallei does not attack bones or joints. It will eat away connective and lymphatic tissue, but will leave everything else untouched." Mr. Gaiger came to London on 10th July and went into hospital. The lesions in the forearm had then healed and those in the hand were all narrow sinuses leading to the bare bone which could be detected easily with a probe. "Fresh cultures were made on agar, and then on potato, and a guinea pig was inoculated. The evidence was submitted to authorities, who would admit no doubt that the organism was the bacillus mallei." Further operations were performed and in September a further Report of the County Medical Officer—General. 53 X-ray photo showed on comparison with the previous one that the bone had been eaten away and a finger was removed, the metacarpal being taken off where it was healthy and the whole treated as an open wound. The infection still spread and after further operations vaccine treatment was again tried, but the patient's condition necessitated its discontinuance after three doses and ultimately on 15th December, 1911, the arm was amputated above the elbow. Three days after this operation the disease appeared in the right wrist and later in the left ankle and groin and later still in other parts of the body. The bacillus mallei is stated to have been found in cultures taken in May, 1912, and during June and July the patient was again treated with vaccine. Mr. Gaiger states that the vaccine was apparently beneficial and that a quite noticeable effect was to bring doubtful places to a head more quickly than would have been the case in the ordinary way. Operations were performed from time to time during the course of vaccine treatment. It was noticed that sinuses healed much more quickly after a bout of fever, provided it was short and not too high. Complete recovery was effected on 25th June, 1913, although it is stated that the left ankle had not quite regained its former freedom of movement. Leprosy. This disease is not endemic in Great Britain, such cases as occur either affect persons of foreign origin or those who have been at some time in residence in foreign countries. In December, 1913, a paragraph appeared in a newspaper to the effect that a case of leprosy had oceurred in London which was attributed to the wearing of furs said to have been bought in Whitechapel. Enquiries were made at the time, but no evidence was found to substantiate the report. Cholera and Plague. No case of Asiatic cholera or plague occurred in 1913, but a suspected case of cholera was reported by the medical officer of health of Lambeth. In this case the patient was taken suddenly ill at 5 a.m. on October 12th with symptoms of a very severe attack of gastric trouble, and at noon he was in a collapsed condition. A specimen of the stools was sent to the Lister Institute for examination the result proving negative. The patient subsequently recovered. 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 1913 was 51.3 deg. Fahrenheit, which is 1.8 degrees above the average of the preceding 70 years. The rainfall during the year amounted to 22.44 inches, being 1.68 inches below the average of the preceding 65 years. The temperature and rainfall in each month of the year 1913 are shown in the following table:— Month. Temperature of the air. Departure of mean monthly temperature from average of preceding 70 years. Rain and other forms of precipitation. Departure of mean monthly rainfall from average of preceding 65 years. Absolute maximum. Absolute minimum. Mean for the month. Number of days it fell. Amount collected. deg. F. deg. F. deg. F. deg. F. Inches. Inches. January 52 26 41.0 + 2.4 20 2.65 +0.77 February 55 24 41.1 + 1.7 12 0.81 —0.67 March 59 28 45.1 +3.3 20 2.43 +0.91 April 67 29 47.1 0.0 20 2.23 +0.66 May 84 36 56.0 +3.0 13 1.16 —0.76 June 87 42 60.3 +1.1 8 0.73 —1.31 July 76 46 60.0 —2.4 12 2.12 —0.28 August 80 45 61.6 +0.1 11 2.07 —0.27 September 77 42 59.0 + 1.9 11 1.25 —0.90 October 67 36 53.6 +3.5 15 3.58 +0.80 November 60 28 48.1 +4.6 17 2.53 +0.31 December 55 28 41.8 + 1.8 9 0.88 —0.95 54 Annual Report of the London County Council, 1913. B—Administration. Dairies, Cowsheds and Milkshops. The Council received during the year 174 applications for cowhouse licences, 171 of which were granted. The numbers of applications for licences received during the last twenty years and the numbers granted are shown in the following table. Cowshed premises. It will be seen that the number of these premises in London is continually decreasing. Year. No. of applications received. No. of premises for which licences were granted. 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 1909 216 214 1910 203 199 1911 194 187 1912 180 180 1913 174 171 In 1903 effort was made, in conjunction with the medical officers of health of metropolitan boroughs, to secure uniform statistical statement of the proceedings of the local authorities in London. Tables showing these proceedings included in this report have therefore, in the main, been compiled from tabular statements in the annual reports of medical officers of health, but in some cases it has been necessary to use figures otherwise appearing in their reports. Inspection of cowshed premises. The following table relating to cowsheds has been thus prepared:— Metropolitan borough. Number of cowshed premises. Number of inspections by the sanitary authority, 1913. Number of prosecutions by sanitary authority, 1913. On register at end of 1912. Added in 1913. Removed in J913. On register at end of 1913. Battersea 2 – – 2 Frequent. Bermondsey 2 – 1 1 7 – Bethnal Green 13 – – 13 60 – Camberwell 10 – 1 9 138 – Chelsea 1 – – 1 6 – Deptford 2 – – 2 39 – Finsbury 3 – – 3 13 – Greenwich 4 – – 4 17 – Hackney 15 – 1 14 200 – Islington 5 – 1 4 53 – Kensington 1 – – 1 45 – Lambeth 12 – 1 11 22 – Lewisham 13 – – 13 125 – Paddington 1 – – 1 4 – Poplar 13 – 1 12 78 – St. Marylebone 5 – – . 5 40 – St. Pancras 6 – 1 5 84 – Shoreditch 7 – 1 7 53 – South wark 3 – – 3 42 – Stepney 31 – – 31 53 – Stoke Newington 1 – – 1 2 – Wandsworth 12 – 1 11 47 – Westminster, City of 1 – – 1 26 – Woolwich 17 – 1 16 32 – Totals for 24 districts 180 – 9 171 — – Report of the County Medical Officer—General. 55 Milkshops. Section 5 of the London County Council (General Powers) Act, 1908, gives power to local sanitary authorities to remove from the register or to refuse to register the name of any person carrying on or proposing to carry on the trade of a dairyman or purveyor of milk upon premises which are in the opinion of the sanitary authority unsuitable for the purpose. These powers have been much used, with the result that the sale of milk in general shops has materially decreased in recent years. The following table shows the number of milkshop premises at the end of 1912 and 1913 in the metropolitan boroughs of London, the number of inspections and the proceedings taken. Inspection of milkshop premises. The table has mainly been compiled from information contained in the annual reports:— Metropolitan borough. Number of premises, (a) Number of inspections, 1913. Number of notices, 1913. Number of prosecutions, 1913. On register at end of 1912. Added in 1913. Removed in 1913. On register at end of 1913. City of London 638 27 25 640 Not stated. Battersea 170 3 11 162 553 29 – Bermondsey 248 43 37 254 910 32 – Bethnal Green 243 8 7 244 869 132 4 Camberwell 612 31 23 620 1,313 9 – Chelsea 112 14 13 105 159 4 – Deptford 201 48 35 214 676 4 – Finsbury 242 36 25 253 205 43 – Fulham 197 14 5 206 660 – – Greenwich 166 5 11 160 200 14 – Hackney 315 13 13 315 1,890 10 – Hammersmith 333 36 31 338 881 7 – Hampstead 100 4 2 102 301 17 – Holborn 184 13 9 188 704 6 – Islington 582 7 29 560 1,043 63 – Kensington 204 7 10 201 1,295 9 – †Lambeth 143 57 2 198 594 48 – Lewisham 163 13 10 166 274 – – Paddington 120 4 1 123 172 4 – Poplar 392 17 13 396 – – – St. Marylebone 230 13 14 329 536 10 – St. Pancras 413 – – – – – – Shoreditch 291 17 18 290 2,997 15 – Southwark 451 109 71 489 1,625 17 – Stepney 1,051 38 488 601 1,954 170 9 Stoke Newington 55 – – 58 94 1 – Wandsworth 356 55. 30 381 999 42 – Westminster 399 58 1 456 1,235 88 – Woolwich 117 – – – – – – Totals 7.581 – 6,793 – – – 147(a) (a) 1,256 Tuberculosis of the udder in London cows. London County Council (General Powers) Act, 1904 (Part V.) Cows kept in London cowsheds have been inspected since February, 1899, by a veterinary inspector appointed by the Council under the Dairies, Cowsheds and Milkshops Order of 1899. Under this order, the use of milk for human consumption from cows certified by a veterinary surgeon to be suffering from tuberculosis of the udder is prohibited. In 1904 this power was supplemented in London by additional powers, incorporated in the London County Council (General Powers) Act of that year, for the removal of any cow from any dairy, farm or cowshed in the county (elsewhere than in the City), if suspected to be suffering from tuberculosis of the udder, and if, upon slaughter, these suspicions were verified, a sum equal to three-quarters of the agreed value of the animal (not exceeding £22 10s.) became payable by the Council. If 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, became payable by the Council. Further powers have been conferred upon the Council by the Tuberculosis Order of 1913, which came into operation on 1st May, 1913. Under this order, the Council is required not only to deal with cows affected with tuberculosis of the udder, but also with cows giving tuberculous milk, or suffering from induration or other chronic disease of the udder, and with all bovine animals suffering from tuberculosis with emaciation. The veterinary inspector is empowered, with the owner's consent, to apply the tuberculin test in cases where the evidence of disease obtained by clinical methods is not conclusive. All persons having in their possession or under their charge animals which appear to come within the purview of the order, including animals exposed for sale in market or sale yards, and all veterinary surgeons detecting such cases in the course of their practice, are required to notify the cases to the Council, and it is the duty of the Council to arrange for the veterinary examination of such animals and, if affected with tuberculosis in any of the forms specified in the order, the animal has to be valued on two bases, (i.) on the basis that the animal is not affected with tuberculosis, and (ii.) on the basis that it is so affected. (a) Figures in italics refer to persons registered. + The milkshop premises are being re-registered under new regulations 56 Annual Report of the London County Council, 1913. The Council has then to slaughter the animal and conduct a post mortem examination. Should the post mortem examination reveal the presence of tuberculosis in an advanced stage, only one quarter of the valuation (as a tuberculous animal) is payable to the owner as compensation; if the disease be found not advanced, three-quarters of the valuation of the animal (as a tuberculous animal) is payable; if the animal is not affected with tuberculosis in any of the forms specified in the order the owner is entitled to the full value of the animal plus £1. The carcases and hides become the property of the Council, and any amount realised by their sale is paid into the County Fund. One-half of the compensation, after deducting salvage receipts, is refunded to the Council by the Treasury. Articles are also inserted in the Order dealing with the restriction of the use of milk, and the isolation of suspected animals, together with the disinfection of the cowshed in which the affected animal is discovered. Although the provisions in the L.C.C. (General Powers) Act, 1904, already referred to are not repealed by the Tuberculosis Order of 1913, the Council now proceeds in respect of the seizure of animals and compensation under the Tuberculosis Order. During the year 1913, there were five inspections of the cows kept in the 171 London cowsheds and the results of the examinations of the veterinary inspector at these routine inspections are given in the subjoined table:— Details of Examination. 1st Period. 2nd Period. 3rd Period. 4th Period. 5th Period. 30th Dec., 1912 to 10th Feb., 1913. 11th Feb., 1913 to 22nd April, 1913. 23rd April, 1913 to 2nd Aug., 1913. 3rd Aug., 1913 to 19th Nov., 1913. 20th Nov., 1913 to 28th Jan., 1914. No. cowsheds visited 177 177 174 165 169 „ revisited 3 6 22 7 5 No. special visits under Tuberculosis Order of 1913 Not in force Not in force 84 62 18 No. of cows examined 2,835 2,822 2,524 2,550 2,814 No. of cows re-examined 17 44 652 130 105 No. with healthy udders 2,764 2,741 2,447 2,489 2,765 No. suffering from tuberculosis of the udder 1 4 17 10 4 No. suffering from tuberculosis with emaciation 0 0 0 1 0 No. with acute mastitis 8 17 i9 13 8 No. with chronic induration or hypertrophy 22 20 28 20 21 No. with atrophy of udder 36 25 10 19 14 No. with injuries to teats or udders 4 15 3 1 2 Between 1st January and 30th April, 1913, 12 cows with tuberculous udders were slaughtered under the L.C.C. (General Powers) Act, 1904. From the 1st May, 1913, when the Tuberculosis Order came into force, to the end of the year, 46 cases were dealt with under the order, and of these 25 cows were seized and slaughtered. The remainder were not found on clinical examination to be affected with tuberculosis within the meaning of the Order. On post mortem examination, 16 of the 25 cows which were slaughtered were certified as suffering from advanced tuberculosis, while in the remaining 9 cases the disease was not advanced. Tuberculous milk; London County Council (General Powers) Act 1907. Part IV. Part IV. of the London County Council (General Powers) Act of 1907 empowers the County Medical Officer of Health or other duly authorised person to take, within and without the County, samples of milk produced or sold or intended for sale within the County; and, having obtained a justice's order, in company with a veterinary surgeon, to enter any dairy from which milk is being sold or suffered to be sold or used within the County, and to inspect the cows kept therein, and if the Medical Officer or such authorised person has reason to suspect that any cow is suffering from tuberculosis of the udder he may take samples of the milk of such cow. If it appears to the Council that tuberculosis is caused, or is likely to be caused, to persons residing in the County from the consumption of milk from any dairy, or from any cow kept therein, the Council may make an order prohibiting the supply of such milk in the County until the order has been withdrawn, and any person contravening the order is liable to a penalty not exceeding £5, and for a continuing offence to a daily penalty not exceeding 40s. Appeal may be made against the Council's order. On 11th February, 1908, the Council delegated to the Public Health Committee the authority conferred by Part IV. of this Act, dealing with tuberculous milk, and fixed the 1st July, 1908, as the date upon which the Act should become operative. The method of procedure adopted is as follows: samples are taken by the Council's inspectors from churns of milk consigned from the country to the various London railway termini, and these are submitted to the Lister Institute for bacteriological examination. In the case of those samples in respect of which the examination proves that there is evidence of the presence of tubercle bacilli, a clinical examination of the cows at the dairy farm from which the milk is consigned is made by a veterinary inspector appointed for the purpose under the Act, and cows found to have tuberculous udders are certified for the purposes of the Dairies and Cowsheds Orders and copies of the certificates forwarded to the local sanitary authorities concerned. Report of the County Medical Officer—General. 57 During the year 1913, 2,900 samples of milk were taken. The milk had been sent to London from the following counties: Bedfordshire, Berkshire, Buckinghamshire, Cambridgeshire, Cheshire, Derbyshire, Devonshire, Dorsetshire, Essex, Gloucestershire, Hampshire, Herefordshire, Hertfordshire, Kent, Leicestershire, Lincolnshire, Middlesex, Norfolk, Northamptonshire, Nottinghamshire, Oxfordshire, Rutlandshire, Shropshire, Somersetshire, Staffordshire, Suffolk, Surrey, Sussex, Warwickshire, Wiltshire and Yorkshire, and from Ireland and Wales ; the samples were taken principally from churns at stations of the Great Western, the Great Eastern, the Great Northern, the Great Central, the Midland, the Metropolitan, the London Brighton and South Coast, the London and North- Western, the London and South-Western, the North London, and the South-Eastern Chatham and Dover Railway Companies. The following table shows the number of samples taken during the year under review, the counties from which they were derived, and the results of bacteriological examination at the Lister Institute. County. No. of samples taken from churns for examination. No. of samples found to be tuberculous. No. of samples found not to be tuberculous. No. of samples the examination of which was not completed owing to accident and other causes. Bedfordshire 51 4 46 1 Berkshire 187 15 164 8 Buckinghamshire 143 10 132 1 Cambridgeshire 14 2 12 – Cheshire 16 2 12 2 Derbyshire 138 30 105 3 Devonshire 4 – 4 – Dorsetshire 57 4 52 1 Essex 63 10 53 – Gloucestershire 112 3 99 10 Hampshire 93 4 88 1 Herefordshire 2 – 1 1 Hertfordshire 63 7 56 – Kent 22 4 18 – Leicestershire 253 34 210 9 Lincolnshire 19 1 15 3 Middlesex 2 – 2 – Norfolk 12 1 10 1 Northamptonshire 151 9 138 4 Nottinghamshire 21 1 19 1 Oxfordshire 179 5 164 10 Rutlandshire 2 – 2 – Shropshire 15 2 13 – Somersetshire 191 14 170 7 Staffordshire 214 33 173 8 Suffolk 20 2 18 – Surrey 30 3 27 – Sussex 120 14 98 8 Warwickshire 53 3 43 7 Wiltshire 646 60 552 34 Worcestershire 7 – 6 1 Total 2,900 277 2,502 121 This table shows that out of 2,779 completed examinations of samples taken from churns consigned to London, 277 proved to be tuberculous, i.e., 9.9 per cent. Some of the samples were derived from churns containing milk from more than one farm. The last annual report gave a similar account of 2,885 samples of milk examined during the year 1912, of which 241, or 8.4 per cent., were found to be tuberculous. 23610 i 58 Annual Report of the London County Council, 1913. Farms inspected in English counties. 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 the year:— County. No. of farms inspected. No. of cows inspected. No. of cows with tuberculous udders. Bedfordshire 3 62 1 Berkshire 15 558 3 Buckinghamshire 7 274 1 Cambridgeshire 2 46 – Cheshire 2 120 1 Derbyshire 28 1,002 2 Dorsetshire 5 248 – Essex 7 586 – Gloucestershire 2 53 – Hampshire 3 98 – Kent 4 126 – Leicestershire 23 575 4 Norfolk 1 25 – Northamptonshire 10 256 – "Nottinghamshire 1 10 – Oxfordshire 5 173 1 Shropshire 1 32 – Somersetshire 35 886 1 Staffordshire 20 652 1 Surrey 3 126 2 Sussex (East) 1 50 1 Sussex (West) 13 499 1 Warwickshire 3 70 – Wiltshire 69 3,221 7 Total 263 9,748 26 This table shows that 0.27 per cent. of the cows examined were certified by the Council's veterinary inspector to have clinical symptoms of tubercular disease of the udder. The supply of milk for human consumption from the cows thus affected was immediately stopped. It will be observed that inspection was made of the cows at 263 farms and only 26 cows were certified to be suffering from tuberculosis of the udder. It should be borne in mind, however, that various circumstances prevent the discovery at every farm of a cow suffering from tuberculosis of the udder. In a number of cases, for instance, the farmer whose name was on the churn was found, on inquiry, not to have sent the milk into London on the date on which the sample was taken. In other instances, diseased cows had been removed before the inspector's visit. In nearly every case in which a tuberculous cow, or a cow suspected to be tuberculous, was found, the farmer undertook to withhold the milk of the suspected animal from London. The farms, moreover, are as far as practicable reinspected within a few weeks Since the introduction of the Tuberculosis Order of 1913, it has been the practice to notify the county council concerned of all cases presenting symptoms suggestive of tuberculosis in one of the forms specified under the Order, although the clinical signs were insufficient to enable the Council's veterinary inspector definitely to certify the cases. In several instances this action has led to the slaughter of animals giving tuberculous milk. Offensive Businesses. In the year 1913 the County Council received 226 applications for licences for slaughter-house's and granted 223. The following table shows the numbers of applications received and the numbers of slaughter-houses licensed in recent years. Slaughter houses. It will be seen that the numbers of these premises is continually decreasing:— Year. No. of applications received. No. of premises for which licences were granted. Year. No. of applications received. No. of premises for which licences were granted. 1892 543 537 1903 350 346 1893 538 529 1904 338 333 1894 518 506 1905 322 318 1895 497 485 1906 310 308 1896 478 470 1907 301 294 1897 460 460 1908 281 273 1893 442 429 1909 265 264 1899 419 411 1910 257 255 1900 405 393 1911 247 243 1901 384 381 1912 235 234 1902 371 362 1913 226 223 59 Report of the County Medical Officer—General. Inspection of slaughterhouses. The number of slaughter-houses in each metropolitan borough (other than those under the jurisdiction of the City Corporation) and the frequency with which these slaughter-houses, in most of the boroughs, were inspected, is shown in the following table : — Metropolitan borough. Number of slaughter-houses (a). Licensed at end of 1912. Licence lapsed or refused in 1913. Remaining at end of 1913. No. of inspections, 1913. No. of notices, 1913. Battersea 3 3 556 Bermondsey 1 — 1 20 ' — Bethnal Green 4 — 4 29 — Camberwell 11 11 137 — Chelsea 5 — 5 30 — Deptford 3 1 2 56 — Finsbury 3 1 2 104 — Fulham 3 — 3 45 — Greenwich 4 — 4 39 — Hackney 21 1 20 354 — Hammersmith 8 — 8 120 6 Hampstead 4 — 4 36 — Holborn 1 — 1 13 — Islington 29 1 28 1,579 — Kensington 10 — 10 275 1 Lambeth 18 1 17 64 6 Lewisham 13 — 13 115 — Paddington 7 — 7 408 — Poplar 14 — 14 89 1 St. Marylebone 7 1 6 90 ' — St. Pancras 16 1 15 548 — Shoreditch 5 — 5 10 — Southwark 6 — 6 65 — Stepney 6 2 4 17 1 Stoke Newington 14 — 4 9 — Wandsworth 16 2 14 323 5 Woolwich 12 — 12 46 4 Totals, 27 districts 234 11 223 5,177 24 Offensive businesses. During the year the business of a soapboiler in Southwark was discontinued. The number of authorised offensive businesses, except those in the markets under the jurisdiction of the City Corporation, at the end of the year was as follows :— Fat melters 15 Manure manufacturers 2 Tripe boilers 20 Soap boilers 9 Glue and size manufacturers 5 Tallow melters 4 Knackers 4 Gut manufacturers 3 Fellmonger3 6 — Bone boilers 2 70 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. Inspection of offensive trade premises- The boroughs in which these premises are situated, the number of premises, and, for most boroughs, the number of inspections, are shown in the following table :— Metropolitan borough. No. on Register at end of 1913. No. of inspections, 1913. Metropolitan borough. No. on Register at end of 1913. No. of inspections 1913. Battersea 2 19 Lambeth 2 6 Bermondsey 12 183 Poplar 6 21 Bethnal Green 1 3 St. Marylebone 2 38 Camberwell 4 8 St. Pancras 2 — Deptford 3 26 Shoreditch 1 1 Finsbury 1 5 Southwark 4 68 Greenwich 3 12 Stepney 7 28 Hackney 1 11 Wandsworth 3 64 Islington 6 91 — Total 60 Nuisances. N uisances from stable manure. There are Few references in any of the reports to nuisance arising from accumulations of stable manure. This fact has been observed every year since 1909. There is little doubt that the more rigid enforcement of the bylaws and the obvious reduction in the number of horse-drawn vehicles have together combined materially to reduce nuisance from this cause. It must not be overlooked, however, (a) The seven slaughter-houses under the jurisdiction of the City of London Corporation are not licensed by the London County Council. 23610 12 60 Annual Report of the London County Council, 1913. as was pointed out last year that the removal of small accumulations of manure will probably become a matter of increasing difficulty, inasmuch as contractors will not find its collection sufficiently remunerative. The question is deserving of the consideration of local authorities who have power to act under section 36 of the Public Health (London) Act, 1891. Smoke nuisances. The following table, which is compiled entirely from information contained in the annual reports, shows the action taken by sanitary authorities in respect of smoke nuisance during the year, so far as this is stated in those reports. Metropolitan borough. Observations and inspections. Nuisances and complaints. Intimations. Statutory Notices. Summonses. City of London — 13 13 — — Battersea — 40 21 4 1 Bermondsey 45 (chimneys) — 14 — — Bethnal Green 100 (chimneys) — 21 3 — Camberwell — — 100 — — Chelsea — 1 — — — Deptford 90 — — 21 2 Finsbury 72 9 9 — — Fulham — — — — — Greenwich 174 — — 5 — Hackney 1,079 — 58 — — Hammersmith 18 (premises) A number 5 6 — Hampstead 24 15 3 1 — Holborn 110 — 3 1 — Islington 92 3 — 3 — Kensington 301 3 — —• — Lambeth 6 (premises) 17 — — — Lewisham 244 — 4 — 1 Paddington 16 (premises) 11 — — — Poplar — 54 34 23 1 St. Marylebone 1,191 — 5 2 — St. Pancras 550 — 66 — — Shoreditch 14 (premises) — 16 2 — South wark 88 40 11 9 1 Stepney — 59 59 — 2 Stoke Newington — 5 2 — — Wandsworth 417 57 — 44 — Westminster, City of 2,046 45 (a) 125 3 — Woolwich 42 17 17 — — Housing Act, 1890 Part I. Bradystreet area, Bethnalgreen. Housing of the Working Classes. On 24th February, 1904, an official representation under Part I. of the Housing of the Working Classes Act, 1890, was made to the Council by the medical officer of health of the Metropolitan Borough of Bethnal-green. This representation related to an area of about four acres, on which were 226 houses inhabited by 1,286 persons. The average death-rate on this area was at that time 28.5 per thousand, the death-rate for the whole of the borough being 21.3 per thousand. The houses were described as being almost all in the worst possible condition, and it was alleged that " nothing short of clearing the area and rebuilding the houses would be effectual." It appeared to the Committee of the Council which considered the representation of 1904 that the re-development of the area on more modern lines could be effected by private enterprise, and they pointed out to the borough council that in these circumstances the re-arrangement of the area at the public expense was not altogether justifiable and urged the borough council to exercise in the meantime its powers under the Public Health and other Acts for remedying the evils connected with the area. The borough council did not accept the view of the Council's Housing Committee, and after further correspondence the borough medical officer of health made, on 4th April, 1912, a new formal representation. This comprised an area slightly exceeding seven acres, the area represented in 1904 being about four acres in extent. Instead of 226 houses with 1,286 persons, 528 houses and tenements with 3,058 persons were included, so that, in most respects, the area originally represented was more than doubled. The population on this site was about 430 to the acre, as compared with 169 to the acre for the borough of Bethnal-green, and 60 to the acre for the whole county of London. The death rate of the area was stated to be 24.74 per thousand, as against 16.71 for the whole borough, and about 14 for all London. This death rate was not so high as in the Tabard-street area, but the population to the acre was much larger in the Brady-street area. Many, or most, of the houses were in as bad and decayed a condition, and were as incapable of being made fit for human habitation, and as deserving of destruction as those in the Tabard-street area. On the other hand, the ground plan construction of the Brady-street area, although very defective, was not so objectionable as was the case in Tabard-street. The Brady-street area was, moreover, in the hands of a smaller number of separate owners than was the Tabard-street area, and for this reason it appeared to the Housing Committee that it would be more practicable to deal with it under the powers of Part II. of the Act of 1890, and the provisions of the Housing, Town Planning, etc., Act, 1909, if strongly used. The borough council was, however, strongly averse from further proceedings under Part II. of (a) Complaints only. 61 Report of the County Medical Officer—General. the Act, on the ground (1) that they would not be effective, and (2) that the cost incurred would fall exclusively upon the local rate, Bethnal-green being one of the poorest of the metropolitan boroughs. As a result the Council, on 29th-30th July, 1913, decided that it was not at present prepared to undertake an improvement scheme for this area under Part I. of the Housing of the Working Classes Act, 1890, in view of the fact that further legislation on the subject was practically certain at no distant date, and that such legislation would in all probability enable the area and other similar areas to be dealt with in a more satisfactory manner and at less cost to the rate-payer than was the case under the present law. In pursuance of the provisions of section 10 of the Housing of the Working Classes Act, 1890, a copy of the official representation with regard to the Brady-street area was sent to the Local Government Board, together with the Council's reasons for not acting upon it, and on 24th October, 1913, the Board held at the Bethnal-green Town Hall a local inquiry into the matter, but the Board did not announce its decision during the period dealt with in this report. Housing, Town Planning Act, Section 17 Article V. of the regulations made by the Local Government Board in September, 1910, under this Act, requires that the " medical officer of health shall include in his annual report information and particulars in tabular form in regard to the number of dwelling houses inspected under and for the purposes of section 17 of the Act of 1909, the number of dwelling houses which on inspection were considered to be in a state so dangerous or injurious to health as to be unfit for human habitation, the number of representations made to the local authority with a view to the making of closing orders, the number of closing orders made, the number of dwelling houses the defects in which were remedied without the making of closing orders, the number of dwelling houses which, after the making of closing orders, were put into -a fit state for human habitation, and the general character of the defects found to exist. He shall also include any other information and particulars which he may consider desirable in resard to the work of insDection under the said section." Information of these proceedings is not given in tabular form in several of the reports, and the following table has been mainly compiled from the information otherwise contained in them:— Metropolitan borough. No. of houses inspected. No. of houses dealt with under Section 15. No. of representations, 1913. No. of closing orders, 1913. No. of houses, defects remedied without closing orders. No. of houses, defects remedied after closing orders No. of houses demolished. Remarks. (1) (2) (3) (4) (5) (6) (7) (8) (9) Battersea 2,802 — Bermondsey — — 45 45 — 9 — 36 demolition orders made. Bethnal Green 578 34 — 18 380 4 13 4 to be demolished. Camberwell 66 — — — 44 — r Chelsea — — 6 — — — 6 Deptford 3,269 — 22 22 — 10 17 21 demolition orders made, 8 determined included in column 7. Finsbury 971 — 1 1 — — — Fulham 80 — — — 62 — — 18 houses, repairs not completed. Greenwich 397 — — — 270 — — 3 houses closed 4 demolished voluntarily Hackney 90 85 2 2 88 2 2 houses in col. 7 converted to workshops. Hammersmith 622 — — — 244 — — — Hampstead 7 — 7 7 — — — — Holborn 67 — 4 2 62 2 — 2 houses closed voluntarily. Islington 15 8 4 1 3 demolition orders, 2 houses acquired by L.C.C. Kensington 168 — 59 15 35 5 — — Lambeth 775 27 24 24 11 13 27 houses demolished voluntarily. Lewisham 764 4 4 2 2 — Paddington 179 6 — 3 18 2 1 Poplar 156 30 30 13 A number of demolition orders were made early in 1914. St. Marylebone 1,058* 54 25 25 822 — 1 St. Pancras 1,545 — 72 72 1,474 — — — Shoreditch 30 — 1 1 10 — — — Southwark 28 7 7 7 — — — — Stepney 8 houses closed. Stoke Newington 608 All defects remedied under P.H. (L.) Act, 1891.- Wandsworth 2,739 — — — — — Do. do. Westminster, City of 34 1 — 1 — 5 10 houses included in a scheme. Woolwich 5,489 1 52 14 26 4 1 — * Not including 445 tenements in blocks of buildings. 62 Annual Report of the London County Council, 1913. Some further information which cannot be put into tabular form is contained in some of the reports as to the working of the Housing Acts, and as to their uses and difficulties. Underground Rooms. The number of underground rooms dealt with in 1913 in the several metropolitan boroughs is shown in the following table:— Metropolitan borough. No. of rooms illegally occupied. No. of rooms closed or illegal occupation discontinued. Metropolitan borough. No. of rooms illegally occupied. No. of rooms closed or illegal occupation discontinued. Battersea 112 112 Lambeth 16 16 Bermondsey — — Paddington 7 10 Bethnal Green 15 15 St. Marylebone 157 157 Camberwell 2 2 St. Pancras 124 124 Chelsea — — Shoreditch 7 7 Deptford — — Southwark — — Finsbury 8 .8 Stepney 47 25 Fulham 6 6 Stoke Newington 6 6 Greenwich — — Wandsworth 3 3 Hackney 9 9 Westminster, City of 35 35 Hampstead 128 128 Woolwich 3 — Holborn 19 19 Islington 21 21 Total 801 759 Kensington 76 56 Under Section 17 (7) of the Housing and Town Planning Act, 1909, a room habitually used as a sleeping place, the surface of the floor of which is more than three feet below the surface of the part of the street adjoining or nearest to the room, is deemed to be unfit for human habitation, if it is not on an average at least seven feet in height from floor to ceiling, or does not comply with regulations which the local authority with the consent of the Local Government Board may prescribe. So far as is shown in the annual reports of medical officers of health, regulations made by eleven authorities have been approved by the Local Government Board, these authorities being the metropolitan borough councils of Battersea, Fulham, Hampstead, Kensington, Lambeth, Poplar, St. Marylebone, St. Pancras, Stoke Newington, Wandsworth and Woolwich. In Holborn and Paddington new by-laws were still under consideration at the end of the year. Overcrowding. In the 1911 census the total number of families living in overcrowded tenements, that is, in tenements comprising rooms occupied by more than two persons each was found to be 121,638, including 758,786 persons of whom 289,802 were children under ten years of age. On this basis of overcrowding figures are given, which enable comparison to be made of the conditions existing at the time of the censuses of 1901 and 1911. From the following table it will be seen that generally there has been a decrease during the last decennium in the percentage of the total population living in overcrowded tenements of one and two rooms, with a corresponding increase in the percentage living in overcrowded tenements of three and four rooms. The nett increase in the percentage of the total population living in overcrowded tenements of one to four rooms is 0.04. Expressed as a percentage of total tenements, the table also shows an increased use of tenements of one to four rooms in the census years 1901 as compared with 1891, and 1911 as compared with 1901, of 10.5 per cent., and 4.2 per cent. respectively. It may not be out of place here to mention that tenements of less than four rooms contain 43.3 per cent. of the private family population of London, including 6.24 per cent. in single-roomed tenements, 15'84 per cent. in tenements of 2 rooms, and 21.2 per cent. in tenements of 3 rooms. As an interesting fact, it may also be noted that of the 1,023,951 private families enumerated in London, 95,724 or 9.3 per cent. consist of single persons in the proportion of 58.594 females to 37,130 males The table enables comparison to be made of the percentages of total tenements and of overcrowded tenements for the whole county in the several census years, 1891, 1901, and 1911. The details for each of the London boroughs for the two last-mentioned years only will be found in Appendix II. of the Annual Report for the year 1912. 63 Report of the County Medical Officer—General. Tenement of Percentage of total tenements. Overcrowded tenements. (Tenements occupied by more than 2 persons per room.) Percentage of total population living in overcrowded tenements. 1891. 1901. 1911. Inc. ( +) or Dec. (—) 1891. 1901. 1911. Inc. (+) or Dec. (—) 1891-1901. 1901 1911. 1891-1901. 1901-1911. 1 room 9.2 14.7 13.5 + 5.5 — 1.2 5.10 3.26 2..58 1.84 —0.68 2 rooms 16.4 19.8 19.2 + 3.4 — 0.6 7.84 6.54 6..14 1.30 —0.40 3 „ 15.8 17.8 21.4 + 2.0 + 3.6 4.57 4.14 4..93 0.43 +0.79 4 „ 14.1 13.7 16.1 — 0.4 + 2.4 2.19 2.07 2.40 0.12 +0.33 1.4 rooms 55.5 66.0 70.2 + 10.5 + 4.2 19.70 1601 16.05 —3.69 +0.04 Study of the detailed tables forming Appendix II. of the Annual Report for 1912 shows that increase in the percentage of overcrowded tenements of less than five rooms, comparing the years 1901 and 1911, was most marked in Shoreditch (4.10 per cent.), Fulham (2.78 per cent.), Finsbury (2.68 per cent.) and Camberwell (2.64 per cent.). The largest decreases occurred in Holborn (5.72 per cent.), St. Marylebone (3.37 per cent.), Westminster (2.92 per cent.), and the City of London (2.78 per cent.). In the annual report for 1901 attention was directed to the increase of overcrowding in the eastern districts. On the basis of overcrowding adopted in the tables, this increase is still to be observed except in the case of Stepney, where the proportion of overcrowded tenements has diminished during the decennium by 1.48 per cent. It should, however, be noted that the standard of overcrowding used in these tables is of necessity the arbitrary one used by the Census Office, and the application of the statutory definition of overcrowding based on a measurement of cubic space per head would undoubtedly give very different results. For the whole county, moreover, the average number of occupants per room, which declined between 1891 and 1901, still further declined between 1901 and 1911 for all tenements of less than five rooms. The following table, showing the number of dwelling rooms found overcrowded, according to the standard prescribed by the bylaws relating to houses let in lodgings, in each metropolitan borough is compiled from information supplied by the medical officers of health, in their annual reports :— Metropolitan borough. No. of dwelling. rooms overcrowded. No. remodied. No. of prosecutions. City of London 3 3 Battersea 68 68 — Bermondsey 61 61 — Bethnal Green 231 231 — Camberwell 104 104 Chelsea 2 2 — Deptford 48 48 — Finsbury 102 102 — Fulham 38 38 — Greenwich 33 33 — Hackney 90 89 — Hammersmith — — — Hampstead 10 10 — Holborn 39 39 — Islington 156 156 — Kensington 111 111 — Lambeth 19 19 — Lewisham 36 36 — Paddington 195 246(a) — Poplar .. .. .: 180 180 St. Marylebone 89 89 — St. Pancras 35 35 — Shoreditch 298 298 — Southwark 494 494 — Stepney 487 487 5 Stoke Newington 16 16 —• Wandsworth 75 75 — Westminster, City of 137 137 — Woolwich 101 101 — Totals 3,258 3,308 5 (a) Including rooms found overcrowded in 1912. * These figures relate to the County of London as constituted at the date of the census, but the subsequent changes in the county area do not seriously affect the value of the figures for the purposes of comparison with the later years. 64 Annual Report of the London County Council, 1913, Houses let in lodgings. Registration and inspection of houses let in lodgings. The following table has been compiled from the annual reports of medical officers of health, and shows the number of houses let in lodgings on the register, the number of inspections, notices issued and proceedings taken during the year 1913. []###Metropolitan borough. Number of places. No. of Inspections, 1913. No. of Notices, 1913. No. of Prosecutions, 1913. On register at end of 1912. Added in 1913. Removed in 1913. On register at end of 1913. City of London 227 — — 222 — 272 — Battersea 123 —- 9 114 309 84 Bermondsey 228 — 10 218 872 117 — Bethnal Green 528 280 232 576 2,042 596 — Camberwell 262 30 292 531 565 — Chelsea 569 — — — — — — Deptford 273 68 52 289 564 195 — Finsbury 1,209 21 1,188 6,611 1,239 — Fulham 114 — — — — — — Greenwich 238 5 — 243 273 148 — Hackney 470 470 387 221 — Hammersmith 2,451 247 184 2,514 — 755 — Hampstead 425 17 73 369 371 183 — Holborn 606 41 6 641 901 239 5 Islington (a) — — (a) 12,160 1,325 20 Kensington 2,094 11 12 2,093 7,470 900 6 Lambeth 372 372 744 — Lewisham 3 2 — 5 14 3 — Paddington 1,348 55 27 1,376 7,597 2,360 6 Poplar 1,137 11 — 1,148 2,633 285 1 St. Marylebone 1,001 241 29 1,213 7,970 2,030 — St. Pancras 2,358 — — — — — — Shoreditch 272 8 — 280 449 316 — Southwark 1,229 30 12 1,247 12,819 3,000 5 Stepney 2,911 2,509 2,911 2,509 5,310 2,819 8 Stoke Newington 207 — — 220 Frequent — Wandsworth 292 _ 292 930 531 — Westminster 1,345 — 45 1,300 6,810 1,235 — Woolwich 432 10 10 432 531 360 Houses let in lodgings —by-laws Reference was made in the annual reports for the years 1910-12 to a provision in the Housing, Town Planning, etc., Act, 1909 (section 16) which extends the power of making by-laws as to lodginghouses for the working classes so as to impose duties upon the owner of the premises in addition to or in substitution for any other person. So far as can be gathered from the annual reports, new by-laws have been adopted in Battersea, Bethnal Green, Hackney, Islington, Kensington, Paddington, Poplar, St. Marylebone, Shoreditch, and Westminster. In Lambeth new by-laws have been drafted. In last year's report relating to St. Pancras it was stated that inasmuch as inspection under the Housing, Town Planning Act is to supersede inspection under Section 94 of the Public Health (London) Act, there is no intention to recast the by-laws. Dr. Whitehouse has pointed out that the by-laws at present in operation in Deptford are quite inadequate, only 10 per cent. of sublet houses being registered. Woolwich is in a very anomalous position in this respect. At present three different sets of by-laws are in existence, one each in Woolwich, Eltham and Plumstead. The by-laws in Eltham assign a rent limit which nullifies all action, and no houses have ever been registered in this parish. In the by-laws relating to the other two parishes all the sections dealing with structural defects are in abeyance owing to (a) No register is now kept, under the Borough of Islington's new by-laws, but during the year there were 1,848 houses on the lists for inspection. 65 Report of the County Medical Officer—General. difficulty in fixing the responsibility as between " landlord " and '' tenant." New by-laws have been under consideration for several years, in fact ever since the formation of the borough, and on two occasions a draft code has been submitted to the Local Government Board. The Board, however, required certain alterations to which the borough council could not agree, and the question of making new by-laws has been deferred. Death Rates in Council's Dwellings. The following death-rates obtaining among tenants of the Council's buildings relate to dwellings within the county which were occupied during the whole of the year 1913. The population thus dealt with comprised 28,882 persons, and the death-rate at " all ages," after correction for age and sex distribution, was 9'6 per 1,000 living, compared with 142 for London :— Cause of death. Death-rate per 1,000 living, 1913. Council's dwellings. London. All Causes—All Ages 9.6 14.2 „ „ age 0—5 21.6 37.3 „ „ 5—20 2.3 2.5 „ ,, ,, 20 and upwards 10.2 15.5 Diarrhcea 0.5 0.8 Principal epidemic diseases (excluding Diarrhcea) 0.4 0.7 Phthisis 0.9 1.3 Tubercular disease. other than Phthisis 0.6 0.3 Bronchitis 0.5 1.3 Pneumonia 1.0 1.3 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 cases of infectious disease. £ s. d. 1895 626 29,574 — — 16 12 37 6 0 99 1896 596 29,140 28,331 — 31 30 112 16 0 71 1897 581 28,718 26,121 — 31 30 92 11 0 48 1898 560 28,332 27,658 — 29 29 167 3 0 44 1899 544 28,448 28,229 1,162 25 22 183 9 0 54 1900 528 28,311 28,428 668 16 13 102 15 0 40 1901 514 28,037 35,225 2,133 16 15 96 3 0 166 1902 491 28,970 40,512 1,449 22 21 98 4 0 684 1903 470 28,893 33,402 4,790 6 6 26 11 0 53 1904 451 28,896 27,501 2,970 15 14 62 6 0 66 1905 413 27,571 28.158 1,565 21 16 77 3 0 14 1906 402 28,063 30,028 2,349 4 4 11 1 0 22 1907 395 28,651 33,630 2,307 3 3 12 9 0 27 1908 387 28,379 32,297 2,429 1 1 2 2 0 13 1909 383 28,302 29,324 1,286 3 3 22 0 0 19 1910 368 27,914 26,733 1,589 2 2 7 4 0 13 1911 364 28,000 25,243 2,066 2 2 5 8 0 16 1912 351 27,110 25,354 1,872 5 5 7 5 0 9 1913 346 26,562 25,634 1,856 8 7 23 11 6 8 Proceedings before the magistrate were instituted in eight cases, resulting in seven convictions, the penalties inflicted amounting to £19, with £4 l1s. 6d. costs. One summons was dismissed with costs against the Council. The number of cases of notifiable infectious disease—other than phthisis—reported in common lodging houses was as follows : Erysipelas, 3 ; diphtheria, 3 ; scarlet fever, 1 ; enteric, 1 ; total, 8. 23610 K 66 Annual Report of the London County Council, 1913. The following table shows the total number of common lodging houses, and the authorised accommodation for the different classes of lodgers in the several districts other than the City of London on 31st December, 1913 :— Sanitary district. Number of Houses. Authorised Accommodation. Men. Women. Couples. Total. Battersea 3 99 66 — 165 Bermondsey 5 1,287 — — 1,287 Bethnal Green 12 610 — — 610 Camberwell 5 466 — — 466 Chelsea 6 236 — — 236 Deptford 8 1,155 80 — 1,235 541 Finsbury 8 484 57 — 541 Fulham 2 43 51 — 94 Greenwich 3 121 — — 121 Hackney 7 498 — — 498 Hammersmith 9 466 — 4 474 Hampstead — — — — — Holborn 25 1,476 144 — 1,620 Islington 40 1,093 187 18 1,316 Kensington 22 401 272 — 673 Lambeth 7 693 — — 693 Lewisham 1 30 — — 30 Paddington 7 195 37 — 232 Poplar 8 1,001 — — 1,001 St. Marylebone 12 1,028 109 1,137 St. Pancras 7 610 36 — 646 Shoreditch 12 752 — — 752 Southwark 41 3,021 449 — 3,470 Stepney 53 5,201 747 180 6,308 Stoke Newington 1 37 — — 37 Wandsworth 8 175 5 16 212 Westminster, City of 12 2,130 62 — 2,192 Woolwich 22 465 51 516 London—excluding the City of London ' ' 346 23,773 2,353 218 26,562 Deaths among inmates oi 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 738; the large majority of these deaths occurred in Dublic institutions. Table showing the number of deaths of males at five age periods Irom certain cause.s per 1,000 deaths from all causes in London (1912) and licensed common lodging-houses (1912 and 1913). Cause of death. Age 25 to 35. Age 35 to 45. Age 45 to 55. Age 55 to 65. Age 65 and upwards. London. 1912. C.L.H 1912. C.L.H. 1913. London, 1912. C.L.H. 1912. CL.H. 1913. London, 1912. C.LH. C.L.H. 1912. 1913 London1912. C.L.H. 1912. C.L.H. 1913. London, 1912. C.L.H. C.L.H. 1912. 1913. Phthisis 411 625 438 318 416 473 201 284 355 116 256 11 189 27 2 83 18 85 Other tubercular diseases 19 62 7 11 10 9 13 3 21 29 8 - - Alcoholism (including cirrhosis of the liver) 9 31 18 22 21 28 6 92 26 70 130 78 78 59 33 63 62 47 34 42 70 68 90 80 32 27 24 Violence, suicide 110 94 84 81 22 21 64 33 45 47 149 145 108 83 95 Cancer 23 — 42 56 33 42 115 64 151 Circulatory diseases Nervous diseases 159 31 104 222 213 95 242 163 123 283 145 112 145 137 296 165 172 178 188 249 Bronchitis 15 31 62 36 67 74 55 123 160 110 82 134 87 49 28 114 Pneumonia 93 63 125 92 41 121 70 95 240 336 195 Other causes 118 — 84 119 57 105 124 11 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 67 Report of the County Medical Officer—General. Phthisis in common lodginghouses. Since the year 1909, when the Local Government Board issued its first Order requiring the notification of phthisis, inquiry has been made with regard to 1,070 persons notified under the Orders and giving addresses at common lodging-houses licensed by the Council. Of this number 1,006 were males and 64 were females. The age distribution of 1,050 of these cases was as follows :— 0— 5— 10— 15— 20— 25— 35— 45— 55— 65— 1 2 1 10 26 160 279 344 184 43 As the result of inquiry information was obtained in respect of 906 of the patients as to whether their illness began before or after they had resorted to this mode of living. Of the total (906) the onset of illness was stated in 322 cases to date from a time prior to that when resort was made to common lodging-houses, while in 76 other cases it was practically coincident with entry. As regards cases developing after commencement of this mode of life, in 147 cases the illness was first manifested before the expiration of three years ; in 69 cases from three to five years ; in 134 cases in from five to ten years ; in 16 cases between ten and twenty years, and in 45 cases the illness developed after more than twenty years of common lodging-house life. Furnished rooms. The question as to the need of greater control being exercised over houses let in turnished rooms to persons of the common lodging house class has been for some time under consideration. During 1912 the Council of the Royal Borough of Kensington appointed a Committee to inquire closely into this subject with special reference to the Notting-dale area, and after investigation it was suggested to the Local Government Board that legislation should be promoted to require keepers of such houses to be licensed annually under conditions similar to those obtaining in the case of common lodging houses. As a result the Board communicated with the County Council suggesting that the latter should endeavour to deal with certain of the premises as common lodging houses which in the opinion of the Board appeared to be used as such. The Council acted on this suggestion and selecting a group of houses in Crescent-street, summoned the keeper for keeping a common lodging house without a licence. The case came before the magistrate on 31st July, 1913, and was dismissed on the ground that the premises were not used as a common lodging house, there being no community of eating of sleeping accommodation. The Council appealed against this decision. The appeal came before Justices Channell, Rowlatt and Atkin in the King's Bench Division on 13th December, 1913, but was dismissed, the magistrate's decision being upheld. Seamen's lodging houses. In July, 1901, the London County Council made by-laws under Section 214 of the Merchant Shipping Act, 1894, for the inspection, sanitary condition and well ordering of seamen's lodging houses. In 1909, after experience of their application, the by-laws were amended, a new series was issued and came into force on 1st January, 1910. By an Order in Council dated 19th February, 1910, powers were conferred on the County Council for the licensing of seamen's lodging houses. The first licensing meeting was held in May of that year and since that date all such premises are annually licensed. At the end of the year 1913, the number of seamen's lodging houses under supervision was 44, situated in the following metropolitan boroughs :— Metropolitan borough. Houses. Lodgers. Poplar 14 387 Stepney 30 733 Total 44 1,120 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 convictions. Penalties and costs. No. of cases of infectious disease. £ s. d. 1902 97 1,665 2,842 - - 1903 102 1,748 1,956 4 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 4S1 38 9 8 43 7 0 2 1907 82 1,550 1,431 2,169 70 8 7 38 19 0 5 1908 85 1,571 2,081 78 3 3 24 0 0 6 1909 80 1,524 1,983 84 7 6 15 0 0 — 1910 37 1,157 2,404 197 15 14 90 9 0 — , 1911 36 1,173 1,465 204 7 6 52 13 0 — 1912 41 1,066 1,079 210 18 13 81 12 0 — 1913 44 1,120 1,814 237 15 4 29 16 0 — 23610 K 2 68 Annual Report of the London County Council, 1913. Proceedings before the magistrate were instituted in 15 cases resulting in 4 convictions, the penalties amounting to £25 with £4 16s. costs. In only two of the cases were proceedings necessary in respect of licensed houses. Of the eleven unsuccessful cases, one was dismissed, the evidence adduced on behalf of the Council being in the magistrate's opinion insufficient to prove that the lodgers found on the premises had been at sea within four weeks in accordance with the definition of " seamen " in the by-laws. This definition is as follows :— " ' Seaman ' means any male person other than the holder of a certificate of competency or service as master, mate, or engineer, in the merchant service who, within four weeks immediately preceding the date of any transaction or occurrence within the scope of these by-laws has been employed in any capacity whatsoever on board a ship . . . As the evidence in the remaining ten cases was of a precisely similar nature to that in the case dismissed, the summonses were not proceeded with. The difficulty of enforcing compliance with the Order in Council of February, 1910, which provides that none but duly licensed persons may keep seamen's lodging houses or let lodgings to seamen within the administrative County of London without a licence, is a real one, for to secure a conviction the Council's officers have not only to prove that the lodgers are seamen within the ordinary acceptation of the term, but that such seamen have been employed on board a ship within a period of four weeks. No cases of infectious disease were reported among inmates of seamen's lodging houses during the year. Cleansing of Persons Act, 1897. Cleansing of Persons Act, 1897, etc. The Cleansing of Persons Act, 1897, provides " that any local authority shall have the power when in their discretion they shall see fit, to permit any person who shall apply to the said authority on the ground that he is infested with vermin to have the use, free of charge, of the apparatus (if any) which the authority possesses for cleansing the person and his clothing from vermin." It is also provided that the use of such apparatus shall not be considered to be parochial relief or charitable allowance, and local authorities may expend any reasonable sum on buildings, appliances, etc., required for carrying out the Act. The Act, however, is a permissive one only. For several years the metropolitan borough councils, with some few exceptions, took very little action under the provisions of this Act, and so recently as 1906 except in boroughs like St. Marylebone, St. Pancras and Poplar, there was little progress to record. General Powers Act, 1904, sects. 19,20, 21, 24 It was recognised, however, in dealing with verminous persons and more particularly in the case of children, that the cleansing of the individual could be of little service unless accompanied by the cleansing of the home and the purification of articles of furniture and clothing. The London County Council, therefore, in its General Powers Bill of 1904 inserted clauses empowering local authorities to cleanse, purify, or destroy articles which the medical officer of health certifies are filthy, dangerous, or unwholesome. In addition, power was obtained to compel owners to strip and cleanse any house or part of a house certified by the medical officer of health to be infested with vermin. These clauses became law and have been increasingly used, so that during the year 1913 more than 100,000 articles of clothing and bedding are recorded as having been freed from vermin, and if the exact figures were obtainable it would probably be found that twice this number of articles was dealt with. During the last three years, moreover, an average number exceeding 10,000 rooms a year received the attention of the borough councils on account of their verminous condition. General Towers Act 1907, sects. 36-40. A further impetus was given to this work by the passing of the London County Council (General Powers) Act of 1907. This Act contained clauses empowering the Council, as Education Authority to make arrangements for the cleansing of school children, and as supervising authority for the cleansing of the inmates of common lodging houses. In both cases power was obtained to detain and convey to suitable premises for the purpose of cleansing any person failing to comply with a twenty-four hours' notice. Section 38 of the Act expressly provided that the Council might enter into agreements with local authorities possessing suitable stations for the cleansing of school children and inmates of common lodging houses, and incidentally this section has been the means of securing a considerable extension throughout London of the facilities for cleansing which were first provided after the passing of the Clensing of person Act 1897. Children Act, 1908. Sect. 122. Almost immediately following the General Powers Act of 1907, the Children Act, 1908, was passed. This Act also gave power to cleanse when necessary elementary school children, and, indeed, in some respects afforded greater facility of action than the Council's Act. In London, therefore, Section 122 of the Children Act has been mainly used, but it has been supplemented by the powers obtained in 1907. From this brief statement it will be seen that considerable attention has of recent years been directed to this most important question of personal hygiene. The development of the Council's scheme for securing the cleanliness of school children is fully discussed in Part II. (Education) of this report, and it will only be necessary here to summarise the results of the action taken by the several borough councils. With very few exceptions, all the London boroughs have now made provision for personal cleansing, and most of the annual reports of medical officers of health contain information as to the 69 Report of the County Medical Officer—General. Number of cleansings during the year 1913. action taken. The number of cleansings at the several stations as shown in the following table has been obtained from this source :— Metropolitan borough. Adults. Children. Metropolitan borough. Adults. Children City of London Islington 15 893 Battersea 1,323 1,090 Poplar 302 2,237 Bermondsey 35 2,649 St. Marylebone 8,005 2,076 Bethnal Green 19 — St. Pancras 1,091 3,127 Camberwell — *2,714 Southwark 72 2,532 Deptford — 1,975 Stepney 1,780 4 Greenwich — 173 Stoke Newington 2 415 Hackney 38 2,328 Wandsworth 2 — Hampstead 7 178 Westminster, City of 46 1,418 Holborn 42 — Woolwich 132 519 Cleansing adults. As mentioned in the annual report for 1910, the principle adopted by the Council with regard to the cleansing of adults from common lodging-houses was that the sanitary authorities should cleanse, free of charge, any persons sent for that purpose to the cleansing station by the County Council from common lodging-houses within their respective districts, and that a fee should be paid for cleansing all persons sent from common lodging-houses not within the district where the cleansing was performed. Agreements to this effect have been made with the borough councils of Bermondsey, Camberwell, Hackney, Poplar, St. Marylebone, St. Pancras, and Woolwich. From the information supplied by the Council's inspectors it appears that during the year 1913, 1,433 men and 40 women were, by reason of their beds having been found verminous, sent to have their clothing cleansed. Of these numbers 1,297 men and 37 women were known to have been cleansed, 125 men and 3 women went away and could not be traced. In nearly all the London boroughs, whether personal cleansing is undertaken or not, considerable effort is made to deal with verminous homes notified as the result of action by the school authority, and many of the reports refer to the large amount of work involved in this connection. This additional visiting, moreover, has had an influence for good far beyond its immediate aim, and many other defects have been found and remedied as the result of the special inquiries made by the sanitary inspector or health visitor. In addition, many thousands of articles have been purified and thousands of rooms cleansed, and this work alone cannot be regarded as unprofitable, affecting as it does the welfare of the whole community. Cleansing of verminous rooms or premises. The details obtainable from the annual reports concerning the cleansing of rooms are showi in the following table:— Metropolitan borough. Number of rooms or premises cleansed. Metropolitan borough. Number of rooms or premises cleansed. City of London - Lambeth 927 rooms. Battersea Not stated Lewisham 27 rooms Bermondsey Not stated Paddington 280 premises. Bethnal Green 143 premises Poplar 251 rooms. Camberwell 103 premises St. Marylebone 303 rooms. Chelsea 265 rooms St. Pancras 252 rooms Deptford 125 rooms Shoreditch 601 rooms. Finsbury 47 premises Southwark †2,590 rooms. Fulham 232 rooms Stepney 2,420 rooms. Greenwich 94 premises Stoke Newington 163 rooms. Hackney 446 premises Wandsworth 618 rooms. Hammersmith Not stated Westminster 228 premises. Hampstead 67 rooms Woolwich — Holborn 57 premises Islington 233 premises Total for 24 boroughs { 8,841 rooms 1,799 premises Kensington 271 premises Vermin Inquiry. On pages 62 and 63 of the annual report of the medical officer of health for the year 1911, the question of the seasonal prevalence of three particular kinds of vermin (fleas, lice, and bugs), is discussed at some length, and diagrams were prepared illustrating the subject. The diagram included in this report gives the result of five years' work in connection with the observation of the seasonal prevalence * Including adults. † 1,366 of these cleansed by owners. 70 Annual Report of the London County Council, 1913. of the three kinds of vermin. The work of the inspectors has unquestionably stimulated the action of common lodging-house keepers, and it was thus only to be expected that considerable improvement would be observed when the records for lice and bugs came to be examined; the work of exterminating these two kinds of vermin is comparatively simple, in view of the possibility of destroying them by cleansing sheets, bedsteads, walls and floors. In the case of fleas no corresponding improvement is recorded and this, doubtless, is largely due to the greater difficulties encountered in dealing with these pests. It may be, moreover, that flea prevalence is to a large degree a question of temperature, rainfall, etc. The efforts of public health authorities working with the object of diminishing the prevalence of vermin are being persisted in, and it is possible that this work may have even more far-reaching effect than is now generally appreciated. Water supply to tenement houses. Sanitary authorities have made considerable use of the powers provided by section 78 of the London County Council (General Powers) Act, 1907, for requiring the provision of a water supply to the upper floors of tenement houses. So far as can be gathered from the information contamed in the reports of medical officers of health, the following table shows the extent to which the powers referred to have been applied during 1913 :— Metropolitan borough. No. of premises caused to be supplied. No. of legal proceedings. Battersea 107 Bethnal Green 3 — Deptford 7 — Finsbury 18 — Fulham 29 — Hackney 17 — Hampstead 115 — Holborn 15(a) — Islington 175 — Paddington 37 — Poplar 8 — St. Marylebone 203 3 St. Pancras 353 — Shoreditch 19 — Southwark 68 2 Stepney 6 — Westminster, City of . 15 — Woolwich 18 — Total for 18 boroughs 1,213 5 Revenue Act, 1903 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:— 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. (a) Number of notices served. In the majority of cases the work was completed daring the year. 71 Report of the County Medical Officer—General. Applications for certificates, Revenue Act, 1903. The number of applications received and certificates granted during 1913 is shown in the following table:— Metropolitan borough. No. of houses for which applications for certificates were received during 1913. No. of tenements comprised therein. No. of tenements for which applications for certificates were Granted. Refused. Deferred or withdrawn Battersea 3 7 5 2 Bermondsey None — — — — Bethnal Green None — — — — Camberwell 37 109 55 41 13 Chelsea 17 397 376 21 — Deptford 29 62 62 — — Finsbury 9 — — All — Fulham — 512 420 103 89 Greenwich 3 21 21 Hackney 13 31 31 — — Hammersmith 85 227 78 — 149 Hampstead 9 22 2 — 20 Holborn 2 5 — 5 — Islington 8 31 24 7 — Kensington 77 168 152 — — Lambeth 29 84 38 10 26 Lewisham 51 98 96 2 — Paddington 4 26 25 1 — Poplar — None — — St. Marylebone None — — — — St. Pancras 6 234 2 blocks — Shoreditch 2 91 91 Southwark 143 1,413 1,413 — — Stepney 8 70 56 14 — Stoke Newington — — — — Wandsworth 30 69 61 — 2 Westminster, City of 5 221 220 — 1 Woolwich None — — Section 35 of the Housing and Town Planning Act extends to common lodging-houses, at which the charge does not exceed sixpence per night, the provisions of Section 11 of the Revenue Act, and hence reference is made in some of the reports to the action taken by medical officers of health in respect of these houses. In certain instances modifications and improvements of houses were made by keepers with a view to their obtaining exemption from inhabited house duty. Factory and Workshop Act, 1901. Section 132 of the Factory and Workshop Act, 1901, requires that every medical officer of health shall every year report specifically on the administration of the Act in workshops and workplaces in the district under his supervision. A form of table is prescribed by the Home Secretary for the exhibition of those particulars which lend themselves to statistical statement. From such tabulated statements contained in the annual reports of the metropolitan borough councils, a summary table has been prepared for the year 1913. (See Annendix XX.) Workshops. It will be seen from the following table, comparing the work done in 1913 with that done in previous years that there is little variation from year to year in the number of defects found. The number of workshops under inspection shows some diminution, mainly due, perhaps, to differences in classification. 1907. 1908. 1909. 1910. 1911. 1912. 1913. Number of workshops on register 37,891 37,673 37,782 37,742 43,035 44,592 40,864 Number of inspections, excluding inspec- 81,171 84,058 84,174 89,040 89,995 84,854 83,897 tions of outworkers' premises Total number of defects found 22,071 22,012 21,522 21,888 21,013 20,946 20,763 Want of cleanliness 8,319 7,130 7,256 7,248 6,725 6,734 6,450 Want of ventilation 652 639 727 607 681 594 810 Overcrowding 295 237 278 250 253 263 237 Sanitary conveniences Insufficient 256 278 377 262 293 281 328 Unsuitable or defective 4,229 5,255 5,377 5.402 5,516 5,289 5,611 ( Not separate for sexes 388 376 292 312 277 324 344 72 Annual Report of the London County Council, 1913, Ice-cream premises. Places where food is prepared for sale. Section 43 of the London County Council (General Powers) Act, 1902, gives powers for controlling the conditions under which ice cream is prepared for sale. The provisions of this section are now widely applied and nearly all the reports give account of the action taken. The following table summarises the information thus available and shows the number of these premises in each metropolitan borough and other particulars :— Metropolitan borough. Number of places. No. of inspections, 1913. No. of notices, 1913. No. of prosecutions, 1913. On register at end of 1912. Added in 1913. Removed in 1913. On register at end of 1913. City of London 215 269 Battersea 181 33 26 188 575 21 — Bermondsey 120 — 6 114 148 6 — Bethnal Green 103 14 6 111 263 — — Camberwell 163 6 22 147 449 8 — Chelsea 28 1 2 27 39 1 — Deptford 132 22 16 138 219 8 1 Finsbury 106 — 1 105 108 20 — Fulham 140 2 9 133 152 6 — Greenwich 125 13 21 117 124 — — Hackney 190 8 198 257 21 — Hammersmith 170 52 23 199 388 28 2 Hampstead 80 4 3 81 126 13 — Holborn 35 22 3 54 163 — — Islington 224 42 27 239 83 22 — Kensington 171 33 19 185 556 18 — Lambeth — — Lewisham — — Paddington 110 10 4 116 122 1 — Poplar 124 120 268 5 — St. Marylebone 104 13 12 105 118 7 — St. Pancras 491 491 289 2 Shoreditch 93 7 2 98 155 19 — Southwark 120 6 114 172 44 — Stepney 201 38 8 231 429 64 — Stoke Newington 38 — Wandsworth 322 51 27 346 528 51 — Westminster, City of 174 180 298 51 — Woolwich 89 7 14 82 164 8 Other premises where food is prepared for sale. Further powers for the sanitary control of premises upon which food is prepared for sale are conferred upon sanitary authorities by section 8 of the London County Council (General Powers) Act of 1908, which provides against contamination of the food by urinals, waterclosets, ashpits, etc.-, requires that the water supply shall be free from contamination by any watercloset, prohibits drain inlets within the building and the deposit of refuse beyond that which is required for the purposes of the trade, and, moreover, requires due cleanliness to be observed in regard to the room or shop and the apparatus and utensils and persons employed in it. A considerable amount of work has been done in London under these powers, various conditions having been dealt with in their administration. The annual reports of medical officers of health supply information as to the number of premises inspected and the number of inspections as shown in the following table :— Metropolitan borough. Premises used for the preparation and sale of food.(a) Number of inspections. Metropolitan borough. Premises used for the preparation and sale of food, (a) Number of inspections. City of London 899 Kensington — 1,316 Battersea 104 — Lambeth 248 — Bermondsey 1,103 7,424 (b) Lewisham 46 65 Bethnal Green.. 212 1,042 Paddington 359 739 Camberwell 189 103 Poplar 283 908 Chelsea 69 73 St. Marylebone 262 522 Deptford 121 134 St. Pancras 175 220 Finsbury 228 228 Shoreditch 193 — Fulham — — Southwark 1,281 2,233 Greenwich 119 254 Stepney 418 828 Hackney 131 134 Stoke Newington 28 — Hammersmith 186 — Wandsworth 617 963 Hampstead 394 '615 Westminster, City of. 4,464 quarterly Holborn 397 2,095 Woolwich — 120 Islington 687 320 (а) Other than bakehouses, milkshops, slaughterhouses, and ice-cream premises. In some cases the figures relate to restaurant-kitchens only. (b) Including visits for the purpose of sampling under the Food and Drugs Act. 73 Report of the County Medical Officer—General. Inspection of food. A very considerable amount of work is done throughout London in connection with the protection of the food supply. As regards meat, the City of London Corporation, which has the control of the Central Markets, has the greatest amount of responsibility; indeed, it is estimated that three-fourths of the meat imported into the United Kingdom passes under the observation of the officers of the Corporation either in the Central Meat Markets or in the City Cold Stores. It is noted, however, that there is a growing shortage in the supplies of meat exported to this country from America owing to the rapid growth of the population of the United States and Canada. Incidentally it is mentioned that in the States a decrease of 16,000,000 head of cattle has taken place during the last six years, while the population is said to have increased 21 per cent. According to the report of the chief veterinary inspector of the City of London, tuberculosis still occupies most of the attention of the inspectors in the markets, and more than 53 tons of meat were seized on account of this disease. The total quantity of unsound meat seized as unfit for food amounted to more than 1,052 tons. In all the boroughs of London special attention is directed to the purity of the food supply, and in nearly all the reports mention is made of seizures and surrenders not only of meat but of unsound or unwholesome food of every description. Shelters. The following figures, which are taken from the annual reports, show the extent to which the existing shelters were used during the year 1913, for the accommodation of persons and families, while their homes were being disinfected. Metropolitan borough. No. of persons accommodated. Metropolitan borough. No. of persons accommodated. City of London Kensington (a) Battersea 5 Lambeth 1 Bermondsey 16 Lewisham Bethnal Green Paddington (a) Camberwell — Poplar Chelsea 45 St. Marylebone 39 Deptford St. Pancras — Finsbury 7 Shoreditch — Fulham — Southwark 16 Greenwich — Stepney 5 Hackney 11 Stoke Newington — Hammersmith Wandsworth Hampstead Westminster, City of Holborn 9(a) Woolwich — Islington 7 Mortuaries. The number of bodies received into the mortuaries of the metropolitan borough councils during the year is shown in the following table:— Metropolitan borough. Total number of bodies received into mortuary. Number of infectious bodies received into mortuary. Metropolitan borough. Total number of bodies received into mortuary. Number of infectious bodies received into mortuary. City of London 205 Kensington 239 Battersea 266 18 Lambeth 383 — Bermondsey 180 2 Lewisham 142 Bethnal Green 334 — Paddington 333 2 Camberwell 308 — Poplar 437 — Chelsea 127 — St. Marylebone 282 — Deptford 110 4 St. Pancras 416 7 Finsbury 335 3 Shoreditch 362 1 Fulham 149 1 Southwark 180 2 Greenwich 131 — Stepney 572 2 Hackney 452 1 Stoke Newington 63 — Hammersmith 209 —— Wandsworth .. 205 — Hampstead 107 — Westminster, City of 328 1 Holborn 90 — Woolwich 179 3 Islington 575 '— (a) No shelter maintained by borough council. In the case of Holborn 9 persons were accommodated in the Finsbury Borough Council's shelter. 2361 74 Annual Report of the London County Council, 1913. Homeless persons. With a view to determining the number of homeless persons in London, the Public Health Committee of the Council has from time to time instructed the medical officer to take a night census of all the persons found to be taking shelter on staircases or under arches, and to enumerate all people, obviously unable to provide themselves with a bed, found in the street on the particular night chosen for the census. Two censuses were undertaken during the year 1913, one on the night of the 4th February, and one on the night of the 24th October. When the first census of homeless persons was made, on the night of the 29th January, 1904, the district included for the purpose was necessarily restricted owing to the experimental nature of the inquiry. From the experience gained on that occasion, however, it was found possible in 1905 to map out a larger area, roughly approximating to an ellipse, having its centre at St. Paul's Cathedral, a major axis of eight miles from east to west, and a minor axis of five miles from north to south. In all succeeding enumerations the same area has been chosen for exploration and thus it is possible fairly to compare the several results obtained. On every occasion counting has begun at one o'clock a.m., certain groups of officers working from the centre outwards, and other groups from the boundary towards the centre of the appointed area. By this means the possibility of error due to duplication in counting is reduced to a minimum. The outstanding feature of the comparative table showing the results obtained since the beginning of the year 1904 (see chapter XXXII.a) is the remarkable fall in the numbers obtained since the year 1910. This reduction has been accompanied by a decline in the number of persons frequenting common lodging houses and casual wards. The changes which have been effected in the Poor Law administration have doubtless contributed in great measure to the reduction in the number of persons recorded as homeless, but are not in themselves sufficient to account for the total reduction in the numbers of persons dealt with in the series of reports to which reference is now being made, and it is obvious that the improvement is due to a combination of circumstances in which the administration of the Poor Law is only one element. Water supply. In his eighth annual report Dr. Houston once more comments upon the disadvantages arising from the absence of the "unrestricted right" to obstract 130 million gallons of water daily from the River Thames independently of its flow. He points out that in the case of the Thames especially a drought may mean that the land is able to absorb and purify many active pollutions, whilst the river is being fed with relatively pure underground water unalloyed with surface drainage. Further reference is made to the excessive growth of algæ in the Staines reservoirs, which caused considerable trouble in 1912-3. There was a recurrence of this difficulty during the year 1913-4, due to the excessive development of Asterionella. Tabellaria, the cause of the trouble in 1912-3, was not present to any marked extent. Filtration was rendered very difficult and it became necessary to treat the Staines water chemically, and to dilute it largely with raw Thames water, which, fortunately, at the time, was of exceptionally good quality. The water remained free from appreciable taste during the whole period. Dr. Houston again urges the importance of adequate storage of raw water antecedent to filtration and circulation, and refers to his previous reports for evidence as to the remarkable purifying effect of storage as measured by the destruction of typical bacillus coli. He states that " the death of B. coli is as sure and safe an indication to the bacteriologist of the death of the microbes of water-borne disease as, to take a homely illustration, the death of coarse fish in a water would lead the fisherman to assume the coincident or previous destruction of the less hardy forms of fish-life, e.g., trout." The main disadvantage of storage is the likelihood of excessive development of algae from causes not yet understood, although upon occasion no trouble of this kind has arisen over long periods. The conclusion arrived at by Dr. Houston is that to a progressively increasing extent the Metropolitan Water Board is securing the reasonable if not the absolute " safety " of the metropolitan water supply. National Insurance Act, 1911. (Treatment of Tuberculosis). The National Insurance Act, 1911, enables county councils to make provision at the request of insurance committees for the treatment of insured persons suffering from tuberculosis, provided a grant under the Finance Act, 1911, is made to such councils by the Treasury. In April, 1912, a departmental committee which had been appointed to report upon the general policy in respect of the problem of tuberculosis in the United Kingdom, for the guidance of the Government and the local bodies concerned, issued an interim report. This report recommended that, for the prevention, detection, and treatment of the disease, existing public health administration should be supplemented by the establishment and equipment of two units linked up to the public health and medical work carried on by the medical officers of health, viz. : (1) the tuberculosis dispensary, and (2) sanatoria and hospitals. It was suggested that schemes for the whole population, non-insured as well as insured, should be drawn up by the councils of counties and county boroughs, or by combinations of these bodies, on the lines recommended in the report. The Local Government Board, in a letter dated 19th October, 1912, asked the London County Council to make arrangements as a temporary measure with theMetropolitan Asylums Board for the use of their accommodation for the sanatorium treatment of insuredpersons, in order to overcome the difficulty experienced by the London Insurance Committee in securing appropriate accommodation in consequence of their inability under the terms of the National Insurance Act, 1911, to enter into agreement with the Metropolitan Asylums Board, owing to the fact of its being a poor law authority. In submitting this letter to the Council on 5th November, 1912 (page 1,071) the Public Health Committee 75 Report of the County Medical Officer—General. referred to the fact " that the Local Government Board had addressed circular letters, dated 14th May and 1st July, 1912, to the councils of all counties, except London and to county boroughs, and that these letters laid special stress upon the necessity for the organisation, by those councils, of complete schemes for the treatment, within the areas under their administration, of all tuberculous persons." In order that provision for insured persons should not be delayed the Council, without waiting for the settlement of the question of the Council's general position, opened negotiations with the London Insurance Committee and the Metropolitan Asylums Board with a view to the temporary accommodation of insured persons in existing institutions belonging to the last-named authority. The Council was consequently in a position on 17th December, 1912 (p. 1,673) to receive the provisional grant of £10 offered by the Treasury, the acceptance of which was necessary before any expenditure could be incurred by the Council, and to approve arrangements which had been accepted by the Metropolitan Asylums Board and the London Insurance Committee for the provision of accommodation in the institutions of the Metropolitan Asylums Board for the treatment of insured persons suffering from tuberculosis. At the time the foregoing arrangements were agreed upon between representatives of the parties, it was hoped that the Metropolitan Asylums Board would be able to provide accommodation for 500 persons in one institution. Subsequently, however, the Metropolitan Asylums Board found themselves unable to do this and submitted amended proposals providing 300 beds for men at Downs Sanatorium, Sutton, Surrey, and 200 beds at the Northern Hospital, Winchmore Hill. Accommodation was available at Downs Sanatorium on 10th February and the numbers were gradually increased until the full accommodation for 300 men was completed on 22nd May, 1913. Sanatorium beds for 100 women and 100 beds for observation or hospital cases (men and women) were provided at the N orthern Hospital, Winchmore Hill ; of the latter cases 75 beds were for men and 25 for women. Later the distribution of accommodation was varied so as to provide for 250 men (sanatorium cases) and 50 men (hospital cases) at Downs Sanatorium, and 150 women (sanatorium cases), 25 men (hospital cases) and 25 women (hospital cases) at the Northern Hospital. Admissions to the Northern Hospital commenced on 3rd March, 1913. Particulars respecting the number of patients treated at each institution from the date of opening till 31st December, 1913, are given in the subjoined table :— Downs Santo rium. Northern Hospital Winchmore Hill. Ordinary cases. Hospital cases. Ordinary cases. Hospital cases. Total both sexes. Men. Women, Men. Women. Admitted to Institution 1,147 66 397 149 103 1,862 Discharged 893 14 253 121 (including 33 transferred to Downs) 67 1,348 Died 37 13 — 26 18 94 Undergoing treatment on 31.12.13 217 39 144 2 18 420 During the course of the year enactments were passed removing the disability of the Metropolitan Asylums Board, as a poor law authority, in dealing directly with the Insurance Committee, and extending the powers of county councils and sanitary authorities for making arrangements for the treatment of tuberculosis. Having regard to these new powers, the Council agreed to the termination on 31st March, 1914, of the temporary agreement among the London County Council, the London Insurance Committee and the Metropolitan Asylums Board. The preliminaries towards framing a complete scheme for London are fully described in Chapter XXXIII. of this volume. It will here be sufficient to note that some of the borough councils had already prepared dispensary schemes in connection with their own areas, and some correspondence was involved in relating these schemes to the general scheme for the county as a whole. In this way a number of individual schemes were reviewed, and it was possible before the end of the year for the Council to give a qualified approval in two instances, viz :—Southwark and Chelsea. Briefly stated, the London scheme as foreshadowed by resolutions during the year, comprehends the provision and maintenance of dispensaries by the borough and city councils, aided by grants from the County Council and the provision of residential treatment. The arrangements made by the Metropolitan Asylums Board with the Insurance Committee for the residential treatment of insured persons left the question of such provision for uninsured persons to be dealt with by the Council. Much difficulty was felt in deciding as to the accommodation required in the absence of reliable data, especially in view of the exceptionally favourable position of London in respect of well-equipped institutions for the care of the sick. Taking into consideration the hospital provision in London and 23610 L 2 76 Annual Report of the London County Council, 1913. the sanatorium accommodation within a reasonable distance of London, it was, however, considered that 160 hospital beds distributed in convenient localities in London and 240 sanatorium beds would constitute a suitable initial provision for uninsured adults. These figures are exclusive of those advanced cases which hitherto have largely found their way ultimately into poor law institutions and which present a distinct problem having regard to the desirability of accommodation being found for them as near as possible to their homes. If, as is probable, it should be found subsequently in actual experience that this accommodation is insufficient for growing needs, the question of further accommodation can then be considered. In the case of children educational considerations and the different characteristics of the groups of cases to be dealt with require to be borne in mind. The main groups are (1) those suffering from bone and joint tuberculosis, and (2) those suffering from pulmonary tuberculosis, (3) there is also a third group suffering from tuberculosis of the skin, glands, and other organs to be considered. It is possible to form some estimate of the dimensions of the problem of the first or surgical class owing to the need for surgical interference having brought the cases to light, and the knowledge acquired through the work of the Council as education authority in connection with its day schools for physically defective children. The second or medical group is at present a very indeterminate quantity about whose dimensions there is no general agreement. The problems connected with children are discussed in the section of this report dealing with education. It will here suffice to mention that it is estimated that the following accommodation already exists for dealing with children who while under treatment can reside at home and at the same time be educated in day schools :— (а) Surgical cases.—Day schools for physically defective children, 1,500. (b) Medical cases.—Day open air schools, 300. It is considered that, as a beginning, 500 beds should be acquired in residential institutions, viz., 350 for surgical cases, and 150 for medical cases. Of the latter 125 should be for pulmonary cases and 25 for glandular cases. The Council, on 4th November, 1913 (p. 860), passed the following resolution :— That any comprehensive scheme for dealing with the treatment of tuberculosis in London shall provide that the Council shall make arrangements with the Metropolitan Asylums Board, with hospitals and with sanatoria for the provision of residential accommodation required for London uninsured patients suffering from tuberculosis, and that it be referred to the Public Health Committee to consider and report whether adequate provision can be made in this manner without the Council being called upon itself to own and manage institutions. Since this date the Public Health Committee have been engaged in pursuing inquiries in various directions with a view to ascertaining the extent to which residential hospital and sanatorium provision would be necessary and the institutions through which it would be possible to obtain it. The' Central Fund for the Prevention of Consumption have given assistance to the Committee in supplying particulars respecting their institutions, and figures have been obtained from the London Insurance Committee. Replies have been received from a number of hospitals to which inquiries have been addressed, from which it would appear that all the residential hospital accommodation likely to be required for immediate use is obtainable and at the end of the year negotiations had been opened with the hospitals and with sanatoria already established with a view to definite offers of accommodation being made to the Council. The scheme for co-ordinating the work of the various agencies dealing with the treatment of tuberculosis was only in draft at the end of 1913 and will be referred to in the report for the ensuing year. Health Visitors. Under the provisions of section 6 of the London County Council (General Powers) Act, 1908, any sanitary authority (including the City Corporation) may on or at any time after the first day of January, 1909, appoint suitable women (to be known as health visitors) for the purpose of giving to persons advice as to the proper nurture, care and management of young children and the promotion of cleanliness and discharging such other duties (if any) as may be assigned to them in accordance with the provisions of the section. The section also authorised the Local Government Board to make regulations prescribing the qualifications, mode of appointment, duties, salary and tenure of office of health visitors appointed thereunder and provided that no appointment of a health visitor should be made otherwise than in accordance with such regulations. On 4th September, 1909, the Local Government Board issued an order, known as the Health Visitors (London) Order, 1909, in which the qualifications, duties, etc., of these officers were defined. By this order a woman is qualified for appointment as a health visitor if she— (a) is a duly qualified medical practitioner within the meaning of the Medical Acts; or (b) is qualified for the appointment of nurse by having undergone, for three years at least, a course of instruction in the medical and surgical wards of any hospital or infirmary, being a training school for nurses, and having a resident physician or house surgeon ; or (c) is certified under the Midwives Act, 1902 ; or (d) has, for a period of not less than six months, undergone in a hospital or infirmary, receiving children as well as adults, and having a resident physician or house surgeon, a course of instruction including subjects relating to personal hygiene, and holds the certificate of the Royal Sanitary Institute for Health Visitors and School Nurses, or the Certificate or diploma of the National Health Society, or of any other body which may from time to time be approved by the Local Government Board; or 77 Report of the County Medical Officer—General. (e) has, in the service of a Sanitary Authority, or of the Council of a Borough or of another Urban District or of any other Public Body or Authority in England or Wales, discharged duties which, in the Board's opinion, are similar to those described in the Act or prescribed by these Regulations in relation to the office of Health Visitor, and produces such evidence as, in the Board's opinion, suffices to prove her competency. (2) Where, in the opinion of the Local Government Board, the circumstances so require, the Sanitary Authority may, with the Board's consent, and subject to such conditions as the Board impose, appoint to the office of Health Visitor a woman who, though not possessing any such qualification as is above prescribed, has a competent knowledge and experience of the theory and practice of nurture, of the care and management of young children, of attendance on women in and immediately after childbirth, and of nursing attendance in cases of sickness or other mental and bodily infirmity. The sub-joined table shows the number of health visitors employed in the county from 1910 until the present time, and particulars as to women sanitary inspectors are also inserted for the purpose of comparison :— 1910. 1912. 1914. Sanitary Inspector. Health Visitor. Performing Dual Duties. Sanitary Inspector. Health Visitor. Performing Dual Duties. Sanitary Inspector. Health Visitor. Performing Dual Duties. City of London 2 1 2 1 2 — — Battersea 1 1 1 — 1 1 1 — 2 Bermondsey — 1 — — 2 ' — 2 — Bethnal Green — — 1 — — 1 — 2‡ — Camberwell 1 — — 1 — — 1 Chelsea 1 — — 1 — — 1 — — Deptford — 1 — — 1 — — — 3f Finsbury — 2 1 — 2 1 — 2 1* Fulham 1 — — 1 — — 1 — — Greenwich — — — 1 — — 1 1 — Hackney 2 — '— 2 1 — 2 1 — Hammersmith — 1 — — 1 — —- 1 — Hampstead — — 2 — — 2 — — 2 Holborn 1 — — 1 — — 1 — — Islington 2 — — 2 — — 2 — — Kensington 2 2 — 2 2 — 2 3‡ — Lambeth 2 1 — 2 1 — 2 1 — Lewisham 2 — — 2 — — 2 — — Paddington 2 — — 2 — — 2 i — Poplar 1 1 — 1 2 — 1 2 — ♦ St. Marylebone 3 — — — — 3 — — 3 St. Pancras 2 — — 2 — — 1 2† — Shoreditch — 1 —. — 1 — 2 Southwark 3 — — 3 — — 1 — 2 Stepney — 1 — 1 — 2 — Stoke Newington — 1 — — 1 — — 1 Wandsworth — 2 — — 2 — 1 2* Westminster 2 — — 2 1 — 2 1 — Woolwich 1 — 1 1 1 1 1 London County 31 12 10 28 16 13 26 24 17 The section also authorises the Council to pay out of the County Fund and charge to the Exchequer Contribution Account any sum or sums by way of contribution towards the salaries of any person appointed as a health visitor not exceeding in the case of any such person one half of her salary ; and on 26th January, 1909, the Council expressed the opinion that the status of a health visitor should not be less than that of a woman sanitary inspector, and stated that in determining the amount which it would contribute, it would take into consideration the question whether the officer was paid a salary commensurate with her status as indicated. Contributions were in due course made by the Council in respect of officers employed during the year 1909-10, but since that time there has been no sum available for the purpose, after claims in respect of services having prior calls upon the account have been satisfied. It is, however, anticipated that there will be a sufficient surplus in respect of the year ended 31st March, 1914, to enable the Council to make a contribution for that year. * Nominally Sanitary Inspectors, but do some health visiting. † Of these, one is a temporary appointment, which may be made permanent. At present temporary—a permanent appointment has been made by Borough Council, but Local Government Board would not approve.—Still under consideration. (f) One appointment at present vacant, but will be filled in due course. ‡ One temporary appointment. 78 Annual Report of the London County Council, 1913. Midwives Act, 1902. The number of midwives giving addresses in London whose names appear on the Roll of Midwives for 1913 is 4,821. This number includes midwives who may have removed from the County, but, owing to the fact that they are not practising, their present addresses have not been reported to the Central Midwives Board, and consequently appear as London addresses. Of this number, 574 notified their intention to practise during the whole vear or for shorter periods. The qualification of the London midwives is as tollows :— Qualification of Midwife. Number not giving notice of intention to practise. Number giving notice of intention to practise. Total. (a) Holding certificates from the Central Midwives Board 2,718 329 3,047 (o) Holding a certificate, obtained as the result of an examination prior to the passing of the Midwives Act 1,439 169 1,608 (c) Enrolled by virtue of having been in bona fide practice as midwives a year previous to the passing of the Act 90 76 166 4,247 574 4,821 Inspection The midwives in classes (a) and (b) are entitled to use the description " certified midwife by examination." Of those giving notice of their intention to practise, the untrained midwives, class (c) represent 13.2 per cent. The 574 midwives who gave notice of intention to practise cannot be taken as the number actually practising in the County. In some institutions it is the custom for a midwife to act as an assistant for three months or less after she is qualified, and her place is then filled by another newly qualified assistant, who in her turn gives notice of intention to practise. At any given time it may be estimated that some 400 to 450 midwives, or about 10 per cent. of those on the roll are in actual practice in London. The remaining 90 per cent. act for the most part as monthly or general nurses under medical supervision. Of the practising midwives 47 were working entirely within poor-law institutions or lyingin hospitals and were under medical supervision ; 160 others were attending patients on behalf of charitable, poor-law or other institutions, and were paid either a salary or a fee for each case allotted to them. The remainder practised independently. All practising midwives, except those working in hospitals under medical supervision, are subject to inspection by the Council's officers, to ascertain whether they are complying with the rules of the Central Midwives Board as to cleanliness, the possession of antiseptics and appliances, the keeping of registers and case books and the sending of the required notices to the Local Supervising Authority. The work of inspection was carried out by Miss E. Macrory, M.B., Ch.B., L.M., D.P.H., and Miss M. A. Pilliet, M.B., Ch.B. In addition to the ordinary routine inspection, special visits are paid to the midwife when any case of a septic nature or a persistent high temperature occurs in her practice, and in all cases of inflammation of an infant's eyes. The inspectors also advise midwives on any points of difficulty which may arise in the course of their duties, and in some instances instruct the midwives as to methods of work. On occasion a midwife is accompanied by the inspector either to a confinement or on a subsequent visit to a patient to ascertain whether her methods of work are efficient. This is done where there is any reason to believe that the midwife's work is not up to standard, and also in cases where a midwife has applied to the Central Midwives Board for approval to her supervising the training of pupils for the Board's examination. The inspectors paid 1,755 visits to midwives or institutions employing midwives. In 1,214 cases the report was satisfactory, in 56 unsatisfactory, and in 485 the midwife was not seen. Most of the unsatisfactory reports related to cases in which some slight breach of the rules had occurred,and the midwife's attention was called to the matter by the inspector, who was subsequently able to report favourably. In cases of a more serious nature, or where the midwife had a bad record previously, the matter was reported to the Midwives Act Committee of the Council, and a letter of caution was sent to the midwife. This occurred in seven instances for the following reasons :— Omitting to advise the seeking of medical assistance for the mother 1 Delay in advising medical aid for inflammation of eyes 1 Failure to notify case of infectious disease 3 Employment of uncertified person as substitute 1 Insufficient attention to patients 1 Charges of malpractice, negligence or misconduct against four midwives were investigated during the year, and in two instances prima facie cases of negligence and misconduct were established against the midwives concerned. The name of one of these midwives was in due course removed from the roll and the Council was requested by the Board to furnish further reports with regard to the other midwife. 79 Report of the County Medical Officer—General. Fees charged by midwives. The fee a midwife receives for attending a confinement and for the subsequent 10 days' visiting varies in different localities from 5s. per case upwards, but usually a fee of 7s. 6d. to 10s. is expected. The charities employing midwives pay 5s. or 6s. a case, and provide the midwife with registers, forms, antiseptics, etc. It is apparent from the number of cases taken by midwives and the small fees paid that very few can rely solely on their practice as a means of livelihood. Many of them are married women who do not trouble to obtain a large practice; a few keep lying-in homes ; others, especially those with a fairly large practice, are approved by the Central Midwives Board to give practical instruction to pupils preparing for the Board's examination. The pupil resides with the midwife and goes with her to cases. The fees for pupils are usually about £1 1s. per week, which includes board and lodging in addition to the practical instruction given bv the midwife. Maternity charities. Many midwives are employed in Poor Law Infirmaries, and a large proportion of the 3,000 confinements in infirmaries are conducted by midwives, and many of the infirmaries are approved as training schools for pupil midwives. Over 5,000 cases are taken annually into the maternity hospitals, and some 18,000 to 20,000 are delivered in their own homes by midwives working either for maternity hospitals or in connection with one or other of the free maternity charities. Births notified by midwives. From information received under the Notification of Births Act the following figures have been obtained showing the number of births notified by midwives :— 14 midwives reported over 500 cases in the year. 5 ,, ,, between 400 and 500 cases in the year. 8 ,, ,, „ 300 and 400 „ „ 14 ,, ,, „ 250 and 300 „ „ 15 ,, ,, „ 200 and 250 „ „ 27 ,, ,, „ 150 and 200 „ „ 41 ,, ,, „ 100 and 150 „ „ 71 ,, ,, „ 50 and 100 „ „ 92 ,, ,, „ 20 and 50 „ „ Uncertified women. Most of the midwives who had 300 cases and upwards have qualified assistants, and many are approved by the Central Midwives Board to supervise the work of pupils. From information received under the Notification of Births Act, it is computed that some 30,000, or 25 per cent. of the total births in London, are attended by midwives, excluding the cases attended by midwives in infirmaries. By Section 1 (2) of the Act it has been illegal since March, 1910, for any woman, unless she be certified under the Act, habitually and for gain to attend women in childbirth except under the direction of a registered medical practitioner. Since the Act became operative enquiries have been made into all cases in which it has come to the knowledge of the Council that a delivery had been conducted by an uncertified Woman, and in 24 instances there was evidence that the woman had been engaged beforehand and had received fees for three or more confinements. Proceedings were instituted and fines in twenty-one cases amounting to £27 17s., with £15 3s. 6d. costs, were imposed. In three cases, the woman was convicted and bound over for 12 months. In one instance an uncertified woman was tried on a charge of manslaughter and was sentenced to four months' imprisonment. Most of the other women reported as having conducted cases were found on enquiry to have acted in emergency, or had only conducted one case and, consequently, could not be described as practising habitually; these women were informed of the provisions of the Act, and in some cases cautioned bv letter. Medical help. The rules of the Central Midwives Board provide that in certain circumstances a midwife must decline to attend alone and must advise in writing that the case requires medical help. The form on which this written advice is given is sent to a medical practitioner, and a copy is forwarded to the local supervising authority. During the year 3,076 of these notices were received from 370 midwives. The figures for the previous years were : 1905, 1,113 ; 1906, 2,320 ; 1907, 2,533 ; 1908, 2,755 ; 1909, 2,894; 1910,3,026; 1911, 3,477; 1912,3,603. Midwives in infirmaries and hospitals acting under the direction of a qualified medical practitioner are not required to comply with this rule. The number of instances of advising medical help in the practice of midwives during the year may be summarised as follows :— 2 midwives reported advising medical help between 60 and 80 times during the year. 20 „ „ „ „ 40 and 60 „ 28 „ „ „ „ 20 and 40 59 „ „ „ „ 10 and 20 „ 261 „ „ „ „ less than 10 times during the year. The reasons assigned by the midwife for giving the advice were as follows:— Pregnancy— [ ###]Purulent discharge 5 Abortion or miscarriage 30 Fit 4 Varicose veins 13 Ante partum haemorrhage 106 General unhealthy conditions 31 189 80 Annual Report of the London County Council, 1913. Labour— Presentations— Diagnosis not made 6 Difficult breech 37 Elbow 4 Shoulder 3 Face 22 Foot 8 Funis 33 Transverse 43 Difficult twins 4 Persistent-occipito-posterior 21 Hand 14 Abnormal (details not given) 25 Placenta pævia 21 Prolonged labour (uterine inertia, contracted pelvis, etc.) 452 Laceration of perineum 285 Prolapse of uterus 5 Haemorrhage during labour 18 Retained or adherent placenta 189 Exhaustion or collapse 19 Hysteria or fits 14 Rapid pulse 3 Other conditions .. ... 64 1,290 Lying-in— Rise of temperature 254 Post partum haemorrhage 99 Pain or swelling in leg 15 Abdominal pain or swelling 16 Pain or swelling of breast 13 Quick pulse 5 Eclampsia, convulsions 10 Condition of vagina 2 Puerperal mania 4 Offensive lochia 4 Sub-involution of uterus 3 Excessive sickness or headache 7 Skin eruptions 7 Other illness 30 - 469 Child— Injury at birth 13 Malformation or deformity 58 Skin eruption or rash 24 Jaundice 25 Convulsions 23 Partial asphyxia 20 Bronchitis, etc. 31 Cyanosis 16 Inflammation of eyes 286 Feebleness and prematurity 451 Haemorrhage 9 Stillborn 40 Death of infant 44 Diarrhcea 4 Inflammation of navel 5 Abnormal sickness 4 Other conditions in child 74 1,127 Infectious diseases in patient's house 1 3,076 Assuming that 30,000 births are attended annually by midwives, the above figures show that medical assistance was required in 10 25 per cent. of the cases ; in 6.5 per cent. on behalf of the mother and in 3.75 per cent. on account of the child. 81 Report of the County Medical Officer—General. During the year, 224 midwives reported having stillbirths in their practice, the number of Still births. stillborn children being 602. This represents 2.0 per cent. of the births. 1 midwife reported 13 stillbirths 13 2 midwives each reported 11 stillbirths 22 2 „ „ 10 „ 20 2 „ „9 ,, 18 2 ,, ,, 8 „ 16 12 „ „7 „ 84 9 ,, ,, 6,, 54 11 „ „5 ,, 55 10 ,, „ 4 , 40 27 ,, 3 „ 81 53 „ „ 2,, 106 93 „ „ 1 stillbirth 93 224 602 The form for notifying stillbirths provides for information as to (a) sex of child ; (b) period of gestation ; (c) whether macerated or not; (d) presentation. The information obtained under (a) showed that 326 still-born infants were males, 273 females, and in three cases the sex was not stated. The following table shows the information obtained under (b) and (c):— Condition of child. Total cases. Period of gestation. Full term. 6 months. 7 months. 6 months or less. Not stated Macerated 347 170 75 82 18 2 Not macerated 239 164 23 29 22 1 No statement 16 5 3 1 0 7 Total 602 339 101 112 40 10 The presentations were as follows :— Vertex 386 Hand, arm and shoulder 7 Complicated vertex 36 Funis 1 Breech 97 Placenta prævia 1 Complicated breech 4 Born before arrival and presentation Footling 27 not known 38 Transverse 4 Face or brow 1 Total 602 Some additional information was obtained as to still-born infants not macerated, of eight or more months' gestation, as follows :— Concerning the child— Cord round neck 4 One of twins 2 Hydrocephalus 1 Concerning the mother— Malformed child 4 Difficult labour 1 White asphyxia 2 The rules of the Central Midwives Board require the midwife to notify to the local supervising Death of authority all cases in which the mother or child dies prior to the attendance of a registered medical mother or practitioner. In 44 cases midwives notified the deaths of infants. By the courtesy of the London coroners, notices are sent of inquests in winch midwives are concerned and one of the Council's inspectors attends the court to hear the evidence and learn whether the midwife has complied "with the rules of the Board. Eighty-four inquests were thus reported upon, including cases attended by uncertified women as well as by certified midwives. including cases attended by uncertified women as well as by certified midwives. In the following table particulars are given with respect to these cases :— Confinement conducted by Total number of inquests. Deaths of mothers. Deaths of infants. Midwives 83 1 82 Uncertified women 1 0 1 84 1 83 23610 M 82 Annual Report of the London County Council, 1913. The medical evidence given at the inquests as to the cause of death was as follows :— Mothers. Infants. Exhaustion due to septicaemia Atelectasis 8 Suffocation at birth 4 Suffocation in bed 17 Prematurity and debility 14 Convulsions 8 Bronchitis and pneumonia 4 Want of skilled attention at birth 3 Cerebral haemorrhage 3 Syncope 7 Marasmus 6 Congenital heart disease or malformation 5 Stillbirth 4 1 83 Puerperal fever. During the year 1913, 349 cases of puerperal fever were notified in the County, and the Registrar General records 139 deaths from puerperal septic disease during the year. Two deaths recorded by the Registrar General refer to cases which were notified in 1912. The term puerperal septic disease used by the Registrar General includes puerperal septicaemia, pyaemia and sapræmia, as well as peritonitis and metritis occurring in connection with parturition. A list of deaths is received weekly from the Registrar General and the deaths are compared with the notified cases so that it is possible to ascertain whether the latter terminate fatally. Of the 349 notified cases, 95 proved fatal, a case mortality of 27.2 per cent. Of the remaining deaths recorded, three occurred in London institutions, the patients having been confined outside London and probably notified as puerperal fever in the districts where the confinements took place. The other deaths related to cases which were not notified. Early information of notified cases of puerperal fever is received from the Metropolitan Asylums Board or from the borough medical officers, and information as to the person bv whom the patient was delivered has been supplied by the latter. patient was delivered has been supplied by the latter. The following table gives the results of these inquiries which 'relate to the 349 notified cases and 44 deaths of cases not notified in London :— Delivery conducted by Cases. Deaths. (a) Medical practitioners (including cases attended by medical students and also cases in which a medical practitioner was in charge of the case, but the birth took place before his arrival) 236 79 (6) Certified midwives (including cases in which birth took place before the arrival of the midwife) 91 24 (c) Medical practitioner and certified midwife, i.e., cases in which a midwife was unable to deliver and called in a medical practitioner 2 1 (d) Hospitals and poor law institutions 48 26 (e) Cases of miscarriage or abortion where no attendant was engaged 15 9 (f) Uncertified person acting in emergency 1 — 393 139 The cause of death as stated in the death certificates in the 139 fatal cases occurring in London is shown in the following table :— t- Cause of death. Notified cases. Unnotified cases. Total. Puerperal septicaemia, toxaemia, and septic absorption 63 24 87 (11) Puerperal peritonitis 8 11 19(9) Pyaemia 6 4 10(1) Sapraemia 5 — 5 Puerperal fever (not defined) 9 — 9(1) Metritis, perimetritis, parametritis and endometritis 2 2 4(1) Pelvic cellulitis 0 — — Salpingitis 1 1 2(2) Septic pneumonia 1 2 3(2) 95 44 139 83 Report of the County Medical Officer—General. The number of fatal cases of puerperal fever which followed abortion or miscarriage was 27. The classification of these cases is shown by the figures in brackets in the last column of the above t.ahlp The age incidence of the 393 cases was as follows Total. 15-20 20-25 25-35 35-45 Over 45 Recovery cases 254 9 61 130 52 2 Fatal cases 139 2 35 70 31 1 In each case where a midwife was concerned the Council's inspector visited her, learnt particulars of the case, made enquiries as to any other patients recently attended, and took steps to ensure that the rules as to disinfection were fully carried out before the midwife resumed her work. The rule which requires that medical help shall be advised when the patient's temperature rises to 100.4 deg. and remains above that figure for 24 hours has proved useful in affording information concerning cases in which there is danger of the development of puerperal fever; 254 notices were received stating that medical assistance had been advised for this reason. The inspector learnt from the midwife whether the high temperature was persistent, and in 163 cases it was found that the temperature had fallen, or that no further symptoms of puerperal fever had occurred. In cases of puerperal fever the services of the nurses of the Queen Victoria Jubilee Institute, the Ranyard and the Holloway Institutes are usually available, so that when the midwife ceases to visit, the patient is left in the hands of a skilled nurse to carry out the directions of the medical practitioner called in. In cases where a midwife has pupils or assistants one of them is sometimes set apart to nurse the septic case, attending no other patients meanwhile. A midwife is thus usually able to carry out disinfection and resume her work with as little delay as is necessary to ensure that she is no longer likely to be a source of infection to other patients. The following table shows the day of the puerpenum on which (a) the rise of temperature (if noted) occurred, (b) medical aid was obtained, and (c) the death took place if the case were fatal. Day of confinement. 2nd day. 3rd day. 4th day. 5th day. 6tll day. 7th day. 8th day. 9th day. 10th day. After 10th day. Not stated. Total. Rise of temperature— Recovery cases 2 8 4 12 11 5 5 3 2 1 6 8 67 Fatal cases 1 2 3 6 1 3 1 2 — — 4 1 24 Medical aid obtained— Recovery cases 5 5 4 11 8 6 5 4 4 4 7 4 67 Fatal cases 3 2 1 3 3 3 1 3 — — 4 1 24 Day of death in fatal cases — — — 1 — 2 1 3 1 1 15 — 24 The parity of women who contracted puerperal fever was ascertained from the midwife to be:— TotaL Primipara. 2 para. 3 para. 4 para. 5 para. 6 para. 7 para. 8 para. 9 para. 10 para. Over 10 para. Not stated. Kecovery 67 18 11 10 9 3 2 4 3 0 I l 5 Fatal 24 7 6 l 2 1 3 — — — l l 2 The following conditions were noted among the cases of puerperal fever attended by midwives:— Recovery. Fatal. Laceration of perineum 10 2 Retained or adherent placenta 1 2 Ante partum haemorrhage 1 — Post partum haemorrhage 4 2 Prolonged labour 2 1 Macerated infant 1 — Domestic trouble after confinement 4 — Phthisis 1 __ In nine cases ol puerperal tever, birth took place before the arnvaj ot the midwife. 23610 m 2 84 Annual Report of the London County Council, 1913. Ophthalmia Neonatorum It is the duty of a midwife to advise that medical help is required when inflammation of the eyes, however slight, occurs in infants. Great stress has been laid by the Council on the importance of strictly observing this rule. When a notice is received from a midwife that medical assistance has been sought on this account, the Council's medical inspector at once visits the infant to ascertain that it is receiving the medical assistance which the midwife has advised, and the medical officer of health of the borough in which the patient resides is immediately informed of the condition of the case and whether the infant is being removed to a hospital for treatment. The midwife is also visited to learn particulars as to the case, the antiseptic precautions taken beforehand, and the disinfection adopted by the midwife after each visit to the case. It was found in some cases that when medical assistance was obtained, the medical practitioner, after examining the infants' eyes, gave directions to the parents as to the course of treatment and left instructions for them to seek medical help again if the inflammation did not yield to treatment, and if there was no improvement in the condition of the child's eyes. So long as the midwife remained in attendance the treatment was for the most part carried out, at all events once a day; but many of these cases had not recovered by the tenth day, the time the midwife usually ceases her attendance. It was also found impossible for the midwife personally to attend to the infant's eyes as often as was requisite, i.e., in some cases four or five times daily, and this duty was then left to the friends of the patient, who were utterly ignorant of the need for using clean rags and sterile water. The Council felt therefore that risk was being incurred by allowing cases of inflammation of the eyes to receive no more attention than was bestowed on them by the people living in the house. The Queen Victoria Jubilee Institute, the Ranyard Nurses Society, the Holloway Nursing Institute, and the Nursing Sisters of St. John the Divine were therefore approached and asked if they would be willing to allow their nurses to undertake, under the direction of the medical practitioner called in, the care of these infants in order to see that the necessary irrigation or swabbing of the eyes was properly done, and at the proper intervals. All the above societies readily consented and during the year their services were made use of in 24 cases. During the year 286 notices were received from midwives, stating that medical assistance had been advised on account of inflammation of the eyes of infants. The Council's inspectors investigated all the cases and endeavoured to watch the progress of the patients and learn the final result. 208 cases were reported to be completely cured. In 5 cases there was impairment of vision, 13 died while still suffering from the disease, and in 60 instances the result could not be ascertained owing to the removal of the parents, who could not be traced. The day of the puerperium on which signs of inflammation were first noticed was : day of confinement, 10 cases; second day, 24; third day, 30; fourth day, 25; fifth day, 36; sixth day, 34; seventh day, 24; eighth day, 37; ninth day, 27; tenth day, 16; later than tenth day, 20; not ascertained, 3 cases. A history of vaginal discharge in the mother was obtained in 107 instances, i.e., in 37 per cent. of the cases. The antiseptics used for the child's eyes at birth or as soon afterwards as possible were boracic lotion in 127 instances; pechloride of mercury (1 in 4,000 or weaker) in 101; silver nitrate (a 1 or 2 per cent. olution) in 29; protargol in 4, and biniodide of mercury in 1 instance; in the remaining cases sterile water was used. An interval between the birth and the use of an antiseptic occurred in 47 instances owing to the fact that the infant was born before the arrival of the midwife. The following facts relating to the 5 cases in which impairment of vision supervened were learnt : (1) Vaginal discharge in mother. Perchloride of mercury solution used for eyes fifteen minutes after birth. Onset on fifth day and medical help obtained at once. Result—Sight of one eye impaired. (2) Vaginal discharge in mother and father under treatment for specific disease. Boracic lotion used for eyes at birth. Onset on day of birth and medical help obtained at once. Result— Sight of one eye lost and the other affected. (3) Vaginal discharge in mother. Boracic lotion used for eyes at birth. Onset on second day and medical help obtained at once. Result—Sight of both eyes impaired. (4) No history of vaginal disease in mother. Boracic lotion used for eyes at birth. Onset on seventh day and medical help obtained at once. Result—Cornese undamaged, but infant suffering from chronic ciliary blepharitis. (5) No history of vaginal discharge in mother. Boracic lotion used for the eyes at birth Onset on fourth day and medical help obtained at once. Both eyes affected. Result—Loss of sight of one eye. 286 cases of inflammation of the eyes occurred in the practices of 136 midwives. 1 midwife had 16 cases during the year 16 2 midwives each had 11 cases during the year 22 1 midwife had 8 cases during the year 8 2 midwives each had 6 cases during the year . 12 4 ,,,,5,, ,, 20 8 ,, ,,4 ,, ,, 32 18 ,, ,,3,, ,, 54 22 ,,,, 2,, ,, 44 78 ,, ,,1 case „ ,, 78 136 286 85 Report of the County Medical Officer—General. All the midwives who had three or more cases during the year have extensive practices, and it was found that many of the cases reported were very slight and the eyes were normal in a few days. So far as could be ascertained there was no evidence that infection was carried from one case to another. The Council has endeavoured to secure accommodation for the mother and infant so that while the child was being treated it would not be deprived of the advantage of being breast-fed, but only two institutions have at present sufficient accommodation for this purpose. In March, 1911, the Council made an order extending the provisions of section 55 of the Public Health (London) Act, 1891, to ophthalmia neonatorum. Of the 2,013 cases notified from that time until the end of this year, 507 were in the practice of midwives. Classes for Midwives The Council has arranged classes for the further instruction of midwives at four centres in London. These classes are attended by midwives who have been in practice for many years, and also to some extent by pupils to supplement the training they are receiving elsewhere. Midwives showing lack of knowledge of their work have been advised by the Council's inspectors to attend these classes. - Lying-m i homes In 1773 an Act (13 Geo. III., cap. 82) was passed requiring the licence, by Justices of the Peact at Quarter Sessions, of lying-in hospitals and other places appropriated for the charitable receptioE of pregnant women, but no power was given in this Act for the supervision of the premises. As regards premises conducted by certified midwives or at which they are employed, a certain amount of control is conferred by the provisions of the Midwives Act, 1902. There are, in the county, over 100 premises in which women are received for delivery, and il had for some time past been within the knowledge of the Council that some of these houses werf conducted in a manner which called for increased supervision both from a sanitary and a mora] standpoint. During the year representations were made to the Council by certain charitable societief that, since the National Insurance Act, 1911, came into operation unmarried women of the working class who formerly obtained admission to poor law infirmaries for confinement were now in a position owing to the receipt of maternity benefit, to pay for attention, and in [fact many cases entered lying-in homes of doubtful character. In these circumstances it seemed to the Council desirable that steps should be taken to secure additional authority to deal with these premises, and on 21st October, 1913, it decided under the provisions of section 4 of the Borough Funds Act, 1872, as applied by the County Councils (Bills in Parliament) Act, 1903, to promote legislation in the session of Parliament of 1914 to confer upon the Council power to prohibit the use of any premises as lying-in homes or institutions unless they and the person or persons in charge thereof had been licensed by the Council. This decision was subsequently modified by the substitution of registration for licen ing. Work of the chemical and analytical branch of the Public Health Department. The Council's Chemist and the staff of the late chemical and gas department, with the exception of those engaged exclusively in connection with gas testing and photography, were transferred to the Public Health Department as from 1st October, 1913, and formed into a chemical branch of the department. In addition to the regular work of the branch the following special inquiries were undertaken in 1913 by the staff. I. An examination during the months of June, July and August of the water of the River Thames between Charing Cross and Grays. This work was continued in December, 1913, and during the present year. It forms part of a series of observations which have been made at intervals since 1893 in the late chemical and gas department in connection with the treatment of sewage at the outfalls. A report on the results of this work was presented to the Main Drainage Committee. It involved the collection and examination of samples representing the condition of the river at various localities between the points indicated on 1,909 occasions. II. An examination of the solid matter (dust, etc.), deposited from the air in the neighbourhood of a dust destructor, concerning the working of which complaints had been made. Great variations in the character of the deposit were found at different distances from the shaft of the destructor. III. The continuation of an examination of the waters of canals and streams in the county. In addition to the above-mentioned special inquiries 5,704 samples of all kinds were examined in the central laboratory and 2,550 samples of sewage, sewage effluent, river water, and chemicals used in sewage treatment, in the laboratories at the two outfalls. The samples examined at the central laboratory may be classified as follows:— (a) Examined in connection with Statutes:— (1) Fertilisers and Feeding Stuffs Act, 1906.—Most of the samples came from the farms of the Council's institutions but some were obtained from dealers within the county, as it was desired to ascertain to what extent, if any, such articles were of inferior quality. The results on the whole show a great improvement on the conditions which prevailed some years ago, although the general quality of some materials has altered for the worse. The Chemist is agricultural analyst for the county under the Fertilisers and Feeding Stuffs Act, and Mr. E. T. Shelbourn is deputy analyst. (2) Petroleum Acts. The samples examined under these Acts include those taken by inspectors of the Public Control department at wharves and other places where petroleum is handled or stored and others found on unlicensed premises or of a suspicious nature. Some samples are also examined in connection with lamp accidents and other disasters. The question whether a substance is petroleum to which the Acts apply can be in most cases determined by its flashing point, but not infrequently an extended chemical examination is necessary before the point can be decided, as many substances other than ordinary mineral oil are considered to be petroleum for the purposes of these Acts. 86 Annual Report of the London County Council, 1913. (3) L.C.C. General Powers Act, 1912. This Act regulates the storage of the less volatile rades of petroleum and of inflammable oils. It is necessary that the flashing-point and general chemical character of a substance should be determined before it can be decided whether it comes under the operation of this Act. The Chemist and Messrs. Shelbourn and Andrews are, by resolution of the Council, appointed to test petroleum under the Petroleum Acts. (4) Samples of mortar and other building materials are examined as to their compliance with the Council's byelaws issued under the Building Acts. The results obtained from the examination of samples in connection with statutes are sum marised in the following table:— (1) Fertilisers and Feeding Stuffs Act, 1906 Satisfactory. Unsatisfactory. Total. Fertilisers 3 25 28 Feeding stuffs 19 66 85 (2) Petroleum Acts — — 332 (3) L.C.C. General Powers Act, 1912. (Storage of Petroleum - — 85 (4) London Building Act - — 11 (b) Examined in connection with works or contracts undertaken for the Council:— Building materials 346 144 490 Foods for necessitous children 43 2 45 Other articles 93 22 115 Many of the building materials examined were for use in constructional work at the New Comity Hall, others were for schools, fire stations and other places where building operations were being carried out. The other articles examined include paints and oils, etc., used in repainting bridges and other structures under the control of the Council. (c) Stores supplied to the Council and its Committees:— Satisfactory. Unsatisfactory. Total. Food stuffs 313 56 369 Oils, paints, etc. 639 154 793 Cleansing materials 272 43 315 Disinfectants 44 24 68 Incandescent mantles 507 763 1,270 Coal 280 — 280 Miscellaneous - — 1,418 (d) Articles in respect of which special information was required.—Under this heading are included materia's brought to the notice of Committees or officers, materials which had failed in use, drinking and other waters and many other articles. (e) Specimens of urine examined in connection with the medical examination of school children and others.—An attempt has been made to carry out this work systematically and in future reports it may be desirable to refer at greater length to experience gained in this connection. During the three months, October, November, December, 1913, 264 specimens were examined. In addition to the laboratory work, advice on chemical matters was given to chief officers of other departments on several occasions. At the Northern and Southern Outfall laboratories samples representing the daily variations of sewage, sewage effluent and river water at high and low tide, were examined as shown below:— Northern Outfall. Southern Outfall. Sewage 312 312 Effluent 312 312 River water 619 619 In addition samples of lime and sulphate of iron were examined at the two outfalls. The extended examination of the water of the River Thames already referred to, was conducted by the chemical staff at the outfalls. The section from Barking to Charing Cross was undertaken by Mr. E. B. Pike from the Northern Outfall, and the lower section from Grays to Crossness by Mr. J. W. H. Biggs from the Southern Outfall. 87 Report of the County Medical Officer—General. CHAPTER XXXIIa. SPECIAL REPORTS SUBMITTED BY THE MEDICAL OFFICER OF HEALTH DURING THE YEAR 1913. I. Report by the Medical Officer Submitting the Result of a Census of Homeless Persons Taken on the Night of the 14th February, 1913. Since the beginning of 1904 the Public Health Committee of the Council has on several occasions instructed the medical officer of health to take a census of homeless persons in London, and the eighth of these enumerations was made on the night of the 14th February, 1913. The following figures enable comparison to be made of the several results:— dumber of persons found homeless at night Date. Men. Women. Young Persons. Total. 29th January, 1904 1,563 184 50 1,797 17th February, 1905 1,869 312 — 2,181 8th February, 1907 1,998 402 4 2,404 15th January, 1909 566 170 23 2,388 †l.629 17 2,747 18th February, 1910 732 220 †1,778 17th February, 1911 768 256 2 1,785 *†694 †651 9th February, 1912 758 213 12 1,203 †220 - 14th February, 1913 370 121 — 649 †l52 †6 In explanation of the above table it should be mentioned that in each case where the sets ot figures are shown in brackets for any one • year, the uppermost denotes the- number of persons, presumably homeless, found actually in the street on the particular night. The figures marked with a dagger relate to persons who were accommodated for a few hours in shelters, but were not provided with beds. These persons would have been in the streets had it not been for charitable effort. The 1521 men coming within this category on the night of the 14th February, 1913, included 52 men at work in the King's Tents belonging to the Church Army; 82 men in a shelter used in conjunction with the Tents; 18 men sitting up in the Salvation Army shelter in Middlesex-street, City. There were also 6 women sitting up in a shelter in Rochester-row belonging to the Church Army. The people found actually in the streets included 370 men and 121 women. For comparison with the figures obtained on previous occasions, therefore, the total number of homeless persons is 649. This is less by 554 than the total for 1912, and is the lowest recorded number. In order to include as far as possible all persons who might reasonably be regarded as homeless, it has been the practice in previous reports to make some reference to the number of persons occupying free beds in licensed common lodging-houses, and night refuges for the destitute not licensed by the Council. These figures have not in any instance been included in the above table inasmuch as they have not on every occasion been available, but they are worthy of mention, and are here recorded for the sake of comparison with the numbers obtained in previous years. In licensed common logding-houses where no charge is made there were 1,217 men, 44 women, and 10 young persons, as against 1,298 men, 41 women, and 15 young persons on the night of the 9th February, 1912. In the shelters not licensed by the Council there were 249 men 234 women, and 6 children, to be compared with 286 men, 399 women, and 14 children in 1912. Various charitable agencies, moreover, gave 127 tickets to destitute men entitling them to a free bed in an ordinary common lodging-house. The information in this and the preceding paragraph is summarised in Table V. Before instituting any further comparison of figures it is necessary to refer briefly to~changes of administration which have had a undoubted influence on the homeless person and the casual * 160 of these men were in a shelter consuming soup and bread, but would be turned out immediately on the conclusion of their meal. f Men or women accommodated for a few hours in shelters but unprovided with beds, t A smaller area than in later years. For purposes of comparison the total may be estimated at about 2,000 persons. 88 Anunal Report of the London County Council, 1913. pauper, and perhaps, indirectly, an effect upon the use made of the accommodation in common lodging-houses. Early in November, 1911, with a view to securing greater uniformity of administration in the 28 casual wards of the Metropolis, the Local Government Board issued the Metropolitan (Casual Paupers) Order, 1911, forming under the Metropolitan Poor Act, 1867, a new district co-terminous with the Metropolitan Asylums district for the relief of the casual poor. The managers of the Asylums Board were constituted the managers of the new district and the existing casual wards were transferred to their control. The Local Government Board in forwarding the Order pointed out that uniformity of administration was of the first importance, more especially as regarded the treatment of the habitual vagrant. It was suggested that under the powers given by the Order, the Metropolitan Asylums Board would be able to make more adequate arrangements to ensure to destitute wanderers and wayfarers the provision of food and shelter, and that experience might make it possible to obtain some classification of casual paupers so as to differentiate the occasional from the habitual vagrant. On 1st April, 1912, the Metropolitan Asylums Board assumed control of 24 of the 28 casual wards of the Metropolis, the remaining 4 wards being discontinued. Steps were at once taken to secure uniform observance of the Regulations, and to equalise the tasks and the dietary. In addition, the wards were connected by telephone and a central index of vagrants established. It is a remarkable fact that with the inauguration of the new scheme the numbers of applicants for admission to the casual wards rapidly declined. From a weekly return published by the Local Government Board it appears that on the night of the 7th February, 1913. the casual paupers relieved numbered only 561. On the corresponding Friday nights in the years 1910-1912, the numbers ranged from 1,112 to 1,033. It has been pointed out, moreover, that the reduction in numbers has not been accompanied by an increase in the number of vagrants making use of the casual wards in the extra-Metropolitan area. There still remained the problem of dealing with those persons who remain all night in the streets. As an attempt towards solving the difficulty a scheme was on 30th October, 1912, put into force for dealing with homeless persons in the Strand district, including the Embankment. The Metropolitan Police were supplied with tickets for distribution to homeless persons found on their beats. These tickets had to be taken to an office on Waterloo Pier, where inquiries were made and tickets were issued entitling the holder to lodging at a casual ward or shelter as the case might be. The shelters are maintained by the several voluntary agencies affiliated to the scheme. During the month of November, 1912, of the 2,966 tickets distributed by the police 2,608 were presented at the office on Waterloo Pier. Of this number of persons 595 were given tickets for charitable institutions, and 2,013 were given tickets for admission to casual wards. 551, or nearly 93 per cent. of the first-mentioned tickets, were used and 996, or just over 49 per cent., of the latter. The facts just stated have a very important bearing on the relationship existing between the homeless person, the casual pauper, and the common lodging-house inmate, and the following tables enable comparison to be made of the variations existing at the time of the enumerations in the several years. The latest figures relating to the casual ward accommodation have been kindly supplied by Mr. T. Duncombe Mann, the clerk of the Metropolitan Asylums Board. Licensed Common Lodging Houses. Date. Authorised accommodation. Number of persons occupying beds. Men. Women. Couples. Total. Men. Women. Couples. Total. 29th January, 1904 25,718 2,281 447 28,893 21,058 1,517 390 23,442 17th February, 1905 25,671 2,450 422 28,965 21,055 1,578 87 Children 23,381 357 34 Children 8th February, 1907 25,599 2.436½ 245 28,525 20,438 1,598 207 22,450 15th January, 1909 25,976 2,365 245 28,831 20,059 1,483 161 21,864 18th February, 1910 25,902 2,344 245 28,736 19,346 1,456 177 21,156 17th February, 1911 25,376 2,376 245 28,242 19,470 1,356 189 21,204 9th February, 1912 25,352 2,455 245 28,297 19,710 1,373 196 21,499 14th February, 1913 24,900 2,229 218 27,565 18,876 1,273 24 Children 174 20,526 29 Children Casual Wards. Date. Accommodation. Beds. How used. Persons. Men. Women. Women and children. Total. Men. Women. Children. Total. 29th January, 1904 1,243 410 114 1,767 1,034 175 9 1,218 17th February, 1912 1,263 420 120 1,803 926 210 3 1,139 8th February, 1907 — — — 1,882 — — — 1,137 15th January, 1909 1,241 444 122 1,807 1,001 184 3 1,188 18th February, 1910 1,219 454 119 1,792 928 173 6 1,107 17th February, 1911 1,220 452 123 1,795 962 129 — 1,091 9th February, 1912 1,233 456 125 1,814 900 132 1 1,033 13th February, 1913 796 288 81 1,165 493 52 1 546 89 Report of the County Medical Officer—General. 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. Accommodation (beds). Persons. C.L.H. Cas. wards. Total. C.L.H. (Inmates.) Cas. wards. (Inmates.) Homeless. Total.* 29th January, 1904 28,893 1,767 30,660 23,442 1,218 1,797 26,457 17th February, 1905 28,965 1,803 30,768 23,381 1,139 2,181 26,701 8th February, 1907 28,525 1,882 30,407 22,450 1,137 2,404 25,991 15th January, 1909 28,831 1,807 30,638 21,864 1,188 2,388 25,440 18th February, 1910 28,736 1,792 30,528 21,156 1,107 2,747 25,010 17th February, 1911 28,242 1,795 30,037 21,204 1,091 1,785 24,080 9th February, 1912 28,297 1,814 30,111 21,499 1,033 1,203 23,735 14th February, 1913 27,565 1,165 28,730 20,526 546 649 21,721 it reierence be made to the last table it will be seen that since 1904 there has been a steady and continuous reduction in the total numbers of the three classes of persons now under review. More detailed examination of the figures shows that this reduction in the years 1905-10 could be mainly attributed to a decline in the common lodging-house population, inasmuch as the number of casual paupers showed little variation, and the numbers of homeless persons were maintained at a high level and reached a maximum in the last year of the period. In the report on the enumeration of homeless persons in the year 1911 it was pointed out that there was some modification of the scheme for providing homeless persons with free food and shelter at night without sleeping accommodation, inaugurated by certain charitable institutions. Efforts in connection with this scheme reached a maximum in the winter of 1909-10, and their relaxation in the following year was accompanied by a marked decrease in the number of homeless persons. In 1912 whilst the common lodging-house population showed a distinct rise, the number of homeless persons still further declined. In dealing with the figures for 1913, however, it would appear to be necessary to abandon the idea that the relationship of the three sections of the community is as close a one as was formerly thought. On the original assumption it would naturally be expected that the remarkable fall (1,041 persons) in the number of casual ward inmates and homeless persons would be accompanied by a corresponding increase in the number of common lodging-house inmates. On the contrary, however, there is a reduction in this last mentioned class of 973 persons. This remarkable result would seem to point to the fact that in addition to the changes in the administration of the Poor Law above referred to, there are other unrecognised forces exercising a determining influence on these sections of the community. With a view to studying the effect produced upon the common lodging-house population by the carrying out of the new scheme of the Metropolitan Asylums Board, the Chairman of the Public Health Committee of the Council directed in September last that a census of common lodging-houses inmates should be taken. This enumeration was made on the night of the 16th September, and resulted in a total of 19,399 persons being obtained. It was estimated that at this time at least 1,000 persons were away harvesting or in the hop-fields. With the exception of this occasion it may be mentioned that the number of inmates on the night of the 14th February last is the lowest recorded in any enumeration undertaken by the Council. On the night of the 25th November last the number was 21,223, and in a report on the result of this census it was observed that the number was unusually low, and that it would be interesting to learn whether the usual winter depression in unskilled trades had any bearing on the question. Apparently, from whatever the cause, there has been during the past winter a reduction in the amount of absolute poverty as compared with preceding winters. In previous reports it has been the practice to include a table showing the number of persons regarded as "homeless" but found to be actually taking shelter on staircases and under arches on the night in each year when the census was taken. Details are also given of the weather conditions, but the variations have not been sufficiently marked to draw any conclusions as to their effect upon the recorded numbers of homeless persons. The table is, however, here reproduced for purposes of record:— Weather conditions and number of persons found cm staircases and under arches. Year. Weather conditions. Males. Females. Total. 1904 Cold at first followed by rain 100 68 168 1907 Fine and not very cold — — 50 1909 Heavy rain followed by strong, cold wind 49 39 88 1910 Fine and not very cold 10 20 30 1911 Fine and not very cold 11 53 65 1912 Rain early, afterwards fine, and not cold 25 23 48 1913 Fine and not very cold 20 21 41 * These figures do not include the persons in the unlicensed homes and institutions referred to in Table No. IV. who might also be regarded as belonging to the common lodging house glass. 23610 N 90 Annual Report of the London County Council, 1913. For some years past special mention has been made of the use of cheap and free shelters by women. During the past year the conditions already reported have not materially changed. The number of really homeless women is comparatively small, and with the exception of Providence-row Night Refuge and Field-lane Refuge, which are generally full, little use is made of the free accommodation provided. The Salvation Army Shelter in Hanbury-street, where a charge of 3d. is made, still has vacant beds, though the number received on the night of the 14th February last shows some increase on the number received on the census night in 1912. Generally, the female population in common lodging-houses is declining, and the use of the casual ward accommodation for women has diminished in proportion to the general reduction in the numbers of casual paupers discussed in the early part of this report. A feature of the enumerations of 1909 and 1910 was the system instituted by the Salvation Army of allowing homeless men to sit and rest for some hours in certain of their shelters after receiving a free meal of soup and bread. In 1910, as many as 1,428 men were provided for in this way by the Salvation Army alone, and 350 men took advantage of similar facilities offered by other charitable associations. During the winter of 1910-11 this system was considerably modified so far as the Salvation Army was concerned, and during the past two winters there has been further restriction, so that there were only 18 men accommodated in this way on the night of the 14th February last, and these men were received at the City shelter in Middlesex-street. The Church Army in 1911 somewhat extended its scheme in connection with the King's Tents, but in 1912 dealt with a much smaller number of men, while the figures for 1913 show a further reduction. The total number of men working or resting in shelters was 152, as against 1,778 in 1910. It should be pointed out that extended observation by the Council's inspectors shows that the Embankment has been practically cleared of persons of this class. Cheap and free food.—The distribution of cheap and free food has this winter been carried on to a very much less extent than in former years. The inauguration of the Embankment scheme of the Metropolitan Asylums Board has, as a matter of course, imposed restriction upon this form of charity inasmuch as its continuance would have rendered the scheme impracticable. Medland Hall, too, has discontinued the giving of tickets for bread and margarine. The Euston-road Soup Kitchen, founded some 65 years ago, still supplies many thousands of cheap and free meals. The Field-lane Refuge and Ham-yard Hospice provide free meals to individuals and families all the year round. Daily Graphic coupons are still issued, and are available at Salvation Army and other institutions throughout London. Several charitable agencies provide single meals such as tea or dinner, but generally it may be said that the casual pauper is not catered for in this way to the same extent as in former years. I append the following tables summarising the information obtained on the night of the 14th February, 1913:— Table I. shows the number of homeless persons found in streets and on staircases, and their distribution in sanitary areas. Table II. shows the authorised accommodation in common lodging houses, the number of beds occupied, and the number of beds vacant in the City of London and in each metropolitan borough. 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 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. summarises the information contained in the second and third paragraphs of the report, and shows the total number of persons who might be regarded as homeless on the ground of being unable to pay for a bed, but does not include persons permanently provided for in public institutions. W. H. Hamer, Medical Officer of Health. 27th February, 1913, 91 Report of the County Medical Officer—General. TABLE I. Number of Homeless Persons found in the streets and on staircases distributed according to Sanitary Areas. Sanitary area. Men. Women. Young persons.   Battersea __ 5 — Bermondsey 9 — - Bethnal Green 4 — - Chelsea 4 3 — City of London 31* — - Finsbury 11 2 - Fulham — 2 - Hammersmith — 9 — Holborn 3 1 — Islington 38 30 — Lambeth 29 3 - Paddington 2 — — Poplar 3 1 - St. Pancras 8 1 - Shoreditch 22 4 — Southwark 41 23 — Stepney 121 33 - Wandsworth 1 - - Westminster 43* 4 - Totals 370 121 — * On the 9th February 1912, the figures for the Cities of London and Westminster respectively were 130 men, 8 women ; and 187 men, 57 women. These are the areas most aflected by the new Poor Law scheme referred to in the Report. TABLE II. Common Lodging Houses. Sanitary District. No. of Houses. Accommodation. Census on 14th February, 1913. No. of vacant bi 14th Februa 1914. eels on ry. Men. Women. Couples. Men. Women. Couples. Men. Women. Couples. Bettersea 3 99 66 — 73 37 26 29 Bermondsey 5 1,297 — — 1,023 — — 274 183 — — Bethnal Green 13 673 — — 490 — — — Camberwell 5 549 — — 364 — — 185 — — Chelsea 6 236 — — 134 — — 102 8 — — City of London† 1 455 — — 447 — — 8 — — Deptford 8 1,155 80 — 684 19 — 471 61 — Finsbury 7 484 — — 375 — — 109 — — Fulham 2 43 51 — 38 41 — 5 10 — Greenwich 3 121 — — 90 — — 31 — — Hackney 7 498 — — 365 — — 133 — — Hammersmith 9 466 — 4 329 — 3 137 — 1 Hampstead — — — — — — — — — — Holborn 25 1,489 162 — 1,262 109 — 227 53 — Islington 41 1,164 187 18 754 118 9 410 69 9 Kensington 22 401 267 — 282 146 8 Chldn. 119 121 — Lambeth 7 693 — — 541 — — 152 — — Lewisham 1 30 — — 23 — — 7 — — Paddington 7 195 37 — 140 16 — 55 21 — Poplar 9 1,143 — — 548 — — 595 — — St. Marylebono 14 1,094 109 — 940 85 — 154 24 — St. Pancras 7 610 36 — 473 21 — 137 15 — Shoreditch 12 764 — — 595 — — 169 — — Southwark 41 3,071 449 — 2,504 177 — 567 272 — Stepney 53 5,238 667 180 3,887 434 | 147 14 Chldn. 1,351 233 33 Stoke Newington 1 37 — — 29 — — 8 — — Wandsworth 8 175 5 16 150 3 15 5 Childn. 25 2 1 Westminster, City of 13 2,255 62 — 1,965 40 — 290 22 — Woolwich 22 465 51 — 371 27 2 Chldn. 94 24 — Totals 352 24,900 2,229 218 18,876 1,273 174 29 Chldn. 6,024 956 44 Note. in addition to the figures above given, there were in Rowton Houses on the same night, 4,875 men and 205 vacant beeds. †For the relating to the City of London, I am indebted to Dr. W. H. Collingridge. 23610 N 2 92 Annual Report of the London County Council, 1913. TABLE III. Number of permanently Free Beds in premises licensed as Common Lodging Houses on the night of 14th February, 1913. In other licensed Common Lodging Houses from 140 to 150 beds occupied on that night were paid for by charitable institutions, chiefly by the Church Army, the City Temple Mission, and the Willow-street Mission. Premises. Free beds. For labour. Men. Women. Children. Men. Bermondsey. Salvation Army, Spa-road _ 537 Bethnal Green. Church Army Labour Home, Warner-place — — — 53 Finsbury. Church Army Labour Home, Banner-street — — — 114 Kensington. Barnardo's Home, Penzance-place 19 8 — Stevnev. Medland Hall 306 — — — Barnardo's Home, Commercial-street — 25 2 — Salvation Army, Quaker-street — — — 190 Westminster. « Ham-yard Hospice, Great Windmill-street \ 17 — — — 323 44 10 894 Unoccupied on night of census 40 64 — 74 TABLE IV. 1 Number of persons in Shelters, etc., not licensed as Common Lodging Houses. Sanitary district. Free beds. For labour. Men. Women. Children. Men. Bermondsey. (1) — 26 — — Holborn: (1) 27 16 — — (2) — 14 — — Southwark. (1) — — — 143 Stepney. (1) 18 — — — (2) 144 111 6 — 189 167 6 143 There were on the same night in the Labour Homes and Homes for Women of the Church Army 60 men and 67 women. 93 Report of the County Medical Officer—General. TABLE V. A table summarising the information contained in the second and third paragraphs of this report, and showing the total number of persons who might be regarded as homeless on the ground of being unable to pay for a bed. Description. Men. Women. Young Persons. Total. Number of men who were received in a Salvation Army shelter and were sitting up 18 — — 18 Number of men in the King's Tents 52 — — 52 Number in shelters in connection with the King's Tents 82 6 — 88 Persons found homeless in the streets 370 121 491 In licensed common lodging houses where no charge is made 1,217 44 10 1,271 In unlicensed houses where no charge is made 249 234 6 489 Beds in licensed common lodging houses paid for by charitable institutions 141 1 — 142 Persons in casual wards 493 52 1 546 Total number of persons found homeless, or rest1 ing in shelters, or occupying free beds in common lodging houses, shelters and casual wards * 2,622 458 17 3,097 3,603 810 42 4,455 * The figures in italics are the totals for the night of the 9th February, 1912. 94 Annual Report of the London County Council, 1913. II. Report by the Medical Officer Submitting the Result of a Census of Homeless Persons taken on the nlght of 24th october, 1913. With a view to determining the number of homeless persons in London the Public Health Committee of the Council has from time to time instructed the medical officer to take a night census of all the persons who were discovered taking shelter on staircases or under arches and to enumerate all people found in the street on the particular night of the census who were obviously unable to provide themselves with a bed. The ninth of these enumerations was made on the night of the 24th October, 1913, and the following table enables comparison to be made of the results obtained since this work was commenced in 1904:— Number of persons found homeless at niglil. Date. Men. Women. Young Persons. Total. 29th January, 1904† 1,563 184 50 1,797 17th February, 1905 1,869 312 - 2,181 8th February, 1907 1,998 402 4 2,404 15th January, 1909 566 170 23 2,388 †l.6291 18th February, 1910 732 220 17 2,747 †1778 17th February, 1911 768 256) 2 1,785 *†694 †65 9th February, 1912 758 213 12 1,203 †220 — 14th February, 1913 370 121 — 649 †152 †6 534 141 2 694 24th October, 1913 †17 - In explanation of the above table it should be mentioned that in each case where the sets of figures are shown in brackets for any one year the uppermost set denotes the number of persons, presumably homeless, found actually in the street on the particular night. The figures marked with a dagger relate to persons who were accommodated for a few hours in shelters, but were not provided with beds. Only 17 men came within this category on the night of the 24th October last, but in this connection it should be noted that the difference of time of year is all important. It is not possible fairly to compare the results of a census taken at the beginning of the winter season when most of the charitable agencies have scarcely commenced to alleviate the distress caused by the seasonal diminution of employment among casual workers, with the results obtained in the middle of February when perhaps charitable effort is at a maximum. No previous census of homeless persons in London has been taken during October. It will be seen that the total number (694 persons) is slightly in excess of that obtained in February last. The difference is small and the fact that the time of the year was not identical no doubt had some influence. There is no reason, therefore, to suppose that it is due to any permanent increase in the number of homeless persons. The number of persons occupying free beds, in licensed common lodging-houses and night refuges for the destitute not licensed by the Council, is also affected by the circumstance just mentioned. In licensed common lodging-houses where no charge is made there were 1,013 men, 27 women, and 17 children as compared with 1,217 men, 44 women, and 10 children in February last. The shelters not licensed by the Council are, however, affected to a greater extent than common lodginghouses, inasmuch as some are closed during the warmer seasons of the year, and had not, as a matter of fact, reopened at the time of the last census. The occupants of unlicensed shelters, therefore, show a large decrease when comparison is made with the number obtained in February last. The figures respectively are 178 men, 138 women, 26 children in October, and 249 men, 234 women, and 6 children in February. A complete statement of the number of persons who might be regarded as homeless on the ground of being unable to pay for a bed is given in Table V. at the end of this report. All the enumerations have been conducted on similar lines, counting being begun at one o'clock a.m. The method adopted was for groups of officers beginning at the appointed time to work from the centre outwards and from the boundary inwards of the included area It should also be mentioned that it has always been assumed that persons apparently homeless found in the street after one o'clock a.m. would not be able to obtain shelter in a charitable * 160 of these men were consuming soup and bread in a shelter, but would be turned out immediately on the conclusion of their meal. †Men or women accommodated for a few hours in shelters but unprovided with beds, ‡ A smaller area than in later years. For purposes of comparison the total may be estimated at about 2,000 persons. 95 Report of the County Medical Officer—General. stitution, most of which, from the experience of the Council's officers, are full up soon after midnight, and would not be likely to go to the casual ward with its accompanying restrictions at So late an hour. In this connection it should be noted that the casual wards are now opened at six o'clock p.m. in October. There is, therefore, little doubt, having regard to the experience of past years, that the bulk of the people found in the streets and counted as homeless would remain there all night. In the report on the February census brief reference was made to the Metropolis (Casual Paupers) Order, 1911, designed to secure greater uniformity in the administration of the casual wards. The use of four of the London wards was discontinued and the remaining twenty-four were placed under the control of the managers of the Metropolitan Asylums Board, who were constituted the managers of a new poor law district created by the Order, coterminous with the Asylums district. In addition to this power was given to the Metropolitan Asylums Board "to ensure to destitute wanderers or wayfarers the provision of food and shelter," and the Local Government Board suggested that experience might make it possible to obtain some classification of casual paupers so as to differentiate the occasional from the habitual vagrant. The question of considering how this object could best be attained was already being considered by the Metropolitan Poor Law Inspectors' Advisory Committee. This Committee includes representatives of Government departments, the Police, and various voluntary agencies interested in the subject. The consulting medical officer of the London County Council, Sir Shirley Murphy, is also a member. After the transfer of the control of the casual wards an addition was made by the inclusion of the Chairman of the Metropolitan Asylums Board and of its Casual Ward Committee. An experimental scheme was evolved having for its object the provision of facilities for giving every homeless person the opportunity of securing food and shelter. The Metropolitan Asylums Board was asked to administer the scheme, which was in the first instance limited to the A division and part of the E division of the Metropolitan Police districts. The area included was that part of London on the north side of the River Thames bounded on the north by the Marylebone and Euston-roads, on the east by Farringdon-road, and on the west by Park-lane, the Green-park, and Vauxhall-bridgeroad. As described in the report on homeless persons of last February the Police in this selected area were given, for distribution to homeless persons, tickets which had to be taken to an office on Waterloo Pier, in charge of a casual ward superintendent with long experience of the vagrant, and the holders of the tickets were referred by him to the casual ward or to one of the institutions of the voluntary agencies affiliated to the scheme. Much of the voluntary work has been undertaken by the Salvation Army and the Church Army, while the Morning Post Home and Willow-street Mission have helped, and many other bodies expressed their willingness to co-operate if topographical difficulties could be overcome. The first two nights after the scheme was put into operation 598 tickets were issued by the Police, and 483 were presented at the office on Waterloo Pier. 327 tickets for charitable institutions were issued and 263 were used. The tickets for casual wards numbered 156, of which 73 were used. These results were surprisingly large and were probably due to curiosity, for afterwards the numbers diminished rapidly and the tickets issued by the Police during December varied from 16 to 110, and for the whole month averaged only 52 a night. Since the Metropolitan Asylums Board undertook the administration of the casual wards it has been found possible to reduce considerably the number of wards maintained. In part this is a natural corollary of the transfer, for it was obviously impossible that some thirty different authorities should, in making statutory provision for the casual, be able to work as economically as a single authority dealing with London as a whole. The uniform observance of the regulations, the equalisation of the tasks and of the dietaries, the system of transfer tickets, the keeping of a central register of vagrants, and the linking up of the wards by telephone have also contributed in considerable measure to the same end. The changes here indicated have had a marked effect upon the use of the casual wards, and it will be seen by reference to the tables following that the number of casuals accommodated on the night of the 24th October last is the lowest yet recorded in this series of reports. It should be mentioned that the figures relating to the casual wards on the occasion of the last two enumerations have been supplied by the courtesy of Mr. T. Duncombe Mann, the Clerk to the Metropolitan Asylums Board. Licensed Common Lodging Houses. Date. Authorised accommodation Number of persons occupying beds. Men. Women. Couples. Total. Men. Women. Couples. Total. 29th January, 1904 25,718 2,281 447 28,893 21,058 1,517 390 23,442 17th February, 1905 26,671 2,450 422 28,965 21,055 1,578 87 Children 357 23,381 34 Children 8th February, 1907 25,599 2.436½ 245 28,525 20,438 1,598 207 22,450 15th January, 1909 25,976 2,365 245 28,831 20,059 1,483 161 21,864 18th February, 1910 25,902 2,344 245 28,736 19,346 1,456 177 21,156 17th February, 1911 25,376 2,376 245 28,242 19,470 1,356 189 21,204 9th February, 1912 25,352 2,455 245 28,297 19,710 1,373 196 21,499 14th February, 1913 24,900 2,229 218 27,565 18,876 1,273 24 Children 174 20,526 29 Children 209 24th October, 1913 ... 24,338 2,296 218 27,070 18,936 1,483 20,854 • 17 Children 96 Annual Report of the London County Council, 1913. Casual Wards. Date. Accommodation. Beds. How used. Persons. Men. Women. Women and children. Total. Men. Women. Children. Total. 29th January, 1904 1,243 410 114 1,767 1,034 175 9 1,218 17th February, 1905 1,263 420 120 1,803 926 210 3 1,139 8th February, 1907 — — — 1,882 — — — 1,137 15th January, 1909 1,241 444 122 1,807 1,001 184 3 1,188 18th February, 1910 1,219 454 119 1,792 928 173 6 1,107 17th February, 1911 1,220 452 123 1,795 962 129 — 1,091 9th February, 1912 1,233 456 125 1,814 900 132 1 1,033 14th February, 1913 796 288 81 1,165 493 52 1 546 24th October, 1913 643 227 68 938 352 46 1 399 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 (beds). Persons. C.L.H. Cas. wards. Total. C.L.H. (Inmates.) Cas. wards. (Inmates.) Homeless. Total.* 29th January, 1904 28,893 1,767 30,660 23,442 1,218 1,797 26,457 17th February, 1905 28,965 1,803 30,768 23,381 1,139 2,181 26,701 8th February, 1907 28,525 1,882 30,407 22,450 1,137 2,404 25,991 15th January, 1909 28,831 1,807 30,638 21,864 1,188 2,388 25,440 18th February, 1910 28,736 1,792 30,528 21,156 1,107 2,747 25,010 17th February, 1911 28,242 1,795 30,037 21,204 1,091 1,785 24,080 9th February, 1912 28,297 1,814 30,111 21,499 1,033 1,203 23,735 14th February, 1913 27,565 1,165 28,730 20,526 546 649 21,721 24th October, 1913 27,070 938 28.008 20,854 399 694 21,947 * These figures do not include the persons in the unlicensed homes and institutions referred to in Table No. IV. who might also be regarded as belonging to the common lodging house class. In the last report on homeless persons it was observed that since 1904 there had been a steady and continuous reduction in the total numbers of the three classes of persons under review. Until and including the 14th February last all the enumerations had been made in the early part of the year, and thus they were fairly comparable. The figures for February, 1913, however, were remarkable for the reason that the considerable fall (1,041 persons) in the number of casual ward inmates and homeless persons was accompanied by a large reduction (973 persons) in the number of common lodging-house inmates instead of the increase naturally anticipated on the assumption of a close inter-relationship among the three sections of the population in question. It was evident that the time at which the census was taken was an exceptional one and that the special conditions obtaining had affected the results. The figures now available show that, while the number of homeless persons has increased by 45 the number of casual ward inmates has diminished by 147. On the other hand, the common lodging-house population has increased by 328, and this in spite of the fact that the number of free beds was some 200 less, and the number of beds paid for by charitable agencies, including the keepers themselves, was reduced by more than 100. When it is remembered, moreover, that two of the principal night refuges were not open on the night of the census but small importance need be attached to the increased number of persons found in the streets. It is difficult, however, to draw conclusions from a single enumeration at the beginning of the winter, and it would be interesting to learn whether these numbers are maintained. The Poor Law scheme referred to in the early part of this report is an effort in the direction of relieving London of its homeless class, and if pursued it should be possible to deal effectively with the comparatively small numbers, having regard to the size of the London population, found on the occasion of the last two enumerations. In previous reports it has been the practice to include a table showing the number of persons regarded as "homeless" but found to be actually taking shelter on staircases and under arches on the nights in each year when the census was taken. Details are also given of the weather conditions, but the variations have not been sufficiently marked to draw any conclusions as to their effect upon the recorded numbers of homeless persons. The table is, however, here reproduced for purposes of record :— Weather conditions and number of persons found on staircases and under arches. Year. Weather conditions. Males. Females. Total. 1904 Cold at first followed by rain.. 100 68 168 1007 Fine and not very cold — — 50 1909 Heavy rain followed by strong, cold wind.. 49 39 88 1910 Fine and not very cold 10 20 30 1911 Fine and not very cold 12 53 65 1912 Rain early, afterwards fine and not cold 25 23 48 Feb. 1913 Fine and not very cold 20 21 41 Oct. 1913 Foggy, somewhat cold 22 28 50 97 Report of the County Medical Officer—General. Cheap and free food.—Last winter the distribution of cheap and free food was carried on to a very much less extent than in former years and at the time of writing this report the practice has not been revived. The inauguration of the Embankment scheme of the Metropolitan Asylums Board has, as a matter of course, imposed restriction upon this form of charity, inasmuch as its continuance would have rendered the scheme impracticable. Medland Hall, too, has discontinued the giving of tickets for bread and margarine. The Euston-road Soup Kitchen, founded some 65 years ago, still supplies many thousands of cheap and free meals. The Field-lane Refuge and Ham-yard Hospice provide free meals to individuals and families all the year round. Several charitable agencies provide single meals, such as tea or dinner, but generally the distribution of food on a large scale, referred to in the reports for 1911 and 1912, has now ceased. I append the following tables summarising the information obtained on the night of the 24th October, 1913:— Table I. shows the number of homeless persons found in streets and on staircases, and their distribution in sanitary areas. Table II. shows the authorised accommodation in common lodging houses, the number of beds occupied, and the number of beds vacant in the City of London and in each metropolitan borough. 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 common lodging house3 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. summarises the information contained in the second and third paragraphs of the report, and shows the total number of persons who might be regarded as homeless on the ground of being unable to pay for a bed, but does not include persons permanently provided for in public institutions. W. H. Hamer, Medical Officer of Health. 6th November, 1913. TABLE I. Number of Homeless Persons found in the streets and on staircases distributed according to Sanitary Areas. Sanitary area. Men. Women. Young persons. City of London 35 3 - Battersea 2 — - Bermondsey 16 2 — Bothnal green 3 — - Chelsea 1 — - Finsbury 15 3 2 Fulham 1 — — Hackney 8 1 — Hammersmith 3 2 — Holborn 12 7 — Islington 43 25 — Kensington 3 2 — Lambeth 45 8 — Paddington 11 — — Poplar 3 1 — St. Marylebone 12 4 — St. Pancras 12 4 — Shoreditch 13 — — Southwark 38 12 — Stepney 96 39 — Westminster 162 28 - Totals 534 141 2 23610 o 98 Annual Report of the London County Council 1013. TABLE II. Common Lodging Houses. Sanitary Area. No. of Houses. Accommodation. Census on 24th October, 1913. No. of vacant beds on 24th October, 1913. Men. Women. Couples. Men. Women. Couples. Men. Women. Couples. Battorsea 3 99 66 — 84 44 — 15 22 — Bermondsey 5 1,287 — — 1,039 — — 248 — — Bcthnal Green 12 610 — — 458 — — 152 — — Camberwell 5 549 — — 360 — — 189 — — Chelsea 6 236 — — 112 — — 124 — — City of London 1 453 — — 449 — — 4 — — Deptford 8 1,155 80 — 779 9 — 376 71 — Finsbury 7 484 — — 376 — — 108 — — Fulham 2 43 51 — 40 44 — 3 7 — Greenwich 3 121 — — 103 — — 18 — — Hacknoy 7 498 — — 363 — — 135 — — Hammersmith 9 466 — 4 329 — 2 137 — 2 Hampstead — — — — — — — — — — Holborn 25 1,476 144 - 1,339 130 — 137 14 — Islington 40 1,093 187 18 804 121 14 289 66 4 Kensington 22 401 272 — 278 167 3* 123 102 — Lambeth 7 693 — — 551 — — 142 — Lewisham 1 30 — — 23 — — 7 — — Paddington 7 195 37 — 156 32 — 39 5 — Poplar 8 1,001 — — 528 — — 473 — — St. Marylobone 12 1,028 109 — 952 75 — 176 34 — St. Paneras 7 610 36 — 559 23 — 51 13 Shoreditch 12 752 — — 648 — — 104 — Southwark 41 3,021 449 — 2,382 295 — 639 154 — Stepney 53 5,230 747 180 3,772 430 180 11,458 303 — 14* Stoke Newington 1 37 — — 32 — — 5 — Wandsworth 8 175 5 16 145 4 13 30 1 3 Westminster, City of 12 2,130 62 — 1,879 62 — 251 — Woolwich 22 465 51 — 396 47 — 69 4 — Totals 346 24,338 2,296 218 18,936 1,483 209 5,402 796 9 17* * Children. Note.—In addition to the figures given above, there were in Rowton Houses on the same night, 5,001 men and 18 vacant beds. In the Mary Curzon Hostel, a new home for women, thore were 35 women and 1 child. 15 beds were vacant. TABLE III. Number of permanently Free Beds in premises licensed as Common Lodging Houses on the night of 24th October, 1913. In other licensed Common Lodging Houses 33 free beds were provided on that night. Premises. Free beds. For labour. Men. Women. Children. Men. Bermondsey. Salvation Army, Spa-road — 622 Belhnal Green. Church Army Labour Home, Warner-place — — — 35 Finsbury. Church Army Labour Home, Banner-street — — 105 Kensington. Barnardo's Home, Penzance-place — 10 3 — Stepney. Medland Hall 150 — Barnardo's Home, Commercial street — 17 14 Salvation Army, Quaker street — — — 183 Westminster. . Ham Yard Hospice, Great Windmill street 18 — — — 168 27 17 845 Unoccupied on night of census 2 77 — 123 99 Report of the County Medical Officer—General. 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) — 21 — — Holborn. (1) 32 — — — (2) — 12 — — Southwark. (1) — — — 97 32 33 — 97 There were on the same night in the Labour Homes and Homes for Women of the Church Army 140 men and 105 women, and 20 boys. TABLE V. A Table summarising the information contained in the second and third paragraphs of this report, and showing the total number of persons who might be regarded as homeless on the ground of being unable to pay for a bed. Description. Men. Women. Young Persons. Total. Number of men who were received in a Salvation Army shelter and were sitting up 17 — — 17 Persons found homeless in the streets 534 141 2 077 In licensed common lodging houses where no chargo is made In unlicensed houses whero no chargo is made 1,013 178 27 133 17 20 1,057 312 Beds in licensed common lodging houses paid for by charitable institutions ... 33 — — 33 Persons in casual wards 352 40 1 399 Total number of persons found homoless, or resting in shelters, or occupying free beds in common lodging housos, sholtors and casual wards * 2,127 352 40 2,525 2,622 458 17 3,097 * The figures in italics are the totals for the night of the 14th February, 1913. 101 Report of the County Medical Officer—Education. CHAPTER XXXIII. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER (Dk. W. H. Hamkr) FOR THE YEAR 1913. Part II.—Education. Introductory Note. During the year 1918 progress has been made with the development of the school medical work in the directions foreshadowed in the annual report for the year 1912. Among other things attention has been especially directed to the reorganisation of medical and dental inspection and reinspection, to the extension of facilities for medical and dental treatment, to "following-up," to the effective control of infectious disease, and to widening the scope of the personal hygiene and cleansing schemes. Modical Inspection and Staff considerations. As regards the routine medical inspection of children in elementary schools it may be noted that 226,215 children were examined, and that 86,787 were referred for treatment for various remedial defects. The question of the numerical strength of the medical staff and of the kind of officers to be employed in this work has during the year received a considerable amount of attention. The ordinary work of medical inspection had hitherto been carried out by a staff of eight full time permanent, 22 full time temporary, and six part time school doctors distributed in the several areas under the supervision of the four divisional medical officers. The inspection of children in special schools and higher educational institutions, and other special work was carried out by a separate staff of officers. Early in 1918 the Board of Education caused an investigation to be made by its medical inspectors into the working of the administrative arrangements for inspection and treatment then in force as the result of the decision of the Council of the 25th July, 1911. In the course of their enquiry the Board's inspectors visited the local offices of the divisional medical officers, the treatment centres and the schools, and their comments and criticisms were communicated to the Council in a letter dated 24th June, 1918. This letter is reproduced in extenso on pp. 4.6, and inasmuch as the questions raised are fully dealt with in that part of the report, it is unnecessary here to do more than state that the Board expressed general approval of the arrangements for inspection and reinspection, but pointed out the need for certain developments and further made a number of criticisms on points of detail. The methods adopted for meeting these criticisms and the various considerations which influenced the Council in arriving at its decisions are discussed in detail on pp. 6.8. In view of the importance of the issues raised and inasmuch as the matter does not conveniently fall into place in the subsequent report it may be well here to refer to the fact that a subject which specially occupied the Council's attention was the determination of the proportion of permanent to temporary, and of part time to whole time officers, to be employed. In this connection I reported as follows:— "The extremely satisfactory work which has been performed by the staff during the past year could not possibly have been obtained from a staff previously untrained in the duties and unskilled in the use of the necessary forms and symbols required in recording the results of medical inspection. It is necessary that the school doctor should possess a training in public health; his duties include reporting upon the sanitary and hygienic conditions in the schools under his charge, and it is imperative that a considerable proportion of the staff should be skilled in the methods of investigating outbreaks of infectious disease, inasmuch as prompt and decisive action must be taken at the school itself, in order to avoid the dangers to life and interference with school work which such outbreaks entail when extensive spread of disease takes place. Furthermore, it is desirable that the staff, as a whole, should be thoroughly acquainted with school conditions, with educational methods, and with the physical and mental development of normal and abnormal children, inasmuch as it is their duty to advise in cases of backwardness, of retarded development, of speech defect, and of other nervous conditions and defects which may render a child suitable for special education. In this connection they should also possess a trained knowledge of the conditions of the special sense organs in relation to education for these vitally affect a child's school progress. . . . The filling up of the Board of Education's schedule for each child necessitates familiarity with a number of special and complicated forms, symbols and criteria. Celerity and accuracy in assessing and assigning to its proper category each particular item, under consideration during the inspection of the child, must be attained if the work is to be both economically and satisfactorily carried out. This knowledge, celerity and accuracy can only be acquired by the school doctor after considerable practice. . . It was proposed when medical inspection was first undertaken in London that the quarter-time staff originally employed should hold office only for three years. When new doctors were appointed, the supervision and training, which their inexperience of the conditions of work entailed, threw a great burden upon the supervising staff, and frequent changes resulted in such slow and unsatisfactory work being done that the Council continued, as far as possible, to utilise the services of the doctors beyond the limit of time originally fixed, with the result that permanency and continuity in the work were, so far as possible, maintained." As already mentioned, the general questions raised by the Board of Education's letter concerning the work of the school medical staff are dealt with in succeeding pages, and it must, therefore, here suffice to say that on 24th February, 1914, the Council decided that the number of divisions should be increased to five, each under the control of a divisional medical officer; that 17 full time permanent, 20 full time temporary, and 20 part time school doctors should be employed 102 Annual Report of the London County Council, 1913. in medical inspection; that the temporary full time doctors should be engaged for 3 years, and th^ part time doctors for 2 years; and that each permanent full time assistant should have a share in the whole work of the department, including routine medical inspections of age groups; special inspections of ailing children outside age groups; following up of cases found defective (e.g., re-inspections, visiting treatment centres, and addressing parents); work in connection with open-air schools, playground classes, feeding centres, physical exercise classes, holiday excursions, etc.; medical inspections in special schools and higher education institutions; special work in connection with investigation of eye and ear defects; public health work, including investigation of infectious disease, buildings. tuberculosis, snecial renorts. etc. Dental Inspection. in auuiuoii io me general meuicai examination oi elementary scnooi cmiaren oy me scnooi doctor, special dental inspections are made by qualified dentists, the services of the dentists engaged in treatment work at the centres being utilised for the purpose. During the year, however, a slight deviation from last year's method has been adopted, inasmuch as an address to parents on the care of the teeth is given at the time of each dental inspection instead of once at each school. Whilst the half-hour devoted to the address somewhat diminishes the time available for inspection, this apparent loss of time is more than counterbalanced by the improved attendance of children for treatment. During 1913 the total number of children examined by school dentists was 31 858. find 25.492. ov 80 nm- np.nt. wfirfi found tn remiire dental treatment,. Medical and Dental Treatment. As shown on p. 35 there has been during the year 1913 a very large increase in the facilities provided by the Council for medical and dental treatment. This is specially to be observed with regard to nursing treatment centres and dental centres, and further arrangements are contemplated with a view to extending in yet greater degree such provision. At the end of the year, if hospitals be included, there were in all 34 centres, providing for the treatment of 84,350 children, figures which may be compared with the 28 centres for the treatment of 73,058 children at the end of 1912. "Followingup." The important branch of medical treatment work described as "following up" has also received special attention throughout the year. Indeed, it was not until some little time after the beginning of the year 1914 that the arrangements were completed. The work of the school care committees has now been placed on a permanent basis, the organising staff has been increased, their duties have been defined, and the section of this staff engaged upon medical treatment work lias been allocated to the public health department under the direct control of the school medical officer. Re-inspection of children referred for treatment. Associated witn me work ot tollowing-up is mat oi re-examination by the school doctor in ill cases in which treatment has been recommended and this supervision is carried out by means of reinspections. The reorganisation of the medical staff to which reference has just been made has rendered possible the necessary expansion in the work of reinspection. It is estimated that about 32,500 children are referred for treatment annually in London. During the year 1913 about 36,000 reinspections were made, but in many cases repeated examinations are needed to ensure idequate medical supervision until treatment is completed, and the annual number of reinspections is estimated at 150,000. Provision has now been made for this increase of work and changes of method have been adopted with the object of preventing leakage. Government Grants. In August, 1918, the Board of Education issued new regulations on this subject wherein for the first time it is provided that grants will be made in respect of medical inspection in addition to those formerly paid in respect of medical treatment and work ancillary to treatment. The grant received for the year 1912 was £12,958 8s. 10d., approximately 58 per cent. of the cost of treatment or 28 per cent, of the cost of inspection and treatment. The grant made in respect of the work of inspection and treatment for the year ended 31st July, 1918, is £31,191 Is. 6d., or precisely 46 percent. of the total expenditure as set out in the Council's claim. The letter of the Board intimating this decision is as follows, and is dated 26th March, 1914 :— "I am directed to inform the Authority that their application for grants under Part I. of the "medical grant regulations in respect of the whole work of the school medical service connected "with public elementary schools has received the consideration of the Board. They have decided "to make a grant of £31,191 Is. 6d., and payment of this sum will shortly be made. "In forwarding this large grant the Board desire to express their recognition of the "improvements which have been effected in the work of the Authority's school medical service, "and, in particular, their appreciation of the extension of the facilities for treatment." Infectious disease. in comparing tne nonncauons oi lniectious disease among scnooi cmiaren, it win oe ODservea that while diphtheria has remained almost stationary, scarlet fever shows a distinct increase on the average numbers for the three preceding years. Measles shows a decline in the notifications received from the schools, the total number for the year being the lowest recorded for eight years. It may be remembered that the wave of prevalence reached its maximum of recent years in the early part of 1911, and during 1913 the disease was at a low ebb. Advantage has been taken of this diminished prevalence to study methods of limiting school outbreaks of measles and some discussion of the question will be found in the subsequent report, pp. 98 to 102. Personal hygiene scheme. In the annual report for 1912 the development of the cleansing scheme was traced from the voluntary work carried out in 1902, to the arrangements adopted by the Council in 1912, involving the whole time employment of 22 nurses. At the end of that year agreements had been made with 16 borough councils for the use of their cleansing stations, the Council itself had established four stations, and the Committee of St. Cecilia's House also provided facilities. During 1913 the number of stations has been increased to 22, and at 18 of these treatment has been extended by the inclusion of scabies. 858,691 children were examined, of whom 29,903 were found to be verminous. 15,241 children were cleansed by the parents and 41,458 cleansings were carried out by the Council and borough councils. The very large increase in the number of children cleansed voluntarily shows that parents are beginning to realise the importance of the subject, a result which 103 Report of the County Medical Officer—Education. cannot fail to be of benefit to the children. Certain modifications have been introduced into the Council's arrangements for securing cleanliness. In the scheme which deals exclusively with children with unclean heads, provision has been made for specially communicating with parents in cases where the condition is one of only slight degree of uncleanliness. The scheme for dealing with children suffering with verminous bodies or clothing has been modified so as to hasten the process of cleansing, and to secure closer co-operation with the local authorities for the purpose of dealing with clothing. etc.. in the homes. Examination of Candidates. The number of candidates for permanent appointments in the school service and candidates for scholarship awards who were medically examined increased from 5,984 to 6,045. Special reports were made in regard to 798 employees who were unable to carry out their duties owing to personal illnees, a decrease of 143, or 15.2 per cent. In addition, 203 claims for exceptional treatment in respect of illnesses alleged to have been contracted during the course of school duties were investigated. The pupils in the Council's institutions for higher education, and the London County Council scholars in attendance at aided secondary schools, have also been inspected. The open-air schools at Birley House and Shooters Hill were both kept open throughout the year. The Kensal House School for tuberculous children has been continued. The playground classes have largely increased in numbers and some of them were held in the public parks. 7,655 children were examined with a view to admission to special schools; of these 4,060 were Open air Schools Special Schools certified as suitable lor admission thereto and the remainder were either returned to tne elemental}1 schools or found to be unsuitable for any of the Council's institutions. The results of the periodical re-examination of the children in the schools for the mentally and physically defective, are shown in the report, and a considerable amount of time has been spent on questions relating to family history, heart cases in physically defective schools, classes for myopes and the partially deaf. S[>ecial Reports of School Doctors. Many of the school doctors have found it possible to devote time to the investigation ol special subjects, and the following reports, of which considerable use has been made in subsequent pages, have been received during the year:— School Doctor. Subject. Dr. Ruth Balmer Open-air classes at Broad-street, Cayley-street, Heckford-street. „ E. J. Boome i. Remedial exercise classes, The " Chaucer " School (B. and G.), pp. 61 and 04. ii. Open air classes at Farncombe-street. „ Cresswell Burrows Open-air classes at Bow-creek, British-street, the " Hay Currie," Oban-street. „ G. Chaikin i. Footgear of school children. ii. Remedial exercise class, Catherine-street School, p. 65. iii. Open-air classes at Canal-road- ,,A. R. Cowell i. Difficulties experienced in obtaining treatment for defects found. ii. Latent visual defects in school children. iii. Open-air class, St. Matthias. ,, A. M. Davics i. Maryon-park, Blackheath-road,Creek-road and Bellcnden-road school journeys ii. Remedial exercise class, Hughes-fields School, p. 61. iii. Open-air class, Lucas-street. ,, Jessie Duncan Remedial exercise class, Eltringham-street (G.) School, p. 66. ,, L. Haden Guest Playground class at Surrey-square School. ,, C. F. Hadfield Remedial exercise class, Moreland-street (G.) School, p. 67. „ Helen B. Hanson Results of X-ray treatment for ringworm, p. 106. ,, M. G. Edis i. Conditions of school hygiene and arrangements for medical inspection in Nuremburg. ii. Penrose-street school journey. iii. Open-air classes, Sandford-row and West-square. „ C. T. W. Hirsch i. Comparative investigation of the condition of leavers examined in twenty] elementary schools. ii. Report on Shooter's-hill open air School, p. 71. iii. Remedial exercise class, Union-street School, p. 61. iv. Open-air classes at Eglington-road, Maryon-park and Wood-street. „ H. R. Kidner i. Holy Trinity school journey. ii. Remedial exercise class, Frankham-street. p. 63. iii. Open-air classes at Alverton-street, Southwark-park and The " Redrifl." „ F. C. Lewis i. Remedial exercise class, Cook's-ground School, p. 68. ii. Open-air class, Holy Trinity. „ C. L. Leipoldt i. An investigation into the occurrence of Stiller's signs in children with reference to cases of malnutrition, pp. 24—30. ii. Report of school journey of Torriano Avenue school children, pp. 75-82. iii. Open-air class, New End. „ Margaret C. Macdonald i. Investigation of the vision of 804 infant children, p. 10. ii. Ruby-street summer camp. p. 75. iii. Remedial exercise class, Snowsfields School, p. 67. „ A. J. Malcolm i. Harwood-road school journey. ii. Open-air class, Finlay-street, " The Peterborough." ,, T .Muirhead Martin Report upon children treated for nose, ear and throat complaints at the Hackney School Treatment Centre, p. 36. „ T. J. T.McHattie i. "Mirror writing" in school children, p. 20. ii. Remedial exercise class, Hungerford-road (G.) School, p. 66. iii. Open-air class, Poole's-park. „ Elizabeth M. McVa.il Open-air classes at Berkshire-road, Gainsboro-road. „ R. H. Norman i. Comparison of nutrition of breast and bottle-fed children in Infants' Departments. p. 31. ii. Vision of children who have been supplied with spectacles, iii. Netley-street school journey. iv. Remedial exercise classes, Prospect-terrace (B.) and Camden-street (G.) Schools, pp. 61 and 65. 10* Annual Report of the London County Council, 1913. School Doctor. Subject. Dr. E. F. Palgrave i. Malnutrition in relation to faulty home management, p. 30. ii. Saunders-road and Addison-road school journeys. iii. Open-air class, Fulham-palace-road. ,, Agnes Parson i. (with Dr. Edis) Conditions of school hygiene, etc., in Nuremburg. ii. Open-air classes, Olga-street and Wolverley-street. ,. 0. H. Peters i. Relative degrees of mental deficiency. ii. Hague-street school journey. iii. Remedial exercise class, Deal-street (G.) School, p. 06. ,, A. J. Scott Pinchin. i. Remedial exercise class, Garratt-lane. p. 60. ii. Open-air classes at the " Earlsfield," Garratt-lane and The " Wandle." ,, Mabel Russell i. Sleeping conditions of school children in East End schools, p. 31. ii. Open-air classes at The " Ben Jonson," Essex-street, St. Paul's-road, St. Thomas Colet. „ W. J. M. Slowan i. An investigation into cases of inequality of the pupils of the eyes, found amongst 5,000 school children, p. 15. ii. Battersea-park-road school journey. iii. Remedial exercise class, Church-street (G.) School, p. 68. iv. Open-air class, Priory-grove. „ E. Bellingham Smith i. Remedial exercise class, Winchester-street School, p. 62. ii. Open-air class, White Lion-street. „ L. R. Tosswill i. Medical inspection and following up. * ii. Open-air classes at Ambler-road, Queen's-road, Richard-strcct. „ A. E. Wells i. Littlehampton school journey. ii. Open-air classes, Faunce-street and the "John Ruskin." „ F. T. H. Wood i. Relation between nasal obstruction and superior protrusion, p. 18. ii. Report on Birley House Open-air School, p. 69. iii. Sydenham-hill-road, Holbeach-road and Manor-lane school journeys. iv. Open-air classes at Gordonbrock-street School. „ E. Colston Williams i. Woods-road and Mantle-road school journeys. ii. Remedial exercise class, Weston-street (G.) School, p. 67. The Utter of the Board of Education dated 24th June, 1913, on Medical Inspection and Treatment. Reference has already been made in a previous paragraph to the letter of the Board of Education of the 24th June, 1913. This letter is of particular interest as expressing the views of the Board upon the working of the school medical service for the first time since the inauguration of the new administrative arrangements approved by the Council on the 25th July, 1911, and referred to in some detail in the annual report for 1912. The points raised in the letter have received the very careful consideration of the Council, and in view of the importance of the issues raised it has been thought well here to quote the letter in full before dealing with the questions raised in their appropriate order. The letter is as follows:— 1. I am directed to inform the Council that the Board have received reports from Dr. Eichholz. Dr. Crowley and Dr. Janet Campbell, three of their medical officers, on the recent inspection of the working of the arrangements made by the Council in connection with their school medical service. In the course of the inspection, the Board's medical officers had an opportunity of seeing most of the Council's assistant medical officers carrying out medical inspection, of visiting most of the treatment centres and hospitals comprised in the Council's scheme of treatment, and of inquiring into the administration of the work generally. 2. The Board are glad to learn from the reports that, subject to certain qualifications the actual work of medical inspection is being carried out satisfactorily by an efficient staff of medical officers who seem to be keenly interested in their work. Further, the organisation of the work of inspection as a whole, particularly the arrangement under which the area is divided into four sections, each under the charge of a divisional medical officer responsible for the supervision of the assistant medical officers in his section, appears to the Board to be satisfactory. In this connection the Board note that the requirements of article 58 (b) of the code appear to be strictly complied with, and that a suitable examination is now made of all children entering school. 3. With regard to the routine inspection of the children in the groups prescribed by the code, the Board understand that the weighing and measuring of the children and the testing of vision are, as a rule, undertaken by the nurses apart from the medical examination and in some cases on a different occasion, and that this part of the work is not in fact adequately supervised by the medical officers. As regards the testing of vision, the Board consider it very desirable that the medical officer should himself examine all cases reported as the result of the preliminary examination by the nurse to be defective, so that he may be in a position to take full responsibility for all cases referred for further examination and treatment, and to estimate with accuracy any changes in visual power at subsequent examinations. In connection with the examination for defective hearing, the Board, entertain some doubt whether sufficient attention is in all cases given to the detection and estimation of this defect. 4. The Board are glad to learn that systematic arrangements have been made for the re-examination of cases of defect found in the course of medical inspection. They also desire to express their appreciation of the system adopted for ascertaining whether 105 Report of the County Medical Officer—Education. treatment is or is not obtained for defects discovered in the course of medical inspection and of the valuable work done in this connection by the care organisers. 5. In certain respects, however, the existing arrangements in regard to following up do not appear to the Board to be altogether satisfactory. In the first place, the Board understand that at present, although the greater part of the work undertaken by the.care organising staff is concerned with the results of medical inspection and treatment, this work is not in fact placed under tie direct conirol of the school medical officer. In the Board's view it is essential, if the work of the Council's school medical service is to be carried on with full efficiency, that the whole of the school medical work, including inspection, following up, and treatment, should be placed under the control of the school medical officer. I am accordingly to suggest that the Council should consider the advisability of transferring to the staff of the school medical officer those care organisers who are engaged in work connected with the school medical service, and that similarly arrangements should be made for that part of the work of the voluntary care committees connected with the school medical service, eome of which cannot at present be considered satisfactory, to be carried on under the supervision and control of the school medical officer. In this connection I am to invite the attention of the Council to paragraph 4 of circular 792, and to point out that the Board are only prepared to make grants under the medical treatment grant regulations in respect of ancillary undertakings "if carried out by the school medical officer or his staff or under his direction or supervision." 6. In the second place, the Board gather that, while the system adopted for securing co-ordination between the school medical and school attendance departments is in itself satisfactory, full use is not at present being made of it. They understand that the number of children absent from school on medical grounds who are under observation by the Councils medical officers, foims but a small fraction of the whole. In this connection I am to say that it appears to the Board desirable that the medical officer should be cognisant of all cases of children absent from school on medical grounds for more than a specified period, with a view to ensuring that, on the one hand, the children return to school as soon as they are fit to do so, and that, on the other hand, they do not return too soon to their own detriment or that of other scholars. 7. In this connection, I am to remind the Council that the Board have on previous occasions drawn attention to the desirability of establishing inspection centres to which cases could be referred by the medical officers from routine medical inspection for more detailed examination, and to which children could be sent by the teachers, school nurses, attendance officers and care committees for examination. It will also be remembered that in recent agreements with the committees of management of treatment centre^ provision has been made for the use of the premises of the treatment centre for the purpose of an inspection centre. The Board understand, however, that, in fact, very little use has been made of the treatment centres for this purpose, and that the inspection centres held at the offices of the divisional medical officers on Saturday mornings have not proved altogether successful, owing to the difficulty of securing the attendance of the children. It would appear that the centres have been regarded merely as places where children could be examined at the request of the attendance officer, and not also as centres serving a comparatively small area from which the school medical work might radiate, and a continual supervision over individual children, so far as necessary, might be exercised. I am accordingly to suggest that the Counci 1 should consider the advisability of providing such facilities as will ensure that there shall be centres reasonably available for all the children. 8. With regard to the arrangements for medical treatment, the Board desire to draw the attention of the Council to the following points— (i.) It appears that in certain cases the arrangements made do not secure that the medical officers of the treatment centres are furnished with sufficient information as to the nature of the defects for which the children are referred to the centres. (ii.) The Board understand that in certain districts the arrangements made in regard to dental treatment, while providing for the inspection by a dentist of children in the six to eight age group, include a considerable proportion of older children selected by medical officers—thus interfering with the normal development of the scheme of dental treatment on preventive lines. This may be a temporary necessity, but should not be regarded as a permanent arrangement. (iii.) The arrangements with regard to the treatment of minor ailments do not appear to be altogether satisfactory. The Board understand that in practice a large proportion of the children requiring such treatment do not obtain it, partly owing to the insufficient supply of facilities for treatment and partly owing to the absence of provision for securing the prompt attendance of the children at treatment centres. The Board gather that at present but little difference is made between such cases and the more serious cases, such as those requiring operative treatment, and that before a child can be treated for a minor ailment all the detailed procedure required in the more serious cases, including reference to the care committee, is usually gone through. In the opinion of the Board, the first essential of any scheme for the treatment of minor ailments which is to be effective is that the children should be enabled to obtain treatment expeditiously. 23610 p 106 Annual Report of the London County Council, 1913. I am also to suggest that the Council should consider further the existing practice in regard to the treatment of cases of discharging ears. Having regard to the fact that a certain proportion of these cases are of a serious nature, it seems desirable, with a view to ensuring adequate treatment, that facilities should be provided for an examination by an expert aural surgeon where this appears to be necessary. 9. Finally, it appears to the Board desirable that the Council should consider the possibility of extending the functions of the assistant medical officers. In the opinion of the Board there is a serious danger that unless more variety is introduced into the work of these officers the restriction of their duties, in practice largely to routine medical inspection, re-examinations and special examinations, will have an iujurious influence on the work generally. At the present time the quality of the Council's staff of whole-time assistant medical officers appears, as already indicated in paragraph (2) above, to be high. It seems probable, however, that if the existing limitations were to be maintained, either the enthusiasm of the medical officers for their work would diminish with a resultant loss of efficiency, or there would be a tendency for the medical officers to seek employment in areas where a wider scope for their activities presented itself. With a view to securing greater variety, I am to suggest that in addition to carrying out the work of routine medical inspection in his district, together with re-examinations and special examinations, each assistant medical officer should be entrusted with other kinds of work, as, for example, the further examination of visual defects, public health work, including investigations of infectious diseases in schools, the medical inspection of children in secondary schools, scholarship candidates, etc., work in connection with the special schools, research and laboratory work, and some share in the working of the administrative arrangements. The extension of the work of the inspection centres, recommended in paragraph (7) above, would tend in the same direction. I am to add that it appears to the Board that the work of treating minor ailments arises naturally out of the work of the inspection centre, and can most effectively be carried on in intimate conjunction with the work of the inspection centre by the officers responsible for that work. If such an arrangement could be adopted in London, it would not only widen the scope of the assistant medical officers' work, but would, in the Board's view, tend to remove many of the difficulties which have arisen through the separation of medical inspection from medical treatment. 10, I am to request that the Board may be furnished in due course with the observations of the Council on the matters referred to in the present letter. Prior to the receipt of the Board's letter certain of its criticisms had been anticipated and were receiving attention. The following observations may be made, taking the paragraphs in the Board's letter in their numerical order. Paragraphs 1 and 2 are introductory and state that subject to certain qualifications, the actual work of medical inspection has been carried out satisfactorily by an efficient staff of medical officers, and that the organisation of this section of the work as a whole is satisfactory. In paragraph 3 of the Board's letter the suggestion is made that tbe weighing and measuring of children and the testing of vision, usually performed by the nurse, are not adequately supervised by the school doctors. It is.imperatively necessary in order that the requisite number of children shall be examined by the doctor at each of his visits that some routine work should be carried out by the nurse in preparation for the inspection. The results, moreover, of the physical measurements made by the nurses during 1911 were found to be in complete agreement with the standards arrived at in former years from measurements made by the medical officers. It has been arranged that in future these officers shall themselves take the physical measurements both at the inspections and at subsequent reinspections of children suffering from malnutrition. The school doctors have also been instructed to examine all cases of defective vision reported as the result of the preliminary examination by the nurse, and during the year the standard of defect for which children were referred for treatment was raised from 6/18 to 6/12. In connection with the examination for defective hearing it was arranged that the preliminary examination for hard-of-hearing classes should be made by the school doctor, cases considered suitable being further examined by the Council's otologist. In paragraph 4 the Board expresses appreciation of the system of reinspection. As already mentioned, the estimated number of first reinspections is 92,500 annually, and from the statistical material at present available it may be gathered that some 62 per cent. require a second reinspection. If this work is to be carried out in a complete manner it will, therefore, be necessary to provide for an annual number of reinspections approaching 150,000. Moreover, the supervision of children in school notified as "tuberculosis contacts'' involves a large amount of additional labour. Extension of this work in the direction indicated has now been provided for by the increase of staff. Paragraph 5 deals with "following up." This is'fully discussed on pp. 146 and 147. The arrangements now made allocate to the school medical officer's department the whole of the organising staff engaged in medical treatment and "following up" and in effect follow generally the suggestion made by the Board. In paragraph 6 the Board draws attention to the desirability of making greater use of the system of co-ordination between the school medical officer's and the school attendance departments. An arrangement is now in force whereby all children out of school on medical grounds for a period of three months are reported by the attendance officers to the school medical officer. Some statistics as to the working of this scheme will be found on p. 149. 107 Report of the County Medical Officer—Education. Paragrapu 7 of the Board's letter deals with the establishment of medical inspection centres. Arrangements had already been made for the school treatment centres to be available for special medical inspections, but owing to the fact that the statutory inspections and reinspections in the schools occupied the whole of the school doctors' time it was not possible to make arrangements for special inspections as frequently as might be desirable. It was found difficult, moreover, to secure the attendance of children 011 Saturday mornings. For these reasons special examinations were made in the schools in conjunction with the ordinary statutory inspections. It is desirable that the number of special inspections should be increased, and it is hoped to effect this by some rearrangement during the ensuing year. In paragraph 8 certain points in connection with medical treatment are criticised— (1) It is pointed out that the arrangements which are made do not secure that the medical officers of the treatment centres are furnished with sufficient information as to the nature of the defects of the children referred to them. It was originally intended that the following-up card made out in the case of each defective child should actually follow the child, and be available at the centre for the information and use of the surgeon, but it was not found possible to carry this into effect, owing to certain difficulties, one of which was that the organising staff was not, at the time, under the direction of the school medical officer. Arrangements have now been made for the work to be carried out, and the extra labour involved has been taken into account in forming an estimate of the necessary organising staff. (2) The Board point out that a considerable proportion of children older than the 6-8 age group are referred to dental centres for treatment, and they indicate that this, in their opinion, is undesirable. The difficulty caused by congesting the centres with older cases is fully realised and whenever possible this is avoided. It must be pointed out, however, that in some areas no other provision for dental treatment exists, and in cases found by the school doctors in urgent need of such treatment there would be failure to get relief, unless it were by utilising the Council's arrangements. It is the practice, however, to restrict the making of appointments for older children to those most urgently needing assistance, and to give facilities to them only at times when there is an insufficient number of children of the 6-8 age group forthcoming to fill the centre to its fullest capacity. v3) The Board consider that the arrangements in regard to nursing treatment are not satisfactory. This the Board find is partly owing to the insufficient supply of facilities, and partly due to the absence of provision for securing the prompt attendance of the children treated at the centres. As regards the ensuing year, further nursing treatment schemes have been sanctioned by the Council in connection with the Peckham, Woolwich and Deptford treatment centres, and in connection with the Battersea centre. With regard to the provision for securing the attendance of children, it is evident that the method of supply which is adopted in the case of the more serious ailments is not altogether suitable in cases requiring nursing treatment. Further, a serious defect,which experience has disclosed, is that there is no provision for referring cases except through the supervising doctor, who visits the centres, as a rule, only once a week. The result is that many cases in urgent need of nursing aid are deferred until too late to prevent acute conditions passing into the chronic stage, in which they require prolonged treatment before a cure can be effected. The present agreements provide for re-inspections being made at the treatment centres, and a system has been adopted whereby the school doctor will in addition inspect children referred by care committee workers, school nurses, teachers and attendance officers, with a view to referring immediately to the proper department those suitable to be dealt with under the Council's arrangements. The organiser of care committee work at the centre will communicate with the Care Committee in order that the necessary investigation and assessment may be made. The Board further suggest that facilities should be provided for examination by an expert aural surgeon of the more serious cases of discharging ears. In the experimental scheme which was applied in the borough of Paddington it was found advantageous to refer all cases which resisted treatment after a certain period to the Council's otologist. Mr. Yearsley, however, has the charge of the deaf centres, which occupy most of his three sessions given weekly to the Council. He sees at present at the head office a certain number of difficult cases referred by school doctors, but his other engagements do not admit of extension of this work, and assistance has therefore been given him. In the final paragraph the Board indicate the fines upon which, in their opinion, the school medical service should, in future, be arranged. The Board further point out the necessity for giving, within the limits of the service, a greater variety of work than is now provided for the rank and file of school doctors. The Board suggest the following directions in which this extension of work should take place— The further examination of visual defects; public health work, including investigation of infectious diseases; the medical inspection of children in secondary schools; of scholarship candidates, etc.; work in connection with special schools; research and laboratory work; and some share in tho administrative arrangements. The Board also suggest that the medical supervision of nursing treatment work could be carried out by the school medical staff. These points may be dealt with seriatim. (a) Further examination of visual defects.—The Council's ophthalmic surgeon, Mr. Harman, is in charge of blind schools and myope classes, which occupy nearly the whole of the three half-days per week upon which he is retained by the Council There are numerous cases of visual defect which it is impossible adequately to examine at the routine inspections, and while Mr. Harman sees at the head office a certain small proportion of children referred by school doctors, he is, like Mr. Yearsley, unable to extend this work, owing to lack of time. There are among the permanent and temporary school doctors a number who have had special training and experience in ophthalmic work, and allowance has now been made whereby school doctors with suitable experience shall hold sessions for the further investigation of cases both of visual and of aural defects. 23610 P 2 108 Annual Report of the London County Council, 1913. (b) The investigation of infectious diseases in the schools was already in part carried out by the school doctors, but difficulty was experienced in making all the investigations considered advisable. In the new organisation of the work provision has been made for more complete investigation of this kind. (c) The medical inspection of children in secondary schools, and special schools, and of scholarship candidates was carried out by a separate staff consisting of five full-time officers and two part-time officers. It was provided by rearrangement of duties that a considerable portion of the work of this staff should be carried out by the school doctors in the various districts, thus relieving the officers of a higher grade of certain duties of a purely routine nature and setting them free to deal with cases which require special investigation. It was borne in mind, moreover, that under the Mental Deficiency Act, 1913, a number of difficult cases must arise, and unless some such rearrangement of duties as that above outlined had been carried out, it would have been impossible for the staff to deal with the new Work. (d) and (e) Research and laboratory work and administration.—Arrangements have been made whereby each permanent whole time school doctor attends the central office periodically in order to obtain an insight into details of administration. Time is also allowed for research and laboratory work, and opportunity is afforded for studying the methods of the medical officers engaged upon special work arising out of the school medical service. Medical Inspection. The Board of Education's regulations under the Education (Administrative Provisions) Act, 1907, place upon Local Authorities the duty of providing for the examination of children on entering school life and again just prior to leaving school, and the tables appended to this report show the details of the inspection of London elementary school children in the form prescribed in the Board's schedule. The schools are grouped in metropolitan boroughs. In addition to the age groups prescribed by the Board the Council has voluntarily made provision for the inspection of an intermediate age-group, and the results of this inspection are also given in the Appendix. In the year 1913 the Council further decided to extend the inspection of the age-groups to the special schools for Deaf, Blind and Mentally Defective children, and particulars as to the general physical condition of children in these schools are, therefore, also shown for this year, but as the figures are small they are given for London as a whole. The work of inspection during the year 1913 was carried out by a staff of 30 full time doctors and 6 quarter-time doctors, working under the direction of 4 divisional medical officers. IJnder this system it has been possible to exercise closer supervision over the work and by this means to bring about a greater degree of uniformity in the standards adopted by the school doctors in their routine inspections. The doctors were assisted in their work by a staff of 90 nurses, who prepare the children for examination and assist in the weighing, measuring and vision testing. Arrangements are made whereby some of the children in each school are inspected each term, so that the school doctor visits each school, however small, in his district at least once a term, and opportunities are thus afforded for any special cases in other age-groups to be brought to his notice. The date of the inspections at all schools is advertised in the Council's Gazette, and the parents of children due for examination are invited to be present. A representative of the School Care Committee is also invited to be at the school at the time of the examination in order to make arrangements to secure that where necessary the child receives medical treatment. Where a child is found to be in need of treatment an advice card is issued to the parent. If the parent be not present at the inspection the school nurse visits the home and delivers the card to the parent. The scheme of inspection hitherto pursued is as follows. During the first term of the year "leavers'' are examined, The term "leavers" is taken to mean children who during the year reach the age of 12 years, i.e., for the year 1913 this group comprised all children born during the year 1901. The advantage of adopting this plan lies in the fact that any children who may be found defective and in need of treatment are kept under supervision during the remainder of their school life, whereas if they were examined at a time nearer the leaving age many of them would have left school without securing treatment and the following up of such cases would be impossible. During the second term the inspection is mainly devoted to examination of entrants—that is, children entering school life or children who have not hitherto been inspected at the present or at a former school. The age of entrants varies considerably but the vast majority are under six years of age. The tollowing table shows the ages ot entrants examined during the year Age 2-3 Age 3-4 Age 4-5 Age 5-6 Age 6-7 Age 7-8 Total. Boys 9 6,082 13,146 16,894 2,973 913 40,017 Girls 6 5,444 12,097 18,255 2,984 817 39,603 Total 15 11,526 25,243 35,149 5,957 1,730 79,620 During the third term of the year inspection relates to the examination of outstanding cases in the entrant and leaver groups and, in addition, to the examination of children reaching the age of eight during the year—i.e., for 1913, children born during the year 1905. The inspection of this intermediate group has not hitherto been required in the Code issued by the Board of Education, but the Board have now intimated to local authorities that they will require the examination of an intermediate age group in the year commencing April, 1915. Although in some respects convenient, the method of dealing with a separate age group in each term has certain grave disadvantages; chief amongst those is the alternation of periods of- pressure 109 Report of the County Medical Officer—Education. and of shortage of cases which the system throws upon the treatment centres. Thus, for instance, the inspection of infants produces very few cases referred for treatment for visual defect, and, in consequence, there is some difficulty in making full use of the centres during the latter part of the summer term, so far as treatment for eyes is concerned ; whereas towards the end of the Easter term there is a tendency to congestion of cases. It would, therefore, be of considerable advantage if arrangements could be made whereby some of the children of each age group could be examined in each term. The difficulty in the way of making such arrangements arises from the fact that the Code requires that all entrants must be examined during the educational year in which they enter school. Inasmuch as the educational year ends in July, and a very large proportion of entrants attends school for the first time during the summer term, it is necessary if the Code is strictly to be carried out, for the work during this term to consist largely of the inspection of this age group. Special and urgent cases are examined at any time the school doctor visits a school; in addition arrangements are made for special cases to be sent for examination to other schools in the neighbourhood where the school doctor is in attendance, or to some convenient centre, while exceptionally difficult cases, more especially of visual defect or aural disease, are referred for expert examination at the head office. The record of medical inspection of each child is entered on a card which is kept in the school, and the information on the cards is summarised and shown in the tables in Appendix II. Presencs of Parents at Inspection.—A parent or relative of the child was present at inspection in 138,236 cases or in just over 70 per cent. The percentage among entrants was 79'7 : among children aged 8-9, 68.6 ; and among leavers, 57.9. In the case of girls in the last age-group a parent was present in 63.4 per cent. of the cases and among boys in this group a parent was present in 52*3 per cent. of the examinations (see Appendix I). The interest shown by parents in the school medical inspection of their children is strikingly illustrated by the fact that when entrants were examined, in such boroughs as Southwark, Berinondsey, Camberwell, Shoreditch, and Westminster, in over 80 per cent, of the cases the parent made it convenient to attend, although to a large extent in these boroughs both parents are in employment. In Holborn the percentage was lowest (64'2), in no other district did the percentage fall below 70 when entrants were being examined. Figures showing the proportion of cases in which parents were present in the case of the examination of boys, girls and infants respectively, are given in the following table:— Children examined. Parents present. Percentage. Boys (Senior) 58,786 31,619 53.8 Girls (Senior) 58,752 43,161 73.5 Infants 79,620 63,456 79.7 Totals 197,158 138,236 70.1 The time devoted to medical inspection by the doctor gives on the average about six minutes per child and for the nurse about eight minutes per child. It is thus found possible to examine about 25 children during a session of 2½ hours. This rate of examination, however, places a considerable tax upon the officers engaged continuously in inspection. Children are classified as to the condition of their clothing, state of nutrition, cleanliness of head and body, and condition of teeth (see Appendix I). The classification is made into three groups, " good," " average," "bad," except in the case of nutrition, where the grouping is in four divisions, good, normal, sub-normal, bad (i.e., malnutrition). In the tables in the Appendix (p. 124) the percentage of children in each group is shown for the schools in each of the London boroughs. In making comparisons between the various boroughs the question of the general standard of the neighbourhood must not be lost sight of. Each school doctor must necessarily fix his own standard from his general experience, and it must inevitably result that what would be termed "fair" in a good neighbourhood is termed " good" in a poor neighbourhood. Reference to the tables shows that in Hammersmith Schools among entrants nearly 92 per cent. were classed as having good clothing, and 0 3 per cent. as having bad ; the corresponding figures for Hampstead were 48 per cent. and 6 per cent. In Battersea 23 per cent. of the entrants examined were reported as having " bad " teeth ; in Poplar the figure was 1.8 per cent. The percentages for the whole county were as follows :— Cothing and boots. Nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 Boys. Entrants 53.9 42.5 3.6 30.7 58.5 10.5 0.3 86.6 12.8 0.6 77.7 20.6 1.7 62.2 27.7 101 Girls „ 55.1 42.3 2.6 32.7 57.5 9.5 0.3 73.4 24.9 1.7 770 21.3 1.7 630 27.2 9.8 Boys, ago 8-9 47.5 45.4 7.1 22.0 62.2 15.5 0.3 87.1 12.3 0.6 72.0 25.1 2.9 51.4 36.6 120 Girls, ago 8-9 51.4 439 4.7 25.1 61.4 132 0.3 67.3 30.3 2.4 737 24.2 2.1 51.6 36.3 121 Boys., ago 12 49.1 45.4 5.5 26.4 58.9 13.9 0.8 87.3 12.3 0.4 73.1 24.3 2.6 60.0 40.0 10.0 Girls, ago 12 51.8 44.8 3.4 30.6 55.1 13.7 0.6 67.2 30.4 24 74.8 231 2.1 52.4 390 8.6 110 Annual Report of the London County Council, 1913. The condition of clothing was generally better among girls than among boys, and nutrition was also slightly better among girls. The heads of girls were more frequently found to be unsatisfactory, but in general cleanliness of the body girls were reported to be better than boys. Cases for medical treatment.—In Appendices II to V tables are given showing the number and percentage of cases referred for treatment in each of the three age-groups for the schools in each of the London boroughs. From the tables it will be noticed that 72,437 children, or 36.8 per cent. were referred for treatment out of the 197,158 children examined in the three age-groups. Among entrants the percentage was 29.7, among the children aged 8-9, 41, and among leavers 42 2. The eyesight of entrants is not tested, and this accounts in a large measure for the smaller percentage of this group being referred for treatment. Among girls the number of cases was slightly higher than amongst boys, the percentages being 37.1 and 36.5 respectively. Woolwich, Southwark, Poplar, and Shoreditch show the largest proportion referred for treatment, and Hammersmith, Lewisham, Kensington, and Marylebone the lowest. In Woolwich a large percentage of dental cases accounts for the high figure. Vision.—The vision of children aged 8-9 and of leavers is tested by means of the Snellen types at a distance of six metres, each eye being tested separately, and in addition to the determination of the acuity of vision special note is made of any cases of eye disease or squint. In the testing of vision a difficulty is sometimes experienced with children in the intermediate age-group who are not familiar with the letters, and this may to some extent account for the fact that so many children in this age group fail to read the six-metre type at the proper distance. The next sized type is one that should be read by the normal eye at a distance of nine metres, and the other sized types at 12, 18, 24, 36, and 60 metres respectively. The vision in the tables in the Appendix is classed as follows : (1) Children with normal vision, i.e., those who read the smallest type at six metres (6/6) with both eyes tested separately ; (2) children who read at six metres the type normally read at nine metres (i.e. 6/9) with one or both eyes ; (3) bad vision, i.e., children who read at six metres the type normally read at 12 metres (1/12), or worse in one or both eyes. The classification as regards vision of the children of the two age-groups of which the eyesight was tested in London schools may be made as follows:— Class 1. 6/6 in both eyes. Class 2.6/9 in either or both eyes. Class 3. 6/12 or worse in either or both eyes. Cases referred for treatment. Boys aged 8-9 11,244 36.7% 13,295 43.4% 6,092 19.9% 4,164 13.6% Girls „ 8-9 9,747 32.2% 13,980 46.1% 6,577 21.7% 4,511 14.9% Boys „ 12 13,813 51.1% 7,073 26.2% 6,134 22.7% 4,191 15.5% Girls „ 12 12,013 43.8% 8,380 30.5% 7,045 25.7% 4,767 17.6% If the child wears spectacles the vision is tested whilst the glasses are being worn. As a general rule children whose vision is 6/12 or worse in either eye are referred for treatment unless the doctor is satisfied that improvement cannot be effected. In many cases children, when wearing spectacles, do not and cannot attain normal vision. From the above table it is clear that the vision of the elder children, as tested by the Snellen types, is more acute than that of the younger group, 47.4% of the former having normal vision and only 34.4 of the latter, but when class 3 is considered it is found that among older children 24.2°/o have bad vision and among the 8-9 group the percentage is 20.8. It has been pointed out in previous reports that there are two processes at work in relation to visual acuity, as tested by the Snellen types, during the progress of school life. In the first instance there is a gradual education of the physical and mental powers leading, in the great majority of children, to an apparent increase in the acuity of vision ; in the second instance there is a deterioration of vision in a minority of the children due to pathological causes, leading to an increase in the number of cases at the older ages with severe defect of visual acuity. It has been possible this year to analyse the whole of the children inspected with regard to the degree of visual acuity, and the resultant figures here given illustrate very clearly the progress of these two processes during school life. Dr. Margaret Macdonald's investigation into the vision of infant children. Owing to the immaturity of their mental development, and to the fact that there exists no ready means of testing the visual acuity of infant children, no entry of the condition of eyesight is recorded in the medical inspection schedule relating to entrants. In the ordinary course of things, therefore, it is only when children exhibit some gross sign of visual defect, such as squint, that they come under the notice of the doctor in the Infant department. Dr. Margaret C. Macdonald has conducted a very careful investigation into the eyesight of 804 infant children in schools under her care. As, for the reasons explained above, knowledge of the visual conditions of elementary children under the age of eight is very limited, her enquiry is rendered the more valuable. The report, which is summarised below, demonstrates the exceedingly great difficulty experienced in investigating the acuity of the special sense organs in very young children, owing to the quick onset of fatigue and the lack of development of the higher centres of the brain. In addition to exhibiting the results of the investigation of the conditions of eyesight of the children, Dr. Macdonald's report contains interesting comments upon the very surprising variations of daylight illumination encountered in various parts of one and the same school building. 111 Report of the County Medical Officer—Education. In the four schools selected by Dr. Macdonald the vision of children from 4 to 7 years of age was tested by means of a Cohn's " E " specially prepared for this enquiry. The usual method of examination, in which the child holds his own card so that the limbs of the " E " point in the same direction as those on the test card 6 metres distant, was very soon abandoned, as the response of the younger children was naturally slow, owing to the complex mental processes involved. This was the case even when the teachers gave the children a few lessons beforehand. A simpler method, where the child shows by arm movements the direction required, was substituted except in one school, in which the head teacher gave instruction concerning the " E " in the course of the educational regime. The children, after drawing the " E," cut it out and pasted it on a piece of brown paper, and they then, being thoroughly familiar with it, responded to the test with singular rapidity, treating it throughout as part of a game. During the examination the rapid onset of fatigue in young children was well observed. After seeing one or two of the letters the child's attention wandered, and with the exception of the school just mentioned, resort was necessary to a stimulus in the shape of a brightly coloured sweetmeat. It was found also that if each letter was isolated from the others on the card the child responded much more readily. Accordingly a square hole admitting only one E at a time was cut in a piece of thick brown paper, which was held over the card and moved from one sized E to the next. By this means of concentrating attention a child who at first found difficulty at 6/9 could be brought to see 6/6. The children were found to respond with much greater readiness during the morning than during the afternoon session, when they were duller and more listless, and afternoon sessions for the purposes of this investigation were as far as possible abandoned. The test was carried out in the brightest daylight available as measured by the lumeter. The remarkable differences in daylight illumination in various parts of the same school were in some cases rather startling. In one school the room where the vision test was carried out was illuminated to the degree of 70 foot candles, whereas the degree of illumination in the greater part of the hall was one foot candle power, and only in one or two bright spots did it rise to three. The degree of daylight illumination should have been at least 30 foot candles. The accuracy of the examination was verified afterwards by subjecting those children whose vision was found to be 6/12 or worse to a retinoscopic examination under a mydriatic. Five children did not attend for this further examination for the reason that three had obtained spectacles and two had left the district. Ten children were found to have five or more dioptres of hypermetropia, one child aged 7 having seven dioptres in the vertical diameter and eleven dioptres in the horizontal. It is interesting to note that the vision of this child was 6/9; she had a slight convergent squint. One child aged 56/12 was found suffering from high myopia, and was recommended for a myopia class. Squint was present in two per cent. of the children examined. The result of retinoscopic examination of 37 children with defective vision was as follows:— Ennnetropia, 1; hypermetropia, 13 ; hypermetropic astigmatism, 15 ; myopia, 0; myopic astigmatism, 4: mixed astigmatism, 3: irregular cornea (due to old corneal ulcers), one case. The following tables analyse the results obtained from the examination of 410 girls and 393 boys:— Age. Total. Vision. 6/18 & less 6/12 6/9 6/6 Other Cases. 4 7 — — 1 [l.i.s.] 5 41/14 31 1 — 7 23 — 5 65 3 — 6 55 61/2 68 — — 9 56 6 108 6 2 9 86 61/2 62 — 1 55 — 7 48 — — 3 [1 alt. squint] 45 — 74 21 — — 1 19 410 10 3 42 344 11 Good 6/6 84% Fair6/9 and 6/12 11% Bad 6/12 3% Amb =Amblyopio. R.I.S.—Right internal strabismus. L.I.S.=Left internal strabismus. Visual acuity— Girls. 112 Annual Report of the London County Council, 1913. Age. Total. Vision. 6/18 and less. 6/12 6/9 6/6 Other Cases, 4 13 — 2 11 — 41/2 28 — — 5 21 6 79 2 [1 alt. squint] — 9 67 51/2 78 3 [1 alt. squint] — 4 70 6 90 2 [1 alt. squint] 1 8 77 61/2 51 3 1 — 47 — 7 24 — — 2 22 — 30 — — 6 23 Totals 393 10 2 36 338 7 Visual acuity— Boys. Good 6/686 % Fair 6/6 and 6/9 10% Bad 6/18 and less 3 % Amb.=Amblyopic. R I.S.=Right internal strabismus. L.I.S.=Left internal strabismus. Dr. Macdonald's results are based upon rather small numbers, but they tend to show that it is possible to demonstrate by special methods of investigation a very much higher proportion of normal visual acuity in infant children than is obtained in the ordinary routine inspections in the case of even the oldest age group, i.e., 84 per cent. girls and 86 per cent. boys in entrants, as against 43.8 per cent. girls and 51.18 per cent. boys in the older age group, and further that the cases of serious visual defect are much rarer amongst infants than amongst older scholars. It is probable, however, that if all the children had been tested under a mydriatic it would have been found that a much larger proportion of the infants had abnormal conditions of the eyeball. The power of overcoming hypermetropic defects possessed by the very young eye in virtue of the extraordinary elasticity of the crystalline lens is well known, and is well demonstrated by the case recorded by Dr. Macdonald in which the child was able under exceptional stimulus to attain a visual acuity of 6/9 in spite of the fact that it possessed such a very grave defect as 7 dioptres of hypermetropia in one diameter and 11 dioptres in another. In regard to the difficulties produced by the necessarily rough results which are given by the tests of visual acuity which it is possible to use in school inspection, Dr. Cowell reports the frequency in his experience with which masked or latent defect is recorded during school inspections in children suffering from passing illness. Such children when in their usual health readily pass the tests, but after an attack of influenza or similar illness are temporarily incapable of reading the smaller denominations of type. Comparing boys with girls as tested with the Snellen types it is seen that the vision of boys is considerably better than that of girls, and the difference is more marked at the higher age. It has been frequently pointed out that the reason for the larger percentage incidence of defective vision in girls, particularly at older ages, is very probably due to the less hygienic conditions of training in respect to vision to which 'girls are subjected both at school and at home. A more detailed analysis is given of the vision of 5,843 of the 13,179 cases of children aged 12 in class 3 (vision 6/12 or worse in either or both eyes). The analysis relates to children aged 12 (i.e., born in 1901) examined during the first term of the year in the schools in the Boroughs of Hampstead, Holborn, Islington, City of London, Stepney, Shoreditch, Bermondsey, Lambeth, Wandsworth, Camberwell, Deptford, Greenwich, Lewisham and Woolwich. A comparison between the two eyes shows that it only rarely occurs that there is a great difference between the visual acuity of either eye taken separately. The visual acuity of the right eye is greater than the left in a few more instances than those in which the left proved to be the better eye. Of the 2,731 boys whose vision was analysed the vision was found to be better than in the right eye in 2,040 cases and in the left eye in 2,009 cases. Both eyes were better than in 1,683 cases. Among girls the corresponding figures for the 3,112 cases analysed were, right eye, 2,355 ; left eye, 2,289 ; both eyes, 1,991. The difference between the vision in the two eyes in individual cases is shown from the following summary of vision of these 2,731 boys and 3,112 girls. Both eyes alike. Right eye worse. Left eye worse. Boys 1,032 (37.8 per cent.) 846 (31.0 per cent.) 853 (31.2 per cent.) Girls 1,371 (44.1 per cent.) 810 (26.0 per cent.) 931 (29.9 per cent.) 113 Report of the County Medical Officer—Education. The following table shows the analysis of the vision of those 5,843 children, giving the number of cases of (6/6 or 6/9) 6/18,6/24 etc., in the left eye, where the right eye is (6/6 or 6/9) (6/ 12 or 6/18) etc. Right Eye. Left Eye (6/6 or 6/9) (6/6 or 6/9) 6/ 12 6/ 18 6/ 24 6/ 36 6/ 60 Worse than 6/ 60 Total. Boys 219 150 68 63 42 21 563 (6/6 or 6/9) Girls 244 134 71 68 22 14 553 6/12 Boys 241 431 89- 31 27 7 3 829 Girls 228 609 133 43 23 9 5 1,050 6/18 Boys 118 120 315 62 19 10 4 648 Girls 103 124 416 67 25 13 4 752 6/60 Boys 63 47 54 156 24 3 3 350 Girls 58 32 62 169 29 12 2 364 6/36 Boys 41 29 23 20 100 5 3 224 Girls 44 19 31 33 137 7 3 274 6/60 Boys 33 11 7 11 8 29 — 99 Girls 18 8 6 4 13 36 3 88 Worse than 6/60 Boys 12 2 4 — 2 — 1 21 Girls 10 6 4 4 — 3 4 31 Total Boys 508 859 642 348 243 96 35 2,731 Girls 461 1,042 786 391 295 102 35 3,112 Of the 13,179 children aged 12 years, 925 were noted as wearing glasses. The vision of these children has been separately tabulated and divided into two classes ; (1) cases where the school doctor considered that the glasses effected all the improvement that was possible and where there was, consequently, no need for further treatment, and (2) cases where the glasses were unsuitable and the child was referred for treatment to remedy the deficiency in vision. (1) Children wearing spectacles which it was considered could not be improved upon. (2) Children wearing unsuitable spectacles. Right Eye. Left Eye. Right Eye. Left Eye. 6/16 6/9 6/12 Worse than 6/12 Total 6/6 6/9 6/12 Worse than 6/12 Total 6/6 Boys 37 3 3 13 56 6/6 — — — 4 4 Girls 32 7 5 7 51 — — — 4 4 6/9 Boys 3 40 22 11 76 6/9 — 6 — 10 16 Girls 8 67 17 28 120 — 1 2 15 18 6/12 Boys 2 13 45 18 78 — — 3 5 7 15 Girls 2 15 61 18 96 6/12 — 2 10 12 24 Worse then 6/12 Boys 7 10 14 49 80 Worse than 2 11 13 62 88 Girls 7 15 21 64 107 6/12 — 9 11 72 92 Total Boys Girls 49 49 66 104 84 104 91 117 290 374 Total 2 20 12 18 23 83 103 123 138 23610 114 Annual Report of the London County Council, 1913. From the foregoing it will be seen that of 925 children wearing spectacles, 664, or 72 per cent., had glasses which apparently remedied the defect as far as possible, and 261, or 28 per cent., had glasses which could be improved upon. Of those with suitable spectacles, the glasses made the vision equal to normal in 69 instances ; 128 had fair sight (i.e., not worse than 6/12 in one or both eyes), 185 had poor sight (i.e., 6/12 in the poorer eye), and 282 (42.5 per cent.) had bad sight. If a comparison be made between children aged 12 wearing glasses deemed to be suitable, and all children of that age whether wearing spectacles or not, the following result is obtained:— No. of cases. Sight 6/6 in both eyes. Sight 6/9 in either or both eyes. Sight 6/12 or worse in either or both eyes. Children with suitable spoctaclea 664 69 (10.4%) 128 (19.3%) 467 (70.3%) All children 54,458 25,826 (47.4%) 15,453 (28.4%) 13,179 (24.2%) Among 261 children wearing glasses considered unsuitable and who were referred for further treatment, none could with the aid of the spectacles read with each eye the 6 type at six metres, only 7 could read the 9 type at 6 metres, and 22 the 12 type at 6 metres ; the remaining 2-32 failed to read the 12 metre type at 6 metres with both eyes (tested separately). External eye diseases. In the schedule of the Board of Education the term " external eye disease includes blepharitis, conjunctivitis, diseases of cornea and lens, muscular defects (squints, nystagmus, twitchings), etc. During the year 1913, 4,038 cases of external eye disease wore found and noted for treatment, as shown in the following summary (details as to the cases in each borough will bo found in the Appendices III to V). No. of children examined. Cases of oxternal eye disease. Cases of eye disease referred for treatment Entrants. Boys 40,017, 1,821 4.5% 1,099 2.7% „ Girls 39,603 1,842 4.7% 1,070 2.7% 8-9 (i.e., children born in 1905) Boys 31,643 1,228 3.9% 550 17.% Girls 31,257 1,287 4.1% 544 1.7% 12 (i.e., children born in 1901) Boys 27,143 914 3.4% 382 1.4% Girls 27,495 996 3.6% 393 1.4% Cases of external eye disease are more prevalent among infants, and the prevalence decreases with age. There appears to be a slightly higher incidence among girls, but if only the severer cases (i.e., those referred for treatment) are considered, the incidence on boys and girls is practically the same. The records show how the numbers of external eye cases are made up, and an anatysis has been made of the cases reported among children examined in the boroughs of Islington, Hampstead and Shoreditch, which taken together are fairly representative districts, and comprise about one-ninth of the London school children examined. Entrants. 8-9 Leavers. Boys. Girls. Boys. Girls. Boys. Girls. No. of children examined 4,041 4,179 3,646 3,703 3,302 3,177 No. of cases of eye disease 242 241 167 216 170 169 „ „ „ for treatment 170 165 79 97 97 74 Cases of Blepharitis 56 64 46 58 42 55 „ ,, „ for treatment 40 47 29 40 23 30 Cases of Conjunctivitis 31 21 18 24 15 21 „ „ for treatment 20 13 8 16 9 12 Cases of Squint 101 94 72 70 72 46 „ „ for treatment 72 64 26 34 47 20 Cases of Ophthalmia 19 17 7 9 6 8 ,, „ for treatment 19 17 5 9 6 6 Opacities noted 17 14 9 16 17 24 „ „ for treatment 5 1 1 - 3 - 115 Report of the County Medical Officer—Education. The cases of squint among infants form 40.4 per cent. of " external eye diseases," the percentage is 37.1 among children aged 8-9, and it falls to 34.8 among leavers. There is a heavier incidence on boys in each age-group. Blepharitis accounts for 24.8 per cent. of eye disease among entrants, 21.5 per cent. among children of the 8-9 age group and 28.6 per cent. among leavers. Conjunctivitis forms about 10.8 per cent, of the eye diseases in each of the three age groups. Cases of ophthalmia numbered 66 in these three boroughs, the majority of them being among the entrants ; other eye diseases were noted in 136 cases, forming 11.3 of the eye diseases in these boroughs. These cases include keratitis, iritis, ptosis, and cases of epiphora, severe eye strain, etc. Keratitis, or corneal ulcer, was reported in 237 cases among school children inspected in London, including special and urgent cases. Of these cases, 13 were reported as being interstitial keratitis, the majority of these cases being urgent cases specially selected because of some evidence of specific disease. The figures for the inflammatory conditions included under the heading of external eye diseases cannot be taken as in any way representing the total incidence of these diseases in the elementary school population. Such conditions being often exceedingly painful, the children are out of school, and do not, therefore, come under the notice of the school doctor. Of children out of school for prolonged periods on account of ill-health 8'7 per cent. are returned as suffering from diseases of the eves. (See r p. 149). Dr. Slowan s report upon asymmetry of pupils ol the eyes. Dr. W. J. M. Slowan, who has made notes upon cases of inequality of the pupils of the eyes in 5,000 children inspected by him, points out that when the opposite sides of the body are critically compared, defects in symmetry may often be discovered, which would not have been detected by a cursory inspection. These defects are frequently found apart from any question of patholo- gical causation, and can only be regarded as personal peculiarities. Amongst these variations differences in the sizes of the pupils are found in a certain number of cases, and various theories have been advanced to account for these inequalities of size. Thus it has been suggested that in the case of irides of different colour the less pigmented eye will have a smaller pupil as more light will reach the retina. But as a matter of fact the irides are practically always found to be of the same colour in the case of unequal pupils, and in any case light falling on either retina stimulates the reflex pupillary centre for each eye equally. Again, it. has been suggested that the presence of glandular enlargements in the neck might, by acting on the sympathetic nerves, cause inequalities in the pupils, but nothing has been noted in this investigation that would support this theory. A considerable number of cases is met with in which there is apparently no reason for the occurrence of asymmetrical pupils, but as will be seen from the following analysis certain facts have been elicited. Thus while boys and girls appear to show this abnormality in equal proportions, it is found in three times as many blue eyed as brown eyed children, and the left pupil is larger than the right in the large majority of cases, when the condition of inequality exists. Unfortunately, Dr. Slowan does not give the proportions between brown and blue eyes amongst the normal children he examined. Among the 5,000 children examined by Dr. Slowan, inequality of the pupils of the eyes was observed in 107 cases, or 2.14 per cent. of the whole number. These cases have been analysed as follows:— Of 51 Boys the left pupil was larger than the right in 35 cases. Of 56 Girls do. do. 42 „ Of 107 children the iris was blue in 83 cases. Do. do. brown in 24 „ In 10 cases out of the 107 vision was defective, and in each case the left pupil was larger than the right. Eight of the children had blue, and 2 had brown eyes. Of the blue-eyed children in 6 cases the vision of the eye with the larger pupil was the more defective, in 2 cases the less defective. Among the brown-eyed children the proportions were equal Anthropometrioal measurements. Height and weight.—The heights and weights of children are ascertained at the time of the medical examination. In the annual report for 1912, the average heights and weights of children aged 8 and 12 in the elementary schools in London were given and compared with similar figures for the whole of England. The figures then published showed that at the earlier age the boys were both taller and heavier, while in the later age-group the girls had the advantage in both height and weight. The following table shows how the average weight increases with each addition of five centimetres to the stature. Age has little influence on the weight if the stature remains the same. A child of 5 years of age whose height is 105-110 centimetres will weigh nearly as much as a child of the same height at 8 years of age, and a child of 8 whose height is 125-130 c.m. will weigh but slightly less than a child of 12 years of age having the same height. In order to compare the weights of children in each of these groups of stature, differing by 5 centimetres, the average height of the children in the group is shown, as it is obvious that in a group of children of 110—115 c.m., all aged 5, the greater part of them would be nearer 110 c.m. than 115 c.m., and with children of 8, whose height is 105-110 c.m., the greater number would be nearer 110 c.m. than 105 c.m. The figures given relate to measurements of about 6,000 children in various London Boroughs, comprising 1,000 boys and 1,000 girls in each of the three age groups. It will be noticed that from 95 c.m. to 105 c.m. the weight increases by about 1 kilogram for each increase of 5 centimetres in height; from 105 c.m. to 125 c.m. the increase in weight is about 11/2kilograms per 5 c.m., and from 125 c.m. to 140 the increase is approximately 2 kilograms for an increase of 5 centimetres in stature. On the other hand an increase of age from 5 to 8 years, the height being constant, means an increase in weight of 1 kilogram. 23610 Q 2 116 Annual Report of the London County Council, 1913. The next table has been compiled from measurements of about 1,000 boys and 1,000 girls at each of three ages. The average height and weight of the children is shown in groups according to stature. The heights are in centimetres and the weights in kilograms. 95-100 c.m. 100-105 c.m. 105-110 c.m. 110-115 c.m. 115-120 c.m. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Boys aged 5 97.50 15.59 102.24 1653 106.85 17.70 111.60 1913 Girls „ 5 97 56 1516 102.24 16.24 106.98 17.50 111.68 18.79 Boys aged 8 107.76 19.14 112.50 20.33 117.03 21.77 Girls „ 8 107.36 18.54 112.37 20.03 117.05 21.46 120-125 c.m. 125-130 c.m. 130-135 c.m. 135-140 c.m. 140 -145 c.m. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Boys aged 8 12198 23.58 126.35 25.24 131.45 26.90 Girls „ 8 121.86 23.28 126.51 2515 Boys aged 12 122.74 25.04 127.40 27.06 13.218 28.89 137 03 30.97 141.66 33 38 Girls „ 12 122.65 24.85 127.43 26.31 132.24 28.39 136.94 30.32 141.84 32.71 Comparison of heights and weights in elementary and special schools. Table showing average heights and weights of boys and girls in ordinary Elementary Schools and in special Schools for the Mentally Defective. Age 7¾ Age 81/4 Age 3/4 Age 111/4 Age 113/4 Age 12 1/4 Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Ht. Wt. Boys Ordinary Schools 117.50 21.77 119.74 22.63 121.98 23.46 133.94 29.27 13614 30.57 138.34 31.87 Special Schools 115.29 21.69 116.55 21.90 118.93 22.90 130.18 28.47 131.75 29.09 133.51 30.17 Girls. Ordinary Schools 116.94 20.18 119.34 22.02 121.74 22.86 135.92 29.92 137.32 30.77 138.72 31.62 Special Schools 112.75 19.14 118.06 21.68 120.38 22.98 130.60 27.76 131.22 28.33 134.69 30.25 No. examined in Special Schools Boys 44 102 76 176 240 76 Girls 24 84 48 129 178 66 The above table shows a comparison of the heights and weights of mentally defective and ordinary children at 6 different ages, comprising two groups of three arranged about the two ages, 81/4 and 113/4f respectively. The average height and weight of children in ordinary schools was found in 1911 to be—At age 8: Boys, height, 118.62 c.m.; weight, 222 kilograms; Girls, height, 118.14 c.m.; weight, 21.6 kilograms. At age 113/4 (vide supra): Boys, height, 136.14 c.m.; weight, 30.57 kilograms ; Girls, height, 137.32 c.m. ; weight, 30 77 kilograms. Assuming that the growth is the same between the ages 73/4, 81/4 and 83/4, and again between 111/4 113/4 and 121/4, the average heights and weights at these ages have been calculated in the cases of ordinary school children. With regard to children in Special Schools the heights and weights of children from 71/2.8, 8-81/2, 81/2-9, 11-111/2, 111/2-12, and 12-121/2 have been grouped and the average height and weight for boys and girls in each group has been found. It is obvious that in examining a group of children reaching the age of 8 in a given year, those examined in the latter part of the year, as is the case in these schools, are more likely to be older (i.e. over 8) and in the group of children 71/2-8 there would be more nearer to 8 than to 71/2, so that the average age of these children is slightly over 73/4. In the same way in the age group 81/2-9 the average age is less than 83/4, The same applies in the age groups 11-111/2 and 12-121/2, the younger group being more than 111/4 and the older group less than 121/4. The heights and weights at these definite points 73/4, 83/4, 113/4 and 121/4 years have been calculated on the assumption that the rate of growth at each age is constant. It will be noticed that in each group the special school children were below the average of ordinary children in both height and weight,except girls aged 83/4 whose weight was a trifle greater, and in this one group the number of children was only 48. For the purposes of this table any cases in which the age was not definitely obtained in years and months have been neglected. Report of the County Medical Officer—Education, 117 Heights and weights in relationship to malnutrition. In cases recorded as suffering from malnutrition the growth of the child is retarded both in height and weight. The following table shows the average height and weight of children aged 5, 8, and 111/4-121/4 years of age who have been noted as suffering from malnutrition compared with school children generally. Age 5 Years. Ago 8 Years. Ago 113/4-121/2. Years. Ht. Wt. I* Ht. Wt. I* Ht. Wt. I* Average child 103.5 16.9 .163 118.4 21.9 .185 136.6 30.6 .224 Malnutrition case 97.28 13.14 .135 110.88 18.50 .167 129.86 25.11 .193 * I=Index of kilogram of Wt. per centimetre of Ht. It will be noticed that with the increase of age there is an increase of the kilogram per centimetre index for children recorded as suffering from malnutrition, to about the same extent as among ordinary children, though the average height and weight, and the kilogram per centimetre index are considerably lower among the former class at each age. The following table relates to 145 children aged 111/4-121/4 who were reported by the school doctor as requiring special investigation as to nutrition, and shows the relationship of weights and heights among elementary school children (boys and girls) generally, and among these ]45 children. Average Height. Average Weight. Average Height. Average Weight. Average Height. Average Weight. Average Height. Average Weight. Average Height. Average Weight. Average Height. Average Weight. c.m. k.g. c.m. k.g. c.m. k.g. c.m. k.g. c.m. k.g. c.m. k.g. Boys. All 122.74 25.04 127.40 27.06 132.18 28.89 137.03 30.97 141.66 33.38 „ Ill-nourished only 117.00 22.00 121.85 2300 126.95 25.33 131*56 26.78 136.70 27.90 142.33 29.77 Girls All 122.65 24.85 127.43 26.31 132.24 28.39 136.94 30.32 141.84 32.71 Ill-nourished only 117.00 22.50 121.50 22.84 126.80 23.40 131.80 25.80 137.20 27.75 141.30 320 Nose and Throat.—The presence of enlarged tonsils and adenoid growths was noted [as shown in the table below. As regards the column relating to treatment of these conditions, it should be noted that the removal is invariably effected in one operation, therefore the figures for treatment for the two defects are combined, a case of enlarged tonsils and adenoids being counted as one case in column 5. Cases of Enlarged Tonsils. Percentage of children examined. Adenoids. Percentage of children examined. Cases of Tonsils or Adenoids for treatment Per cent. of cases examined. Entrants Boys 5,478 13.7 3,863 9.7 3,316 8.3 „ Girls 5,218 13.2 3,102 7.8 2,945 7.4 8.9 Boys 3,523 11.1 2,122 6.7 1,942 6.1 „ Girls 4,011 12.8 1,831 59 1,956 6.3 Leavers. Boys 2,626 9.7 1,326 4.9 1,447 5.3 „ Girls 3,250 11.8 1,226 4.5 1,590 5.8 The percentage of cases of adenoids and enlarged tonsils declines in the higher age groups and to some extent this is due to the fact that many of the children of the older ages were treated for this complaint when younger. There appears to be a slightly higher incidence of adenoids amongst boys ; but, as regards enlarged tonsils, in the later age groups a larger proportion of girls were affected. Considerable variation is shown in the tables with regard to the percentages of children noted as suffering from these defects in various districts. In Holborn the proportion of cases noted as having enlarged tonsils was as high as 30 per cent. of the cases examined, but these no doubt included many very slight cases. The proportion of cases noted for treatment in this borough, 4.2 per cent., is below the general average for London. In comparing one district with another it is always difficult to eliminate the personal factor; for instance, one doctor will note slight degrees of enlargement of tonsils which another might ignore; the figures for treatment may be taken as a safer basis for comparison as the standards adopted are naturally more uniform. Other diseases of the nose such as rhinitis and mouth.breathing (when not associated with adenoids) were reported in 7,440 cases, or 3.8 per cent. of the cases examined, of these 1,180 were referred for treatment. The cases were more numerous among boys than among girls and the incidence highest on the lowest age group, decreasing as the age increased. 118 Annual Report of the London County Council, 1913. Dr. Wood's report upon the relation between nasal obstruction and superior protrusion. Two statements are often made concerning the incidence of protrusion of the upper incisor teeth. Firstly, that superior protrusion is commonly associated with adenoids; secondly, that where not so accompanied there is invariably a history of use of the " comforter " or the habit of thumb-sucking for a long period. With a view to testing these statements an enquiry was conducted bv Dr. F. T. H. Wood with the 11-12 year-old group of children medically inspected in 1913. Children showing superior protrusion were separated from the lists; in these nasal obstruction was noted as absent, present, or previously treated by the removal of adenoids; the state of nutrition was entered, and where possible the method of feeding during infancy and the use or non-use of a " comforter " was enquired into ; in addition, the presence or absence of superior protrusion in the parent attending the inspection was noted. A summary of the notes made shows that 1,175 children were inspected ; that 88 showed well-marked superior protrusion, and 172 showed it slightly—a total of 260 ; enquiry as to method of feeding and use of " comforter " was made in 47 of these 260. (a) In the 88 cases of marked superior protrusion there were 39 entered as "no adenoids," 38 as " adenoids," and 11 as " adenoids previously removed" ; while in the 915 cases without superior protrusion there were 825 " no adenoids," 52 " adenoids," and 38 " adenoids previously removed." In other words, the existence of nasal obstruction at some period was diagnosed in 55.7 per cent. of children with superior protrusion, as against 9.8 per cent, in children free from it, (b) In the second place of the 47 cases of superior protrusion where the mother was present and enquiry was made, 34 were mainly or wholly breast-fed, 13 were bottle-fed, and prolonged use of the " comforter " was admitted in 24. (c) Finally, 27 of these 47 mothers showed obvious superior protrusion themselves (and as the sex incidence is not very unequal, one may assume its existence in some of the fathers of the 20 cases where the mother was free.) The conclusions that may be tentatively put forward on this matter are:— 1. That superior protrusion is not always associated with adenoids. 2. That the statement as to the invariable use of the " comforter " in cases without adenoids is not strictly correct. 3. That the presence of superior protrusion in the parent is a more important predisposing factor than is commonly stated. 4. That some of the cases of nasal obstruction with associated superior protrusion submitted to the routine operation for adenoids are treated too late to relieve symptoms. Enlarged glands of the neck. Enlargement of the sub-maxillary or cervical glands was reported in 20,651, i.e. 10'5 per cent. of the cases examined, but only 708 of these cases were considered severe enough to require treatment. In Holborn the proportion of children reported as having enlarged glands was 97'4 of the number examined, but only one case was referred for treatment, a percentage considerably below the general average for London. The relationship of adenoid growths and other defects. The relationship between the presence of adenoid growths and defective hearing was commented upon in my report for 1912. The neglect of adenoids in early life affects the ability of the child,to profit to the full extent by the teaching in school, and renders the sufferer dull and backward generally. In the borough of Shoreditch the proportion of children aged 12 with defective hearing was found to be 65 per cent. of the number examined, The records of the children in this age-group in Shoreditch examined during the first term of 1913 have been analysed, and 116 (or about 7 per cent.) were reported to have adenoids. Of these 116, 53 had defective hearing; in 63 cases hearing was normal. Thus of the children with adenoid growths over 45 per cent had defective hearing against 6'5 per cent. of the children generally in Shoreditch schools. The presence of adenoids was noted in 53 cases of defective hearing out of a total of 98 cases of hearing defects ; 18 of the remaining children had enlarged tonsils, 18 suffered from otorrhea without either large tonsils or adenoids, and in 9 cases neither adenoids, large tonsils nor otorrhea was present to account for the defect. In Bermondsey, on the other hand, of 51 cases of defective hearing 30 were noted as having adenoids; there were in all 170 cases of adenoids reported among children aged 12, and the proportion of children with adenoids who had defective hearing was 18 per cent.; the cases of defective hearing generally form only 2-8 per cent, of those examined, so that the result of the comparison is about the same, and is shown as follows :— Percentage with detective hearing of all children inspected Percentage of children with defective hearing reported as suffering from Adenoid growths. Shoreditch 6.5 45.0 Bermondsey 2.8 18.0 In regard to the relation between adenoid growths or enlarged tonsils and the mental condition of children the following table gives the figures for the children in elementary schools, and similar figures relating to the children of the same age examined during the year in schools for the mentally deficient. Included in the table is a column showing " other diseases of nose, as many of the cases in this category are cases of old adenoids— No. examined Cases of Enlarged tonsils. Cases of adenoids. Tonsils and adenoids for treatment. Other diseasos of the nose. Other disoasos of nose for troatment. Children aged 12 B. 27,143 2,626 9.7% 1,323 4.9% 1,447 5.3% 1,059 3.9% 204 0.75% Elementary Schools G. 27,495 3,250 11.8% 1,226 4.5% 1,590 5.8% 801 2.9% 125 0.45% Children aged 12 B. 714 81 11.3% 61 8.5% 49 .6.9% 60 8.4% 7 10% Special Schools G. 505 66 13.1% 40 7.9% 33 6.5% 47 9.3% 8 1.6% Report of the County Medical Officer—Education. 119 It is seen that an appreciably higher proportion of mentally defective children suffer from complaints of this nature. Speech.—The information with regard to defects in speech is classed under two headings— stammering and other defects of speech. The number of cases of stammering noted during the year was 625, and 1,939 other defects of speech were reported. Among both boys and girls stammering was most frequently found in the oldest age group, whilst other defects of speech were most prevalent in the youngest group. Of the children examined infants showed a percentage of stammerers of 0.24 boys and 0.10 girls ; the intermediate age-group 0.44 boys and 0.15 girls, and leavers 0.88 boys and 0.24 girls. The total 625 (0.32 per cent. of the children examined) was made up of 473 boys and 152 girls, and the cases for treatment were 14 and 5 respectively. Stammering among boys appears to be three times as prevalent as among girls. Other defects of speech occurred in 1,939 cases (0.98 of the number examined), 1,135 were boys and 804 girls. 39 cases were referred for treatment, 25 boys and 14 girls. Mental condition.—The mental condition of children is classified in three groups—(1) normal, (2) dull or backward, (3) mentally defective. Entrants are not reported upon in regard to mental condition. The following are the figures relating to the two age-groups:— Class 1. Normal. Class 2. Dull or backward. Class 3. Mentally defective. Boys, 8-0 27,957 88.3% 3,591 11.4% 95 0.3% Girls „ 27,800 890% 3,367 10.7% 90 0.3% Boys, 2 24,002 88.4% 3,125 11.5% 16 0.1% Girls „ 23,728 86.3% 3,745 136% 22 0.1% The percentages relate to the total number examined in each age group. It must be remembered that children suffering from mental defect come under observation and are drafted into special schools as a rule before the intermediate age is reached. 88 per cent. of the children were classed as normal, and 118 per cent. as dull or backward. Islington showed a percentage of 64 backward children among leavers, but this is probably due to the standard adopted by the school doctor in estimating the mental condition. Heart and circulation.—The school doctors take special note of disease of the heart and give directions for the guidance of the teacher as to care in physical exercises, swimming, etc. A special note of this condition is also made when selecting children for school journeys and country excursions. During the year valvular lesions and other defects of the heart were reported in 4,336 cases (2.2 per cent. of the children examined). 533 of these cases (0.3 per cent. of those examined) were referred for treatment. It is further to be noted that children suffering from heart disease form a large group amongst those admitted to special schools for the physically defective, and that the most numerous group of children out of school for prolonged periods falls into this category. Antenna was noted in 6,076 instances (3.1 per cent. of the children examined) and the number of cases for treatment was 1,529 (0.8 per cent. of children examined). Heart Disease. Anaemia. Cases reported. Cases for treatment. Cases reported. Cases for treatment. Entrants. Boys 618 1.5% 62 0.2% 1,172 2.9% 280 0.7% „ Girls 639 1.6% 68 0.2% 1,038 2.6% 261 0.7% 8-9 Boys 699 2.2% 68 0.2% 1,022 3.2% 207 0.7% „ Girls 713 2.3% 89 0.3% 1,103 3.5% 243 0.8% Leavers. Boys 715 2.6% 105 0.4% 717 2.7% 217 0.8% „ Girls 952 3.5% 141 0.5% 1,024 3.7% 321 1.2% The incidence of heart disease rose from 1.5 per cent. among entrants to 3 per cent. among leavers, girls being more frequently affected than boys. Anaemic children were most common in the middle age group, as was noted also in last year's report, although the more pronounced cases were highest among the elder girls. Lungs.—Diseases of the lungs other than phthisis were reported in 9,951 cases (5.1 per cent. of the children examined). 2,630 (1.3 per cent. examined) were noted for treatment. The percentage was 6 9 among entrants and 3.8 in the other age-groups. The incidence on boys was slightly higher than on girls. Bronchitis is mainly responsible, and in the borough of Islington, where the cases have been analysed, this complaint accounts for 86 per cent. of the cases among the entrants having disease or defect of the lungs. Pneumonia and pleurisy, being acute conditions, are rarely discovered in children attending school, and asthma is comparatively rare, only seven cases being reported in the whole of the Islington schools (nearly 14,000 children examined). Nervous Diseases.—2,179 cases of nervous diseases were found (1.1 per cent of the children examined) and 377 of these (0.2 per cent of the examined) were recommended for treatment. Amongst entrants 0.8 per cent had nervous complaints, but in the older age-groups the percentage 120 Annual Report of the London County Council, 1913. was 13. Epilepsy, chorea, and paralysis were chiefly noted among the older children and infantile paralysis among the younger ones. Boys and girls were found to be equally affected in the two younger age-groups, but among the leavers the percentage was slightly higher among girls. In Hampstead, Islington and Shoreditch out of 22,048 children examined, 256 cases of nervous complaints were noted and 55 of these were referred for treatment, 37 of the 256 were cases of epilepsy (minor or major), 21 of chorea, 32 of paralysis, 3 of hemiplegia and 1 of paraplegia; the remaining 162 cases included such conditions as habit spasm, neuralgia, night terrors, etc. In scbool work occasionally a striking peculiarity is exhibited by certain children whose attempts at writing appear unintelligible until held before the mirror, when it is found that the reflection is perfectly legible. Such cases are reported from time to time in the public press and give rise to no little wonderment. The condition is one of considerable interest, both pedagogically and medically. It is associated with various forms of defect of speech and with certain nervous diseases; it is particularly frequent in certain types of mental defect and in the condition of lefthandeness Dr. McHattie's report on mirror writing. Dr. McHattie has investigated the frequency of occurrence of mirror writing in normal school children. He points out that this condition is to be frequently observed in persons suffering from certain disorders of the nervous system, e.g., hemiplegia, hysteria, locomotor ataxy, &c., and that it has been said to be not uncommon in normal persons. Elder (Ency. Med. viii., 123) places the percentage of mirror writing with the left hand amongst normal people over ten years of age as high as 1039 per cent., the proportion for females being 14.73, while that for males is only 339 per cent. In children under 15 years of age he gives the percentage as 3.63 for males, 2.06 for females. These figures he deduced from a study of only 461 persons of all ages. Dr. McHattie has examined the left hand writing of 1,240 children of ages ranging from seven years to 14 years, and discovered only seven instances which could be described as mirror writing. Of these seven cases one was that of a girl whose right hand had been partially disabled by an attack of infantile paralysis. Omitting this case; in which there existed an organic nervous lesion, the proportion among normal children was very small, being only 0.48 per cent. Of the 1,239 children 654 were boys, of whom two, or 0.3 per cent. were mirror writers, and 585 were girls, of whom four, or 0.68 per cent. wrote in this manner. While the proportion of those who wrote words (generally their names) backwards was thus very small, a comparatively large number, when made to write figures with their left hand, were found to reverse one or more of the figures from 2 to 7. Thus, of 501 boys tested in this way 11 or 219 per cent. reversed one or more figures, one of them reversed more than three of the figures from 2 to 7. Of 511 girls, no less than 27 reversed their figures, or 5.28 per cent., while seven of them reversed three or more of their figures. It is possible that further investigation may prove that the proportion of those reversing less familiar words would be larger than those reversing their own names. In no case in which figures were written with both right and left hand was there observed a reversal with the right hand. The following tables show the number of children examined in different standards and the number affected for words and figures. Children tested with words only. Standard 1 2 3 4 5 6 7 Total. Per cent. No. examined—Boys 92 78 131 120 105 70 58 654 Mirror Writers — — 1 1 — — — — .305 No. examined—Girls 103 85 79 79 82 45 113 586 Mirror Writers 4 — — — — — 1 5 .85 Children tested with figures as well as words. Standard 1 2 3 4 5 6 7 Total. Per cent. No. examined—Boys 64 45 112 98 85 55 42 501 Figures Reversed 4 — 3 3 1 — — 11 2.19 No. examined—'Girls 102 85 79 79 82 45 39 511 Figures Reversed 11 5 4 4 — 2 1 27 5.28 The annexed Diagrams A and B give reproductions of writing with the right and left hand of the seven children already mentioned. Diagram A.—M.L. Girl. Age 9. St. I.—Dull and backward child but improving after summer in open-air class. Writes well with right hand but reverses all words and figures with left. Reads reversed words easily. Given word to copy with left hand does so reversed and says it looks like copy. Diagram A. Diagram B. 121 Report of the County Medical Officer—Education. Diagram B. Case 1.—B.W. Girl. Age 13. St. VII.—Bright and intelligent girl. Reverses both words and figures with left hand. Figures 2 to 9 all reversed and written from right to left. Cunnot read reversed word (i.e. word written and then blotted). Can write correctly with left hand when set to do so. Case 2.—W.S. Boy. Age 13. St. IV.—Words reversed. Figures 2 to 7 written left to right the only ones reversed being 4 and 6. Case 3.—A.P. Girl. Age 7. St. I.—Words reversed but figures correct. Case 4.—L.P. Girl. Age 7. St. I.—Dull and backward. Very short time at school. Partial paralysis right arm and hand. Cannot write with right hand. Reverses with left. Case 5.—A.S. Boy. Age 10. St. III.—Reverses words. Figures 2 to 7 reversed except 4, 5 and 7, and written in order from right to left. Case 6.—F.C. Girl. Age 7. St. I.—Words reversed. Figures 2, 4 and 5 reversed and written from left to right. Cannot read reversed word. Cbpies word correctly with left hand but initial letter (word London) L is reversed. Ear disease and hearing.—Diseases or defects of the ear were reported in 4,724 cases (2.4 per cent. of the children examined) and 2,442 (1.2 per cent.) were referred for treatment. Otorrhea, otitis and deafness due to obstruction from cerumen are included in this class. Ear disease was slightly more prevalent among girls, and the highest incidence (2 6 per cent.) was amongst entrants. In Hampstead, Islington, and Shoreditch 551 cases were noted, 328 severe enough to need treatment, 389 of the cases in these Boroughs were cases of otorrhea and 46 were cases of otitis, the remaining 116 cases were probably principally cases of obstruction of the auditory meatus. The special attention of teachers was drawn to the necessity of reporting at once any case of suppurating ears coming to their knowledge so that treatment might at once be obtained. There is some difficulty in cases of ear discharge in getting the parents to persevere in taking the children for treatment. The disease in its chronic state is so protracted that the parents lose heart, and too frequently the children are allowed to lapse into a deplorable condition. The Council at the present time has under consideration the question as to the possibility of taking further steps in the direction of improving and facilitating the treatment of discharging ears. Dr. C. J. Thomas has made the following analysis of the results of following up 500 consecutive cases of discharging ears— (I.) Children reported as having been brought under treatment— No. Percentage of the Whole. At home or by private doctors 45 9 At treatment centres 114 23 At hospitals or dispensaries 169 34 Total brought under treatment 328 656 The results of treatment in the 328 cases as found on primary re-inspection were as follows- No. Percentage of the Whole. Satisfactory and complete 168 33.3 Treatment still continuing 105 21 Result not satisfactory 55 11 (II.) Children reported as not having received treatment— No. Percentage of the whole. Still requiring treatment 132 26.4 Discharge ceased 38 7.6 Deaths 2 .4 Total 172 34.4 (Of the children whose condition had not been found satisfactory at the first re-inspection 67 had been re-inspected a second time at a later date (six to nine months after the primary re-inspection) ; of these 45 had received attention and 22 were cured; 16 were still under treatment, and 7 were still unsatisfactory; 22 had still received no further attention, and of these 19 were still suffering ; while in three the discharge had spontaneously stopped.) With regard to the two deaths, one of the children is reported to have died of "ear and brain trouble," and the other of " abscess of the brain." Inquiries were made in regard to 103 of the cases reported as not having received treatment, and the following tabular statement compiled from the replies is exceedingly interesting as giving a picture of the difficulties to be overcome and the work to be performed in getting the necessary attention paid to children suffering from this and other ailments. It will be seen that 25 children had, in point of fact, received some kind of treatment, but that the school doctor had not been informed of this, while apart from these cases in which treatment had not been able to effect a cure, the chief causes of 23610 R 122 Annual Report of the London County Council, 1913. failure were refusal on the part of parents, or neglect or inability on their part to take advantage of opportunities offered or to persevere with treatment when once begun— Tabular statement of replies to enquiries concerning 103 cases reported as not having received treatment. Reason why treatment was not obtained. (1) Present position of cases. (2) Has now had treatment or is under treatment. Arrangements now made for treatment. Arrange men is now in hand. Parents refuse treatment. Said to have recovered. Away ill Left-— being traced. Left London. Council's scheme. Other treatment. Council's scheme. Other arrangements. Treated or under treatment at time of re-inspection, but statement not furnished to school medical officer Council's scheme 2 1 .. .. .. 1 .. .. .. .. .. Other treatment 23 2 13 1 3 1 .. 1 1 .. 1 Commenced treatment but lapsed before cured— Council's scheme 17 7 .. 2 .. 4 (*)3 l .. .. .. Other treatment 2 .. 1 .. .. .. 1 .. .. .. .. Arrangements for treatment made but failed to attend— Council's scheme 20 8 2 1 1 (†)6 1 .. .. 1 .. Other arrangements 7 3 1 .. 1 1 .. .. .. 1 .. Arrangements in hand at time of re-inspection 3 2 1 .. .. .. .. .. .. .. .. Away ill, measles 1 .. .. .. .. 1 .. .. .. .. .. Away in country 1 1 .. .. .. .. .. .. .. .. .. Hon. secretary, care committee, ill 1 .. 1 .. .. .. .. .. .. .. .. No secretary to care committee 2 .. .. .. .. 1 .. .. 1 .. .. Apparently not followed up by care committee .. (†)4 1 2 .. .. 1 .. .. .. .. .. Parents refuse treatment (¶)20 5 5 .. .. 3 (**)6 1 .. .. .. Total 103 30 26 4 5 19 11 3 2 2 1 (*) Two cases were referred to the special officer, care committee organisation. (†) One case was referred to Invalid Children's Aid Association. (†) One case was overlooked owing to confusion between two sisters. (¶) In one case there were special home difficulties. (**) Four cases were referred to the special officer, etc. Defective hearing.—Among younger children accurate testing of hearing is impracticable under school conditions, but in older children the whisper test is applied if there appears to be any sign of deafness. Defective hearing was noted in 3,429 children (1.7 per cent. of the number examined) and 1,233 cases were referred for treatment. Many of these cases are associated with adenoid growths. The older age group showed a higher percentage (2.3) of cases. Girls showed a slightly higher percentage than boys. Among leavers the proportion in Shoreditch was over 6 per cent. and in Bermondsey about 2.8 of those examined, while in Marylebone and Paddington it was 0.l and 0.4 per cent. Tuberculosis.—Phthisis was reported by the school doctors in 809 cases, 0.4 per cent. of the children examined, 393 being referred for treatment. In many of the cases the symptoms were slight, and under the conditions necessarily existing at school inspections, difficulty was experienced in coming to a definite diagnosis. The number of children notified under the Tuberculosis Regulations (B) by the school doctors during the year as suffering from tuberculosis was 161 boys and 161 girls with the pulmonary form of the disease, and 337 boys and 232 girls with other forms of tuberculosis. An examination of contacts is carried out in some districts by the school doctor, and particulars of these contact cases will be found under " special and urgent examinations. The incidence of this disease was highest among " leavers," though the severe cases were about evenly distributed among the 3 age groups. The percentage of cases is the same for boys and girls in each age group. Other forms of tuberculosis (including tuberculosis of bones and joints and tubercular glands) were found in 623 cases, 0.3 per cent. of the children examined. Symptoms were slightly more frequent among boys than among girls, but each age-group was equally affected. Rickets.—Under this head are classed all deformities definitely stated to be due to rickets. 4,212 cases (2.1 per cent. of the children examined) were reported, but only 246 cases were referred for treatment; many of the cases were children with some irremediable defect or condition due to past rickets. Naturally the infant group presented the largest percentage of cases, and the results of the disease were least frequently detected among the elder children. Boys were more frequently found affected than girls, the percentages being 3.6, 2.3, and 2.3 in the infants, middle age-group and leavers as compared with percentages of 2.0, 1.2, and 1.0 among girls. Deformities.—4,035 children with deformities were found i.e. 2 per cent, of the children examined, 737 cases were said to need treatment. The incidence was higher among boys in the 123 Report of the County Medical Officer—Education. earlier age-group and among girls at a later age. The higher incidence among infant boys is probably due in a large measure to deformities following rickets in earlier life, though no history of rickets was noted, while the greater presence of lateral curvature of the spine accounts for the excess of deformities in older girls. In Hampstead, Islington, and Shoreditch, 287 children with deformities were noted, and 63 recommended for treatment. Lateral curvature of the spine accounted for 124 of these cases, occurring chiefly among elder girls. Lordosis (hollow back) occurred in 15 cases and kyphosis (round shoulders) in 18 cases. Here again the elder girls were more frequently affected. 9 children were reported to be club footed. Torticollis or wryneck was noted in 8 cases in these three boroughs. Infectious diseases.—Under the head of infectious diseases are included cases of notifiable disease, measles, whooping cough and chicken pox; but impetigo, scabies, ringworm and other infectious skin diseases are not included. It is comparatively rare for the acute diseases to be detected at routine medical inspections but some cases of measles, chicken pox or whooping cough and a few mild cases of scarlet fever are found on these occasions by the school doctor. An examination is made of contacts of cases of scarlet fever and diphtheria, which are reported to the head teacher under the provisions of the Public Health London Act, 1891. The cases of infectious disease found by the school doctors on routine visits numbered 323 (0.16 per cent. of the children examined). Of the 323 cases 232 occurred amongst the infants. Skin defects and diseases.—The term " defect " includes the presence of vermin or nits on the head or body of a child. 10,901 such cases were found by the doctors on their routine visits. Of these cases 1,875 occurred among boys and 9,026 among girls, the proportion of cases of nits present being as might be expected much greater amongst girls than amongst boys. The defects among boys declined as the age increased, whereas with girls the reverse was the case, 7.6 per cent. occurring among entrant girls and 9 5 per cent. among leavers. It must be remembered that notice of the medical inspection is given to the parents and many of the children come to school specially prepared for the occasion. The Council's nurses visit the schools under the scheme for dealing with verminous children, and as no notice is given of these visits, a much better notion of the ordinary conditions in regard to cleanliness is to be obtained from their reports a summary of which appears on page 86. Skin diseases.—These include ringworm, impetigo, and scabies in addition to all non-contagious skin complaints. 3,733 children were found with skin diseases and 1,559 were referred for treatment. The distribution was as follows:— Cases found. Percentage of hildren examined. c Cases for treatment. Percentage of children examined. Entrants 1,739 2.2 802 10 Children age 8 1,112 1.8 425 .7 Leavers 882 1.6 332 .6 Total 3,733 1.9 1,559 .8 With increasing age there is a steady decline in the number of cases of skin disease. Boys and girls were equally affected. In Islington, Hampstead and Shoreditch the school doctors found 642 children with skin diseases, 301 of whom were referred for treatment. On analysing these cases the following information is obtained:— Total. Entrants. Age 8. Leavers. No. of cases of skin disease 642 (301) 263 (144) 204 (94) 175 (63) „ „ ringworm 58 (26) 28 (14) 14 (7) 16 (5) „ „ impetigo 150 (110) 66 (55) 52 (34) 32 (21) „ „ eczema 112 (44) 64 (31) 24 (7) 24 (6) „ „ scabies 15 (8) 5 (2) 7 (4) 3 (2) The figures in brackets represent cases recommended for treatment. Over 60 per cent. of the severer cases are accounted for by the four complaints enumerated above. In addition to these there were 22 (3) cases of urticaria, 24 (4) of psoriasis, 10 (3) of herpes, 19 (6) prurigo, 22 (4) of seborrhea, 15 (1) ichthyosis. The remainder included cases of dermatitis, xerodermia, and other minor defects ; 15 cases of alopecia were noted. Malnutrition.—Children marked as " nutrition 4"—i.e., badly nourished children—are invariably referred for treatment, and in addition certain cases in class 3 are kept under observation. During the year, 1,210 children were regarded as suffering from malnutrition and 1,178 of them were recommended for treatment. The cases were least common amongst children of the middle age-group. Among entrants 231 children were allocated to class 4 and 460 were noted as malnutrition cases, 50 per cent. of the latter Deing class 3. Among children aged 8-9 years, 185 were grouped in class 4, and 278 were noted as cases of malnutrition, so that only 33 per cent. were class 3 cases. The investigation of cases of malnutrition is of great medical importance. It has been the rule throughout the year to initiate a special enquiry by school doctor and care committee respectively in every case in which the nutrition is returned as 4 in the medical record. An analysis of 885 cases in which the enquiries are complete has been made by Dr. C. J. Thomas, and is to be found in a following section, where special attention has been directed to the history of cases in which tuberculosis is 23610 R 2 124 Annual Report of the London County Council, 1913. associated with malnutrition, pp. 50-55. Several of the school doctors have pursued independent investigations into the causation and concomitants of malnutrition ; see, for instance, Dr. Palgrave on faulty home management, p. 30 ; Dr. Norman on the comparison of breast fed and bottle fed children, p. 31; and Dr. Mabel Russell on the sufficiency of sleep, p. 31. Dr. Leipoldt, too, has investigated the usefulness of certain signs in the recognition of cases of malnutrition, and in view of its importance extended reference will now be made to this subject. There is a class of child vaguely recognised by all who have had experience in school inspection, which will be described by one observer as "congenitally debilitated," by another as " the nervous type," and by yet another as presenting the " pretubercular condition." The children so described, often exceptionally intelligent, and not infrequently of Striking beauty, are constantly brought to notice by reason of their frequent absences from school, their tendency to suffer from manifold ailments, particularly night terrors and chorea, their inability to withstand the slightest pressure with their lessons and the frequency with which they eventually fall victims to tuberculosis. The indefiniteness of the characteristics ascribed to this class of children has, however, led many observers to express doubts as to the reality of their existence, and even to those who pinned their belief upon the existence of such a type of child, recognition has hitherto been much easier than description. Any common physical sign or stigma which will aid in giving definition to this class of child is therefore to be looked upon as exceedingly valuable. Dr. Leipoldt's inve etigation into the presence of Stiller's signs in caees of malnutrition. Dr. C. Louis Leipoldt has investigated in this connection the occurrence in school children, suffering from malnutrition, of certain signs first described by Professor Stiller, of Buda Pesth. Dr. Leipoldt's observations appear to be of sufficient importance to warrant their being published in detail. He points out that every school doctor, in his routine examination of children in the various age-groups, comes across a certain percentage of children who, while not obviously suffering from any ' gross physical defect that calls for treatment, arc yet below a certain standard of health and nutrition which he has in mind as the normal. At present there is no criterion which will serve as a means of properly classifying such children. In 1898 Professor Berthold Stiller, of Budapesth, published the results of an investigation which he had made into the incidence of visceral displacements in patients under his charge. His data led him to the conclusion that a fairly constant phenomenon in these patients was the occurrence of a skeletal abnormality, a floating tenth rib. He further came to the conclusion that this " stigma of physical degeneration" is found not only in patients with visceroptosis, but also in those who present the "habitus phthisicus" of Rokitanski. In his book on the subject, published in 1907, Stiller definitely commits himself to the view that those who present the various typical signs, which may be conveniently styled " Stiller's syndrome," are sufferers from a specific congenital asthenia or habitus asthenicus, to which he has given the name " Asthenia universalis congenita." Before proceeding further it is necessary to describe this syndrome and to make clear the significance which Professor Stiller attaches to certain variations to which reference must be made. Normally, the tenth rib is joined to the sternum by its costal cartilage, which runs smoothly upward to join the costal cartilage of the much more oblique ninth rib. The eleventh and twelfth ribs are not so joined, but their anterior ends are free, and can easily be felt by palpating the hypochondriac regions below the costal margin. The point of the tenth rib, corresponding with the prolongation downwards of the line drawn through the nipple, can usually be easily felt and its junction with the ninth costal cartilage easily traced. In a very small percentage of persons, however, the tenth rib is loose, or floating, corresponding, so far as its want of anterior attachment is concerned, with the eleventh and twelfth ribs. This is the " costa decima fluctuans " of Stiller, which he regards as a conclusive sign of the habitus asthenicus. In a much larger percentage of cases it is not floating, but is fairly moveable, its junction to the ninth costal cartilage being represented merely by a thin strand of cartilage which allows its point to be pushed upwards or downwards by the examiner. This is the " sigma costale " of Stiller, by whom it is regarded as strong accessory proof of the existence of the habitus asthenicus, its value as a clinical sign, according to Stiller, depending largely upon the range and extent of its moveableness. Stiller bases his supposition that asthenia congenita universalis is a well-marked clinical entity upon a series of other signs to which attention had already been directed by older observers. In fact, the description which Stiller gives of his typical " habitus asthenicus " is one closely resembling that already given by Rokitanski. " Thin boned, a gracile skeletal system, a narrow and shallow thorax with wide intercostal spaces, and a sharp epigastric angle, weakly developed musculature, transparent dry skin, well-marked reflexes—this constitutes the habitus asthenicus." If the descriptions given by various authors be combined, the following picture, which very fairly details the main features observable in the so-called " pretubercular" child, is obtained.—Thin, slight figure, with marked slenderness of the limbs, long, slender hands and feet ; narrow, oval face, with a proportionately greater development of the cranium than of the facial bones; smooth, transparent, dry skin, with the surface veins well-marked on arms, thorax, hands, feet, and temples; long eyelashes, and generally long smooth hair, with, in many cases, well-grown downy hair on the arms and back; markedly pale complexion, without definite anaemia ; slight cardiac signs, such as respiratory irregularity, basal and apical bruits after exertion, and intermittent pulse; relatively long, shallow and narrow thorax ; an abdomen small in proportion to the thorax ; a sharp epigastric angle ; a short and stiffened first costal cartilage (Freund's sign), and a marked flattening of the angulus Ludovici (Rothschild's sign) ; costa decima fluctuans or sigma costale (Stiller's sign); deficient chest expansion and limited pulmonary capacity ; tendency to atony of the stomach and intestines, leading eventually to dyspepsia, habitual constipation, and intestinal stasis, with gradual pigmentary changes in the skin ; tendency to glandular enlargement, and physiological stigmata of physical degeneration, such as achylia gastrica or orthostatic albuminuria ; want of co-ordination, slight choreic or athetotic movements, nystagmus, and twitching of the facial muscles; markedly excitable, neurasthenic temperament, accompanied with considerable variations in the blood pressure ; increased knee and ankle reflexes, 125 Report of the County Medical Officer—Education. with, in advanced cases, a tendency towards ankle and patellar clonus ; special liability to fatigue, both mental and physical, which results in weakness of the muscles of support, leading to scoliosis and flat feet. It is easy to see that this description fits, so far as certain of its general particulars are concerned, almost every case of malnutrition or of " pretuberculosis," just as it fits, also, the condition which Lane has described under the name of " chronic intestinal stasis." It is possible that the cases of the latter condition, as seen in children, are primarily cases of asthenia congenita, in which the pigmentation, the intestinal atony, the slight thyroid enlargement, the gastric disturbances and the subjective signs are merely the result of the original congenital diathesis. A consideration of Professor Stiller's views led Dr. Leipoldt to pay some attention at routine inspections to the question of the costa decima fluctuas, more especially of late, when its value as a clinical sign of the existence of the asthenic habitus has become clearer. In most children it is comparatively easy to demonstrate the sign when it exists. The point of the tenth rib is usually external to the nipple line prolonged downwards. In a normal rib this point cannot be felt as a sharp end, but is palpated as a smooth cartilaginous prolongation of the rib that joins evenly with the cartilage of the more oblique ninth rib. This junction, normally, is similar to that of the other ribs, only differing from the upper costal cartilages in the fact that the cartilage of the tenth rib is thinner and a trifle more elastic. In a normal child, however, the tenth rib cannot at its end be pushed below or above the cartilage of the ninth. In a fair percentage of cases there is a varying degree of downward and upward movement on palpation ; these form the first group of cases and are of comparatively little clinical significance. When the point of the tenth rib can be felt, and its connection with the ninth costal cartilage made out as a strand which permits of more or less free up and down movement on pressing it with the fingers, the case belongs to the second group, and the sigma costale is really present, though its degree has still to be estimated. Practice and experience can alone enable the examiner to do this. In the third, and much rarer class of cases, the point of the tenth rib can be grasped between the fingers, and little or no connecting strand of cartilage or ligament can be made out; this is the costa decima fluctuans in its absolute sense, and is a very valuable sign of the asthenic condition. In such cases there is an inclination to take the tenth rib for the eleventh. The only way to avoid this mistake, especially when the twelfth rib, as sometimes is the case, is rudimentary or absent, is carefully to count the ribs first from above downwards and then from below upwards. As the children in which both the sigma costale and the floating tenth rib occur are generally thin, with lax abdominal parietes, and not very resistant musculature, the actual palpation of the costal margins presents little difficulty if care be taken to carry it out gently, so as not to irritate the skin and cause the child, involuntarily, to contract the latissimus dorsi and oblique muscles. In a few cases the examination must be carried out with the child lying down, but generally such a procedure is necessary only in fat, well nourished children, in whom the examination is nearly always negative so far as the existence of Stiller's sign is concerned. In most cases in which the existence of this rib abnormality has been shown, Dr. Leipoldt has taken the chest measurement, and, where the parent has been present, made enquiry into the family history to find out, if possible, whether there existed any " hereditary tubercular predisposition," or whether any of the family suffered from gastric or nervous complaints. As the record card did not afford space for all the data elicited by such examination, additional notes were also made, only the chest measurement and any findings as to pulmonary, cardiac, or general conditions being noted on the card. In order to have some definite means of classification, Dr. Leipoldt adopted two record marks—" S.S (Stiller's sign) in cases in which the tenth rib is absolutely free, and S.C.I or S.C.2 (sigma costale) when its mobility was marked in greater or less degree. It is interesting to study the facts elicited by enquiry into the family history and the subsequent more careful examination of the child in cases in which the sign was found. The following cases will illustrate this. J.C. aet. 11. Condition, pale, thin faced, slight, overgrown boy. Height, 139.2 cm. ; weight, 28 5 kilograms ; chest measurement, 68 cm., expiration, 72 cm. inspiration. Cardiac condition normal. S.C.2 present. Knee reflexes much increased; no clonus, palpebral or finger tremor. Thyroid normal. Teeth, class 2. Two small hard glands under left sterno-mastoid ; no waxy discharge in ears ; head clean. The boy is said to be " excessively fidgety in school." On his mother's side there is a strong family history of consumption (uncle, grandmother, two aunts, and two cousins said to have died of pulmonary phthisis); on his father's side some family history of " paralysis." Two brothers and one sister suffer from " nervousness and stomach complaints " ; one from lung trouble for which he is being treated at Mount Vernon Hospital. The boy himself is stated by the mother to be healthy and has had no infectious disease, but suffers from headaches (there is no sign of astigmatism), dyspepsia, and nervousness ; has suffered from incontinence. J.W. aet. 11. No physical defect found. S.C.2. Height, 132 cm. ; weight, 28 kilograms ; chest measurement, 61 cm. expiration, 67 cm. inspiration. Knee jerks normal. On mother's side strong family history of consumption ; on father's side, one uncle suffering from the disease. One aunt on father's side operated upon for " floating kidney." The boy shows at present no chest or gastric signs, but is a highly strung, nervous lad. Kidneys are not palpable. A.W. aet. 11. Height, 139 cm. ; weight, 30 kilograms ; chest measurement, expiration 63 cm., inspiration 70 cm. Furred tongue ; pallor. Teeth, class 2 ; slight tenderness on deep pressure in right iliac fossa. Cardiac condition normal. Expiration sound at both apices prolonged but not rough. Inguinal and axillary glands markedly palpable ; one enlarged cervical gland in left posterior triangle. Boy has frequent attacks of sick " headache " ; vision is 6/9 ; slight astigmatism is probably present (treatment card given). Father suffers from " bronchitis and asthma " ; mother is healthy; one uncle on mother's side suffers from consumption; one aunt on father's side died in hospital after" an operation on her stomach." The boy's knee reflexes are brisk, but he shows no other signs. 126 Annual Report of the London County Council, 1913. Dr. Leipoldt in his earlier routine inspections, in the Deptford and Bermondsey schools, merely noted, privately, in his note books, whether the floating tenth rib was present, without at the same time stating whether the child showed evidence of the status asthenicus or not. The only record for these earlier cases he, therefore, possesses is the entry " S.S." (Stiller's signs) occurring among his other notes. Since 1912, however, he has kept more careful notes, usually with the addition of some indication as to the degree of mobility of the rib, the weight, height, chest circumference, colour, and general state of the child. Taking the Deptford and Bermondsey schools, on classifying 500 children examined at various routine inspections, the existence of Stiller's sign was recorded in 68 cases. As no record was kept of the degree in which the tenth rib was moveable in these cases no attempt is made to adopt any refinements of classification here. Some of the points of interest mentioned in the notes are, however, available. Number of boys examined, 250. S.S., present 27. Per cent. 10.8. Number of girls „ 250. „ „ 41. „ 164. Total number „ 500. „ „ 68. „ 136. Boys.—Of those who presented Stiller's sign every one was below the average weight in relation to his height. Chest measurements are not available. Eighteen were stated to be " pale—no definite anæemia;" in three of these well-marked basal murmurs developed after exertion, such as jumping or running about the room. Fifteen had " prolonged expiratory murmur at right apex ; no dulness ; no other signs." Ten had oral sepsis, pigmented skin, or glandular Enlargement; five had slight lateral curvature, described as " postural" ; nine had flat feet. Advice cards for teeth, curvature anæmia, and in one case for hydrocele, were given in 11 cases out of the 27. One showed marked intermittency of the pulse; one had otorrhœea, for which he was being treated ; three were apparently normal. Girls.—Of the 41 who showed Stiller's sign, no fewer than 29 were noted as presenting " pallor ; no definite anaemia " ; one had slight tremor of the fingers, diagnosed as " chorea" ; five had errors of refraction, for which advice cards were given; three had " slight enlargement of the thyroid; no symptoms" ; 18 had " slight flat feet"; nine had " slight lateral curvature " ; one had marked gastric symptoms, " succussion splash, probably dilatation " (advice card given); 20 had carious teeth (no record whether advice card was given) ; one had " scaphoid scapula, perhaps congenital lues " ; one had a mitral systolic murmur; seven were apparently normal, since beyond the note "S.S." there was no other record. As no good purpose would be served by tabulating all the notes made during inspections this year only certain series of inspections of infant entrants, and of children born in the years 1901 and 1904 are taken, sufficient in number to enable some general conclusions to be drawn. Boys.—Out of 1,093 boys examined at 18 schools during 1913, 181 showed fairly well marked sigma costale ; four showed Stiller's sign. This gives the following percentages: Sigma costale 16.5 per cent. ; Stiller's sign 0.36 per cent. Analysing the statistics, it is found that of the four boys who showed Stiller's sign, two were entrants below six years of age, one born in 1901 and one born in 1904. Of these all had marked signs of gastric disturbance. The following are the notes:— 1. Undersized weakly child, height 100 cm., weight 15.8 kilograms, chest measurement not taken; child fretful and crying, teeth carious, stomatitis, pigeon chested; S.S. ; has had convulsions, incontinence, and probably worms; pallor, no bruit; breathing shallow, no adventitious sounds. No family history of tuberculosis obtainable. Mother states child had " meningitis " when a baby. 2. Thin, wiry child, markedly pale complexion, veins on chest wall well marked ; down on arms and back. Height 110 cm., weight 17 2 kilograms ; chest measurement not taken. Fidgety, restless child, said to be subject to night terrors; teeth good, no glands in posterior triangles palpable. Tongue coated; is stated to vomit frequently; no succussion splash. Constipated; is given senna and liquorice powder. History of consumption on mother's side. Cardiac and pulmonary examination negative. S.S. 3. Born 1904. Tall, thin boy, 130 cm. high, 26.8 kilograms in weight; chest measurement, expiration 51 cm., inspiration 63 cm. Breathes well, lung sounds well marked over both lungs, no adventitious sounds. Sharp epigastric angle, asthenic habitus, abdomen somewhat protuberant, not lumpy. Was treated in infancy at Great Ormond-street for " tubercular peritonitis." Teeth sound, but tongue furred. Slight lateral curvature, unilateral flat foot. Suffers from sick headaches; eyesight normal ; reflexes increased. Father's brother has consumption: two uncles on mother's side stated to have suffered from consumption ; mother's father was in asylum. No family history of visceral displacement. 4. Born 1901. Height 140 cm. Weight 32 kilograms. Chest measurement, expiration 60, inspiration 69 cm. Pale, reflexes increased, nervous lad, badly nourished. Well marked succussion splash (examined at 11a.m.; last meal at 8.15 a.m.) Constipation. S.S. Teeth sound; no sign of oral sepsis; no tremor; thyroid normal. Cardiac sounds normal; lungs, prolonged expiration note over both apices, a few rhonchi at left base; no other adventitious sounds. Parent not present; boy does not know particulars of family history. All these four cases showed marked pallor. In the first the most probable cause of the poor nutrition was worms ; in the second and fourth malassimilation, due to atony of the stomach or bowels, probably underlay the bad physique. Here, as in the other cases, there was well marked diminished pulmonary capacity, as judged by the chest measurements. In order to obtain a standard by which to judge the chest measurements, similar to that presented by the table of average heights and weights for 127 Report of the County Medical Officer—Education. London children—which serves as a means of comparison in these cases—Dr. Leipoldt has taken a fairly large series of chest measurements, and averaged them as follows:— Height in centimetres. Expiration in centimetres. Inspiration. 104 51.8 55 109 536 57.6 116 5682 62 1205 57 63 125 58.2 64.4 130 60.4 66.4 135 61 68.5 140 62 69.5 145' 63.5 71 150 66.5 76 These averages agree fairly well with the table of Guttmann, although the physique of his children is generally a trifle below that of the average normal London child. In both tables it is shown that the chest capacity markedly increases in children above 135 centimetres in height. Measurements of the chest in young children (entrants) are not very reliable, and the first three rows of figures are therefore merely approximate averages. Taking the series of 181 boys who showed the sigma costale, it was found that 101 or 55.8 per cent. had a pulmonary capacity below the average for their height, 92 or 50.8 were below the average weight for their height, 84 or 46'4 per cent. were above the average height for their age, and only three were normal in respect to average height, weight, and chest expansion. It was unfortunately impossible to work out the average chest measurements for the girls, for a comparison of which, in these cases, reliance was placed entirely upon Guttmann's tables. Of the 181 boys, 72 or 39.3 per cent. were noted as " normal," that is to say they presented no obvious defects. In the majority of cases, however, their family history showed that these children were "burdened" with nervous, asthenic, or tuberculous "predispositions." Sixteen of them had a well-marked family history of consumption on mother's or father's side ; twelve had a father or mother suffering from gastric complaints; three had evidences of insanity in the family ; five had a paralytic family history ; two had brothers or sisters suffering from what was evidently neurasthenic dyspepsia; one had a mother suffering from visceroptosis for which she had been an inmate in a London hospital. In none of these normal cases was the habitus asthenicus well marked ; in a few it was not present at all, the children being well nourished, strong, muscular, and florid complexioned. Particular stress is laid on these normal cases since they appear to support Stiller's view that the asthenic condition may be latent in childhood, giving rise to no symptons until physical stress has to be endured or some infectious process supervenes. To all intents and purposes these children are normal; the closest investigation into their history does not elicit any evidence of gastric, nervous, or tubercular trouble ; that very valuable help to the school doctor in investigating the nervous condition of a child, the master's report, gives no aid in their cases; the boys are average normal school boys, neither good enough nor bad enough to cause them to be prominently noticed by their class master. Yet, in many cases, they have these curious family antecedents. It would be well, therefore, to follow them up and see what happens to them in later life. This, of course, it has been impossible to do. Two cases, however (not included in the above series of normal children), have some bearing on this point and may be summarised here. At one school, in the course of a routine inspection, a little boy was seen who presented the costal sign in a marked degree, but was otherwise normal. Some months later the same boy was brought up for presumed chorea. He then had tremor of the fingers and forearms, nystagmus, marked increased knee reflexes, slight ankle clonus, but no cardiac signs. He was excluded, and an advice card was given. On reinspection three months later he was found to have considerably improved, but he still showed nervous signs of which he had had no indication at the time of the first inspection. A little girl in Holmes Road school, who showed the sigma costale in an equally marked degree, but who was also malnourished with a very evident habitus asthenicus, was later on specially examined for " general ill-health." Her nutrition was found much below the average ; she was profoundly anaemic, with basal and apical systolic murmurs, brisk knee jerks, and slight tremor of the fingers. She was put on milk feeding and tonic treatment, but during the holidays she was taken to hospital and subsequently died at home, the cause of death being certified as " gastritis." The point on which Stiller lays particular stress is that children who show these costal stigmata are congenitally weaker than normal children ; they resist infection less well than do the latter ; they are more prone to nervous diseases and diseases of nutrition; and they are, generally speaking, less stable than other children of a similar age. Dr. Leipoldt has been specially struck with the number of " only children " in his series who show this costal sign. Out of his 181 boys he notes that 29 were only children, who presented characteristic mannerisms, among which psychical phenomena such as idioglossia, nervousness, phobia in various forms, and even melancholia, were noted. Out of the 181 cases in the series, a family history of tuberculosis was obtainable in 53, or 293 per cent.; of nervousness or neurasthenia—a much more difficult matter to investigate—in only 15, or 8.2 per cent; of gastric trouble in 32, or 17.6 per cent.; of paralysis in only 3, or 16 per cent.; of visceroptosis in only 12, or 6'6 per cent. In the others either no information could be obtained about the family history or the investigation was negative. Other results.—Anaemia and pallor ; 84, or 464 per cent. of the boys were pale or anaemic; in 29 this anaemia was sufficiently grave to call for treatment; in 22 there were haemie, murmurs; in 4 there were mitral systolic murmurs not traceable into the axilla; in 11 there were apical presystolic 128 Annual Report of the London County Council, 1913. bruits, disappearing after exertion ; in 10 there was slight intermittency of the pulse; in 6 the blood pressure was markedly low ; in 24 it was high. No special note was made of the area of cardiac dulness. Lung conditions.—In 8 boys there were signs of slight pulmonary lesions, generally rhonchi, moist rales, or signs of slight bronchitis; 15 were classed as "pretubercular," mainly on the ground of deficient expansion, irregularities in the breathing at the apices, or slight crepitations in the upper or lower lobes ; 19 had a prolonged expiration note at the apices; 6 had cough without any pulmonary signs ; none had definite impairment of percussion sound over the lungs ; in one a tentative diagnosis of " enlarged bronchial glands " was made. No child was notified as tuberculous. It has not been attempted to include in this series any child who was definitely tuberculous, the intention being to deal with those borderland cases in which the impairment of nutrition was the main feature. Cases noted as definitely tuberculous or " malnutrition due to some definite defect" were therefore disregarded, even when S.S. or S.C. was noted against them. Condition of the mouth.—Bad teeth were noted in 61 cases; in 34 the condition was sufficiently marked to require treatment (3), the others were placed in class 1. Oral sepsis, apart from bad teeth, was noted in 23 cases, generally as " furred tongue " or septic tonsils. High palate and long or split uvula, curiously enough, were only noted in three cases. Enlarged tonsils needing treatment were noted in 18 cases. Foul breath, not depending on carious teeth or obviously septic tonsils, was recorded in a fairly large number of cases, 56 or 31.0 per cent. Gastric and abdominal condition.—Tenderness in the right iliac fossa, chronic catarrhal appendicitis, and chronic appendicitis were noted in 12 cases out of the 181, a notably high percentage (6.6 per cent.). Of these, two cases were subsequently operated upon, and three were medically treated during sub-acute attacks; one had been operated upon before being seen. Succussion splash or positive evidence of dilatation of the stomach was present in only two cases (apart from the one already mentioned in the boy who showed Stiller's sign), but slight and recurrent gastric symptoms, pointing to nervous dyspepsia, were recorded in 19 cases. Constipation, worms, diarrhœa, and fæcal incontinence were noted in 33 cases. Protuberant abdomen was noted in three cases. Nervous conditions.—Brisk knee jerks were recorded in 114 cases; slight tremor and palpable tremor in 21; "nervousness" was recorded in 62; subjective neurasthenic symptoms could be definitely elicited in only two cases. On the other hand signs of fatigue were present in 44 boys, one of whom was noted as " overstrained," sixteen had " insufficient sleep," three did " work outside school " ; for the rest no cause could be found for the fatigue. One child, who presented no other signs, was stated to be a somnambulist; nine children suffered from night terrors; sixteen from nocturnal enuresis ; five from enuresis both during the day and when asleep ; one child was a head nodder ; eight children had slight habit spasm; five suffered from fits (?epilepsy), two (infants) were noted as " spasmophilic "; eighteen children had speech defects ranging from slight slurring to well marked stuttering and stammering. To the psychic phenomena reference has already briefly been made. Errors or vision were noted in 23 cases; and in some of these a card was given (although the vision, as tested by Snellen's types, was normal) because there existed some doubt as to whether or not the child suffered from eye strain. These slight and doubtful cases were afterwards followed up, and it was found that with one exception their vision had been declared normal either at an eye hospital or at the school treatment centre. The symptoms of eye strain in these cases appear therefore to have been associated with that nervous dyspepsia to which these children, according to Stiller, are so liable. Curiously enough none of the cases showed any sign of congenital syphilis. The relative frequency of Stiller's stigmata in children who show evidence of such hereditary taint in the shape of eye lesions, Hutchinsonian teeth, or the scaphoid scapula is striking. Similarly only a few children were found to be rickety. It wasfound impossible within the limits of Dr. Leipoldt's report to deal with all the smaller points noted. It may be mentioned, however, that a fair percentage of the cases had scoliosis, lordosis, round shoulders, and flat feet. These could usually be classed as postural deformities, due to muscular weakness and fatigue strain to which asthenic children are strikingly subject. In two children other stigmata were observed ; webbed toes in one, and bilateral enlargement of the pisiform bones in another : in both the stigma was hereditary. The most interesting point about these children, and the one to which attention is specially drawn, is the fact that the largest percentage of them were children in whom the question arose as to the propriety of referring them to class 3 or class 4 so far as nutrition was concerned. It has already been stated that some of the children were normal, but it remains a fact that Stiller's stigmata are found much more frequently in under-nourished than in well-nourished children. While some of the remainder were not quite bad enough to be classed as 3, comparatively few could at once be assigned to class 2. The majority were borderland cases, between 3 and 4. Among these were children in whom could be found no positive sign of tuberculosis, but who had so marked an asthenic appearance that it was justifiable to class them as " pretubercular." Similar cases had been noted in children who did not present Stiller's signs, and these served as a standard for comparison with the pretubercular cases among the 181 boys. In following up the two sets of cases, Dr. Leipoldt was struck by the fact that children in whom Stiller's sign had not been recorded, generally improved markedly when they had had the benefit of good food, open air, and tonic treatment; in some cases where the malnutrition was due to septic absorption through carious teeth, constipation, or gastric disturbance, the improvement was rapid and quite satisfactory after these defects had been suitably treated. In the children with the sigrna costale, on the other hand, the progress was by no means so satisfactory. Notwithstanding the fact that these children were put on tonic treatment, sent to the country or the seaside, and enjoyed the advantage of good homes, excellent food, regular hours of sleep, and adequate recreation, their progress was apparently nil; they came back, and were found at reinspection, to be more or less in the same condition as before, pale in colour, with lax musculature, with but little 129 Report of the County Medical Officer—Education. adipose tissue, under normal weight, and with deficient chest expansion. These facts seem to justify the conclusion that the sigma costale is a reliable sign in estimating the prognosis in a case of malnutrition; if it is present the probabilities are that the child will benefit but little from ordinary tonic and open-air treatment so far as immediate results are concerned. Such children will have to be kept under observation throughout their school life, and also later on, for while it is perhaps too sweeping a deduction to make, as Stiller does, that these children are all potential neurasthenics, consumptives, and enteroptotics, the fact remains that they are suffering from a congenital constitutional weakness which places them in an inferior position so far as resistance to the factors that establish ill-health is concerned. Girls.—The results of the investigation so far as girls are concerned were even more striking than with the boys. It would be superfluous to give here all the details entered in Dr. Liepoldt's notes; the enumeration of a few salient points alone is therefore attempted. Altogether 2,105 girls were examined ; among these 382 or 181 per cent. had the costal sign in a more or less pronounced form, while 14 or 0.6 per cent. showed Stiller's sign. These percentages are higher than for the boys, and agree closely with those given by Stiller, Moritz, and, so far as nephroptosis is concerned, with those of Blum. Dr. Leipoldt's impression, however, is that the percentage is too high, 6ince a slight fluctuation of the tenth rib is very common in girls—certainly much more so than in boys—and undoubtedly, in the earlier cases, from which these data were taken, Dr. Leipoldt states that he took these slight degrees of moveability as abnormal and classed them as sigma costale 1. Making allowance for these errors, the percentage of girls is probably very close to that of the boys. It is usually stated that enteroptosis is much more common in females, but this is perhaps one of these statements often copied in the text books that will not bear the test of investigation. Out of the 382 girls noted as possessing the sigma costale, 48 or 12.5 per cent. were normal, using the word in the sense in which it has been employed in dealing with the boys. 189 out of the 382, a percentage of 49.4, were below the average weight for their height; 110 or 28.7 per cent. had chest expansion below the average for their height (using Guttmann's tables). In 102, a percentage of 26.7, a family history of tuberculosis was obtained; in .19 a family history of enteroptosis; in 64 of nervousness or psychical disorder and nervous disease, including paralysis ; in 45 of gastric disease; in six (not included under the nervous cases) of diabetes ; in 17 of tumour or cancer. In 129 children no adequate family predisposition to any of these diseases could be ascertained. The fourteen cases which showed Stiller's sign—absolute moveability of the tenth rib—presented interesting features. Well marked family history of tuberculosis, 9 cases. History of enteroptosis in parent or relative, 2 cases (1 doubtful). History of nervous or gastric trouble, either alone or combined with tuberculosis, 6 cases. No history of hereditary disposition elicitable, 2 cases. Normal, 2 cases. Defects of teeth, oral sepsis, 4 cases. Defects of nutrition : Three girls were markedly malnourished, and put down as 4 ; five were below the normal average weight for their heights. Two were above the average weight. With one exception all were pale; this exception was a girl with malar flush, high blood pressure, and slightly pigmented skin. Evidence of fatigue was marked in six cases. Nervous defects : with one exception all had increased knee reflexes; none had ankle clonus or tremor. One had well marked vaso-motor signs of nervous irregularity; in three the pulse was intermittent; one had cardiac irregularity of the respiratory type. Ten had nervous psychic disturbances, fidgetiness, night terrors, fits of temper, &c. One was psychasthenic; one had incontinence. In four the kidneys were palpable; in one, an entrant, the liver and spleen were easily palpable, four had enlargement of the thyroid, one with rather prominent eyes but with no cardiac signs or tremor. In six there was evidence of gastric or intestinal atony (constipation ; dilated stomach). Eight were typically asthenic in appearance and build. These findings justify the conclusion that the graver degree of moveability of the tenth rib is to some extent an index of the asthenic condition of the child. Unfortunately it was impossible to follow up these "children in detail. It may be said, however, that at least two of these cases would not now be classed as S.S., but rather as S.C. 2. Illustrative cases have already been given to show the general condition found in a child presenting the sigma costale in the second degree ; the third degree, S.S. is really a rare sign, and in two recent cases it seems to be associated with the absence or under development of the twelfth rib. Nervous signs in the girls were less prominent than among the boys ; yet a relatively large percentage of thein had gastric symptoms, which could legitimately be classed as nervous in origin. Such were frequent bilious attacks—eye strain being excluded—precordial uneasiness in some cases amounting to oppression and pain, headache, hiccough, furred tongue, and in a few cases epigastric tenderness. Definite evidence of dilatation in the form of succussion splash was obtained in only three cases. It should be borne in mind that such a sign shows the existence of a relatively large degree of dilatation of the stomach in a child, and that its importance is, therefore, far greater in these children than it would be in adult patients. In cases with marked gastric or intestinal signs, the asthenic habitus was well developed and the family history usually showed evidence of hereditary tuberculous disposition. Among the girls a far larger percentage of children showed two defects, enlarged thyroid and lateral curvature, than the boys. The enlargement of the thyroid was in most cases entirely unaccompanied by any other signs indicating Basedow's disease, and appeared to be associated chiefly with septic absorption either from carious teeth or from constipation. Two such children presented, most markedly, signs of so-called "chronic intestinal stasis," with pigmentation of the skin, a high blood pressure, and symptoms of fatigue. Yet in both cases it seemed clear that their condition was accounted for by the state of the mouth ; under the dental treatment they rapidly improved although their intestinal atony was still noticeable in the irregularity of the bowels. It is needless to point out that such conditions, as Stiller observes with justice, may be accounted for by assuming the existence of a congenital asthenic state in which atony of the intestines and stomach is a well marked feature. 23610 s 130 Annual Report of the London County Council, 1913. The scoliosis was usually of the first or second degree, and could be ascribed to faults iu posture accentuated by muscular weakness. In some cases it was accompanied by flat feet, due, so Dr. Leipoldt was led to believe, to the faulty position assumed during physical exercises in which the children were made to stand with their toes turned out. Minor deformities of this kind are interesting from the point of view of treatment. It is usually impossible to get the children to go to an orthopaedic department where they can get proper corrective exercises, either free standing or with apparatus ; the parents grudge the time and expense necessary for such regular attendance. If they go to an ordinary hospital, they are in nine cases out of ten, told that there is nothing the matter with them, since these minor degrees of scoliosis are usually overlooked. It seems that the only reasonable method of dealing with these cases is to establish, at some central school, classes for the treatment of these smaller degrees of curvature which could be attended at certain times by children who go to neighbouring schools, and where the exercise could be supervised by the school doctor. In asthenic children such regular exercises would be specially beneficial in improving, so far as is possible, the general condition and carriage of the body. Some General Conclusions.—From the data already mentioned, it appears that some general conclusions may justifiably be drawn. 1. Out of a total number of 3,198 children examined, all of school-going age, the costal sign, to a greater or less degree, was present in 563 or 17'6 per cent., of whom only 120 or 21'3 per cent, could properly be classed as normal. 2. Among the children in whom a defective physical condition was found to exist, a large percentage showed, to judge from the family history, a disposition towards tuberculosis, nervous disease, gastric trouble, or enteroptosis. 3. The costal sign, in conjunction with signs or symptoms denoting gastric or intestinal atony, and in a markedly asthenic child, is of decided clinical significance so far as the general nutrition of the child is concerned. 4. Such children should properly be classed as 4 so far as nutrition is concerned. The prognosis, so far as improvement is concerned, is in their case considerably worse than in other malnutrition cases in which the sigma costale is not found. 5. Children with a pronounced costal sign generally show a diminished pulmonary capacity as judged by the chest measurements. Such children should be encouraged to take deep-breathing exercises, and especially to swim, since both the exercise and the stimulating effect of the water upon their skin appear to have a markedly beneficial result. 6. Children in whom the sign occurs and who have a pronounced family history of tuberculosis should be followed up, even if at the inspection they appear to be normal. Such children may properly be classed as " pretubercular," more especially if they show the habitus asthenicus, and have anomalous chest signs pointing to deficient entry of air at the apices. 7. Children with the costal sign who have a tendency towards gastric or nervous trouble should similarly be kept under observation. Dr. Palgrave's observations on faulty home management in relation to malnutrition. Dr. ralgrave has made observations upon malnutrition, as caused by faulty home management, ' during examination of children in the Hammersmith schools. His conclusions are based on consideration of the child's height and weight, together with such points as pallor, facial expression, and muscular " tone." In many instances more than one cause might reasonably be assumed to be at work, and it was thus impossible to assign the case to its group with accuracy. But amidst the confusion of causes of malnutrition one point appeared to stand out very clearly, and that was that very many of the cases were due, either directly or indirectly, to faulty management in the home ; 436 cases (241 boys, 195 girls) were noted in which the " nutrition " appeared below normal, and the following is a list of the causes found :— 1. Tuberculosis in some form. 2. Heart disease. 3. Hernia. 4. Dental caries. 5. Throat affections (tonsils and adenoids) 6. Intestinal parasites. 7. Constipation and indigestion. 8. Lung trouble other than tuberculosis. 9. Eczema. 10. Prematurity of birth. 11. Neglect or poverty and ignorance. 12. Improper feeding. 13. Rickets. The children fell into these (approximate) age groups:— Boys. Girls Between 4 and 5 years 85 67 „ 7„ 8„ 102 85 „ 11 „ 12 „ 54 43 As a result of information gathered during the enquiries Dr. I algrave has tabulated in the following design the rule that faulty home management plays in causation. 131 Report of the County' Medical Officer—Education. He points out that almost every factor in the list, if not directly due to some error in hometreatment, may be, at any rate, partly attributable to this cause. For example, if children's hands were kept cleaner and their nails shorter intestinal parasites would not be so common as they now are. Amongst the 436 cases a history of worms was elicited in over 11 per cent. Other points discussed by Dr. Palgrave in relation to malnutrition, are ignorance on the part of parents of the value of fresh air, of regular habits, and of care for the teeth, all three of which are important accessory factors. Wilful neglect and over-employment out of school were, in his experience, exceedingly rare contributory causes. Ignorance is more potent as a cause than wilful dereliction of duty. He is of opinion, however, that the work which has been done in educating parents towards an understanding of the need of care of teeth is beginning to bear fruit, and reports to the same effect were made by Dr. Cowell and Dr. Tosswill. Dr. R. H. Norman undertook an investigation during the summer session of 1913 in the infants' departments of unselected schools in the Boroughs of St. Pancras and Holborn, to determine if any difference could be found in the nutrition of children, who, during their first year of life, had been fed on breast-milk, or otherwise on cow's milk, or one of the various artificial infants' foods. If a child had been fed on breast-milk and nothing else for the first six months of its existence, it was regarded as a breast-fed child, this period being the most important in a baby's life, and these cases are classed together with those who had breast-milk, and breast-milk only, for the first nine or twelve months, i.e., a breast-fed baby is one fed entirely on mother's milk for the first six months of life or longer. Dr. Norman's report on a comparison of the nutrition of breast and bottle-fed children in the infants' departments of the L.C C. elementary schools. The investigation was limited to the infant departments, and the ages of the children ranged from 3 to 8 years of age, the bulk of them being 4, 5, or 6 years old. Details of the methods of feeding 313 children of these ages were obtained, of these 158 were boys, 155 girls. The first fact emerging was the preponderance of breast-fed over bottle-fed babies, thus 70.7 per cent. were brought up on their mother's milk, 29.3 per cent. on cow's milk or one of the artificial foods. It was noticed that the poorer the home conditions the more likely was the infant to have been breast-fed. There was scarcely any difference in each group in the percentages of boys and girls brought up by the one or the other method. The following table gives an analysis of the results of the enquiry:— Breast Fed. Bottle Fed. Ago. Sox. No. of children. Percentago of total No. Percentage below average weight Percentage below average height. Percentage of total No. Percentage below average weight. Percentago lelow average height. 4 Boys I 66 69.3 60 63 30.7 53 70 Girlsi 38 74.4 64 57 25.6 70 30 5 Bovs 70 68.5 50 77 31 4 36 50 Girls 80 77.5 56 62 225 44 72 6 Boys 32 65.7 57 52 34.3 72 72 Girls 37 62.2 82 52 37.8 64 . 50 The numbers are too small to justify final conclusions, but so far as they go tend to show :— 1. A. preponderance of breast-fed over bottle-fed children, roughly 2 to 1. 2. A greater percentage of breast-fed children fall below the average weight than bottlefed ones. 3. A greater percentage of breast-fed children fall below the average height than bottle fed ones. No superiority of breast-fed children as compared with bottle-fed ones could therefore b( distinguished at school age in this series of cases. Dr. Norman mentions in his report the fact that the better the home the more likely is the baby to be bottle-fed ; it seems clear therefore that he was here contrasting children from two types of home and it is much more important to a baby to be born into the right type of home than to be brought up by one particular method of feeding rather than another. Closely associated with the existence of malnutrition is the question of the conditions under which the children are housed and particularly those under which they sleep. Lack of sufficient sleej is not infrequently the main cause to which is to be ascribed undernourishment or backward develop ment. Dr. Mabel Russell has during the past year paid attention to this factor while inspecting children in the Stepnev area. She reports that:— Dr. Mabel Rut sell's enquiry into the sleeping conditions of some Stepney school cnildren. A considerable number of the children in that area do not get sufficient sleep. It is by no means uncommon to have a child brought up by the Head Teacher, with the request " will the School Doctor examine him in order to ascertain whether the small amount of progress this child is making, in his general work, is due to some physical defect or to laziness." On examining such a child, and further investigating the case, one frequently finds (especially among the Jewish children) that the child, aged eight or nine years, does not go to bed until 11 p.m.—and often later; that he shares a bed with two or three other persons (often adults), that there are in 23610 •8 2 132 Annual Report of the London County Council, 1913. addition two or three persons occupying the same room, and that the window is not open during the night. Sometimes it is found that although the child may be going to bed regularly at 8 p.m., the bedroom is at the same time the sitting and work room, with the result that the first sleep is necessarily much broken. Period of nightly sleep obtained.—An enquiry was made among 100 Jewish children between the ages of seven and eight years with the following result— 16 children were being put to bed at 8 p.m. ; 62 between 9 and 10 p.m.; 2 from 9.30 to 11 p.m. ; 16 at 11 o'clock ; and 4 from 11 until midnight. One effect of lateness in going to bed is that the children rise late, and hurry to school without any breakfast other than "a cup of tea." Unbroken Sleep.—It is a little difficult to find out whether a child's sleep is unbroken, without actually observing it, but the probability of sleep being disturbed is fairly certain, if several persons share the same bed, some of them being adults retiring at a different hour. Of the 167 children (Jewish and Christian) among whom the enquiry was made it was found that 19 each slept in a bed alone ; 57 each in a single bed with one other person ; 53 with two other persons ; 32 with three other persons ; and 6 each shared a bed with four other persons. Inquiry into the hygienic condition of the sleeping apartments of 133 children moderately poor gave the following results:— Number of persons to each room 2 3 4 5 6 7 Number of children at each degree of crowding 39 32 44 12 5 1 Of these 11 admitted having the window open at night "about an inch" (the inquiry was made during the waim weather). It is very unusual to find on close enquiry that the vest or shirt, worn during the day next the skin, is removed at night, and it is no uncommon thing to find among the poorer Jewish children the night shirt serving during the day as an ordinary shirt. In order to obtain some means of comparing the effect [of unsatisfactory sleeping conditions upon the health of the children the average total increase in height and weight of the children in two playground classes was taken. One playground class was situated in Bethnal Green, the other in Stepney. Both were classes of girls of comparable ages, and the circumstances of the parents of the children in the Bethnal Green and Stepney class were similar. The figures worked out as follows the figures were taken from 52 children):— Total increase in Height Total increase in Weight Number sleeping in a bed. [April-October.] [April-October.] 1 or 2 3.1 c.m. 2. 3 kilograms 3 1.7 c.m. 1.3 „ 4 l.l c.m. 0.78 „ Enlarged glands and other defects. It was impossible to eliminate other factors, such as poverty ; but on the whole the figures appear to indicate that the children sleeping under more satisfactory conditions show greater increase in height and weight than those whose sleep is necessarily more broken owing to overcrowding. Glands.—Swollen glands other than submaxillary and cervical were noted at medica inspections in 298 children, 39 cases being referred for treatment. These cases include enlarged thyroid glands and lymphatic glands in any part of the body. Of these 298 cases 138 were amongst entrant boys. Other diseases or defects.—Under this heading are classed digestive disorders, urinary diseases, injuries, debility (when not associated with anaemia or malnutrition), hernia, abscesses and enuresis, as well as anv other complaints not specially provided for on the record card. 4,757 such cases were noted, 2,335 being recommended for treatment. In Hampstead, Islington, and Shoreditch there were 683 cases of " other defects " noted, and of these 107 were cases of enuresis, mostly occurring amongst younger girls. There were 39 cases of hernia, the largest proportion occurring amongst entrant boys who had umbilical hernia. Condition of teeth of school children. Condition of teeth.—Particulars as to the condition of the teeth classed as good, fair or bad will be found in the appendix. The school doctors are instructed to report all children with defective teeth, but there is considerable variation in practice, some school doctors reporting all cases where there is the slightest sign of decay in either temporary or permanent teeth, and others reporting only cases where the decay is more serious. In all cases of oral sepsis, and in general where there are three or more teeth affected with caries, the case is referred for treatment. 133 Report of the County Medical Officer—Education. During the year 80,988 children were reported as having carious teeth, and 33,111 were recommended for treatment. The proportion in the various age-groups was as follows:— No. examined. Reported as having carious teeth. Recommended for treatment. Entrants. Boys 40,017 14,739 36.8% 5,425 13.6% Girls 39,603 13,874 35.1% 5,409 13.6% 8-9 Boys 31,643 14,654 46.0% 5,891 18.6% Girls 31,257 14,703 47.0% 6,162 19.7% Leavers. Boys 27,143 11,732 43.2% 5,211 19.2% Girls 27,495 11,286 41.0% 5,013 18.2% Total 197,158 80,988 41.1% 33,111 16.8% It will be seen that 41 per cent. of the children examined were reported with carious teeth and 16.8 per cent. were recommended for dental treatment. The serious cases were 136 per cent, among entrants, 19. 2 among children 8 to 9, and 18.7 among leavers. In Woolwich over 50 per cent of the leavers examined were recommended for dental treatment, in Kensington less than 2 per cent. The school doctor in recommending cases for treatment is no doubt influenced to some extent by the. existing facilities for treatment. In Woolwich there is a centre for dental treatment in the most thickly populated part of the borough, and it is easily accessible from most of the schools, while in Kensington no centre exists, and in Greenwich, where also there is no centre, the number referred for treatment was 9 per cent. of those examined. In both Greenwich and Kensington centres for providing dental treatment are being instituted. On the other hand, where there is no dental centre accessible, a large number of cases may be referred for treatment but fail to obtain it. In addition to the cases of dental caries discovered by the school doctors, the qualified dentists employed by the Council in inspection in the schools also referred 25,492 cases for treatment. The examination of the dentist is restricted, however, to children of 6, 7, and 8 years of age. During the year 31,858 children were specially examined in this way, and 80 per cent. were found to require treatment. treatment. The special dental inspections made in 1913 in connection with the several treatment centres are detailed in the following table:— Centre. No. of children examined. No. of children found to require treatment. Percentage of cases requiring treatment. Deptford 5,006 3,495 69.82 Fulham 2,254 1,775 78.75 Hackney (from 30.9.13) 696 562 8075 Hammersmith (from 15.7.13) 1,014 934 92.14 Islington (from 26.6.13) 1,088 873 80.25 London Hospital (from 8.10.13) 257 223 86.80 Norwood 2,174 1,816 83.54 Peckham (from 11.4.13) 1,429 1,113 77.90 Poplar 3,554 2,843 80.00 Queen's (from 30.6.13) 1,286 1,113 86.56 St. Cecilia's (from 26.6.13) 1,048 803 76.62 St. George's Dispensary 2,431 2,019 83.00 St. Marylebone Dispensary 1,804 1,584 77.82 St. Pancras (from 16.4.13) 1,886 1,607 85.20 South London (Battersea) (from 30.10.13) 491 453 92.26 Wandsworth 4,192 3,228 77.00 Western Dispensary (from 3.12.13) 301 291 96.70 Woolwich (from 1.9.13) 947 760 80.26 Total 31,858 25,492 8001 Venereal Disease.—Evidence of congenital syphilis among London School Children is comparatively rarely found in the reports of the school doctors, but it must be borne in mind that these reports only relate to children in the elementary schools. The presence of the Hutchinsonian type of teeth was noted in 58 cases. Interstitial Keratitis was reported in 13 children. Skin eruption of a syphilitic character, or other evidence of the presence of syphilis was found in 15 cases. The proportion of cases is much higher among children examined as special or urgent cases, and cases are far more prevalent in Special Schools and Schools for the Physically Defective, particularly the Blind Schools, in which many cases of defective sight attributable to venereal disease in the parents are met with. Particulars of enquiries made by Mr. Yearsley and Mr. Harman will be found on pp. 117—122. In the case of one family it was reported that a child under school age was suffering from congenital syphilis, a brother age 5 was examined and found to be apparently well, while a sister age 7, who was also examined, was noted to have opacities interfering with vision. Congenital venereal disease. 134 Annual Report of the London County Council, 1913. The figures for 1913 are as follows: — No. examined. No. with Hutchinsonian Teeth. No. with Interstitial Keratitis. Other symptoms of Syphilis. Total. * Routine—Entrants, 8-9, Leavers 199,858 54 3 8 63 Specials (all ages) 17,463 4 10 7 20 58 13 15 83 * These figures represent the number of children reported to be affected. In some eases both Hutchinsonian Teeth and Interstitial Keratitis or other symptom occurred in the same child. Physical condition of children in special schools. Examination of Children in Special Schools.—During 1913 the children in special schools for the Deaf, Blind, and Mentally Defective, arriving at the ages of 8 and 12, were examined by the school doctors as to their general physical condition. The particular defects for which the children were referred to the special schools were kept under constant supervision by the special school doctors, quite apart from any age-group examination. Children in Schools for the mentally defective.—During the year 1,009 boys and 700 girls were examined in these schools, the proportion in the age-groups being— Cases referred for treatment. No. exam'd. Total. Teeth. Vision or eye disease. Ear disease or hearing. Heart disease or awemia. Nervous diseases. Skin diseases. Tuberculosis. Boys age 12 714 313 43.8% 143 20.0% 114 16.0% 26 36.% 14 2.0% 6 .8% 11 1.5% 2 .3% Girls „ 505 231 45.7% 92 18.2% 98 19.4% 18 36.% 7 1.4% 6 1.2% 5 1.0% 2 .4% Boys age 8 295 121 41.0% 47 15.9% 24 8.1% 29 9.8% 5 1.7% - 8 2.7% 1 .3% Girls „ 195 87 44.6% 39 20.0% 14 7.2% 22 11.3% 1 .5% 1 .5% 5 2.6% - While in regard to teeth and visual defect the percentage of children requiring treatment is much the same in these schools as in the ordinary schools, it is noteworthy that a larger proportion of cases of ear disease and defective hearing, nervous diseases, heart disease and anaemia, and, as already pointed out, tonsils and adenoids, were noted for treatment among mentally defective children than among children in ordinary elementary schools. Schools for deaf and blind children.—The number of children in these schools is about 700, viz.:—400 in schools for the deaf and 300 in those for the blind. The number of children arriving at the ages fore.xamination is, therefore, necessarily very small. The following are the figures of children examined and the number referred for treatment for various causes. Schools for Blind. 8choola for Deaf. No. examined. No. for treatment. Teeth. Nose and throat. Eyee. Ear disease. No. examined. No. for treatment. Teeth.* Nose and throat. Eye disease. Ear defects. Bovs age 12 32 11 7 —- 1 1 39 13 2,1 4 2 Girls „ 12 39 15 4 4 — — 34 7 1 — 4 — Boys age 8 27 9 4 1 1 — 32 5 1 2 2 2 Girls „ 8 13 3 2 — — — 26 8 3 — 4 — The proportion recommended for treatment in these schools is very similar to that for ordinary elementary schools, but the figures for particular defects are too small to make a trustworthy comparison. Special examinations Special and Urgent Examinations.— Ihe cases included under this heading comprise children who are referred for examination for some special defect and children examined in open air classes or as to suitability for holiday journeys. The children in these groups are not classified with regard to Clothing, Cleanliness, Teeth, Vision, &c. 25,563 children were examined as special or urgent cases during the year. during the year. The figures showing the number referred for treatment and the reasons for treatment were :— No. examined. No. for treatment | Skin disease Teeth. Fyes or Far vision, disease. Hearing Heart disease. Anmraia Lungs. Phthisis Other Tubelt cular disease Deformities. Ir- fectious disease. Ma;nu- triticn. Boys 12,258 6,219 50.7 1,011 8.2 547 4.5 2,214 799 18.1 6.5 223 1.8 66 .5 142 1.2 190 1.6 145 1.2 78 .6 83 .7 34 •3 104 .8 Girls 13,305 6,748 50.7 840 6.3 586 4.4 2,574 796 19.3 60 248 1.9 125 .9 196 1.5 141 1.1 168 1.3 65 .5 90 .7 59 .4 89 .7 135 Report of the County Medical Officer—Education. In this group the number of cases requiring treatment forms more than 50 per cent. of those examined. As might be expected, skin diseases are often detected and the children brought forward for special examination. Cases of Phthisis and Infectious disease were frequently found at these special inspections. These special cases, being selected, cannot be compared for statistical purposes with cases found at routine examinations; the large numbers of cases requiring treatment among them show the advantage that is derived from the frequent visits of the school doctor to a school. In cases where the doctor is not due at a school for some time, the child if the case be urgent is sent for examination to a school in the neighbourhood where the school doctor happens to be in attendance. Some of the cases are those of children who have previously been excluded from school for some cause and are being examined to ascertain their fitness or otherwise to return. Other cases where there is a question as to the child's mental condition are brought forward for the doctor's opinion as to whether the child should be submitted at the statutory examination for admission to a school under the Elementary Education (Defective and Epileptic Children) Act. It is arranged that special and urgent cases requiring a more thorough examination than can be made in the school, and certain cases that are out of school, should be examined at a centre. During the year 646 boys and 897 girls were examined at these special inspections. 872 of these cases were referred by the Divisional Superintendents, 243 by Head Teachers, 135 by the Divisional Medical Officers or the School Doctors, 72 by the Care Committees, 30 by the School Nurses, and 127 cases by the School Medical Officer. The Invalid Children's Care Association brought forward four cases and the parents themselves asked for an examination in three instances. Of the 1,543 cases examined, 560 cases were referred for treatment. Phthisis was the reason for treatment in 76 cases, ear disease or hearing in 77, eye disease or vision in 133 cases, and malnutrition in 43 instances. The figures relating to defects found are set out in the appendix. In case of an outbreak of infectious disease in a school an examination is made by the school doctor of the "contacts." If there is doubt the children are excluded and kept under observation. This close scrutiny of children, who have possibly been exposed to infection, is work which must be carried out, but which throws a very heavy burden upon the medical staff engaged in the schools. Scarlet fever in particular is a disease which calls for much vigilant examination of contacts, inasmuch as mild and missed cases are exceedingly common. The exceptional prevalence of this disease during the past year has greatly added to the work of the department as may be gathered from the fact that no less than 25,782 children were examined as contacts of sufferers from infectious disease between April and December alone. Sudden illness in School.—Many special examinations are asked for in cases where a child has a fit in school. If necessary, a doctor is called in at the instance of the head teacher, and the facts are reported to the school managers. The school doctor subsequently examines the child to determine whether the case is one suitable for scheduling for examination under the Defective and Epileptic Children Act, or whether the attack was due to some functional disorder of a temporary nature. Special observation is kept upon these latter cases, and if any further attack occurs the fact is at once reported and a further examination arranged. Exemption from Domestic Economy Classes.—Where a girl is reported to be-unfit for domestic economy classes the school doctor makes a special examination and reports whether exemption should be made on the ground of health. Anæmia, heart disease, and rheumatism were the reasons for advising exemption in many cases. Medical Treatment. In the annual report for 1912 the growth of the Council's medical treatment scheme was traced from its inception in January, 1910, until the close of the year to which that report related. It was there shown that, beginning with arrangements with six hospitals, providing for the treatment of some 12,000 children, the scheme had been developed so that by the end of the year 1912 12 hospitals, and 22 school treatment centres had been included, providing for the treatment of more than 73,000 children, at an estimated cost of about £20,000. During 1913 these arrangements have been further extended, so that at the end of the year means of treatment were available for 84,350 children, and further centres were contemplated which would have the effect of increasing to an approximate total of 100,000 the number of children for whom facilities for treatment of one kind or another are provided. It has been found necessary during the year under review to make some readjustment as regards the provision made at some of the hospitals and centres for the treatment of the several ailments, due in part to the fact that children now being inspected in the intermediate age- groups, or as leavers, have already been treated as the result of the provision made in 1910 and 1911. The following notes show the reason of the changes made as regards each ailment separately. Eye defects.—It was found that the numbers of children attending the hospitals and centres for eye defects approximated very closely to the provision made under the agreements, and inasmuch as it was deemed desirable to refer for further inspection children of the intermediate age-group whose visual acuity was only 6/12, the provision made was increased accordingly. Ear, nose, and throat ailments.—With regard to these ailments experience has shown that the facilities for treatment arranged by the Council have effected a reduction in the number of school children suffering from defects of this class, and the figures for 1912 showed that the number of children suffering from enlarged tonsils and adenoids was 31,230 as against 35,614 in 1911. It was found possible, therefore, to reduce the provision made under this heading at some of the centres, It is only by keeping under continuous observation the children in whom unhealthy conditions of the throat are found to exist that it is possible to form an opinion as to the grave dangers 136 Annual Report of the London County Council, 1913. attending the neglect to remedy such conditions. It is the school doctor who is pre-eminently in a position to arrive at a judgment on these points. Aural surgeons are agreed as to the predominance of the existence of unhealthy overgrowth of the adenoid tissue of the throat among the causes of disease of the middle ear in children with consequent suppuration and ear discharge. A considerable proportion of school children suffer from the latter condition; when established, not only does it lead to progressive deafness but it also brings about the most profound disturbance of the general health and it is directly responsible for many deaths in young children from that most terrible of diseases, meningitis. The presence of adenoid growths apart from production of ear disease of a gross kind is responsible for attacks of temporary deafness in children. It is a noteworthy fact that in several cases in which children have been killed by traffic in the street it has been found that the record of medical inspection shows the presence of adenoids with or without slight deafness, A recurring transient deafness is thus a particularly dangerous thing in a child. A permanently deaf child is wary and avoids danger, but a temporarily deaf child is accustomed to rely upon its hearing, and thus may easily be run over by swiftly moving and heavy vehicles. Apart from the dangers arising from ear disease and deafness the effect of adenoid over-growths in producing faulty habits of breathing with consequent ill development of the chest and predisposition to tuberculous infection is in itself a reason for strongly advising treatment for the condition in all cases in which obstruction to nasal respiration exists. In view of the fact that the question has recently been raised as to the advisability of referring for treatment all children suffering from these unhealthy conditions of the throat the following report by Dr. Muirhead Martin on the work of the aural department at the Hackney School Treatment Centre will be read with interest. Dr. Muirhead Martin's report on the examination and treatment of children in the Aural Department at the Hackney Schocl Treatment Centre for the nine months onding July 31st, 1913. In reviewing the results of the examination of children suffering from ear, nose and throat defects made at the Hackney School Treatment Centre it should be mentioned that the examinations were systematically carried out, and as gross defects alone were looked for and recorded, the tables show only such conditions as were undoubtedly harmful to the boys and girls from the standpoint both of physical health and scholastic efficiency. The figures under-estimate rather than exaggerate the amount of disease present. It may perhaps be said that the number of boys and girls examined is too small to be of great statistical value. Nevertheless the figures do give some idea of the relative prevalence of diseases of the ear and throat among school boys and girls coming for medical supervision to a school treatment centre. There were 162 boys and girls examined and 122 were operated upon for tonsils and adeDoids. Dr. Martin points out that as his report is merely a preliminary one, it is yet too soon to speak in a final manner concerning good effects which may accrue from the treatment. The method adopted was first of all to ascertain the trouble complained of by the parents, and then to note the result of the examination. In 54.9 per cent of the cases the mothers had nothing to complain of in the health of their children, but had simply followed the advice of the school doctor in seeking treatment. In the other cases the following symptoms were indicated:— Complaint. Percentage. (a) Discharging ears 11.7 (b) Deafness 135 (c) Earache 4.3 (d) Snoring 3.7 (e) Mouth breathing1.8 (f) Sore throats 6.1 (g) Nasal discharge 3.08 (h) Enlarged neck glands 1.2 (i) Blocked nose 8*08 (j) Night terrors 0 61 (k) Defective speech 1.8 (/) Difficult breathing 1.8 (m) Sleep walking 0*61 (n) Irritable1.2 (0) Cough1.2 On examination the following conditions were revealed: — Objective. Percentage. (1) Rhinitis35.8 (2) Wax17.81 (3) Chronic suppurative otitis media 35 8 (4) Adenoids 87. 03 (5) Enlarged tonsils 67.9 (6) Enlarged turbinals 37.6 (7) Deflected septum 35.3 (8) Perforation of drum or old cicatrix 6.79 (9) Nasal diphtheria 061 (10) Furunculosis (ears) 0.61 (11) Aural polypus 37 (12) Eustachian catarrh 0.61 (13) Bifid uvula 1.2 (14) Eczema of ears 1.8 (15) Old mastoid (unhealed) 0.61 (16) Post nasal catarrh 4.9 (17) Conjunctivitis and debility 1.2 Report of the County Medical Officer—Education. 137 Of the 162 cases examined— 52. 46 per cen. were boys and 47.53 per cent. were girls. The ages of the children ranged from 4 years up to 14 years, and are recorded as follows:— Sex percentage. Age. Percentage. Boys. Girls. 4 10.4 9.2 12 5 14.1 7.4 6.7 6 9.2 3.1 61 7 8.6 49 37 8 9.2 4.9 4.3 9 87 1.8 1.8 10 3.1 1.2 1.8 11 166 8.0 8.6 12" 16.0 8.0 8.0 13 4.9 1.8 3.1 14 3.7 1.8 1.8 This table of age incidence refers mostly to nasal obstruction from adenoids.* The theory that adenoids tend to disappear at puberty may prove a disappointing one. The structure of adenoids reveals a fibrous connective tissue framework supporting masses of lymphoid cells. A contraction of this fibrous tissue causes gradual shrinking of the adenoid mass. This change, however, is independent of the age of the patient. There is no definite period at which it must occur ; so that it is foolish to wait, for the secondary effects continue to progress. There is only one sensible method of treatment—removal of the growths. This was done in 75.3 per cent. of the cases considered, as already mentioned, and it is hoped thereby that the chances of serious middle ear disease, with its many complications and sequelæ—which would eventually, Dr. Martin thinks, have occurred in many of his cases—will be lessened, and something will have been done towards lowering the very high percentage recorded in the tables. The Eustachian catheter was passed in three cases of continued deafness with benefit. These cases had elsewhere been operated upon for tonsils and adenoids. Several of the cases were referred to the"Minor Ailments " department of the centre for syringing of the nose and ears. It will be observed from the table that the percentage of children with enlarged tonsils is 67.9. Such cases should be treated without delay, as the child is especially liable to all sorts of affections of the throat, and is more prone than other children to suffer from the more serious complications of such infectious diseases as scarlet fever and diphtheria. Unless enlarged tonsils are removed early their evil effects—the nasal speech, the narrow deformed chest—may remain permanently with the child even after removal of the offending tonsil. If the hygiene of the mouth were properly attended to, i.e., brushing of the teeth and removing or stopping of decaying teeth, there is no doubt that enlarged tonsils would be of less frequent occurrence. The percentage of children with adenoids was 87.03, and other causes of nasal obstruction were as mentioued in the tables. Some of the effects produced by the presence of enlarged tonsils and adenoids may be tabulated in this way:— (1) The blood not properly oxygenated giving: (a) Stunted growth. (b) Heavy and dull mental condition ; child cerebrating slowly. (c) Anaemia. (2) Breathing interfered with, producing : (a) Badly expanded lungs. (b) Malformed chest ; narrow, flat, or pigeon-chested. (3) Greater liability to disease of the respiratory system, e.g.: (a) Colds, bronchitis, &c. (b) Phthisis. (4) Local conditions of the throat make the child more liable to: Sore throat, quinsy, rheumatism, infectious diseases, and nasal catarrh, which frequently spreads to the middle ear and causes deafness. (5) Expression of face : Mouth always open ; dull, heavy, stupid-looking. (6) Speech : Nasal and indistinct. This is a formidable list, and when it is borne in mind that some of the effects of the presence of enlarged tonsils and adenoids may be permanent, even after the removal of the offending cause, it is not difficult to appreciate how important a thing it is that enlarged tonsils and adenoids should be removed as early as possible. Many of these children are incapable of gleaning the full benefit of their school training, because they are retarded in their progress on account of these defects ; they consequently require a greater amount of attention from their teacher, which is given at the expense of the other boys and girls. At the Hackney School Treatment Centre every precaution was taken to reduce the shock of the operation on tonsils and adenoids to a minimum. The children were made happy and comfortable * Dr. Martin comments upon the age distribution, but was unaware of the disturbing factor that only certain age-groups are medically inspected at school. This factor is the probable explanation of the irregular variations of the incidence at the different ages. 2.3610 T 138 Annual Report of the London County Council, 1913. With few exceptions they came into the operating room without fear, and took the anaesthetic without struggling. It would be well to arrange if possible for the children operated upon to return to the centre for instruction in breathing exercises until they learn to breathe quite naturally through the nose with the mouth shut, so that children who remain mouth breathers, even when the nasopharynx has been satisfactorily cleared, may have a normal condition established. Ringworm.—The objections formerly raised by parents to the X-ray treatment of their children for this ailment appear to be diminishing, and some of the centres had quite considerable waiting lists. Having regard to this fact ringworm wa3 added to the classes of ailments already treated at two existing centres and the numbers of cases under agreement at other centres was increased. Nursing treatment.—Under this heading are included the cases hitherto described as " minor ailments." The early arrangements for this branch of treatment provided that 25 new cases should be referred to the centre each week. In practice, however, these numbers were found to be unmanageable, and, owing to the steady accumulation of old cases attending for continuing treatment, caused undue congestion and difficulty. During the year, therefore, the average weekly number of new cases referred to each centre was reduced to 15. At the same time, moreover, the centre authorities were guaranteed a capitation payment of 4d. for all the cases for which provision was made. Although the immediate effect of the altered arrangement was to reduce the provision made at each centre, it was thought better to compensate for the reduction by the establishment of new centres in convenient positions rather than by increasing the facilities at existing centres. This policy is still being pursued, and at the end of the year arrangements had been made for the treatment of 12,320 cases as against 12,540 cases in 1912 when the provision made was on the basis of 25 new cases a week at each centre. Further centres, moreover, are contemplated, and at the time of writing there is already available accommodation for some 2,000 additional cases which is to be increased to 4,000 in the immediate future. Thus there will shortly be some 23 centres providing for more than 16,000 children, instead of, as at the end of 1912, 12 centres providing for 12,540 children. Teeth.—The greatest increase, however, has taken place in the provision made for the treatment of dental defects, the actual numbers arranged for at the end of 1913 being 31,240, as against 18,850 at the end of 1912. This increase shows that considerable effort has been made to deal with the great need that existed for this branch of treatment, but there is yet necessity for further provision, which is being met by the establishment of fresh centres, and arrangements are already completed or in progress for the treatment of some 10,000 additional cases annually. Comparison of the provision for treatment, including only the centres actually at work at the end of the years 1912 and 1913 respectively, may be made as follows:— Ailments treated Numbers under agreement, 1912. Numbers under agreement 1913. Increase + or decrease — Eye defects 21,220 22,480 + 1,260 Ear, nose and throat 19,060 16,020 — 3,040 Ringworm 1,388 2,290 + 902 Nursing and treatment 12,540 12,320 — 220 Teeth 18,850 31,240 + 12,390 Totals 73,058 84,350 + 11,292 During the year it was found advisable to amend in some respects the terms of agreement with the various committees providing facilities for the treatment of school children, more especially as regards the payments to be made by the Council. For instance, it had been the practice generally for such payments to be made on the basis of £50 per annum for each doctor, surgeon, or anaesthetist employed on one half-day a week, and pro rata for every half-day so worked. In addition, a capitation payment was made of 2s. for each major ailment treated in respect of defects of the eye, ear, nose and throat, and teeth, and 7s. for the X-ray treatment of ringworm. The new agreements provide for the same rate of payment as regards the services of a doctor, surgeon and anaesthetist, and as regards the capitation fees for ringworm, and eye, ear, nose and throat defects, but in the case of the older dental centres where the initial expense of establishment has to some extent been met, the capitation fee has been reduced to Is. for all cases treated during the year in excess of 1,000. All new dental agreements, moreover, provide that the half-time services of a dentist including inspection and treatment shall be paid for at a rate not exceeding £200 a year. At all the centres treating major ailments the services of a nurse are provided by the Council, and in some cases additional assistance is given by arrangement with nursing associations which also undertake the treatment of minor ailments, the Council paying £50 a year for the services of a doctor on one half-day a week, and £100 for the equivalent of the whole time services of a nurse, including the cost of equipment, travelling expenses, &c. In some cases a small grant of £12 10s. is made towards the first year's rent at nursing treatment centres where the initial expense is heavy, and in all cases a capitation fee of 4d. is guaranteed on the number of cases for which agreement is made. Upon the establishment of a new centre the Council makes a grant of £100 for equipment for the purposes of medical treatment, £50 for dental treatment, and £75 for X-ray apparatus, but all the material purchased under these grants remains the property of the Council, and by the terms of the agreement is to be returned on the expiry of the contract. At the suggestion of the Board of Education the new agreements with committees of local medical practitioners now contain a clause securing that the work of the centre shall be under the general supervision of the school medical officer. This supervision is carried out through the DIAGRAM C. 139 Report of the County Medical Officer—Education. divisional medical officer, who is instructed to visit all the centres iu his district and to report periodically upon the working of the arrangements. The selection of the premises to be used as school treatment centres is the subject of careful inquiry as to position, arrangement, equipment, and maintenance. The premises, moreover, as well as the arrangements for treatment must be approved by the Board of Education. Generally, a private house is used, sometimes an existing dispensary, sometimes a nurses home. Each centre should be readily accessible from the neighbourhood of the schools which it serves, and though London is on the whole well provided with .the means of transit, there are limitations in this respect in certain parts of the county. Reference to the map included in this report will show that the schools north of the river are now fairly well provided for in the matter of hospitals and centres, but south of the river there are gaps, and some difficult journeys are involved. Gradually, however, the lacunae are being filled, and when the new centres now contemplated are established, the marked difference between north and south will be materially diminished (see Diagram C). In illustration of the character of the constituent units of the Council's medical treatment scheme the following notes on the several hospitals and centres, with which arrangements were made in 1913, may be of interest. (1) Belgrave Hospital for Children, Clapham Road, 8.W.—Provision has been made at this hospital for the treatment of 500 eye cases, and 500 ear, nose, and throat cases a year. The Council's cases are dealt with in the afternoons when, as a rule, no other patients are in attendance. The children are received in an attractive waiting room and here particulars relating to the case are entered in a special register. It is insisted upon that children shall be accompanied by an adult person whenever possible ; in default of this, one of the Council's organisers is present during the treatment of the child, and receives the necessary instructions for the parent. Arrangements are made for nurses to visit the homes at the surgeon's request, and nurses are sent to the homes after operation in all cases. Children are prepared for operation in a small room opening from the waiting room; they are then taken with their parents to the dispensary from which direct access is obtained to the operating theatre. After the operation the child is placed on a mattress in the recovery room, and attended by a nurse until the surgeon is satisfied that the patient is fit to return home. (2) Charing Cross Hospital.—The arrangement between the Council and the governing body of this hospital provides for the treatment of 250 eye cases, 500 ear, nose and throat cases, and 70 ringworm cases a year. There has not always been a full attendance of ear, nose and throat cases, but it has been deemed desirable to retain the existing numbers, as this hospital, owing to its central and easily accessible position, is very useful for dealing with cases from outlj'ing districts when other centres are full. The children are received in the ordinary out-patients' hall, where they are, however, kept apart from other patients. In the aural department no other patients are seen at the special times arranged for dealing with children referred to the hospital by the Council. In the event of a child requiring operation appearing delicate or neglected, the surgeon obtains through the school care committee a report on the home circumstances before making an appointment for the operation. When the appointment is made special attention is given to the general health of the child, and the person in charge is given printed instructions as to the preparation for the operation and as to the care of the child after the operation. The attendance of the parent is not insisted upon, but the attendance of a responsible adult is required on the day of the operation. This hospital is within the district of the Westminster Health Society, which has a special organisation for attending to matters concerning the health of children in its district, and it has been arranged for nurses to visit the homes of all children operated upon and to carry out home nursing of children when necessary. Children in other districts are dealt with through local nursing associations. (3.) Deptford Children's Health Centre, George Street, Deptlord Green.—This centre was established by Miss Margaret McMillan in June, 1910, and at first was supported entirely by voluntary subscriptions. Since October of the same year the Council has given financial assistance in respect of dental treatment, and since January, 1912, in respect of medical treatment also. In addition to ailments for which the Council makes provision, the centre also deals with general ailments such as anaemia and debility, and at a branch centre known as the " Evelyn Medical Home " breathing exercises, massage, and treatment for spinal curvature are carried out. Cases under the Council's scheme requiring operations for enlarged tonsils and adenoids are also treated at this Home. The health centre in George Street consists of two rooms only, in which, with the exceptions mentioned, all the treatment is carried out. One room on the ground floor is used largely as a waiting and play room. The room above is that which is used principally for treatment, and here it often happens that several children are being dealt with for different ailments at the same time. Moreover, apart from the Council's work, the treatment of children under school age is also carried on here. The Home in Evelyn Street, besides being used as a centre for all operations under the Council's scheme other than dental, is used for remedial exercises, and has been adapted as a night camp for girls, the garden at the rear being used for this purpose, and on an adjoining open space an open air school is held. The agreement with the Council now provides for the treatment of 440 eye cases, 880 ear, nose, and throat cases, 3,520 dental cases, and 660 nursing treatment cases a year. The attendance of the children is very good. Miss MacMillan not only treats children for the specific ailment for which they are referred, but attempts to make the centre an agency by which their general health and well being is supervised. There is no doubt that the centre exercises an influence in the neighbourhood of a remarkable kind, and its beneficial results are evident in the neatness, cleanliness, and manners of the children who attend. (4) Fulham Treatment Centre, 18 and 20, Bagley's Lane, Walham Green, S.W.—This centre was opened for dental treatment by Mrs. G. M. Trevelyan in June, 1912, and extended to provide medical 23610 T 2 140 Annual Report of the London County Council, 1913. and nursing treatment in October, 1912. Both medical and dental work are now carried on under agreement with a local committee under the chairmanship of the medical officer of health of the borough Dr. J. C. Jackson, Mrs. Trevelyan acting as honorary secretary. The agreement provides for the treatment of 660 eye cases, 660 ear, nose and throat cases, 1,540 dental cases, and 660 cases requiring nursing treatment. The premises consist of a pair of adjoining private houses adapted for the purpose, and are conveniently situated within easy access of Walham Green Station and close to several omnibus routes. The treatment has been very satisfactory and the attendance of children has been well (maintained. The capitation payment for dental cases treated at this centre has been revised, and the payments now made are at the rate of 2s. a case for the first 1,000 cases, and Is. a case for all additional cases. (5) Hackney treatment centre, 8, Lower Clapton-road, N.E.—The agreement with the committee of Hackney medical practitioners provides for the treatment of 880 eye cases, 880 ear, nose and throat cases, 660 minor ailment cases and 1,540 dental cases a year. The premises consist of a suite of six rooms in a large house at No. 8, Lower Clapton-road, which is the headquarters of the nursing staff of the Hackney District Nursing Association. The situation of the treatment centre is excellent in every way, being quite close to the various tramway, omnibus and railway routes which traverse Hackney in all directions. There is a separate entrance to the rooms used as the treatment, centre. On the ground floor there are two large rooms, one is used as a waiting room for parents and children and the other for the treatment of minor ailments. Upstairs there are four rooms on the first floor. Two of these are used for the examination of eye cases on one afternoon a week, and on the other days for undressing children preparatory to operation. The two remaining rooms, which are adjacent to one another, are used as operation and recovery rooms. (6) Hammersmith treatment centre, Carnforth Lodge, Hammersmith-broadway.—This centre, which was opened on 11th March, 1913, for nursing treatment, is organised by the Hammersmith and Fulham District Nursing Association at their headquarters at Carnforth Lodge. A special structure has been erected in the garden at the back for the reception and treatment of the children. The rooms used are very well situated, the light is good and the place very quiet. The children are admitted through the garden by a side entrance. The centre is in a very accessible position, close to Hammrrsmith-broadway. The number of new cases receive 1 is 15 a session. A capitation payment of 4d. a case is made on a minimum of 660 cases a year, and a grant of £12 10s. is allowed to the association in respect of the rent of the premises for the current year. Arrangements have also been made with the association for the treatment at the centre of 1,540 dental cases a year. (7) Home and In firmary for Sick Children, Lower Sydenham, S.E.—The arrangements made by the Council for treatment at this hospital provide for the treatment of 250 eye cases and 250 ear, nose and throat cases annually. Throat cases and eye cases are sent here alternately in successive weeks. The operations are carried out by the ordinary staff of the hospital, who attend on Friday afternoons to deal with Council cases only. The throat and ear cases, mostly operation cases, are seen in the out-patients' department attached to the hospital, where the waiting-room accommodation is adequate. The operations are performed in the operating room of the hospital, one of the small wards adjoining being used as a waiting and undressing room. The Council makes an allowance of £10 a year to the authorities of the home in respect of the extra nursing assistance which has been necessary in connection with the cases sent to the hospital. (8.) Islington treatment centre, 37, Thorn hill-road, Barnsbury, N.—This centre is situated in the midst of an area which is relatively poorly equipped with hospital accommodation. The agreement with the local committee of medical practitioners provides for the treatment of 880 eye cases, 880 ear, nose, and throat cases, 264 ringworm cases, and 660 cases requiring nursing treatment. Recently the work has been extended to include treatment for 1,540 dental cases annually. The work is carried on in an excellent house, with good accommodation, consisting of a large waiting-room for parents and children, whilst another large room on the same floor is used for the examination and treatment of minor ailments. On the first-floor there are two rooms—one used for operations and for the examination of eye cases, the other as a recovery room. The X-ray apparatus is fitted in a room in the basement. Dental cases are treated on four half-days a week. The attendance of the children and the work at this centre have been generally very satisfactory. There appears to be here much less difficulty in securing attendance for treatment than in some other parts of London. (9.) London Hospital.—The work at this hospital is almost too well-known to need description. It should be mentioned, however, that it was at the request of the London Hospital authorities that the system was inaugurated whereby the Council's officers attend certain of the hospitals to regulate the attendance of the children, to supply information to Care Committees with regard to treatment, and to secure nursing assistance in the homes. At the London Hospital the surgeons attach special importance to the co-operation of the Care Committees, and it has often been found possible to arrange for convalescent home treatment to adopt special measures with regard to trachoma, and to supplement in several ways the treatment given at the hospital. The Council has made arrangements for the treatment of 3,000 eye 'cases, 3,500 ear, nose, and throat cases, 350 ringworm cases, and 1,540 dental cases, 8,390 cases in all, a very considerable proportion of the total numbers for which arrangements have been made in London as a whole. Separate waiting-rooms, consulting-rooms, and operating-rooms are allotted to the Council's cases. A nurse from a district nursing association visits the homes of the children after operations and to give nursing treatment for suppurating ears. The nurse also applies atropine in cases where the parent is unable to do this successfully. Children attending with a ringworm voucher card are sent directly to the surgeon without passing through the receiving room, but no case is treated by X-rays without the written consent of the parent. Situated in the heart of a populous centre there is no difficulty in securing the attendance of the full numbers, and most excellent work is being done. (10.) Marylebone nursing treatment centre, 25, Exeter-street, Lisson-grove, N.W.—The arrangements at this centre, which is provided by the Paddington and St. Marylebone District Nursing 141 Report of the County Medical Officer—Education. Association, came into operation on 22nd February, 1913. Nursing treatment only is given, the guaranteed attendance being 660 cases per annum. A nurse attends the centre every day, and visits the homes of the children when necessary. The accommodation consists of two rooms on the ground-floor, the front rooru being used for treatment and the back room as a waiting-room. A side entrance affords access to the latter room. (11.) Metropolitan Ear, Nose and Throat Hospital, Fitzroy-square, W—The arrangements at this hospital differ from those in force at the other hospitals included in the Council's scheme, inasmuch as the agreement does not provide for the attendance of a definite number of children annually, and a different method of payment is adopted. As a rule only one or two patients are sent by the Council on any one day. In view of the small number of cases referred to the hospital, an inclusive capitation payment of 6s. is paid and the patients are seen by the ordinary staff of the hospital. The children are specially registered and are given precedence over other out-patients, They are, moreover, allowed to make their first attendance at any time in the afternoon. Operations are usually fixed for only a few days later than the first attendance, and the parents are required to sign their consent to the operation in a register kept for the purpose. Operations are performed about 9.30 in the mornings, and, as a rule, children are ready to leave about 2 p.m. The hospital is open every day, and the convenience of the parents can thus be considered in making appointments. (12) Metropolitan Hospital, Kingsland-road, N.—The Council's arrangements with this hospital began in February, 1912. These provide for the attendance of 500 eye cases and 500 ear, nose and throat cases a year, and these numbers have been fully maintained. One session a week is devoted to eye and one to throat cases, but operations upon throat and nose cases are performed at a separate session. The arrangements generally at this hospital are very satisfactory. (13) Miller General Hospital, Greenwich-road, S.E.—The present agreement with this hospital provides for the treatment of 500 eye cases, 500 ear, nose and throat cases and 88 ringworm cases a year. Payment for the treatment of ringworm is made at the rate of £1 a case, but this sum includes the services of the surgeon in charge of the X ray apparatus. The waiting room accommodation is not altogether satisfactory, but the hospital authorities are of opinion that school cases would best be dealt with at a treatment centre, and it is only pending the making of suitable arrangements with local practitioners that they have consented to renew the agreement. Negotiations are now in progress for the establishment of a dental centre in the neighbourhood with a view to its extension to include medical treatment on the expiration of the agreement with the Miller Hospital. (14) Norwood treatment centre, 3, Chestnut-road, Norwood.—This centre was the first of the school treatment centres established bv committees of local medical practitioners, and was opened in September, 1910. The premises consist of a double-fronted detached house, and six rooms which have been specially fitted up are used for the purposes of the centre. At present provision is made for the treatment of 880 eye cases, 440 ear, nose and throat cases, 176 ringworm, and 1,540 dental cases. The children and their parents are received in a large cheerful waiting room on the right of the entrance hall. The roam the other side of the hall is used as a consulting room. On the first floor four rooms are used, one as an operating room, one for preparing the children for operation, one as a recovery room and one as an X ray.room. There is also a bath room used for rinsing mouths after dental treatment. One of the Council's nurses attends this centre daily to assist the surgeons and make the appointments for both medical and dental cases; she also supplies information to the school care committees in connection with the following up of children who fail to keep appointments, or who require home treatment; a second nurse is supplied by the Council to assist the dentist. Generally the attendance is good and the treatment is very satisfactory. (15) Peekham treatment centre, 412, Old Kent-road.—The existing agreements provide for the treatment of 660 eye cases, 880 ear, throat and nose cases, 176 ringworm cases, 1,320 minor ailments and 1,540 teeth cases a year. The centre is situated in the Old Kent-road, and is easily accessible from Peekham, Rotherhithe and Camberwell. The premises consist of a ground floor room divided for use as a waiting room, and for the treatment by the nurse of minor ailments. On the first floor are the operating room and the recovery room. The latter is also used as a consulting room by the minor ailment doctor and ophthalmic surgeon. A portion of it is converted by a wooden partition into a dark room for retinoscopy. On the second floor are situated the dental operating room and a room which is used as a preparing room on operation days and for the X-ray apparatus. One of the Council's nurses is constantly in attendance at the centre. The arrangements for the treatment of the children at this centre are excellent and the attendance has been most satisfactory. The number of attendances of children for nursing treatment has been especially high, and the nurse provided by the Ranyard Nursing Association has found it difficult to carry on the work single handed. Arrangements have therefore been made for the daily attendance of two nurses to deal with the treatment of 1,320 cases a year. (16) Poplar treatment centre, 69, East India Dock-road, E.—This centre is organised by a voluntary committee, and the agreement provides for the treatment of 880 eye cases, 1,320 ear, nose and throat cases, and 660 minor ailments cases per annum. The premises rare situated adjacent to the various tramway and omnibus routes of Poplar and Stepney, and they are admirably suited for the purpose of a school treatment centre. The rooms are large, well-lighted and well-ventilated, and the uppermost floor is devoted to the offices of the district organiser of care committee work. The fact that the premises are spacious enough to permit of the accommodation of the care committee workers and the treatment of patients under one roof is found to be of considerable advantage. The ground floor contains two large rooms, one of which is used for the examination of eye cases and the other for the treatment of minor ailments. Adjacent to these two rooms is another portion of the house, which contains an excellent waiting room for parents and children. On the first floor there are two large rooms, one of which is used as an operating room and the other as a recovery room, and here, again, there is a waiting room and proper lavatory accommodation. The second floor contains the three rooms which, as above-mentioned, are devoted to the office work of the care committee organising staff. 142 Animal Report of the London County Council, 1913. During the opening weeks two sessions per week were devoted to the treatment of eye cases and three sessions to the treatment of throat cases. It soon became obvious that more sessions were required for eye work, and there was some difficulty in obtaining the full number of throat cases. As one of the members of the staff was able to do either eye or throat work an arrangement was then made whereby the number of sessions devoted to eye work could, when necessary, be increased to three per week and those devoted to throat work be reduced to two. At the end of the year this centre had only been in operation for about eight months, but from the commencement the attendance of the children has been very good and satisfactory work is being carried out. (17) Poplar Hospital for Accidents, East India Dock-road, E.—The hospital is situated in East India Dock-road, within easy access of schools in Poplar, Bow and Bromley, and Limehouse. It was one of the earliest of dental treatment centres, the arrangement with the Council beginning in March, 1911. The rooms allocated for dental treatment are reached from the out-patients' entrance in Brunswick-road. There is a large waiting room for parents and children, practically out of hearing of the consulting room, a small waiting room (at some distance down the corridor) where the " next child " waits without a parent, and adjoining this is the consulting room. Beyond the consulting room are two waiting rooms used on " gas " days as recovery rooms. Papers and magazines are provided for parents and puzzles and games for children in the large waiting room, there are toys in the small waiting room, and specially attractive toys are set out in the consulting room round the dental chair. Provision is made for the treatment of 1,980 cases a year, and " gas" cases are taken on one afternoon it) alternate weeks. The nurse collects the voucher cards and takes the children in order of arrival, except that children accompanied by fathers, or mothers with babies, are given preferential treatment. An attempt was made to summon parents at intervals of 15 minutes, but this led to confusion owing to unpunctuality, and the plan was given up. One child is always ready in the small waiting room. The dentist sees the parent after the child has been treated and explains what has been done and the importance of brushing the teeth, etc. If " gas " is ordered the appointment is made by the nurse and instructions as to preparation and a card of printed instructions are given. Some difficulty was at first experienced in securing the attendance of children at the centre, but latterly there has been a considerable improvement in this respect. (18) Queen's Hospital for Children, Hackney-road, E.—The arrangements with the authorities of this hospital provide for the treatment of 1,540 dental cases annually, and began in July, 1913. A half-time dentist at a salary of £200 a-year is engaged, and the anaesthetist attends on one session a fortnight. Premises adjoining the hospital have been specially equipped for the purpose, and form a very satisfactory centre, serving the crowded districts of Bethnal Green, Haggerston and South Hackney. The attendance of the children is very good. (19) Rotherhithe Nursing Treatment Centre. Bermondsey Settlement, Farncomle-sireet.— This centre began work in a single room at the Bermondsey Settlement in March, 1913, for the treatment of minor ailments only. Later, the settlement authorities also allowed the use of a second room as a waiting-room for parents and children on the doctor's day. More recently proposals for the extension of the arrangement to include dental treatment have been the subject of negotiation, and some considerable alterations are now being made to adapt the premises for this work. It is contemplated that provision will be made for 1,540 dental cases, in addition to the 6b0 nursing treatment cases per annum included in the existing agreement. (20) Royal Eye Hospital, St. George's-circus.—This hospital is easily accessible by tram from nearly all parts of South London, and is used to a very large extent for the treatment of children living south of the liver. When the Council entered into an agreement with the committee of the hospital for the treatment of school children the hospital was enlarged in order that the children might, as far as possible, be dealt with apart from other patients. The arrangements provide for the treatment- of 4,000 eye cases a year. The difficulty which was previously experienced, owing to the fact that a large number of children attended at hours when the children's department was not open, has been minimised by making arrangements for the children's department to be open every week-day morning, and a special notice has been placed at the hospital directing parents to bring their children at this time. (21) Royal London Ophthalmic Hospital, City Road, E.C.— The present arrangements at this hospital provide for the treatment of 5,000 children a year. A special children'sidepartment has been provided for dealing with refraction cases, and t he accommodation and arrangements for accommodating the children are well designed. The cases are all seen in the special department, and those requiring treatment for eye diseases are referred to the ordinary out-patients' department. Refraction cases are registered in the special department, and their records are kept there. In the out-patients' department children are given precedence over adults in order to minimise the period of waiting, and those requiring treatment are dealt with on the first visit. Refraction cases form about four-fifths of the number treated, and all cases for which glasses are prescribed are required to attend for reinspection within a year, the care committees being reminded of the appointment by one of the Council's organisers. (22) St. Cecilia's School Treatment Centre, 535, Commercial Road, E.—This centre is conveniently situated with regard to the main omnibus and tramway routes. Originally opened for the treatment of minor ailments and the cleansing of verminous children its scope has recently been increased by the provision of facilities for the treatment of 1,540 dental cases a year. The number of minor ailment cases for which agreement is made is 440 per annum. The arrangements have been and continue to be satisfactory. (23) St. George's Dispensary, Blackfriars.—This centre may be said to constitute the foundation of the Council's dental treatment scheme, for in Januarv, 1910, advantage was taken of the offer of Dr. R. A. Kirhy to provide dental treatment for elementary school children free of charge for one year. The experience gained as the result of this experiment was most valuable and helped in no small measure to facilitate the development of the dental scheme now in operation. 143 Report of the County Medical Officer—Education. The premises are situated in the densely populated area adjacent to Blackfriars-road, and arc easily accessible. The waiting room, is a pleasant one, and it opens on to the street. The consulting room is reached by a winding staircase, and the recovery room is opposite to it. The centre is open five afternoons a week and there is a " gas" day once a fortnight. There are two dentists, one of whom acts as inspecting dentist in the schools. The number of older children attending is small, and, as far as possible, each case is completed at the first visit. Two nurses are present on extraction days, one assists in the consulting room and the other has charge of the recovery room. Operations begin at 2.30 p.m., and the children are generally kept until 5 or 6 p.m. There has been no difficulty in keeping this centre fully supplied, but a large number of appointments in excess of those required have to be made. In connection with the work of this centre a member of the school medical staff has in some instances visited schools and interviewed parents of untreated children with good results. At the end of 1913 apparatus was installed for the X-ray treatment of ringworm, and arrangements were made for the treatment of 176 cases a year. Ear, nose, and throat eases have been treated since October, 1912, to the number of 440 a year; provision is, moreover, made for 2,640 dental cases. (24) St. George's Mission, 53, Ethelred Street, Lambeth.—This centre was opened in November, 1912, for the treatment of minor ailments by a voluntary committee under the direction of Mrs. Anstruther. Arrangements have been made for the treatment of 660 new cases per annum. Owing to the proximity of the centre to St. Thomas' Hospital, the attendance at first was not good, but since it has become better known there has been considerable improvement in this respect. The " following-up " work at this centre is being especially well done. (25) St. Marylebone General Dispensary, 30, Marylebone-lane, We/beck-street, W.—This centre, established by the committee of the St. Marylebone General Dispensary, was opened for the dental treatment of Council cases in October, 1912. The premises are situated at the corner of Welbeckstreetand Marylebone-lane, and are very convenient of access for a large number of non-provided schools in Marylebone. The rooms used in connection with the treatment of the children consist of a corridor which is used as a waiting-room, a small treatment room and a recovery room. The present arrangements provide for the attendance on three sessions a week of 1,100 cases a year. Although the accommodation is somewhat limited the treatment is being carried out in a very satisfactory manner, and the attendance is good. (26) St. Mary's Rmguorm School, Eltham.—This school is organised by the Southwark Catholic Rescue Society in connection with their work. The present arrangement with the society includes the treatment by X-rays of 66 cases a year, for which a payment of £1 Is. a case is paid by the Council. The school is situated in High-street, Eltham, close to the tram route from Woolwich and omnibus routes to Lewisham and Lee; a very convenient centre for this isolated district. Quite recently there has been some little difficulty in supplying the necessary cases, but the treatment, the average duration of which is about four weeks, has been very satisfactory. (27) St. Mary's Hospital, Paddington.—Arrangements have been made at this hospital for the treatment of 500 eye cases, 500 ear, nose and throat cases and 176 ringworm cases a year. The children are received in the ordinary out-patients' department, but are registered in separate books. Special benches are provided for them in the waiting room, and they are dealt with by the surgeons apart from the other patients. Urgent cases are seen at any time. In the aural department the surgeons insist on the attendance of parents, and a form of consent is thus not required. After operation the children lie on mattresses in the recovery room and are covered with blankets. They are seen by the surgeon before being allowed to leave, usually after the lapse of about two and a half hours, but longer if necessary. All children operated upon are visited by district nurses, but syringing of the ears at home is not undertaken unless it is found that the parents are unable to do it. Generally the arrangements are very satisfactory and the attendance is exceptionally good. (28) St. Pancras treatment centre, 26, Prince of Wales Road, N. W,—This centre was opened on 18th November, 1912, and the present arrangements include the treatment of 880 eye cases, 880 ear, nose and throat cases, 660 minor ailment cases, and 1,540 dental cases a year. The house is semidetached, with a small garden front and back, and is conveniently situated as regards tramway and omnibus routes. A room on the ground floor is used as a waiting room, but in fine weather the children are allowed to stay in the garden. The " minor ailments " nurse is provided by the St. Pancras District Nursing Association. For some little time after the opening of the centre the attendance was not satisfactory, but as a result of a conference between members of the local association and the centre authorities certain alterations in the method of referring cases for treatment were introduced and the attendance has since improved. (29) Shoreditch nursing treatment centre, 80, Nichols-square, Hackney-road.—This centre has been quite recently established in a thickly populated area where a number of large elementary schools are within very easy access. The centre serves a large portion of South-West Bethnalgreen, as well as a considerable area in Shoreditch. Provision has been made for the treatment of 660 new minor ailment cases per annum. The premises consist of two extremely convenient, though small, rooms within the residence of the nursing staff at 80, Nichols-square. Very successful work is being carried out at this centre. (30) South London nursing treatment centre, 56, Wickersley-road, Battersea.—Nursing treatment was given at this centre, which was organised by the South London Nursing Association. The arrangements were put into operation on 14th December, 1912. The premises consisted of a small house near Clapham-junction. The doctor, instead of attending for two-and-a-half hours on one session a week, attends for a shorter time on each of two sessions, and this plan has been found of great advantage in facilitating the discharge of cases. Recently the committee of the centre have taken 144 Annual Report of the London County Council, 1913. larger premises at 12, Grayshott-road, Battersea, and have provided facilities for dental treatment of 1,540 cases a year on the usual conditions. This centre has been exceptionally well attended since the opening, and arrangements have been made for the attendance ot 1,320 new cases requiring nursing treatment annually. The doctor visits the centre on two sessions a week, and two nurses are in daily attendance. (31) Wandsworth centre, 315, Qarratt-lane, Wandsworth,—This centre was established in January, 1911, shortly after that started at Norwood, by a committee of local medical practitioners. Although the accommodation is somewhat limited, the arrangements for the reception and treatment of the children are very satisfactory. The present agreement provides for the treatment of 880 eye cases, 880 ear, nose and throat cases, 220 ringworm cases, 660 " minor ailments" cases and 2,200 dental cases. The ringworm cases are not treated at Garratt-lane, but at the private house of Dr. Macrory, at Bridge-road, Battersea, but with the opening of the new centre contemplated at Tooting the use of the Battersea premises will be discontinued. The centre is widely known among the parents in the district, and no difficulty is experienced in securing the attendance of the children. The present agreement permits of the services of the anæsthetist for dental cases on one session a fortnight only. Treatment is given on six sessions a week, and it was found impossible, under the existing conditions, to cope with the accumulation of cases requiring gas treatment. It was, therefore, decided to allow the services of the anaesthetist on one session a week instead of on one session a fortnight. The committee of the centre also desired that an anaesthetist might be engaged on two sessions a week, instead of one, in the throat department. There has been some pressure of work in this department, but it was thought that the services of the anaesthetist were not required regularly on two sessions a week. In the agreement, therefore, provision was made for his attendance on one day a week, and it was arranged that extra sessions, not exceeding 15 during the year, at a rate of £1 2s. 9d. a session, should be allowed, at such times as, in the opinion of the school medical officer, they were necessary. (32) Western Dispensary, Rochester Row, Westminster.—This dispensary was founded in 1789, but the premises are of recent construction and well arranged. The agreement with the Council for the treatment of 1,540 dental cases per annum only came into force in December, 1913, so that there has been little time to judge of the results, which promise, however, to be very satisfactory. New methods of recording cases have been introduced here which it is hoped, after some further experience, may be extended to other centres. (33) Women's Hospital for Children, 688, Harrow-road, W.—This centre is situated in a district containing a large number of elementary schools, and is on omnibus and tramway routes which render it accessible from most parts of Marylebone, Paddington and North Kensington. Two houses have been adapted for the purpose, and there is a large room on the first floor where eye and aural cases are examined. There is a small waiting room on the same floor for parents and children. When eye cases are seen, part of this room is darkened by a curtain which can be drawn across a recess. A small room on the ground floor is used for minor ailments, and the parents and children wait their turn to see the doctor in an adjoining room. A third room on the ground floor is used by the nurse for her treatment of minor ailment cases. The nurse is provided by the Paddington and St. Marylebone District Nursing Association. The present agreement provides for the treatment annually of 500 eye cases, 500 ear, nose and throat cases, and 660 minor ailment cases. (34) Woolwich centre.—The original centre was organised by the committee of the Woolwich and Plumstead Cottage Hospital, and the arrangements provided for the annual treatment of 500 eye cases and 1,000 ear, nose and throat cases. A local committee of medical practitioners have since arranged for the establishment of a new centre at 61 and 63, Brewer Street, Woolwich, which is in a more central position than the Cottage Hospital, and as from the 31st July, 1913, the agreement between the Council and the committee of the hospital was terminated. The new centre is much more conveniently situated, and the premises are commodious and well equipped. The attendance hitherto has been very good. Treatment is provided for 440 eye, 880 aural, 176 ringworm, and 1,540 dental cases a year. In addition daily nursing treatment is given, the agreement providing for the attendance of 660 new cases a year. With regard to the use made of the facilities provided by the Council for medical and dental treatment, the following table may be of interest. The total numbers under agreement differ somewhat from the numbers given earlier in this statement, inasmuch as they are based on the average numbers throughout the year instead of the actual numbers on the 31st December, 1913 :— Ailments. Average numbers under agreements during 1913. Numbers treated under these arrangements, during 1913. Eyes (refraction and diseases) 21,745 21,464 Ear, nose and throat 17,794 13,618 Ringworm 1,638 1,646 Nursing treatment 12,082 10,159 Teeth 27,093 20,130 Totals 80,352 67,017 In relation to the numbers for which provision is now made these figures show that it may be necessary to increase still further the facilities for the treatment of eye defects. On the other hand it would appear that the number of ear, nose, and throat cases has attained a maximum, and that the number of these defects is being steadily reduced as the result of treatment. It may be anticipated, therefore, that no considerable increase will be necessary under this heading. With regard to Report of the County Medical Officer-—Education. 145 worm the increased provision already made is sufficient for present needs, but the ultimate demands for X-ray treatment cannot be at present gauged. The question of nursing treatment has already been discussed. It is obvious that larger provision would be justified, and yet the number of patients treated falls considerably short of that which might be expected. This form of treatment presents inherent difficulties inasmuch as regular attendance for varying periods is required, and it follows that the centres must be relatively numerous, and so situated as to be easily accessible from the children's homes. This end is being kept in view. As regards dental treatment Mr. Wallis reports that the attendance of children at the centres is on the whole extremely good; the dentists and nurses appear to be popular and are assisted in every way by the efforts of the local organisers and care committees. With the first two centres started, viz., St. George's Dispensary and Poplar Hospital, a very real difficulty was experienced in securing the attendance of a sufficient number of children, and it was often necessary to make a very large number of appointments in the hope that perhaps one-third of the number might be kept. The educative influences at work during the last two or three years have reduced this difficulty, and many parents are now found ready and even anxious to secure treatment for their children. The attendance of children at all the centres is still found at times to be subject to variation, which is due perhaps to special local circumstances, weather conditions and similar influences which have a disturbing effect of a temporary nature. Treatment is as far as possible limited to children of 6, 7 and 8 years of age, but in many cases children of other ages referred by the school doctor also receive attention. These older children require considerably more of the dentist's time than the children of the selected age group, and in the later schemes it has therefore been impossible to deal with them. Exception, however, has been made in the case of children suffering from serious oral sepsis or cases in which operations for the removal of adenoids or enlarged tonsils cannot be performed owing to the condition of the teeth. At all the centres the principle adopted is that every saveable tooth is conserved and every unsaveable tooth is extracted, so that after treatment each child's mouth should be free from any source of dental sepsis. Considerable congestion has been experienced at some of the centres owing to the large number of children awaiting treatment under an anaesthetic, and it has been necessary to provide extra sessions in order to dispose of these cases. The results of dental treatment for the year 1913 are shown in the following table:— Centre. No. of children attended. No. of attendances. No. of teeth or roots extracted. No. of stoppings. No. of other operations, e.g.; scaling, immediate regulation, application of Ag. N03, etc. No. of general anaesthetics. Nitrous Oxide. Ethyl Chloride. Other general anaesthetics . Temporary Permanent Deptford 2,874 3,914 4,996 1,111 5,038 568 980 - - Fulham 1,407 1,689 5,908 676 2,270 707 282 — - Hackney (from 30.9.13) 351 494 843 60 359 54 99 15 - Hammersmith (from 17.7.13) 564 635 2,096 176 286 36 — 150 - Islington (from 7.7.13) 534 790 1,882 229 779 204 183 — - London Hospital (froml3.10.13) 243 345 1,195 219 371 24 83 — - Norwood 1,419 2,244 5,485 613 3,634 309 336 — - Peckham (from 21.4.13) 829 1,136 1,810 345 1,598 344 221 30 - Poplar Hospital 1,504 2,070 5,130 634 2,415 1,008 97 145 242 Queen's Hospital (from 7.7.13) 695 958 3,189 366 1,300 12 — 194 - St. Cecilia's (from 7.7.13) St. George's Dispensary 488 695 1,507 161 276 4 161 — - 2,103 2,779 6,722 1,377 3,732 91 272 233 64 St. Marylebone Dispensary 974 1,878 3,067 247 1,362 126 — 416 - St. Pancras (from 7.4.13) 1,114 1,728 4,039 594 783 — 349 — - South London (Battersea) (from 10.11.13) 226 312 999 101 230 13 34 16 — Wandsworth 2,129 2,940 11,483 1,332 688 6 715 - - Western Dispensary (from (from 8.12.13) 77 102 275 — 131 30 19 — — Woolwich (from 3.9.13) 599 847 1,271 241 363 18 79 — — Totals 20,130 25,556 61,897 8,482 25,625 3,554 3,910 1,119 306 A striking feature of the Council's medical treatment scheme as now constituted is the development of the " Medical Treatment Centre." As pointed out in the last annual report the tirst institution of this kind was opened in July, 1910, in Hampstead. An extension of use of this type of centre was suggested by the Council in 1911, and as the result of a conference with the officers of the Board of Education in May, 1912, some modifications were made in the agreements and arrangements relating to certain new centres were approved. At the end of 1913 among the institutions approved for the medical treatment of school children there were 16 centres specially established for this work. Apart from the 9 general hospitals included in the scheme, moreover, treatment is afforded at certain dispensaries and special hospitals, so that, adopting the classification of school clinics as set out by the Chief Medical Officer of the Board of Education on pages 172 and 173 of his annual report for 1912, there were in all 25 school treatment centres. Whilst it is now generally admitted that the hospital is, in London especially, a most important element in the construction of a complete scheme, the medical treatment centre possesses greater elasticity and lends itself in some respects more readily than the hospital to the needs of the education authority. On page 176 of the report to which reference has just been made, the Board's Medical Officer, after discussing the difficulty of co-ordination between the hospital and the school medical service, 23610 u 146 Annual Report of the London County Council, 1913. continues;—"Then,treatment as carried out at a hospital can seldom be complete in the fullest sense. The arrangements do not allow of effective after care, and for this purpose the child who has been treated must be transferred to the school clinic. Particularly in respect of what are called " minor ailments " is hospital treatment of necessity somewhat unsatisfactory. A large proportion of these conditions require daily treatment of a simple kind. This treatment is easily carried out by a trained nurse under medical supervision. In regard to these ailments the actual provision of ointment or lotion is the least important element in their treatment; it is the regular, careful, and appropriate application that really matters. For this reason it may be said that the hospital is not, in most cases, a satisfactory place for the treatment of such conditions." In London the hospitals do not themselves undertake nursing treatment, but arrangements have been made for this work to be done at 17 of the medical treatment centres. Another advantage of the nursing treatment centre is its adaptability for dental work, and more recent extensions of the treatment scheme have been in the direction of using premises for dental and nursing treatment combined, this type making for economy in management, organisation, and nursing assistance. "Following Up." An important part of any medical treatment scheme, and one to which in London the Council has paid particular attention, is the work briefly referred to as " following up." As mentioned in the last annual report every large school or group of small schools has a School Care Committee, and the work of these care committees is co-ordinated by a staff of paid organisers in the employ of the Council. In connection with the scheme of medical treatment very considerable use has been made of this organisation, which in effect acts as an intermediary between the education authority and the parent. The work of the care committee, so far as medical treatment is concerned, deals with all the processes which lie between the discovery of the defect in the child by the school doctor and the arrival of the child at the appropriate hospital or treatment centre, the work of seeing that tbe child attends the hospital or centre regularly until cured, and the carrying out of any adjustments required in the home environment of the child during the course of treatment in order to facilitate the cure, and subsequently in order to prevent the recurrence of tbe defect or disease. The energies of the voluntary worker, or in her absence, of the organiser, are devoted to persuading the parent of the importance of obtaining treatment, discussing with her the ways and means of obtaining treatment, deciding which cases are suitable under the Council's scheme, determining the time most suitable to the particular parent, applying for vouchers, assessing the amount to be paid, explaining the necessary preliminaries and impressing the parent with the necessity of observing the times mentioned, doing all that is possible to ensure that all appointments are kept, receiving notices from the centre as to further visits necessary, ensuring, as far as possible, that these visits are made, using further persuasion in cases where there has been failure to keep the first or subsequent appointments, receiving reports from the organisers as to necessary adjustments in the home and environment of the child, ensuring, so far as possible, that these are being carried out, considering the ways and means to be adopted for supplying spectacles to each particular case (in cases of defective vision), advising and helping the parents in every way necessary, and seeing that the school doctor, at the re-inspection, is apprised of what has been done. The conditions of no two cases are alike, and the whole of the work calls for tact, judgment, thought, and knowledge. It is obvious that the medical section of care committee activity calls for no less thought, tact and knowledge than any other section, and differs chiefly in the urgency and and despatch with which the problems have to be met and dealt with. The chief part played by the organisers in dealing with this work is the making it possible for the care committees to carry out the important duties detailed above, and the success of the work, as a whole, depends upon the close touch the organisers engaged in the work of " following up " in the treatment centres have with the care committees, and the knowledge they have of the capacities, predilections and constitution of the individual care committee with which they have to deal. It is clear, therefore, that it is absolutely impossible to remove the organising of the following up " work from the general scope and structure of the care committee organisation; the work must fail from the moment when the organisers, whose chief function is making it possible for the care committees to do their work, are no longer in direct touch with the care committee. During the year to which this report relates a committee of the Council has given careful and prolonged consideration to the respective duties of the organisers and the school care committees, and has had regard to the principles just enunciated in arranging that the organising staff dealing with medical treatment and work ancillary to treatment should be wholly included in the public health department under the supervision of the school medical officer, while that portion of the staff which deals with non-medical work remains under the supervision of the education officer. As a temporary measure during 1913 as in 1912, one half of the time of one of the principal organisers of children's care work, and the whole of the time of one of the district organisers was placed at the disposal of the public health department, and the whole organising staff performed its duties in connection with medical treatment under the direction of the school medical officer. The Board of Education criticised the then existing arrangement in its letter of the 24th June, 1913, but as has been noted the matter had already then, for some time, been receiving the attention of a committee of the Council. So many considerations were involved, however, that it was not until the early part of 1914, that the question was finally settled in the manner above described. The method adopted for securing that each case is adequately "followed up" is as follows. Each school care committee is notified of the date of medical inspection in the schools, and a representative is invited to be present. The organisation thus provides for the committee to be cognisant from the outset of all the details affecting the health of the children. If treatment isrequired the parent is notified and the case is followed up by the school care committee. If found 147 Report of the County Medical Officer—Education. suitable for treatment under the Council's scheme an application is made by the care committee and a voucher card is issued by the district organiser, who also arranges, through the care committee for the case to be kept under observation until treatment is completed. For each child found to require treatment a special card is kept at the school in addition to the medical record card. Upon this special card, which is of a distinctive colour, the school doctor enters particulars of the defects found, the care committees record the progress of treatment, and the school doctor again in turn notes the results of reinspection. A record of defects and of the results of reinspection in respect of each child examined is also kept at the central office in order to prevent leakage, and to form a rota for securing medical supervision at stated intervals until the school doctor is satisfied that the treatment is completed. Towards the end of 1911 the work connected with the making of appointments for children to attend the hospital and treatment centres was transferred from the central office to the district organisers' offices, and arrangements were made for an officer of the Council to attend the hospitals and centres for the purpose of regulating the attendance of the children and of enabling the cases to be "followed up" until treatment was completed. Seven additional assistant organisers were authorised for this work, four clerical assistants were transferred to district organisers' offices, and the voucher and " following up " work in connection with the Norwood and Wandsworth centres was performed by a nurse. Upon the transfer of the medical work to the public health department ttere were, therefore, 12 officers engaged in this work, and the number of cases dealt with annually was 28,000 for medical treatment, and 8,000 for dental treatment. During the last two years, not only has the number of cases for which the Council has provided treatment been almost trebled, but the work of "following up" has been very considerably extended. Under existing arrangements a member of the care committee is present at more than 80 per cent. of all medical inspections, and 70 per cent. of re-inspections. In order that the care committee may be in a position to follow up the cases it is necessary that the officers who attend the hospital and centres should keep the committees fully informed of all the stages in the treatment, and much additional work is thus entailed. Moreover, more detailed information is now forwarded to the care committees than was the case two years ago. The arrangements for the supply of spectacles in necessitous cases and for the visits of nurses to the children's homes after operations have been performed, and generally the whole of the "following up " work make additional calls upon the staff actually engaged in the treatment centres. A most important point which should be here mentioned is that surgeons at hospitals and centres tend more and more to rely upon the Council's organisation for the following up of the children treated by them. Through the organisers they transmit to the school medical officer suggestions for the modification of school curriculum in cases which formerly would have been given certificates for total exclusion from school. This extends also to hospitals with which no agreements have been made, but which admit and welcome the daily attendance of an organiser. From time to time additional staff has been allowed as new centres were'opened, but no extra staff has been allowed in respect of the developments which have taken place in the " following up " work, and it has been necessary for the organising staff to work considerably beyond the ordinary office hours in order to cope with the work. A careful inquiry has been made with a view to determining the amount of time taken up in carrying on the work in connection with the hospitals and centres throughout the county, and, as a result, it is found that one officer working full time can, with the necessary supervision, perform all the work, including where necessary special visits to care committees and regular attendance at dental inspections, connected with the treatment and " following up " of 2,200 medical cases or 4,400 dental cases in a year. This question of the necessary increase of staff was considered concurrently with the general question of organisation and the number of officers now engaged upon this branch of the work ancillary to medical treatment is 66, viz.:—One principal assistant organiser, five district organisers, 48 assistant organisers, and 12 clerks. Reinspection of children found defective. No system of " following up" can be looked upon as satisfactory which does not provide for the reinspection of the child found defective by the school doctor. During the past year an attempt was made to reinspect three months after inspection all children found defective. whatsoever the complaint for which they had been referred for treatment or placed under observation. Those not found satisfactorily treated were further reinspected six months after the first reinspection. Tables will be found in Appendices VII-XV shewing the results of these reinspections. Refraction cases.—The number of children reinspected during the year who had been referred on account of defective vision was 16,698. Of these 9,339, or 56 per cent., were found at the first reinspection to have been treated, while 44 per cent. had had no treatment. Of the 9,339 children who had received treatment, in 5,842 cases, or 62.6 per cent.of those treated, and 35 per cent. of the whole number referred, the treatment was found complete and satisfactory. Further, of those who had procured treatment 6,713, or 72 per cent., had obtained it under the Council's scheme. By the time the second reinspection was held it was found that 56 per cent. of outstanding cases had received treatment, so that within a year of the defects being discovered 72.3 per cent. of the children found with defective vision had been treated; in the great majorityof cases (78 per cent.) the results were complete and satisfactory. Ear, nose, and throat ailments.—The number of children reinspected who had been recommended for treatment for these defects was 16,000. Of these 7,137, or 44.6 per cent., had received treatment by the time they were first reinspected, while the remaining 55.4 per cent. had not yet been dealt with. It was found that 56'9 per cent, of those obtaining treatment had received it under the Council's scheme. The records of second reinspection showed that of outstanding cases 39'6 per cent, eventually 23610 u 2 148 Annual Report of the London County Council, 1913. obtained treatment, the net result being that 56.9 per cent. obtained treatment, and of these in 87.5 per cent. of the cases the result was considered satisfactory. It is to be noted that a somewhat higher proportion of ear, nose, and throat cases remains untreated than of cases of defective vision. The repugnance to operation entertained by many parents no doubt accounts for this. An examination of the figures given in Appendix VII shows that on the whole more satisfactory results were obtained in the cases dealt with under the Council's arrangements than in those obtaining treatment through other channels; the percentage of cases which discontinued treatment before being remedied, or which from other causes remained uncured, being only 5.8 in the case of centres with which the Council had agreements, as opposed to 9.9 at other hospitals and 25.1 among those treated by a private practitioner. The close connection kept up between the care committees and the treatment centres, or hospitals, through the Council's organisers, provides a machinery whereby cases are followed up during treatment, and successive visits to the centre until treatment is complete are in this way assured in the majority of cases. Dental treatment.—The cases reinspected which had been referred by school doctors as requiring treatment for dental caries amounted to 29,833. Of these 9,912, or 33.2 per cent., were found to be treated, leaving 19,921, or 66"8 per cent., untreated; at the second reinspection treatment was found to have been obtained in 32"3 per cent, of outstanding cases. The amount of leakage in tbe case of teeth is greater than in the case of any other form of defect, as only 49'7 per cent, of those referred, or slightly less than half, obtained treatment. Only 396 per cent, of those treated obtained it through the Council's agency. It must be remembered, however, that the arrangements made by the Council do not extend to children above the age of nine, and that in effect facilities do not exist for dental treatment of children over this age. The figures here dealt with'relate to children found at medical inspections, and are quite distinct from the figures of the special dental inspections carried out amongst children aged 6 to 8 in connection with the dental treatment centres. The workers on the care committee often make complaint because of the refusal to receive the older children at the dental centres. It has been necessary, however, rigidly to observe the rule that only in special cases can children older than 8 be admitted for treatment. Whenever disproportionate numbers of older children have been given such facilities, it has inevitably resulted in the work at the centres becoming disorganised owing to the accumulation of cases requiring anaesthetics. Exceptions when made are generally in favour of children on whom the throat surgeon is unable to operate, until the mouth has been placed in a cleanly condition, and of children whose certificate for fitness to hold a scholarship is being withheld until treatment for oral sepsis has been carried out. Minor ailments.—Reinspections were held of 7,770 cases which had been reported as requiring nursing treatment; 5,032, or 64'8 per cent., were found to have obtained treatment; 45'9 per cent. of these w«re treated at the institutions maintained by the Council, 21.1 per cent. by private practitioners and 33 per cent. through other agencies. 64.3 per cent. of cases outstanding from first reinspections had obtained treatment on the second reinspection. Other ailments.—Of conditions for which the Council makes no special arrangements, 12,435 cases were reinspected ; of these 6,225, or precisely 50 per cent., were found to have obtained treatment. Of the outstanding cases the percentage obtaining treatment before the second reinspection was 55'6 per cent. The total numbers of defects requiring treatment under revision during the year amounted to 82,736 ; of these 37,645 or 455 per cent. were found at the first reinspection to have been treated; and in 25,258 cases, 67'1 per cent. of those treated or 30.5 per cent of all defects referred, the report was made that the treatment was complete and satisfactory. From the records of reinspection during the year it was found that 58.1 per cent. of defects had been treated, and in 80.9 per cent. of these, or 4.7 per cent. of all defects referred, it was reported that the treatment was complete and satisfactory. The percentage of defects which had not been treated and still found to be requiring treatment at the second reinspection was 24'9 per cent., and of those which had been treated 10 per cent. were found to have discontinued attendance before treatment was complete or remained from other causes uncured. The reinspection figures for each successive term shew a steady increase in the proportion of children taking advantage of the arrangements for treatment made by the Council with hospitals and treatment centres as indicated in the following table, giving, in the case of all defects treated, the percentage which obtained treatment through the Council's scheme:— Date of reinspection. Refractions. Minor ailments. Ear, nose and throat conditions. Dental cases. Christmas term, 1912 68.0 28.2 41.3 24.7 Spring term, 1913 69.4 37.5 53.7 37.9 Summer term, 1913 72.6 44.7 57.5 35.8 Christmas term, 1913 73.8 51.4 58.8 45.6 In the appendices are given tables showing under the various county electoral areas the results of the school doctors' reinspections of children found suffering from defects for which provision is made under the Council's scheme. Considerable variations are found in the areas in the percentages of children who thus obtain treatment. These variations depend partly upon the facilities for treatment provided in each locality, but to a greater extent upon the ease with which voluntary workers can be obtained to serve upon the care committees. At the first reinspection the average percentage, for 149 Report of the County Medical Officer—Education. the whole of the County, of children who had received treatment was 57.9. The best results were obtained in the North and West of the County, where care committees are provided with numerous workers. Thus the ten electoral areas in which the best results are shown comprise St. Pancras (W.), 77.3 per cent., St. Pancras (N.) 74.7 per cent., Hackney (S.) 70.1 percent., Hampstead 69'4 per cent., Kensington (S.) 69.2 per cent., Hammersmith 69.1 per cent., Fulham 67.6 per cent., Hackney (C.) 66.9 per cent., Kensington (N.) 66.5 per cent., Paddington (S.) 66.4 per cent.; while the poorest results are obtained in areas confined to districts south of the Thames, with the exception of one area in the far east, viz., Bow and Bromley, thus, Clapham has 49.6 per cent., Walworth 49.2 per cent., Southwark (W.) 48 9 per cent., Battersea 48.4 per cent., Bermondsey 45.7 per cent., Newington (W.) 43.8 per cent., Bow and Bromley 40.6 per cent. Co-operation between School Attendance Officers and the Public Health Department. During the Michaelmas term, 1912, an arrangement was made for the medical Certificates concerning children out of school for periods of three months and upwards on account of ill-health to be submitted to the school medical officer by the attendance branch of the education officer's department. At the expiry of six months the result of the experiment was found to be satisfactory, and it was decided that the practice should be continued. During the year 1913 the procedure was placed upon a permanent basis ; particulars of all children out of school for a period of three months on account of ill-health are reported each month to the school medical officer by the attendance department and a card index for each child is kept in the public health department. An analysis of the causes of absence relating to 3,560 such returns is given below. Rheumatic conditions— Acute rheumatism 119 Heart disease 229 Chorea 368 716 20.l per cent. Nervous conditions— Paralysis 33 Epilepsy 60 Brain disease 31 Other nervous conditions 57 181 = 5.l per cent. Tuberculous conditions— Lungs 377 Glands 68 Other organs 88 533 = 15.0 ,, Diseases of chest (excluding phthisis) 225 = 63 „ Anæmia and debility 421 = 11.8 „ Ringworm 234 = 6.6 „ Various 87 = 2.4 „ Infectious diseases 181 = 5.1 „ Diseases of skin 165 == 4.6 „ Diseases of ear, nose and throat 103 2.9 „ Diseases of eyes 310 = 8.7 „ Diseases of kidneys 28 = .8 „ Rickets, etc. 15 = .4 „ Scabies 42 = 1.2 „ Surgical conditions 168 = 4.7 „ Diseases of digestion 36 = 1.0 „ Illegible and unsatisfactory certificates 113 = 3.2 „ Specific disease 2 = .1 „ 3,560 100.0 „ It will be seen that the rheumatic group of diseases forms the highest proportion—slightly over 20 per cent. of the total—among the causes that produce protracted absences from school. Next comes tuberculosis in various forms, 15 per cent., and amongst other noteworthy conditions are ringworm, 6.6 per cent., and diseases of the eyes, 8.7 per cent. The analysis of the ages of the children given in the following table shows that at each age more girls are absent than boys. Ages 5 6 7 8 9 10 11 12 13 Boys 151 149 81 67 63 51 58 65 69 Girls 199 174 116 99 118 108 139 175 207 Total " 350 323 197 166 181 159 197 240 276 Number of children absent for more than three months distributed according to age and sex. The above table shows that at the ages of 5 and 6 an excessive number of children are absent no doubt on account of the hesitation felt in starting school attendance in the case of delicate children. Between the ages of 7 and 11 the number of children absent, both boys and girls, is comparatively low. After the age of 11 the number rapidly rises, especially in girls. This is probably due to the fact that girls at this age are useful at home, and a tendency, therefore, exists to magnify the seriousness of complaints which at younger ages would not constitute a cause for absence. 150 Annual Report of the London County Council, 1913. This tendency no longer exists to the same extent in the case of boys, inasmuch as it is exceedingly difficult with the present regulations for a boy out of school on medical grounds to be employed in wage-earning occupations. An analysis is given in the following table of the action taken in cases in which further following-up was considered advisable. Division. Certificates. Children. Referred for examination, by divisional medical officer. Divisional medical officer informed. Referred to attendance officer for further enquiry. Referred for: examination for special school. Referred for examination by ophthalmologist. Registered epileptic. Referred to organiser of care committees. Referred to school nurse for report. Camberwell 141 135 8 10 2 - 2 2 - - Chelsea 122 152 7 28 8 - - 1 - - City and Stepney 21 171 5 71 2 1 (P.D.) - 1 - - Greenwich 322 322 3 36 6 1 (P.D.) 2 6 — — Hackney 17 24 1 2 — - — — — — Islington 62 106 9 20 6 1 (P.D.) — 2 — — Lambeth 85 100 — 4 3 - — 1 - - Paddington 52 55 2 5 — — — 2 - - Poplar 96 344 31 92 5 1 (P.D.) 11 1 - St. Panoras 98 137 18 13 6 - - 1 - - Southwark 252 1,095 44 166 20 — 1 9 5 4 Wandsworth 199 690 17 63 17 — — 6 — — Total 1,467 3,331 145 510 75 4 (P.D.) 5 42 6 4 Many of the causes of absence are due to conditions which, while producing great suffering and incapacitating children from attending school, should with proper care and attention be cured in a shorter period than three months. Such conditions are scabies and various external affections of the eyes. A beginning has been made in the direction of notifying such cases to the local care committees with a view to the investigation of home conditions and ensuring regularity of medical treatment, and in suitable cases to the provision of daily nursing or convalescent treatment, or to securing attendance at the cleansing stations. The results of the examination by the Council's own medical staff in 93 cases, as a result of which it was found that more than half were fit for school, are as follows:— Fit to return to School Unfit to return to School Attendance not to be pressed. Part-time attendance. Physically de-fective school. Further examination. Camberwell 11 1 — 2 — 1 Chelsea 1 — — — — — City and Stepney 2 — 1 — — — Greenwich 3 5 — 3 — — Hackney — — — — — — Islington 2 — — — 1 — Lambeth 4 — — — — — Paddington 1 — — — — — Poplar 8 — — — 1 — St. Pancras 6 7 — — 1 1 Southwark 4 10 — — — 1 Wandsworth 8 5 — — 2 1 Total 50 28 1 5 5 4 Malnutrition. By instruction of the Children's Care Sub-Committee reports are made from time to time upon the action taken and the results obtained in cases of malnutrition found by the school doctors at routine and other school inspections. A special enquiry form is therefore issued to the school care committee concerned in the case of each case of malnutrition reported. This form contains headings referring to the supply of information as to the home conditions found and the action taken in regard to the child. When the form is received a special reinspection is made wherever possible by the school doctor who previously reported the case. Accurate weighings of the child are made by the school doctor personnally both at inspections and reinspections. Complete returns have now been received in regard to 885 cases, and these returns are now available for analysis, and have been examined by Dr. C. J. Thomas. 519 of the children were boys and 366 were girls. The cases were separated into three classes in regard to the condition of the homes, viz., "good" homes, "fair" or "doubtful" homes, and "poor" homes. The children were further classified into three age groups, viz., infants, intermediate group (7 to 10 years), and older children (11 to 13 years):— Boys. Girls. Homes. Good. Fair. Poor. Good. Fair. Poor. Older group 57 53 87 46 43 55 Intermediate group 77 48 108 33 42 62 Infant group 31 29 39 22 25 38 Totals 165 130 224 101 110 155 151 Report of the County Medical Officer—Education. It should be borne in mind that malnutrition and underfeeding are not interchangeable terms. A considerable number of underfed children are classified as "nutrition 3"; the cases investigated in this report are returned as "nutrition 4," and are diagnosed as suffering from poor nutrition to such a degree as to constitute a pathological condition. Associated Conditions.— It will be seen that 266, or 30 per cent., were children coming from homes considered good and reported in such terms as "very superior," "very comfortably off," "maid kept," etc.; 240 or 27 per cent. came from fair or doubtful homes; and 379 or 43 per cent. from poor homes in which poverty was a factor in the production of the ill-nourished condition. In many cases more than one contributory factor was mentioned and it was found impossible always to decide which of the conditions named was to be assigned as the main cause. Analysing the main conditions found in association with malnutrition, the following results are obtained:—Poverty, 379, i.e., in 43 per cent. of the cases; neglect, 53 (6 per cent.); tuberculosis, 167 (19.2 per cent.); past or recent illness other than those specifically named, 139 (16 per cent.); decay of teeth and oral sepsis, 104 (12 per cent); enlarged tonsils, adenoid growths and ear discharge, 81 (9 per cent.); rickets, 64 (7 per cent.); congenital weakness, premature birth, etc., 42 (5 percent.); intestinal parasites, 19 (2 per cent.); rapid grow th, 26 (3 per cent.); want of sufficient sleep, 27 (3 per cent.). Tuberculosis in relation to malnutrition.—Next to poverty, and bulking largely all through as a cause of malnutrition, is tuberculosis. The distribution of tuberculosis according to age and sex was as follows:— Boys. Girls. Per cent. Per cent. Older group 15.7 16.6 Intermediate group 18.3 14.0 Infant group 25.2 200 and according to type of home as follows:— Good. Fair. Poor. 17. 3 per cent. 22.2 per cent. 18 per cent. Thus, while tuberculosis in conjunction with malnutrition was diagnosed more frequently amongst infants and more frequently amongst younger boys than younger girls, there was very little difference found as between good homes and poor homes. Where malnutrition is a result of tuberculosis the condition as regards poverty could hardly be expected to make a difference, and this is what the above figures indicate. A critical consideration of the cases shews that tuberculosis was suspected as a cause or result of malnutrition in a number of the cases in addition to the 167 in which it was possible to diagnose this disease. Many cases in which only malnutrition was diagnosed belonged to homes in which it was stated that phthisis existed in other members of the family and doubtless many of such cases would ultimately be found to owe their malnutrition to incipient tuberculosis. Whether tuberculosis is the cause of malnutrition or malnutrition the precursor of tuberculosis it is in many cases impossible to determine. Either may follow upon the other. One precursor of malnutrition given in 5 per cent. of the cases is congenital debility. This condition is never found amongst necessitous families and is practically confined to "good" families. It is frequently termed the "pretubercular condition" on account of the great probability of such children eventually succumbing to an attack of tuberculosis. It appears very clear from a consideration of all the circumstances that malnutrition and tuberculosis are very closely connected and that in a very large proportion of all cases the general measures extended to combat the one condition are those that must be applied in the other. It may safely be said that a town child suffering from malnutrition if not already the subject of tuberculosis will almost inevitably fall a prey to the disease sooner rather than later if vigorous preventive measures applicable to the particular case are not applied in time. The following 30 successive cases of malnutrition with tuberculosis are taken without selection as they came to hand, and serve to show the means for combating the disease which have been available during the past year and the results obtained by their application:— Z.18 Sex, male. Age, 8 years. Height, 115 c.m. Weight, 17 kilograms. Condition of home, good. Mother a widow. Sleeps badly. School feeding, no. School dinners offered and refused. Cause—phthisis. Advised to go to Stepney Dispensary. Result—No benefit. Z.119 Sex, male. Age, 7 years. Height, 112.5 c.m. Weight, 17.7 kilograms. Number in family, 4. Number of rooms, 1. Condition of home, poor. Mother dying. Milk and oil advised by school doctor. Cause—Tuberculosis of lung, neglect (flea bitten). Action—School feeding, breakfast, dinner and milk (parent paying). Reported to the National Society for the Prevention of Cruelty to Children. Efforts made to put children in homes. Result of re-inspection—No improvement. Z.199 Sex, male. Age, 8 years. Height, 121 c.m. Weight, 20.6 kilograms. Number in family, 6. Number of rooms, 4. Condition of home, good. Bad family history of phthisis. Milk and oil advised by school doctor. Cause—Early tuberculosis. Action—Cod liver oil and malt at school, parent paying. Sent to tuberculosis dispensary. Re-inspection—Not improving; lost weight. Z.l l Sex, male. Age, 8 years. Height, 105 c.m. Weight, 18 kilograms. Number in family, 8. Number of rooms, 4. Milk and oil recommended by school doctor. Cause—Abdominal tuberculosis. Action—Milk and oil at school. Admitted to infirmary later. Re-inspection—Improved. Weight increased to 20 kilograms. 152 Annual Report of the London County Council, 1913. X.63 Sex, female. Age, 12 years. Height, 140 c.m. Weight, 29 kilograms. Number in family, 7. Number of rooms, 4. Condition of home, fair. Insufficient sleep. Cause—Phthisis. Action—Tuberculosis dispensary. Result—Losing weight (28.6). X.l Sex, female. Age, 12. Height, 131 c.m. Weight, 25 kilograms. Number in family, 6. Number of rooms, 4. Condition of home, poor. Father, drunkard, in infirmary. Mother, epileptic. 16 children, 5 died of fits. Cause—Phthisis. Action—Convalescent home. Result—Getting on well. X.52 Sex, female. Age, 12. Height, 128 c.m. Weight, 27 kilograms. Father died of phthisis. Cause—Phthisis. Action—Malt and milk from dispensary. Result—Worse, losing weight (26 kilograms). X.186 Sex, female. Age, 12. Height, 153 c.m. Weight, 27 kilograms. Number in family, 5. Number of rooms, 3. Condition of home, poor. Mother a widow, works. Cause—Phthisis. Action—Infirmary. Result—Still in infirmary. X.97 Sex female. Age, 12. Height, 120 c.m. Weight, 21 kilograms. Number in family, 6. Number of rooms, 5. Mother a widow. Oil and malt recommended. Cause—Pht hisis. Action—Excluded from school. Result—Losing ground (weight, 20 kilograms). Y.200 Sex, male. Age, 5. Height, 99 c.m. Weight, 16 kilograms. Number in family, 5. Number of rooms, 2. Condition of home, poor. Father has phthisis. 12 children dead. Cause—Tuberculous peritonitis. Action—Had treatment, operation, convalescent home. Result—Improved "cured." Weight increased (17.4). Y.222 Sex, male. Age, 6. Height, 101 c.m. Weight, 14.3 kilograms. Number in family, 7. Number of rooms, 3. Condition of home, poor. Father in infirmary. Cause—Enlarged glands tuberculous; poverty. Action—Help from Guardians; boy sent to convalescent home. Result—Still ill nourished. X.101 Sex, female. Age, 12. Height, 128 c.m. Weight, 24 kilograms. Condition of home, very comfortable. Cause—Tuberculosis; otorrhœea. Action—Tuberculin treatment; going to a sanatorium. Result—Good. X.160 Sex female. Age, 12. Height, 132.5 c.m. Weight, 23.6 kilograms. Number in family, 9. Number of rooms 6. Condition of home? fair. Insufficient sleep. Mothor a widow. Cause—Phthisis. Action—Milk at school, parent paying. Dispensary treatment. Result—Improved. X.274 Sex, female. Age 12. Height, 136 c.m. Weight, 30 2 kilograms. Number in family, 7. Number of rooms, 5. Condition of home, " fair." Father, " bronchial." Mother works. Cause—Tuberculous glands. Action—Medical treatment and cod liver oil. Result—Getting worse. Y.6 Sex male. Age, 5. Height, 102 c.m. Weight, 15 kilograms. Number in family, 5. Number of rooms, 5. Condition of home, good. School doctor advised oil. Cause:—Phthisis. Action—Sent to Chest Hospital; oil obtained from there. Result—After three months, no improvement, lost weight (14 kilograms). After six months, improved, gained weight (16.2 kilograms). Z.10 Sex, male. Age, 5. Height, 96 c.m. Weight, 15 kilograms. Number in family, 9. Number of rooms, 3. Condition of home, unsatisfactory. Sleep, not enough. Closed windows. Home feeding adequate, but injudicious. Cause—Phthisis. Action—Attended hospital 16 weeks between inspection and re-inspection. Result—Not improved. Y.20 Sex male. Age, 5. Height, 94 c.m. Weight, 15 kilograms. Number in family, 5. Number of rooms, 3. Condition of home, "poor but not necessitous." Cause—Tuberculous glands, rickets, unsatisfactory mother, injudicious feeding, premature birth, neglect. Action—Medical treatment. Result—No improvement, lost weight. Y.97 Sex, male. Age, 6. Height, 115 c.m. Weight, 17 kilograms. Number in family, 2. Number of rooms, 3. Condition of home, poor. Mother consumptive. Cause—Phthisis. Action—Sanatorium. Result—Still away. Y.231 Sex, male. Age, 6. Height, 82 c.m. Weight, 12 kilograms. Number in family, 6. Number of rooms, 2. Condition of home, poor. Father died of phthisis. Mother works. Cause—Phthisis. Action—Excluded from school, medical treatment, admitted to infirmary. Result—Still away. 153 Report of the County Medical Officer—Education. Z.159 Sex, male. Age, 7. Height, 95 c.m. Weight, 10.8 kilograms. Number in family, 5. Number of rooms, 2. Condition of home, poor. Cause—Tuberculous peritonitis, dental caries. Action—Excluded from school, medical treatment, referred to Invalid Children's Aid Association. Result—No improvement. X.316 Sex, male. Age, 8. Height, 121 c.m. Weight, 22.4 kilograms. Number in family, 2. Number of rooms, 1. Condition of home, poor. No father. Mother works. Cause—Poverty, tuberculosis. Action—Dinners and milk at school. Treatment at dispensary. Result—Considerably improved, phthisis now better, weight increased. X.415 Sex, male. Age, 8. Height, 110 c.m. Weight, 185 kilograms. Number in family, 9. Number of rooms, 3. Condition of home, poor. Insufficient sleep. Cause—Pulmonary tuberculosis. Action—Excluded from school, referred to Invalid Children's Aid Association. Result—No improvement, lost weight. Z.126 Sex, male. Age, 8. Height, 106 c.m. Weight, 17 kilograms. Number in family, 8. Number of rooms, 3. Condition of home, poor. Sleep prevented by fleas. Cause—Pulmonary tuberculosis, necessity. Action—School meals, oil from hospital. Result—No improvement. Z.88 Sex, male. Age, 8. Height, 106 c.m. Weight, 17 kilograms. Number in family, 6. Number of rooms, 2. Condition of home, poor. School doctor advised milk and oil. Cause—Tuberculosis, rickets, carious teeth. Action by Care Committee, not fed at school, but malt and oil obtained from dispensary. Re-inspection—Slight improvement, weight increased (19"3 kilograms.). Z.101 Sex, male. Age, 8. Height, 116 c.m. Weight, 20 kilograms. Number in family, 4. Number of rooms, 3. Condition of home, " fair." School doctor advised milk and oil. Bad family history of phthisis. Father died of " chest trouble." Cause—Poverty, tuberculosis. Action taken—Out-relief, Guardians giving malt and oil. Not fed at school. Re-inspection—Slight" improvement. Y.39 Sex, male. Age, 8. Height, 107 c.m. Weight, 14'5 kilograms. Number in family, 5. Number of rooms, 3. Condition of home, " fair." School doctor advised milk and oil. Cause—Tuberculous glands, insufficient food. Father dead. Action taken—Dinners and milk in school, attendance at tuberculosis dispensary. Result—Improved, weight increased 17.4 kilograms. Z.79 Sex, male. Age, 8. Height, 108 c.m. Weight, 16.4 kilograms. Number in family, 9. Number of rooms, 4. Condition of home, " fair, but stuffy." Oil advised by school doctor. Cause—Tuberculosis, mother starved before birth, intermittent poverty, verminous. Action taken—" Will not take milk," "cannot take oil" ; attends dispensary. Result—Slight improvement. X.297 Sex, male. Age, 12. Height, 148 c.m. Weight, 35 kilograms. Number in family, 9. Number of rooms, 6. Condition of home, good. Mother died of bronchitis. Cause—Pulmonary tubercle. Action—Medical treatment (Mount Vernon). Result—No improvement. X.240 Sex, male. Age, 12. Height, 144 c.m. Weight, 31 kilograms. Number in family, 8. Number of rooms, " whole house." Condition of home,"very superior." Cause—Phthisis. Action—Sent to country, medical treatment, cod liver oil. , Result—Improving. X.367 Sex, male. Age, 12. Height, 126 c.m. Weight 27 kilograms. Condition of home," good." Cause—Phthisis. Action—Tuberculosis dispensary. Result—Slight improvement. In connection with the causation of malnutrition, lack of parental care should be taken into consideration. The family histories obtained have been very carefully scrutinised with the following result:— Good homes (266)—Mother dead, 15 cases ; mother seriously ill, 5 ; mother works, 5 ; father dead, 11 ; father seriously ill, 6. "Fair " homes (240)—Mother dead, 14 cases ; mother seriously ill, 7 ; mother works, 21 ; father dead, 17 ; father ill, 9 ; father drinks, 2 ; mother drinks, 7. Poor homes (379)—Mother dead, 10 cases ; mother ill, 10 ; mother works, 64 ; mother blind, 1 ; mother epileptic, 1 ; father dead, 47 ; father ill, 27 cases ; fathor in infirmary, 4 ; father a lunatic, 1 ; father deserted home, 6 ; father drinks, 6 ; mother drinks, 8 ; in inebriates' home, 1. It may be assumed, therefore, that maternal care was lacking in the homes in 10 per cent, of the good homes, 20 per cent. of the fair homes, and 25 per cent. of the poor homes. In 30 cases one parent had died of phthisis, and in 26 further cases one parent was reported to be suffering from phthisis. Of the other main conditions mentioned as antecedent or concomitant in cases of malnutrition it is only necessary to mention that rapid growth as a cause is found only amongst boys and girls of the older age group, and that want of sleep is mentioned chieflv in older boys, and is associated with out of school work, the majority of cases being in Jewish boys, who are required in addition to ordinary school work, to apply themselves to religious instruction in the evenings. Action taken.—The measures taken by care committees in cases reported as " malnutrition " may be divided into four groups:—(i.) School feed ing with or without medical treatment; (ii.) medical treatment alone; (iii.) convalescent or institutional treatment ; (iv.) other action, such as home visiting and advice. 23610 x 154 Annual Report of the London County Council, 1913. The following table analyses the various types of action according to the assessment of the home conditions:— Good homes. Fair or Doubtful homes. Poor homes. School feeding with or without treatment 54 (20%) 50 (20.5%) 280 (72%) Medical treatment alone 86 (32%) 89 (37%) 34 (9%) Convalescent treatment 22 (8%) 19 (8%) 40 (10%) Other action 105 (40%) 83 (34-5%) 35 (9%) Of those definitely decided to belong to necessitous homes 82 per cent were met either by school feeding or by convalescent treatment; in good or fair or doubtful homes in 20 percent. school feeding was arranged, in the vast majority of cases the parents paying for the oil or milk provided. About 10 per cent. of all the cases were met by convalescent treatment, this being a larger proportion than might possibly have been anticipated. Amongst the cases of malnutrition recorded school feeding was specially recommended by the school doctors in 215 instances. These were classified into "good" homes, 50; fair or doubtful homes, 58; poor homes, 107. Feeding at school was arranged in 130 cases, viz., 19 from "good" homes, 19 from fair or doubtful homes, and 92 from "poor" homes. The school feeding in the majority of cases of malnutrition took the form of milk or cod-liver 0i1 supplied during the morning recess. The regular administration of extra feeding in this form is a very useful adjunct to other methods in all cases of malnutrition. Many of the debilitated children even from good homes are the better for it. Where it is arranged for by the Care Committee the parents often gladlv pay if able to do so. Results.—In the majority of cases re-inspections were held and the results are analysed below as "improved," "no improvement," or "worse." "Improvement" was held to have taken place if an appreciable increase of weight had occurred, "no improvement" if no appreciable increase had taken place, and the condition was considered "worse" if there had been loss of weight, however slight. Re-inspected. Improved. Not improved. Worse. Good homes. School feeding 47 37 (79%) 9 (19%) 1 Medical treatment 77 62 (80%) 14 (18%) 1 (died) Convalescent treatment 16 16 (100%) - - Other measures 90 62 (69%) 24 (26%) 4 Fair homes. School feeding 37 33 (89%) 4 (10%) — Medical treatment 79 52 (66%) 19 (24%) 8 (10%) (1 died) Convalescent treatment 13 12 (92%) 1 - Other measures 76 49 (64.5%) 23 (30%) 4 (5.5%) (1 died) poor homes. School feeding 246 191 (78%) 47 (19%) 8 (3%) Medical treatment 33 22 (67%) 9 (27%) 2 (2 died) Convalescent treatment 19 16 (80%) 2 1 Other action 33 17 (52%) 13 (40%) 3 (8%) (1 died) It is seen that in all three classes convalescent treatment has given the best results, viz., 100 per cent improvement in children from good homes, 92 per cent in fair homes, and 80 per cent in poor homes. When the weights are taken into consideration it is found not only that greater numbers improve but also the degree of improvement is greater than is attained by any other means. It will further be seen that in doubtful and in poor homes medical treatment alone and "other measures" are not productive of such good results as when they are combined with school feeding. The figures are more significant if the total numbers are taken in each class. Thus:— Re-inspected. Improved. Not improved. Worse. Good homes 230 177 (77%) 47 (20.4%) 6 (2.6%) Fair or doubtful homes 205 146 (71.2%) 47 (22.9%) 12 (5.9%) Poor homes 331 246 ( 74.3%) 71 (21.1%) 14 (4.6% Total 766 569 (74.3%) 165 (21.5%) 32 (4.2%) It is thus seen that while the best results are obtained when the homes are "good," that in the "fair" or "doubtful" homes the results are not as good as in the "poor" homes. It would seem that standards of "necessity" which apply in normal cases should not be applied too rigorously when ill-nourished children are in question; where the home conditions may be satisfactory when the inmates are in good health, the presence of illness in the home necessitates the provision of articles 155 Report of the County Medical Officer—E hicaliun. which would constitute luxury if no ill-health existed, and the provision of these comforts, such as extra milk, is beyond the means of many homes assessed as fair. The practice of different care committees varies greatlv in this respect. It would be well in all cases of malnutrition, where doubt exists as to whether the home is above or at the poverty line, if milk meals or cod liver oil were given in school during the morning recess, as experience shows it is unsafe to rely upon this being done regularly in such cases at home. Even in good homes the parents will often gladly pay for milk meals given under these conditions in school. The following case is one which shows the benefit of giving meals in school. Re-inspected four months after inspection, the child was found to have put on 1*2 kilograms in weight only; the school doctor then urged the provision of school feeding ; this was carried out and a further re-inspection five months later showed an increase of 3-4 kilograms—a very great improvement. Z.77 ... Sex, female. Age, 12. Height, 131 c.m. Weight 24 kilograms. Milk and school dinners recommended. Number in family, 7. Number of rooms, 2. Condition of home, poor. Cause—Underfeeding, poverty. Result— 21.5.13. Weight 24 kilograms. 12.9.13. Weight, 25.2 kilograms, dinners and milk started. 23.2.14. Weight, 28.6 kilograms—very great improvement. In regard to the measures taken to remedy malnutrition one other means must be especially mentioned. Next to the effect of convalescent treatment, dental treatment in cases where oral sepsis was a contributory cause has given examples in which the most striking degree of improvement has occurred. This, perhaps, is not surprising when it is remembered that in such cases, when unremedied, all food ingested is mixed with the products of bacterial decomposition arising from the unhealthy state of the mouth. It will be noted that six deaths occurred amongst the 885 cases; one in a " good" home, two in " fair" homes, and three in necessitous homes. The following are the particulars :— X.161 ... Sex, male. Age, 12. Condition of home, necessitous. Cause, poverty. Admitted to infirmary soon after being seen by school doctor. Died in infirmary. X.422 ... Sex, female. 1 Age, 6. Height, 97 c.m. Weight, 16 kilogr. Number in family, 8. Number of rooms, 2. Condition of home, bad ; sleep insufficient. Action taken, none. Died of measles and pneumonia 3 days after being taken ill. Z.lll ... Sex, female. Age, 9. Height, 110 c.m. Weight, 14.4 kilogr. Condition of home, poor. Cause—Tuberculosis. Excluded from school, attended dispensary. Finally died. Z.67 ... Sex, male. Age, 10. Weight, 30.7 kilogr. Cause—Cyst on liver and tuberculosis. Action—admitted to hospital and died. Z.72 ... Sex, female. Age, 8. Height, 101 c.m. Weight, 13 kilogr. Condition of home, fair. Milk, malt and oil given in school. Died. Y.46. ... Sex, female. Age, 5. Height, 104 c.m. Weight, 15 kilogr. Number in family, 4. Number of rooms, 2. Condition of home, good. Cause—Carious teeth, ? tuberculosis. Medical treatment obtained. Died of intestinal ulceration and meningitis. Medical inspection of feeding centres. Reports have been received from the school doctors upon 287 feeding centres during the year. The centres were visited at the hour during which the children were being fed and in addition to the sanitary condition of the centre reports were made upon the dietary, the methods of feeding, refusal of food, and other points of hygienic importance. The number of cases in which unfavourable reports were made is relatively small. Out of 51 centres upon which unfavourable reports were made last year, it was found that 18 have been since closed and of the remaining 33 the conditions considered unsatisfactory have been improved in 22 cases. Warming centres. Sanitary accommod tion, &c. The warming was reported to be insufficient in 22 centres ; in most cases the means of heating exist, but use is not made of them. It was reported that sanitary accommodation was lacking or unsatisfactory in 34 instances. In most of these no accommodation exists. The extent to which this lack is to be considered unsatisfactory depends, of course, to a large extent upon the distance of the centre from the contributory schools. The rule by which the head teachers instruct the children to use the school accommodation before leaving for the centre is probably satisfactory where the distance is small, but in the case of distant centres this is hardly a sufficient safeguard. Fortunately in most instances the schools are near. The provision at one feeding centre was reported to be in an insanitary condition and needing attention. Provision of utensils, Ac. in 21 cases the provision of utensils was reported insufficient. The question of drinking mugs is one of considerable difficulty. Sharing of mugs is a practice sometimes met with which on hygienic grounds is strongly to be deprecated. It is unnecessary, and indeed undesirable, to place drinking supplies upon the tables ; and the most satisfactory plan is that whereby children wishing for water to drink may have it after the meal is over from a tap, under which the mugs may be rinsed if it is necessary for them to be used a second time. There is at some centres inadequate seating accommodation, and overcrowding or standing at meals results. Insufficiency in one or two centres led to the undesirable result that more than one child used the same utensils without intervening cleansing. Cleanliness Uncleanliness of utensils and furniture were reported in four instances. This was due either to insufficiency of help or to carelessness. The use of fingers instead of forks or spoons for conveying food to the mouth is of frequent occurrence. In some instances cliildren are found to attend at the dinners with extremely dirty hands, and as the class of child, whose personal cleanliness leaves something to be desired, is also the class which 23610 X2 156 Annual Report of the London County Council, 1913. uses fingers in preference to other means of conveying food to the mouth, every effort should be made to insist upon both cleanliness and proper table manners. In this connection the relation between dirty hands used in feeding and suffering from intestinal parasites should be pointed out. In a recent investigation by one of the school doctors into malnutrition it was found that 11 per cent, of the children suffered from worms. The school doctors point out in several cases improvement since last year in both manners and cleanliness. The hygienic conditions in these respects depend largely upon the character and sufficiency of the supervision. In addition to uncleanliness of hands, hurrying over meals is a fault somewhat frequently reported. Sufficiency and suitability of dietary. Generally the reports are satisfactory with regard to both quantity and quality of the food supplied. In a few instances the quantities provided seemed insufficient on the date of inspection. With regard to quality, it appears that while the meals supplied by the cookery centres are most satisfactory, those supplied by the Alexandra Trust are more reliable than are those provided by local caterers. The lack of green vegetables, which are so necessary for the health of ill-nourished children, is again commented upon by several school doctors, and the apparently insurmountable difficulty experienced in supplying them is to be deplored. It is occasionally reported that the potatoes are served black, soapy and unappetising. The food supplied by local caterers is very variable, sometimes it is of good quality, in one or two instances it is upon occasion so bad as to be uneatable. Refusal of fjod. This Was noted in 24 reports. In one or two instances it was justified by the nature of the food given, but refusal is mostly due either to total absence of appetite in the case of sickly children, or to the rejection by children of food to which they are unaccustomed. There appear to be local prejudices with regard to articles of diet, and dishes readily eaten at some centres are disliked at others. Thus, the rice and currant pudding meal is reported at Trinity Hall, Stewart-road to be the most popular of all, while at the Eton Mission, Gainsborough-road, some 20 children refused it altogether and about a third did not finish the quantity given. In such cases, of course, much depends upon the firmness of the supervisors or attendants. At some centres an improvement in this respect is recorded. Thus, at Honeywell-road School where refusal of soup was formerly prevalent, it is now reported that the soup is always well taken. Tuberculosis. In the work of medical inspection of school children special attention has been given to the detection of early cases of tuberculosis, and to bringing such cases promptly under the notice of school care committees and others actively engaged in securing appropriate treatment. In some boroughs arrangements have been made with the local medical officer of health to furnish divisional school medical officers with particulars of child contacts with the cases of tuberculosis notified to them under the Tuberculosis Regulations, 1912, and special observation has been kept upon these cases by the school doctors. In Deptford, where the Borough Council have established a dispensary, arrangements have been made for co-operation between the dispensary and the school medical service and school care committees. As a complete dispensary system becomes established throughout the county this co-operation will be extended, and it will be possible to arrange that " contacts " shall, for the purpose of diagnosis, be dealt with at the dispensaries, and school doctors will refer thereto doubtful cases when the conditions of school medical inspection do not permit of definite diagnosis. The question of school attendance or certification for residential institutions will remain the function of the school medical officer. The work of the school medical service in connection with open-air schools and playground classes for debilitated children, and children suffering from tuberculosis in early non-infectious stages, and also such work in connection with schools for physically-defective children is dealt with elsewhere in this report. The problem here reviewed is that connected with the position brought about by the compulsory notification of tuberculosis under the Local Government Board Tuberculosis Regulations 1912, the establishment of dispensaries by borough councils, and the constitution of the Council as an authority under Section 64 of the National Insurance Act 1911, for providing institutional treatment for persons suffering from this disease. School medical inspection has supplied a considerable number of data as to the nature and extent of the problem so far as it affects children. During 1913, 809 children, or 0'41 per cent, of those examined in the schools under the Administrative Provisions Act were found to be suffering from pulmonary tuberculosis and a further 623, or 0.32 per cent., from other forms of tuberculosis. The boroughs in which the lowest percentages of pulmonary tuberculosis were reported comprise Lewisham, 0.04 per cent. ; Hampstead, 0.10 per cent., Greenwich, 0.11 per cent.; St. Pancras, 0.13 per cent.; Wandsworth, 0.13 per cent.; Lambeth, 0.18 per cent. ; Hackney, 0.17 per cent. ; while those with the heaviest percentages were Stepney, 0.94 per cent.; Shoreditch, 0.89 per cent.; Paddington, 0.84 per cent. ; Hammersmith, 0.72 per cent. ; Poplar, 0.76 per cent.; Bethnal Green, 0.68 per cent. On the whole it is clear that the incidence of tuberculosis in school children varies inversely with the average standard of comfort of the inhabitants of the district. In a report upon malnutrition as found in school children (p. 50) the close inter-relation of this condition with tuberculosis is pointed out, and the detailed notes of cases there set out give some idea of the measures it has been possible to adopt, under existing conditions, in the case of children found to be suffering from tuberculosis. In the report on children out of school for long periods on account of ill-health (p. 49) it is shown that 533 such children are registered as suffering from tuberculosis, viz., lungs, 377 cases; glands, 68 cases; other organs, 88 cases; the total being 15 per cent, of the whole number so excluded. 157 Report of the County Medical Officer—Education. A fact to be observed is the need for a combination of hospital and educational systems. So far as cases capable of treatment as out-patients are concerned, the dispensary, general practitioner, and out-patient departments of hospitals can be relied upon for treatment, and open-air day schools and special schools with curricula under the supervision of the school medical officer will meet the need. For cases which cannot be dealt with at their homes residential institutions with provision for education, as well as for treatment, are required. The physical condition of tuberculous children is such as to require prolonged treatment with a maximum of rest to the part affected. The extent to which rest is essential varies according to the type of case. In some cases very little interference with education is necessary, while in other cases treatment should be the predominant feature. The tuberculous cases may be divided as follows, viz.— (1) Those suffering from bone and joint tuberculosis. (2) Those suffering from pulmonary tuberculosis. (3) Those suffering from tuberculosis of the skin, glands and other organs. (4) Suspects, i.e., cases noted by bacteriological methods to be tuberculous or found on medical examination to be pre-disposed to the disease and presenting uncertain signs which point to the possibility of the disease in an incipient form. (1) Children suffering from bone and joint tuberculosis—As a result of experience in these cases it is considered that two years should be regarded as the minimum period likely to be required for the treatment of those of a moderate character and that, in severe cases, a much longer period may be necessary. From time to time more active medical and surgical measures may delay education, but for the most part curative methods in the form of rest can be applied without interference with the mental and, within certain limits, the physical activities of the children. Some of the cases have to be confined to lied and will need constant nursing attention for prolonged periods. Save for brief periods, they will, however, be quite able to benefit by education. Other cases require less surgical attention though nursing care is essential. Properly warmed and ventilated wards and facilities for moving beds into the open air are a necessary part of the provision required for these children. It is probable that there are something like 3,000 surgical cases in London. Of these, some 1,500 are in attendance at physically defective schools. Poor-law and other residential institutions will probably account for about 1,000, some of those in poor-law institutions being, no doubt, children of parents not otherwise coming within the poor law, but forced to avail themselves of these institutions owing to the lack of other accommodation. The remainder may be classed as in-patients or out-patients at London hospitals who are unfit for various reasons to attend physically defective schools, and who are unable to secure admission to or are unsuitable for existing residential schools. It may be estimated that some 350 additional sanatorium beds for surgical cases are needed. (2.) Children suffering from pulmonary tuberculosis.—These children fall within two divisions, («) those which can be dealt with in open-air schools, and (b) those which should be sent to residential institutions of a sanatorium character. (a) The cases which can be dealt with in open-air schools present the milder type of lung affection, where there is no cough or expectoration, in which education can be the predominant feature as part of graduated exercises, and where the exertion of travelling to and from the school is not likely to undo the benefits of the regulation of activity which will form part of the treatment at the school, aud where the parents can be relied upon to prevent undue exertion out of school, hours. The accommodation provided for these children will also be suitable for cases classified as " suspect" or as definite cases of tuberculosis without localising signs, such as are termed in some reports "pretuberculous." It is not necessary, indeed, in many respects it is undesirable, that such cases should be treated in open-air schools exclusively confined to this class of suspected tuberculous children. Open-air schools of the Shooter's-hill type, in which the groups of anaemic, badly nourished, and other physically defective children are accommodated, are most suitable also for this class of child. Children of these types (i.e., mild cases of tuberculosis and suspects) should be able to profit to the full from suitably arranged special school education. While educational requirements can be met to a very large extent, the influence of the curriculum on their health should be carefully scrutinised. Such children would avail themselves of the local dispensary provision, and the home conditions would be under the supervision of the local medical officer of health. It will, however, be found in some cases that insufficient control is exercised over the activities of the children out of school hours, and in other cases that the home environment is of such a nature that complete removal during a considerable portion of the period of school life as contrasted with partial removal during the few hours of school sessions will mean all the difference between complete recovery and mere prolongation of an otherwise fatal disease. With a few minor alterations and additional equipment a proportion of the children accommodated at the open-air school could remain there at night. The children could sleep in the open-air classrooms on the hammock couches provided for use during the day, and would use the feeding, cooking and bathing equipment which form a part of the ordinary open-air school equipment. The ordinary school meals would suffice, but hot milk or cocoa would be necessary at night and breakfast in the morning. An attendant would be necessary to take charge at night. There are obvious difficulties in finding suitable sites for such schools in a large city like London. Usually only a few acres constituting the private grounds attached to a large house can be obtained, and, in order to secure the land it is necessary to purchase the buildings with the site. These are generally unsuitable for the purpose of an open-air school, and consequently, unduly increase the cost of the site. The provision of accommodation in the country would involve expenditure for travelling expenses of the children, but it is questionable whether the lower cost of land and the better hygienic conditions would not justify this course under certain conditions. In other cities, notably in New York, open-air schools have been provided on disused hulks in the river. During the greater part of the year, at all events, the Thames offers favourable conditions, and, if 158 Annual Report of the London County Council, 1913. suitably placed hulks could be adapted for the purpose, accommodation of (his kind should be taken into consideration, particularly for children living in central London or within easy reach of the river. Disused naval ships might be considered in this connection. For cases suitable for such open-air schools some 1,000 places should as a commencement be provided in addition to the accommodation provided at Birley House (100) and Shooter's-hill (75) and at Kensal-rise (120). (b) Pulmonary cases requiring residential accommodation are those spoken of as cases of open tuberculosis, in which there is cough and expectoration. It has already been stated that rest of the affected parts is the principal feature of treatment. For the more definite tuberculous cases requiring residential accommodation provision will have to be made for some of the children to lie in bed all day, when they will be unable to receive any considerable education. These institutions will be more medical than educational. They will probably require a larger site than the day open-air school, and the rooms and wards should be so arranged as to enable cots to be wheeled into and for beds to be provided permanently in the open air. A larger nursing staff will be required than at the day school, and it will be necessary to provide them with night quarters apart from the children. Daily supervision by a medical officer of special experience will be necessary. As an initial provision it was estimated that 125 beds would be sufficient for these cases and for children who, after careful observation in the open-air school, are found not to improve or to lose ground. (3) Children suffering from tuberculosis of the skin, glands, or other organs.—A small number of these cases will require a relatively short stay in the country to accelerate cure. It would probably be sufficient if 25 beds are provided for these cases, the bulk of which can be dealt with in open-air schools and the tuberculosis dispensaries. With regard to accommodation, the schools for physically defective children generally meet the needs of surgical cases who are able to reside in their homes and are not suffering from chronic abscesses and other septic conditions, but the difficulty in London in securing suitable sites for open-air day schools has already been referred to. Attention has been directed largely to securing, in the first instance, suitable residential accommodation. It is considered that provision should be made for the education of children capable of receiving it and, for this purpose, the Education Committee are of opinion that any institution recognised by the Board of Education under the Elementary Education (Defective and Epileptic Children) Act 1899 can be regarded as satisfactory from an educational point of view. It is desired that any expenditure which may be incurred by the Council shall be used for the purpose of enabling existing institutions to bring into use beds at present unoccupied through lack of funds or to carry out enlargements. In other words, the intention is to avoid the displacement of patients who would be dealt with without the intervention of the Council. With this object enquiries have recently been addressed to a number of sanatoria and visits paid to a number of institutions, from which favourable replies had been received. It was considered that, in the beginning, about 150 beds would be sufficient, further accommodation being provided as may be found necessary. Payment not exceeding 20s. per bed per week, including education, was regarded as a reasonable sum for the maintenance of the children. The Council were able early in 1914 to obtain 50 beds for pulmonary cases at Nayland Sanatorium, near Colchester. Negotiations were then still in progress with regard to the additional beds required for surgical cases. Exercises for children suffering from physical defects in elementary schools. In 1912 certain experimental remedial exercise classes held in the elementary schools, for children selected on account of physical defect by one of the medical officers were favourably reported upon. It was decided to continue the experiment and in the year 1913 it was intended that special classes in remedial physical exercises should be held at the undermentioned schools :— Boys. Junior Mixed Departments. Latimer Road. The Chaucer. Frankhani Street. Moreland Street. Garratt Lane. Sellincourt Road. Snowsfields. Hughes Fields. Girls. Weston Street. Johanna Street. The Chaucer. Betts Street. Prospect Terrace. Camden Street. Middle Row. Rosebery Avenue. Catherine Street. Pritchard's Road. Union Street. Deal Street. Church Street, Kennington. Winchester Street. Eltringham Street. Kennington Road., The Highway. White Lion Street. Hungerford Road. Cooks Ground. Owing to various circumstances the class at Kennington Road was not started, and those at White Lion Street, Sellincourt Road and Eltringham Street were discontinued. (A report was, however, made on the class at Eltringham Street.) A special chart was prepared for the use of the school doctor and a supply sent to each school. It should be noted that the numbers in the special classes did not generally exceed 20, and the children were selected in the first instance by the school doctors for such defects as might be expected to be remedied by graduated exercises which could be given by class teachers possessing the necessary training. The medical reports upon the classes show that extremely good work was accomplished and that considerable benefit to the children was obtained. The results were not altogether uniform. The lack of suitable clothing and footgear for exercises in certain of the classes was noted by the school doctor as militating against success; in one case at Weston Street, Dr. Williams found the child's movements greatly impeded by 9 layers of clothing on the chest. In many classes, however, suitable drill garments have been provided and in these classes the results were exceedingly good. The great benefit to cases of spinal curvature accruing from crawling exercises and 159 Report of the County Medical Officer—Education. a bdominal exercises (involving lying upon the floor in the absence of a form provided for the purpose) is pointed out by the school doctors. In some of the classes such exercises were included. In others the doctors deplored their absence. The individual cases where improvement is noted to have occurred include postural spinal defects, defects in breathing including mouth breathing and contracted chests, muscular weakness and defective cardiac tone. One case of definite heart disease, included in the class at the.Chaucer school, was found by Dr. Boome to have greatly improved by the carefully graduated exercises administered, although in the majority of cases the doctors excluded from the classes cases oi valvular lesion of the heart. General improvement of the children's physical condition is noted by all the doctors ; the averag( increase in chest measurement and in chest expansion being satisfactory, and in some classes surpris' ing. Thus, at Winchester Street, the 23 boys in the special class showed an average expansion of the chest of If inches in July, but in January this had increased to 2½ inches ; the average chest expansion of normal boys in the school of the same age at the latter date was 2¼ inches. The boys, therefore, who were selected as below the normal in physique had at the end of 6 months not only caught up but even advanced, beyond the average shown by their fellows, in chest expansion. In many classes an increase in mental capacity was reported in the children as their physical condition improved. It is clear that such remedial classes carried out in the elementary schools are capable of producing exceedingly satisfactory results and deserve a permanent place in the Council's arrangements for the physical care of children. If the full benefits are to be attained, however, attention is necessary to the clothing worn by the children during the exercises, and the introduction is advisable of certain exercises not included in the ordinary syllabus, such as abdominal exercises generally, for which the provision of a form is advisable, and crawling exercises. While postural spinal defects have almost invariably been cured or greatly improved in these classes, in the graver conditions where spinal deformities have become fixed no imorovement has resulted nor was it expected that improvement would take place. Treatment of cases of spinal curvature A report was recently presented to the Children's Care (Central) Sub-Committee upon the question of the Council making arrangements for the treatment of cases of spinal curvature generally, and particularly with regard to the Council making a grant towards the cost of remedial exercises already being carried out at the Deptford Health Centre. Upon enquiry it was found that, although the methods used at the Deptford Health Centre are excellent and the results good, yet the cost per child is high. Thus the maximum number of cases it is possible to treat at the centre per annum is 60, while the cost of treatment per annum is probably £150 to £180. The main reason for this high cost per case is the fact that the children have to attend for long periods before they are discharged as cured. On an average each child attends 105 times spread over a period of 35 weeks. Much of this time, however, is spent in general exercises, each patient requiring special individual exercises only for one or at most two months, i.e., 24 attendances. If the centre were linked up with other agencies much of the time and expense could be saved and more than this the knowledge and experience of those engaged in the work could he made to react with great benefit upon the entire scheme for the provision of physical exercises in the schools. With the arrangements made it should be possible that the general exercises required by the children under treatment should be given in special classes in the ordinary schools. The trained gymnast at the centre should visit the special classes in the ordinary schools and in this way her special knowledge would be at the disposal of the teachers of the special class ; the congestion at the centre would be relieved, more cases could be treated and the cost per case considerably reduced. Arrangements should also be made for the Treatment Centre to be linked up with the Orthopaedic Department of a great hospital in order that cases requiring individual apparatus or operative treatment could be drafted to the latter, and vice versa, cases at the hospital which had reached the stage of requiring individual exercises only would be transferred to the treatment centre. With regard to the application of physical exercises to individual children the following scheme would apply:— Normal child General physical classes in school. Abnormal child examined by school doctor and (a) Requiring special attention in performance of general exercises. Special class in school. (b) Requiring individual exercises. Treatment centre or exercise department of hospital (c) Requiring individual apparatus or operafive treatment. Orthopaedic department of hospital. These three divisions could then be linked together in such a way that children can be transferred from one to the other as the needs of each particular case demand It would be necessary to have the Board of Education's sanction to treating these classes as educational courses and allowing the attendances to count for grant as in the case of visits to domestic economy and manual training classes. The linking up of the arrangements for remedial exercises with the schools in the foregoing manner would provide a means whereby the experience gained in the intensive study of individual children at the Orthopædic Department of the great hospitals at one end would influence the general application of physical exercises to the whole of the school children through the medium of ordinary class drill at the other. At present there is want of cohesion between all the activities dealing with physical exercises in London and there is a considerable body of knowledge in existence which is not being fully utilised. A scheme such as is sketched above would enable a plan to be evolved whereby the Council's inspectors and organisers of physical exercises, the medical officers of the public health department, the orthopaedic surgeons and trained gymnasts at hospitals and treatment centres, the teachers in the schools and the 160 Animal Report of the London County Council, 1913. lecturers and instructors at general training colleges for teachers and at training colleges for teachers of physical exercises, could be linked up together with advantage to each element and to the whole physical education of London. Inasmuch as general interest in this subject is now being manifested the following reports by the school doctors upon the remedial exercise classes carried out in the schools during the past year are given in full. Reports of school doctors. The Chaucer Bermondsey—(Boys.) (Dr. Boome).—These children were selected from a class of backward boys requiring special teaching. Twenty-one boys were chosen, the ages ranging from 10 to 13 years. The postural defects noted were—scoliosis, 7—viz., slight curves to left, 4, slight curves to right, 3; kyphosis, 6; lordosis, 5. These defects were improved by the exercises and in 5 cases quite disappeared. The effect on the muscular system was good, the scapular muscles being especially developed. The increase in height, weight and chest expansion is shown in the following table, the average gain for all the boys being 1.97 centimetres, 1.66 kilograms, and 2.7 centimetres respectively. Initials. Ago. Yrs. Weight in Kilograms. Height in Centimetres. Chest expansion in Centimetres. Pulse rate por minute. May. Dec. Gain. May. Dec. Gain. May. Dec. Gain. May Dec. A. A 12 29.3 29.6 0 3 132-5 135.0 2 5 4-5 7.0 2.5 84 78 B. W. 12 Abs. 33.1 — Abs. 144.5 — 6 0 7.5 1.5 80 80 B. D. 13 31.0 33.9 2.9 137.0 139.0 2 0 4-5 5.5 1.0 72 76 C. C. 12 30.9 34.3 3.4 130.5 132.2 1-7 5-0 6.5 1.5 90 72 C. A. 12 36.9 35.9 0.0 140.5 142.5 2 0 4-0 8.O 4.0 66 72 F. H. 12 32.8 32.8 0.0 135.5 137.0 1-5 3-5 6.5 3.0 78 72 F. F. 12 34.2 35.1 0.9 138.0 138.5 0 5 4 0 6.5 2.5 84 78 H. R. 12 31.2 34.8 3.6 128.2 130.0 1-7 4 0 7.5 3.5 64 72 K. P. 12 28.0 28.8 0.8 129.0 131.5 2-5 4 0 7.0 3.0 72 76 L. H. 11 24.8 26.7 1.9 120.5 123.5 3 0 5 0 7.5 2.5 84 78 P. A. 12 27.9 29.2 1.3 130.0 132.0 2 0 5-0 8.0 3.0 76 72 P. P. 12 30.8 32.5 1.7 136.5 138.5 2-0 3 0 6.0 3.0 72 72 S. C. 13 37.2 37.8 0.6 152.5 153.5 1-0 6-0 9.0 3.0 84 84 S. C. 13 29.6 30.8 1.2 137.0 139.7 2-7 5 0 8.5 3.5 60 72 S. W. 10 29.6 Absent — 134.0 Absent S. J. 10 30.6 340 3.4 133.5 133.2 0.0 3.0 5.5 2.5 84 80 T. W. 12 27.2 27.6 0.4 132.0 133.5 1.5 4.0 7.5 3.5 80 72 U. H. 12 34.9 36.7 1.6 138.5 140.2 1.7 4.0 6.0 2.0 72 72 W. F. 12 28.5 30.4 1.9 125.0 128.7 3.7 3.5 5.0 1.5 68 72 W. W. 12 32.4 33.8 1.4 137.2 138.5 1.2 4.5 8.0 3.5 80 72 W. J 13 30.7 32.8 2.1 133. 0 135.2 2.2 3.5 5.5 2.0 72 72 The pulse rate of the boys Was considerably lower than in the case of the girls, as will be seen from comparing the tables. . It will be noticed also that in this class there was a tendency to a drop in the rate. One boy was retained in the class who had a systolic murmur at the apex (conducted to the axilla) with displacement of the apex beat downwards and externally. At the end of the class, however, it was noted that the apex beat had come in to the normal, the systolic murmur remaining. The boy had presented no untoward symptoms during the exercises and he had considerably improved. The murmur was undoubtedly organic. The nutrition of the heart muscle and compensation had been increased by the graduated exercises. A boy who suffered from fits, which were epileptic, was a member of the class. During the exercises he had no " fit," and at the termination of the course, they had considerably lessened in frequency. The mental condition of the boys was benefited by the regular exercises. Tredgold says in his book on " Mental Deficiency" : "Mental action and motor activity go handin-hand, and in the development of muscular co-ordination lies one of our best means of cultivating self control and regularity of mental action." These boys were not mentally defective in the strict sense of the word, but were of the class who would benefit by an industrial training less scholastic than that of the ordinary elementary school. Garratt Lane, Wandsworth (B.)—(Dr. Scott Pinchin.).—22 boys of ages 8 to 12 were included in this class ; all the children were of the poor type usual in this school, and it was arranged for all of them to have either milk orcod liver oil during the morning. Their general condition was a good deal improved and the local condition for which they Were included in many cases showed some improvement. The average increase in weight during the six months was 1.2 kilograms, or about normal; in height 1.4 cm. or below normal. The chest expansion showed a marked improvement in nearly all cases. The average chest measurement at the commencement on full expiration and inspiration respectively was 24¼ inches to 26 inches ; on completion of six months 24½ inches to 26¾ inches, a gain of a clear ½ inch in expansion ; the flexibility of the chest also seemed to be much improved in nearly all cases. Several children were included for very defective breathing, undeveloped and rickety chests : all these considerably improved with the drill. Two included for general muscular mal-development also improved. One boy with a bad spinal curvature secondary to torticollis, for which he had been operated on shortly before the class commenced, was much improved, but probably more of the improvement was due to the removal of the cause than to the drill. Six boys with slight curvatures were improved. Four boys with kyphosis or kypho-lordosis and one with lateral curvature made no improvement. All the boys had shoes to drill in and many of them had jerseys. All were having some extra nutriment, so that the conditions in which the class was held may be taken as being favourable. 161 Report of the County Medical Officer—Education. The conclusion arrived at is—that for the improvement of the general physical condition the class is beneficial, the breathing is improved as is also the muscular tone, and thus any deformities due to " flabbiness " of the muscles are corrected, but for the improvement of any deformity that has become at all fixed (exclusive of any cases requiring remedial exercises) the class is of very little service. An instructor who has had special training is necessary to get good results, for he would have a good knowledge of the defects that occur in drilling and would be better capable of noticing and remedying faulty positions. Local centres where a class could be taken two or three times a week by a specially trained teacher would be a great boon, as at present it is necessary to send any child with curvature of any degree to a hospital or special class in town and most of the parents cannot afford either the time or money to attend with any regularity. Hughes Fields, Greenwich (B.)—(Dr. Davies).—The boys selected to form this class were of about the same age, 10 to 11J years, and, as near as could be. of the same physical capacity. They were such as appeared likely to benefit by the physical exercises laid down in the instructions, and in three cases previous existence of adenoids or throat affection indicated suitability for exercises designed to improve the respiratory capacity. The exercises occupied from 20 to 30 minutes each morning, and were conducted, practically always, in the open air. The master in charge of this class has had special experience in physical drill, and has taken great interest in the progress of the class. Of the 25 boys selected, three have been omitted from the tabulation : one boy left early in the summer term : another was away hopping in September, and absent owing to sickness at the final visit on 9th December : a third was absent unwell during the latter half of the term. Four visits were made to the school for the purpose of weighing, measuring and examining the boys, viz., on 24th April, ,5th June, 11th September and 9th December. The ages of the boys varied between 9 and 12 : fourteen were in their eleventh year. Their weights in 16 instances were below the standard for London children, 15 of these being also below the standard for height. The chest measurements were taken with the lower edge of the tape above the nipples in front, and its upper edge below the scapular angle behind: the mean of the measurements in deepest inspiration and expiration has been taken as the chest measurement. Heights and weights were taken in ordinary clothing without boots. There was an increase in weight and in chest measurement in 16 boys : in 4 others there was slight increase in weight without any increase in chest girth : in 2 there was actual, though slight, decrease in weight, the chest measurement having in one of the boys increased, in the other diminished. Twelve boys had been noted previously as suffering from some physical defect: five from throat affection (enlarged tonsils, or adenoids, or both); three from blepharitis ; two from defective nutrition ; one from anæmia, and one from discharging ears. None of these defects were actually present during the period under review, except blepharitis in one boy, and ear discharge in another. The exercises were carried out according to the syllabus. They consisted chiefly in breathing exercises (5 minutes), trunk bending, shoulder movements, arm swinging and knee bending and stretching, but included many others as well. From 20 to 30 minutes each morning were given to this training, always in the open air. Running, leap frog and other games (also in the open air) formed part of the exercise. The only actual physical defects made out were in the two boys S. and T. In both cases there was contraction of the thorax, probably rachitic. S. also suffered from bronchial catarrh to some extent. This boy's weight increased by 1.8 kilograms : his chest measurement increased by 3 centimetres, and although his range of expansion was only 3 centimetres, his maximum of 61 in June became his minimum in December. T. also had a contracted chest and limited expansion : this hardly improved at all, and his weight remained stationary at 24.4 to 24.5 kilograms, considerably below the normal. With this exception it may be said that improvement resulted in all the boys in regard to their general condition. Prospect Terrace, S. St. Pancras (B.)—(Dr. Norman).—This class was started on June 2nd, 1913, with 20 selected boys. It was later reduced to 14, four boys having left the school and two being withdrawn owing to parents' objections. 13 were present at the final inspection. The instructress was one of the lady teachers in the school, who is well suited for the position, being enthusiastic and thorough. The boys go through the exercises every morning session, 20 minutes being given to them (9.40 to 10 o'clock). Not one of the boys is on the feeding list, but most of them are of a poor type of physique, and many are anaemic. 7 out of the 13 were noted as mouth breathers, when the selection was made at the end of May. After 8 months, only one boy was noted going through the exercises with his mouth open. The nose breathing drill is well done, the only criticism to be made is that there is an inclination to conduct the in and out breathing too rapidly. There is a very decided improvement in the carriage and gait of every member of the class, and no doubt exists as to the utility of the training. Union Street, Woolwich (B.)-(Dr. Hirsch).—This class commenced in April, 1913, and continued during term time until December, 1913. 25 children were chosen, mostly those of poor physique due to lack of tone of muscle. Three had signs of rickets. Ten showed slight lateral scoliosis; in seven of these the curvature was merely the consequence of faulty carriage and disappeared when they stood correctly to attention. The remaining three had lateral scoliosis; with the modified Kellett Smith level there was a difference of about half an inch, the angle of the right scapula being also about lower than the left, and with the plumb line the curve, mid dorsal in all, was demonstrated. Practically all the boys in the school were inspected, so as to obtain the most suitable cases. The ordinary exercises in the syllabus were given ; the teacher's attention being directed to the need of individual supervision for each child, especially as to correct position from which the respective exercises should be taken. In addition the following exercises were employed. (1) Standing against support, head to heels pressed against wall, arms to side, lifting arms out and up while breathing in, lowering while breathing out. 23610 Y 162 Annual Report of the London County Council, 1913. (2) Standing with arms to side, bending both forearms up, so that the fingers slightly bent touch outer part of the shoulders, extending out both arms, then into bent position, then to side. (3) Body bending back resting against post, arms loose, feet few inches from post, bending forwards and downwards,and raising, so that each vertebra in turn from below upwards touches door post. The average weight on 13th April was 29 kilograms ; on 13th December, 31.6 kilograms. Average height on 13th April was 134.7 centimetres; on 13th December, 1384 centimetres. Average chest (inspiration) on 13th April was 69.06 centimetres ; on 13th December, 69.4 centimetres. All round there is a distinct improvement. The lateral scoliosis cases still show the angle of the right scapula lower than the left at rest, but they hold themselves distinctly better. In the three actual cases a 3/8 "block made the Kellett Smith level true, in April a block was required. Additional exercises of course could be used for the scoliosis cases especially with the ribstool and plinth,as well as the creeping movements advocated by Kellett Smith, but for these a special training in the teacher would be required and of course more frequent medical supervision. Some teachers in the schools are quite prepared to undertake such work, and judging from the results obtained at a small class supervised at the Invalid Children's Aid Association the result would be most satisfactory. Winchester Street, Finsbury, C. (B.)—(Dr. Bellingham Smith).—The class was composed of 23 boys selected for various conditions of ill-health. Spinal Curvature.—12 cases, of these 1 had a double curve with rotation of vertebrae, the deformity being not entirely reducible, 7 had double curve, all reducible, 2 had single lateral curvature, 2 had marked kyphosis and round shoulders. Deformities of chest.—2 cases, (a) Rickets, (b) Post adenoid. Mal-development.—9 cases, the result of prolonged mal-nutrition, defective home surroundings old rickets, etc., and in most of them the mal-development was both physical and mental. The class was formed on the 9th July, 1913, and all preliminary measurements, etc., were completed on the 26th July, 1913. Since that date all defects as regards adenoids, vision, etc., have been corrected and where necessary the children have been fed or given extra milk. The class drilled daily in the playground for 20 minutes. No special drill was utilised for special cases, but a uniform series of exercises was employed. The regularity of attendance, the interest taken in their drill, the mental progress in school, and the increase in height, weight and chest measurement have been recorded every month in the case of each child. The figures for these different headings are given below. The results were-as follows:—Spinal curvature cases (12)—8 cases absolutely straight, 4 very much improved; in case of double lateral curvature and rotation, the rotation has disappeared and curvature is less and easily reducible. Both the chest cases were very much improved. There was also great improvement in general physique and appearance of the children suffering from mal-development except in two cases where the feeding and home surroundings were bad and the mental calibre of a low order. Attendance—14 regular, 7 irregular, 2 very irregular, due to illness. Interest taken—10 very good, 10 good, 3 fair. Mental progress—10 good, 10 fair, 2 none, 1 case away ill. Home surroundings—6 good, 13 fair, 4 poor. In 11 cases extra nourishment was provided—3 had dinners and milk ; 5 had dinners only ; 3 had milk onlv. The weight, height, and chest measurements are as follows :— July 26th, 1913. January 21st,.1914. Year. Weight. Kilogrs. Height. Cms. Chest in inches. Weight. Kilogrs. Height. Cms. Chest in inches. Expiration. Inspiration. Expiration. Inspiration. Child born in 1901. —(1) 21.6 114 22 233/4 23.3 118 22½ 25 Increase — — — — 1.7 4 0-85 1-25 Children born in 1902— (1) 27 1305 23 24¾ 28.8 135.5 23½ 26¼ (2) 27.5 130 23½ 26 29.9 133.5 24¾ 27½ (3) 24.8 128 23½ 24| 27.9 132.5 24 26½ (4) Absent — — — — — — — Average increase — — — — 2.4 4.3 0.83 1.62 Clildren born in 1903.—(1) 24.6 125 23 24¾ 27.3 129 23¼ 26¾ (2) 25.4 123.6 22¾ 245/8 26.6 131.5 23 26 (3) 25 119 22¼ 23½ 27.2 124 23 25 (4) 21.4 116.2 22¼ 25 25 120 23¾ 26½ (5) 21.7 114.5 22½ 24¼ 24.2 119 23¼ 25 Average increase — — — — 2-4 4 0-7 1.9 163 Report of the County Medical Officer—Education. Year. July 26th, 1913. January 25th 1914. Weight. Kilogrs. Height. Cms. Chest in inches. Weight. Kilogrs. Height. Cms. Chest in inches. Expiration. Inspiration. Expiration. Inspiration. Children born in 1904 — (1) 22.6 118.5 21½ 23 23.6 124.5 21¾ 24 (2) 24.6 121.5 22¾ 25 ( Absent (3) » 24.6 123.5 22¾ 25 26.1 127.5 23¼ 25½ (4) 20 113.5 22½ 24 21.9 118 22½ 25¾ Average increase — — — — 1-4 4.8 0.33 1.01 Children born in 1905 — (1) 19.6 113.5 21¾ 22½ 21.8 118.5 22½ 24 (2) 22.2 121 22½ 24½ 25 130 23½ 26¼ (3) 21 114.5 21½ 22½ 23.5 120.5 22 24¼ (4) 23.4 118 22 24¼ 24.5 123.5 21¾ 25 (5) 20 112.5 217/8 23½ 23.5 117.5 22½ 24½ (6) 21 121.5 23 25 25 128. 23¼ 26¼ (7) 17 103 20¾ 22½ 18.2 106.5 20½ 23 (8) — Absent — — — — — — Average increase ... — — — — 2.4 5.8 0.30 1-25 To obtain some idea of the relative improvement effected in this class the above figures for the chest expansion were compared with those of a similar number of children of like age from other classes who have drill three days a week. The results were as follows :— Special class (July) Special class (Jan.) Ordinary class (Jan.) Average expansion of chest of whole class 1¾ inches. 2½ inches. 2¼ inches. Maximum of individual 2½ inches. 3¼ inches. 2½ inches. Minimum of individual ¾ inch. 1¾ inch. 1¾ inch. It will be seen that increased drill has been sufficient to place the defective children ahead of the average child in respect of chest development, and it may be said that this class more than justifies its existence. Its success is undoubtedly due to the keen interest shown in its formation by the head-master, and the intelligent co-operation and energy exhibited by its instructor. Frankham Street, Deptford (J.M.)—(Dr. Kidner).—The children were selected from a number presented by the head teacher of the junior mixed department as apparently requiring additional attention to physical culture beyond ordinary drill. This school draws its pupils from an extremely poor neighbourhood where gross overcrowding exists, and speaking generally the children are pale, ill-nourished, badly clothed and dirty. The age of those selected was from 8 to 9 so the number available was comparatively small and few cases presented any marked deformity. Both boys and girls were included. Average number present, twenty. Originally the class was held on the roof playground but afterwards the school hall was used in order that games with piano accompaniment could be included. The large amount of dust raised during the games counterbalances the advantage of the piano, rendering it advisable in the future to delete the music. Exercises were performed daily in the early morning (9.40 to 10.0). About half the time was devoted to games. Tables of exercises were drawn up by the head teacher in consultation with the inspector of physical exercises. These included marching, arm and leg movements, head and trunk bendings and turnings and simple balance exercises. The " arch " and " abdominals " received, on account of the age of the children, less attention. Considering the nature of defect (kypho-lordosis) for which most cases were included this is unfortunate. There appears to be no reason why carefully graduated abdominal exercises should not be performed by the youngest children even when no apparatus is available. The " jump " was represented by games involving running and dodging. Breathing exercises were, naturally, included. The suggestion was made that these should be performed more often, after each movement, and that greater attention should be paid to abdominal breathing. The common errors in such exercises as neck bending, trunk turning and twisting and in the wing and neck rest positions were 23610 Y 2 164 Annual Report of the London County Council, 1913. exemplified fully but improvement was observed in these after the class had been held for some months. Seven visits were paid to the class, two visits being devoted to a physical examination of the children. Note was made as to the reason why they were included in the class and a measurement made of the chest and of the respiratory excursion. The other inspections were of the children actually doing their exercises. The effect of the exercises on various conditions are as follows :— Average increases—height, 2-7 c.m.; chest measurement at rest, 0-85 c.m.; excursion (least to greatest) 0-3 c.m. Kypho-lordosis .. .. 5 Improved. 4 Slightly improved. 2 Unaltered. Lateral curvature .. 1 „ 1 „ 2 „ Mouth breathing and enlarged tonsils .. 2 „ 3 „ 5 „ Further points such as quickening in response, improvement in carriage, the manner in which the exercises were carried out, and improvement in general appearance were noticed, but, presumably owing to the bad conditions under which the children live, the results were not well marked. From observations made of the class under working conditions some improvements can be suggested to increase efficiency. Cases should be selected from higher departments where defects are commoner. The number in class should be limited to, say, twelve. It is found difficult to ensure correct form if the class is large. Practically individual attention is necessary. The class should always be in open air when weather is dry. It is advisable, but doubtfully practicable, that a tunic should be worn and that abdominal exercises, involving lying on the ground, should be included. Chaucer, Bermondsey (Girls)—(Dr. Boome).—This class was held from 5th May, 1913, to 12th December, 1913. The children were chosen from 60 others. They were originally selected by the head teacher because they had been recommended for treatment at previous medical inspections. Finally 20 children were picked out on account of round shoulders and faulty posture habits. On close medical examination 2 children were exempted as suffering from doubtful early phthisis, and were replaced by two others. The class was held every day for 20 minutes either in the hall of the school, or when the weather permitted on the roof playground, and the routine consisted of handkerchief drill, breathing exercises, physical exercises, simple dancing (country dances and dance steps). Breathing exercises were given after the handkerchief drill and during the class. The teacher was careful not to give breathing exercises after the more vigorous exercises, but first gave simpler exercises, e.g., " heel raising," thus allowing the heart to settle down. The physical exercises were carefully selected beginning with the simpler and ending at the latter part of the term with the more difficult exercises as laid down in the syllabus of Physical Exercises (Board of Education), Tables 1.15 then 37.48 and 66 (kneeling). Every endeavour was made by the teacher in charge of the class to get the children to enjoy the exercises, rather than look on them as a task. At the outset of the class the teacher in charge was present during the medical examination of each child. Whilst the child was being examined faulty positions and postural defects, if any, were pointed out to the teacher. As the children were stripped to the waist, it was easy to emphasise the faults and point out the remedy. After the medical examination the children, still stripped to the waist, were put through the following simple movements : (i.) Fundamental standing position ; (ii.) Wing or " hips firm " ; (iii.) Rest; (iv.) Stretch; (v.) Trunk bend; (vi.) Kneel. The common faults noted were in (i.) Protruding abdomen. Curved back; (ii.) Elbows too far back; (iii.) Head too far forward ; (iv.) Arms forward; (v.) Knees bent. Rigid spine; (vi.) Bad balance. Rigidity. The postural defects found in the class were:— Kyphosis (round shoulders) 6, very slight; 3, slight. Scoliosis 6, slight curves to left; 4, slight curves to right. Lordosis 4, „ „ It is interesting to note that in the class were 3 cases of uneven vision (not corrected) associated with slight lateral curves, 2 to the left and one to the right. The vision noted in each case was respectively 18.24, 18.12 and 18.12. There was marked improvement in these cases at the end of the class. The postural defects noted above were decreased and in 4 cases disappeared entirely. It was noticeable that the deportment of the children was improved and in several cases became graceful. The sacro-spinal group of muscles was developed, and the scapulo-spinal group showed marked improvement. In the fundamental standing position, where at first protrusion of the abdomen occurred, there was great improvement owing to the strengthening of the abdominal muscles. Shortened pectoral muscles were stretched by the exercises and the set of the shoulders and chest development consequently improved, in a number of cases. Rigidity of the chest wall and trunk moreover disappeared with the regular exercise. It will be seen from the tables that there was a decrease as a rule in the pulse rate, the regular exercises having a beneficial effect on the heart. Anaemia was benefited, so that the nutrition of the heart muscle was improved. The teacher was particularly instructed to see that the breath was not held during the exercises. There was a great tendency for the children to do this at first, especially those who were overkeen. This fault was commented on a year or so ago in the army, where the drill instruction was given by non-commissioned officers not under medical supervision. This accounted for a good number of dilated hearts with consequent invaliding from the service. Towards the end of the class, it was seen that the children did the exercises smartly with the least amount of effort. In no case was there the slightest dilation of the heart, as shown by the displacement of the apex beat from the mid clavicular line. There were 5 cases of bronchial catarrh noted at the first medical examination; these all cleared up. 165 Report of the County Medical Officer—Education. The average increase in chest expansion was 1.3 cms. This figure seems very small, but it must be remembered that the class consisted of some of the poorest children in London, badly nourished and badly clothed. Mouth breathing was improved. Deep sub-clavicular fossae practically filled up at the end of the class. The weights were as follows. The average gain was 1 "9 kilograms. Weight (Kilograms). Chest (Centimetres) Expansion. (Centimetres). Pulse rate. Age. Initial. May. Dec. May. Dec. May. Dec. May. Dec. School Meals 12½ B. E. 24.8 261 60 63 3.5 5.5 90 84 9 3. L. 21.2 22.4 58.5 60 4.0 5.5 78 78 92/2 B. E. 19.55 21.3 57.5 57.5 4.0 4.5 96 80 Dinner. 95/12 C. E. 21.7 23.5 58.5 59.5 2.5 3.0 96 78 Dinner. 114/12 C. A. 233 24.7 62 63 3.5 4.0 96 84 Dinner. 102/2 C. A. 27.6 30 67 68.5 5.5 6.0 102 96 Breakfast and dinner. 125/12 D. E. 260 28 60 61.5 4.0 4.5 78 78 12 E. A. 20.45 22 59 61 5.0 6.5 84 78 Breakfast, dinner and milk. 127/12 F. L. 28.3 30.4 63 65 4.0 5.5 90 90 Breakfast, dinner and milk. 91/12 G. I. 22.35 23.9 59.5 60.5 3.5 5.0 96 90 9 H. M. 24.4 25.8 60.5 61.5 5.5 6.0 102 84 Breakfast, dinner and milk. 91/12 H. V. 19.7 21.3 57 59.5 3.0 4.5 102 90 97/12 L. E. 2315 25.9 59 59.5 3.0 3.5 90 90 Breakfast, dinner and milk. 127/12 S. M. 29.3 33.8 62.5 63.5 3.5 4.0 96 84 9 8/12 S. E. 23.3 25 60 61.5 3.0 4.5 96 90 Dinner. 114/12 S. M. 23.05 24.4 59.5 61 4.5 5.5 102 90 127/12 H. E. 27.6 31.3 63.5 66.5 4.5 7.0 102 102 Breakfast and dinner. 11 M. C. 25.8 27.2 61 64.5 4.0 6.0 90 98 An attempt was made to trace any beneficial result in the mental state of the class. With that end in view the various class mistresses were requested to watch the children and to note the progress in their school work. It appeared that there was mental improvement in 8 children. The remarks of the class mistresses in these cases are appended :— E. C. " Ellen is much sharper than she used to be." L. B. " Has improved generally. Is bright and cheerful, working well." E. D. " Elsie has been much brighter lately." She (teacher) does not know why. A. E. " Seems brighter in every way." I. G. "Ivy is naturally quiet." Mrs. K. (teacher) thinks she is brighter and altogether has " more life " in her. M. H. " She has much improved and is considerably more energetic." M. S. (Mouth Breather) " Much brighter lately." C.M. " Was very listless in her class and quite contented to sit still and play with her fingers. Seems much brighter lately and certainly is interested in her work." Camden Street, E. St. Pancras (G.)—(Dr. Norman).—This class originally (June, 1913) consisted of 23 girls specially selected. Eight have left the school, one has been excluded on account of organic heart disease. Three girls were absent at the final inspection, eleven only forming the class. The girls show considerable improvement for the 8 months' special drill, but in their exercises there was a lack of energy and enjoyment thrown into their movements, in striking contrast to the boys examined in the special class at Prospect Terrace, St. Pancras, E. They do not show so much improvement as the boys in similar classes, and it will be advisable for them to remain in the class for a considerable time longer. The girls are drilled each day for a period of about 20 minutes. Catherine Street, Hoxton (G.)—(Dr. Chaikin).—The children were selected for the above class from those presented by the head mistress. They were examined twice. The spinal deformities were postural. The class was held daily for 20 minutes. The teacher was very enthusiastic. The exercises were those of the Board of Education with the addition of crawling. There were 13 children in the class so that individual attention could be given. Every praise should be given to the head teacher and the teacher in charge for the interest and care shown. An attempt was made to interest the parents by inviting them to the first examination. The numbers in the class were few, and rightly so, for only with small numbers can individual attention be given. (1) Changes in antero-posterior curves.—5 children had antero-posterior curves ; 3 of these improved. (2) Changes in lateral curvature.—11 children had lateral curvature. 10 of these improved ; 4 were noted with unequal shoulders; 1 improved. (3) Changes in measurement.—Circumference of chest in " rest " position expressed in centimetres. 3 gained 1 centimetre. 5 gained 2 centimetres. 2 gained 3 centimetres. 1 gained 4 centimetres. There was thus general improvement. The most noticeable change was in the case of two children who were rickety. The girls with uneven shoulders did not improve as well as might have been expected. This is, no doubt, due to their practice of nursing babies. 166 Annual Report of the London County Council, 1913. Deal St. Whitechapel (Girls)—(Dr. Peters).—23 children were included in the class and examined ls< May, 1913; Shave left the school or ceased attending class; 15 remained in the class till the final examination—22nd Jan, 1914. Of the last named, some of whom had more than one defect, there were, at the beginning of the class, 7 cases of kyphosis, 5 of lordosis, 2 of scoliosis, 5 of round shoulders, 4 of shoulder down, 2 of hips prominent, and one of rotation of vertebrae; but in January it was found that the following defects had improved or recovered :—kyphosis, 5; lordosis, 4; scoliosis, 1; round shoulders, 3 ; shoulder down, 3; hips prominent, 1; rotation of vertebrae, 1. The chest measurements of the above 15 cases were:—increase deflated 0.86 inch per child; increase expanded 0.88 inch per child ; increase in " Expansibility " 0 01 inch per child. The agegroups were, born in 1900—8 children; 1901—3 children; 1902—1 child; 1903—2 children ; 1904—1 child. The class has been exercised for 20 minutes every morning, between 9 and 10 o'clock, in the Girls' Hall. In general, rubber-soled shoes were worn. The exercises practised were those contained in the Board's manual, from Standard IV. upwards. At the end of these exercises organised games, generally of a competitive nature, were practised for about 5 minutes. The class was capably conducted. As regards the general deportment of the girls, and increase in briskness, physically and mentally, there could be no doubt as to the marked improvement. The increase in girth of chest, deflated, showed a probable improvement in nutrition, after allowing for the natural growth in girth of chest in girls of this age. The increase in " expansibility" was not great. The defects noted at the first examination, which consisted almost wholly of kypho-lordosis, with accompanying round shoulders, were all of a slight nature, and as they were not fixed, but mostly merely temporary postural deformities, it is, perhaps, not too much to claim that the numbers of defects improved by the exercises received were actually as high as 18 out of 26. It was evident that efforts had been made also to correct the tendency to lordosis from over extension of the spine when called to stand at attention. One case was excluded from the class and sent for hospital treatment because of the advanced nature of the deformity. Eltringham Street, Wandsworth (Girls)—(Dr. Duncan).—This class was held in the Girls' department of the above-named school from April 10th till December, 1913, when it was discontinued. The class was composed of 25 girls chosen from the different classes on account of bad posture and various slight deformities, e.g., narrow chest, round shoulders, etc. They were all minor defects and none of the cases required medical treatment. The class was held in the hall for 20 minutes each morning. As many of the girls as possible wore special drill dresses so that the movements could be well seen by the teacher. The following were the defects found:—round shoulders and flat chest, 11 ; mouth breathers, 5; light scoliosis, 4; narrow chest, 3; general malnutrition and poor physical development, 2. Special attention was given to deep breathing. The chest measurements were taken in 21 cases (1 had left and 3 were absent) and it was found that 9 were the same as at the first examination, 9 had increased ½ inch, 1 had increased ½ inch, 1 had increased 1 inch, 1 had increased 2 inches. All the girls had gained in height. There was a decided improvement in the physical condition of all the children. They were smarter and carried out the various movements with greater precision than one usually sees in the ordinary drill class. The head teacher states that their work in the classroom showed great improvement. " Highway," St. George's-in-the-East (Girls).—(Dr. Ruth Balmer).—There were originally twenty-three girls in the class; there were in January, 1914, only eighteen, and of these five were absent at the final inspection. The class was held every morning for twenty minutes. The children wore their ordinary clothes and in many cases these were quite unsuitable, their movements being hampered by numerous skirts, stiff and constricting corsets and heavy boots and shoes. This interfered much with the progress of some of the girls. But in spite of the fact that only three of the girls wore rubber-soled shoes, their movements were wonderfully noiseless and light. The first exercise of the class is always "handkerchief drill." By this means the air-passages are cleared, and it is an excellent preparation for the other exercises. None of the members of the class suffered from any marked deformity. There was one case of slight scoliosis, which is now practically cured. Six of the girls were round-shouldered and these had all improved. Five of them were more or less mouth-breathers. They showed marked improvement. In two cases the shoulders were uneven in level and this was still the case. With two exceptions the dimensions of the girls' chests had increased, the average increase being—inflated, 0.84 in.; empty, 0.79 in. The general muscular tone of the girls was good. The Headmistress reports a general improvement in the girls. She said, " They show more self-control and concentration on their work." Hunger/ord Road, Islington, W. (Girls.).—(Dr. HcHattie).—This class was started in August. The girls, of whom it consists, were selected by the Head Mistress and medically examined at the beginning of the autumn term. Those passed as suitable numbered 20, and their ages ranged from 8 to 13 years. No girl showing any evidence of valvular lesion of the heart was admitted to this class. The girls were drilled daily in exercises adapted from those prescribed by the Board of Education. Of the 20 girls who entered this class 17 were examined a second time on January 21st. Of these 3 were cases of lordosis, of which 2 showed marked antero-posterior curvature; 4 were cases of scoliosis with dorsal curve to the left; 10 showed both lateral and antero-posterior curvature. Of other deformities present there were—4 cases of flattening of the chest; 1 case of genu valgum; 1 case of marked rachitic curving of both tibiae. The time during which this class has been held is scarcely long enough to judge of definite results so far as the actual deformities are concerned ; but, though the number noted as improved in this respect is small, most of the girls show a tendency to stand and walk better. Of the 17 girls 6 showed definite and marked improvement. Of these 6, 1 had marked scoliosis, 4 had both lordosis 167 Report of the County Medical Officer—Education. and scoliosis and 1 had slight lordosis. Of the 4 with flat chest, 2 show improvement in the spinal defect, the other two are unimproved. Moreland Street, Finsbury, E. (Girls)—(Dr. Hadfield).—This class was commenced at the beginning of May, 191-3, and all the children composing it were examined and a special record made for each either on May 5th or June 9th, 1913. They were reinspected on January 16th, 1914. Twenty-three children have been in the class during this period, although owing to various causes the number included at any one time has been somewhat less. The class was taken in the School Hall for twenty minutes each school day. The considerable amount of success attending the class must be largely attributed to the great keenness and interest shown by the head mistress and the teacher in charge. For the purposes of the class each pupil was provided with a "combination garment" which formed a very suitable dress for the work. These garments were made partly at the school and partly at the pupils' homes. The cost was also divided between the school and the parents. With regard to individual physical defects, all the children showed improvement—naturally some more than others. Spinal Curvature—Antero-posterior.—No tubercular cases were admitted. The cases of round shoulders and lordosis show improvement. Lateral.—All have improved. In some the curve has quite disappeared. Fixity of Spine.—This was a marked defect in most cases. Some have not improved much. The majority are decidedly better. Shoulders.—Now nearly all hold their shoulders better, though they tend to drop into a bad position again when not at attention. This shows that considerable time will be necessary to eradicate the habit of bad position. Chest.— Nearly all cases show increased chest measurement and increased chest expansion. In one other important feature there has been very real improvement, viz., in the girls' mental condition. A number of those selected were unsatisfactory in various ways especially in the lack of inhibition and control both mental and physical. In fact they were presented for examination for this reason. It is satisfactory to find that the teachers record that marked benefit has been the result. "Snowsfields'" (Bermondsey),—(Girls).—(Dr. Macdonald).—A special physical exercise class for 26 anaemic and debilitated girls was started soon after the Easter holidays, and has been conducted very satisfactorily by one of the assistant teachers for two complete terms. The special class is drawn together from all standards of the school for half an hour daily, sometimes for two half-hours, morning and afternoons, if the hall is available. The class is always taken by the same teacher, who has been able, with the help of the head teacher, to devise a graduated system of physical exercises, partly from the syllabus and partly from additional exercises, such as skipping, dancing, and games. In other ways also everything that is possible is being done to improve the physical and medical condition of the children, and during the past month, owing to the poor and wretched home conditions of the children, and their debilitated conditions, as the result of inadequate nourishment, arrangements have been made to give each child half a pint of hot milk every morning at 10.30 o'clock. The results have been unexpectedly good—the children's appearance has altogether changed. They now appear happy and bright, the head teacher remarking that the children do not now look like the same girls, and they are much more responsive in their work, keener, and more alert than formerly was the case. The average increase in chest expansion was 1.27 c.m. The organisation of the class has demanded much extra time and trouble on the part of the teacher, but the results appear to have justified the experiment. Weston Street, Bermondsey (Girls).—(Dr. Colston Williams).—Twenty-two girls were selected from Classes 1-5 (the lowest class being omitted); the ages ranged from 8-13 years. The girls were chosen chiefly on account of bad posture, but a few on the ground of general slackness of muscular tone. Four girls left school during the term ; the roll in January was 18; the average attendance before Midsummer was 16 3, and after was 13. Twenty minutes per day were given in the morning session before playtime. The girls took off boots or shoes immediately after entering the hall; those ready first skipped with single ropes until the whole class was ready. (1.) Breathing. The girls lie on their backs on the floor for deep breathing exercises. (2.) Tables 12, 13, 14 and 15 (B. of E. syllabus). One table taken daily. . (3.) Simple dances. (4.) Skipping (with music). Those girls showing postural deformities, such as round shoulders and dorsal curvature were much improved. Chest expansion as a rule shows little increase, with the curious exception of one still untreated case of adenoids. The way in which the exercises are carried out by the children has greatly improved, especially in the case of the delicate and weakly, all being now quicker in response and displaying improved muscular balance. The clothing of the children in some cases is most unsuitable ; one child at the last visit was wearing nine layers of clothing over her chest and her arm movements were impeded. The class has exercised every day without interruption. Recommendations for a future class.—(1.) A suitable, light gymnastic garment. (2.) The formation of a list in the school during routine medical inspection of all cases likely to benefit by such special class exercise, the final selection to be made from this list, with the inclusion of suitable cases noted by the teachers during the year. (3.) Milk for underfed children in the class. The head mistress took the class herself, and the general results, which have been exceedingly good, must be ascribed to the interest she has shown and the pains taken by her in teaching the children. Betts Street, St. George-in-the-East (Girls).—(Dr. Ruth Balmer).—This class has been held every morning for twenty minutes since May, 1913. There were originally nineteen girls in the class aged about twelve years, two have now left and one was absent at the final inspections at the end of the year 1913. The girls were suitably dressed in loose tunics and knickers and all wore rubber-soled shoes. They seemed thoroughly to enjoy the drill and did the exercises, running, etc., with energy, precision, spring, and lightness. The chief defects among the girls were spinal curvatures, 168 Annual Report of the London County Council, 1913. 9 cases—4 cases scoliosis, 2 cases kyphosis, 2 cases lordosis, and 1 case rotation of vertebrae. There were 2 cases of flattened chests, 5 cases of shoulders unequal in level, 2 cases of nasal obstruction. Two of the girls had no special defect. The improvement in the various defective conditions noted was:— Two of the cases with slight lateral deviation presented no curve and the shoulders were level. In one case of fixed lateral curve the muscular tone was good and the girl said she had much less backache since the commencement of the class. The flattened chests seemed improved. The cases of unequal shoulders had improved. The mouth breathers were much improved. In every case there bad been an improvement in the development of the chest, the average increase in girth being : inflated, 0.87 in. increase ; empty, 1.03 in. increase. The headmistress points out that the girls have showD great improvement mentally as well as physically. Pritchard's Road, Beihnal Green, N.E. (Girls).—(Dr. Agnes Parson).—The class consisted of 20 girls who were picked out from a number of others selected for bad posture or poor physique ; of these 12 only were present at the last detailed examination. Several girls were of very poor physique on entering the class and their nutrition was below the normal. The following defects were found, which made the children suitable cases for the class:— Kyphosis, 8 (the curve was not fixed in any case); defective mobility of spine, 5 ; hollow back, 2 ; defective mobility of shoulders, 3 ; chest expansion, very poor, 2 ; poor, 5 ; fair, 3 ; good, 2. The girls have improved very much in carriage and general appearance, their muscular development has also improved and they look generally healthier and more alert. The drill is performed with much keenness and interest, and all the girls appear to enjoy it thoroughly. One anaemic girl confessed on questioning to feeling tired, and in her case the drill is to be discontinued. Condition of children in regard to deformity at final inspection:—Kyphosis—much iin-. proved, 3; improved, 4; no improvement, 1. Defective mobility of spine—much improved, 1 ; improved, 4. Hollow back—1 improved, 1 very slight improvement. Defective mobility of shoulders —2 improved, 1 much the same. Two girls were noticed to have slight lateral curvature of the spine, in both cases their physical condition had improved, but they will need careful supervision. Chest expansion—very poor, 1; poor, 1; fair, 3 ; good, 7. Church Street, Kennington (Girls) (Dr. Slowan).— Seventeen girls examined in April and September; 3 were mouth breathers, 9 had varying degrees of curvature, and 5 suffered from both defects. The three mouth breathers all improved in regard to this condition ; the chest measurement increased 10 mm. in two, and in the third remained unaltered. There were 9 curvatures—4 lateral, 4 antero-posterior, 1 combined. (a) 4 slight scoliosis (3 to left, 1 to right)—one improved and chest measurement increased 20 mm.; 3 remained unaltered. (b) 4 slight antero-posterior curvatures, 1 lordosis corrected and chest increased 30 mm. ; 3 kyphosis—1 improved and chest increased 50 mm.; 2 and 3, unaltered, but chest increased 10 mm. in each. (c) 1 kypho-scoliosis, unaltered, chest increased 20 m.m. Five mouth breathers with curvature. (a) 1 slight lordosis corrected but slight scoliosis appeared, mouth-breathing improved, chest measurement as before. (b) 2 slight kyphosis—(1) unaltered, mouth-breathing improved, chest measurement as before ; (2) mouth-breathing not improved, chest increased 10 mm. (c) 2 scoliosis, both to left—(1) corrected mouth-breathing, improved chest measurement, unaltered; (2) unaltered, mouth-breathing not improved, chest increased 20 mm. In 10 of the 17 the chest measurement increased 10 to 50 m.m. Cook's Ground (Chelsea) Girls' (Dr. Lewis).—The children, 20 in number, were selected in September by the school doctor for physical defects, which required more systematic physical exercises than are obtained in the usual school physical exercises. A few cases of generally poor muscular development and mouth breathing were also included. The children attend daily for 30 minutes immediately before the afternoon session, at the Chelsea Physical Training College, which is situated quite near to the school (about a quarter of a mile). The children thus have the advantage of a specially7 trained student, who takes the class under the immediate direction of the Principal (Miss Wilke). A table was originally set which has been gradually increased in severity as the children have improved. The more marked improvement is to be found in the general physique, and especially in the balance, as tested by a simple balance movement in all cases except two. The chest expansion throughout the class, with two exceptions, has increased by 2'5 c.m. (average of 18 girls). The average chest expansion is 6 c.m., and the maximum 8 c.m. Two children, originally selected for the class on account of general mental subnormality, have not shewn any marked improvement, but of these one is a girl of such poor nutrition that little could be expected. The postural curves of kyphosis and scoliosis for which 12 were included all shew very marked improvement. It should be added that in this class abdominal movements with the [children lying on the floor were insisted on as a part of the regimen. These exercises are usually omitted from the school tables by the teachers, and it may be urged that their absence from the exercises is a grave source of lordosis, inasmuch as the back muscles of the trunk become unduly developed and lead to permanent lengthening of the rectus abdominalis, with consequent hollow back and visceral displacement. This class has been in existence for three years, having been originally started by Dr. Shrubsall (Assistant Medical Officer), and it has the unique advantage of being always taken by an expert student of the Physical Training College. As showing how popular the class is among the children it may be said that the competition to be included is very great, but the number is strictly limited to 20. 169 Report of the County Medical Officer—Education. Open-air Schools. The two open-air schools maintained by the Council have been fully described in previous reports. Both have been continued throughout the winter months. No difficulties have been experienced, and the results upon the health of the children have been uniformly good. The schools were visited once a fortnight by the doctors, and each child was seen at least once in three months. At each visit the doctors also saw cases to which special attention was drawn by the head teacher, nurse, or managing committee, and the doctors advised as to those children who should be excluded, those fit to return to an ordinary elementary school, and those who should be invalided. The results of medical inspection in the ordinary elementary schools have been such as to show that there is a need for additional open-air schools, but although many enquiries have been made it has not yet been possible to acquire suitable sites for additional open-air schools either north or south of the Thames. The Birley House and Shooters Hill schools were respectively under the medical supervision of Dr. F. T. H, Wood and Dr. C. T. W. Hirsch, from whose reports the following particulars have been taken. Birley House School. In April, 1913, 17 scholars remained from the previous year and another 57 were admitted after medical examination. The conditions determining their admission may be grouped as under, some children being included in more than one class:— Anaemia 36 Malnutrition and general poor physique 28 Phthisis 5 Recent surgical tuberculosis 5 Tubercular glands 3 Enlargement of glands (non-tubercular) 10 Other conditions 9 At various times during the year, additional children were taken in and 16 were returned fit for the elementary schools, 5 were discharged by the managing committee as not taking full advantage of the benefits of the school, 2 were invalided as unfit for any school attendance and 2 left on reaching the age of 14. The usual medical and dental defects were discovered and reported on during the periodic examinations and were in most cases remedied, particular attention being given to securing treatment of the teeth. At the end of the year all the children were re-examined and 48 were found fit for return 1o the elementary schools, while 38 were continued for a longer period ; this latter group included one boy who had attended regularly for four years—a unique record in view of the fact that the open-air school does not recognise the ordinary holidays. No observer could fail to be struck with the improvement in the general bearing and appearance of the children, an improvement which the following tabular statements nartiallv illustrate. The table below, which shows the average weights in kilograms at the commencement of the year compared with the corresponding averages of all London elementary school children, is an indication of the poor physique of the scholars selected. Boys. Girls. Age last birthday. (1) No. of children. (2) Average weight on admission. (3) Average weight of all L.C.C. school boys. (4) Age last birthday. (5) No. of children. (6) Average weight on admission. (7) Averago weight of all L.C.C. school girls. (8) 7 2 19.35 22.00 7 3 19.40 21.2 8 4 20.72 23.47 8 5 21.90 22.92 9 10 24.46 25.46 9 11 22.56 25.00 10 7 25.00 27.59 10 7 26.73 27.16 11 14 27.23 29.25 11 16 26.91 29.87 12 10 33.43 32.46 12 9 29.08 33.32 13 3 35.75 36.40 13 3 32.53 37.71 Table showing the average gain in weight (in kilograms) in each age group during the year, compared with the corresponding averages of all London elementary school children. It may be recalled that the increase has occurred in children who had previously not been making the standard gain. Boys. Girls. Age last birthday. (1) No. of children. (2) Average gain in tho year. (3) Average gain in standard boys. (4) Ago last birthday. (5) No. of children. (6) Average gain in the year. (7) Average gain in standard girls. (8) 7 2 2.65 1.45 7 3 2.33 1.72 8 4 3.17 1.99 8 5 2.94 2.08 9 10 2.90 2.13 9 11 3.33 2.16 10 7 3.30 2.36 10 7 3.33 2.71 11 14 3.40 2.51 11 16 4.69 3.45 12 10 3.63 3.94 12 9 3.95 4.39 13 3 3.33 2.83 13 3 6.33 4.09 23610 z 170 Annual Report of the London County Council, 1913. Table showing the average weekly gain in weight (in kilograms) at various ages, compared with the corresponding average weekly gain of all London elementary school children: — Boys. Girls. Age last birthday. (1) No. of children. (2) Average weekly gain (3) Average weekly gain in standard boys. («) Age last birthday. («) No. of children. (6) Average weekly gain. (?) Average weekly gain in standard girls. (8) 7 2 •052 7 3 •046 8 4 • 062 •03 8 5 •058 •03 9 10 •057 •04 9 11 •065 •04 10 7 •065 •04 10 7 •065 •05 11 14 •066 •05 11 16 ■092 •06 12 10 •071 •06 12 9 •077 •07 13 3 •052 •06 13 3 •124 •08 Table showing the weekly increase in weight expressed as percentage of body weight on admission, compared with the corresponding percentage increases in all London elementary school children:— Boys. Girls. Age last birthday. (1) Birlev House, 1913-14. (*) Birley House. 1912. (3) London elementary schools, 1906. <♦) Age last birthday. (s) Birley House, 1913-14. (6) Birley House. 1912. (?) London elementary schools, 1906. (8) 7 •24 •29 7 •24 •18 •15 8 •29 •19 •14 8 •26 •50 •16 9 •23 •23 •16 9 •29 •32 •16 10 •26 •25 •16 10 •24 •32 •17 11 •24 •24 •15 11 •34 •32 •19 12 •21 •31 •18 12 •26 •36 •23 13 •15 •34 •17 13 •38 •33 •22 The above table shows more clearly than any other the benefits obtained by "putting the weakly child in a favourable environment—for the proportional gain of the open-air scholar exceeds that of the child in its old surroundings in varying degree up to 100 per cent. The htemoglobin content of the blood was estimated (by Tallquist's scale) three times during the year and the improvement noted can be taken as an indication of the quality of the increased body weight. Expressing the normal as 100, the averages at certain intervals were— Boys. Oirls. At the seventh week ... ... ... 88 9 ... 83*7 At the twenty-fourth week ... ... 928 ... 85-l At the forty-ninth week ... ... ... 93-5 ... 88*1 The following shows the estimated changes in haemoglobin content in 42 weeks :— Boys. Oirls. Number showing decrease of 5 per cent. ... 3 ... 5 Number stationary ... ... ... ... 8 ... 8 Increase of 5 per cent. ... ... ... 13 ... 20 Increase of 10 per cent. ... ... ... 9 ... 7 Increase of 15 per cent. ... ... ... 4 ... 2 Many of the children at entry were found to have poor chest expansion, and considerable attention was given to breathing exercises with encouraging results. Thus the boys who gave an average chest measurement at entry of 22*4 inches (expiration) and 23'8 inches (inspiration) had corresponding figures at discharge of 229 and 24 7, while the girls' averages were 220 and 23'8 inches respectively at entry and 23'2 and 254 on discharge. Some notes on individual children are appended, from which it can be seen that the tubercular children generally shared in the improvement made, but that not much diminution of the enlarged cervical glands of some of the cases was produced, although the general health was benefited. S.C.—M.—aet. 11—phthisis; tubercular signs since 1911; large initial gain in weight; improvement maintained. E.W.—F.—aet. 9—phthisis ; signs first noted March, 1913; constant absences—moderate gain. D.S.—F.—aet. 10—phthisis ; large initial gain followed by acute illness and loss ; invalided after six months. 171 Report of the County Medical Officer—Education. C.C.—M.— aet. 12—former phthisis; fourth year of attendance; still makes steady weight increases. F.R. —M.—aet. 12— ? phthisis ; had not attended school for five years before admission; delicate, distressed appearance ; no abnormal lung signs ; large initial increase maintained. C.S.—M.—aet. 9—? phthisis ; had not attended school for three years (under school doctor's observation wilh tubercle of left luug); large initial increase. R.P.—M.—aet. 11—recent operation for tubercular glands; large increase in weight well maintained. A.S.—M.—aet. 11—enlarged glands; no diminution in size, but large steady weight increase. A.W.— F.—aet. 11—tubercular glands; removed by operation; large steady increase in weight. In conclusion, it may be noted that this year's work confirms the experience of the previous six years as to the existence of a class of delicate, weakly children capable of mental and physical improvement when receiving modified instruction in natural surroundings. Shooters Hil School. This school recommenced work m April, 1913, with 62 children remaining over from the previous year and 36 new admissions. During the year 51 were admitted and 30 discharged, one because of rheumatism, as she was not a suitable case, the others because their health had so improved that they were fit to return to ordinary elementary schools; 31 were attending the Tuberculosis Dispensary ; the defects noted among these were as follows:— Poor nutrition and suspicion of early phthisis, ° including cases of poor chest expansion 21 cases Malnutrition 1 „ Anaemia 7 ,, Adenitis neck (? Tubercular) 5 „ Tonsils and Adenoids 2 „ Defective teeth 12 „ Defective vision 1 „ Rickets 4 „ Talipes Valgus 1 „ Otorrhcea 4 „ Conjunctivitis 1 „ Strabismus 1 „ Polypus, ear 1 „ Scoliosis (lateral) 1 „ Blepharitis 1 „ None had acute phthisis or advanced tuberculosis, evening temperatures were absent and most had merely suspicious symptoms, such as prolonged expiration at one apex, flatness on percussion, or merely poor chest expansion coupled with anaemia. A certain number had tuberculous glands. The morbid conditions noted as present among the other children were as follows:— Malnutrition 12 cases. Early signs, phthisis 14 „ Poor expansion, chest 24 „ Adenitis, neck (? Tubercular) 21 „ Defective teeth 34 „ Tonsils and Adenoids 9 „ Otorrhœa 5 „ Arthritis (Tubercular) 1 „ Eczema 1 „ Anaemia 31 „ Tendency to chorea 2 „ Blepharitis 5 „ Nasal Polypus 1 „ Asthma 1 „ Scoliosis (lateral) 6 „ Kyphosis 1 „ Defective vision 6 „ Paralysis (facial) 1 „ Rickets 2 „ Conjunctivitis 1 „ Rheumatism 1 „ Practically all the dental, throat, eye and minor defects were followed up by the care committee and treatment obtained. Remedial exercises were carried out at the school for the spinal cases and those with poor chest expansion, with a result that the difference between inspiration and expiration was increased in some from 4 cm. to as much as 9 cm., and in the cases of lateral curvature the Kellett Smith level was corrected with a quarter-inch block instead of requiring an inch block as originally noted. 23610 z 2 172 Annual Report of the London County Council, 1913. The average attendance was about 101. The weather conditions were, on the whole, favourable ; the following table gives some information on this point, and likewise where the day's rest was taken—wood, field, or bungalow. Month. Weather. Where rest was taken. Remarks. Fine for the time of year. So. of days. Medium. No. of days. Wet. No. of days. Cold for the time of year. No.of days. Fog. No. of days. In Wood. No. of days. In Field. No- of days. In Bungalow. No- of days. (1 (2) (8) (4) (5) (6) (7) (8) (9) 10 On eight occasions rest began in wood or field and was moved to Bungalow on account of rain. April, 1913 7 7 8 4 — 12 3 7 May „ 16 3 6 2 — 12 6 4 June „ 13 5 5 2 — 10 11 — July 11 4 9 1 — 16 3 4 August „ 13 4 7 2 — 17 2 1 September „ 12 4 8 1 — 15 3 4 October „ 15 5 6 1 2 16 1 5 November „ 14 1 8 1 1 6 2 12 December „ 8 * 6 5 5 1 — — 21 January 1914 11 — 4 14 3 — 19 The following table gives, for each sex and age, the average weight, height, percentage haemoglobin and chest measurements on inspiration in April, 1913, and January, 1914. Age. (1) Average weight. Average height. Average Haemoglobin test. Average chest measurements at inspiration. April, 1913. kilograms. (2) January, 1914. kilograms. (3) April, 1913. c.m. (4) January. 1914. c.m. (5) April, 1913. (6) January, 1914. (7) April, 1913. c.m. (8) January, 1914. c.m. (9) Boys. 8 years 22-0 23.7 116.5 122.0 70.0 85 .0 61.0 64.0 9 22-7 24.3 121.4 124.8 72.1 82.1 82.4 63 .6 10 25-6 27.8 128.4 132.1 76.9 86.0 64.4 66.6 11 29-0 31.3 132.9 136.7 76.1 86.1 67.7 69.0 12 29-6 31.5 133.2 136.7 74.7 85.3 67.7 69.1 13 29-3 31.7 135.8 139.4 , 75.5 87.5 66.7 69.1 14 32-9 35.3 141.5 145.4 78.3 87.5 69.7 71.0 Girls. 8 years 20.6 22.6 117.6 120.5 71.2 85.0 59.7 62.0 9 25.5 27.8 125.7 129.5 72.1 82.1 62.7 65.1 10 25.7 28.0 124.3 128.2 73.6 84.1 62.4 65.0 11 26.3 29. 1 128.7 132.6 69.4 83.1 62.5 65.0 12 „ 29.8 32.7 134.4 139.4 70.0 83.3 66.0 68.6 13 „ 38.2 42.5 142.2 148.7 80.0 87.5 67.5 68.5 14 „ 345 396 1430 147-8 75.0 87.6 71.5 73.0 These figures show a general improvement, which is also borne out by the increased smartness and intelligence to be observed in the children. It was frequently said at other schools that children regarded almost as mentally defective, had returned, after a sojourn at the open-air school, completely changed—bright, energetic, and good workers, in contrast to their condition prior to entering Shooter's Hill school. Kensal House tuberculosis school. This school has been under the regular supervision oi Dr. K. b. Walker, the medical officer of the Paddington Tuberculosis Dispensary, who is attached to the Council's service for the purpose of (a) the selection of children for admission to the school (6) the' medical inspection of the children under the Education (Administrative Provision) Act, 1907, and periodical medical examinations under the Education (Defective and Epileptic Children) Act, 1899; (c) reporting to the school medical officer in regard to applications for exemption from further school attendance, and the supervision of the medical side of the work of the school when so instructed. The dispensary doctor chooses from among his patients those children whom he considers to be suitable for admission to the school, and when making his selection he is guided by the result of the examination of chest, mouth, teeth, etc.; general appearance, nutrition, clothing and cleanliness ; and the willingness of the parent to co-operate with the school authorities. The question of residence is also important, and the children admitted to the school are drawn from the streets in the immediate vicinity thereof. At the examinations, the parents are invited to attend, and are of much assistance to the doctor, who is thus able to give advice in regard to general conditions, and to persuade the parents to send to the treatment centres children suffering from defective vision, enlarged tonsils, adenoids, and carious teeth. The number of children on the roll on the 1st January, was 97, and on 31st December, 94. The average attendance for the year was 83. There was no marked variation in the attendance from month to month; January had the highest figure, 90.4, for the year; but in August, there was a definite drop, due to many of the children being sent on holiday to the country. 173 Report of the County Medical Officer—Education. There was a steady increase in the stature and weight of the children. The following tables show that the chief increase took place in the autumn months, while in summer there was on the average little increase—even a decrease. Year of Birth. (1) Average Weights in Kilograms. Boys. Girls. 1st week. (2) 25th week. (3) 45th week. (4) 50th week. (5) Increase during whole period. (6) 1st week. (7) 25th week. (8) 45th week. (9) 50th week. (10) Increase during whole period. (11) 1906 - - - - - - - - - - 1905 19.3 20.0 210 20. 9 1-6 19.9 20.1 21.8 22.6 2.7 1904 23.0 23.4 24.9 26.7 3.7 23.5 23.3 25.1 25.2 1.7 1903 26.3 26.7 28.4 28.5 2.2 26.5 26.6 28.8 29.2 2.7 1902 26.5 27.0 28.7 28.6 2.1 27.3 27.6 30.0 30.4 3.1 1901 30.0 30.8 32.7 32.7 2.7 31.1 31.5 34.2 34.4 3.3 1900 29.2 30.3 32.8 32.8 3.6 31.5 32.2 34.8 35.8 4.3 1899 29.8 30.1 31.7 31.6 1.8 36.3 38.5 42.1 42.0 5.7 1898 — — — — — 33.4 34.6 38.0 38.4 5.0 Year of birth. (1) Average Heights in Centimetres. Boys. Girls. 2nd week. (2) 52nd week. (3) Increase. (4) 2nd week. (5) 52nd week. (6) Increase. (?) 1905 111.4 115.8 4.4 115.8 121.4 5.6 1904 123.2 128.7 5.5 119.6 124.4 4.8 1903 128.4 133.6 5.2 130.3 134.8 4.5 1902 128.2 133.3 5.1 131.3 138.0 6.7 1901 132.9 137.7 4.8 142.7 149.5 6.8 1900 138.8 143.5 4.7 140.2 147.0 6.8 1899 138.6 142.0 3.4 147.0 154.1 7.1 1898 ~~ — — 145.2 149.8 4.6 The dispensary authorities have provided free dinners and other assistance in cases of extreme poverty, and every effort has been made to ensure that children leaving the school shall proceed to suitable occupations. Playground classes. Playground classes have now been held for five years in connection with the elementary school maintained by the Council. The various types of classes are as follows:— Type A.—A class held at a centre and composed of specially delicate children drawn from neighbouring schools, the same class working in the open-air all the summer. Type B.—A class in whieh the children are specially selected from various standards in one school, the same children being in the class for the whole period. Type C.—A class in which the pupils are drawn from a particular school only, but are all in one class, the same class working in the open-air during the whole of the summer. Type D.—A class in which the pupils are drawn from a particular school only, and various classes are taken out in turn into the open. There were 4 classes of type A, 1 of type B, 61 of type C, and 39 of type D. Considerable attention was paid by the school doctors to the oversight of the health of the children in the first three types of classes but it was considered unnecessary to pay special attention to classes of type D. The results of the majority of the classes of types A, B and C, from the point of view of improvement in the health and physique of the children were good, but there were some notable exceptions to the rule, and even where the results were good they might still have been better in some instances if there had been more concerted action between the doctors and the care committees in the case of ailing aud debilitated children. Particularly was this the case in the type A classes, where difficulty in obtaining regular following-up of the defective children was experienced largely owing to the fact that those coming from contributory schools where removed from the observation of their own care committees. Another obstacle to the improvement in the condition of the children was the unsatisfactory and unsuitable character of many of the shelters in the playgrounds under which the desks were placed, and in which a considerable portion of the time of the classes was spent. Some of the older shelters, though solidly and expensively built, are quite unsuitable for class purposes; they are dark and ill-ventilated, become close and stuffy upon occupation, and they are in reality less hygienic for class purposes and approximate less to open-air conditions than do the classrooms in the school itself. In the erection of playground shelters in the future these points should be borne in mind, as it should be practicable without added expenditure to ensure that the shelters should be suitable for class purposes in the summer months. Many interesting observations were made by the school doctors 174 Annual Report of the London County Council, 1913. as to the type of child which improves most readily under the open-air conditions. Children suffering from tuberculosis did not, as a rule, do well. This was especially noted in the poorer classes where such cases were more numerous. In one or two of the better classes, however, the school doctors reported improvement in children suffering from this disease. In many cases the growth of the children in the playground classes was compared with that of the children in the ordinary classrooms. An unpremeditated opportunity for comparison of the condition of the children of the playground classes with the rest of their fellows in the school was afforded upon Empire Day, when Dr. C. J. Thomas, assistant medical officer, visited several schools in the East End in company with two of H.M. Inspectors. In three of the schools visited the playground classes were massed in the hall with the other classes, and there was no indication in attire which would serve to identify them ; it was, nevertheless, in each case perfectly easy to distinguish the playground classes solely by their bright and healthy appearance compared with the other children. Type " A " Classes.—The four classes of this type were all held in the playgrounds of schools situated in the more densely populated districts of the East-end, and the children selected for attendance were generally of a low type mentally, very badly nourished, exceedingly dirt}', poorly clad, and, in many cases, apparently neglected. A large proportion of them suffered from physical defects of a more or less serious nature, but it proved exceedingly difficult to persuade the parents to obtain treatment. A few cases of phthisis were discovered amongst the children upon medical examination, and none of these showed any improvement during their stay in the class. It has been pointed out in previous years that only a proportion of the children admitted to this type of class show improvement, there being invariably a number of children for whom the full regime of an open-air school with its careful attention to feeding and periods of rest is necessary to effect any improvement. Thus, at the Daniel-street (Bethnal Green, S. W.), class, while 17 boys showed great improvement in general physical condition, in 10 others no improvement in health could be detected, and of these 2 were cases of suspected pulmonary tuberculosis and 2 had tuberculous glands. At the "Lawrence" (Bethnal Green, S. W.), class 7 made satisfactory progress, 3 fairly satisfactory, 10 were unsatisfactory and 4 very unsatisfactory. At the Turin-street (Bethnal Green, S. W.), class Dr. Peters reports that at one end of the list were a number of children whose inherent vital powers were manifested in considerable and steady improvement under the open-air conditions, while at the other end was a group of children who showed practically no inherent re-active powers. Dr. Russell (Daniel-street) points out that cases of functional heart trouble, of catarrhal conditions generally, of moderate degrees of anaemia, and especially those with unstable nervous systems did well in playground classes, while children with organic heart disease, rheumatic cases generally, and children suffering from phthisis did not improve. The justice of these observations is borne out by independent reports upon individual children received from many other school doctors. Type " B " classes.—The "Forster" (Islington, N.), class was the only one of type B. Considerable improvements had taken place in the conditions under which the class was carried on, the canvas awning erected in the playground being of great assistance. Dr. Tosswill reports that of 31 girls examined, 17 received considerable benefit, 9 others showed improvement, and 5 children made no progress. The last included one child with heart disease, one with profound anaemia, and one who had been away for a considerable time " hopping." Dr. Tosswill further reports favourably as to the good effects ot the regular time for sleep afforded at the beginning of the afternoon session. This appears to be the only playground class where such an arrangement was introduced. It is unfortunate that the conditions under which the playground classes are generally held do not admit of this regular sleeping hour, which is found to be such an important factor in the improvement of the health of the children in the open-air schools at Birley House and Shooters-hill. Type " C" classes.—The open-air classes of type C were kept under supervision by the school doctors, who submitted detailed reports upon 59 of them. Forty-six of these classes are said to have been attended with satisfactory results to the health of the children, while in 13 the results were inconclusive or unsatisfactory. Eleven of the unsatisfactory classes were composed chiefly of children coming from poor and neglected homes and difficulties in regard to out-of-school supervision, together with the unsatisfactory environment of the classes, accounted for want of improvement. Although nominally of type C many of the classes were really of type B, the children being selected by the teachers on account of physical defect or mental dulness. The school doctors, in many instances, point out that the subnormal children in classes situated in good surroundings and in schools where co-operation on the part of the care committees was effective improved under the open-air conditions to a greater extent than did the normal children. Many instances are quoted of individual children who steadily lost weight in the open-air until put on milk meals, when they began to improve. Thus a necessitous child at Bow-creek (Poplar), is reported by Dr. Burrows to have lost no less than 3.5 kilograms in the first three months; the doctor then recommended milk meals, and from the time they were given she gradually put on weight. At Essex-street {Mile-end), and St. Paul's-road (Mile-end), where the care committee co-operation was obtained, and the poorer children were given milk meals, the general result was good, while in other similar cases in the East-end, where co-operation with the care committee was not effective, the results were unsatisfactory from the point of improvement in physique. Many of the classes were this year held in open spaces and parks, and on the whole the results of these were better than in the case of classes held in the playgrounds, which were sometimes hot and dusty, and where the shelters were often inconvenient and unsuitable. At Olga-street (Bethnal Green, N.E.), school, one class of girls was held in Victoria Park, and another in the school playground. Dr. Parson, who inspected them, used one of the classes held in the school as a control, and the results of physical measurements show a regular gradation, the class in the park showing greatest improvement in physique during the six months, while the children in the ordinary classroom showed least. In several other instances children in the ordinary classrooms of similar age were measured by the school doctors in order to form a basis of comparison, and where the playground class met under 175 Report oj the County Medical Officer—Education. favourable conditions the advantage in gain in physique rested distinctly with those meeting under the open-air, as opposed to the indoor conditions. On the other hand, in some instances, where the conditions of the playground class were unfavourable, as at the "John Ruskin" (Newington, IV.), (Dr. Wells) and Wolverley-street (Bethnal Green, S.W.,) (Dr. Parson) no improvement could be detected in the outdoor as compared with indoor children. The careful measurements made of the children brought out several points of interest, in addition to the relation of improvement of physique to feeding mentioned above. Dr. Burrows reports the case of a child who developed ear discharge, and during the time this persisted lost weight steadily, but regained the lost weight when renovery was effected. Dr. Wells points out that on resumption after the holidays there is a general loss of weight for the first fortnight, both on the part of the children in playground classes and of the controls in the ordinary schools. Almost complete freedom from colds and general improvement in children suffering from catarrhal conditions under the open-air conditions is reported, and almost every school doctor reports individual cases in which improvement occurred. These include a considerable number of cases of anæmia and functional heart troubles, of bronchitis, of moderate degrees of enlargement of the tonsils and of nasal obstruction, of ear discharge and of external eye diseases. One especially interesting case of improvement is reported by Dr. McHattie. It was that of a child belonging to Poole's-park (Islington, N.,) school, who was awaiting admission to a special school. She was included with the other children who formed the open-air class meeting in Finsbury-park. She made very remarkable improvement in physique, and this was accompanied by a complete change in her mental condition. The head teacher wrote (7-1-14)—" Since the six months spent in the Finsburypark open-air class the child has progressed by leaps and bounds. The improvement is still maintained. She has not only caught up the other children in attainments, but is much better than many of them. At the beginning of the open-air period she could not play, and it was very difficult to arouse in her any interest to play. Now she is quite keen on games." This child has been removed from the waiting list for the special school, and the head mistress considers that, unless there is a relapse in the child's physical condition, that she will be equal to, or above, the average in mental attainments. During the coming year steps are being taken to secure closer co-operation with the care committees with a view to ensuring the "following up " of children attending the open-air classes, and the question of improvements in the planning of playground shelters from the point of view of their use for class purposes in the summer months is receiving attention. School journeys undertaken during 1913. A number of requests were made by head teachers during the summer of 1913 for the medical examination of children, whom it was proposed to take for school journeys extending Over a period of from one to two weeks. The responsibility of the teachers accompanying the children is no light one, and it is advisable that they should have medical opinion both with regard to the physical fitness of the pupils and to the possible presence of contagious conditions amongst the children proposed to be selected for the journey. Reports were received from the school doctors in regard to 26 such journeys (18 boys, 7 girls, and 1 of both boys and girls), in which the children were seen both before and after the excursion was made. In one instance—that of the Torriano-avenue school excursion, in which both boys and girls participated—the school doctor accompanied the party and spent the whole of the holiday amongst the children, and he has furnished a comprehensive account of the observations he made. In view of the fact that the number of such educational excursions is yearly increasing, somewhat extensive quotation has been made from his report, inasmuch as his observations cannot fail to be of assistance to teachers who undertake the organisation of such visits. In two other instances, one in Derbyshire and the other in Surrey, the school doctor visited and inspected the conditions under which the boys were housed. The stimulating effect of a change, even for a short period of time, from conditions of town life to those of country or seaside surroundings upon nutrition and general health are well known, and all the reports contain descriptions of the general improvement in nutritional conditions as shown by the appearance of the children and by actual measurements. The average increase made in weight was about 0.4 kilograms in excursions lasting one week and 0.8 kilograms in excursions lasting a fortnight. In the case of the Ruby-street school journey, Dr. Macdonald kept the boys under observation for a considerable period and reports that the average increase in weight of each boy during the excursion was at a rate 18 times as great as his increase in weight in the ordinary way. Several instances in which chronic conditions of ill-health entirely disappeared during the excursions were recorded. A short abstract of the report by Dr. C. Louis Leipoldt on the school journey of the Torrianoavenue school children was presented to the Elementary Education Sub-Committee, and was ordered by them to be printed and distributed to all the schools for the guidance of those taking part in such excursions. The followiner is a more comDlete account of Dr. Leiooldt's observations. Dr. Leipoldt's report on the Torrianoavenue school excursion, March, 1913. Introductory.—Recognising that the results obtained from inspection, before and after such an excursion, are not in themselves sufficient to enable useful conclusions to be drawn, but that it is eminently desirable to have further data with regard to the work done, the nature of the strain on individual children and other points, Dr. Leipoldt decided to accompany the party to Shanklin and to take notes on these various noints. While much has been written about school journeys from the point of view of the educationist and the teacher, very little had been done with regard to the investigation of certain points of medical interest. The medical literature on the subject is very scanty. Dr. Leipoldt has been aided, however, in his investigation by his private notes of various holiday camps, in 176 Annual Report of the London County Council, 1913. which from 60 to 80 children of school going age participated. The results obtained from these observations are of value for purposes of comparison with the present excursion, and have been used in this way. Method of Examination.— At the preliminary inspection, in addition to the usual investigation, special attention was paid to the condition of the heart, lungs, and general state of nutrition. Weights and heights were taken in the ordinary manner, though as regards weight, fractions of a kilogram were registered. In some cases the chest measurement was taken, and these proved very useful ultimately. The condition of the feet and back was also noted. Special attention was paid to fatigue, both mental and physical. The cardiac condition was investigated by percussion and auscultation. At Shanklin the routine examinations were confined to the boys, who were examined in the evening after their return from an excursion, and in certain cases in the morning before they started on their walk. Such routine examinations were directed chiefly to the state of the heart and circulation, to investigating the amount of fatigue present, and to recording the state of the blood pressure. Notes were taken during the actual walk as well, and particulars obtained with regard to pulse rate, fatigue, and strain in certain cases. The children soon became interested in these routine examinations, and the consequent absence of nervousness and excitement greatly added to the value of the data obtained. On the return to London a routine examination of all the available children was carried out. For various reasons it was not possible to examine all the children. There are, however, particulars with regard to 46 children. At the final examination the general condition of the child was carefully investigated, special attention being again given to the condition of the heart. Weights and heights were again registered, under conditions as closely approximating to those of the preliminary examination as possible. The Excursion Party.—The children who took part in the excursion were a group of 50 selected, somewhat arbitrarily, from various classes at Torriano-avenue school. The children attending this school are, perhaps, relatively higher in the social scale than those in most ordinary elementary schools ; the fact that the total charge for the week's outing was approximately a guinea still further limited the selection to children of comparatively well to do parents approaching the secondary school type. In cleanliness and general appearance these selected children were distinctly above the average, although from a medical point of view their condition was not so obviously superior. Of the fifty children seen at the preliminary inspection four did not accompany the excursion for various reasons. In one case the child had a bad dental abscess, which was pointed out to the mother, who was told that unless the condition was cured it would be very unwise for the child to go. As he did not improve under treatment he did not join the party. In several other cases defects were found and pointed out at the inspection. In every case the parents were advised, and treatment was obtained in many cases. There remained a few cases in which, while the defects were not such as were amenable to immediate treatment, it became a question whether it was advisable or not to allow the child to take part in an excursion that involved a certain amount of physical effort and strain. After consultation with the head master, and having regard to the fact that he would himself accompany the excursion, Dr. Leipoldt concluded that it was justifiable to allow them to go. In no case did the selection of such children prove detrimental to their general health, but in every case they appeared to have derived some benefit from the excursion. As finally constituted the party consisted of fifty children, four children not previously examined having been substituted for the four who were unable to go. Of these substitutes three were physically fit and quite capable of taking part in the excursions ; the fourth, the youngest child in party, was a boy from the Infant department, and not a suitable case for selection. He had been allowed to accompany the party mainly because two of his brothers were members of it, and because he had much wanted to come. Events showed, however, that the boy was manifestly too young, and was consequently a drag on the rest. His physical condition was not good as he was suffering from bronchitis, and he was not capable of looking after himself to the same extent as the other juniors. The children varied in age, the maximum age being over 14 and the minimum, that of the boy in the infant department, just over six. In addition the party comprised eleven adults, the teaching staff being represented by the head master, two assistant masters, and four assistant mistresses. For the excursions the children were split up into small sections, each in charge of a master or mistress who was responsible for supervision and discipline. One of the masters served alternately as House Master and superintended the boys, while one of the mistresses acted as permanent House Mistress during the excursion, and supervised the lodging arrangement of the girls. The programme was drawn up with discretion, the journeys being graded. Undoubtedly too much was crowded into the last day. The weather was unfavourable, and the excursion consisting in a walk round the dockyards and the town of Portsmouth proved more tiring than was anticipated. Sight seeing is always likely to be much more fatiguing than country walks, although the actual distance traversed may be smaller in the former case, the walking upon the hard road and the periods of standing being a greater strain upon the children than steady regular walking with short rests in a sitting or lying position. Clothing and equipment.—Every child was instructed to bring an extra suit or dress for Sunday, extra stockings and underclothing, night attire, slippers or light shoes for evening wear; brush, comb, toothbrush, soap and towel, and an overcoat. The use of the school jersey— a dark navy blue woollen garment, warm and roomy, without being too loose—and of the school cap for the boys, was compulsory. Many of the boys wore an ordinary coat over their jersevs. In a few cases the children were overclothed, and in several cases the underwear was unsuitable. The greatest benefit is obtained when the clothing permits of a certain amount of 177 Report of the County Medical Officer—Education. ventilation and access of fresh air directly upon the skin. The best costume for boys is a jersey, shorts not reaching below the knee; strong boots or shoes and woollen socks, the upper edge of which is just above the edge of the boot uppers; with these should be worn knitted woollen stockings without feot, but with an elastic band to slip beneath the instep; a simple double of the stocking above or below the knee keeps it up, thus obviating the use of garters or straps. The underwear worn by the children varied greatly; some wore flannel, which was quite unsuitable owing to closeness of texture; some wore linen, which was even less suitable; others wool, which was, on the whole, admirable; and a few flannelette or mixtures, which appeared to give satisfaction. The most desirable underwear for such an excursion is of a mixture of linen and wool with open mesh; but this cellular underwear is expensive. Accommodation.—The party stayed at a temperance hotel in Shanklin, which had proved satisfactory on a former excursion. The adult members of the party had rooms either at the hotel or were accommodated in lodgings. The girls, and some of the boys, were given large double-bedded rooms in the hotel on the second floor; the majority' of the boys were accommodated in a set of rooms in an outside building. These latter rooms were above a stable, and were not quite statisfactory, owing to the want of adequate ventilation. Single and double beds were provided, some of the junior boys sharing a single bed. One of the masters slept in an adjoining room in this outbuilding, and so exercised supervision. Diet.—The children were given breakfast, a cold luncheon to take with them on their walks, and a hot dinner on their return in the evening. Generally speaking, the diet allowed each child was in excessof the normal caloric requirement, even taking into consideration the extra physical work done. A rough calculation of one day's diet gave nearly 3,000 calories, the amount of proteid and carbohydrate being especially large. As a sample menu of one of the dinners the following will serve:— Roast veal. Boiled turnips. Steak pie. Suet pudding. Greens and potatoes. Custard and fruit. From this it will be seen that the diet given was a very generous one, and this possibly accounts for the one or two cases of slight gastric and bilious attacks which occurred. From a medical point of view the main criticism must be that such a diet could hardly be fully assimilated after an excursion that involved some amount of fatigue, and that it was too constipating. For a future occasion the addition of fresh unboiled green vegetables, such as watercress, and of fresh fruit, such as apples might, be suggested. From the children's point of view the catering left nothing to be desired. Each child had as much to eat as he or she wanted, and all declared themselves perfectly satisfied with the food. Sleep.—All the children were generally in bed by nine o'clock, some of the juniors preceding the others by an hour. Most of them were dressed and outside their rooms by seven o'clock in the morning. This gives an average of ten hours' sleep, which is perhaps too little. It must be remembered, however, that the excitement of the outing and the late meal were not conducive to early sleep, and to have sent the children to bed sooner would scarcely have secured more sleep. Experience, in junior boys' camps, is that ten hours' sleep is ample when the child is not doing mental work that involves a strain. The compulsory advancement of the hour for retiring only entails considerably more supervision on the part of the masters or officers, since the children do not drop off to sleep but spend the extra hour in talking. On this occasion the younger children were carefully inspected for signs of fatigue due to insufficient sleep, but such signs were not found. All turned out in the morning fresh and vigorous and eager for the day's walk. The mental work done after return from the excursions was comparatively slight. After dinner there was a short examination by the sectional leaders on the incidents and sights witnessed during the day. This was more in the nature of an informal talk than of a formal examination, and certainly could not be held to involve" unnecessary mental strain. Children who wished to go to bed were excused from this examination, and on several days the masters and mistresses held the marking tests in the train on returning from an excursion, the evening thus being left free for conversation, singing, or games. Sickness and accidents.—With a well-selected party the incidence of sickness on a school excursion should be small. With unselected children, some of whom are in a low state of health, as in holiday camps, the incidence is relatively high. With regard to accidents, injuries of a serious nature can nearly always be guarded against by proper supervision; where they occur it is usually found that there has been some laxity with regard to such supervision. Minor accidents are comparatively common, and can scarcely be guarded against. On this excursion the supervision was excellent, and no serious accidents occurred. In one or two cases sore feet were complained of, largely the result of ill-fitting boots and too thick socks. The only severe case of this kind was that of one of the girls ; proper attention to the footgear and simple treatment of the blisters were all that was required iu this case. The effects of exposure to sun and wind were seen in a few chapped faces ; but beyond slight temporary inconvenience no great harm results. Antomic children are not very susceptible to such exposure, and in their case the subsequent tanning of the skin is much less apparent than in the case of more ruddy children. The chief condition needing treatment was undoubtedly constipation. The vigorous open-air exercise, with free action of the skin, a diminished supply of drink, and probably a richer fare than the children are accustomed to, were responsible for this. Probably an accessory cause is always the break in home habits for the time being and the neglect to empty the lower bowel with any degree of regularity. The results of such neglect, leading as they do to habit constipation, are sufficiently serious, especially in the case of girls, to demand the attention of teachers and others responsible for the care of the children. 23610 AA 178 Annual Report of the London County Council, 1913. A few cases of slight bronchitis were found ; in two treatment was necessary. Of these latter one was a slight case which did not interfere with the child's holiday in the least; on the contrary the open-air walks undoubtedly accelerated the cure. The other case was that of the smallest boy in the party. This child had not been examined before joining, and on arrival at Shanklin he was suffering from a severe cough. Examination revealed numerous rhonchi over both bases and bubbling rales in the left lower lobe. He improved considerably and was allowed to take part in the walks, accompanying the juniors, except on one day when his condition was not favourable and he was left behind to rest at the hotel. This was the only case in which there was a condition which could in any way be accounted serious. He was much too young a child to have been included in the party, and it would have been better not to have brought him. At the final examination one child was found to be suffering from what seemed to be appendicitis. This boy had been one of the most active on the excursion, and had never complained of anything. He had, however, had a previous attack of iliac pain and sickness some months before. The first symptoms in his case developed on the day after his return, and were put down to his having eaten something that disagreed with him. Another child was found to be suffering from slight bronchitis, and a third from scabies. Taking everything into consideration it may be concluded that the health of the children was remarkably good ; when the weather conditions are taken into account, the freedom from slight pulmonary complaints was striking, especially in comparison with children of a similar class and age who had remained in London and who could, to some extent, be taken as controls. Nutrition.—One of the most important points in estimating the hygienic and general value of the school excursion must be the effect of the outing on the nutrition of the children. The degree of nutritional excellence was expressed by the figures 1, 2, 3, or 4—1 being excellent, 2 good, 3 poor, and 4 malnourished. In estimating the nutrition according to this standard the usual observations were made ; the appearance of the skin was noted, changes in its elasticity, and colour in the shape of pigmentation, were considered, and the texture of the hair and smoothness of the nails were observed ; special attention was paid to oral sepsis, condition of the musculature, presence of glandular enlargement, hairiness of back, or signs of lymphatic hyperplasia, while the ratio of weight to height was also taken into consideration. Finally, a brief investigation into the home conditions of the child, and his or her method of life and general history, was made, the hours of sleep and work being noted. These observations were made in combination with those taken to estimate the degree of fatigue present. At the final examination a similar comparison was instituted, and from the data thus obtained an attempt was made to estimate the improvement, if any, in the nutrition of the child. The following is a summary of the results obtained :— Girls.—At the preliminary examination 7 were noted as " Nutrition 1" at the final examination these girls were again classed as 1 although their general condition had improved sensibly. Twelve girls were noted as 2. Of these at the final examination 8 had improved to 1, 3 were still 2, while 1 was not re-examined. Three were noted as 3 at the preliminary inspection ; at the final examination all those had improved, their nutrition being noted as 2. Boys.—Eight were noted as 1 at the preliminary inspection; at the re-examination all these had improved. Fourteen were noted as 2 before leaving. Of these 12 on their return had improved to 1 ; 1 was still 2, and 1 was not re-examined. Three were noted as 3 at the preliminary inspection ; at the re-examination all 3 had improved so that they could now be considered as 2. These results show that in the majority of cases there was a decided and striking improvement in the nutrition of the children directly due to the outing, while in comparatively few there was little improvement. In only two cases was there any loss of weight unaccompanied by obvious signs of physical deterioration in other respects. Heights and weights.—Taking only the records of those children who were fully re-examined, since these alone are available for comparison, the following results were obtained :— Girls,—Average height at first examination, 145*1 cm.; on return, 145'3 cm. Average weight on first examination, 35 kilograms; on return, 35'4 kilograms. One girl apparently lost 1 cm. in height. This was the child who had suffered from sore feet, and in her case there was a slight dropping of the arch of the foot. An increase of 1 cm. in height was recorded in five children. A loss of weight was recorded in one child, whose weight at the preliminary examination was 25 kilograms, while at the final examination she registered only 24 6 kilograms. An increase of weight was noted in 10 cases out of 18, the greatest increase being 1 kilogram, while the smallest was 0*2 kilogram. Boys.—The average height of 24 boys before starting on the excursion was 138-6 cm. ; the average height on return was 139'45. The average weight of the same group of 24 boys before starting was 30'12 kilograms ; on their return the average weight was 30'8. The individual improvements in height and weight among the boys were, however, much more marked than among the girls. The greatest increase n height was 2 cm. (two cases) ; an increase of 1 cm. was noted in nine cases. The greatest increase Tin weight was 4.6 kilograms; other increases were 2.8, 2, 1.2, 1*1, 09, 0'8 (four cases), 0.6, 0.5 (two cases), 0'4, and 0'2 respectively. In one case only was there a loss in weight, from 25 kilograms to 24.6. Fatigue and mental strain.—At the preliminary examination it was noted that several children were unduly tired and fatigued, and some attempt was made to estimate the degree of fatigue with a view to comparing it with the child's condition on the return. Apart from the ordinary signs of lassitude and physical and mental weariness which are well known to every teacher since they show themselves in the child's inattention during the class lesson, in mind wandering, in mistakes in simple matters of arithmetic or other class work, in yawning, listlessness, or actual drowsiness, there 179 Report of the County Medical Officer—Education. are one or two other signs which are useful guides to the amount of fatigue present. One of these is the response to stimuli applied to the peripheral nerves. The average normal child responds readily and instantly to such stimuli; the fatigued child responds slowly or not at all. In this degree of reudiness of response to slight stimuli is found a valuable guide to the amount of fatigue present. At the preliminary examination several children were found to be tired, with feeble response to stimuli, dilated pupils, and inability to concentrate their mind for any length of time—all signs of mental fatigue, in most cases accompanied with bodily fatigue as well. The causes of this fatigue in school children are want of sleep, malnutrition, overwork or class strain, and actual physical illness. Of these the last was responsible for perhaps one case, that of a boy who was suffering from dyspepsia, and who had had frequent " bilious attacks." Want of sleep accounted for five cases ; in one the child was at work early in the morning and went to bed late at night, obviously getting less sleep than he needed ; in a second case out-of-school work was also responsible for the fatigue, while in the remainder no sufficient reason could be assigned for the fact that the children went to bed later than they ought to have done. In each of these five cases there was a certain amount of poverty of nutrition, though in three only could the nutrition be put down as three, while in no case was it poor enough to be put down as four. Overwork, in the majority of cases, is due to activity out of school. In the case of boys, in which its effects are much more apparent than in girls, the prevailing causes are choir practice and Scout drills; these keep the children often until a late hour so that they get to bed after nine or even ten, thus much diminishing the hours of sleep. Class strain is of comparatively rarer incidence ; it is found where the children have task work or home work, and is much rarer, therefore, in the less hard worked elementary scholar than in the boy who attends a central or secondary school. Among the children examined at the preliminary inspection there was no case in which the fatigue could be directly ascribed to class strain. Following up these notes particular attention was paid to the children at Shanklin, observing more in detail those who at the preliminary inspection had been found to be fatigued. The mental and physical work entailed by the excursion involved a certain amount of strain, and it was interesting to note exactly in what way the children stood this strain. In the case of the five children specially noted it was interesting to observe how rapidly they lost their original signs of mental fatigue, became responsive to stimuli, alert and brighter, and, judging from the marks they obtained, they certainly showed that they were not behind their fellows in attention or observation. In a few of the juniors there were slight evidences of mental fatigue after an excursion which had not involved much mental strain, but which had given them the opportunity of having unlimited play on the beach; in these cases the mental fatigue was undoubtedly a concomitant of bodily weariness, and could not be ascribed to the amount of mental work done during the day. It is a frequent criticism that on an excursion of this kind the children are mentally overworked " The mind should be given a complete rest; all holiday tasks should be avoided " is a recommendation sometimes made. Apart altogether from the fact that an excursion wholly devoid of educational interest cannot rightly be termed a school excursion in the generally accepted sense of the words, and would therefore not be sanctioned as such by the Board of Education, a protest should be made against the inference that the ideal holiday for school children consists in aimless wandering or playing on the beach with intervals of rest devoted to the consumption of large quantities of good food. Yet some such ideal is undoubtedly in the mind of those who advocate a school excursion divorced of its instructional and educative aspects and devoted entirely to recreation. Such a holiday comes rather in the scope of a holiday camp, and observation on three successive camps, recruited from children of school going age, strongly impressed on Dr. Leipoldt the fact that a fortnight's " dolce i far niente " existence is by no means successful in avoiding mental fatigue. The experience of camp officers is very similar, and it is now generally understood that it is an eminently desirable thing to give the children in such camps something to occupy themselves with to avoid the monotony of aimless wandering about between what may be called organised recreations. On this excursion the lectures were admirably given and the sections excellently handled. The periods of rest were well arranged, and so much variety was introduced into the class work that all strain was avoided. The children were placed in a position to learn a great deal without unnecessary stress, and there can be little doubt that most of them considerably profited in consequence. With regard to physical fatigue, observation led to the conclusion that few of the children felt the strain of the walks to any great extent. This was largely due to the fact that the rate of progression was always slow- -averaging perhaps two miles an hour—with frequent halts, and that several of the walks were done under almost ideal conditions of climate. The sociable nature of the excursions too had an important psychological value which no doubt contributed to this limitation of fatigue. Yet another factor was the avoidance of any attempt to make the children walk in regular order or to adopt a constrained attitude and carriage of body. It is well to lay stress on this last point, for undoubtedly fatigue is engendered by adopting the attitude which is "described in some manuals as " the correct method of walking " ; in this the body is carried erect, the shoulders are thrown back, and the head is inclined backwards. As a matter of fact the correct attitude in walking is with the body inclined slightly forwards; this attitude has recently been recommended for adoption in the French army, and is the one assumed by Alpine guides and others accustomed to prolonged walks. It is the attitude which is naturally assumed when walking over uneven ground, and is the only one that essentially corrects the faulty position caused by sedentary occupation. In girls especially this attitude should be insisted upon, care being taken that the carriage of the head is correct and that the eyes are not habitually kept lowered. The inclined attitude relaxes the strain on the sacro-lumbar articulations and gives free play to the leg muscles without straining those of the abdomen as the vertical attitude does. It is the attitude which children naturally adopt when Walking and is the least fatiguing. Care must of course be taken that it does not degenerate into a slouch which is an exaggeration of the normal forward inclination with, in addition, a forward stoop of the shoulders and a downward craning of the head. 23610 AA 2 180 Annual Report of the London County Council, 1913. At the final examination all the children presented a notable improvement so far as mental and physical conditions could be tested, the response to stimuli being in all cases good. There was no evidence of mental strain. The only outstanding cases of physical strain, apart from those discussed under the heading of " Heart Conditions," were cases in which there was a dropping of the arch of the foot. Ill two cases this was due only to stretching of the leg muscles, in one it was probably due to relaxation of the ligaments in the case of a girl who had worn ill-fitting boots. Open air play or work is much less likely to lead to fatigue than similar work or play done in confined quarters or in a class room. On a school excursion the incidence of fatigue appears to bear some relation to the clothing worn by the children. Where a minimum of covering is worn the children, climatic conditions being equal, appear to stand the strain of a long walk much better than when they are closely covered. The weight of the clothing does not appear to have any great effect; it is rather the texture that is primarily responsible. The wearing of constricting bands, garters in boys or tight belts, and stays or corsets in girls, by interfering with the free circulation of the blood is another cause of fatigue on excursions which can and should be guarded against. The presence of an actual physical lesion, such as a blistered foot caused by ill-fitting boots, very rapidly engenders fatigue, even though the amount of work or exercise done is relatively small. The effect of this in one cose, a girl, was very marked ; she became slow, inattentive, and tired, although she was doing the same work, and expending the same energy, as the juniors who showed no signs whatever of fatigue during the walk. Taking all these data it is obvious that the majority of the children returned from the excursion much improved in physique. The improvement in some cases was most marked, while in others it was not so apparent. In one or two cases there was, apparently, no visible improvement, although the children, on examination, proved to be much more sensitive to stimuli (see also observations under Heart conditions). Colour and appearance of the skin were improved in almost all cases, the change being most marked among the boys. Conditions of the heart and circulatory system.—Undoubtedly the main point of interest, from a medical aspect, in regard to these excursions, is the question of cardiac overstrain and its results. For these reasons Dr. Leipoldt accompanied the children on all their excursions, and took immediate observations in regard to certain cases, with routine evening examinations on their return from the walks. This arrangement had the extra advantage that it made him familiar with the individual conditions of the children, find that it largely obviated the nervousness with which some children regarded a medical inspection. At the preliminary examination eight children were found to have slight irregularities in the condition of the heart, though in no case was there any definite evidence of organic defect. All these cases were carefully considered, and it was decided that in none of them was there sufficient reason to exclude the children, since experience in camps has shown that such conditions generally improve markedly under improved hygienic and open-air conditions. At the same time a note was made in each case, and it was decided to pay particular attention to these children at the routine examinations held after each journey. In all there were 19 children who presented a condition of the heart which might reasonably be styled as a departure from the normal, though the degree and extent of such abnormality differed widely in each case, and in no case was grave enough to warrant exclusion of the child from the party. Seven children whose hearts were normal at the first examination were found on their return to have a marked increase in the area of cardiac dulness ; of these four were cases of normal hypertrophy after exercise, and two were cases which may justifiably be reckoned as cases of moderate dilatation. In several other cases in which there was an increase in the area of cardiac dulness before starting, no further evidence of dilatation or hypertrophy was found on their return. In two cases a change in the heart sounds was noticed at the routine examinations at Shanklin. In several cases a soft systolic basal murmur developed after return from an excursion; tais in every case disappeared after a night's rest Taking all the cases and studying them in relation to the response of the children's hearts on the actual excursions, in two cases only was there marked evidence of cardiac dilatation, and both were in children who were obviously weak. In the one case the child ought not to have accompanied the party, and in the other something more might have been done to guard against overloading the stomach and engendering fatigue. In this latter case no blame could possibly attach to the teachers or those in charge of the party, since at the preliminary examination the child's heart was noted as normal and no extra precautions were suggested. When it was found that he stood the strain badly every precaution was taken to prevent undue fatigue and overstrain. Increase in the area of cardiac dulness was found to be more common in the boys than in the girls, although the "official" work done by both was identical in severity and character. The reason for this is probably because the boys managed to get through a vast amount of extra and entirely " unofficial " work in the shape of romps on the beach or on the walks, and in this manner threw a much greater strain upon their hearts and muscles. It is difficult, if not impossible, to guard against such extra exertion without unduly limiting the liberty of the children and restricting the amount of enjoyment they contrive to get out of the excursions. A careful " leader " will, however, use his discretion to check undue enthusiasm on the part of the children, especially' on the return journey, and above all in the evenings after meals. The absence of any evidence of severe cardiac overstrain on this journey must be ascribed largely to the excellent supervision of the leaders and to the discipline maintained indoors, especially in regard to retiring at night. While it is impossible by any preliminary examination and in the absence of medical supervision on the journey itself, to eliminate all chance of overstrain—since a child whose heart appears normal may respond badly to the strain, while one whose heart appears weak may respond well and derive great benefit from the regular walks—it must always be the duty of the leaders to pay Report of the County Medical Officer—Education. 181 particular and individual attention to children who are found to be suffering from slight breathlessness after ascending an incline at the normal rate of progression. It cannot too strongly be urged that every form of exercise entails a certain amount of strain, upon the child's heart, but it must also be pointed out that in a child this organ is very quickly responsive to all calls made upon it and adapts itself readily to altered conditions. Too much has probably been made of cardiac overstrain in children, and it is possible to take too grave a view of the alterations in the evidences yielded by ordinary clinical examination of the heart in children who have been subjected to physical strain. Making allowances for the difficulties and inexactitudes in limiting the area of cardiac dulness by percussion, it may be granted that an increase in such dulness is apparent in 60 per cent, of children who have undergone a more or less severe physical strain, or at least an unaccustomed physical strain, for several days, but such increase seems to be perfectly natural and harmless and on a par with the increase in the development of the calf muscles and the chest expansion which almost always accompanies it. It is, in fact, a physiological use hypertrophy, and cannot honestly be regarded as evidence of cardiac dilatation unless it is accompanied by other evidences of such weakening such as feeble pulse, irregularity, a fall in. the blood pressure, and the presence of cardiac murmurs. The observations made on this journey support this view and show very clearly that real dilatation is to be met with only in children who have also other signs to show that they have been exposed to too severe a strain which has harmed other organs besides the heart. Orthopcedic Conditions.—A few cases of slight lateral curvature were noticed at the preliminary examination. There was no change in these at the final inspection, although the general condition of these children had improved. The cases of flat feet have already been referred to. It may be added that the one case, in which the sinking of the arch was marked, could scarcely be said to have been directly due to the walks. Flat foot is caused more by standing than by walking, since the standing attitude tires one group of muscles which in consequence relax, while walking exercises both groups. Where marked flat foot is the result of walking strain it is invariably due to ill fitting boots and sore feet, as it was in this case; a much rarer cause is fracture of the metatarsals, brought about by suddenly bringing down the foot on a hard road while the leg muscles are relaxed. This is not uncommon in soldiers on a march who have been walking at ease, and are suddenly called to attention, but is hardly likely to happen in the case of children, since the fracture is one by muscular violence. In the case of marked swelling and soreness of the feet after a long walk it is, however, well to examine the injured foot to exclude such an accident since permanent flat foot results if the lesion remains untreated. Summary of Conclusions.—After careful study of all these children, and a consideration of the data elicited before and after the trip, it is possible to summarise all the available conclusions in a few paragraphs. (1) All the children benefited in some way from the change and the holiday, some, however, much more than others. The increase in weight and height was greater than recorded on other short trips of a similar nature by English or Continental observers. (2) Provided proper care is taken in supervising the children and in grading the amount of work done, there is no reason to conclude that children, who are not quite normal and up to the usual physical standard, are harmed by taking part in a short trip of this kind. On the contrary there is distinct evidence that such a holiday conduces to their improvement. (!i) The age limit of children allowed to participate in such a journey should not, except in very exceptional circumstances, be below eight years. Younger children are an inconvenience, and their proper care and supervision require much greater individual exertion on the part of those in charge. In addition they hamper the party in every way, and the evidence tends to show that the amount of benefit they derive from such a short trip is less in comparison with that gained by older pupils. (4) Fatigue is best guarded against by attention to such responsible factors as clothing, footgear, sleep, and intestinal sepsis due to constipation. There is no reason to deprive the children of mental work, provided that due care is taken to attend to these factors. (5) Children with slight bronchial catarrh and " functional" cardiac conditions need not be excluded, as they undoubtedly benefit from the journey. Their selection, however, entails some care and discrimination, and when they are allowed to go, special attention should be given to them on the journey. (6) Greater stress should be laid on the importance of insisting on an adequate amount of sleep, the minimum of which should be nine and a half hours. Longer periods should be allowed for on occasions when the following day's excursion involves extra physical effort. (7j Similarly, stress should be laid on the importance of regular and proper evacuation of the natural reservoirs, and every facility should be afforded to the children to attend to these matters of personal hygiene. A preliminary lecture by the teachers responsible is, perhaps, the best way of bringing home to the children the importance of this matter. Care should be taken that the diet given includes a reasonable amount of peristaltic stimulant in the form of cellular fibre, or fruit juice. (8) The gravity of incurring cardiac strain is undoubtedly great in children who are feeble and ill-nourished, but has been magnified out of all proportion to the reality. An increase in the area of cardiac dullness when the child returns is common and harmless; for purposes of comparison the heart sounds, the blood pressure, and the rate of the pulse are better guides than the evidence yielded by percussion. (9) It is highly desirable that a final inspection of the children should be made by the doctor or nurse at least 48 hours before the party leaves for its destination, so as to exclude children who may have developed defects which have not been noticed at the ordinary preliminary inspections. This is especially desirable in regard to skin diseases. 182 Annual Report of the London County Council, 1913. (10) Attention should be paid to the carriage of the body during the walks and to the condition of the children's feet. An attitude with a slight forward inclination of the trunk should be encouraged as it is the normal and best attitude, while stiff and exaggerated upright positions should be condemned. During the periodical rests on the march the children should be encouraged to relax their muscles by assuming horizontal positions, when possible, on the ground for a few minutes. (11) Chest measurements should in all cases be recorded before and after an excursion so as to give some indication of the amount of improvement of chest expansion obtained. (12) The advantages offered by the trip should be used as a means of inducing the parents, or the children themselves, to obtain medical treatment for defects found, and children not treated should be excluded unless satisfactory reasons are given for the delay in obtaining treatment. (13) Fatigue, both bodily and mental, is more common in children who suffer from temporary and for the most part avoidable defects engendered by the changed conditions of the trip, and may be noted in such children even when the amount of physical or mental effort has been relatively small. It should be guarded against as mentioned in paragraph 4, and not by avoiding all teaching or instruction on the journey or by unduly limiting the amount of physical exercise. At the same time the latter should be graded, commencing with short excursions and long resting periods and ending by longer marches with briefer halts. It is advisable that on the last day the amount of work done should be relatively small. Instruction in Hygiene. Elementary Schools— Instruction in Hygiene of Upper Standards. In connection with the report of the departmental committee on tuberculosis the Public Health Committee of the Council suggested the desirability of making instruction in all simple facts of hygiene compulsory, at least as regards the elder children attending the schools. Prior to this suggestion of the Public Health Committee the Education Committee of the Council had taken steps with a view to instruction being given in hygiene, and the temperance syllabus issued by the Board of Education in 1909 was sent to every senior department as a suggestive guide to teachers. At the present time some of the teachers who have been impressed with the importance of the question make it a practice to introduce instruction in hygiene incidentally during the course of instruction in other subjects. This is entirely voluntary on the part of the teachers. A certain amount of instruction in hygiene is included in the Council's syllabus of instruction in domestic subjects. This is the only way in which instruction in the subject is compulsory and it only applies to girls. In the introduction of the Code for Elementary Schools, 1912, the Board of Education state—" The school must at the same time encourage to the utmost the children's natural activities of hand and eye by suitable forms of practical work and manual instruction ; and afford them every opportunity for the healthy development of their bodies, not only by training them in appropriate physical exercises and encouraging them in organised games, but also by instructing them in the working of some of the simpler laws of health." In section 2 of the Code " Hygiene and Physical Training " are included amongst the subjects which may be taught in schools for older scholars, and the subject of hygiene is defined as " instruction adapted to the ages and sexes of the scholars in the elementary rules of personal health, particularly in respect of food, drink (including alcohol), clothing, cleanliness and fresh air ; and careful cultivation of a correct posture at writing and other lessons. Apart altogether from the question of tuberculosis it would be advantageous that instruction in the elementary laws of health should be part of the routine instruction given to every elementary school child. Hygiene is now a compulsory subject at all training colleges for teachers, and all teachers in the Council's service hold a csrtificate for the teaching of physical exercises which ensures the possession of a certain amount of acquaintance with the laws of health. There are also lectures and classes for teachers in the Council's evening schools in health, home nursing, and infant care, and a special course of lectures on the prevention of consumption for teachers in elementary schools. The school doctor pays visits in each term to every department for the purpose of medical inspection of the scholars, and although the time at his disposal is limited in view of the statutory duties he has to perform under the Education (Administrative Provisions) Act, yet his advice and co-operation is of great advantage in this respect to the head teachers of the schools in his district. The advice given at this time to parents and, to some extent, to the elder children has an important educational effect from the practical side. The question of the possibility of making instruction in hygiene more general in the upper standards of the elementary schools is still under consideration. Teaching of Infant Care. A conference consisting of members of the teaching staff, the inspectorate, domestic economy instructresses and representatives of the Board of Education and the Public Health Department was convened in the latter part of the year to consider the question of the teaching of Infant Care and Management in Public Elementary Schools. General agreement was found with regard to the desirableness of incorporating the subject in the curriculum. Attention was chiefly directed in the discussion to two questions, viz., (1) whether such teaching should be given in the ordinary schools by the class teachers on the one hand, or in the domestic economy centres on the other hand ; and (2) whether special apparatus should be provided for demonstration purposes and if so of what nature. After considerable discussion it was agreed that it was preferable that the subject should form part of the curriculum for elder girls in the ordinary schools. With regard to apparatus, the discussion turned chiefly upon the question of the provision of a washable doll. Some of the members of the conference thought it necessary that a doll of a certain weight and specific gravity should be provided, but it was pointed out from Report of the County Medical Officer—Education. 183 the medical side that this was of little importance as the important points in respect to washing a baby could only be learnt from actual experience, the use of the doll mainly consisting in riveting the interest of the girls during demonstrations. It was recommended by the conference that those headmistresses who desired to include the subject in the curriculum should be allowed to do so and that the necessary apparatus should be supplied. It was considered that the greater part of the apparatus could be obtained from the present requisition list, but in addition a model washable doll, a galvanised oval tub, and a few other incidentals would be necessary, the total cost of which would be about 15s. per school. The approval, however, of these proposals has been adjourned until after the consideration of the general question of the attitude of the Council in regard to developments in education to which the Council is not committed pending the allocation of Government grants. The Teaching of Sex Hygiene. In view of the fact that resolutions have from time to time been forwarded by conferences of members of the Council and managers of schools and members of care committees recommending that instruction in sex hygiene should be given in the elementary schools, the Elementary Education SubCommittee appointed on the 29th April, 1913, a section to consider and report as to what action, if any, could be taken with reference to the question of instruction in sex hygiene and purity in the public elementary schools maintained by the Council. Evidence was taken from a number of witnesses, amongst whom were two officers of the Public Health Department, Dr. C. J. Thomas and Dr. Josephine Fairfield. The medical evidence was to the effect that direct instruction in matters of sex hygiene was undesirable as a class subject in elementary schools. It was pointed out that reticence and modesty were great safeguards and that collective teaching is an evil inasmuch as it tends to break down these natural barriers. Dr. Fairfield gave evidence as to the undesirable conversation subsequently carried on by the children, in an instance in which the instruction had been given partly upon ethical and partly upon religious lines to children of ten to eleven. Recent methods of psychological analysis have shown the very great danger of giving children premature shocks in regard to sex matters. Dr. Thomas pointed out that boys who indulged in vicious habits were conscious of wrong-doing, and that knowledge had little effect in arresting it. If it were sought to cure the trouble it was necessary to improve the moral outlook generally. It was a difficult thing to deal with and was generally tackled by giving the children erroneous ideas about the seriousness of the results. The results physically were not very serious, but the mental result was exceedingly grave in those cases in which considerable exaggeration in respect to the physical effects had been used in imparting information to boys already in the grip of the habit and who, while honestly desiring to become free, found difficulty in conquering it. Both officers agreed that in specific instances private talks with individual children by head teachers or school doctors would be beneficial, and both were of opinion that instruction should be given in secondary schools and training colleges inasmuch as many young men and women were launched into the world to fend for themselves without a knowledge of dangers and diseases which existed. * Personal hygiene. The work of the school nurses, in so far as personal hygiene is concerned, is divided into four parts, viz., inspection, verminous heads only, vermincus persons and clothing", and scabies. Elementary schools— personal hygiene inspection The nurses are required to visit each school according to a rota so arranged as to ensure that every department is systematically examined. The head-teachers are given three days' notice of the nurses' visits in order that arrangements may be made for the attendance of children in regard to whom advice is desired. At these visits each child in the department mentioned on the rota is individually examined. The nurse separates the hair with a metal comb, which is disinfected after the examination of each child ; examines the under-clothing of all case? of suspected verminous body conditions ; notes any abnormal conditions as regards throat, suppurating ears and fingers, obvious neglect, &c. ; and notes and reports every case of scalp ringworm detected, and in doubtful cases sends stumps to the head office for microscopical examination. Upon the completion of the examination in one department the nurse visits the other departments, and examines children found unsatisfactory at previous visits, and children about whom the teachers require advice, interviewing parents if necessary. The nurse also assists the teachers generally by suggesting temporary procedure in cases of suspected outbreak of infectious or contagious disease, affections of the skin, ophthalmia, offensive discharge, &c.; by advising in regard to the many small and doubtful points concerning school hygiene that may be submitted to her, and by drawing the attention of tbe school care committees and managers to cases in which their help would be valuable. It has not been possible, during the year, to compile complete statistics in regard to this portion of the nurses' work, but the following figures which refer to five of the fifty-eight electoral areas furnish some idea of its magnitude:— Number of examinations 349,282 „ found clean 250,888 „ found verminous 98,394 Percentage found verminous 28. The number found verminous includes all degrees of unsatisfactory condition from the case of a few nits on the hair to cases of head, body, and clothing infested with pediculi. In schools where *The Education Committee, on 20th May, 1914, decided that the teaching of sex hygiene as a class subject in public elementary schools should not be approved. 184 Annual Report of the London County Council, 1913. conditions are very unsatisfactory one of the two cleansing schemes is applied, but the slight cases are invariably cleaned up as a result of the rota inspections ; hence the apparent disparity in the numbers found verminous. Of the two schemes, one deals with children suffering only from verminous heads and the other with the child " who or whose clothing is in a verminous or foul or filthy condition." In the former the procedure is as follows. Elementary schoolsverminous heads The school nurse examines all the children at the school and notes the condition of their heads, using strict precautions against contagion. The head teacher is then supplied with a white card for each child whose head requires cleansing. The card, which draws attention to the condition and contains directions for cleansing, is enclosed in a sealed envelope and taken home by the child. In the case of those children whose condition is not sufficiently bad to be called unclean, but is nevertheless not quite satisfactory, yellow cards are issued. At the end of the first week all cases not treated are separated from the other children and a red card with full details is filled up by the nurse for each child still unclean. This is forwarded to the divisional superintendent, who has the card delivered at the home by the attendance officer. At the end of the second week, the assistant superintendent of school nurses visits the school and examines the children proposed for exclusion. After exclusion the divisional superintendent takes out a summons ; but any child properly cleansed before the hearing of the case is re-admitted to school, examined by the nurse, and the summons is not pressed, the circumstances being explained to the magistrate. The following table shows the results of the examinations in those schools where the cleansing scheme as applied to heads has been put into operation during the year :— Department Number Examined Number Clean Number slightly dirty heads Number verminous Number Yellow Cards served N umber White Cards served Number Red Cards served Number Proposed for Exclusion Number Excluded for Prosecution (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Boys 1 1 1 • 1 1 1 Girls 43,504 26,454 9,748 7,302 4,193 7,302 4,453 3,494 2,685 Infants 14,517 10,942 2,196 1,379 764 1,379 712 504 363 Mixed 11,358 8,673 1,621 1,064 526 1,064 729 536 397 Special 449 315 63 71 82 71 34 31 26 69,829 46,384 13,628 9,817 5,565 9,817 5,929 4,566 3,472 The parents of 247 children were prosecuted, and fines varying from 2s. to I2s. 6d., with costs, were imposed. The percentages in the specially selected schools in which the head scheme has been applied of children verminous amongst children examined was 141 in 1913, as compared with 15'8 in 1912, a decrease of 1*7. This scheme was not applied throughout the county as since the enactment of the Children Act, 1908, some magistrates were reluctant to convict under the attendance by-laws and preferred that cases of verminous children should be dealt with under Section 122 of the Children Act. The scheme was therefore modified in districts where the difficulty existed, so that instead of a child being excluded from school, the preliminary notice under the verminous persons and clothing scheme (see below) was issued. This modification has since been extended to all districts served by a cleansing station. Elementary schools— Verminous perBons and clothing. The procedure for giving effect to Section 122 of the Children Act, 1908, afforded opportunities at each stage for parents voluntarily to send their children to a station for cleansing. To each child found verminous was handed in a sealed envelope a card addressed to the parent drawing attention to the condition and to the facilities for bathing. If advantage were taken of the facilities, each child was if necessary given three baths, and in the event of a relapse into a verminous state the procedure was repeated. If, however, the child was not sent for voluntary cleansing or was not adequately treated at home, a statutory notice under the Act was served. Again opportunities for gratuitous cleansing were offered, and if accepted a series of three baths was given to each child. If the verminous condition complained of remained unremedied, compulsory cleansing ensued, when in order completely to cleanse the head the hair infected with nits was snipped off. E elapse after voluntary cleansing was followed by the re-issue of the statutory notice, but relapse after compulsory cleansing resulted in police court proceedings. It was found that as the procedure became known parents availed themselves of the facilities for voluntary baths, but the child was not kept clean, and after various cleansings it became necessary for the child to resume attendance at the station. In order to avoid this the scheme was amended so that, instead of an unlimited number of voluntary baths, only two series of three baths at each stage was permitted. The practice of keeping the medical officers of health of the several boroughs informed concerning the various stages reached in the case of each child cleansed under the scheme was further extended during the year. Generally, a large amount of work is now boing performed by borough councils in securing the cleanliness of the home, with beneficial results, not only to the individual but to the community. In cases of repeated relapse into uncleanliness it must be the home conditions that are in fault, and no personal cleansing scheme can be regarded as -complete that takes no account of this factor in the problem. Diagram D. Report of the County Medical Officer—Education. 185 Iu the annual report for 1912 a diagrammatic scheme was published, but it has been found necessary to revise this scheme in certain minor respects. The modifications are shown below, the portions omitted being underlined and additions printed in italics. CLEANSING SCHEME (PERSONS AND CLOTHING). Slight cases. Advice given. Severe cases. Remedied by parents. I Unremedied. A Card given offering voluntary baths at cleansing station. Local Medical Officer of Health informed. Opportunity accepted. Opportunity neglected. Three voluntary baths given. Child cleansed. In case of relapse begin again at A; a second, opportunity is given. In case of further relapse proceed under C. C Child separated from others in school, Divisional Superintendent directed to serve Statutory Notice. Local Medical Officer of Health informed. I Parents now come voluntarily to station. I Child cleansed by parent. In case of relapse begin again at C- No steps taken by parent. D Three voluntary baths given. In case of 1st relapse commence again from C. In case of 2nd relapse. F E Child examined within 24 hours by ~ nurse and conveyed to station for compulsory bath. Child cleansed in one operation. Local Medical Officer of Health informed. I E Divisional Superintendent asked to serve statutory notice in which no opportunity of voluntary bath is given. I I G F If the child again becomes vermin- — OU8 police court proceedings are taken. Pending the hearing, the child, if not cleansed, is excluded from school. After a conviction the child is taken again to the centre for a compulsory bath. I Cleansed by parent. In case of relapse begin again at E. I No steps taken by parent, proceed under F. There are now 22 stations for the cleansing of verminous children, 18 of which belong to borough councils with whom the Council has entered into agreements. The total number of stations originally authorised was 23, but the committee of St. Cecilia's House equipped a station in Whitechapel and an agreement was concluded with them. Negotiations to secure the co-operation of the borough councils of Bethnal Green and Lambeth were fruitless, and the Council has acquired in these districts premises which are undergoing the process of adaptation. There will ultimately be 24 cleansing stations, six established by the Council and 18 by other authorities. The sanitary authorities with whom agreements exist are Battersea, Bermondsev, Camberwell, Deptford, Greenwich, Hackney, Hampstead, Islington, Kensington, City of London, Poplar, St. Marylebone, St. Pancras, Southwark, Stoke Newington, Westminster, Woolwich. Each station serves an area approximately of a mile radius. The Corporation of the City of London which provides for the cleansing of children free of cost to the Council at first only undertook to deal with children residing within its area, but during the year consented to cleanse children attending schools within the City. The areas served by the stations to a radius of one mile are shown in the accompanying map, and are shaded to indicate the nature of the t>ro vision made (see diagram DV The total number of examinations made by the nurses under the scheme was 858,691 and 29,903 children were found to be verminous; of these 15,241 were cleansed by the parents. The following table shows the number of cleansings (not children cleansed) carried out at each station:— Council Stations— Central-street 3,642 Finch-street 4,088 Fountain-road 1,523 Sedlescombe-road 2,383 - 11,638 Other Stations— Battersea 1,089 Bermondsey 2,638 Camberwell 2,648 Deptford 1,978 Greenwich 405 Hackney 2,176 - 10,934 Carried forward 22,570 23610 BB 186 Annual Report of the London County Council, 1913. Brought forward 22,570 Other stations—(continued)— Hampstead 283 Islington 2,973 City of London 72 Poplar 2,233 St. Cecilia's House 1,494 St. Marylebone 1,918 St. Pancras 3,925 South wark 3,588 Stoke Newington 417 Westminster 1,418 Woolwich 567 - 18,888 41,458 This number is an increase of 14,545, or 54 0 per cent., when compared with the number for last year, and is to be accounted for in the main by the additional stations and the opportunities given for voluntary cleansing. During the year 638 parents were fined amounts varying from 2s. to 10s., with 2s. costs. The following table compares the work done in the year under review with that for the year 1912:— Number examined. Number clean. Number verminous. Number returned clean. Number of statutory notices served. Number cleansed at stations. (1) (2) (3) (4) (5) (6) Bovs— 1912 188,926 181,378 7,548 3,511 4,037 3,285 1913 248,074 238,248 9,826 4,672 2,171 5,154 Increase or decrease + 59,148 + 56,870 + 2,278 + 1,161 — 1,866 + 1,869 Girls— 1912 202,720 194,738 7,982 3,245 4,737 3,995 1913 288,729 278,124 10,605 5,012 2,698 5,593 Increase or decrease + 86,009 + 83,386 + 2,623 + 1,767 — 2,039 + 1,598 Infants— 1912 171,101 166,005 5,096 2,157 2,939 1,675 1913 227,054 220,753 6,301 4,096 2,137 2,205 Increase or decrease + 55,953 + 54,748 + 1,205 + 1,939 — 802 + 530 Mixed 1912 57,169 55,191 1,978 788 1,190 877 1913 81,981 79,865 2,116 1,076 632 1,040 Increase or decrease + 24,812 + 24,674 + 138 + 288 — 558 + 163 Special— 1912 10,443 9,474 969 478 491 516 1913 12,853 11,798 1,055 385 260 670 Increase or decrease + 2,410 + 2,324 + 86 93 — 231 + 154 Totals— 1912 630,359 606,786 23,573 10,179 13,394 10,348 1913 858,691 828,788 29,903 15,241 7,898 14,662 Increase or decrease + 228,332 + 222,002 + 6,330 + 5,062 — 5,496 + 4,314 It will be observed that whereas the number of children examined has greatly, and the number found verminous has slightly increased, there is a considerable diminution in the number of statutory notices which it became necessary to issue. This fact is accounted for by the increase in the number of cases cleansed at home (viz., 15,241, an increase of 5,062, or 49-7 per cent), and the increase in the number taking advantage of the voluntary baths. This result appears to show that parents are responding- to the efforts made to secure a higher standard of cleanliness among school children. Scabies In addition to dealing with children suffering from ordinary verminous conditions arrangements have been made for children suffering from scabies to be cleansed at a number of the stations. This disease is responsible for long periods of suffering and absence from school and a considerable loss in grant. Most of the children suffering are having medical treatment, but the parents do not possess the necessary facilities for bathing and the sterilisation of clothing. The hospitals have been informed of the facilities given at the cleansing stations, and it is hoped that with their co-operation much will be done to eradicate this trouble from among school children. The children attend the cleansing stations, bringing their ointment, on the latter portion of those days when the station is open. This time is kept exclusively for the attendance of scabies cases so that they shall not mix with ordinary verminous cases. When a child attends at the station a notification is sent to the local Medical Officer of Health in order that action necessary in the home may be carried out. The bath is thoroughly cleansed and the towels sterilised after each case. All towels Report of the County Medical Officer—Education. 187 and other materials used in connection with the scabies cases are kept apart. Cases attend at the stations twice a week, but if the child is not cured after eight baths the case is reported for special examination by the school doctor, and further baths are not given until definite instructions have been issued. The stations at which children suffering from scabies are bathed are the Council's stations at Central-street, Finch-street, Fountain-road, Sedlescombe-road, and the stations of the Borough Councils of Battersea, Camberwell, Deptford, Greenwich, Hackney, Hampstead, Kensington, Poplar, Marylebone, St. Pancras, Southwark, Westminster and Woolwich; cases are also bathed at the station of the Corporation of the City of London. The difficulties arising from the serving of the statutory notices, necessitated by the Children Act, are accentuated bv the fact that the children, after cleansing, become reinfected by contact with members of the household who are above or below school age, and in regard to whom compulsory powers for cleansing do not exist. This is particularly so in regard to cases of ssabies, and it sometimes happens that, although the local Medical Officer of Health has taken action in the homes, as many as from 20 to 30 cleansings are given before a cure is effected, [n one case 37 baths were given. The school nurses again assisted the executive committee of the Children's Country Holiday Fund by examining for the detection of any infectious disease {e.g., ringworm) or any form of uncleanliness among the children whom it was proposed to send to the country as soon as the summer vacation began. The scheme comprised (1) a preliminary examination (2) au inspection beginning immediately after the Whitsun holidays and ending within four weeks, and (3) a fiual examination during the last two weeks of the term. The object of the preliminary examination was to ascertain in good time the children who would require special care and to warn the parents that if unsatisfactory conditions were not remedied the children would not be sent on the holidav. The Children's Holiday Fund. the first inspection at which a Children's Country Holiday Fund visitor was present, was made at the ordinary rota visits, but for the purposes of the final inspection the nurses were authorised to devote ten working days, beginning on July 6th, always provided that the arrangements for assisting the school doctors at medical inspections were not disturbed. To facilitate the examination of the children, at the final inspection, the schools were grouped and the children attended at a convenient central school, the details of these arrangements being left to the nurses and the visitors or honorary secretaries of the local committees. . The scheme worked very smoothly and gave general satisfaction; this was probably due to the freedom in the matter of arrangements allowed to the nurses, who in many cases took much trouble in order to ensure that the children should not be prevented from obtaining their holiday. The Executive Committee of the Fund have again asked the Council to permit the nurses to assist in the work. The personal hygiene scheme which is applied in all the girls' secondary schools except two, and in one of lhe boys' secondary schools, and kindred institutions was varied during the year in so far as candidates for the teaching profession were concerned. Hitherto, all pupils who were found on examination to be defective as regards personal hygiene were given three opportunities for remedying the unsatisfactory condition, a period of one month elapsing between the first and last of the series of examinations. This scheme was continued in the cases of pupils who did not propose to enter into the teaching profession, but in the latter cases it was considered important to ensure a still higher standard of cleanliness, since persons who are themselves found repeatedly to be in an unsatisfactory condition cannot be expected to impart instruction or to set an example in cleanliness to others. The scheme was, therefore, amended so as to provide that candidates for the teaching profession who were found to be defective on account of personal hygiene on more than one occasion should be deemed to be unsuitable for the profession, provided that an interval of at least a fortnight intervened between the first and subsequent examination. The preliminary examinations in all cases were carried out by school nurses, and pupils in whom unsatisfactory conditions remained unremedied were seen by an assistant superintendent of nurses, upon whose report official action was taken. In obstinate cases scholarships were withdrawn from scholarship-holders, and fee-paying pupils permanently excluded from the institutions. Few cases were unsatisfactory at the second examination, and a still smallei number at the third, but during the year five pupils were proposed for permanent exclusion from thi institutions, and 12 for withdrawal of scholarships owing to unremedied defects in personal hvffiene Socondary schools and kindred institutions- Verminous heals. The following table shows the conditions found during the year :— Examination, 1913. Number of pupils. Number found verminous Percentage. Boys. Girls. Boys. Girls. Boys. Girls. (1) (2) (3) (4) (5) (6) (7) Spring 75 3,840 - 165 - 4.29 Summer 75 4,144 - 249 - 6.00 Autumn 72 4,518 3 378* 4-16 8.36 *One of these was also a case of scabies. Seasonal Prevalence of Fleas. For the past five years effort has been made to obtain statistical information of fluctuations in the seasonal prevalence of fleas. At first limited to observations made by the Council's inspectors of common lodging houses, it has since the latter end of 1912 been found possible to broaden the scope of the inquiry by the inclusion of material made available by the examination of elementary school children. In the 123610 bb 2 188 Annual Report of the London County Council, 1913. accompanying diagram (E.) the first four curves are based on the routine examination of beds in common lodging houses ; the curve for 1913 is based mainly on the examination of school children, but the gaps caused by the holiday periods, when no children were examined, have been filled in from the common lodging house figures. It is found that the two methods of inquiry give results which correspond sufficiently closely to justify the interpolation of the figures. The curves show a considerable amount of correspondence in the several years. The possibility of the intermediation of certain common biting insects in causing the spread of diseases which have a high autumnal prevalence is deserving of further study. The subject has been referred to in previous reports (vide reports of the County Medical Officer of Health for the years 1909, 1911 and 1912). Great stress should in any event be laid upon the importance of the efforts of public health authorities now directed to diminishing the prevalence of vermin. Even if the risk of communication of disease be set aside insect pests cannot be tolerated, for the bad effects of their influence upon the health of young children is clearly demonstrated by a study of the results of medical inspection in the schools. Examination of Candidates. Candidates taking up permanent appointments in the school service are examined in the Public Health department before commencing work. Candidates for scholarships are also required to be examined before the scholarship is finally awarded. The number of candidates submitting themselves for a first examination during the year was 6,045. They may be classified as (a) candidates for entrance to the permanent service, (b) cases specially referred, and (c) candidates for award of scholarships. Permanent service candidates. This division includes alJ who work on the stan ot the various educational institutions, i.e., teachers and instructors, matrons, nurses, and needlewomen, schoolkeepers and caretakers in all classes of educational establishments under the Council. The numbers medically examined will not coincide with the number of appointments, as candidates from the Council's training colleges, having been under regular medical inspection, are not further examined on entering the permanent service within the year after leaving college. Appendix XYI gives particulars of the various candidates examined and the conditions noted as present. Of the 294 referred candidates, 16 (5 males and 2 females with defective teeth and one male and 7 females with defective vision) were referred a second time, owing to the condition not having been remedied ; one female was referred a second time for both defects. Seven candidates (2 males and 5 females) were rejected for the reasons set out below:— Status. No. rejected. Reason of rejection. Vision. Chest. General health. Under standard chest measurement M. F. M. F. M. F. M. F. M. F. Head and assistant teachers and instructors — 5 — 1 — 2 — 2 — — Schoolkeepers 2 — — — — — — — 2 — Cases specially referred. In addition to the first examination, 798 referred cases were dealt with. These referred cases relate to leave granted to employees absent owing to personal illness; to cases in which questions have arisen in regard to students in institutions for higher education whose health is considered such as to render exceptional attention advisable; to teachers returning to duty after extended leave of absence (a) owing to personal illness, (b) for educational purposes, (c) to married women under No. 115 of the regulations in regard to the education service, and to teachers about to be superannuated. The number of references under review, compared with those for the preceding year, shows a decrease of 143. or 15T9 per cent. In addition, 203 cases (an increase of 89*7 per cent.) were medically investigated in which claims were received from teachers and others in the permanent service for exceptional treatment as regards sick pay and re-imbursement of medical and other expenses in respect of illnesses alleged to be due to conditions under which they were required to carry out their duties. Scholarships and candidates for the teaching profession. The medical examination of candidates for the Council s scholarships serves a triple purpose. It prevents unsuitable scholars from taking up awards ; it is a factor in promoting the health and well-being of suitable scholars by insisting on the remedying of remediable defects ; and it safeguards the Council against pecuniary loss due to the payment of grants to scholars who are physically unfit to take advantage of a scholarship, and whose ultimate breakdown is but a matter of time. The scholarships and awards granted by the Council fall into three divisions, each of which requires different treatment in so far as the medical examination of the candidates is concerned. These divisions are as follows :— (а) County scholarships enabling candidates to proceed to institutions of university rank. (б) Technical scholarships enabling candidates to receive instruction in trades ; and special scholarships. (c) Awards enabling candidates to prepare for the teaching profession. The county scholarships are of four grades (junior, supplementary junior, intermediate, and senior) and provide a complete scheme by which a boy or girl may proceed by various stages from the public elementary school to the highest grades of education, whether at a university, technical college, or other institution, providing advanced training for a professional career. In medically examining Diagram E. Report of the County Medical Officer—Education 189 these candidates the stage of the scholarship is carefully noted, as the strain increases with the award, and it sometimes happens that a candidate who has been accepted for a junior county scholarship is rejected for the succeeding awards because attendance at higher institutions would be injurious to health. The medical examination of junior county scholars practically gives the defects of the brightest children of the age group, 11 3'ears old last birthday, and as the children must, in any case, remain in school until 14 years of age, the rejections are few. Most useful work is done, however, by making it a condition of award that all remediable defects shall be treated before the children are allowed to take up the scholarships. Supplementary junior county scholarships are reserved for children of less than 14 and not less than 13 years of age who by reason of late development or other cause fail to obtain the junior county scholarships. The intermediate county scholarships are open to boys and girls who are from 16 to 17 years of age on 31st July in the year of competition, and are tenable at approved secondary schools or technical colleges until the end of the school year in which the scholar attains the age of 18, but may be in special cases renewed for a further period of one year. The senior county scholarships are intended to assist candidates of the age of 18 and upwards who desire to pursue a course of study at an institution of university rank. Appendix XYII (A) shows the number of candidates for county scholarships examined and the conditions found. Of the 880 junior county scholars who were referred back ior various detects, excluding those 6 (girls) whose scholarships were finally withdrawn, 101 (32 boys and 69 girls) were referred again owing to the conditions not having been remedied. A further analysis of these numbers shows that the causes of the Recond reference were for— Sex. Want of cleanliness. . Vision. Teeth. Throat. Ears. Hip. General health. Boys —. 23 6 2 2 — — Girls 9 55 10 2 1 1 1 Some of the scholars were referred again for more than one defect. Of the 106 supplementary junior county scholars who were referred back for various defects, 4 boys were referred again, 2 owing to defects of vision and 2 owing to dental defects not having been remedied, and 4 girls were also referred for defects of vision, I girl for teeth and 1 girl for heart. heart. The following table shows the nature of the defects of 8 girls who were rejected— Award. No. rejected. Reason of rejection. Want of cleanliness. Vision. Throat. General health. Junior county 6 3 2 1 ~ Supplementary junior county 2 1 ~ ~ 1 Of the candidates passed as fit 43 junior county scholars, 17 supplementary junior county scholars, and 5 intermediate county scholars were accepted with defects that did not easily lend themselves to treatment but which would not interfere with their studies. The Council's scheme of trade scholarships is intended to encourage students to devote themselves to special branches of technical or industrial work. In medically examining the candidates the standard of examination is varied according to the trade that the scholar proposes to follow, because each trade has its peculiar effect upon the health of the workers. Appendix XVII (B) shows the number of candidates examined in connection with each award, and the conditions found. Of the 238 students referred, 21 (8 boys, 13 girls) were referred a second time owing to the conditions not having being remedied. An analysis of these numbers is given in the following table— Scholarship. Number referred a second time. Reason for rejection. Want of cleanliness. Vision. Throat. Teeth. Ears. M. F. M. F. M. F. M. F. M. F. M. F.. Boaufoy institute 1 ... ... ... 1 ... ... ... 1 ... ... Book production 2 ... ... ... 2 ... ... ... ... ... ... ... Building and Allied Trades 3 ... ... ... 2 ... 1 ... 1 ... ... ... Cookery 1 3 ... ... 1 2 ... ... ... 1 ... ... Corset making ... 1 - ... ... 1 ... ... ... ... ... ... Dressmaking ... 1 ... ... ... 1 ... ... ... ... ... ... Engineering 1 ... ... ... ... ... ... ... 1 ... 1 ... Millinery ... 2 ... 1 ... ... ... ... ... 1 ... ... Tailoring ladies' ... 2 ... ... ... 2 ... ... ... ... ... ... Upholstery ... 4 ... 2 ... 3 ... ... ... ... ... ... 190 Annual Report of the London County Council, 1013. Some of the scholars were referred again for more than one defect. 23 candidates (7 boys, 16 girls) were rejected for reasons set out below— Scholarship No. rejected. Reason of rejection. Want of cleanliness. Heart. Vision. Chest. Sundry defects. (1) (2) (3) (4) (5) (6) (7) M. F. M. F. M. F. M. F. M. F. M. F Artificers (boy) 7 ... ... ... ... ... 3 ... 2 2 1 enlargei thyroid 1 under standard measure. ment. ... Corset making ... 2 ... 2 ... ... ... ... ... ... ... ... Dressmaking ... 1 ... ... ... ... ... 1 ... ... ... ... Embroidery ... 1 ... ... ... ... ... 1 ... ... ... ... Ready made clothing designing and making of ... 5 ... 3 ... ... ... 2 ... ... ... ... Tailoring, ladies' ... 4 ... ... ... 1 ... 1 ... ... ... 2 1 kyphosis 1 back (scoliosis) Upholstery ... 2 ... 2 ... ... ... ... ... ... ... ... Waistcoat making ... 1 ... ... ... ... ... 1 ... ... ... ... The Council has made provision for a number of awards of a special character which cannot well be classed as trade scholarships. Appendix XYII (C) shows the number of candidates examined and the conditions found. Of the 294 special scholarship candidates who were referred 27 juuior domestic economy scholars (girls) were referred a second time owing to defects not having been remedied. The defects are indicated in the following table— Scholarship. Number referred a second time Referred for Want of cleanliness. Vision. Throat. Teeib. Ears. (1) (2) (3) (4) (5) (6) (7) Domestic economy junior 27 10 15 1 2 1 Some of the candidates were referred again for more than one defect. 25 girls were rejected for reasons set out below. Some of the candidates were rejected for more than one defect— Scholarship. Number, rejected. Reason of rejection. Want of cleanliness. Heart. Teeth. Vision. Throat. Sundry defects. (1) (2) (3) (4) (5) (6) (7) (8) M. F. M. F. M. F. M. F. M. F. F. F. M. F. Blind ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 (not capable of handwork.) Cripple ... 2 ... ... ... ... ... ... ... 1 ... ... ... 2 1 hysteria. 1 spinal caries. Domestic economy ... 22 ... 13 ... 2 ... 2 ... 5 ... 1 ... 3 1 anaemia 1 ears. 1 general health. The Council's awards for the training of elementary school teachers provide a complete scheme by means of which a boy or girl may proceed by various stages from the public elementary school to a training college for teachers, and when conducting the examination the medical officer is required to certify that the candidates are in a fit state of health to take advantage of a scholarship, and that they are likely ultimately to satisfy the requirements of the Board of Education for recognition as certified teachers. The ages of the candidates are as follows—Pupil teachers of handicraft not less than 14 on the 31st July in the year of the award ; bursars, 16 to 18; student Report of the County Medical Officer—Education. 191 teachers, not less than 17; training college students, not less than 18 on 1st August of the year of admission to a college; domestic economy training scholars, 18 to 30. The results of the medical examination are shown in Appendix XVIII. Of the 397 candidates who were referred, 25 (5 boys, 20 girls) were referred more than once for reasons indicated below— Awards: Number referred a second time. Referred for Want of cleanliness. Teeth Vision Heart Anaemia Hernia. (1) (2) (3) (4) (5) (6) (7) (8) M. F. M. F. M. F. M. F. M. F. M. F. M. F. Bursars 1 12 ... 1 ... 2 1 7 ... 1 ... 2 ... ... Student teachers 3 4 ... 3 ... ... 1 1 ... 1 ... 1 ... Training college students 1 4 ... ... ... 1 1 3 ... ... ... ... ... ... One of the candidates was referred again for two defects. 33 candidates (3 boys, 30 girls) were rejected for the reasons given in the subjoined table— Awards. Number rejected. Reason of rejection. Want of cleanliness. Hearing. Vision. Heart. Sundry defects. (1) (2) (3) (4) (5) (6) (7). M. F. M. F. M. F. M. F. M. F. M. F. Bursars ... 16 ... 1 ... ... ... 6 ... 3 ... 6 1 lungs, 1 anaemia. 1 Graves' disease. 1 stammer. 1 general physique. 1 paresis of left arm. Student teachers ... 11 ... ... ... 1 ... 4 ... 1 ... 5 3 general health. 1 chronic otorrhoea. 1 general medical grounds. Training college students 3 3 ... ... 1 1 1 ... 1 ... ... 2 1 scar on cornea. 1 skin disease. Medical inspection in training colleges, secondary and trade schools. Since 1908 medical inspection has been carried out in all the Council's training colleges, secondary schools, trade and technical schools. Each student is examined once a year, and each institution visited once in six weeks, so that the doctor can be consulted concerning pupils presenting any symptoms likely to affect their health or work. Every student has a medical record card showing at a glance the condition, so that the students are continually under observation and are not permitted to continue at the institution if through illness or other causes they become unfit. Appendix XIX (A) shows the delects noted. L.C.C. Train^ ing Colleges Secondary and Trade Schools The principals, head masters and head mistresses thoroughly recognise the advantages to be gained not only to the scholar but indirectly to the school, for the efficiency of teaching must largely depend on the receptivity of the pupil and this again on conditions of good health. More and more do those in authority tend to consult the doctor on health questions, and they devote a considerable amount of time and energy to interviewing and writing to parents with the result that steps are taken to remedy the defects found. This co-operation of principals, parents and students with doctors brings about a harmonious working of the scheme with most gratifying results. Appendix XIX (B) shows the conditions remedied. In October, 1911, it was decided that the Council's scholars in attendance at non-maintained secondary schools, and all scholars attending aided trade and domestic economy schools at which a system of medical inspection had not been adopted should be periodically examined. These examinations began in the year 1912 and were continued in 1913. In many cases the scholars were examined at the institutions at which they were in attendance, but in others the examinations were conducted at the bead office in order to meet the wishes of the governors who preferred such an arrangement on the ground either of lack of accommodation, or the undesirableness of differentiating at the schools between the holders of the Council's scholarships and other pupils. As in the Council's institutions a medical record card was filled in for each scholar so that the scholars were continuously under observation and were thus not permitted to continue at the institution if through illness or other causes they became unfit. The head masters and mistresses exercised vigilance and showed keenness in obtaining prompt treatment of any ailments noted ut the medical examinations, and the parents responded to their efforts. Non maintained institutions 192 Annual Report of the London County Council, 1913. Training colleges Avery Hill Training College.—During the year the health of the students in the training colleges has oh the whole been excellent, the great majority showing a definite improvement as a result of their college course. This improvement was most noticeable in the cases of the older women wbo entered college after teaching for some years. The striking feature of the first examination of these latter was the bad condition of their mouths, which presented a contrast to those of the young students who had been under medical observation in their school days. It was rare to find a good set of teeth; several students were almost edentulous, and many had septic mouths, with resultant anaemia, digestive troubles, etc. A considerable proportion had untreated visual defects, or were wearing unsuitable glasses. Treatment of these conditions relieved the frequent headaches, of which many complained. Ihe actual weight records of students at Avery Hill have been analysed by the Physical Exercises and Hygiene Lecturer, with the results shown in the following table. In only two cases was the decrease in weight accompanied by any symptoms of ill health. Year of entrance. Increased both years. Increased first year only. Increased second year only. Increased first year, decreased second year. Decreased first year, increased second year. Decreased first year only. Decreased both years. Unchanged during two years. (1) (2) (3) (4) (5) (6) (7) (8) (9) Per cent. Per cent. Per cent. Per cent. Per cent. Per cent. Per cent. Per cent. 1911 37 5.4 63 22.5 14.4 2.7 9 3 Home students. 2 Lodgings. 2 Hostels. 3 College 2.7 1912 58 3.2 75 8.6 18.2 0 4.3 3 Day students. 1 Hostel. 0 Islington Training College.—Dr. A. C. Williams has noted the relation of ability and physical conditions in the students at the Islington Training College. From information given by the authorities of the college the students were divided into two nearly equal groups according to their intellectual ability, and these groups contrasted in respect to nutrition, and the conditions of the hearing, vision, spine and teeth. Complete records were available for 102 senior students. As regards nutrition there were no very striking differences, but those existing tend to show that ability and good nutrition go together. Visual defect was slightly more common in those of lesser ability. The spinal lefects, which were usually very slight, were more prevalent in the superior group. There was no marked difference in the two groups as regards the condition of the teeth. London Bay Training College.—Dr. Fairfield draws attention to the relatively less satisfactory physical condition of the students at this College, at which many students take a course for a degree and train for the teaching diploma at the same time. The students suffer from the drawback attached to absence of opportunities for recreation attached to a non-residential college, while the calls of home life^and the need of working under adverse conditions add materially to the difficulties. Many students admitted that they had insufficient sleep and inadequate midday meals. Moorjields Training College.—A large proportion of the students now attending Moortields are women who have already been teaching in the Council's service for a varying number of years. The Principal takes the keenest interest in medical inspection and is herself present at all the examinations. The college maintains its high level for hygiene and successful treatment of defects discovered by medical inspection. Excellent dinners are provided at a cost of 6d., and the Principal insists on the students partaking of them, to their great advantage. Secondary and Trade Schools Cleanliness.—The doctors visiting the girls trade schools point out the advances in hygiene which have been made during past years. While the general standard of cleanliness is high throughout the Higher Educational institutions, individual evidences of carelessness in the hygiene of skin and teeth are still found in all classes of institutions, more especially among flie eleven and twelve year old girls. This is probably due to the withdrawal of maternal supervision at an age when the children are supposed to be able to look after themselves. Unexpected inspection is a very valuable stimulus in counteracting this childish carelessness. The custom adopted at one school of giving 12 lessons in elementary hygiene to all eleven-year-old children, thereby including the scholars immediately after entrance, has proved most valuable. A serious difficulty in the way of reform is bad home tradition. Certain unhygienic practices, such as the habit of retaining the day garment at night for fear of catching cold, and the dread of touching water at certain times for fear of innumerable evils, are widespread. Thus apparent evidences of neglect are frequently due to excess of care on the part of the mother, who is only acting up to what she has learnt from all her female relatives since childhood. In one instance when a would-be teacher had been advised to continue her regular washing, the parent came to the school and stated that the doctor had given instructions which would kill the child. Lack of opportunity of proper cleansing in the home is another very important factor in preventing instruction in hygiene from being effective. For example, at one trade school, out of 85 girls questioned only four had hot water or baths in the house. A few had boilers, but for the vast majority there was only a cold water tap in the scullery or kitchen, and the kettle was the only source of hot water for cooking, laundrying, or personal washing. At another school the trade and domestic economy students were offered the use of baths on the premises once a week, if they cared to apply. Sixty girls who sent in their names were questioned about the conditions in their homes. Eighteen of the 60 had no water in their room at all, 16 of these had a tap on the landing, but in Report of the County Medical Officer—Education. 193 two cases it was downstairs in the yard. These 18 cases had no means of disposing of waste water in the house. Every drop had to be carried outside, and in the two worst cases downstairs to the yard. In the remaining 42 cases there was only a cold water tap in the house, and in some of these homes also the waste water had to be carried out to be emptied. It is very satisfactory to note that in spite of these unfavourable conditions the standard of cleanliness at the school was high. The gymnastic mistress states that whereas some years ago the girls took no advantage of the baths when offered the use of them, this year the experiment has been very successful. Dr. Gowdey points out that a considerable amount of time is spent on individual instruction in such simple matters as the importance of a daily wash, of cleaning the teeth, or of not sleeping in day garments. She considered that it would avoid repetition and prove to be a saving of time if health talks of about 15 minutes were given at every medical inspection to the pupils presented for examination and to as many others as possible. This experiment has been tried in three schools. Girls of 14 years and over were selected, as many as a classroom would hold, and the subject was approached from the point of view of discharges or excretions from the body and the importance of washing these away, whereas if allowed to remain smells, personal discomfort, and unwholesome conditions could only result. These lectures are wanted as much, if not more, in secondary schools as in training colleges, in which they are already an established fact. Girls reaching puberty in secondary schools are just in a plastic condition to receive skilled help in these matters, otherwise they are only imbued with old nurses' fallacies, which are so difficult to uproot in later life. In all three schools the head mistress and staff who were present expressed great satisfaction at the way in which the subject was approached and requested a continuation of these talks on health matters. At the Shoreditch Technical Iustitute, in connection with the scheme of instruction in domestic subjects, the girls in rotation reside a few weeks at a time in a flat and are there taught housewifery as it should be in small homes, attention to personal cleanliness, and refinement in eating and table manners generally. School Dinners.—Cases of malnutrition from actual lack of food are very exceptional in higher educational institutions. The condition of chronic slight underfeeding produces symptoms difficult to distinguish from those arising from lack of sleep, fresh air and exercise, or even from overstrain. In all guspicious cases it is usual to urge that all possible nourishment should be taken at school. Dr. Gowdey and Dr. Fairfield draw attention to the importance of hot dinners in place of cold lunch. Many girls do not take sufficient breakfast, and the interval between breakfast and a late dinner is such as to render them tired and unwilling to eat when the time comes, especially if they have just assisted in preparing this meal. At one school the girls are encouraged to take a personal interest in the kitchens, and " old girls " have been allowed to study housekeeping under the housekeeper in charge of the catering. On wet'' games afternoons" the girls make jams, puddings, etc., which are consumed at the common dinner. The tables are divided into small sections, each presided over by an elder girl who acts as " mother " and serves the food. These devices have succeeded in more than doubling the number of diners. It would be well if all could partake of the hot mid-day dinner provided at the school. Difficulties have arisen of a financial character, the parents being unable or unwilling to pay for the school dinners, and in one instance from the school dining room accommodation being too limited. At this school at the end of term the doctor noted several pupils with markedly rapid pulses, some as high as 144 and 158 a minute, and on enquiry learnt that these pupils went home to mid-day dinner, some having as much as a 20 minutes' walk each way, which left only some 20 minutes to partake of a meal. In cases where the pupil has been persuaded to remain for the school dinner beneficial results have been noted in pulse and otherwise. Rapid pulses are often the forerunners of Graves' disease, and it is not uncommon to find slightly enlarged thyroids and exophthalmos developing in girls of school age under the strain of hurry and examination. Dr. Gowdey, who noted the chief features in the dinners provided at six secondary schools, fouud that the price of a meat dinner varied from 5d. to 8d., while 3d. was the usual cost of a vegetarian dinner. The numbers attending varied from 14'4 per cont. to 30'2 per cent, of the total number of girls in school. The cost of service varied from 24 per cent, to 64 per cent, of total takings, the higher wages being at the school where the dinners were the least popular as shown by the fewer pupils remaining to dinner. In some schools the headmistress and staff dine with the pupils, which is an obvious advantage, leading to improvement in the manners and hygiene of the pupils. The doctors acknowledge the great and valuable aid they receive from the heads of the schools in securing the treatment of the various defects noted at the medical inspection; nothing goes so far in this direction as personal influence on the parent. Dental treatment is on the whole more difficult to secure than medical, and in some areas the quality of the work done by unqualified dentists to whom many pupils went in spite of advice is of the most careless description. A particularly flagrant case was that of a fee-paying pupil at a trade school found to have 13 carious teeth, many being septic. She went to an unqualified dentist who offered to give her artificial teeth for 10s. Her father could ill afford this, for he was an artisan earning under 30s. a week, and had a hard struggle to keep the girl in a Trade School. However, he agreed, and the " dentist " extracted the upper incisors, giving the girl four artificial teeth on an ill-fitting plate which he attached round the septic molars. Nothing was done to the lower jaw. When such a case becomes the subject of discussion among the girls in an institution it is uphill work to press for dental treatment. Treatment of remediable defects. Residential Institutions. During the year there were 8 residential industrial schools and 6 (2 blind, 3 deaf, and 1 mentally defective) residential special schools with accommodation for about 1,020 children. Since the 1st January, 1914, the Council has taken over full responsibility for the Portslade Industrial School 23610 cc 194 Annual Report of the London County Council, 1913. (accommodation 120) which was formerly owned jointly by London and Brighton authorities. To each institution is allocated a medical officer who briefly is required: (1) to attend the school at least once every week and at such other times as may be necessary, and to enter the visits and the names of the patients attended by him in a book kept for the purpose ; (2) To examine the children on admission; (3) to attend any cases of illness occurring amongst the children and to make a note on the cards kept for the purpose of all serious cases of illness, their course, duration and treatment prescribed; (4) to furnish reports to the school medical officer on the health of the inmates ; (5) to furnish any other reports or certificates that may be required to the school medical officer; (6) to give immediate notice to the coroner of the district of cases of sudden or violent death or cases where he does not feel justified in giving a death certificate of any inmates and to report the circumstances of the case to the school medical officer. Generally, the medical officers are seldom required to make special reports, but a return of sickness is made monthly. The salaries of the medical officers are according to the following scale : £30 per annum in respect of schools where the total number of children requiring medical attendance is 30 or under and an additional 8s. a year for each child beyond 30. A dentist is also allocated to each institution, who is required to visit the school once in each quarter; to perform all necessary extractions, scalings and stoppings; to arrange the work in such a way that every child in the school is kept as far as possible free from such oral sepsis as may be due to unhealthy conditions and to extract teeth and roots that cannot be rendered healthy ; to see and, if necessary, treat every child once in each year; to note on the appropriate cards the condition of each child's mouth and the treatment carried out, and enter the names of the children treated in a book provided for the purpose ; to make a short annual report on the condition of the children in the school with special reference to oral sepsis ; and to co-operate with the superintendent in devising means for maintaining the general cleanliness of the teeth of the children in the school. During the year the dentists made 93 visits to the schools and treated 945 cases, but some of the children were treated more than once. In many instances conservative treatment was carried out at the private surgery of the dentist. Industrial Schools. The recommendations in regard to medical care of the Departmental Committee on Reformatory and Industrial Schools were as follows :— " More systematic medical care, periodical medical inspection of the children, and the keeping of physical records to be required in all schools. At every school there should be a medical officer whose appointment involves the performance of a prescribed schedule of duties. These duties should include (1) the examination of all children on admission in regard to infectious and contagious diseases, before they are allowed to mix with the other inmates of the school; (2) thorough medical inspection on the lines of a prescribed schedule of all inmates at regular intervals; (3) periodical re-examination of children found to be defective and of other children needing it before undertaking special training or work; (4) keeping necessary physical records ; (5) undertaking or obtaining adequate medical treatment in all cases needing such attention; and (6) subject to the general control of the central authority, the effective supervision of the sanitation of the buildings, diet, corporal punishment, physical training, and the general arrangements of the school routine and curriculum in their relation to the health and growth of the children. The advice of the medical officer should also be sought in regard to the means and methods of education, in so far as they should be modified for the mentally retarded or defective child. More effective supervision to be exercised by the central authority over the arrangements for medical care and inspection." These recommendations were in harmony with the practice of the Council in its own schools. The Home Office have issued a new form of quarterly medical report requiring information as to daily average number of inmates under care in the school during the quarter, number of visits to the school paid by the medical officer during the quarter, number of sick cases under treatment at the commencement of the quarter, number of new sick cases presented to the medical officer for treatment during the quarter, number of sick cases remaining under treatment at the end of the quarter, deaths, discharges, daily routine, dental work, dietary, buildings, and examination ot all inmates. The report requires that cases of illness shall be enumerated under certain specified headings. Considerable clerical work is involved not only in completing the report, but iu keeping the necessary records in order that the report may be satisfactory compi'ed. This clerical work was apparently anticipated by the Home Office, since the form states : " So far as is possible the informat-on required by this form should be filled in by the clerk of each school under the direction of the medical (jfficer." The form formerly used was a comparatively simple one and could readily be completed at the end of each quarter, but in view of the detailed nature of the new form it has been necessary to arrange for an officer at each school to keep records and to make proper entries on the forms under the direction or the medical officer. Places of detention The three places of detention maintained by the Council were fully described ic the annual report for 1912. During the yeac 1913, 2,781 children were admitted as follows : Harrow-road, 1,210 ; Pentonville-road, 1,224 ; and Ponton-road, 347. The accommodation and classification of the institutions are fctated below :— Harrow-road 45 boys,]12 to 16 years of age. Pentonville-road 51 boys, 7 to 12 } ears of age ; 33 girls, 7 to 11 years of age. Ponton-road 40 infants under 7 yea-rs of age ; 30 girls 11 to 16 years of age. Report of the County Medical Officer—Education. 195 The children are examined on admission by the medical officer of the institution, who fills up on a prescribed torm the conditions noted on examination. When a child or young person is committed to a certified school this form and the elementary school medical record card, if any, are forwarded to the school and are retained thereat until the child or young person to which they refer attains the age of 16 or 19 years, as the case may be, when they are returned to the Council. Dr. Hawkes has endeavoured to keep a record of the amount of medical attention required during the past year at Pentonville-road, and he states that out of the 1,016 cases recorded, 117 or 115 per cent, were sent to the sick room, of this number 91 were isolated at the examination on admission, and 26 were taken ill during the period of detention. There was a daily average of 4 under treatment or observation, and the average period of confinement was 13 days. Four cases of infectious fever occurred, and 16 were isolated as contacts. Fifty-five suffered from eye or skin troubles, due to dirt and neglect, the remainder were made up of various ailments. Ir addition, 220 children were found, upon admission, to be suffering from minor surgical ailments which needed daily attention, but were not so severe as to necessitate treatment in bed. A large number of children also received medical attention for coughs and colds, and the following figures show the assistance rendered by the nurse :— Surgical dressings 2,262 Baths for skin affections 344 Ears syringed for discharge 402 Noses syringed 374 Eyes treated 1,024 4,406 Dr. Hawkes also draws attention to the need for convalescent homes. He states that the normal health of at least 25 per cent, of the children passing through the places of detention is below that of the ordinary elementary school child and far below that of the average middle class child. The resistance to disease is poor and the recuperative power acts slowly. Many ot them are found on admission to be suffering from sores ar.d abrasions of the skin, which in healthy child ret would heal rapidly, and which in these children suppurate and require prolonged treatment before they are healed and even then show a frequent tendency to break down again. Acute tubercular disease is rare. Many children, however, are found with symptoms that point to an infection which, although smouldering at present is always liable to break out unless steps are taken to stop it. Many of these children are discharged by the magistrate because owing to conditions of health they are unfit for training in an ordinary industrial school, and although it is desirable that they should be sent away to the country or convalescent homes, yet they are permitted to return to the unhygienic conditions of a home from which they were probably taken away and charged on account of parental neglect. Such are the conditions under which many of the children admitted to the places of detention have been living, and hence it cannot be matter for surprise to find that about one-third have to pass through the hands of the doctor and nurse for treatment of one kind or other. In connection with the above statements attention may be drawn to a comparison between the children admitted after they have been hopping, and those who have spent the same period in the streets. The children who have been hopping and living in the open air and sleeping under canvas come in with brown skins and greatly increased vitality, though often very verminous, while those who have remained in London are dull and listless. Dr. Hawkes draws attention to the need in places of detention of a separate playground shed and arrangements for organised games. Most of the boys admitted have spent most of their spare time in the streets and the enforced confinement and aimless desultory play in the absence of organised games proves prejudicial to health. Infectious Diseases. The subjoined table shows the incidence of scarlet fever, diphtheria, and measles durin O* the past eight years. The number of cases of whooping-cough reported as occurring among school children during 1913 is also shown, but it is not possible to present similar figures for preceding years. The incidence of scarlet fever and diphtheria upon persons of all ages is compared with the number of school cases notified. Comparative incidence— Scarlet fever diphtheria and measles Ihe accompanying diagrams (r and b) compare the weekly notifications of cases of scarlet fever and diphtheria occurring amongst school children and all other persons during 1913. 23610 cc 2 196 Annual Report of the London County Council, 1913. Disease. Total numbers notified. Weekly mean. Year. All ages. Elementary school children. All ages. L.C.C. school children. Scarlet fever 1906 20,333 8,371 391 161 1907 25,923 12,307 498 237 1908 21,648 10,291 416 198 1909 17,389 7,716 335 148 1910 10,513 4,700 202 90 1911 10,484 4,640 202 89 1912 11,319 5,060 218 97 1913 17,552 7,969 331 150 Diphtheria 1906 7,934 2,549 153 49 1907 8,597 3,170 167 61 1908 7,671 2,809 148 54 1909 6,617 2,212 127 43 1910 5,391 1,861 104 36 1911 7,268 2,572 140 49 1912 7,009 2,571 135 49 1913 7,654 2,663 144 50 Measles 1906 Nonnotifiable. 18,899 Nonnotifiable. 365 1907 26,179 503 1908 19,385 373 1909 20,145 387 1910 25,677 494 1911 31,905 614 1912 19,809 381 1913 15,142 286 Whooping Cough 1913 Nonnotifiable 9,672 Nonnotifiable 182 Scarlet fever During the autumn and winter scarlet fever prevailed in epidemic form both in London and throughout the country generally. From the Local Government Board statistics for the year it appears that the case-rate for London (3-89) was in excess of the rate for the rest of England (2'96), excluding Wales, but less than that of the county boroughs (4.26) in which urban conditions obtain. In the two previous years, 1911 and 1912, it was found that the case-rate of scarlet fever in London was lower than that for the rest of England, as well as for the county boroughs. The number of school children reported suffering from the disease was 7,969, while the number of sufferers of all ages was 17,552. The number of schools which came under special observation on account of scarlet fever was 642, whilst 121 schools were visited by school doctors from time to time during the year for special investigation into the sources of infection and for examining the children with a view to detecting missed or unrecognised cases. The outbreak in England was preceded by an epidemic on the Continent, which commenced in the towns on the borders of the Baltic and North Seas during 1912-1913. In December, 1912, the epidemic wave had reached Amsterdam where considerable spread took place. One factor leading to the wide dissemination of the disease was the mildness of its type. The first indication of any abnormal prevalence in London was observed about the end of May, 1913. The disease was characterised here also by considerable mildness of type. The first sign of unusual prevalence was observed at Cormont-road School, in Lambeth, where investigations were made by two of the Council's medical officers, the investigation having originated because one of the assistant teachers in the infants' department had contracted (29th May) a severe attack of scarlet fever. Upon inquiry it was found that a child sickened with scarlet fever about the 9th May, and subsequently to the illness of the assistant teacher, two other children, who were last in school on 20th May, were notified as suffering from the disease. In both these latter cases the disease was so mild that they were not recognised as scarlet fever until desquamation was observed. Further investigations led to the discovery of a large number of children who showed obvious indication of having suffered from scarlet fever in so mild a form that the majority had never exhibited any signs of serious illness nor had they been absent from school. The majority occurred in the infants' department, but a certain number were detected in the boys' department, while very few were discovered in the girls' department. In a small proportion of cases only were the more serious complications found, such as nasal or aural discharge. The medical officer of health of the metropolitan borough of Lambeth was informed, and at his request all the children showing signs of desquamation or other late indication of the disease were officially notified under the Public Health (London) Act, 1891. The school was kept under close observation and all absentees and exclusions were notified to the local medical officer of health. These precautions may have had the effect of keeping the spread of the disease in check, but considerable difficulty was experienced owing to the fact that the majority of the cases excluded from school by the teachers on suspicion were not looked upon as serious by the parents and were therefore not segregated or removed to hospital. Cormont-road School was kept under close and continued observation and the head teachers were given specific advice with regard to the supervision of the children and were requested to exclude and report all suspected cases to the school medical officer. Diagram F. 1913. SCARLET FEVER. DIPHTHERIA. 1913 D i a g r a m G. Report of the County Medical Officer—Education. 197 At this point it will be appropriate to refer to a group of cases occurring in the Ponton-road Place of Detention in Wandsworth. Owing to the provision of observation wards for new admissions these children were discovered to be suffering from scarlet fever before admission to the common dormitories and the disease was not communicated to the other inmates. Such cases in spite of the mildness of their symptoms are nevertheless of a highly infectious character and infectivity persists for long periods. This was demonstrated a little later by the admission to the Home for Little Boys, Clapham-park of two of the children, referred to above in connection with the Ponton-road Place of Detention, after their return from hospital. In spite of every care on the part of the Metropolitan Asylum Board's authorities and notwithstanding isolation of the children in the Home for a fortnight before allowing them to mix with other inmates, within twenty-four hours of their release from isolation an outbreak occurred in the dormitory to which they had been admitted. The Home was at once placed in quarantine and the two suspected " carriers " were removed to hospital, yet the Home remained a source of infection for further mild cases. Before the end of the summer term several other schools in London, especially in Deptford and Lewisham were invaded. The closure of the schools for the summer holidays cut off the means of investigation so far as school children were concerned, but immediately upon the resumption of school after the holidays it was observed that the incidence of the disease had become generalised throughout schools in all parts of the metropolis, and more particularly in the borough of Islington. School doctors, nurses and teachers frequently detected suspicious cases among the children, i.e., peeling, nasal or aural discharges, and other indications of post-scarlatinal complications. These were excluded from school and reported to the medical officers of health of the boroughs in which the schools were situated. In certain of the boroughs difficulties arose owing to the mildness of the attacks leading to differences of opinion with regard to the nature of the cases. In several cases in which the school doctor's diagnosis was disputed by medical practitioners the subsequent occurrence of desquamation showed that the original diagnosis was correct. Meanwhile, the hospitals of the Metropolitan Asylums Board rapidly filled with cases, the majority of which were of a mild type, and the medical superin tendents of hospitals who were interviewed were agreed as to the mitigated type of the cases and the difficulty of detecting them. It was observed in most of the school outbreaks that the incidence was distributed over various classes and departments, chiefly among friends or relatives. Unfortunately in many cases the possibility of the existence of mild cases in the classrooms was not appreciated by the school teachers who were prone to attribute the subsequent outbreak to other and imaginary causes. The consequence was that attention had repeatedly to be drawn to the necessity of close supervision of the children themselves and of excluding those who showed suspicious symptoms, until they had been seen by the school doctor or had furnished satisfactory medical certificates. A considerable amount of the school doctors' time was spent in visitation of schools for the purpose of investigating outbreaks and examining children excluded bv the teachers, or otherwise coming under suspicion. There was a slight increase in the number of cases of diphtheria during 1913 as compared with the preceding four years. The prevalence was more marked in London than in other parts of the country, the case-rate in London being 1 per cent., as compared with 1.26 for the rest of England and 1.48 for the county boroughs. As in the case of scarlet fever, the incidence of this disease was greatest during the autumn months. The number of cases of diphtheria reported among school children during the year was 2,663, as compared with 7,654 in all persons. The number of schools under special observation was 333, and 83 schools were specially visited by school doctors on account of their showing some indications of possible spread of infection among the children, and 2,222 cultures were forwarded for examination in the laboratory. True diphtheria germs were identified in 112 cases, whilst a further 212 cultures were found to contain germs not definitely distinguishable from the Klebs Loeffler bacillus. The problem of dealing adequately with these bacteriological cases of diphtheria, in which the usual clinical symptoms associated with the disease are not apparent,still remains unsolved,and further organised research into this very important subject upon bacteriological and epidemiological lines would doubtless be valuable. Diphtheria. Goodrich-road School, situated in the Borough of Camberwell, calls for special attention, as it was the school which was most seriously affected by diphtheria during 1913, whereas schools in the neighbourhood remained comparatively free from this disease. Children attending the infants' department were the first to suffer ; 4 cases were notified in September, 16 in October, 9 in November, and 4 in December. Upon the first indication of the spread of the disease, instructions were issued to the head teachers of departments to have each class watched, and to exclude every child from such class showing any suspicious symptoms. In consequence of this action a large number of children were excluded from school, i.e., 2 in September, 47 in October, 20 in November, 5 in December. These exclusions are shown in the subjoined table. All of them were examined bacteriologically at some period of their exclusion, with the result that in October 11 children, and in December 2 children, were found to be carrying Klebs Loeffler bacilli. The disease soon made its appearance in the girls' department, and the figures for this departmen are as follows :— > September. October. November. December. Notified cases - 5 2 4 Suspicious cases, excluded but not notified 2 8 37 5 198 Annual Report of the London County Council, 1913. The children in the infected department were examined on 1st October and 2nd December, and some of them were found to be harbouring diphtheria bacilli. The boys' department was not affected. This school was systematically kept under observation by school doctors and frequent periodical visits were made. On each occasion suspicious cases were examined with a view to detecting carrier cases. In all 96 swabs were taken and 10 children proved to be harbouring diphtheria bacilli, and a further 14 showed the presence of bacilli which could not be differentiated from the true Klebs-Lceffler bacilli. No reason could at first be ascribed for the outbreak, but on 6th December two boys attending the same classroom in the infants were discovered to be carriers and were excluded. The Sunday school and other places frequented by children of this school were closed, and other precautions were carried out to prevent spread of the disease. The chronic intermittent carrier of diphtheria germs, R.C., referred to in full in the report for 1912, is still in one of the Metropolitan Asylums Board hospitals, where she was admitted on June 12th, 1912. She has been under very careful observation and now looks very well, and has grown quite sturdy. A number of methods of treatment for the elimination of the Klebs-Lceffler bacillus from the child's throat and nose have been tried, but cultures from her throat still exhibit the diphtheria bacilli, which on several occasions have proved virulent or partially so. The methods tried have been, segregation with thorough feeding and regular hygiene of nose and throat; inoculation with an autogenous vaccine of 24 hours' growth ; spraying and swabbing with various antiseptics; spraying and swabbing with broth cultures of staphyloccus pyogenes aureus ; and, lastly, swabbing and spraying with protargol, a silver compound, so strongly recommended in carrier cases of cerebrospinal fever. The complete enucleation of the tonsils and removal of adenoids have been found efficacious in many cases. R.C. has not much tonsillar tissue, but it would appear to be worth while to remove this, and the consent of her parents is being sought for this purpose. The facilities afforded by the existence of a laboratory as part of the Public Health organisation have proved to be of very great value in arriving at an accurate diagnosis as to the cause of illness of scholars, both in cases of sore throat associated with infectious diseases, and in the diagnosis of doubtful cases of ringworm and favus and other microbic infections. It has consequently been of very great assistance in the detection of possible foci of infection in the Council's schools. In addition to the work in connection with elementary and secondary school children specimens are frequently received from the Council's places of detention and industrial schools for bacteriological examination. In the following table the number of specimens examined for diphtheria, together with results of the tests, are classified in the respective administrative divisions. The number of cultures examined in connection with residential industrial schools and places of detention are also shown. A few "swabs" have been taken at the head office for various purposes, and these are shown under " Miscellaneous." E. & N.E. Division. W. & N.W. Division. S.E. Division. S.W. Division. Residential institutions. Miscellaneous. Total. I Specimens examined 327 434 1,138 225 82 16 2,222 Diphtheria germs found 19 30 49 10 2 2 112 Suspicious germs found 39 47 101 18 4 3 212 Particulars of the work done in connection with ringworm will be found on page 105. A certain number of miscellaneous microscopical examinations have been made, for example, specimens of materia for examination have been submitted from time to time in connection with the administration of the Midwives Act, and the Council's midwifery classes at evening continuation schools; in other cases contagious diseases of uncertain origin have been investigated among school children by means of a microscopical test. The actual and potential advantages of a well equipped laboratory can scarcely be over estimated as a unit in the administrative machinery of the school medical officer, and it is hoped that the possibilities thus opened up may prove of increasing value as a means of controlling infectious diseases. Measles. During 1913 there was a noteworthy decrease in the incidence of measles. The number of cases notified amounted only to 15,112, which is considerably lower than the figure for any of the seven preceding years as shown in the above table. During the autumn and winter months there was a period of unusual quiescence. The following figures give the incidence of measles in each minrtpr of the vear :— Number of Cases. January-March 7,277 April-June 4,813 July-September (including summer holidays) 2,445 October-December 577 Total 15,112 It will be seen from the above table that measles was most prevalent in the first quarter of the year, and that the incidence gradually diminished until the end of the summer months, after which there was a considerable drop, the number of cases in the last quarter being extraordinarily few. 199 Report of the County Medical Officer—Education. The methods to be adopted for controlling measles require careful consideration. Compulsory notification has been advocated as essential to the control in measles, but in every area in which it has been tried this procedure has ultimately been abandoned. Some authorities are of opinion that systematic closure of infant schools when measles is prevalent is necessary to prevent the spread of the disease, whilst others would limit protective action to the exclusion of children under compulsory schocl age, owing to the greater danger to life when children are attacked by measles at an early age. In this connection it is interesting to note that out of the total number of deaths from measles during 1913, viz., 1,570, no less than 1,460 occurred in children under five years of age. The control of measles in London schools has been the subject of serious consideration by the London Education Authority for the past ten years, and from time to time special investigations have been carried out with a view to elucidating various factors which aid in disseminating infection, and ascertaining the best methods of control. The general practice in the past has been to limit exclusion for protective purposes to children in infants' departments, and in this connection it is important to keep the following general considerations in view:— (1.) It is estimated that 90 per cent. of the children have had measles by the time they leave the infant school. (2.) The severity of an attack of measles varies during each epidemic, and virulence increases with the number of children attacked by the disease. (3.) The severity of an attack depends also on the age of the child ; the younger children usually suffer more severely, and are liable to suffer from complications which may be fatal or which may predispose to tuberculosis, ear discharge, or injury to eyesight. (4.) Climatic conditions also have a marked influence on the spread and severity of the disease. If, therefore, children cannot be protected from contracting measles ultimately, efforts should, at any rate, be made to protect them from an attack in early years. In any scheme for preventing the spread of measles it follows that strict supervision should be exercised over children in infants' departments, particularly children under five years of age. The scheme adopted in London aims at obtaining the co-operation of teachers and attendance officers, and through them, securing the education of parents as to the necessity for care and attention when cases of measles occur in the family. For purposes of school control head teachers are required to furnish from time to time returns showing the proportion of children who have already had measles, together with the range of age in each class, thus providing a basis for taking preventive action upon the occurrence of outbreaks. For various reasons these lists cannot be perfectly reliable, and some cases of measles are not infrequently found to occur in classrooms from which all known susceptible children have been excluded. Consequently it becomes necessary to extend the period during which the children known to be unprotected are excluded, otherwise the object of the exclusion is frustrated. When measles occurs in any class of r.n infants' department, the attention of the head teacher is drawn to the infectivity and danger of the disease, and to the necessity for exercising close supervision, for excluding children who show suspicious symptoms, and for avoiding all mixing and massing of the classes. If the class affected contains children of the age of five or under, those of them who are susceptible are excluded during the period when they may develop the disease and infect other children. It is recognised that certain of the susceptible children, excluded from an infected class, will develop the disease, whilst others will be found not to have been infected or to be immune. After a certain period, therefore, the crop, infected by the first case, will be exhausted and those children who are not infected may safely return to school. In older children the risk of spread is not so great owing to the lower proportion of susceptibles. If the percentage is low little risk is incurred by allowing the few unprotected children to continue attendance at school. On the other hand if the percentage of susceptible children is high, and there are indications of wide spread of the disease, all unprotected children in the department may be excluded for varying periods even though certain of the classes may not already be infected. It is of fundamental importance in the successful control of measles in the schools that the first case should be recognised and notified to the School Medical Officer within eight days of the date of the patient's last attendance at school. It would be of further assistance if the date on which the measles rash appeared could be furnished with the notification, but under present conditions it is not possible to obtain this information. If the occurrence of the first case is notified sufficiently early, it becomes possible for the School Medical Officer to require the exclusion of susceptible children from school attendance before any child, who may have been infected from the first case, becomes capable of infecting other children. Such an exclusion should be calculated to cover the period from the 10th day to the 16th day from the date when the first sufferer ceased attending school. Those children who were infected with measles by the initial case would manifest symptoms of the disease during this period, and those susceptibles who were not infected might afterwards safely return to school. The complete observance of this procedure would ensure satisfactory control and the disease could be kept in check. The aim should be to control the incidence curve, so that instead of its being very markedly accentuated during comparatively short periods at certain seasons, it should take the form of low waves with the least possible difference in height between the crests and the troughs. The actual curve representing the notifications of measles received by the school medical officer is shown in the middle of the annexed diagram (H.), where the notifications received from the schools have been plotted out week by week during a period of seven years. The excess of cases at certain periods followed by periods of depression is well marked. If reference be made to the lowermost curve, which is a theoretical curve, deduced from the actual mortality figures, it will be seen that the form is much more regular and approximates to the low waves just described. The most noteworthy modification of the true wave of notifications is that produced during the period immediately after 200 Annual Report of the London County Council, 1913. Easter when "scheduling" is in progress. As noted in last year's report there results a depression of the curve of measles notifications during this scheduling time and there is a corresponding rise when normal visitation of absentees is resumed after Whitsuntide. Although the methods of control referred to above, under satisfactory conditions, are effective, it frequently happens that the first case notified is subsequently found to be one of a series of cases of the first crop, so that exclusion, when carried out, is too late to prevent the final group of cases and the exclusion carried out with a view to preventing the first crop from falling in schools becoming abortive. The following requirements are, therefore, essential if the spread of the disease is to be controlled. 1. Immediate and early notification of the first case in the infants' department or class. 2. Accurate knowledge in regard to the measles history of the children in the various classes. 3. Segregation of susceptible children during the period of exclusion. To demonstrate how far it is possible to secure the above conditions an experiment has been carried out during the year in the electoral areas of Bermondsey, Southwark W. and Walworth with the object of obtaining prompt visitation of all children absent from school, and of furnishing the School Medical Officer with immediate notification of the first case in each class. In order to carry out this experiment satisfactorily the co-operation of teachers in infant schools and attendance officers was of great importance, and, in this connection, opportunity is here taken to express appreciation of the assistance given in this way. The special procedure adopted was to classify the infant absentees in two groups comprising:— (1) Infants who were absent from school from Friday afternoon to Tuesday morning inclusive. The head teachers were requested to report particulars of these absentees on a special post-card to the divisional superintendent by noon on Tuesday morning. The absentees were visited on Wednesday. (2) Infants absent from Tuesday afternoon to Friday morning inclusive. These were noted as usual by the attendance officer at his routine visit to the school on Friday morning, and he visited their homes on the Monday to the Wednesday following. Precedence in visitation was given to infant absentees over children in the older departments. Whenever an attendance officer discovered a case of measles full particulars, including the date of rash, were telephoned to the Public Health Department, and the School Medical Officer was thus in a position to take more expeditious and consequently more effective action than would otherwise have been possible. By these means it was hoped to obtain the notification of the existence of measles in all cases within a week of cessation of school attendances. This, if achieved, would constitute a great advance upon the usual practice by which it is possible for a child suffering from measles to be absent for 16 or 17 days before notification takes place. The detailed analysis of the working of the scheme which is given in the following pages covers the period from the beginning of the year to the end of the summer term during which period the bulk of cases occurred, i.e. 694. The number of cases reported during the Michaelmas term, namely, 61, was too small to be of any statistical value. Primarily it will be of interest to set out in tabular form the results of the special moasures adopted to obtain early notification, in so far as their bearing upon the action taken is concerned. The subjoined table shows the uutnbor of cases reported in each of the experimental areas and the number of occasions on which action was taken. The object of presenting the table is threefold, viz., to show : (1) The number of occasions on which it was possible by means of the special procedure to expedite preventive action. (2) In what proportion of cases the attendance officers were able to furnish information in advance of the head teacher of the school. (3) The number of occasions on which it was possible to exclude from school attendance the first crop of cases before they had the opportunity of infecting other children at the school. Electoral area. No. of occasions on which action was taken. No. of occasions on which action was expedited by notification from attendance officer. Notifications recoived. No. of occasions when first crop in classroom was caught. First from attendance officer. First from head teacher. Bermondsey 74 34 124 150 12 Southwark W 70 18 58 182 13 Walworth 46 19 77 103 10 Totals 190 71 259 435 35 694 It will be observed that preventive action either by means of the exclusion of unprotected children or closure of classrooms was taken on 190 occasions, and that in 71 cases, or 37 per cent., of Report of the County Medical Officer—Education. 201 the total number the exclusion was expedited under the operation of the scheme. These results are shown in the table below and compared with a control area comprising five contiguous districts:— Areas. No. of occasions on which action was taken. No. of occasions first crop caught. No. of occasions first crop missed. No. of occasions when no secondary cases occurred in class. Experimental Area. Bermondsey, Southwark W. and Walworth 190 35 or 19% 89 or 46% 66 or 35% Contiguous Area. Rotherhithe Newington W. Lambeth, N. Kennington Camberwell, N. 199 23 or 12% 94 or 47% 82 or 41% It will be noted from the above table that there was a difference of 7 per cent, between the two areas in the percentage of cases in which it was possible to take effective action to prevent measles from spreading. If preventive measures are to be effective information must be obtained within 9 days from the date on which the case of measles was last in attendance at school ; the subjoined table shows the periods which elapsed after the last attendance at school before information of the cases, notified in the experimental area, was received. No of days. Attendance officers. Head Teachers. 1 5 1 2 3 29 3 11 25 4 8 40 5 36 41 6 35 51 7 30 56 8 17 43 9 12 29 10 14 22 11 11 27 12 20 22 13 17 23 14 29 22 Over 14 64 263 Total 312 694 The foregoing analysis shows that in 50 per cent, of the cases reported by attendance officers direct to the Public Health Department the information was obtained within 9 days, and in the case of notification from head teachers 47 per cent, of cases were reported within that period. It must be stated, however, that in a large proportion of instances the children contract measles whilst excluded from school by reason of infection in the home or during absence for other causes, and such cases, of course, cannot be regarded as direct infecting agents at the school. The object of the experiment, in addition to that of securing earlier notification, was to determine, as far as possible, the best methods of controlling the disease upon receipt of information of the cases. Different measures were applied in the three electoral areas comprising the experimental district, as follows — Bermondsey. The customary procedure was followed, viz:— (l.) Exclusion of unprotected children from affected class when the proportion of "susceptibles" is considered sufficiently high to favour spread of the disease. (ii.) Exclusion of unprotected children under 5 years when considered necessary as a protective measure. Southwark, W. If over 20 per cent, unprotected children in department:— (i.) Exclusion of unprotected children from affected classes, (ii.) Exclusion of unprotected children under 5 years throughout the department. If under 20 per cent, unprotected :— Exclusion of unprotected children from classrooms affected. 23610 DD Annual Report of the London County Council, 1913. 202 Walworth. If over 20 per cent, unprotected children in department:— (i.) Exclusion of unprotected from classes affected, (ii.) Exclusion of unprotected under 5 years throughout the department. Closure of all classes attended by children under 5 under 20 per cent, unprotected- Exclusion of unprotected from classes affected (i.) Closure of class affected... (ii.) Exclusion of unprotected from classes containing children under 5 years If measles occurred in classes attended by children over 5 years. If measles occurred in classes attended by children under 5. If measles occurred in classes attended by children over 5 years. If measles occurred in classes attended by children under 5 years. Briefly the effect of the above methods is that in Bermondsey the procedure adopted in general practice was applied ; in Southwark, W., the action taken was of a more stringent character ; and in Walworth more rigid precautions still were put into force, including class closure. The number of cases occurring in the experimental areas during the time the experiment has been in progress is obviously too small to enable any final conclusions to be drawn from the figures and a much longer experience of the measures adopted in these areas would be necessary in order to form an estimate of the value of the experiment when judged on this basis alone. The experiment, even during the limited period dealt with, indicates that it is possible to limit the outbreak to the first crop in a greater proportion of cases by the methods adopted. There is, moreover, no doubt that the experiment has been of material value in so far as it has served to keep the teachers, care committees, attendance officers and others alive to the importance of the subject and furthermore has enabled sanitary inspectors and health visitors to visit the cases at home more promptly. These factors alone can scarcely fail to exert a salutary influence and must have the effect of minimising, if not the actual incidence, the seriousness of the sequelae which are so frequently attendant upon an attack of measles. During the working of the scheme various improvements in the machinery suggested themselves which indicate that it may be possible to secure even better results. Since the summer holidays the number of cases was so small that it has not been possible to test the variations which have been made. It is hoped that by the continuance of the scheme during the year 1914 further light will be thrown upon the subject and that more conclusive results will be obtained. Whooping cough. The number of cases of whooping cough reported as occurring among school children has not hitherto been annually recorded. During 1913, however, a daily return of the number of notified cases of the disease was made, and it was found that throughout the whole year 9,336 cases were reported from the schools. The quarterly distribution of the cases shews that the disease was prevalent during the spring and early summer months. There is no doubt that the incidence of whooping cough is subject to seasonal fluctuations in the same way as other zymotic diseases, and it has been suggested that the rise and fall of measles and whooping cough are apt to occur more or less concomitantly, although in 1913 it will be noted that whooping cough became more prevalent in the second quarter when measles was beginning to decline after a period of activity in the first quarter. Number of cases re ported quarterly. Whooping cough. Measles. First quarter 2,604 7,277 Second quarter 3,794 4,813 Third quarter 1,658 2,445 Fourth quarter 1,280 577 Total 9,336 15,112 The disease is very difficult to control in the schools, and such measures as have been tried by the exclusion of healthy children in the classes affected, or the exclusion of children under five, have not proved of very real assistance from a protective point of view, inasmuch as the disease is infectious some time before the characteristic "whoop" is heard, and consequently innumerable opportunities for the transmission of infection have existed before the sufferers are excluded from school. In view of this difficulty head teachers are required by the regulations to exclude from school during the prevalence of whooping cough all children suffering from bad coughs, irrespective of whether "whooping" is detected. The exclusions for whooping cough cannot as a rule be carried out sufficiently promptly to prevent cases in the early and unrecognised stages of the disease from disseminating infection. Although the precaution has been taken under certain conditions of excluding children under five for protective purposes, it is necessary to undertake such action with discrimination and with due regard to circumstances unconnected with school attendance. Whooping cough has been Compulsorily notifiable in Greenwich and Lambeth during the year, but in spite of removal of the sick to hospital, quarantine of contacts for varying periods and disinfection of premises, the control of whooping cough does not appear to have made any greater progress in these boroughs than in the rest of London. 203 Report of the County Medical Officer—Education. Schools under special observation for infectious disease. The numbers of schools and departments under special observation during the year for diphtheria scarlet fever and measles are shown in the following table:— Disease. Departments. Total numbers of departments. Total numbers of schools. Boys. Girls. Mixed. Infants. Special. Diphtheria 60 93 30 269 2 454 333 Scarlet fever 245 337 97 542 5 1,226 642 Measles 20 41 25 749 3 838 754 The subjoined table shows the number of closures of departments or classrooms and special exclusions of groups of children which were resorted to during the year for the purpose of preventing the spread of infection. Number of occasions on which exclusions or closures were carried out. Scarlet fever. Measles. Whooping cough. Co-existence of diphtheria, scarlet fever and measles. Co-existence of measles and whooping cough. Departments closed 1( for 1 day for purposes of disinfection) 5 1 — — Classrooms closed 4 (lroomfor 1 day only forpurposes of disinfection) 23 1 3 — Exclusion of all children under 5 years of age — 26 69 — 4 Exclusion of all unprotected children under 5 years of age — 46 — — Exclusion of unprotected children from whole of infants' department — 17 — — — Exclusion of unprotected children from individual classes — 2,430 — — — Exclusion by local medical officers of health acting under Article 57 of the Board of Education Code. — — — — — Departments closed 1 3 — — — Exclusion of all children under 5 years of age — 6 — — — Infectious diseases in Poor Law Institutions. Children from 20 poor law institutions attend schools maintained by the Council. Correspondence has taken place with the Guardians with a view to securing co-operation in carrying out the regulations of the Council as to the exclusion of children from school on account of infectious diseases. As a result the superintendents of the Poor Law Homes have been provided with books of notification forms whereon they may report cases of infection to the head teachers of school concerned. In the event of any departure from the Council's regulations respecting the exclusion of children from school being desired, provision is made that a duplicate of the form containing reasons for exceptional treatment shall be forwarded to the School Medical Officer for endorsement. Infectious disease in Industrial Schools and Residential Special Schools. The incidence of infectious disease upon the Council's industrial schools and residential special schools has been comparatively low and, with the exception of an outbreak of scarlet fever at the Home for Little Boys, Clapham Park, which is referred to in detail below, there is no outstanding feature to record. Stringent measures are invariably adopted at these institutions in the matter of isolation or removal of the patient and the quarantine of contacts to limit the spread of disease. Special care is also taken that children are not transferred to an industrial school from the Places of Detention or other institutions whilst incubating or suffering from any disease of an infectious nature. The following table shows the number of cases of the various infectious diseases which have been reported from the institutions. It should be noted that one of the industrial schools, viz., Drury Lane, accommodates only day scholars. The remainder are residential institutions. 23610 PD 2 204 Annual Report of the London County Council, 1913. Institution. Accommodation. Age Scarlet Fever. Measles. Mumps. Chickenpox. Ringworm. Scabies. Impetigo. Infective Conjunctivitis. Trachoma. Industrial Schools. Mayford 180 7-14 — — — 2 — — 1 — — Gisburne House 57 Under 14 I — — — — — — — — Brixton. Hill 84 6-14 — — — — 1 1 — — — Gordon House 70 Under 14 1 1 — — 2 — — — — Home for Little Boys 30 Under 7 12 and 2 officers — — 1 — — — — — Stormont House 30 Under 7 — 1 4 — — — — — — Upton House 150 7-14 — — — — — — — — — Highbury 200 7-14 — — — — — — — — — Drury lane Day 200 5-14 — — — — 1 — — — — Special Schools. Anerlev Deaf (Residential and Day) 60 resident 30 day 13-16 1 (contracted during holidays) — — — — — — 1 — Homerton Deaf (Residential and Day) 45 resident 35 day Usually over 7 1 (day scholar) — — — — — — — — Oak Lodge Deaf (Residential and Day) 38 resident 38 day 13-16 — — — 1 — — — — — Elm Court Blind 40 resident 20 day 13-16 — — — — — — — 11 1 true and 1 suspected case Linden Lodge Blind 30 resident 10 day 13-16 — 1 day scholar — — — — — — — Totals 16 and 2 officers 3 4 4 4 1 1 12 1 true and L suspected case Infectious diseases in places of detention. Outbreak of Scarlet Fever at the Home for Little Boys, Clapham Park, S. W.—This outbreak calls for special comment. It commenced in June, and the general incidence may conveniently be divided into three groups, as follows:— Group I. 8 children attacked between 23rd June and 2nd August and two recurrent cases. Group II. 2 children attacked between 30th September and 5th December. Group III. 2 members of the staff attacked between 14th and 30th December. With regard to Group I. three cases occurred on the same day, viz., 23rd June, and one followed two days later. This outbreak was fully investigated and the conclusion was arrived at that the cases were attributable to two children returned from hospital after having suffered from scarlet fever, and who were presumably still capable of transmitting infection. These two children were sent back to hospital. The remaining four cases in the first group occurred on 5th, 7th and 28th July and 2nd August. Investigations were made but no definite common source of infection could be discovered. In view, however, of the extreme mildness of the cases it is probable that they were infected by other children who may have suffered slight unrecognised attacks at an earlier period of the outbreak. This assumption is strengthened by the experience throughout London during the recent general prevalence, in which the disease has been notable (or the mildness of the great proportion of cases. The two cases comprising Group II occurred on the 30th September and 5th December respectively, and had no connection the one with the other. The source of infection in each of these cases was most probably the Lyham-road L.C.C. school where a number of cases of scarlet fever had occurred. It may be mentioned that in one case (H.S.) the child was sent to Belgrave Hospital on 5th December for a minor operation and that when he left the Home he was apparently well. On arriving at the hospital, however, he was found, upon examination, to have a very faint rash on the body. He was notified forthwith as a case of scarlet fever and removed to the Fever Hospital direct from the hospital. The third group of cases affected two members of the nursing staff. As a result of exhaustive enquiries, it was concluded that in both cases the disease was most probably contracted from outside sources. In view of the class of the population from which the children admitted to the Places of Detention are derived there is necessarily a considerable incidence of infectious diseases at these institutions. Skin and eye diseases, e.g. infective conjunctivitis, impetigo, ringworm, scabies, &c., which are mainly due to neglect and uncleanliness, are of frequent occurrence. It is necessary, therefore, that proper arrangements should be made for effectively isolating cases of infectious disease as they arise, and also for the segregation of all contacts in appropriate groups, if serious disorganisation in the working of the institutions and the spread of infection are to be avoided. In February, 1913, Ponton Road Place of Detention was opened for the accommodation mainly of younger children, the building 205 Report of the County Medical Officer—Education. being well adapted for isolation and quarantine purposes. Camberwell Green Place of Detention was closed as soon as Ponton Road Place of Detention was ready for occupation, and the children accommodated therein were transferred to the new institution. The number of cases 0f infectious disease occurring in the institutions or detected upon admission are given in the subjoined table.:— Institution. Accommodation. Age. Diseases. Diphtheria, Scarlet lever. Measles, Whooping cough. Mumps. Chicken-pox. Ringworm. Scabies. Impetigo. tive Conjunctivitis. Ponton road (opened Feb., 1913) 40 children Under 7 1 8 — 7 2 9 3 1 1 15 pentonville 30 girls 33 boys 11-16 7-11 — — 1 2 1 1 7 11 9 9 Harrow road 51 girls 45 boys 11-16 — — — — — — — 1 — — Camberwell green (closed Feb., 1913) — — — 1 — — — — — 4 Totals 1 8 1 10 3 10 10 13 10 28 It may be mentioned that the occurrence of 8 cases of scarlet fever at Ponton Road was not in the nature of a connected outbreak. They may be classified as follows :— (1) Three cases 2nd, 10th, and 15th April. (2) Three cases 21st, 22nd, and 27th June. These children were removed to hospital although the symptoms were so mild that they would have been overlooked under elementary school conditions. (3) Isolated case detected upon admission 30th August. (4) Isolated case detected upon admission 9th October. Ringworm and Farus. Ringingworm.—The following table gives the statistical returns of ringworm compiled to show the numbers of new cases, cured cases, and those outstanding at the end of each school term. It should be noted that at the end of 1912 there were 2,204 children known to be suffering from ringworm. Terms. New Cases reported. Cured cases. Suffering cases at end of term. No. Treatment by which cures effected. No. Treatment being obtained. Spring Term 1,459 1,195 X-rays Ointments and lotions 40% 2,392 X-rays Ointments and lotions 23% from hospitals, etc. Ointments, etc., from pri- 32% from hospitals, etc. Ointments, etc., from pri- 35% vate doctors Chemists and home reme- 18% vate doctors Chemists and home reme- 25% dies 10% dies No treatment 11% 6% Summer Term 2,230 1,771 X-rays Ointments and lotions 48% 2,752 X-rays Ointments and lotions 25% from hospitals, etc. Ointments, etc., from pri- 28% from hospitals, etc. Ointments, etc., from pri- 36% vate doctors Chemists and home reme- 18% vate doctors Chemists and home reme- 23% dies 6% dies 12% No treatment 4% Michaelmas Term 1,884 2,291 X-rays Ointments and lotions 45% 2,277 X-rays Ointments and lotions 33% from hospitals, etc Ointments, etc., from pri- 30% from hospitals, etc. Ointments, etc., from pri- 36% vate doctors Chemists and home reme- 17% vate doctors Chemists and home reme- 21% dies 8% dies 9% No treatment 1% The cases in which children were lost sight of owing to removals or had passed out of the Council's jurisdiction are not recorded in the above table. On the whole, 5,573 fresh cases were discovered during 1913 as compared with 5,311 during the preceding year. During the year large numbers of specimens of hair have been forwarded by school doctors and school nurses for microscopical examination in the laboratory. The subjoined table sets out the results of these examinations, and for purposes of comparison similar figures for preceding years are also shown. 206 Annual Report of the London County Council, 1913. [##]Year. Specimens submitted. Ringworm found. Favus found. Fungus not found. Insufficient material. 1905-6 988 597 104 257 30 1906-7 1,578 1,094 84 336 64 1907-8 2,175 1,705 25 347 58 1908 (Mar. to Dec.) 2,751 2,212 32 423 47 1909 3,019 2,343 37 568 45 1910 3,116 2,400 4 709 3 1911 2,926 2,165 4 757 — 1912 2,820 1,991 41 721 67 1913 3,464 1,979 57 1,415 13 Ringworm is such a troublesome and chronic complaint in childhood, and produces so much interference with school attendance and with the educational progress of the children that it would be a misfortune if the ultimate results of the speediest method of dealing with the disease proved unsatisfactory. Much improvement has been effected in the methods of application of X-ray treatment during the past two or three years. Most of the cases in which unsatisfactory results have been recorded date from the early days of X-ray treatment. Dr. Helen B. Hanson has reported upon the subsequent condition of the scalp in 120 children, in the schools under her charge, who had been treated by X-rays. She found that in 20 cases there were patches upon the scalp on which the growth of hair was scanty or otherwise unsatisfactory. How far these results are due to the effect of the ringworm itself, and how far to the effects of the treatment it is not always easy to determine. Of Dr. Hansoa's cases 109 had been treated in two institutions. It is possible that further investigation will prove that her experience is exceptional, but her report makes it desirable that an investigation should be made upon a larger scale. Favus.—Inasmuch as favus has recently shown some signs of resuscitation, chiefly in the East End, 49 fresh cases having been discovered or reported during 1913, it will be appropriate to review the characteristics of the disease and its history within recent years. Favus is a parasitic disease of the hair which chiefly affects the scalp, though occasionally it is found on other parts of the body. In London it is almost entirely of foreign importation and chiefly occurs among the alien population in the East End. The disease is caused by a fungus which, in many respects, is similar to that of ringworm. Its effect upon the scalp, however, is much more severe in so far as it is more deeply rooted and consequently more resistant to ordinary treatment. X-ray treatment is the most prompt and effective means of cure. A number of cases were found to exist among the school population of East London in 1904. At that time there were 79 known cases of favus in one small area in the East End of about one square mile in extent and 34 cases outside that area. A detailed inspection of the pupils in 21 schools, situated chiefly in the affected area, resulted in the detection of 51 further cases. The opportunity was thus presented for making a new departure in the method of prevention of the disease by forming a special class or school for children suffering from favus where treatment could be supervised, whilst, at the same time, school work might be carried on. On the 28th February, 1905, the Council agreed to establish a favu3 school, and on 6th June, 1906, the school was opened, with a roll of 61 children, in a temporary building situated in Finch Street, Whitechapel. At first treatment was not included in the scope of the work, but the school was supervised by a medical officer, who arranged for the heads of the children to be cleansed and disinfected daily, and for the Ireatment prescribed by a hospital or private doctor to be effectually carried out. Very little progress was made in actual cures until the Board of Education, in August, 1907, agreed to recognise this school as a " special school" under the Elementary Education (Defective and Epileptic) Act, 1899, as this gave the Council power to carry out treatment of the children. In May, 1908, an X-ray apparatus was installed, and thenceforward the cases were cured with comparative rapidity, as is shown in the subjoined table. Quarter ending. Number admitted. Number left cured. Left for other reason. Returned to ordinary school cured. 1906—June ... 59 September — — — — December 12 — 1 — 1907—March 16 4 4 4 June 13 4 4 4 September 3 1 3 — December 11 12 3 12 1908—March 1 2 1 2 June — 6 — 5 September — 6 — 4 December 4 39 — 30 1909—March 16 11 — 9 June—July 7 38 — 38 142 123 16 108 139 207 Report of the County Medical Officer—Education. By the summer holidays 1909 only three cases remained uncured and the school was closed as a teaching centre. With one exception all the children treated were of alien descent. Only four cases were reported as occurring among school children during each of the two years (1910 and 1911) following the closure of the favus school. During 1912 27 fresh cases have come under observation, and, as stated above 49 fresh cases were reported in 1913. The following table will be of interest as showing the form of treatment obtained in the majority of the cases which have occurred during the past two years:— Treatment by X-rays 16 cases cured, 6 still suffering. Other forms of treatment 20 „ 21 „ „ Not yet receiving treatment — 1 „ „ ' At the end of 1913 28 children were known to be suffering from favus. The duration of the disease in each of the cured cases mentioned in the above table is set out below:—- Months. 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 17-18; 31- 36- 1 5 4 1 2 2 1 1 3 — 5 2 3 2 1 1 1 1 It should be borne in mind in referring to the above table that X-ray treatment in a large proportion of cases is only resorted to after other forms of treatment have been tried without effect. Although the increase in favus may only be apparent and mainly due to the large number of specimens submitted for examination in the Council's laboratory in which the existence of favus has been identified, it is probable that, owing to the difficulty of diagnosis, cases certified in previous years as cured may not have been entirely free from infection, and others may have been certified as suffering from ringworm or other scalp diseases. It is possible that there may be more cases of favus amongst the alien population in the East End of London, not only among children but adults also, than is generally recognised, and it is chiefly through the vigilance of the school doctors and school nurses that the additional cases of favus discovered during 1913 have been reported. The differential diagnosis between ringworm and favus is not an easy one to make, and the importance of laboratory aids to diagnosis is apparent in the discovery of these otherwise unrecognised cases. Of the 76 cases reported during the past two years, no fewer than 63 have been discovered as a result of microscopical examination in the Public Health Department. The school nurses are instructed to give special attention to the early detection of cases in the schools and to submit material for microscopical examination. Cases have, moreover, been brought to light in which it was found that persons had been admitted to this country suffering from the disease. With a view to preventing the further ingress of favus into the country through the Port of London by means of immigrants, the Public Health Department is working in co-operation with the Medical Officer to the Port of London Authority and London Immigration Board. Defective Children. During the year six new schools have been opened—two each for mentally defective, Special physically defective and partially deaf children. One school for mentally defective children and one schools, for physically defective children have been closed. The number of special schools with a total average roll of about 11,500 is— Schools for the mentally defective (M.D.) 92 „ „ „ physically defective (P.D.) 37 „ „ „ deaf (D.) 10 „ „ „partially deaf (hard of hearing) 3 „ „ „ blind (B.) 8 „ „ „ myopic (My.) 3 Admission examinations . The procedure in regard to the special examination of children with a view to the admission to special schools has been modified during the year. Formerly the children were nominated by the head teachers on forms specially prepared for the purpose, and, as it was found that on examina- tion many of the children so nominated were cases of retardation due to remediable defects of the special sense organs, it was considered desirable to arrange for the children to be seen in the first instance by the school doctors. This arrangement has afforded a measure of relief, as children found at the preliminary examinations to be suffering from adenoids and like defects are not summoned with their parents to special centres, with a consequence that much less inconvenience, resistance, and alarm is caused, and that speedier arrangements for treatment can be obtained owing to greater co-operation of the school care committees. The total number of children examined during the year was 7,655. 208 Annual Report of the London County Council, 1913. The following table compares the results of the examinations with those for the previous year:— Sex (1) M.D. (2) M.D. and P.D. (3) P.D. (4) Blind. (5) Blind and M.D. (6) Myope. (7) Deaf. (8) Deaf and M D. (9) Par- tially deaf. (10) Industrial Schools. (11) Ele- mentar y Schools. (12) Imbe cile. (13) Invalids. (14) E pilep tics. (16) Total. (16) Boys 1,097 692 59 - 87 74 2 34 94 1,116 78 588 41 3,962 Girls 852 2 705 66 - 150 74 3 50 19 1,170 68 766 36 3,961 Totals, 1913 1,949 2 1,397 125 - 237 148 5 84 113 2,286 146 1,354 77 7,923* Totals, 1912 2,025 4 1,444 106 1 196 111 4 34 32 2,628 138 1,903 114 8,740* * Some of the hard of hearing and myopes on this table are also included under "Elementary School" or " Invalids," and others were seen on more than one occasion during the year. The following return shows the number of exceptional children recorded in the area of the Council, on the 8th January, 1914, and the categories under which they have been certified at a special examination:— Blind (including partially blind) Attending Public Elementary Schools 267 Attending Certified Schools for the Blind 436 Not at School 35 Deaf and Dumb (including partially deaf) Attending Public Elementary Schools 35 Attending Certified Schools for the Deaf 716 Not at School 7 Mentally Deficient (excluding imbeciles and idiots) Attending Public Elementary Schools 488 Attending Certified Schools for Mentally Defective Children 7,575 Not at School 46 Epileptics Attending Certified Schools for Epileptics 69 Not at School 165 Physically Defective Attending Public Elementary Schools 120 Attending Certified Schools for Physically Defective children 3,674 Not at School 308 Rota visits. visits. The special schools were visited at least once a quarter, and every child present was seen at least once during the year. Whenever possible three days' notice of the intended visit of the medical officer was given to the head teacher, who, in the cases of the mentally defective and physically defective schools, was requested to present for examination all children included in the following categories: — (а) Those who had been admitted to the school during the preceding three months. (b)Those who had not been seen for nine months. (c) Those who were applying for exemption or were approaching the age of 14 years. (d) Those whom it was considered desirable to place before the doctor. (e)Those who had attained the age of ten years nine months since the last visit The total number of medical examinations made during the year was 14,555. The following table compares the recommendations made as regards re-classification in the case of scholars attending the schools for the mentally and physically defective, with the recommendations for the previous year (1912). Sex. Elomen- tary school. Blind and Myope. Deaf and partially deaf. P.D. to M.D. M.D. to P.D. Excluded as Imb. Invalid. Exemption recommended. Not suitable for. Suitable for Elder boys. Elder girls. Elder boys. Elder girls. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) Boys 192 3 10 32 7 40 40 146 112 - 380 - Girls 167 4 5 25 3 33 53 147 - 42 - 188 Totals, 1913 359 7 15 57 10 73 93 293* 112 42 380 188 Totals, 1912 426 6 17 55 17 93 99 187 69 30 361 109 Mental Deficiency Act. *In addition to these cases, 313 special examinations were also made in connection with applications for exemption from further school attendance. In view of the passing of the Mental Deficiency Act, Dr. Shrubsall, assistant medical officer, has collected some information with regard to children in the special schools along the lines of the form suggested by the Chief Medical Officer of the Board of Education. Report of the County Medical Officer—Education. 200 Home conditions of mentally defectives.. So far as home conditions are concerned it appeared that the special schools are in the main recruited from the poorer areas of London, and that in these schools there is a larger proportion with defective or unclean clothing. The maximum proportion of mentally defective to normal children was found in the poorer districts occupied by the older English population displaced by the clearance of a large area in Bethnal Green, into Haggerslon, Iloxton, and East Finsbury, which have for long been noted as very poor. South of the river there is much less defect. The upper map in diagram K, facing page 116, shows the distribution of mentally defective children calculated as a percentage of the children scheduled as mentally defective to the total number of children scheduled on 31st March, 1913, according to educational administrative areas. Family history of mentally defectives. In the annual report for 1912 details were given of the distribution of mental detects among the children in 700 families, on an average l.43 children being defective in a family of average size of 6'05 children. Further inquiries into 1,000 families have shown that in 48'6 per cent, some other member of the family was known to be mentally defective or unstable, and in 26'5 per cent, more than one other member was afflicted. The annexed diagram (I.) traces the origin of some mentally defective children. It will be seen that both families show a history of mental defect, phthisis and alcoholism. Epilepsy, &c.—In 16.5 per cent. there was a family history of epilepsy, the parents being stated as the subjects in 5 per cent., and brothers and sisters in 8 per cent. Alcohol.—The history of alleged alcoholism is probably somewhat untrustworthy owing to local and personal variations of opinion as to what constitutes a noteworthy degree of this condition. It was alluded to in greater or less measure in 26 per cent, of the cases. Insanity.—In 12 per cent, of the cases a grand-parent, parent, uncle or aunt, brother or sister had been in an asylum, and there is reason to think that this record erred on the side of underestimating the prevalence of mental instability. The Asylums Committee desired that an arrangement mignt be made with the Education Committee whereby information concerning heredity in relation to feeble-mindedness might be correlated. The Asylums Committee considered that under such an arrangement it might be possible to ascertain how far insanity in the parents was responsible for the mental deficiency of the children in the schools, and enable a judgment to be formed regarding the tendency of insane parents to beget congenital imbeciles. Prior to the request of the Asylums Committee it had been the practice for them to report to the School Medical Officer the admission to the asylums of children who had been in attendance at special schools, and the School Medicnl Officer thereupon forwarded to that Committee particulars of the children concerned taken from the school medical record cards. This method was not, however, altogether satisfactory, and for a period of three months, afterwards extended to a further period of six months, arrangements were made whereby the Asylums Committee notified the names and addresses of all persons admitted to Asylums who had children of school age. Steps were then taken to ascertain which of such children were in attendance at schools for the mentally defective, and the School Medical Officer thereupon supplied the Asylums Committee with any information regarding such children, many of whom were re-examined specially. The experimental period has not yet terminated, but, up to the present, information has been furnished to the Asylums Committee in regard to 51 children, and where necessary, the teachers have been given instructions to avoid mental stress being placed upon such children. Tuberculcsis.—A history of one or more of the family suffering from consumption was given in 39 per cent, of the cases under review. Personal history of mantally defectives. Constitutional Defects.— Ihe following percentages were recorded:— Marked rickets 13.5 Nystagmus 1.5 Congenital heart disease 1.8 Squint 9.0 Hutchinson's teeth, scars round lips, &c. 2.0 Subnormal vision 220 History of prenatal trouble and of 120 Cataract 0.8 difficult labour. Diseases of Childhood.— Infantile convulsions 23.0 Infantile paralysis 1.5 Fits? epilepsy 7.5 Paraplegia 20 Teething.—In 9 per cent. of cases the appearance of the teeth of the 1st dentition is recorded as being late, but in many instances the mothers state frankly that they cannot remember when the child cut its teeth. There is usually a better history to be obtained in this respect in the case of 1st or of only children. Walking and Speech.—This was fully investigated in 1912, and the few additional observations tabulated have not materially affected the results. Age. Percentage who were said to walk. Percentage who were said to talk. 1 24.5 240 2 75.0 70.0 3 91.0 85.0 4 97.5 93.5 5 99.5 99 0 210 Annual Report of the London County Council, 1913. Physical conditions. Speech—Articulatory Defects.—A considerable number of defects of speech have been noted in connection with the examination of children in the special (M.D.) schools. These are in some measure associated with the greater frequency of nasal obstruction and slight deafness among these children, but are often an expression of a retarded development. The delayed onset of speech recorded above persists, and is even accentuated, with growth. Errors of refraction are common among special school children, who present greater difficulties than the normal with regard to treatment. The parents are often careless with regard to securing treatment, and when this has been obtained the children themselves are found to lose or break their glasses with greater frequency than children in the ordinary elementary schools. The fit and condition of spectacles worn by children in the special (M.D.) schools have been investigated by Dr. A. C. Williams, who finds defects are more common than in the ordinary elementary schools. The special schools children are particularly liable to lose or ill-use tbeir spectacles, and they are returned more seldom to the hospital whence the lenses were ordered in order that the fit might be tested. The conditions merit attention, since the treatment of visual defects and, notably, of cases in which squint or eye-strain is present, loses much of its value if the lenses are not properly centred. Out of 42 cases in which spectacles had been supplied the fit was good in 14, not quite perfect without padding in 9. Glasses were seriously ill-fitting in 5 ; broken, bent or otherwise damaged in 12, and lost or rarely worn in 2. The causes of the defective conditions are:— (1) Initial inaccurate fitting. This was much more frequent when the spectacles were sent by post than when they were supplied locally. Of those supplied locally, 83 per cent, were good, 17 per cent, fair and none bad; while of those sent by post, 25 per cent, were good, 35 per cent, fair, and 40 per cent. bad. This failure of the postal method of supply was illustrated in the series investigated in the ordinary schools in 1912, in which 56 per cent, of spectacles thus forwarded were found to be ill-fitting. (2) The weakness of the frames of the spectacles, bending nearly always taking place at the junction of the bridge. (3) Ill-treatment of the glasses by the children. Serious ill-usage was noted in 30 per cent, of the cases, quite apart from minor scratches and general dirtiness. All but five of the 62 children had snectacle cases. the 62 children had spectacle cases. • Dr. Williams suggests that an arrangement, whereby the children can be supplied locally instead of by post, is greatly to be preferred. No glasses can be considered suitable unless actually fitted to the child who wears them ; further, in case of discomfort or small injury, the necessary alteration can be made promptly and at trifling cost. Neglect and ill-use of spectacles is so common that some form of supervision is needed. In some schools the teachers pay special attention to the spectaclcs, and may even keep them at the school to avoid loss, but this procedure cannot be adopted in cases in which constant use is essential. Nasal obstruction.—Conditions of the nose and throat have long been recognised as leading to conditions which closely simulate mental deficiency. Indeed, since their action is mainly by means of partial deafness the sufferers may be regarded as temporarily defective through physical disabilities or sensory deprivation. In this connection Dr. A. C. Williams has devoted special attention to ascertaining the relative frequency of nasal obstruction in the ordinary elementary and the special (M.D.) schools. The proportions among children of the age group 11-12 reported during the snrinar of 1913 were:— Special (M.D.) Ordinary elementary schools. schools. Enlarged tonsils 13.9 10.6 Adenoids 10.5 4.7 Tonsils and adenoids in need of treatment... 8.6 5.8 Other diseases of the nose reported 9.3 3.6 Other diseases of the nose in need of treatment 1.4 0.6 All varieties of nasal disease and obstruction 19.8 8.3 Besides these, there are cases of habitual mouth-breathing without nasal obstruction Insufficient nasal breathing has long been recognised as an accompaniment of many forms of mental deficiency, and associated with a high palate, small naso-pharynx and a conspicuous lack of nasal hygiene. Under these circumstances, a relatively smaller amount of adenoid growth might give rise to symptoms requiring operative relief. The proportion of cases referred for operation from different types of schools is—Special school children, 8.6per cent; ordinary school children, 5.8 per cent.; junior county scholars, 35 per cent. Dr. Williams has noted the children's mental condition before and after the operation in 57 cases in mentally defective schools, and finds—A real improvement in brightness and power of concentration in 7 ; a slight improvement, not certainly attributable to the effect of the operation, in 8 ; no change whatever, beyond the ordinary progress with advancing age noted in the special as in other schools, in 42. The improvement was probably to be attributed to improved hearing, though such improvement was only noted in a few instances. The results tend to show that the children examined had not been examples of spurious deficiency due to adenoids and partial deafness. Lack of control.—Examples of lack of control of spinal reflexes, or of precipitancy of demand for natural relief, have been met with among a certain number of low grade mentally defectives, some of whom have been classed as imbeciles, and others invalided for a time from school attendance for the purpose of securing treatment. 211 Report of the County Medical Officer—Education. These cases will again come up for review in the light, of the Mental Deficiency Act, 1913. Conditions of incontinence and the like are also met with in the difficult group of cases which are both physically and mentally defective. Examples of this are found among the sufferers from spastic paraplegia and some severe cases of hemiplegia. The mental condition of these children may for long remain at a low level or even deteriorate so that they are unable to make reasonable use of the educational measures available in schoolsfor the physically defective, while as a result of their paralysis it is difficult to convey them to schools for the mentally defective. A certain number are so conveyed by ambulances attached to physically defective schools, but it is found that many children require the attention of a nurse, during school hours and the midday recess, since owing to their physical disabilities they are unable to attend to themselves. In many instances it is necessary that their wants should receive immediate attention and this attention cannot always be given by the class teacher, while in the intervals there may be no one available. The teachers can scarcely be expected to undertake responsibility for these cases, some of which have to be invalided as unfit for school attendance. Though advantage would no doubt be taken of any provision of school accommodation for children with both mental and physical defects the return to be expected would be of a low order since the history of many if not the majority of cases is one of ultimate deterioration. Many of such children for whom inadequate home care is available are likely to be subject to be dealt with under the Mental Deficiency Act, though the difficulty of finding suitable institutions ill which they may be placed may not cease for some time to come. In 2,000 cases lack of control of reflexes was recorded 26 times and dribbling- 23 times. Stigmata.—Provrsion is made in the medical record card in use at special schools for records of any stigmata. In the report for 1912 a series of results were recorded, the extraction of notes has been continued and the following percentage frequencies have been derived:— Cretinoid development 1.1 Low forehead 2.3 General retardation 5.6 Narrow forehead 3.0 Microcephaly 2.2 Depressed bridge of nose 1.2 Hydrocephaly 1.5 Broad base to nose 11.0 Cranial asymmetry— Prominent teeth 6.1 In marked degree 5.2 Hutchinson's teeth 1.6 In minor degree 23.0 Epicanthic fold 5.5 Maximum evidence of rickets 7 0 Mongolism 1.7 „ circumference of head under ] 9 inches 68 High arched palate 12.6 „ „ „ 20 inches 362 Narrow palate 9.8 „ „ over 22 inches 12 Cleft palate 1.2 Bossed forehead 5.1 Webbed fingers 0.1 Head Dimensions.—The average maximum horizontal circumference in millimetres from 500 cases was found to be:— Age. Circumference in millimetres. Age. Circumference in millimetres. Age. Circumference in millimetres. 6 495 9 506 12 517 7 506 10 515 13 608 8 508 11 510 14 508 Mental conditions. Reaction of motor mechanism.--Formation and storage of motor ideas. No child in the special M.D. schools at the time of examination failed to imitate a simple movement such as bending the fingers or standing on tip-toe, or to carry out single simple commands as " Sit down." Over 90 per cent, could carry out a familiar but more complex movement such as response to the command hips firm, heels raise, knees bend, showing a considerable power of motor control and concentration. Over 80 per cent., however, assumed a slack standing posture while in over 20 per cent, the position of arms, hands, and fingers when in horizontal extension is described as being of nervous poise. In 2 5 per cent, tremors were noticed, 4.9 per cent, showed marked over-action of the facial muscles, while twitching is recorded in 12 per cent, and a vacant expression in 8 per cent. There was a history of infantile convulsions in 19 per cent., and suggestions of minor epilepsy in 9 per cent. Reactions resulting from sensory stimulation of attention —All the children tested responded naturally to simple tests; thus their eyes followed an object, they grasped an object proffered them or picked one up to command. All matched wools coloured red, green, blue, or yellow, though all did not recognise these colours by name. Two children out of 170 tested failed to pick out the largest box of a series. On testing with a form board the great majority were able to replace them with simpler outlines. Tested by replacing triangular tablets, two of which were taken out of the box, the proportions of successes were : Age. Succeeding. Age. Succeeding. 8 75 11 92 9 80 12 100 10 88 13 100 The formation of memory images, the association of ideas, powers of judgment and estimating relationship were tested by asking the children to name real objects shown them, such as a knife, a key, or a penny; to point to named objects in a picture or to name the objects depicted, to state which of two lines was the longer, to compare similar boxes weighted to 6 and 12, 3 and 9 grams respectively, to arrange five weighted full boxes in order of weight. They were also asked to repeat three or more numerals, to define a simple object such as a cat, and to distinguish by memory between wood and glass, a cat and a rabbit, or flannel and cotton. Finally a problem question 23610 EE 2 Annual Report of the London County Council, 1913. 212 such as, "What would you do if it was raining when you start to come to school?" The following results were obtained:— Age last birthday Numoer succeeding. 9 10 11 12 13 14 15 Number tested 20 20 20 30 30 30 20 Recognised real objects by name... 20 20 20 30 30 30 20 Recognised objects in picture 18 19 18 30 30 30 20 Named objects pointed to in picture 18 19 19 29 30 30 20 Compared lengths of lines 18 19 20 30 30 30 20 Compared two weights 8 11 9 17 19 22 15 Arranged five weights in order with only one error 2 5 8 15 17 21 13 Definition of object. By use 8 10 15 18 21 18 9 By other features 1 - 3 10 9 12 11 Contrasted familiar objects from memory 4 4 7 16 19 25 17 Auditory memory for— 3 numerals 18 20 20 30 30 30 20 4 numerals 17 19 20 28 29 29 20 5 numerals 9 11 11 19 22 21 18 6 numerals 2 2 4 10 12 11 9 Auditory memory for sentences 6 syllables 20 20 20 30 30 30 20 11 syllables 15 16 16 26 27 28 18 18 syllables 9 10 11 18 21 20 16 Replies to problem questions 5 7 6 14 17 18 14 Emotional Conditions.—The notes on these have been expressed in a terminology not easy to sum up. As a general rule the younger children show considerable lack of interest, are distinctly self-centred, and any acts of aggression are usually directed from motives of personal acquisition. The manual training in the elder boys' schools has a marked effect on the volitional spontaneity. Many boys can reallv date their progress from the commencement of constructive work, the advantages of even a slight knowledge of some trade process unfamiliar to some of their normal companions raises their self-respect, and is the first and most powerful incentive to self-effort. About a quarter of the cases seen at admission examination present marked negativism which it requires much effort and coaxing to overcome. Tests of intelligence.—Description of pictures, objects, &c. The results were classified according to the type of response. For example, taking the picture most commonly used, Simple Simon fishing in a bucket with his mother and a cat looking on, the simplest type of response would be simply "boy" or "cat." A more advanced type is boy, cat, hens, lady, &c. Then "boy fishing" " a boy fishing in a pail,"and" a boy trying to fish or pretending to fish in a pail, his mother is laughing at him." The type progresses with age, though the simpler forms persist, the chances of obtaining good numbers of the higher type are kept down by the fact that children who respond well are sent back on trial to the ordinary elementary schools. » Age last birthday 9 10 11 12 13 14 15 One name per picture 5 3 1 1 — — 2 Enumeration of objects 3 4 3 7 5 3 4 Descriptive enumeration 4 3 4 6 5 6 6 Descriptive sentence 6 9 9 11 15 18 5 Interpretation by sentences 2 1 3 5 5 3 3 Reading capacity is recorded in terms of the size of the word read, the type of reading employed, and how far the written matter is comprehended as tested by the response to certain written commands, "Sit down," "Pick up a pen," "Count your fingers," and one involving a calculation such as "If you had a shilling and spent fourpence write down how much you would have left." The results obtained were:— Age last birthday 9 10 11 12 13 14 15 Extent of reading. Letters 8 4 1 — — — — 2-3 letter words 11 14 9 11 6 3 3 Infants' primer 1 2 8 7 10 11 7 Standard I reader. — — 2 8 9 11 6 Standard II. upwards — — — 4 5 5 4 Type of reading Letters or sounds of letters 19 17 10 12 5 4 3 Hesitant or jerky, syllable by syllable 1 3 6 14 17 19 11 Straightforward — — 4 4 8 7 6 Successful response to written command. Motor 1 6 8 11 18 21 18 Arithmetical — — 1 2 7 9 8 213 Report of the County Medical Officer—Education. A response to the arithmetical question has been called successful if any number of pennies was written down irrespective of the correctness of the answer. The children were also tested as to their power of building up a sentence or sentences to include three given words. The types of response may be a complete failure, only one or two of the words being used. Three sentences may be required, as "A cat drinks milk," "a dog catches rats," "a horse has a tail." Two sentences may be used as "a cat drinks milk," "a dog has a tail," or one only as " the dog bit the cat's tail." The nature of the response in 170 cases was:— Age last birthday 9 10 11 12 13 14 15 Fail altogether 7 5 3 1 - - Three sentences required 11 10 8 5 5 1 - Two sentences required 2 5 9 20 18 17 12 One sentence required - - - 4 7 12 8 Calculation.—All the children were able to count to four, and nearly all to 13. Counting up be value of four or five coins, none above one shilling. Age last birthday 9 10 11 12 13 14 15 Correct 6 9 8 17 21 22 16 Incorrect 14 11 12 13 9 8 4 Writing is tested by transcription, dictation, and spontaneous writing, It is very rare for a accurate result so far as spelling is concerned to be obtained in the two latter. The results fror the 170 cases investigated on this occasion have not bsen collected, but on a previous occasion i writing to dictation the sentences " the cat was on the mat" and " two dogs saw a cat on the wall, the results were:— Age last birthday 9 10 11 12 13 14 15 Correct - - 1 6 7 7 6 Spelling errors 12 16 9 20 44 28 16 Practically no response 2 3 3 1 - - - During the performance of such tests as the above, will power can be fairly judged, a long task is useful to test perseverance. So far as the moral character is concerned evidence has usually to be obtained from the teachers, but it appears that many children described as immoral or unfitted to be with other children are those who are merely not amenable to discipline or who repeat in school expressions which are in constant use in the home ; there are others who have irregular outbreaks of rage of an almost hysterical character. Sympathetically but firmly handled in elementary schools these feelings are gradually controlled. In connection with the industrial schools a few cases of actions of a criminal nature are to be met with, but are by no means always performed by those who are mentally defective from an educational standpoint. In view of the importance of the sense of hearing in the education of a child, special attention is devoted to an investigation of all defects. Children noted by the teachers as partially deaf are examined at the schools or at special centres by the school doctors, and all cases in which there is marked impairment of hearing are referred for special investigation by Mr. Yearsley (the Council's otologist). A certain number of cases have also been referred from treatment centres, and this closer linking up of the treatment centre, and the examination by the special officers of the Council, is a satisfactory feature of the year's progress. In his examinations at the Head Office Mr. Yearsley has seen 402 cases, with regard to which the following decisions were arrived at:— Classes for the deaf and partially deaf. Fit for elementary school 47 Do. (front row) 96 Fit for hard of hearing class 83 Do. deaf school 138 Do. mentally defective school 20 Imbecile 3 *Physically defective 7 Invalid 4 Exempt 4 402 * Mostly cases of cleft palate requiring lessons in articulation. In addition to these inspections at the Head Office, Mr. Yearsley visits the day and residential schools for the deaf and partially deaf at frequent intervals. Every scholar in each school is seen during the first quarter of the year; at subsequent visits all newcomers who were absent at the former inspection are re-examined, and at every visit the otologist examines specially all scholars in regard to whom the teachers require advice. 214 Annual Report of the London County Council,1913. During the year additional classes for partially deaf children have been established at Hearnville-road, Balham, and Stanley-street, Deptford. These centres will provide for 87 children, and the classes are organised so as to arrange for separate instruction for children between the ages of 7 and 10, 10 and 11, and 11 and 14. None of the children in these classes can hear the ordinary voice at a greater distance than six feet. Only a few can hear a whispered voice even at so short a distance as two feet, and it is to be noted that the auditory acuity varies very considerably from day to day. Of 63 partially deaf children investigated, the defects were due, in each case, to middle-ear disease ; in 37 of these the disease was of a suppurative character and in 26 catarrhal. Of the suppurative cases, 5 had followed measles and 6 scarlet fever. One of the catarrhal cases was also traced to measles. Further extensions of the classes for the partially deaf are under consideration, and as the present classes are situated on the southern side of the county, it is desirable that any additional classes should be established in the north and north-east. In connection with these extensions it is proposed to remove the class for the partially deaf from the Ackmar-road (Deaf) School in order to avoid any contact between partially and totally deaf children, since this association has been found to act prejudicially to the interests of those with the least degree of defect. The result of the classes has been satisfactory, and their success is due, in a large measure, to the efforts of the teachers, who had more than ordinary difficulties to contend with in the experimental stages of the classes. Advice to parents with deaf children. stages of the classes. The success of the education given to deaf children depends in a great measure upon the action of the parents in the home and with the view of securing their co-operation the following pamphlet was prepared. This pamphlet is circulated to the parents and guardians who bring children to the head office for examination, and arrangements have been made whereby copies of the pamphlet are forwarded to the teachers of the deaf day schools for distribution, if and when necessary. Advice to Parents with Deaf Children.—Your child has been examined and found to be deaf to such extent as to require special education at a school for the deaf, and he (she) will be admitted to one as soon as possible. If you will read the following advice and endeavour to carry it out you will materially help in your child's education and assist the teachers to achieve success. Management of a Deaf Child before School Life.—In order to profit fully by the education given at school, it is of the utmost importance that a deaf child should be properly trained at home. A deaf child should neither be petted nor spoiled, nor severely treated, but should be taught from the earliest age— To keep clean and tidy. To obey cheerfully. To help in the household. To take care of toys. To have a proper respect for the property and feelings of others. And generally to behave nicely. "As your child will be taught to speak you can do a great deal to prepare for this education by the following means ;— 1. Teach the child to look at you when you speak, and thus to understand a great deal of what you say. A knowledge and power of using many words can be acquired if you say the name of anything, such as bread, milk, a toy, etc., and see that the name is repeated before you give the article to the child. Do not make signs, but talk to the child all the time. 2. Teach the child to write and to dra.v on slate or paper, first letters a, b, c, etc., then the child's name, the names of brothers and sisters, and the names of common objects, such as " cat," " ball," "doll," etc., showing the object named. 3. If the child can hear a little, or has heard, it is still more necessary to talk constantly to the child, who, if able to speak, must be made to continue to speak and to ask for everything desired. If this is not done the child will lose speech. " Management of a Deaf Child during School Life.—You can be of great assistance to the teachers by taking an interest in the lessons, by teaching the child the names of things and people at home, by talking to the child, by discouraging the making of signs, and by encouraging the use of the spoken language as much as possible. " It is of great importance that attendance at school should be very regular if the full advantages of the education given is to be gained. Teaching a deaf child is more difficult than teaching one that hears, and requires constant attention and effort on the part of both teacher and child. " Occasional absences break into this constant attention and may undo much of the work being done, and so really harm the child. " Parents are strongly advised to see the teacher frequently to consult on the child's progress, and to assist in the education by every means in their power." Physically defective children. Owing to the increase in the number of physically detective children, a survey of the accommodation is now being made. Reports on accommodation for these children involve two factors, the actual change of numbers, and the type of child admitted to the physically defective schools. Since the passing of the Elementary Education (Defective and Epileptic Children)Act, 1899, the number of children noted as defective has shown considerable increase, but the percentage of the total number examined who were found to be physically defective has only varied from 15.5 to 18.2, except in the years 1909 and 1910, when the percentages were 13.6 and 13.9 respectively. The increase was to be expected, as the extension of medical inspection inevitably brings to light cases which, in the absence of such inspection, may be overlooked. The schools for physically defective children were at one time viewed with suspicion, and the uarents received in general terms advice from medical practitioners not to send the children to school. 215 Report of the County Medical Officer—Education. The schools are now better known, and the value of the work undertaken therein is realised, so that there is a far greater readiness on the part of medical men and women to advise the sending of children to such schools instead of giving certificates recommending absence from school. Coincident with this change there has been far less resistance on the part of the parents to the attendance of their children at special schools, particularly during the earlier years of school life. Every school child has been seen at least once as a result of the more detailed examination undertaken since 1909, so that there should be no large reserve of uninspected children to draw upon, and it may be anticipated that the number of defective children will now be subject only to seasonal variations, and the increases hitherto noted are not likely to continue so long as the present conditions and regulations exist. The condition of admission to these schools has at all times been that the children are, by reason of physical defect, incapable of receiving proper benefit from the instruction in an ordinary public elementary school, but not incapable, by reason of such defect, of receiving benefit from instruction in a certified special class or school. The standard regarded as qualifying for admission has not varied, but the opposition of outside medical practitioners to the admission of defective children to special schools has very largely disappeared. Formerly cases of tubercular joints, which had to remain for long periods in constrained apparatus, although able to get about to some extent, were naturally allowed to attend school from the start. In cases of heart disease, chorea, and similar chronic affections liable from time to time to acute exacerbations, a period had to elapse before public opinion had been sufficiently educated to allow confidence to be reposed in the new school conditions, but in due course children were admitted who formerly received no education. The actual changes in the percentage distribution in the years 1907, 1908, and 1912, during which the medical details were collected on a uniform basis, were as follows— Defect. 1907 Percentage. 1908 1912 Tuberculous disease 45.6 40.3 33.3 Heart disease 11.4 12.5 18.3 Paralysis 17.8 18.6 21.6 Chronic disease (chorea, epilepsy, phthisis) 5.1 6.6 7.7 Various deformities (rickets, septic, congenital) 13.0 15.6 15.9 Other defects (eyes, ears, tracheotomy,etc.) 1.6 1.0 1.0 Delicate, convalescent, and children kept under observation ... 5.3 5.3 2.4 The above comparison shows that the chief decrease has been in cases of tubercular disease, with regard to which it is probable that a more uniform level has now been reached. There has been some increase in the number of cases crippled by paralysis or deformity, and a material decrease in the numbers of children who were delicate, convalescent from acute illness or operation, or admitted to the physically defective school temporarily for observation. The chief increase has been in the case of heart disease. As pointed out in the annual report for 1912, these cases fall into two categories. The first class includes the important group of children who have no organic valvular lesion, but whose heart muscle has been weakened temporarily as a result of some acute illness, usually of an infectious nature, such as scarlet fever or diphtheria. After severe attacks of such illnesses, convalescence is protracted and sudden violent exertion may be attended with serious danger to health or even to life, and it is necessary that the re-establishment of school routine should be slow. Many physicians are inclined to disallow school attendance at an ordinary school, where the children would be exposed to the exertion of games and stair-climbing, and the value of the special schools is now generally recognised by the medical staff of hospitals, who, from time to time, suggest that certain children, though unfit for the ordinary school, might be admitted to a school for the physically defective. In many cases these children, who constitute a small minority of the total heart cases in the special schools, are able to return to the ordinary schools after a time ; but the return thereto depends on the age at which they are admitted to the special schools. The second class consists of children suffering from definite organic, usually valvular, lesions of the heart. This group must be sub-divided into two groups, those with congenital lesions and those in whom the lesion has been acquired as a sequel to some serious illness, such as chorea, rheumatic or scarlet fever. In some cases it is impossible to stats with certainty the category in which a given child should be placed. The ultimate prognosis in congenital cases is unfavourable, but a considerable proportion of the children survive for many years after the school period, and the education they receive not only adds to their happiness, but often enables them to contribute in some measure to their own support by means of various light home occupations. Cases of acquired heart disease were found to constitute 86 per cent, of those of an organic nature, the chief cause being a preceding attack of rheumatism or chorea. In connection with these cases, two factors are of paramount importance—the prevention of fresh attacks of rheumatism and chorea which would be accompanied by further damage to the heart, and the physical education of the damaged heart muscle to enable it to overcome the mechanical difficulties associated with injured heart valves. The risk of recurrence of rheumatism and chorea can be appraised only in general terms. The more remote the original attack the less likely a recurrence, and the younger the child at the date of the first attack the more likely is it to be subject to recurrences. Exposure to damp predisposes to 216 Annual Report of the London County Council, 1913. rheumatism, while long hours of ordinary school subjects have been found to encourage chorea. Hence it is that the travelling to school in an ambulance and the spending of half the day in manual occupations have a preventive function. A case in which the rheumatic condition has once returned is much more unfavourable than one in which there has been a single attack only, so that care is desirable for a long period after the original attack, in order to avoid such an untoward event. The prospects of health for a rheumatic subject with a damaged heart turn largely upon the choice of occupation, for exposure and strain may lead to the early ending of a life which in sheltered and sedentary surroundings might well have attained the average expectancy. Cases are on record in which advice as to occupation on leaving school has been neglected, and the subject has died within a short period ; while others, instead of being able to earn a partial living, have been converted into confirmed invalids. An investigation into the prospects of children in the schools showed that nearly half had a reasonable chance of looking forward to a normal existence if they were able to take ordinary care. A study of the causes of prolonged absence of children from school shows that heart disease is responsible for about 10 per cent., and the increase in the numbers attending is largely due to the more general realisation of the advantages of the invalid schools, so that children no attend who at one time were kept away under medical certificate, which could not have been contested successfully in court. The children suffering from heart disease deemed suitnble for the physically defective schools are those in whom compensation has been but recently established or in whom there is a risk of recurrent attacks of illness leading to further damage. Fully compensated cases with no recent rheumatic history who are able to continue their ordinary occupations are not deemed suitable for admission. A study of 1,234 cases who had been in the physically defective schools at some period during the years 1908—1912 showed the following results.— Still in physically defective school 507 Elementary school 136 Mentally defective school 13 Private, secondar)', and other schools 12 At work 201 Left at 16—unfit for much work 61 Invalided 81 Died 93 Lost sight of—ailing at last note 30 Lost sight of—fair condition at last note 60 Left London 40 1,234 It is probable that the majority of those who were lost sight of subsequent to being invalided have died. There has thus been a fatality rate of between 8 and 15 per cent, in five years, but, on the other hand, 30 per cent, have been able to return to the ordinary schools or to proceed to productive employment. The results obtained from the treatment of cases of heart disease are fully as great as in those of any other crippling lesion. The first medical inspection of all children in the ordinary schoole has now been completed, and it is probable that there will be little fluctuation in the natural groups, and the types of disease represented are likely to have reached the constant level. The lower map included in diagram K. shows the distribution of physically defective children expressed as a percentage of children on the roll in each educational administrative area. Correction has been made for residential institutions. Special Schools for physically defective children who are over 12 years of age. A considerable amount of attention has been given to the question of making provision for boys who are physically defective and over 12 years of age and great difficulty has been found in dealing with the matter. Those children who are invalids (heart cases), and who will, to a great extent, be incapacitated in later life should be permitted to remain in an ordinary physically defective school. Of those who need further educational treatment it is possible that some may be able to travel to handicraft centres and receive manual instruction thereat, but these cases would benefit most by treatment in residential schools. The latter would perhaps be the most economical and best done by extending a system of scholarships available to such institutions as Chailey. These measures would cover the whole range, but considerable elasticity should be allowed so as to include the difficult cases. Physical exercises for physically defective children. Organised physical exercises are desirable for nearly all children ; a few are unsuitable for exercises of any type. The latter class comprises recumbent cases, children in plaster or Thomas splints and those with severe types of heart disease. In such cases a note to the effect that the children are unfitted for physical exercises is made on the medical record card to which teachers can and do refer; these decisions are revised by the doctor at bis visits to the schools. With these exceptions, all children in the physically defective schools can do breathing exercises and simple free arm movements. A few of the children could carry out the whole course of physical exercises given in the Board of Education's syllabus, but there are others suffering from paralysis or joint disease who would be unable to perform the movements of trunk or limbs. Were the complete syllabus adopted the differentiation involved would be complicated and difficult to fit in with the school organisation. It would, therefore, seem most advisable that in each 217 Report of the County Medical Officer—Education. school a definite time should be fixed for physical exercises at a period when all the children will be present; that certain children designated by the doctor should be excluded from all forms of exercises ; that for the rest a short period of 10 minutes a day should be devoted to physical education, but that the syllabus should be limited to breathing exercises and free arm movements. Kindergarten games form a suitable type of recreation for many children but do not replace organised exercises; where such games are utilised for the purpose of recreation it is essential to exclude all children concerning whom it has been noted by the doctor that physical exercises are not to be carried out since there would be risk of iniury to the child or to any remedial apparatus worn. • Scout - training for physically ' defective . children. During the year proposals were made to extend a system of scout training to boys in attendance at the physically defective schools, a very modified form of scouting being adopted, on account of the physical disabilities of the children- It was found, upon enquiry, that any boy who was in attendance at a physically defective school could join the troop of physically defective scouts, which had already been formed, and that the members included a boy with severe spinal caries, one with tuberculous disease of the hip, using crutches, and three with severe heart disease. None of these were really fit to go to the scout meetings, or to do even the modified work and games there carried out. If such scout instruction were to be extended, it would be necessary to select the boys after medical examination, and to carry on the work under medical supervision. Scouting would then become practically a special extension of school work, and would lose most of its special features and therefore of its value, It is very doubtful if any scouting for physically defective children could be carried on with real benefit to the boys. Effects of venereal disease upon children. witn real oenenc to tne ooys. Mr. Bishop Harman. the ophthalmologist to the Council's special schools for the blind and deaf, has devoted special attention to the effect of venereal disease upon the children, and the extent to which these effects are found amongst the elementary school population of London. He has obtained statistics from three sources:—the examination of the children attending the Council's blind schools ; the examination of groups of children attending the ordinary elementary schools ; the examination of the case naners of elementarv school children attending- one of the treatment centres. Blind and partially blind children. All the children admitted to either the special day or residential schools established under the Elementary Education Blind and Deaf Children Act, 1893, are examined by Mr. Harman. The state of their case is recorded, the cause of the blindness is ascertained, either by the clinical evidence of the case, or by additional enquiry from the parents or guardians of the child, or by enquiry directed to the hospital authority under whose care the child has been at any time. Most of these children are examined on a number of occasions. The Council's day blind schools are visited every six months whilst the residential schools are visited every three months, and a report is made on the state of each child, particularly as regards its suitability or not for continuing to be a pupil at that school, a determination which rests mainly on the state of the eyes. There is no part of the body where the effects of venereal disease inherited or contracted by the children from their parents are so distinctive and so permanent as in the eye. When therefore the distinctive features are found in the eyes of children, and there is confirmatory evidence from symptoms in other organs of the body, or when there is definite historical evidence dating the onset of a particular attack of inflammation, the value of these statistics becomes considerable. The total number of blind and partially blind children included this enquiry is 1,100. The causes responsible for their state of blindness are as follows:— Cause of blindness. Number of cases. Gonorrhoea. Syphilis certain. Syphilis probable. Injury or destruction of the cornea consequent on surface inflammations. Ophthalmia neonatorum 266 266 — — Purulent conjunctivitis of later years 47 2 — — Phlyctenular keratitis 38 — — — Inflammation within the eyeball or optic nerve. Interstitial keratitis 211 — 191 13 Iritis without other inflammation 6 — 6 Optic atrophy with or without disseminated choroiditis 222 — 125 13 Buphthalmia 17 — 5 2 Sympathetic ophthalmia 16 — — — Macular defects 23 — 2 Retinitis pigmentosa 21 — — 1 Congenital defects of the eyes. Albinism 25 — 2 — Cataract 142 — 14 — Other congenital defects 66 —— — — Totals 1,100 268 343 31 Amongst the confirmatory signs of inherited syphilis "bad family history." has been placed. Bad family In the following table Mr. Harman has given the histories as regards reproduction of 150 families, history, with 1,001 pregnancies. In each of these families one or more of the children presented definite signs of inherited syphilis. 23610 FF 218 [8 Annual Report of the London County Council, 1913. Pregnancies or each mother. Families. " Healthy " children. Miscarriages. Stillborn. Infant-deaths. Diseased. (1) (2) (3) (4) (5) (6) (V 18 1 10 — — 7 1 17 1 6 2 7 1 1 16 1 1 — — 14 1 15 1 6 2 1 5 1 14 3 11 5 7 13 6 13 5 17 4 10 26 8 12 4 21 6 7 11 3 11 10 50 8 6 33 13 10 7 32 8 3 18 9 9 10 33 11 7 22 17 8 16 54 24 7 17 27 7 15 50 9 4 18 24 6 14 24 3 8 14 25 5 11 23 3 6 6 17 4 17 22 4 5 19 18 3 13 16 2 1 3 17 2 10 4 1 1 3 11 1 11 — — — — 11 1,001 150 390 92 80 229 210 Column (3), "healthy" children, includes all those reported healthy by their parents or guardians, and it also includes those who died from accidental causes and febrile conditions in the years from three and onward where there was no reason to conclude the disorder was directly connected with the syphilitic diathesis or consequent defective vitality. In the 11 families where one child only was born to the mother there are included three or four illegitimate unions and the progeny therefrom. To obtain some standard against which the foregoing returns of family history may be compared Mr. Harman enquired into the family history of a number of women who were attending the West London Hospital. This hospital has a very large clientele amongst the poorest and most deserving of charity of the patients attending any of the great London hospitals. On the average these women are, if anything, a little poorer than the average of the parents of the children whose family histories are included in the foregoing table. Enquiries were made of 150 women. There was no selection of cases, except that persons of known syphilitic history were excluded, but no special methods were adopted to ascertain this. The following return may, therefore, be taken as a fair average return of family history of the poorest section of the London community. Number of pregnanceis for each mother. Families. Healthy children. Miscarriages. Stillborn. Infant deaths. (1) (2) (3) (4) (5) (6) 17 1 9 3 — 5 16 1 11 3 — 2 15 2 19 1 3 7 14 1 12 2 — — 13 3 28 4 — 7 12 3 25 4 3 4 11 6 55 2 2 7 10 6 43 6 3 8 9 7 51 4 1 7 8 9 55 8 — 9 7 6 31 5 — 6 6 17 83 6 1 12 5 15 62 5 2 6 4 17 57 4 — 7 3 25 68 3 1 3 2 20 35 1 1 3 1 11 10 — 1 826 150 654 61 17 94 The difference between the figures of these two tables is marked. Where there was a history of syphilis 150 mothers had no less than 1,001 pregnancies; but of these only 390 resulted in presumably healthy children. Among 150 " average " mothers there were 826 pregnancies, and from these there resulted 654 presumably healthy children. The outcome of the pregnancies in the two classes of cases can be best compared by the rate per thousand births as follows;— " Healthy " children. Miscarriages. Stillborn. Infant deaths. Diseased. (1) (2) (3) (4) (5) Syphilitic 390 92 80 229 210 "Average" 7917 73.8 20.5 113.8 none. The incidence of children aflected by venereal disease amongst the ordinary school population. The incidence of ophthalmia neonatorum in the ordinary London population. Report of the County Medical*Officer—Education. 219 Remark may be made on the fact that the syphilitic mothers had about 17 per cent. more pregnancies than the " average " mothers. This is partly accounted for by the frequency of miscarriages. The short intervals in these cases will allow of several pregnancies within the same time as that occupied by one healthy pregnancy. Further, the frequency of stillbirths, and of infant deaths keeps the family of the syphilitics down, so that where there is the desire for children the pregnancies are increased in number. On two occasions Mr. Harman examined large groups of children attending the elementary schools of the Council with a view to ascertaining to what extent there were signs of affections of the eyes caused by venereal disease. The investigations were undertaken in the ordinary course of school medical inspection, so that besides the condition of the eyes the state of the body generally was available for comparison. In 1903 to 1904 he examined 22,000 children in the East of London in the districts of Hackney, Hoxton and Bethnal Green. Amongst this large number of children he found only five with eyes damaged by ophthalmia neonatorum, and also five suffering from the after effects of interstitial keratitis of syphilitic origin. In 1905 and 1906, Mr. Harman examined in the same manner 18,000 children in Marylebone, and amongst these found only two cases of eyes damaged by ophthalmia neonatorum, and three of interstitial keratitis. The percentage of damaged eyes amongst these two groups of children totalling 40,000, was 0 017 per cent. for ophthalmia neonatorum, and 0 02 per cent. for interstitial keratitis of syphilitic origin. In 1907, in following out an investigation on the incidence of ophthalmia neonatorum, Mr. Harman examined the vision testing returns of the whole of the medical staff of the Council. The returns covered 412,527 children. Amongst these children there were 46 cases of damaged eyes of the sort which appeared to be due to the result of early purulent conjunctivitis. In many cases the history was clear and the diagnosis certain, but in others the conditions of the eyes formed the only evidence available The percentage incidence of defect produced by this one cause works out to 0 0.111. Since all those children whose eyes are badly damaged from disease are removed from the ordinary schools to the blind schools, it is necessary to correct the foregoing return by including the cases on the roll of the blind schools. The London school children number about 790,000 under 14 years of age. Supposing the incidence of ophthalmia neonatorum to be proportionately the same for the whole number as for the part, there would be altogether 88 cases of defect produced by this cause in the schools at that time. In the blind schools there are on an average 92 cases of ophthalmia neonatorum. So the total for London school children would be 180 cases, that is, one child in every 4,400 has had ophthalmia neonatorum of such severity that the eyes received permanent damage, and more often than not the child was blinded. From examination of his hospital case papers Mr. Harman finds that of cases of undoubted ophthalmia neonatorum treated at hospital, whether brought early when the prospects are good, or late when they are bad, no less than 69 per cent. escaped without injury to the cornea. So that the 180 school cases represent only 31 per cent. of a group of children who suffered from the disease. The figures given in the foregoing section must be taken in conjunction with figures showing the incidence of ophthalmia neonatorum taken within the first few weeks following birth. In 1907, Mr. Harman took an unofficial census of one part of London. Eight doctors in private practice were good enough to send him particulars of their midwifery practice. The district is an average London suburb. Half the population live in tenements, the other half in houses with rents from £30 to £80 per annum, though there are few at the higher rental. At the lowest estimate three-fourths of the children in the district attend the public elementary schools. As a measure of prophylaxis against eye disease, seven of the eight doctors were in the habit of relying upon the simple precaution of cleansing the eyes of the infant with boiled water or boracic lotion as soon as it was born, a few used a weak perchloride of mercury lotion in children born of suspicious parents ; but one doctor used silver nitrate of 2 per cent. strength in almost all cases as a prophylactic. The statistics covered 12,680 children born alive ; and of these 110, or 0.87 per cent. were affected by a purulent conjunctivitis ; six, or 0047 per cent., of the infants had one or both eyes damaged in consequence of the attack. These figures have been confirmed by the returns obtained since the application to this disease of the provision for compulsory notification Comparison between Mr. Harman's figures and those relating to the incidence of the after effects of the affection as seen in the schools, may be made as follows :— Number of children. Injured. Total of known cases. Newly born infants L.C.C. School children 12,680 790,000 6=0-047% (1 in 2,100) 180=0 0226% (1 in 4,400) 110=0-87% From this statement it will be seen that the cases of the disease known to have resulted in injured eyes shortly after birth are to the cases subsequently discovered in the schools as 2 to 1. This difference is probably to be accounted for by the excessive death-rate known to occur amongst the children of mothers affected with the disease. 23610 • FF 2 Returns of venereal disease affecting children seen at hospitals 220 Annual Report of the London County Council, 1913. The following figures are taken from two sources, one from a West London, the other from a South London hospital. In each case all the children considered are children attending London County Council schools. West London—Children examined, 1,188— Affected by congenital syphilis 2 , Do., not certain 1 Affected by ophthalmia neonatorum 2 South London—Children examined, 1,670— Affected by congenital syphilis 8 By ophthalmia neonatorum 4 Excluding the one case in which the diagnosis was uncertain, the incidence of disease for these two groups of children, numbering 2,858, is as follows :— Congenital syphilis, 10 cases, or 0 349 per cent. Ophthalmia neonatorum, 6 cases, or 0.21 per cent. In comparing these returns with the returns obtained from the direct examination of the children in school it must be remembered that the children seen at the hospital are those known to have defective vision, and they are sent for treatment on that account. They represent about onetenth of the total children in the schools, so that the hospital figures need to be correspondingly reduced in comparing them with the school figures. If this be done it will be found that the difference is not great when the varying methods of obtaining the returns are considered.. Mr. Harman, on three occasions, has examined the returns relating to the children attending the Council's blind schools. On the first occasion, the examination was completed at the end of 1904 and the number of children dealt with was 255. On the second occasion the total including the previous 255 children, was 363, these were examined prior to and including 1906. On the third occasion, the children numbered 1,100, and they represent all seen prior to and including 1913. Ophthalmia neonatorum and syphilis as cause of blindness Year of investigation. Total seen. Ophthalmia neonatorum. Congenital syphilis. (1) 1904 1906 1913 (2) 255 363 1,110 (3) 94=36.86% 132=36.36% 268=24.35% (4) 48 18.82% 64=17.0% 343=31.2% Relation of venereal disease to deafness. The figures show that there has been a definite diminution of the incidence of cases of blindness caused by ophthalmia neonatorum, and it is reasonable to credit this diminution to the great efforts that have been made to prevent the disease in the past few years. The diminution is really greater than appears by this method of tabulation, for the cases seen and accounted for in the first two counts are included within the last return. The increase of the incidence of the cases of congenital syphilis is affected by the diminution of the cases of ophthalmia. Part of this increase is, without doubt, due to finer methods of diagnosis, cases that formerly were tabled amongst those of " uncertain origin " are now definitely accounted for. It is certain that the number of cases of blindness due to ophthalmia is diminishing both actually and relatively to the other causes of blindness. But there is not sufficient evidence to state certainly that the apparent increase of the syphilitic cases is due to any other cause than the diminution of one large class of cases of blindness and to the better means of diagnosis. Mr. Macleod Yearsley has made a special study of the evidences of the relationship of venereal disease to deafness. During his tenure of office as otologist to the deaf schools, 845 children suffering from acquired deafness sufficiently severe to render it necessary to educate them in special schools or classes have passed through his hands. Of these the number undoubtedly deaf from the effects of congenital syphilis was 61, or 7.21 per cent. Of the 845 children, 427 were boys, with 21 cases of congenital syphilis, 4.9 per cent. ; 418 were girls, with 40 cases of congenital syphilis, 9.6 per cent. ; so as was first pointed out by the late Sir Jonathan Hutchinson, the females affected were greatly in excess of the males. The following table gives an analysis of the symptoms and stigmata in the 61 cases of deafness associated with congenital syphilis. The results closely correspond with experience in other lines of practice. It is usual to find the deafness following the eye symptoms. The most commonly observed accompanying stigmata are interstitial keratitis and Hutchinsonian teeth ; deafness with vertigo is rare. Ocular Manifestations. Of 21 boys. Of 40 girls. Totals. Interstitial keratitis was present in 19 37 56 Iritis was present in 7 13 20 Choroiditis was present in 1 2 3 Optic atrophy was present in 0 1 1 Aural Manifestations. Deafness occurred before eye symptoms in 2 5 7 Deafness occurred after eye symptoms in 19 35 54 Vertigo occurred in 3 0 3 Nasal Manifestation?. Nasal caries, adhesions, deformity (saddle nose), etc., in 1 6 7 Other Stigmata. Hutchinson teeth occurrcd in 11 26 37 Cranial caries occurred in 1 0 1 Tibial nodes occurred in 1 1 2 Joint affections occurred in 1 1 2 Palatal ulceration occurred in 2 4 6 Scarring of oral angles occurred in 2 3 5 Report of the County Medical Officer—Education. 221 Mr. Yearsley has been able to obtain a detailed history of the fraternity in 12 cases represented diagrammatically as follows :— It will be noted that in these genealogical tables, there are only four adults, all of whom appear to have been born before the poison entered the family. All those children marked " healthy " are still quite young and may develop signs of the disease. Cases 5 and 6 are especially interesting. In the former the mother married first a health}' man and had healthy children ; later she married a second time and bore three children of whom two died early and one developed syphilitic deafness and blindness. In No. 6 the father married first a woman who died of " fits " (meningitis) after bearing him three syphilitic children. The two children born of his second wife are healthy. The following table shows the actual number of pregnancies, of living, dead, and deaf and blind children in these 12 families. No. Pregnancies. Living. Dead. Deaf and blind. I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. 7 8 8 4 3 3 10 8 11 4 7 6* 79 5 3 6 3 1 1 5 5 3 3 4 4 43 2 5 2 1 2 2 5 3 8 1 3 3 37 2 1 1 1 1 1 1 1 1 2 .1 2 15 80 52 * One twin pregnancy. The 40 and 48 scheme. f 222 Annual Report of the London County Council, 1913. At a period corresponding to the time at which some child of the family was attending a school for the deaf, the average number of children born to each of these families was 6.6, of whom only 3.5 survived, and 1.2 were deaf, or deaf and blind. These figures may be compared with those given by Dr. Kerr Love for 18 families of children with acquired deafness from congenital syphilis in Glasgow; average number of children born in each family, 8.5 ; surviving, 4.7 ; deaf and blind, 1.2. Condition of School Buildings. Reference was made in my annual report for last year to the Council's adoption of a scheme for the reduction of the accommodation of classrooms to maxima of 40 in senior and 48 in infants' departments within a period of 15 years from the 31st March, 1912. In furtherance of this scheme the following table, compiled from a report by the Education Officer to the Accommodation and Attendance SubCommittee, shows the number of classrooms within the 40 and 48 maxima provided during the two years ended 31st March, 1914:— Council schools— No. of classrooms. In new schools, enlargements and adaptations 147 By modernising 158 By minor structural alterations 480 By writing down the accommodation of existing large rooms 120 Total in provided schools 905 Non-provided schools— New Bchools, enlargements, etc 35 By minor structural alterations 97 By writing down accommodation 3 Total in non-provided schools 135 Grand total provided and non-provided schools 1,040 The effects of intense summer heat upon children in school. Certain resolutions dealing with the effects of intense summer heat upon children in school which were passed by the Central Consultative Committees of Head Masters and Head Mistresses were referred for report. Upon these resolutions the following report was submitted to the Elementary Education SubCommittee :— " Observations made in schools in the hot weather at times when the classroom thermometers register from 83 deg. to 87 deg. Fahrenheit show that the children generally suffer from a considerable amount of discomfort under these conditions. The prevailing complaints reported by the school doctors as being connected with the excessive heat comprise (i.) sore throat; (ii.) headaches and occasional fainting ; (iii.) loss of appetite, sickness and digestive disturbances ; (iv.) sweat rashes, prickly heat and other skin complaints of an irritating character (found in 10 per cent. of the children inspected); (v.) a falling off from the usual standard of cleanliness with greatly increased prevalence of verminous conditions ; and (vi.) mental symptoms, including increased and more easily induced fatigue, inattention and irritability. In spite of the evidence of considerable discomfort caused by the heat it is noteworthy that the average attendance is but little affected. The effects of hot weather are much more noticeable in infant departments than in senior departments, and girls on the whole suffer to a greater degree than boys. The factors which produce the above effects are :— (1) The difficulty of getting rid of animal heat in a confined atmosphere in which the humidity is high owing to respiratory exhalation. In this connection it is to be pointed out that the children in the playground classes attached to schools exhibit none of the more serious effects of heat from which the children inside the classrooms suffer. (2) The effects of heat retention are rendered more severe by the wearing of unnecessarily heavy clothing, especially among girls. One of the school doctors reports that on a day when the classroom temperature was 86 deg. a girl inspected was found to be wearing 'a velveteen petticoat, two flannelette ones, a vest, stays, a cotton dress and an overall, and two boys each wore three flannel shirts in addition to waistcoats and thick coats. Other school doctors report similar cases. In one school only 25 scholars out of 350 were found to have made a change of clothing more suitable to the raised temperature. (3) Many of the nervous symptoms noted were associated with lack of sleep at night owing to unhygienic conditions or habits in the homes. (4) Much discomfort is due to want of attention to personal cleanliness, due in some cases to neglect, in others to lack of facilities for bathing. (5) School doctors report seeing children picking fragments of food out of dustbins. The dangers arising from the eating of tainted food are greatly increased during hot weather. The precautions against the effects of heat in hot weather which can be carried out in school appear to be the following:— (1) Attention to Ventilation.—Adequate cross ventilation of classrooms should be universally maintained. Report of the County Medical Officer—Education. 223 (2) Open Air Classes.—Every opportunity should be taken to carry on classes in the open air during afternoon sessions in hot weather. (3) Bathing.—Every advantage should be taken of existing facilities for bathing. The Council has recently had under consideration a report by the Medical Research Officer upon the question of provision of school baths. (4) Provision of Sun Blinds.—Of late years the tendency has been to plan schools so that every classroom gets direct sunlight; this is an admirable principle which should never be violated, but the corollary is the provision of sun blinds for those classrooms which have a south and south-west aspect. (5) Instruction in Hygiene.—Much can be done to improve matters by instruction given in school on the points of clothing, cleanliness, food and sleep, and the correction of hygienic faults and habits through the school organisation. These points will be borne in mind when revising the pamphlet on the Health of School Children, but it is probable that hygienic instruction in the school is of more value than the distribution of leaflets. (6) Alteration of School Hours.—The utilisation for school work of the relatively cool hour from 8 to 9 in the morning during summer months would enable an extra hour during the afternoon to be spent out of doors and from this point of view at least the proposals contained in the Daylight Saving Bill appear to be worthy of support. (7) Provision of Drinking Water.—The excessive evaporation from the body during hot weather causes suffering if adequate supplies of drinking water are not available. The number of points at which water can be obtained require, under these conditions, to be in excess of that normally sufficient. Provision for the extra supply of drinking water might take the form of jets from which the children may drink directly thus avoiding drinking cups, to which objections are frequently raised." During the year the condition of 123 school buildings was inspected by the school doctors and reports were made as to defects in lighting, ventilation, heating, desking, and sanitary provision generally. Special attention was paid to the question of the sufficiency of supply of drinking water in playgrounds, and some instances were reported in which the number of points was less than that usually adopted by the Council, viz., 1 point to every 100 boys and 1 to every 135 girls and infants. The above 123 schools were distributed throughout the school doctor's areas ; it has been pointed out that it would be more convenient if attention were concentrated upon the areas in which reconstructions and minor alterations under the 40 and 48 scheme were about to be undertaken and this will in future be arranged. The routine inspection of school buildings. Powers and duties of the Council. 224 Annual Report of the London County Council, 1913. CHAPTER XXXIV. Public Health. Many important duties devolve on the Council in relation to public health. These duties are set forth in various Acts of Parliament, the principal Act being the Public Health (London) Act, 1891. This Act authorises the Council to deal with offensive businesses, to make orders adding to the list of infectious diseases notifiable under the Act, and to license slaughterhouses, cowhouses and knackers' yards. The Council is also empowered to take proceedings with respect to nuisance caused by a sanitary authority in removing, treating or disposing of house or street refuse, and to act in default when a sanitary authority fails to carry out its statutory duties. The Act also empowers the Council to make by-laws for regulating (a) the conduct of offensive businesses, and the structure of the premises on which they are being carried on ; (b) the removal or carriage of offensive or noxious matter or liquid ; (c) the removal and disposal of refuse, etc. ; and (d) the construction, etc., of water-closets, earth closets, privies, cesspools and receptacles for dung. The Council is also required under the Act to pay half the salaries of local medical officers of health and sanitary inspectors, and may make representations to the Local Government Board as to the number of sanitary inspectors appointed. Copies of all periodical reports of medical officers of health must be supplied to the Council, and in the event of any medical officer failing to carry out this requirement the Council may refuse to contribute towards his salary. The Council is authorised by section 6 of the London County Council (General Powers) Act, 1908, to contribute towards the salary of a health visitor appointed by a metropolitan borough council any sum not exceeding one-half of such salary. In addition to the powers which the Council possesses under the Public Health (London) Act, 1891, to deal with offensive businesses, section 9 of the London County Council (General Powers) Act, 1908, authorises the Council to make by-laws for regulating the conduct of the businesses of a fish curer, vendor of fried fish, and rag-and-bone dealer. Further, under Part VIII. of the London County Council (General Powers) Act, 1903, the Council is authorised to license premises for receiving horses for slaughter or dead horses. The supervision and licensing of common lodging-houses devolves upon the Council under the Common Lodging Houses Acts, 1851, and 1853, and the London County Council (General Powers) Acts, 1902 and 1907. In addition, the Council licenses seamen's lodging-houses and enforces the by-laws with regard thereto made by it under section 214 of the Merchant Shipping Act, 1894. Powers with regard to safeguarding the purity of London's milk supply are given under various Orders and Acts, and are as follows :—Under the Dairies, Cowsheds and Milkshops Orders of 1885, 1886 and 1899, the Council has power to secure the proper lighting, ventilation, cleansing, drainage and water supply of cowsheds and dairies and the sanitary condition of milk stores and milkshops. The Orders also forbid, under penalties, the use, for human food, of milk from a diseased cow or from a cow with tubercular disease of the udder; under Part V. of the London County Council (General Powers) Act, 1904, the Council is empowered to seize and slaughter, on payment of compensation to the owner, any cow in a London cowshed suspected of tuberculosis of the under; under part IV. of the London County Council (General Powers) Act, 1907, the Council is authorised to take within and outside the county and examine samples of milk entering London ; to proceed to the place from which any sample proving tuberculous was sent to London ; to examine the cows thereat, and, if any are found affected with tuberculosis of the udder, to prohibit the sending into London of further supplies of milk therefrom. The Act also contains provisions for the isolation of cows suffering from tuberculosis of the udder and for notice to be given of such cows to the Council's medical officer. In addition to the duties enumerated above, Part IV. of the London County Council (General Powers) Act, 1904, and Part III. of the London County Council (General Powers) Act, 1909, authorise the Council to represent to the Local Government Board when a sanitary authority has made default in carrying out its duties in regard to the purifying and cleansing of articles and premises and to the accommodation for the storage of food. The majority of the Council's powers and duties referred to above do not extend to the City of London, and, in the matter of the examination of milk under Part IV. of the London County Council (General Powers) Act, 1907, the Council has powers in the City concurrent with those of the City Corporation. On 19th December, 1912, the Local Government Board issued the Public Health (Tuberculosis) Regulations, 1912. These regulations, which came into operation on 1st February, 1913, consolidate and in some respects amend the previous regulations of 1908 and 1911 (two) which related to the notification of cases of pulmonary tuberculosis. The most important change effected by the new regulations is that cases of tuberculosis of all kinds must be notified to the local medical officer of health by the medical practitioner who detects the case. The Local Government Board in its circular letter forwarding copies of the new regulations stated that more than half of the deaths from nonpulmonary tuberculosis were of children under five years of age and that it was probable that a much higher percentage of persons suffering from non-pulmonary tuberculosis were children of this age. The Board, therefore, expressed the hope that the notification of these cases would facilitate the investigation of sources of infection and assist in securing improvement in the conditions under which the children lived. The duty of taking preventive measures devolves in London upon the local medical officers of health. Each of these officers is also required to send weekly to the county medical officer of health a statement of every notification received by him under the regulations. Notification of tuberculosis. Treatment of tuberculosis. Public Health. 225 The Council gave much attention during the year to the question of the treatment of tuberculosis in London. Particulars were given in the last annual report* of the preliminary consideration by the Council of the circumstances arising out of the provision contained in the National Insurance Act, 1911, relative to the treatment of tuberculous persons who were either persons insured under that Act or their dependents, and reference was also made to the temporary arrangements made with the Metropolitan Asylums Board for the provision of residential accommodation for insured persons. The Council was in doubt as to the position which it was intended to occupy in connection with the treatment of tuberculosis in London, and the question was necessarily one of some difficulty owing to the number of authorities and others in London who were concerned. The Local Government Board, however, in a letter dated 11th December, 1912, stated inter alia that, with regard to dispensaries the Board acted on the view, expressed in the report of the Departmental Committee, that the unit should be the metropolitan borough or a combination of boroughs, and added that it had invited the borough councils to provide or arrange for the provision of these institutions. At the same time the Board stated that it was of opinion that the Council should formulate a complete scheme for London so that the work which it was proposed should be done locally through dispensaries might be properly related to the whole scheme, and for this purpose the Board desired to look to the Council to be the central organising body for the provision of institutional treatment whether indoor or outdoor. As the result the Council instructed the Public Health Committee to prepare forthwith and to submit to it a scheme for dealing with tuberculosis throughout the administrative County of London. In compliance with this instruction the Committee first considered as to the appropriate means of providing sanatoria and other residential institutions, and concluded that the Council could best discharge its duties as health authority for London by co-ordinating the arrangements for the treatment of tuberculosis throughout the county, but that in order to do so it did not necessarily follow that it should itself become an active treating authority. In this connection the Committee suggested the possibility of removing the disabilities attaching to the Metropolitan Asylums Board as a poor law authority and of enlarging the scope of its activities so as to enable it to provide for the residential treatment of both insured and uninsured persons suffering from consumption, and with this object they made the following recommendation which was adopted by the Council:— "That in order to allow of a comprehensive scheme for the treatment of tuberculosis in London, and in view of the fact that the Council has hitherto not been an authority providing treatment for tuberculous persons, and that the Metropolitan Asylums Board has available the machinery necessary for the provision of residential treatment, it is essential that the Board should be enabled to become an authority providing institutions for residential treatment for tuberculous persons of all classes." The disabilities attaching to the Metropolitan Asylums Board in respect of insured persona were removed by Section 39 of the National Insurance Act, 1913, which provides that, with the sanction of the Local Government Board, the managers of the Metropoltian Asylums district may "enter into agreement with any county council or county borough council, or, with the consent of the county council, with any authority in a county, for the reception of insured persons or their dependants suffering from tuberculosis or any such other disease as the Local Government Board, with the approval of the Treasury, may appoint under section eight of the principal Act, into hospitals or sanatoria provided by the managers . . ." This Act came into operation on 1st September, 1913, and the Council gave its consent to direct arrangements being made by the London Insurance Committee with the Metropolitan Asylums Board for the treatment in the Board's institutions of insured persons suffering from tuberculosis. The position of the Council in the matter of making provision for tuberculosis treatment was strengthened by the Public Health (Prevention and Treatment of Disease) Act, 1913, which received the Royal Assent on 15th August of that year. Clause 3 of this Act provides that, " it shall be lawful for the Council of any county or for any sanitary authority to make any such arrangements as may be sanctioned by the Local Government Board for the treatment of tuberculosis; provided that the power conferred by this section shall be in addition to and not in derogation of any other power." Pending the passing of the foregoing legislation, the Public Health Committee proceeded, as far as possible, with their inquries and with the consideration of matters connected with the formation of a complete scheme for London. The position to be occupied by the hospitals and their relationship to the dispensaries was considered and it was deemed essential that each dispensary should be linked with a hospital in order that the dispensaries might have the advantage of the help of the consultant staff and of the bacteriological and other equipment of the hospitals for dealing with difficult cases. The Committee further proceeded to consider the distribution of existing institutions, including dispensaries and hospitals, with a view to ascertaining how far the available accommodation could be used and how best the linking of existing dispensaries with hospitals could be effected and the extent to which new dispensaries and residential institutions would be necessary. Various inquiries were made with this object and a number of proposals were under the consideration of the Committee. During this time the Local Government Board had been in communication with some of the borough councils respecting dispensary schemes prepared by them and in some cases the arrangements of the borough councils had been approved. The sanction of the Board, however, contained the following paragraph :— "In order that the dispensary arrangements proposed may be properly related to the arrangements for London as a whole, the Board would suggest that before finally adopting a scheme for the borough, the council should consult the London County Council on the matter." * Annual Report of the London County Council, 1912. Vol. III., pp. 216-218. 23610 GG 226 Annual Report of the London County Council, 1913. Other schemes were forwarded by the Local Government Board to the Council for its observations. It was, therefore, not clear what position the Council was to occupy in relation to those local schemes and a request was made that the Board express its views on the subject. Pending the elucidation of the position, the Council laid down the following broad principles which should be observed in devising local dispensary schemes :— (1) All possible use should be made of existing institutions. (2) Approval should not be given to any scheme which fails to provide for each dispensary being linked up with a hospital, to which special cases shall be referred for consultation or treatment, residential or otherwise. The reply of the Local Government Board to the Council's inquiry was to the following effect:— (1) The Board retained the views expressed in its letter of the 11th December, 1912, and considered that the Council should be the tuberculosis authority for London, and that through the Council all agencies should be properly co-ordinated so as to form parts of a complete scheme. (2) It was essential that the dispensaries should be closely related to the preventive work which it is the duty of the local sanitary authority to carry out, and the Board acted on the view suggested by the Departmental Committee in inviting the borough councils to provide or arrange for the provision of dispensaries. (3) The Board agreed with the view of the Council that all possible use should be made of existing institutions and observed that in its opinion hospitals and other voluntary institutions proposed to be recognised should be willing to work in close co-operation with the local authority. (4) The Board would welcome any suggestion which the Council might be able to maka for securing greater efficiency in the dispensary work and agreed with the Council that, as far as practicable, specially difficult cases should be referred from the dispensary to a general or special hospital. (5) The Board would be glad to learn what general rules the Council would suggest to secure that the dispensaries should form part of the whole scheme for London. (6) As to residential accommodation, the Board considered that upon the Council should rest the responsibility of securing accommodation, both for insured and uninsured persons. (7) The Board suggested the appointment of a Chief Clinical Tuberculosis Officer who should also act as medical adviser to the Insurance Committee. (8) The Board thought it desirable that the cost of the scheme should,at any rate, to a large extent, be borne by London as a whole, but that as dispensaries were to be provided locally, some proportion of the cost should be charged locally. (9) With regard to insured persons, the Board considered that it would simplify matters and enable one agreement to be made by the Insurance Committee in regard to all services rendered to insured persons if the Council were recognised as the providing authority for all institutional treatment. On receipt of this reply the Council passed the following resolution:— That any comprehensive scheme for dealing with the treatment of tuberculosis in London shall provide for a contribution being made by the Council from year to year towards so much of the cost of the dispensary treatment of uninsured persons in the City of London and each metropolitan borough as would otherwise fall on the local rate, after taking into account the promised grant from the Imperial exchequer, provided that such contribution (1) shall not exceed 50 per cent. of such cost, (2) shall in the first instance be made from a date to be fixed hereafter by the Council, and (3) shall be conditional upon the Council being satisfied with the local scheme in force in such area and upon the arrangements and expenditure being annually submitted to and approved by the Council; and that whilst by the above proposals ample funds will be provided to meet the cost of dispensary treatment for uninsured persons, in view of the fact that the Insurance Committee for the County of London have resolved that representations should be made to the Treasury as to the inadequacy of the sums available for defraying the expenses of sanatorium benefit in respect of insured persons suffering from tuberculosis in the County of London, the Council is of the opinion that no comprehensive scheme can be adequately carried out unless provision is made for meeting the full cost of the treatment of insured persons out of the Insurance Fund or by the Government. The Council thereupon proceeded to consider the schemes of the metropolitan borough councils which had been submitted for its consideration. In the first instance, however, it was thought desirable that general principles upon which the Council would be prepared to grant financial assistance to local dispensary schemes should be laid down and it therefore decided (i.) The Council must be satisfied that the premises to be utilised as a dispensary are suitable for the purpose. (ii.) The scheme must include provision, either in the dispensary, or at a hospital working in connection with the dispensary, for the diagnosis not only of ordinary straightforward cases, but also of incipient, anomalous and difficult cases specially referred on the ground of difficulty of diagnosis. (iii.) The physician in charge of the dispensary (or "tuberculosis officer") must be a man of experience, not only in dealing with tuberculous affections, but also in general medicine. (iv.) Proper records and statistics in connection with the work of the dispensary shall be provided of the nature and in the form required by the Council and approved by the Local Government Board. Public Health. 227 (v.) The physician in charge of the dispensary shall supply to the medical officer of health of the borough from which the patientsare drawn, such information as the medical officer of health may reasonably require, and the county medical officer of health shall be entitled to receive this information from the borough medical officer of health. The physician in charge of the dispensary shall also furnish the requisite information to any medical practitioner carrying out domiciliary treatment, or in a case which is referred to a sanatorium to the medical officer of that institution. (vi.) The scheme shall include provision for home visitation of patients, either by the dispensary physician or by the medical officer of health of the borough and his staff and for the examination by the dispensary physician of such cases as the medical officer of health or a medical practitioner may require, either at the dispensary or in the homes of suspects and contacts. (vii.) The scheme shall be conducted with reasonable economy and the arrangements and expenditure shall be annually submitted to the Council for its approval. (viii.) The scheme shall provide for distinguishing clearly between the cost of treating insured and uninsured persons, having regard to the opinion expressed by the Council that insured persons should not be paid for out of the rates. The Council also suggested to local sanitary authorities that they should make arrangements to pay for patients, residing in the districts under their respective jurisdiction, attending dispensaries attached to hospitals in any part of the Administrative County of London. A number of schemes were under consideration and it was possible in two cases, viz., Southwark and Chelsea, to give a qualified approval before the end of the year. During the year under review the reports presented to the Council on the administration of Part IV. of the London County Council (General Powers) Act, 1907, showed that between the date of the coming into operation of the Act and 31st December, 1913, 13,321 samples of milk forwarded from places outside the county had been examined, with the result that 1,323, or 9 9 per cent., proved tuberculous. During the year, 2,900 samples were taken. Of these the examination of 2,682 samples was completed, of which 251 were found to be tuberculous. The Council's veterinary inspector has visited, for inspection purposes, since the Act came into operation, 2,423 farms and inspected 65,795 cows, of which number 663, or one per cent., were found to be affected with tuberculosis of the udder. During the year 261 farms were visited and 9,649 cows were examined, of which 26 were found with tuberculous udders. The owners of the animals affected undertook that the use for human consumption of the milk should be discontinued immediately. Under the provisions of the London County Council (General Powers) Act, 1904, the cows in London cowsheds are examined about five times in the year by a veterinary inspector appointed by the Council. During the year under review 12 animals have been seized and slaughtered under the Act, the post-mortem examination showing in each case that the udder of the animal was tuberculous. The machinery provided under this Act for the seizure and slaughter of cows was, however, not utilised after 1st May, 1913, as on that date the Tuberculosis Order of 1913, issued by the Board of Agriculture and Fisheries under the Diseases of Animals Acts, came into force. The Order provides for the notification to the Council, as the local authority for the execution of the Order in the Administrative County of London, exclusive of the City of London, of any case in which (1) any cow is, or appears to be, suffering from tuberculosis of the udder, indurated udder or other chronic disease of the udder, or (2) any bovine animal which is, or appears to be, suffering from tuberculosis with emaciation. Upon receipt of such notification the Council is required to cause a veterinary inspector to examine the animal and if, as the result, the Council is satisfied that the animal is suffering from tuberculosis with emaciation or, in the case of a cow, is suffering from tuberculosis of the udder or is giving tuberculous milk, the Council is to give notice to the owner and to the Board that the animal is to be slaughtered. Before the slaughter of the animal its value, in its condition at the time of valuation, is to be agreed upon by the Council and the owner, or, failing agreement, is to be settled by a valuer. The special authority of the Board has to be obtained before the animal can be slaughtered if (1) the owner objects, or (2) the agreed value of the animal exceeds £30. The Order also provides (1) for precautions to be taken in respect of milk from cows which are, or appear to be, suffering from chronic disease of the udder or tuberculosis with emaciation or which are suspected of giving tuberculous milk; (2) for the detention and isolation of any cow which is or appears to be, suffering from chronic disease of the udder, or any bovine animal which is, or appears to be, suffering from tuberculosis with emaciation ; (3) for the cleansing and disinfection of that part of a shed or other erection in which a cow suffering from tuberculosis of the udder or giving tuberculous milk or any bovine animal suffering from tuberculosis with emaciation has recently been placed or kept. The powers of the Council under its General Powers Act of 1904 to deal with tuberculous animals are more limited than those conferred upon it by the Order, as under the Act the Council can deal only with cows suspected to be suffering from tuberculosis of the udder. Moreover, there is a considerable difference with regard to the payment of compensation for animals slaughtered. Under the Act of 1904, in the event of the animal slaughtered being found to have been suffering from tuberculosis of the udder, the Council is required to pay to the owner three-fourths of the agreed or ascertained value of the animal before slaughter, or the sum of £22 10s. whichever shall be the less, and, in the event of the animal being found not to have a tuberculous udder, the amount payable is the full value or £30, whichever is the less, plus £1. 23610 GG 2 Milk. Census of homeless persons. 228 Annual Report of the London County Council, 1913. Under the Tuberculosis Order of 1913, the animal is to be valued before slaughter (1) as a tuberculous animal and (2) as a non-tuberculous animal. If the animal be found to have been suffering from tuberculosis (not being advanced tuberculosis as defined in the Order) the owner shall be paid three-fourths of the agreed value of the animal as a tuberculous animal. If, however, the animal was suffering from advanced tuberculosis the compensation payable will be one-fourth of the value of the animal as a tuberculous animal, or the sum of £1 10s., whichever is the greater. In the event of the animal proving to be non-tuberculous the owner is to be paid the full agreed value of the animal, plus £1. The compensation payable in respect of a tuberculous animal is less under the Order than under the Council's General Powers Act. Moreover, the Government has expressed its intention of bearing, for a period of five years from 1st May, 1913, one-half of the amount payable by way of compensation under the Order. The Council now, however, has to deal with all bovine animals and not with cows only as heretofore. From 1st May to 31st December, 1913, 46 cases were dealt with under the Order, and 25 cows were seized and slaughtered in accordance with section 5 (1) of the Order. Sums amounting to £96 13s. 3d. were paid to owners as compensation. In 1904, 1905, 1907 and 1909 to 1912 inclusive, censuses were taken by the medical officer of homeless persons in the County of London in order to ascertain the use made of common lodging houses, and the provision existing for the accommodation of persons of the poorest class. A further census was made on the night of 14th February, 1913, and the medical officer submitted a report showing the number of persons found homeless on that night in the street, on staircases or under arches, the number and sex of persons who might reasonably be regarded as homeless on the ground of not being able to pay for a bed, the arrangements made for the shelter of persons of this description, and other information bearing on the question. The total number of homeless persons found was 649 as compared with 1,203 at the census of 1912. Following the practice adopted in previous years, the report was printed and placed on sale.* During the year licences were granted to keep and use, as common lodging-houses, 287 premises in the County of London, and in the same period seven licensed keepers were fined £18 with £4 9s. 6d. costs for having infringed the Council's by-laws. In one case the Council failed to secure a conviction, and the summons was dismissed with costs against the Council. Proceedings were instituted against the keeper of certain premises in Crescent-street, Kensington, for keeping common lodging-houses without a licence. The summonses came on for hearing at the West London Police Court on 31st July, 1913. It was admitted by the defendant that rooms were let in each house at 1s. a night to persons of the common lodging-house class, but it was stated that there was no common room for the use of lodgers. On behalf of the Council it was argued that the magistrate was bound by the decision of the Court of Appeal in the case of Parker v. Talbot, in which it was held that the definition of a common lodging-house, contained in the Common Lodging Houses Act (Ireland), 1860, was applicable to this country. That definition is as follows— "A 'common lodging-house ' means a house in which persons are harboured or lodged for hire for a single night or for less than a week at a time, or any part of which is let for any term less than a week." The Council, therefore, appealed to the High Court against the magistrate's decision, but the appeal was not heard during the year under review. During the year licences to keep seamen's lodging-houses were granted in respect of 42 premises. Legal proceedings were instituted in several instances for keeping unlicensed seamen's lodging-houses. In 3 cases a conviction followed and fines amounting to £17, with £2 6s. costs, were imposed. Various complaints were made to the Council under the Public Health (London) Act, 1891, as to insanitary conditions or failures in sanitary administration. The practice adopted is, in the case of signed complaints, to forward the complaint to the sanitary authority and to take no further action unless the complainant appeals again to the Council. In the case of anonymous complaints the purport of the complaint is sent to the medical officer of the district, and, unless an intimation is received that action has been taken, an inspection is subsequently made, and, if then found necessary, a further communication is sent to the sanitary authority concerned. In pursuance of the authority conferred upon the Council by section 19 of the Public Health (London) Act, 1891, in one case certain premises were removed from the register, as the right to carry on soap-boiling thereat had elapsed. Section 19 (1) (a) of the Public Health (London) Act, 1891, prohibits the establishment anew and the subsequent carrying on of certain offensive businesses, including that of a manure manufacturer. A business of this nature has been established for many years by Freeland and Smith, Limited, at Railway-arches, Nos. 13 and 14, of the London, Brighton and South Coast Railway Company in Almondroad, Bermondsey, but it was reported to the Council that the business was also being carried on at adjoining premises. It was, therefore, necessary that proceedings should be instituted against the firm, and the Council was advised that it was the duty of the Bermondsey Metropolitan Borough Council to take action in the matter. The borough council, however, dissented from this view, and refused to prosecute, and the Council therefore decided to take proceedings in default in pursuance of section 100 of the Public Health (London) Act, 1891. The case came on for hearing at the Tower-bridge police court on 1st and 8th October, 1913, when the defendants, who pleaded "not guilty," were convicted * Report by the Medical Officer, submitting the result of a ccnsus of homeless persons taken on the night of 14th February, 1913, (No. 1,586) Price 2d. Seamen's lodging houses. Nuisances. Offensive businesses. By-laws under the Public Health (London) Act, 1891. Appeal Committee Midwives Public Health. 229 and fined 2d. for every working day during the six months preceding the issue of the summons and were ordered to pay £15 15s. costs. The number of slaughterhouses, cowhouses and knackers' yards licensed during the year was 223 slaughterhouses, 171 cowhouses, and 4 knackers' yards. By-laws relating to the businesses of a fried fish vendor, fish curer and rag and bone dealer respectively, were made by the Council under the powers conferred by Section 9 of the London County Council (General Powers) Act, 1908, but the approval of the Local Government Board thereto had not been received at the end of the year under review. During the year the Council made a by-law, under section 39 (1) of the Public Health (London) Act, 1891, defining the builder as the person responsible for any infringement of the by-laws already made under that Act relative to the construction of any water closet, privy, ashpit, cesspool or receptacle for dung and the proper accessories thereof. The by-law in draft had been previously circulated among the several local sanitary authorities in the county, outside the City of London, and no objection having been raised thereto, it was subsequently submitted to and approved by the Local Government Board. All the above services are administered under the direction of the Public Health Committee. Under section 212 of the Mertopolis Management Act, 1855, the Council is required to appoint an Appeal Committee to hear and decide appeals under that Act. This section of the 1855 Act is also applied by statute to appeals made under the Metropolis Management Act, 1862, and under sections 37, 41 and 43 of the Public Health (London) Act, 1891. An appeal to the Council is also provided for by section 6 of the Metropolis Management Act Amendment Act, 1890, and the Council has referred such appeals also to the Appeal Committee. During the year 1913, no appeals came before the Appeal Committee. By section 8 of the Midwives Act, 1902, every council of a county or county borough in England and Wales is constituted a local supervising authority over midwives within the area under its jurisdiction. The duties of a local supervising authority are :—(1) to exercise general supervision over all midwives practising within the county or county borough ; (2) to investigate charges of malpractice, negligence or misconduct on the part of any practising midwife; (3) to suspend from practice any midwife if such suspension appears necessary in order to prevent the spread of infection ; (4) to report at once to the Central Midwives Board the name of any midwife convicted of an offence ; (5) during the month of January in each year to send to the Central Midwives Board a list of all midwives who, during the preceding year, had notified their intention to practise within the county ; (6) to keep a current copy of the roll of midwives accessible at all times for public inspection ; (7) to report at once to the Central Midwives Board the death of any midwife or any change in the name or address of any midwife ; and (8) to give due notice to the effect of the provisions of the Act to all persons using the title of midwife. In addition to these duties, every local supervising authority is by section 5 of the Act compelled to pay its proportion of any deficit which may occur in the expenses of the Central Midwives Board, provided such deficit is approved by the Privy Council. In order to carry out its duties of general supervision, the Council has appointed two women inspectors, who are duly qualified medical practitioners, to pay visits of inspection to midwives practising within the County, as well as to make special investigation into any case of puerperal fever occurring in the practice of a midwife, and to attend if possible any inquest held upon the body of a woman or infant upon whom a midwife had been in attendance. During the year 1913 there were 91 cases of puerperal fever in the practice of midwives, and 103 inquests were held in which midwives were concerned, 6 being on the bodies of women, and 97 on the bodies of children. Charges of malpractice, negligence or misconduct on the part of four midwives were investigated during the year, with the result that the Central Midwives Board was informed that in two instances prima facie cases of negligence and misconduct had been established. The charges in the two remaining cases were not sustained, but one of the midwives concerned was censured by the Committee. The Board announced its decision with regard to the charges established in the two cases referred to, the name of one woman being removed from the roll, whilst the other woman was censured. During 1913 the Central Midwives Board also announced its decision with regard to a certified midwife against whom charges had been brought during the preceding year, the name of the midwife being removed from the roll. During the year ended 31st December, 1913, 536 midwives notified to the Council their intention of practising within the County during the year ; and, in addition to these, 14 notices were received from persons who had acted as midwives on specific occasions, and 24 notices from midwives who intended to practise within the County during periods shorter than a year. Before 1st April, 1910, a woman who was not certified under the Midwives Act, 1902, was not prohibited from attending cases of childbirth, providing she did not take or use the title of midwife or any title of a similar nature ; but on that date sub-section 2 of section 1 of the Act came into operation. This sub-section prohibits a woman, other than a legally qualified medical practitioner or a person rendering assistance in cases of emergency, who is not certified under the Act from habitually and for gain attending women in childbirth. It became necessary during the year 1913 to institute legal proceedings against three women for infringing the law in this respect. Convictions resulted in each case, fines amounting to a total of £2 lis., with £1 7s. costs, being inflicted. A conviction was also obtained in January, 1913, in the case of a woman against whom it had become necessary during the preceding year to take legal proceedings. The woman was fined 10s. and 14s. costs. Lying-in homes. Infant life protection. Employment of children abroad. Diseases of animals. 230 Annual Report of the London County Council, 1913. The accounts of the Central Midwives Board showed an adverse balance for the year 1912, and the Council was called upon in 1913 to pay a sum of £103 1s. 3d. as its proportion of this deficit. During the year the necessity was impressed upon the Council, both from the sanitary and from the moral point of view, for some measure of public control being exercised over lying-in homes. A considerable number of houses and institutions at which pregnant women were received were known to exist in London, and the necessity for conferring on local authorities powers to regulate such places was recognised to some extent in the two bills for the amendment of the Midwives Act, 1902, which were introduced in the House of Lords in the session of 1910. Moreover, representations were made by delegates from various charitable societies and others that, as the result of the passing of the National Insurance Act, 1911, unmarried women who formerly obtained admittance to poor law institutions for their confinements, were in many cases receiving maternity benefit under the Act and entering lying-in homes at which, in some instances, they were subjected to immoral influences. The means by which the regulation of lying-in homes could best be effected were carefully considered, and two courses appeared to be open to the Council, (1) by licensing, and (2) by registration. The former alternative appeared to be the better, and the Council accordingly decided to seek powers to enable it to require such places and the persons in charge thereof to be licensed annually. It did not appear necessary or desirable that the Council's powers of licensing should extend to poor law institutions or important hospitals or to a private residence in which a relative of the occupier was received for her confinement, and provision was accordingly made for such places to be excepted from the proposed legislation. It was necessary also, having regard to the variety of institutions and places concerned, that the Council should retain the right to make certain other exceptions. There are certain services closely allied to that of public health which it is convenient to review in this chapter. They are (a) infant life protection, and (b) diseases of animals. The powers of the Counoil in these matters are exercised by the Public Control Committee. The duties of the Council under Part I. of the Children Act, 1908, include the institution of inquiries as to persons who undertake the nursing and maintenance of infants, the fixing of the number of infants which may be kept in a dwelling as to which notice has been given, and the appointment of infant protection visitors to inspect places where infants are kept. The Council is required to satisfy itself as to the proper maintenance of the infants, and may arrange for the removal from a notified house of an infant improperly kept. Notice has to be given to the Council in cases where one infant is received, and the age limit of infants is 7 years. The Act also contains a provision making void any policy of insurance on the life of an infant when taken out by any person who shall have the custody of such infant for reward, and making it an offence for any such person to insure or attempt to insure the life of such infant. Offences are punishable by imprisonment for a term not exceeding six months, or a fine not exceeding £25, and the fines are paid to the Council. On 31st March, 1909, before the Act came into operation, there were 268 homes containing 668 infants under inspection by the Council's officers, and on 31st December, 1913, the numbers had risen to 3,070 and 3,976 respectively. There were also 8 homes with one nurse infant each, which were under inspection by philanthropic societies acting as infant protection visitors under powers delegated by the Council under the Act, and 20 homes, containing 39 children, exempted from official inspection. t The Children (Employment Abroad) Act, 1913, prohibits the removal out of the United Kingdom of a child or (without a licence to be granted by a police magistrate) of a young person, for the purpose of singing, playing, performing or being exhibited for profit. All notices of intention to apply for licences are sent to the Council. The Diseases of Animals Acts, 1894 to 1911, make provision for the prevention, diminution and suppression of contagious diseases in animals, and are enforced in London partly by the Board of Agriculture and Fisheries and partly by the Council and the City Corporation. The Acts are supplemented by Orders made by the Board of Agriculture and Fisheries dealing with infectious disease among animals and the areas in which such disease exists. The Acts and Orders are administered in London outside the City by the Council, and in the City by the Corporation, which body is also responsible as port sanitary authority for enforcing the provisions of the Act relating to foreign animals. The prevalence of contagious disease in animals in London during the year 1913 is shown by the following statement indicating the number of animals attacked :—Glanders, including farcy, 288 cases ; typhoid in swine, 9 outbreaks ; anthrax, 6 cases ; and parasitic mange, 1,261 cases. Compensation amounting to £3,787 4s. 6d. was paid by the Council in respect of glandered horses slaughtered during the year. Four infringements of the Glanders or Farcy Order of 1907 were detected. The number of infringements of the Parasitic Mange Order of 1911 detected was 89, and in 22 cases legal proceedings were taken, penalties amounting in all to £109 3s. 6d. being imposed. During the year the Board of Agriculture and Fisheries issued an Order, entitled the Horses (Importation and Transit) Order of 1913, which came into operation on 1st October, 1913. This Order revokes the previous Order of 1912 and Amending Orders dealing with the importation and transit of horses, asses and mules, and re-enacts those Orders with certain amendments. The two most important amendments are as follows:— Horses, asses and mules brought to Great Britain from abroad are required to be accompanied by a veterinary certificate of freedom from symptoms of glanders (including farcy), epizootic lymphangitis, ulcerative lymphangitis, dourine, horse-pox, sarcoptic mange, psoroptic mange, influenza, ringworm or strangles. Formerly a certificate of freedom from symptoms of glanders (including farcy) only was required. l'ower? and duties of the Council. Metropolitan main drainage area. Treatment and disposal of sewage. Main Drainage. 231 CHAPTER XXXV. Main Drainage. The Council is charged by statute with the responsibility for the provision and maintenance of an efficient main drainage system for the Administrative County of. London. Its powers and duties in this respect are derived mainly from the Metropolis Management Acts, 1855, 1858 and 1862, and under these Acts the Council is specifically required to provide and maintain the necessary sewers and works for preventing, as far as may be practicable, the sewage of London, collected by the local sewers, from passing into the river Thames within the County. The treatment and disposal of the crude sewage also forms an important part of the Council's work. In addition to the county, several adjoining districts drain into the system and the area and resident population thereof (1911) are approximately as follows— Sq. miles. Persons. North—County of London 50 2,683,060 Out-county districts 29 773,239 South—County of London 67 1,839,901 Out-county districts 3 40,001 149 5,336,201 The whole of the sewage of the County of London is dealt with by the Council, but power is reserved to the Council in the West Kent Main Sewerage Act, 1875, to connect any of its sewers with the West Kent sewer, which passes through the southern portion of the metropolitan boroughs of Lewisham and Woolwich. This power has not been exercised. The sewage collected by the local sewers, which are vested in the metropolitan borough councils, and by main and branch sewers under the control of the Council, is conveyed by means of large intercepting sewers to the outfall works. These are situated at Barking on the north side of the Thames, and at Crossness on the south, and are respectively 11 and 13 miles below Londonbridge. The sewage on its arrival at the outfalls is subjected to chemical treatment—i.e., about one grain of proto-sulphate of iron and four grains of lime are added to every gallon of crude sewage. The sewage is then discharged into, and allowed to pass slowly through, large reservoirs or precipitation channels, where the solid matters in suspension subside and the liquid or effluent passes over a weir into channels leading into the river Thames. The residue in the precipitation channels, which is called sludge, is cleared out and pumped into other channels, where the solids are allowed to settle still further. The resultant sediment, which contains about 92 per cent. of moisture, is pumped into the Council's sludge steamers and conveyed to the Black Deep in the Thames Estuary. The following table shows the quantity of crude sewage treated, chemicals used in precipitation, and sludge sent to sea, with the quantity of refuse intercepted at the gratings at the outfall works at Barking and Crossness respectively during the year 1913 :— Barking, gallons. Crossness, gallons. Total. gallons. Sewage treated 58,306,918,286 45,733,395,400 104,040,313,686 Sewage daily average 159,744,981 125,296,974 285,041,955 tons. tons. tons. Lime used 13,343 9,775 23,118 Proto-sulphate of iron used 3,075 2,794 5,869 Sludge sent to sea 1,683,000 946,000 2,629,000 Sludge, weekly average 32,366 18,192 50,558 Refuse intercepted at gratings 3,938 1,450 5,388 From the above figures it will be seen that at Barking Outfall one ton of sludge was extracted from an average of 34,645 gallons of sewage treated ; or slightly less than in the previous year. At Crossness Outfall the average quantity of sewage treated to produce one ton of sludge was 48,344 gallons, which is also less than in the preceding year. The total quantity of sewage treated is shown as about 7.4 per cent. less than in the preceding year. The quantity of sludge sent to sea was 1.1 per cent. more than in 1912. At the Barking outfall there is a one-acre coke bed which has been maintained in action for over nineteen years for the bacterial treatment of some of the effluent produced after chemical precipitation. In view of the continued decrease in the capacity of the bed owing to the disintegration of the material of which it was composed, the use of the bed has for the time being been discontinued. The refuse intercepted at the gratings of each outfall is taken away for agricultural purposes, with the exception of a small quantity, which is dug into the ground or used as manure on the garden plots attached to the workmen's cottages. In addition to this refuse, large quantities of sand and fine gravel are brought down by the sewers, in times of rain, and deposited in the precipitation channels, from which the deposits are removed from time to time. At the southern outfall a sand pit has been constructed to collect the sand and gravel brought down by the southern outfall sewer No 1. Precipitation operations. Main drainage additional works. Storm relief. 232 Annual Report of the London County Council, 1913. The sludge is taken to sea by the Council's sludge vessels, which are six in number, viz., the "Barking," "Barrow," "Bazalgette," "Belvedere," "Binnie," and " Burns " and each is manned by a staff of officers and crew numbering 24. Each vessel carries a load of about 1,000 tons. During the year under review the vessels made 2,629 trips to and from the deposit area in the Black Deep ; the distance travelled being about 289,190 miles. The vessels are insured for £108,000. The series of experiments which were undertaken during the summer months of 1911 and 1912 at the Northern outfall with regard to the precipitation of sewage were continued, and in this case the experiments were conducted during the four months beginning on 1st December, 1913. A special examination was made of the water of the river Thames between Charing Cross and Grays during the summer months, when the aeration of the water is low, with a view of ascertaining, if possible, the causes which lead to this condition. On 5th December, 1899, the Council approved in principle a scheme of main drainage extension works necessitated by the increasing strain imposed upon the existing system owing to the growth of the population. This scheme was estimated to cost roughly £3,772,550. During the year under review, the two outstanding works comprised in the scheme were completed. The southern low-level sewer No. 2 (Battersea to Deptford) was finished and came into use on 9th January, 1913. The total amount of the tender of Griffiths and Company, Contractors, Limited, for the construction of this sewer, was £481,553 9s. 11d. There are certain matters outstanding in connection with the accounts and the final cost cannot, therefore, be stated. The new sewer is constructed partly of brickwork 5 ft. 6 in. and 6 ft. 6 in. in diameter,and partly of cast-iron lined with concrete 7 ft. 6 in. and 8 ft. in diameter, and including connections, is nearly eight miles long. The extension of Abbey Mills pumping station, the other work referred to,was opened by Mr. Cyril Cobb, M.V.O., Chairman of the Council, on Thursday, 29th May, 1913. This extension was designed to relieve the pressure on the existing plant during times of storm, and it can be used in cases of breakdown, or stoppage for any other reason, of the steam pumps. The new engine-house is 180 feet long by 42 feet wide and contains seven centrifugal pumps with suction and delivery pipes 38 inches in diameter, capable of dealing with 700 tons a minute. Each pump is driven by a vertical gas engine capable of developing 475 b.h.p. at about 160 revolutions a minute. There are certain works which, while not specifically provided for in the scheme, are so closely connected therewith as practically to form part of it, and although their cost was not included when the rough estimate of £3,772,550 was prepared, it is anticipated that their inclusion in the scheme will not cause this estimate to be exceeded. They are (i.) the enlargement of the Crossness pumping station; (ii.) the extension of the southern high-level sewer No. 2 from Catford to Nunhead ; and (iii.) the enlargement of North Woolwich pumping station. The necessity for increasing the pumping power at Crossness arises from the fact that in connection with the main drainage extension scheme, the discharging capacity of the outfall sewers has been doubled, and when, in times of storm, these sewers are full, the pumping power at the outfall is quite inadequate. A new engine-house is being erected, and the tender, amounting to £63,690, submitted by Dick, Kerr and Co., Ltd., has been accepted for the work. The new engine-house will be constructed to accommodate eight main driving steam engines and centrifugal pumps, but, in the first instance, only one half of the machinery, estimated to cost £30,000, will be installed. Owing to labour strikes, which occurred last year, the contractors for the erection of the buildings are much behindhand with their work. Contracts have been let for the supply of boilers, engines, pumps, etc., and during the year the undermentioned tenders for the supply and erection of machinery, etc., have been accepted—John Spencer, Ltd., steam piping, etc., £5,570 ; Walton and Clough, Ltd., coal conveyors and elevators, £625 ; Joseph Booth and Bros., Ltd., overhead traveller, £600 ; Arthur Lowcock, Ltd., fuel economiser, £571; and other tenders have also been accepted for smaller items. The southern high-level sewer No. 2, which was constructed as part of the extension scheme above mentioned, extends from Catford to Crossness, and its gradient is such that the contents of the sewer do not have to be pumped. The extension of this sewer from Catford to Nunhead has been completed by Messrs. Wm. Underwood and Bros., whose contract price amounted to £88,398 14s. 9d. The final figures of the cost of the work are not yet available. Owing to the large increase in the amount of sewage pumped at North Woolwich pumping station the Council on 17th December, 1913, authorised the preparation of plans, etc., for the enlargement of this station, and work upon the plans is in hand. Besides the beam engine-house and the new engine-house above referred to there is at Abbey Mills pumping station another house known as the Worthington engine-house, which deals with the flow of sewage from the Isle of Dogs and a portion of that in the Hackney Wick relief sewer. The engines in this house have not proved satisfactory, and their present condition renders it necessary to remove them. It is proposed to substitute centrifugal pumps driven by small high speed compound vertical engines and it will be possible by this means to provide in the existing building four sets of engines and pumps of more than double the present capacity. The hydraulic machinery for the station will, owing to recent extensions, be increased, and it is proposed to remove it from this house to an annexe to be erected. The total estimated cost of the work proposed amounts to £34,000, and preliminary work, including the preparation of plans, is in hand. Tenders have been obtained for the supply, delivery and erection of a hydraulic engine and accumulator and that of the Leeds Engineering and Hydraulic Company, Limited, amounting to £1,090 has been accepted. There is no separate system of sewers in London for dealing with the surface water apart from the sewage, but large storm-water sewers have been constructed to relieve the main and intercepting Illegal discharges into sewers. Building over sewers. Repairs, etc. Main Drainage. 233 sewers in times of heavy rainfall, and at various points on both banks of the Thames there are storm overflows which can be utilised at certain states of the tide. Pumping stations have also been erected for the sole purpose of pumping storm water into the river and, in addition, arrangements are made for discharging storm water by means of auxiliary engines at the Western and North Woolwich sewage pumping stations. The flood relief scheme of 1904, to which reference has been made in previous reports, is nearing completion, though certain other works are still required, but it is not anticipated that the estimate of the cost (£795,000) of the scheme will be exceeded. One of the most important of these is the enlargement of the storm water pumping station in the Isle of Dogs. The existing plant consists of two steam-driven reciprocating pumps, and it is proposed that the station shall be extended so as to accommodate six centrifugal pumps driven by gas. The cost is roughly estimated to amount to £30,000. Following the practice adopted in similar cases, it has been decided to let a contract for the engines and settle the leading dimensions and afterwards to arrange the new building accordingly. Tenders for the engines have therefore been invited. When the Falcon Brook pumping station was erected, only one-half the pumping power for which the station was designed was installed, but in order to obtain the best advantage for the expenditure incurred and to meet the growing needs of the surrounding district, the Council on 7th- May, 1912, decided to complete the equipment of the station, at an estimated cost of £9,500. Contracts were made for the supply, delivery and erection of three gas engines and for the supply, delivery and erection of three centrifugal pumps during the year 1912, and during the current year the tender of W. H. Lorden and Son, Limited, amounting to £1,112 for the construction of the foundations for the engines and pumps was accepted. In addition to the works included in the enlargement and flood relief schemes which had for their object specifically or incidentally the relief of sewers in the Metropolitan Borough of Wandsworth— (i.) the Wandsworth and Battersea relief sewer; (ii.) the Falcon Brook pumping station, and (iii.) the southern low-level sewer No. 2—it has been found necessary owing to the very large development of building operations in the borough since the schemes were prepared to undertake further works as follows :— (i.) A relief sewer from the junction of Balham High-road and Tooting Bec-road to the river Graveney ; (ii.) the improvement of certain portions of the waterway of the river Graveney ; and (iii.) a sewer (the Wandle-valley sewer) with brunches, from the Wandle sewer extension near Mitcham-road to the Wandle sewer at Summerstown to relieve the low lying areas in the valley of the rivers Wandle and Graveney. A contract amounting to £34,319 has been let for (i.) and (ii.), and work to the value of about £25,000 had been completed at the end of the year. The preliminary work of making drawings, etc., in connection with the Wandle-valley sewer, which is estimated to cost £100,000, is in hand. Section 9 of the London County Council (General Powers) Act, 1894, prohibits the discharge into any sewer of the Council, or any sewer or drain communicating therewith, of any chemical or manufacturing or trade or other liquid refuse, or any waste steam, condensing water, heated water, or other liquid of a temperature exceeding 110 deg. Fahr., which either alone, or in combination with other matters or liquid in a sewer, may cause a nuisance, or involve danger or risk of injury to the health of persons entering the sewers, or be injurious to the structure or materials of the sewers or works of the Council. Copies of an order made by the Council on 20th December, 1898, under section 10 of the Act, prohibiting the discharge of dangerous substances into sewers, were served during the year upon a number of persons licensed under the Petroleum Acts, and carrying on businesses such as might produce residues which would be dangerous if discharged into sewers. By Sections 204 and 68 of the Metropolis Management Acts of 1855 and 1862 respectively, the erection in, on, over, or under any sewer of a building, wall, bridge, fence, etc., without the previous consent of the Council is prohibited. During the year 31 licences to carry out works, or to retain existing work over sewers, were granted. After the opening of the new engine-house at Abbey Mills pumping station, steps were at once taken to overhaul the existing machinery at the station. The isolating valves in the beam engine-house which shut off the various sections of the discharge culverts were in need of overhaul and repair. Owing to their construction, they could not be opened without shutting down the whole of the beam engines, and until the new plant was available, this was not possible. There are five valves concerned and the tender of Hunter and English, Ltd., amounting to £1,450 for the work was accepted. In connection with the proposed extension of the Hackney Metropolitan Borough Council's electricity generating station at Clapton, it was decided to divert that portion of the Marsh sewer, which otherwise would have been situated under the new buildings. The Borough council agreed to pay twothirds of the cost of diverting the sewer and, in view of the condition of the old sewer, the Council agreed to pay the remaining one-third, which was estimated to be about equivalent to the cost of repairing the old sewer. The tender of Mr. Daniel T. Jackson amounting to £1,350 for the work was accepted. Certain modifications were subsequently made and it is anticipated that the cost will be below the amount of the tender. Other works of repair, etc., undertaken during the year, and the expenditure sanctioned therefor in each case were as follows :— Northern Outfall.—Renewal of water mains, £1,760 ; repairs to pier, £1,200; new locomotive crane, £675 ; new locomotive, £615. Southern Outfall.—New valves for beam engines, £405. North Woolwich Pumping Station.—Overhaul of engines and pumps, £150. 23610 HH Local sewers. 234 Annual Report of the London County Council, 1913. Abbey Mills Pumping Station.—Repairs to river bank, £947 ; renewal of steam piping' £400; repainting cottages and alterations to sanitary arrangements, etc., £741. Abbey Mills, North Woolwich and Isle of Dogs Pumping Stations.—Repainting, £878. Western, Lots Road and King's Scholars' Pond Pumping Stations.-—Repainting, £567. Northern Outfall Sewer.—Repainting bridges, £2,081. Repairs to Sewers.—Ravensbourne and Sydenham, £1,080 ; Ravensbourne and Lee Green, £300; Regent-street sewer (west branch), £1,000; Northumberland-street sewer, £1,000 ; London Bridge sewer, £1,000 ; RatclifE-highway sewer, £500. Sludge Vessels.—Overhaul and repair, £4,160; provision of new lifeboats, etc., £850. Section 69 of the Metropolis Management Act, 1855, provides that no new local sewer shall be made without the previous approval of the Council and, during the year, sanction was given for the construction of local sewers as shown in the subjoined table. Size. North of Thames. feet. South of Thames. feet. Total length. feet. 4 ft. 3 in. by 2 ft. 10 in. — 330(g) 330 4 ft. by 2 ft 8 in — 1,400(h) 1,400 4 ft by 2 ft. 6 in. 200 — 200 3 ft. 9 in. by 2 ft. 6 in. 360(a) '— 360 3 ft. by 2 ft. 18 — 18 3 ft. — 1,5000(j) 1,500 2 ft. 6 in. — 100(k) 100 2 ft. — 1,460(l) 1,460 1 ft. 9 in. 990(6) — 990 1 ft. 6 in. 2,960(c) 160(m) 3,120 1 ft. 3 in. 2,595(d) 2,020(n) 4,615 1 ft. 16,035(e) 6,750(o) 22,785 9 in. 4,750(f) 8,470(p) 13,220 6 in. — 955 955 Totals 27,908 23,145 51,053 Staff. During the year increases of pay were granted to various employees in the service other than those whose wages had recently been revised and the officers on the sludge vessels. The amount of the increase granted, with few exceptions, was ½d. an hour to men employed at hourly rates of pay, and 2s. a week to men employed at weekly rates. The total cost of increased wages granted during the year amounted to nearly £4,700 a year. (a) Reconstruction 360 feet. (b) Including 230 feet reconstruction. (c) „ 440 „ „ (d) „ 110 „ „ (e) „ 3,425 „ „ (f) „ 2,960 „ „ (g) Reconstruction 330 feet (h) „ 1,400 „ „ (j) Reconstruction (k) „ (l) Including (m) Reconstruction (n) Including (o) „ (P) „ 1,500 feet. 100 „ 1,330 „ reconstruction 160 „ 1,450 „ reconstruction 4,315 „ „ 1,355 „ „ Powers and duties of the Council. Housing of the Working Classes. 235 Legislation. Closing orders, &c. School sites on insanitary areas. CHAPTER XXXVI. HOUSING OF THE WORKING CLASSES. The powers of the Council with respect to the housing of the working-classes are derived from the Housing of the Working Classes Acts, 1890 to 1909, and questions relating thereto are considered by the Housing of the Working Classes Committee. Part I. of the Housing of the Working Classes Act, 1890, as amended by the Acts of 1903 and 1909, places upon the Council the duty of preparing and carrying into effect (after confirmation by the Local Government Board) schemes for the re-arrangement and reconstruction of the streets and houses within insanitary areas which are of such size as to be of general importance to the whole County of London. Any scheme for dealing with such an area must provide for the demolition of the old houses, and the re-arrangement, so far as is necessary for purposes of health, of the streets and alleys comprised therein, and must also provide for the accommodation of at least half the number of persons of the working classes displaced, in suitable dwellings, which, unless there are any special reasons to the contrary, must be situated either on the particular area of displacement or within its immediate vicinity. Part II. of the Act empowers the Council and the metropolitan borough councils, either jointly or separately, to undertake schemes for the re-arrangement and reconstruction of insanitary areas which are too small to be of general importance to the whole County. In any such schemes it is not essential that new accommodation for the persons displaced should be provided, but the Local Government Board may order such provision to be made as may appear to be required by the circumstances. Provision is also made in this part of the Act for the removal of buildings which obstruct the access of light and air to other houses. The Housing, Town Planning, etc., Act, 1909, empowers the metropolitan borough councils to order the closing and demolition of individual insanitary houses, a right of appeal to the Local Government Board being reserved to the owner of the property. The Council has power to take action in default of a borough council, both as regards obstructive buildings and closing and demolition orders. Part III. of the Act of 1890, as extended by the Acts of 1900 and 1909, empowers the Council to acquire land, either within or without the County, and to provide thereon accommodation for persons of the working classes, apart altogether from any displacements that may have taken place. The Act of 1903 provides that where dwellings occupied by 30 or more persons of the working classes are acquired under statutory powers other than the Housing Acts, e.g., in connection with the carrying out of public improvements, the dwellings shall not be entered on until the Local Government Board has approved a scheme for rehousing the persons to be displaced, or has decided that such scheme is unnecessary. As stated above the metropolitan borough councils are the authorities in London for the administration of the provisions of Part II. of the Housing of the Working Classes Act, 1890, and the Housing, Town Planning, etc., Act, 1909, relating to closing and demolition orders and the removal of obstructive buildings, the Council only having the power of acting in default, in which case it must recover the expenditure incurred from the defaulting authority. The vigorous enforcement of these provisions would, in the Council's opinion, do much to ameliorate the evils existing in many unhealthy areas and groups of insanitary houses, which are, unfortunately, far too numerous to permit, on account of the excessive cost, of their being dealt with in a complete and comprehensive manner by means of improvement or reconstruction schemes. It was thought that in some cases borough councils might consider that extensive operations under Part II. of the Act of 1890 might involve expenditure which could not fairly be imposed upon the borough rate, and that the expenditure would in such instances, especially where the assessable value of the borough was not high, be more equitably borne by the county rate, with perhaps a contribution from the borough rate. This cannot be done under the present law, and, consequently, work under Part II. of the Act, which ought to be taken in hand, is probably sometimes left undone or delayed. In order to surmount this difficulty, therefore, it was decided to make application to Parliament for powers to enable the Council, by agreement with any metropolitan borough council, at the request of such council, to exercise on any occasion the powers of the borough council with regard to closing and demolition orders and the removal of obstructive buildings and to defray the whole or a part of any expenditure incurred in the exercise of such powers. The proposed legislation is intended to supplement, and not in any way to detract from, the present powers of the metropolitan borough councils, and action under the new powers, if obtained, can only be initiated at the request of, and must be the subject of future agreement with, the borough councils concerned. The Council had under consideration during the year the question of the choice of sites and the character of the houses which have to be demolished for the purposes of new schools. It is found in practice, when acquiring a site for a new school, that it is often much cheaper to take good residential property with large gardens than a slum area upon which the buildings are thickly crowded. The Council, as the education authority, feels bound to acquire the site involving the minimum of expenditure, and the result is that often well-built and respectably occupied houses are destroyed leaving insanitary property in the neighbourhood. It is obvious that the reverse policy should prevail if this can be done without sacrifice of suitability, but the Council felt that if the selection of a slum area for a school site is made in the interests of public health and housing, the additional cost should not 23610 HH 2 Action taker under Parts I. and II. of the Act of 1890. Tabardstreet, etc., scheme. 236 Annual Report of the London County Council, 1913. fall on the education account. The Council took the view that it would be equitable in such event to charge a portion of the cost against the Dwelling House Improvement Fund, out of which expenditure on schemes under the Housing Acts for the re-arrangement or reconstruction of insanitary areas is met. This the Council has no power to do under the present law and it was decided, therefore, that application for the necessary authority should be made to Parliament in the session of 1914. It often happens that a metropolitan borough council urges the acquisition of an alternative site which, for the reasons stated above, would be more expensive than that selected by the Council, and in certain circumstances the borough council might be disposed to bear some portion of the additional cost involved by taking the more expensive site. It was therefore deemed desirable to include in the application to Parliament a provision to enable any borough council to enter into a voluntary agreement with the Council to contribute towards the cost should it deem it desirable to do so. Under Parts I. and II. of the Housing of the Working Classes Act, 1890, the Council has completed 13 schemes involving the displacement of 16,639 persons of the working classes, and in lieu of the old houses which it has caused to be demolished, has provided new dwellings capable of accommodating 15,020 persons. The Council is at present carrying out another large scheme under Part I. of the Act of 1890, known as the Tabard-street, Grotto-place and Crosby-row (Southwark and Bermondsey) Scheme, 1910, which provides for the clearance of three distinct areas comprising altogether about 17 acres. The scheme involves the displacement of 4,552 persons of the working classes, and rehousing accommodation has to be provided on the Tabard-street area for not less than 2,580 persons. The gross cost of the scheme, exclusive of the cost of erecting the new dwellings, is estimated at £467,000, and the net cost at £389,900. Progress has been made during the year with the acquisition of the various interests in the properties required for the scheme. The first section of the Tabard-street area has been cleared and a new road, 40 feet wide, constructed from Tabard-street to Long-lane. At the end of the year under review tenders were about to be invited for the erection on this section of the area of tenement dwellings designed to accommodate 570 persons. In connection with the scheme, the Council will acquire three fully licensed public-houses and also one house with a beer licence. In accordance with the usual practice of the Council all these licences would be extinguished but, the Council during the year, without departing from its general principles in connection with licensed premises, decided to give favourable consideration to an application from the Home Counties Public House Trust, Limited, for the grant of a lease of a site on the Tabard-street area with a view to the erection of a new public-house to be conducted upon the company's special principles of disinterested management. The proposal was to secure the transfer to this new house of the licence attached to one of the existing public houses. The business was to be conducted upon methods entirely different from those which govern the management of ordinary public-houses, the object of the Trust being not to make large commercial profits, but, while paying a limited dividend necessary to obtain capital funds, to carry out a work of social and temperance reform.* During the year the Council considered an official representation under Part I. of the Act of 1890 relating to an area, about 7 acres in extent, known as the Brady-street area, Bethnal Green. The representation included 528 houses and tenements inhabited by 3,058 persons of the working classes. The density of population on the area was about 430 to the acre, as compared with 169 to the acre for the borough of Bethnal Green, and 60 to the acre for the whole county of London. The death rate of the area was stated to be 24.74 per thousand, as against 16.71 for the whole borough and about 14 for all London. Many or most of the houses on the area were in as hopelessly bad and decayed a condition, as incapable of being made fit for human habitation, and as deserving of destruction as those in the Tabard-street area. On the other hand, the ground plan construction of the Brady-street area, although very defective, was not so objectionable as in the case of Tabard-street. The Council felt that much could be done to mitigate the evils existing in the area by a vigorous enforcement of the provisions of the Acts with regard to closing and demolition orders and a judicious application of section 38 of the Act of 1890, which provides for the removal of obstructive buildings. The borough council, whose duty it is to enforce these provisions, was averse from adopting this method on the ground that they would not be effective, and that the cost incurred would fall exclusively upon the local rate. What mainly influenced the Council in arriving at a decision with regard to this area was the important question of relative expense and the serious question whether the owners of the property should not be called upon to bear a much larger part of the burden of improving or removing their unhealthy and decayed houses. The Council felt that, under the present law, and with the existing practice in valuation by arbitrators, landowners received and the ratepayers had to pay too much for property of this description. The attention of the public and Parliament had been strongly directed towards necessary reforms in the provisions of the Housing Acts. A bill for this purpose passed the second reading by a decisive majority in the House of Commons in the session of 1913. This bill, apart from the * The Council was obliged subsequently to abandon the experiment owing to the refusal of the licensing justices to grant a transfer of the necessary licence either to the managing director of the Trust or to a resident manager. Brady-street area. Capital expenditure on clearance. Rehousing in connection with improvements, etc. Housing of the Working Classes. 237 tested proposal of national grants in aid of local authorities for housing purposes, contained important pro visions modifying, in certain cases, the principles of valuation and compensation. This bill was withdrawn in Comnittee, but the discussions connected with it elicited pronouncements both from Ministers and leading members of the Opposition, which showed that early legislation might be confidently expected, and would be of a thorough character. It was not, therefore, in the opinion of the Council, expedient to arrive at a final decision at the time as to the method of dealing with the Brady-street and similar areas, until it was possible to see the exact form taken by the promised legislation. It was clear that anticipatory announcements of this kind made by responsible leaders, must have the effect of arresting any large action and expenditure in the matter by local authorities until the result was seen. The Council, on 29th July, 1913, passed a resolution to the effect that, after having considered the official representation, it was not at the time prepared to undertake an improvement scheme under Part I. of the Housing of the Working Classes Act, 1890, in view of the fact that further legislation on the subject was practically certain at no distant date, and that such legislation would in all probability enable the area and other similar areas to be dealt with in a more satisfactory manner and at less cost to the ratepayer than was the case under the existing law. The Council's decision was conveyed to the Local Government Board and an inquiry was held by one of the Board's inspectors on 24th October, 1913. The matter was still under consideration at the end of the year. The amount expended on capital account by the late Metropolitan Board of Works and the Council up to 31st March, 1914, in respect of the clearance of insanitary areas (exclusive of the cost of erecting new buildings), amounted to £3,469,901 13s. 0d., while the receipts derived from rents and sales of land, including the amounts charged against the accounts of the dwellings for the housing values of sites appropriated for that purpose, together with the contributions from local authorities towards the cost of carrying out Part II. schemes, amounted to £906,740 1s. 1d. thus leaving the net expenditure at £2,563,161 11s. 11d. In carrying out public improvements other than schemes under the Housing Acts, involving a statutory obligation to rehouse, the Council has displaced 12,244 persons of the working classes, and has provided accommodation in new dwellings for 12,911 persons in lieu of that destroyed. The displacement of persons of the working classes by the Council does not always involve a statutory obligation to provide rehousing accommodation, and, in numerous cases where such obligation has existed, the Local Government Board has, in the exercise of its powers under the Act of 1903, dispensed with the necessity for a special housing scheme. On 14th October, 1913, the Council considered the question of the policy to be pursued with regard to the very large displacement of persons of the working classes involved in the acquisition of property over which compulsory powers of purchase for purposes of the education service were obtained in the session of Parliament of 1913. The number of persons of the working classes to be displaced in various parts of the county amounted to upwards of 6,500, of whom about 3,000 were resident in the four eastern metropolitan boroughs of Poplar, Stepney, Bethnal Green and Shoreditch. In view of the extent of the displacement the Council recognised the necessity for taking action to ensure the provision of adequate housing accommodation in the metropolitan area as a whole, but the Council was averse from undertaking the erection of any further dwellings in the central and thickly built-over parts of London, unless it could be shown that the accommodation was needed for special purposes and for special classes. The Council thought that it should rather meet the requirements of the situation created by this extensive demolition of working-class houses by the provision of cottage dwellings in the suburbs, under Part III of the Housing of the Working Classes Act, 1890, relying upon cheap and rapid transit to convey the workmen to and from their places of employment. Having regard to the somewhat controversial nature of the proposal to provide the new accommodation at a distance from the area of displacement it was decided that the Council's views upon the subject should be laid before the President of the Local Government Board by a deputation of members of the Council. The President in his reply to the deputation said that he knew the difficulty with which the Council had to contend, and that in the past he had done all he could to meet the Council. He could not give any pledge in advance that rehousing in any areas would not be required, for he had to bear in mind his parliamentary duties and obligations, but that he would put the Council to the least expense consistent with the due discharge of these. There should be no difficulty, when the Council could, make out a case, for a dispensation to be granted, but he was unable to give a more definite assurance as he must deal with every case on its merits. The Board took a broad view of the situation, and had regard to travelling facilities by tramway, omnibus and railway, and other factors of the problem such as rates and questions of health. After careful consideration of the whole question by the Council formal application was made to the Local Government Board to decide that it was not necessary to provide new dwellings in the vicinity of the displacements for rehousing the persons of the working classes to be displaced from properties required for purposes of the education service over which compulsory powers of purchase were conferred in the parliamentary session of 1913. During the year the Local Government Board released the Council from rehousing obligations as regards 575 persons of the working classes displaced from properties over which compulsory powers of acquisition had been obtained mostly for purposes of the education service. The Council also decided during the year that special rehousing schemes were not necessary in respect of the displacement of 471 persons from certain other properties acquirod for similar purposes, there being no statutory obligation to rehouse these people. Common lodging houses. Action taken under Part III. of the Act of 1890. White Hart lane estate. 238 Annual Report of the London County Council, 1913. The Council has provided three model lodging-houses for men containing altogether 1,874 cubicles, viz. : Parker-street House and Bruce House, Drury-lane, and Carrington House, Deptford. Under Part III. of the Housing of the Working Classes Act, 1890, the Council has voluntarily provided in various parts of the county a number of tenement dwellings capable of accommodating 4,068 persons, and, in addition, it has acquired four suburban estates at Tottenham, Tooting, Norbury and Hammersmith, comprising about 286 acres, for the erection of cottages. Up to 31st December, 1913, 2,896 cottages with accommodation for 21,164 persons had been completed on these estates, making a total accommodation for 25,232 persons provided under Part III. of the Act, exclusive of certain dwellings and lodging houses which, although erected under Part III., were provided to fulfil statutory rehousing obligations. The White Hart-lane Estate, Tottenham was purchased in 1901 at the rate of £400 an acre, the total purchase money amounting to £90,225. It consists of two detached sections, of which the northern contains about 49J acres, and is about 440 yards distant from the southern portion which is now in course of development. In 1907 the Council commenced to review its policy with regard to the further development of this estate, and correspondence on the subject ensued with the Local Government Board. Ultimately the Council on 26th July, 1910, came to the conclusion that a large proportion of the estate was not required for housing purposes, and permission was sought of the Local Government Board to dispose of some 90 acres of the land. The Board consented to the sale of the northern (detached) portion of about 49¾ acres, and efforts are now being made to dispose of it. As to the remainder the Board thought that sufficient grounds had not been adduced for the sale [of any part of the main (southern portion) of the estate and declined, therefore, to comply with the Council's application in this respect. The Council saw no reason to modify its conclusion that the estate, which without the northern portion comprises some 172¾ acres, was too large to develop solely for cheap-rented dwellings, and, as a way out of the difficulty, application was made to Parliament in the session of 1912 for powers to enable the Council to develop the land on the lines of a garden suburb and not solely for the accommodation of the working classes, and, further, for authority to lease separate plots of land for the erection of better class houses. The Council sought a tree hand in the development of the estate on the lines of a garden suburb, but Parliament, while allowing the land to be used for this purpose, decided that the actual development should be in accordance with a scheme to be prepared by the Council and approved by the Local Government Board. A provision was also inserted in the Act to prohibit the Council itself erecting houses for any other than the working classes, but, on the other hand, the power proposed by the Council to enable it to lease portions of the land in plots for middle class houses was extended by allowing the scheme above mentioned to authorise the Council to sell or let on lease any or all of the land for the purpose of a garden suburb. Further, the scheme may confer exemptions from local by-laws and regulations as to streets and buildings. A preliminary scheme for the development of the remainder of the southern portion of the estate (124½ acres) has been prepared including details of the modifications of the local by-laws for which it is proposed to apply, and will be submitted to the Local Government Board for its approval. The scheme provides for the erection of working-class cottages on 62 acres and for the sale or lease of 43 acres for better class housed, the remaining 19½ acres being devoted to public buildings, open spaces, etc. It is proposed, when the scheme is approved, to proceed to lay out the whole of the southern portion of the estate for the purposes of a garden suburb, to proceed with the erection of working-class dwellings on a portion of the land, and to arrange, as and when opportunity offers, for the sale or lease of the remainder for the erection of houses of a better class although it is doubtful whether it will be practicable to build middle class houses on this estate to be let at more than a very moderate rent. The preliminary estimate for the cost of the roads, sewers and general development, including the provision of open spaces, is £84,500, and for the working-class cottages, £364,000, making a total estimated expenditure of £448,500. Of this sum only £414,000 is applicable to the working-class portion, the remainder being in respect of the construction of roads on the portion to be set apart for better class houses. The scheme provides for the construction of two main avenues, 100 feet wide, starting from the south-east and south-west corners, meeting near the northern boundary of the estate and continuing in a northerly direction. This follows approximately the lines indicated by the London Traffic Branch of the Board of Trade for a main arterial road (the new Cambridge road) running north and south between the Enfield-road on the west and the Cambridge (or Hertford) road on the east, connecting at intervals with each of the old main roads. These two main avenues will be constructed of the full width of 100 feet only in the event of the Road Board consenting to bear a portion of the cost, and the Board has been asked whether it would be prepared to make a suitable contribution out of the Road Improvement Fund. The development of the estate was proceeded with during the year. Roads and sewers have been constructed on about 48¼ acres of the estate adjoining Lordship-lane, and 875 cottages, with accommodation for 6,835 persons, have been erected on the land. During the year the Council accepted a tender for the erection of 9 cottages and a doctor's house at an estimated cost of £3,205, and approved an estimate amounting to £23,468 for the construction of roads and sewers and the erection of 79 cottages on a further portion of the estate. About 28 acres have been laid out as allotments for the benefit of the tenants of the cottages and 3⅓ acres have been laid out as an estate garden. Totterdown Fields estate. Norbury estate. Old Oak estate. Housing of the Working Classes. 289 Administrative buildings are about to be erected, and five shops have been built along the frontage to Lordship-lane, between Waltheof-avenue and Kevilioc-road. During the year the adminstrative buildings at the Totterdown Fields estate, Tooting, were altered and enlarged, extra coal bunks were provided at 72 cottages and inside entrance lobbies were added to 225 of the older three-roomed cottages. The cost of the work was estimated at £989. On the Norbury estate, Croydon (28½ acres) roads and sewers have been constructed and cottages have been erected on about 16¾ acres, and the work of finishing, the roads has been carried out by the Croydon Corporation. Up to 31st December, 1913, accommodation for 3,472 persons had been provided in 472 cottages. Four shops have also been provided. A scheme has been approved by the Council for the development of the remainder of the estate, comprising ll¾ acres, at an estimated cost of £74,000 for the building work and £10,850 for roads, sewers and general development. The scheme provides for the erection of 133 cottages of three rooms and scullery, 35 cottages of three rooms and scullery with small additional bedroom to accommodate one person, and 122 cottages of four rooms and scullery, making a total of 290 cottages. All the cottages, with the exception of 42 of the smallest, will be fitted with bath-rooms. The rents will range from 7s. 6d. to 10s. 6d. a week inclusive. Two shops with dwelling accommodation of five rooms each will also be provided and two-thirds of an acre will be reserved to form part of an open space of two acres which it is proposed to provide jointly with the owners of an adjoining estate. A tender for the construction of the roads and sewers was accepted in June, 1913, and the work was well advanced by the end of the year. The Old Oak estate, Hammersmith (46½ acres), is now in course of development. On the western section of the estate, comprising about 14½ acres, 304 cottages and cottage flats, with accommodation for 2,124 persons, and 5 shops have been erected, and 14 additional cottages are being constructed at an estimated cost for buildings and plans of £4,380. Administrative buildings with an estate office, workshop and store and dwelling accommodation for the superintendent have been provided. A scheme has been provisionally approved for the development of the eastern section of the estate (32 acres) by the erection of 721 cottages and two shops at an estimated inclusive cost for buildings, roads, sewers and incidental works of £218,256. Particulars of the proposed cottages and of the rents at which they can be let are as follows :— Number of cottages. Particulars of accommodation. Rents. 80 85 162 105 37 252 721 Five rooms, scullery and bathroom Four rooms, and small additional bedroom, scullery and bathroom Four rooms, scullery and bathroom Three rooms, and small additional bedroom, scullery and bathroom Three rooms, scullery and bathroom Three rooms and scullery 12s. 6d. a week. 11s. 6d. and 12s. a week. 9s. 6d. to 10s. 6d. a week. 9s. and 9s. 6d. a week. 8s. 6d. a week. 7s. 6d. and 8s. a week. The rents mentioned, which are inclusive of rates, have not been definitely fixed, but are subject to slight adjustment at a later stage. It will be seen that the majority of the cottages, as at the Norbury estate, will comprise three or four rooms for which rents varying from 7s. 6d. to 10s. 6d. a week will be charged. The Council feels that those who require larger houses than those now proposed and who can afford to pay higher rents are provided for by private enterprise. Most of the five-roomed cottages will be erected on the frontage facing Wormwood-scrubs. A tender amounting to £13,100 for the construction of roads and sewers on the eastern section was accepted on 29th July, 1913, and the work is proceeding. When it is sufficiently advanced building operations will be commenced, the Council having already voted the expenditure for about half the total number of cottages to be erected. A church is to be erected on the estate by the Ecclesiastical Commissioners, from whom the estate was purchased. The Great Western Railway Company has been asked to provide a station or a halt on the branch line which is being constructed from Ealing to Shepherd's Bush and which crosses the estate. Such provision would be a great convenience to the tenants on the estate. A temporary school has been erected and a site is about to be allocated for the provision of permanent school accommodation. An acre and a quarter of land abutting on the housing estate and Wormwood-scrubs was acquired for the purpose of constructing an outlet from the eastern section of the estate in the north-west corner. The portion of this land, about one acre in extent, not required for the proposed new road has been added to the open space. Dwellings capable of accommodating 1,982 persons were completed during the year 1913 at an approximate cost for buildings and plans of £63,708. The erection of new cottages designed to accommodate 170 persons and other works incidental to the development of the various estates were undertaken during the year, and the total cost thereof is estimated at £36,200. The standing orders of the Council require that all dwellings shall be so designed that the cost of erection may not exceed a sum which will enable all outgoings, interest, and sinking fund charges, Dwellings provided by the Council. New working-class accommodation. Housing development and workmen's fares. History of housing question 240 Annual Report of the London County Council, 1913. to be paid without placing a charge upon the county rate, and the rents to be charged are not to exceed those ruling in the neighbourhood. Some of the dwellings erected by the Council do not fulfil these requirements, but this is mainly due to the fact that the Council was obliged to build on sites which were so unsuitable as to be unsaleable for the purpose. The Council's dwellings, on 31st December, 1913, contained accommodation for 57,196 persons, reckoned on the basis of two persons a room. With a view to the Council being kept informed as to the provision of working-class accommodation in London and the adjoining districts, a return* is prepared each year showing the amount of new accommodation provided and old accommodation destroyed. The return, which has been prepared for the years 1902 to 1912 inclusive, gives the number of working-class tenements and rooms provided in each borough or district and the rents at which they are let or to be let, and also particulars of the demolitions which have taken place in each district during the year. The return for 1912 shows that for the first time since this record was taken in 1902 there has been a net reduction for the year in the amount of working-class accommodation in the county of London, the number of rooms demolished (6,790) having exceeded the number provided (4,167) by 2,623. In extra-London, i.e., the area known as Greater London exclusive of the county of London, the number of rooms provided was 13,141 and the number demolished 807, or a net addition of 12,334. The average weekly rents at which the new dwellings were let or to be let were, during 1912, 3s. 5¾d. a room in the central districts of London, 2s. 7d. in the outer districts of London and 2s. 4¼d. in the extra-London districts. During the year the Council published a report dealing with the distribution of the working' class population in and around London and the trend of development in suburban districts, as to areas which are yet unbuilt upon, as to districts which are not adequately provided with cheap travelling facilities, and as to the services of motor omnibuses to and from such districts.† A revised account of the Council's housing work up to 31st December, 1912, has been published.‡ * New working-class accommodation. † Housing development and workmen's fares. ‡ Housing of the Working Classes in London, 1855-1912. Housing Accounts and Statistics. 241 CHAPTER XXXVII. ACCOUNTS AND STATISTICS. Working Class Dwellings Accounts, 1919-14—Memorandum by the Comptroller, (Mr. H. E. Haward). These accounts are prepared, subject to audit, in advance of the Annual Accounts of the Council Summary of for the year ending 31st March, 1914. They comprise all the dwellings and lodging houses erected or of owned by the Council. These dwellings are provided either (a) under the Housing of the Working Classes Act, 1890 (Parts I., II. and III.), or (b) under Improvement Acts. The following are the results of the year 1913-14, after interest and sinking fund charges have been met. Details are shown by the Revenue Accounts (pages xlvii. to xlviii.). The results for the year 1912-13 are also given for the purpose of comparison. 1913-14 1912-13 Dwellings— £ s. d. £ s. d. Housing of the Working Classes Act, 1890 Surplus 14,176 - 5 7,562 16 2 Improvement Acts Surplus 4,133 9 - 3,093 18 9 Surplus on dwellings 18,309 9 5 10,656 14 11 Estates in Course of Develoment Deficiency £4,292 11 2 Less—In respect of the utilisation of the 4,322 14 - Acquisition of Lands Fund 1,860 6 3 963 6 - 2,432 4 11 3,359 8 - Net surplus on all dwellings and estates 15,877 4 6 7,297 6 11 The increase in the surplus as compared with 1912-13 is due chiefly to the additional cottages on the large estates completed in 1913-14, and to improved lettings generally during the year, the decrease in the loss due to empty tenements being £4,144. Another cause of the increased surplus is the change in the method of dealing with the Council's stock debt (referred to in the memorandum on last year's accounts) which operates to diminish the charges in respect of debt on this service. Housing of the Working Classes Act, 1890. The Council's operations under the Housing Act comprise (a) dwellings erected under Parts I. and II. of the Act to provide rehousing accommodation for persons displaced by schemes for the clearance of insanitary areas, and (b) dwellings erected under Part III. of the Act to provide accommodation for persons of the working classes, apart from any displacements. Dwellings erected under Parts I. and II. represent, therefore, compulsory provision for rehousing under statutory obligations, whereas dwellings under Part III. represent housing accommodation voluntarily provided by the Council. In certain instances of compulsory rehousing it has been necessary to erect dwellings on sites, on the working of which, owing to their character or situation, an unfavourable financial result was anticipated from the first. These cases are separately shown in the accounts. The account under Part III. is sub-divided to show the results of the dwellings apart from the debt charges on estates in course of development, which are referred to in a subsequent paragraph. Results of year. The results of the year's working under the Housing of the Working Classes Act, 1890 (details on pages xlvii. and xlviii.), are as follows:— Part I £ Surplus 8,258 s. 16 d. 2 „ II Surplus 556 8 11 „ III.—Dwellings Surplus 5,360 15 4 Surplus on dwellings 14,176 - 5 Part III.—Estates in course of development Deficiency 2,432 4 11 Net Surplus for Housing Act 11,743 15 6 Income. The surplus on dwellings under Part III. is after allowing for a deficiency of £1,324 19s. 7d. in respect of Carrington House, a lodging-house erected under Part III. but in fulfilment of rehousing obligations in connection with the Mill-lane, Deptford, scheme under Part II. The gross rental for the year from dwellings under the Housing Act was £170,866 6s. 2d. (page xlvii.). Deducting therefrom allowances for empties, caretakers' quarters and amounts irrecoverable, the net rental amounted to £163,801 14s. 5d., exclusive of £764 13s. 1d. for interest on cash balances. The amount of rent irrecoverable was £149 11s. 7d., or only 0.09 per cent. of the gross rental. The total 23610 11 Expenditure 242 Annual Report of the London County Council, 1913. loss of income due to " empties " was £5,768 12s. 5d., or 3.38 per cent, of the gross rental, as against 5.54 per cent. in 1912-13. Of this loss, £4,050 occurred on four estates, viz., Carrington House, (£2,928, or 38.07 per cent. of gross rental), Preston's-road Estate (£582, or 14.62 per cent.), Hughes Fields Cottages (£361, or 17.59 per cent.), and Hughes Fields Dwellings (£179 or 14.02 per cent.). The total expenditure on dwellings was £150,390. 1912-13. Per cent, of gross rental. Working Expenses— Supervision and collection of rent Rates and taxes (less tax on interest on debt recovered) 1913-14. Per cent, of gross rental. £ £ 10,457 6.35 11,014 6.44 27,621 16.77 29,882 17.49 8,234 5.00 Lighting, heating, water and insurance 8,844 5.18 234 0.14 Stores and incidentals 207 .12 16,944 10.29 Repairs and renewals (transfers to fund) 17,686 10.35 63,490 38.55 67,633 39.58 Debt Charges— Interest (gross) Land £11,934 Buildings 56,111 70,151 42.60 68,045 39.82 Sinking Fund— Land 2,558 Buildings 12,154 13,616 8.27 14,712 8.61 147,257 89.42 Total Expenditure 150,390 88.01 10,381 6.30 Net deductions from gross rental (empties, etc.) 7,065 4.14 Surplus on dwellings (excluding interest on cash balances) (£13,443, less £32) 7,025 4.28 13,411 7.85 164,663 100.00 Gross rental 170,866 100.00 Repairs and renewals fund, A statement is appended (pages li. and Iii.) showing the percentages on gross rental of the several items of income and expenditure for each estate. The repairs and renewals fund has been established with the view of equalising the charges against revenue under this head between one year and another, as the expenditure in future years will naturally be larger than at present, when many of the buildings are new. The sums charged to revenue account and carried to this fund are based on the estimated cost of all repairs and renewals during the loan period, after deducting interest earned on the accumulations of the fund. The credits to this fund during the year exceeded the expenditure thereout by £308 13s. 4d. The amount standing to the credit of the fund on 31st March, 1914, was £44,001 8s. 1d., of which £41,396 15s. 10d. was invested (page lvii.). Estates in course of development The interest and sinking fund charges, less receipts in aid, in respect of the capital outlay on lands acquired under Part III. of the Housing of the Working Classes Act, 1890, and still in course of development, are included in a separate account. The charge on the rates in respect of the deficiency under this head for the year 1913-14 was £2,432 4s. 11d., after deducting £1,860 6s. 3d. in respect of debt charges on the capital expenditure met out of the special fund for the acquisition of lands under Part III., referred to in a following paragraph. The aggregate amount raised in the rates to 31st March, 1914, is £80,687 7s. 1d. (page lvii.). This amount includes the annual instalments of sinking fund to redeem debt. The amount raised in the rates has now been repaid to a considerable extent from the surplus on the completed dwellings (see statement on page 245). Special fund for the acquisition of lands under Part III. of the Housing of the Working Classes Act, 1890. The Council purchased Millbank Prison site under Part 111. of the Act, and when the Council decided, with the sanction of the Home Secretary, to utilise a portion of this land for the purpose of rehousing persons displaced in connection with the Thames Embankment Extension and Improvements at Westminster, carried out under the London County Council (Improvements) Act, 1900, it was arranged that the Westminster Improvement Account should be charged, and the Part III. Account credited with a sum of £50,000, whioh has, under the statute, to be applied towards "the cost of the acquisition by the Council of other lands for the purposes of Part III. of the Housing of the Working Classes Act, 1890." After defraying certain expenditure on the Millbank Site Account, the fund amounted, with interest, on 31st March, 1914, to £55,324 4s. 9d. (page xxxvi,). In accordance with the powers conferred by the London County Council (General Powers) Act, 1908, the Council decided to utilise these moneys in connection with the development of the Old Oak estate. The whole fund has now been so utilised. The sum of £1,860 6s. 3d. being the debt charges for the year 1913-14 on the expenditure met out of the moneys of the Fund has, in accordance with the Council's decision, been taken in reduction of the amount raised in the rate in respect of the development of estates under Part III. Capital expenditure and debt on dwellings and estates. The capital expenditure during the year 1913-14 amounted to £60,993 19s. 7d. (page xxxiii.) and the total expenditure on capital account on the dwellings and estates to 31st March, 1914, was £2,278,374 16s. 7d. (page xxxiv.). The Summary of Financial Results (pages liii. and liv.) shows the apportionment of this figure as between land and buildings. With regard to dwellings erected to rehouse persons displaced by clearance schemes under Parts I. and II. of the Act, the Council's practice is to charge the capital account of the dwellings with the value of the site as earmarked for housing purposes, the account of the clearance scheme being credited with this value. The latter account, which is charged with the cost of clearance and laying out (less sales), is thus placed in the same position as it would have been if the Council had disposed of the land for the erection of dwellings. In the case of dwellings erected under Part III. of the Act the total cost of the land and of its development for building is ohargeable against the dwellings. Housing of the Working Classes—Accounts, 243 A statement is appended (page lix.) showing the estimated commercial value and housing value of all sites utilised for the erection of working class dwellings under Parts I. and II. of the Act, whether the dwellings have been erected by private enterprise or by the Council. As regards sites sold to Dwellings Companies, the aggregate commercial value at the time of disposal is estimated at £472,100, and the aggregate housing value as represented by cash received from Dwellings Companies is £198,915 (page lix.), the difference of £273,185 being charged against the clearance schemes. The aggregate commercial value on the same basis of sites acquired or appropriated by the Council is estimated at £465,804, and the housing value charged to dwellings accounts at £163,361 (page lix.), the difference of £302,443 being charged against the clearance schemes. Capital expenditure on clearance schemes. The statement on page Iviii. shows the capital expenditure on the clearance of insanitary areas under Parts I. and II. of the Housing of the Working Classes Act, 1890, as distinct from the expenditure on dwellings. The net capital expenditure to 31st March, 1914, under both parts of the Act for clearance schemes, amounted to £2,563,161 11s. 11d. The capital expenditure during the year 1913-14 amounted to £45,036 9s. 10d., and was chiefly in respect of the new Tabard-street, etc., scheme. Dwellings under Imporvement Acts. These dwellings were erected in pursuance of statutory obligations to provide rehousing accommodation for persons displaced by improvements, etc., under various Acts of Parliament. Certain dwellings were erected on sites on which, owing to their character or situation, an unfavourable financial result was from the first anticinated ; these are shown under a separate head. Results of year. The result ot the years working or Dwellings under Improvement Acts (details on pages xlix. and 1.) is a net surplus of £4.133 9s . as compared with £3,.93 18s, 9d. in 1912-13. Income. The gross rental for the year from dwellings was £56,234 7s. 7d. (page xlix.). Deducting therefrom allowances for empties, caretakers' quarters, and amounts irrecoverable, the net rental amounted to £54,066 17s., exclusive of £247 12s. 1d. for interest on cash balances. The amount of rent irrecoverable was £45 6s. 1d., or only 0.08 per cent. of the gross rental. The total loss of income due to "empties" was £1,556 14s. 3d., or 2.77 per cent. of the gross rental, as against 4.22 per cent. in 1912-13. The greater part of this loss occurred on three estates, viz. : Durham Buildings (£337 or 21.10 per cent. of gross rental), Hughes Fields Dwellings (£90 or 14.02 per cent.) and Swan-lane Dwellings (£541, or 13.13 per cent.), which account for £968. Expenditure. The total expenditure on dwellings was £50,181. 1912-18. £ Per cent. of gross rental Working Expenses— Supervision and collection of rent 1913-14. £ Per cent, of gross rental. 4,523 8.10 4,594 8.17 8,258 14.79 Rates and taxes (less tax on interest on debt recovered) 9,096 16.18 2,532 4.53 Lighting, heating, water and insurance 2,582 4.59 86 0.15 Stores and incidentals 102 018 5,293 9.49 Repairs and renewals (transfers to fund) 5,286 9.40 20,692 37.06 21,660 38.52 Debt Charges— Interest (gross)— Land £3,343 Buildings 19,971 24,512 43.90 23,314 41.46 Sinking Fund— Land 722 4,762 8.53 Buildings 4,485 5,207 9.26 49.966 89.49 Total Expenditure 50,181 89.24 2,957 5.30 Net deductions from gross rental (empties, etc.) 2,167 3.85 2,913 5.21 Surplus on dwellings (excluding interest on cash balances) 3,886 6.91 55,836 100.00 Gross rental 56,234 100.00 Repairs and renewals fund. The amount standing to the credit of this fund on 31st March, 1914, was £20,004 14s. 9d., of which £19,103 4s. 2d. was invested (page lvii.). The credits to this fund during the year exceeded the expenditure thereout by £688 4s. Capital expenditure and debt on dwellings. The capital expenditure during the year 1913-14 amounted to £186 18s. 4d. (page xli.), and the total expenditure on capital account to 31st March, 1914, in respect of Dwellings under Improvement Acts amounted to £743,538 2s. 4d. (page xlii.). The Summary of Financial Results (pages 1v. and lvi.) shows the apportionment of this figure as between land and buildings. The practice with regard to charging to the capital account of the dwellings, the value of the site is the same as for dwellings erected to rehouse persons displaced by clearance schemes under Parts I. and II. of the Housing Act (see page 242). A statement is appended (page lix.) showing the estimated commercial value and housing value in respect of all sites utilised for the erection of working class dwellings under Improvement Acts, whether the dwellings have been erected by private enterprise or by the Council. As regards sites sold to Dwellings Companies, the aggregate commercial value at the time of disposal is estimated at £255,435, and the aggregate housing value as mainly represented by cash received from Dwellings 23610 II 2 244 Annual Report of the London County Council, 1913. Companies is £131,007 (page lix.) the difference of £124,428 being charged against the accounts of the improvements. The aggregate commercial value on the same basis of sites acquired or appropriated by the Council is estimated at £416,277, and the housing value charged to dwellings accounts at £108,213 (page lix.) the difference of £308,064 being charged against the accounts of the improvements. Financial Results of all Dwellings and Estates to 31st March, 1914. The total financial results on all dwellings and estates from April, 1894 (the date of the opening of the first block) to the 31st March, 1914, apart from contributions from or to rates, are as follows— Dwellings— Housing of the Working Classes Act, 1890— £ s. d. Part I. surplus 47,816 - 9 Part II surplus 3,944 18 11 Part III. deficiency 20,751 19 3 surplus 31,009 - 5 Estates in course of development deficiency 80,687 7 1 Total under Housing Act deficiency 49,678 6 8 Dwellings— Improvement Acts surplus 15,880 15 4 Net aggregate deficiency 33,797 11 4 Contributions from Tramways Account 1,216 5 11 Net contributions from Rates 32,581 5 5 Details on page lvii £33,797 11 4 (The net aggregate deficiency at 31st March, 1913, was £49,674 15s. l0d.) These results are arrived at after (a) charging interest on capital outlay, (6) making full provision for repairs and renewals, and (c) setting aside a sinking fund sufficient to replace the capital outlay on land and buildings and estates in course of development within a period of 60 years. The accumulations of the sinking fund on 31st March, 1914, amounted to £256,284 13s. 5d. (including £17,814 16s. 3d. proceeds of sales). 245 Housing of the Working Classes—Statistics. Housing Statistics—Memorandum by the Housing Manager (Mr. S. G. Burgess). The new buildings completed and opened between 1st April, 1913, and 31st March, 1914, comprise 236 cottages, providing accommodation for 1,777 persons. Ten sheds and 8 shops were also provided and 2-3 room cottage flats were converted to 2-2 room cottage flats. Up to 31st March, 1914, a total of 6,420 tenements in block dwellings, and 3,326 cottages, or a total of 9,746 lettings, containing 27,949 rooms; and 1,874 cubicles in lodging houses, affording accommodation altogether for 57,362 persons, had been provided and opened by the Council. The gross rent receivable for the year 1912-13 was £218,925 17s. 10d., and for the year 1913-14, £226,294 l1s. 3d., being an increase of £7,368 13s. 5d. The financial result of the year's working of all dwellings in occupation, after providing for interest and sinking fund charges on the capital expended, is a surplus of £13,623 6s. 6d., which, after adding interest on cash balances (£1,012 5s. 2d.) and the difference between totals of debt charges on cash and stock basis (£3,673 17s. 9d.), gives a total net surplus of £18,309 9s. 5d., or 8.06 per cent, of £227,100 13s. 9d., the gross rental for the year. The interest and sinking fund charges amount to 49.00 per cent. of the gross rental. The sinking fund, which will redeem the capital expended on land and buildings within a period of 60 years, has been increased during the year by £17.353 14s. lid., and the total sum now set aside in this fund in respect of dwellings in occupation amounts to £234,656 13s. -d. The expenditure for the management of the estates, including repairs, rates and taxes, water, lighting, etc., amounts to 39.32 per cent. of the gross rental. During the year the sum of £22,972 has been transferred to the repairs and renewals account, the unspent accumulations on which, with the interest earned during the year (£1,978 3s. 6d.), now amount to £64,005 2s. l0d. The total addition to the fund was 10'90 of the gross rental. The loss of rent by empties (including the amounts lost at the opening of the new buildings— 236 lettings) is equivalent to 3.23 per cent. of the gross rental. During the year 2,142 tenants left the dwellings. This is equivalent to 22 per cent, of the total number of tenements, as compared with 26 09 per cent. in 1912-13. Of the 2,142 tenants who removed, 184 tenants, or 8.59 per cent. of the number, were given notice to quit by the Council, either for non-payment of rent, disorderly conduct, or some other cause. The remaining 1,958 tenants, or 91.41 per cent., gave notice to the Council and left to suit their own convenience. A total of 6,469 applications for accommodation on the Council's estates (excluding lodging houses) were dealt with, and 524 transfers were effected. These transfers are sometimes to a different estate, owing to the tenant having changed his place of work, and sometimes to a larger or smaller tenement on the same estate, owing to the increase or decrease of the tenant's family. Of the 6,469 applications received, 2,423 or 37.45 per cent. were suited with accommodation. A number of tenants who removed from the dwellings were in arrear with their rent, and left without paying the amounts owing. Every effort has been made to recover these arrears on vacation, but the amount of £194 17s. 8d. or .09 per cent. (1s. 9d. per £100) of the gross rental has been included in the accounts as irrecoverable. During the year the Council did not rehouse any persons who had been displaced by the Council's improvement, clearance and education schemes. The total number of displaced persons rehoused to 31st March, 1914, is 1,756. The usual annual enumeration of tenants of the Council's dwellings was taken in March, 1914, and showed that the rooms (excluding lodging houses), available for letting, were actually occupied by 36,004 persons, or an average of 1.31 persons per room. The birth rate for the year amounted to 23.92 per 1,000, and the death rate (exclusive of the three men's lodging houses) to 8.44 per 1,000. As in previous years, a careful examination of the enumeration returns was made with a view to the detection of cases of overcrowding. The maximum number of persons to be allowed in any tenement in the Council's dwellings has been fixed by the Committee at two persons per room, children up to the age of 5 being for this purpose reckoned as nil, and children between the ages of 5 and 10 as half an adult. This year the number of cases not complying with this standard was 32 or .33 per cent. of the total number of occupied tenements. The overcrowding is usually found to be due to one or more children in the tenement having reached the age of 5 or 10 years, and so being counted in accordance with the Council's scale. This overcrowding is usually remedied by the removal of the family to a larger tenement in the dwellings. A sum of £23,934 4s. 8d. (10.54 per cent. of the gross rental) has been spent in repairs to the buildings during the year. These repairs include external painting at 30 blocks of tenements and 612 cottages and 156 entrance doors only, whitening the soffits and cleaning or painting walls of 140 staircases, comb graining and varnishing the woodwork of 1,733 tenements and cottages, and cleansing repairs at 7,191 tenements and cottages. The whole of these repairs have been executed by direct labour employed in the housing department. During the year 26 small fires occurred in the dwellings. The damage was in every case slight and the total cost of reinstatement, amounting to £43 5s. 6d., was covered by the Council's insurance fund. APPENDIXES. iii. APPENDIX I. Classification of children as to condition of clothing, nutrition, cleanliness and teeth. Percentage of children in each class. 1 = good ; 2 = fair ; 3 = poor; 4 = malnutrition. Number of children examined. Condition of clothing and foot.gear. Condition as regards nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 ENTRANTS. BOYS. City of London 111 64.9 33.3 1.8 30.6 64.0 5.4 - 86.5 13.5 73.9 25.2 0.9 63.1 20.7 16.2 Battersea 1,611 54.0 40.8 5.2 21.9 67.1 10.8 0.2 94.3 5.5 0.2 83.0 16.1 0.9 51.7 25.3 23.0 Bermondsey 1,529 43.5 51.9 4.6 38.0 56.4 5.5 0.1 82.2 16.6 1.2 52.4 43.9 3.7 65.4 23.5 11.1 Bethnal Green 1,294 44.7 45.8 9.5 18.8 50.6 29.8 0.8 91.6 7.8 0.6 73.0 25.5 1.5 66.9 29.6 3.5 Camberwell 2,694 70.0 27.6 2.4 36.9 54.5 8.3 0.3 86.2 12.5 1.3 79.0 18.0 3.0 78.2 17.3 4.5 Chelsea 459 39.4 52.3 8.3 39.9 51.6 8.1 0.4 71.9 24.2 3.9 74.5 21.4 4.1 70.8 25.7 3.5 Deptford 868 65.8 32.1 21 36.2 53.0 10.7 0.1 91.6 7.3 1.1 82.4 16.0 1.6 58.5 26.9 14.6 Finsbury 947 28.1 61.7 10.2 34.2 56.7 8.7 0.4 72.5 25.5 2.0 52.5 43.7 3.8 53.1 33.3 13.6 Fulham 1,387 66.2 32.5 1.3 24.2 61.2 14.3 0.3 96.0 3.9 0.1 93.2 6.6 0.2 57.1 26.2 16.7 Greenwich 1,133 56.1 42.9 1.0 45.2 47.6 6.8 0.4 87.2 12.5 0.3 82.3 17.3 0.4 69.2 28.5 2.3 Hackney 1,851 52.7 45.8 1.5 38.8 55.9 5.1 0.2 90.0 9.6 0.4 88.9 10.8 0.3 77.2 16.7 6.1 Hammersmith 1,070 91.0 8.7 0.3 13.5 80.9 5.4 0.2 96.6 3.4 - 97.2 2.8 - 53.2 31.0 15.8 Hampstead 427 46.4 46.6 7.0 44.7 46.8 7.5 1.0 95.8 4.2 - 91.6 8.2 0.2 48.7 38.9 12.4 Holborn 386 26.7 60.4 12.9 16.8 77.5 5.1 - 84.7 13.7 1.6 82.1 17.1 0.8 56.5 20.5 23.0 Islington 2,545 58.5 37.4 4.1 20.4 55.1 24.1 0.4 89.7 9.9 0.4 88.7 9.4 1.9 73.0 17.5 9.5 Kensington 1,123 42.8 55.1 2.1 31.4 62.0 6.2 0.4 79.1 20.6 0.3 55.0 41.8 3.2 14.5 82.5 3.0 Lambeth 2,490 51.2 45.9 2.9 20.4 70.9 8.6 0.1 94.6 5.3 0.1 81.8 16.8 1.4 65.0 17.8 17.2 Lewisham 1,272 72.3 27.3 0.4 28.1 56.4 15.3 0.2 98.0 2.0 – 85.0 14.6 0.4 73.3 21.0 5.7 Paddington 913 81.8 17.4 0.8 56.7 39.4 3.7 0.2 96.2 3.6 0.2 88.5 10.0 1.5 63.2 33.1 3.7 Poplar 1,651 29.1 66.0 4.9 27.5 58.9 13.5 0.1 87.5 11.9 0.6 80.7 18.5 0.8 62.9 35.2 1.9 St. Marylebone 593 80.8 18.5 0.7 71.2 27.0 1.8 – 87.2 12.5 0.3 92.8 6.5 0.7 72.7 19.7 7.6 St. Pancras 2,048 58.2 38.9 2.9 28.8 63.5 7.4 0.3 83.3 16.5 0.2 82.9 16.0 1.1 55.5 29.4 15.1 Shoreditch 1,069 16.2 79.0 4.8 30.0 63.5 6.3 0.2 49.6 49.9 0.5 48.9 48.8 2.3 92.4 4.4 3.2 Southwark 2,235 23.7 65.4 10.9 17.0 66.9 15.5 0.6 74.9 24.3 0.8 45.8 48.9 5.3 47.4 37.2 15.4 Stepney 3,321 58.1 39.1 2.8 43.4 43.1 12.7 0.8 86.2 12.9 0.9 72.9 25.2 1.9 55.4 35.1 9.5 Stoke Newington 235 37.4 62.2 0.4 41.3 57.0 1.7 - 95.3 4.3 0.4 91.5 7.7 0.8 76.6 20.0 3.4 Wandsworth 2,844 70.0 28.4 1.6 19.7 74.9 5.3 01 91.0 8.9 0.1 88.2 11.1 0.7 75.2 13.4 11.4 Westminster 791 42.9 53.3 3.8 36.7 55.5 7.4 0.4 74.7 22.5 2.8 74.8 22.1 3.1 68.1 28.1 3.8 Woolwich 1,120 50.0 49.1 0.9 42.0 51.2 6.5 0.3 92.0 7.7 0.3 83.1 16.2 0.7 13.6 75.0 11.4 London County 40,017 53.9 42.5 3.6 30.7 58.5 10.5 0.3 86.6 12.8 0.6 77.7 20.6 1.7 62.2 27.7 10.1 ENTRANTS. GIRLS. City of London 111 59.5 38.7 1.8 33.3 57.7 8.1 0.9 60.4 37.8 1.8 65.8 31.5 2.7 63.1 23.4 13.5 Battersea 1,732 55.4 40.1 4.5 23.9 65.1 10.7 0.3 79.9 19.6 0.5 83.9 15.4 0.7 52.2 24.9 22.9 Bermondsey 1,358 50.7 45.1 4.2 37.6 57.4 4.9 01 69.4 29.1 1.5 50.1 45.8 41 65.9 24.6 9.5 Bethnal Green 1,449 45.3 49.8 4.9 25.3 51.8 22.8 01 69.5 26.8 3.7 72.6 26.1 1.3 71.9 25.5 2.6 Camberwell 2,525 70.3 28.4 1.3 37.3 54.5 7.9 0.3 72.1 25.2 2.7 74.7 21.6 3.7 77.9 17.6 4.5 Chelsea 441 39.7 54.6 5.7 39.2 52.4 8.2 0.2 69.8 25.9 4.3 72.5 23.4 41 69.4 25.6 5.0 Deptford 876 72.2 26.8 10 37.8 53.8 8.2 0.2 81.7 16.7 1.6 79.3 19.6 11 63.2 25.7 111 Finsbury 887 30.5 61.9 7.6 39.6 51.8 8.5 0.1 55.0 37.7 7.3 56.2 41.5 2.3 56.3 28.9 14.8 Fulham 1,308 70.0 29.3 0.7 27.9 57.7 14.2 0.2 87.2 11.9 0.9 93.4 61 0.5 52.2 29.4 18.4 Greenwich 1,140 47.3 52.5 0.2 51 0 44.8 40 0.2 81.8 17.4 0.8 86.4 13.2 0.4 71.2 27.8 10 Hackney 2,281 50.1 49.1 0.8 43.4 52.0 4.2 0.4 75.4 24.3 0.3 81.0 18.6 0.4 75.9 18.3 5.8 Hammersmith 1,070 92.7 70 0.3 14.8 79.6 5.5 0.1 85.6 14.0 0.4 98.4 1.5 01 51.9 34.2 13.9 Hampstead 421 50.8 45.4 3.8 33.2 56.8 9.3 0.7 93.6 6.2 0.2 92.4 7.6 — 42.3 43.9 13.8 Holborn 401 28.2 63.1 8.7 20.7 74.9 4.2 0.2 60.6 35.9 3.5 79.8 19.5 0.7 62.6 19.7 17.7 Islington 2,576 59.3 38.3 2.4 20.5 55.4 23.7 0.4 70.6 27.7 1.7 88.2 9.6 2.2 72.6 18.6 8 8 Kensington 983 460 521 1.9 32.6 63.4 3.8 0.2 73.2 24.9 1.9 54.6 41.2 4.2 16.9 79.6 3 5 Lam beth 2,454 54.9 43.6 1.5 21 0 701 8.8 0.1 80.5 18.6 0.9 811 17.0 1.9 64.9 16.2 18 9 Lewisham 1,206 755 241 0.4 34.3 54 0 11.6 0.1 94.6 5.1 0.3 87.9 11.8 0.3 75.8 19.8 44 Paddington 916 83.5 15.7 0.8 62.3 33.4 4.3 – 91.8 7.6 0.6 89.2 9.9 0.9 63.1 31.2 57 Poplar 1,554 41.2 56.7 21 31.3 57.7 11.0 – 57.9 37.7 4.4 79.9 19.3 0.8 65.6 32.7 1 7 St. Marylebone 692 84.4 15.5 01 76.0 230 1.0 – 87.0 13.0 – 94.8 5.1 0.1 73.1 20.1 68 St. Pancras 2,059 59.1 38.5 2.4 28.6 63.4 7.6 0.4 70.9 28.0 1.1 80.6 18.4 1.0 55.1 30.4 14 5 Shoreditch 1,182 21.7 73.9 4.4 38.6 55.7 5.7 – 51.4 47.0 1.6 53.5 44.5 2.0 89.7 5.8 4.5 Southwark 2,269 21.5 69.7 8.8 15.2 70.4 13.9 0.5 53.8 44.2 2.0 45.5 50.8 3.7 48.2 36.8 15.0 Stepney 3,176 58.3 39.7 20 471 42.2 10.1 0.6 63.4 34.2 2.4 73.8 24.7 1.5 55.5 360 8.5 Stoke Newington 212 34.4 64.2 1.4 38.2 61.8 – – 75.5 23.1 1.4 88.2 11.3 0.5 76.4 19.8 3.8 Wandsworth 2,564 68.4 30.7 0.9 21.2 74.8 4.0 0.0 83.5 15.7 0.8 87.5 11.7 0.8 78.0 12.4 9.6 Westminster 716 39.1 53.2 7.7 36.7 55.4 7.8 01 66.8 29.7 3.5 69.4 26.8 3.8 65.9 30.9 3.2 Woolwich 1,044 49.1 50.4 0.5 381 52.1 9.6 0.2 88.7 10.5 0.8 81.5 17.7 0.8 16.3 70.8 12.9 London County 39,603 55.1 42.3 2.6 32.7 57.5 9.5 0.3 73.4 24.9 1.7 77.0 21.3 1.7 63.0 27.2 9.8 23610 kk iv. Annual Report of the London County Council, 1913. APPENDIX I .(Contd.) Classification of children as to condition of clothing, nutrition, cleanliness and teeth. Percentage of children in each class. Number of children examined. Condition of clothing and foot gear. Condition as regards nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 BOYS BORN IN 1905. City of London 129 63.6 31.8 4.6 17.0 72.9 10.1 - 87.6 12.4 - 73.6 22.5 3.9 51.9 33.4 14.7 Battersea 1,188 45.3 47.8 6.9 18.4 72.7 8.7 0.2 93.9 6.1 - 73.2 24.9 1.9 39.7 32.4 27.9 Bermondsey 1,120 42.7 49.0 8.3 25.3 56.6 17.8 0.3 85.4 14.2 0.4 59.8 32.4 7.8 61.1 27.7 11.2 Bethnal Green 1,227 29.0 54.7 16.3 6.6 41.6 51.0 0.8 79.1 20.3 0.6 46.0 51.6 2.4 49.3 47.4 3.3 Camberwell 1,997 63.6 31.7 4.7 26.4 61.7 11.7 0.2 85.4 13.2 1.4 75.0 20.3 4.7 71.5 22.1 6.4 Chelsea 404 37.4 48.0 14.6 33.9 50.3 15.8 — 66.9 26.2 6.9 66.1 28.0 5.9 53.7 40.4 5.9 Deptford 735 66.4 31.3 2.3 20.8 61.7 17.4 0.1 89.5 9.5 1.0 76.3 21.4 2.3 65.2 29.4 5.4 Finsbury 732 18.9 63.9 17.2 21.4 66.1 12.2 0.3 71.9 26.9 1.2 39.1 49.6 11.3 46.0 40.9 131 Fulham 1,231 47.0 49.3 3.7 26.2 53.4 20.1 0.3 96.5 3.4 0.1 87.6 11.8 0.6 45.4 32.9 21.7 Greenwich 818 45.1 51.8 3.1 29.7 59.3 10.6 0.4 72.6 27.4 — 61.0 37.2 1.8 20.9 77.1 2.0 Hackney 1,847 50.8 46.0 3.2 27.7 63.0 9.0 0.3 94.7 5.1 0.2 90.1 9.3 0.6 68.8 21.3 9.9 Hammersmith 773 87.6 121 0.3 10.4 78.5 10.6 0.5 97.9 2.1 — 96.3 3.1 0.6 38.0 46.5 15.5 Hampstead 256 30.5 62.9 6.6 33.6 50.0 16.0 0.4 96.1 3.9 ,— 90.2 9.4 0.4 18.8 57.4 23.8 Holborn 253 19.0 58.9 22.1 6.3 89.0 4.3 0.4 80.6 17.0 2.4 70.3 27.7 2.0 46.3 29.6 24.1 Islington 2,371 53.9 40.5 5.6 16.1 59.8 23.8 0.3 91.8 7.7 0.5 82.9 14.2 2.9 53.8 32.6 13.6 Kensington 708 35.9 53.2 10.9 28.7 62.1 8.9 0.3 58.8 39.7 1.5 36.6 54.5 8.9 3.2 93.1 3.7 Lambeth 1,626 50.2 45.6 4.2 21.3 69.8 8.2 0.7 92.7 7.2 0.1 76.4 22.0 1.6 54.0 25.0 21.0 Lewisham 1,295 72.8 25.3 1.9 15.4 63.6 21.0 — 97.8 2.0 0.2 80.1 18.4 1.5 58.1 36.0 5.9 Paddington 835 60.6 35.8 3.6 47.9 42.8 9.3 — 91.6 7.8 0.6 80.3 17.1 2.6 45.1 44.9 10.0 Poplar 1,344 24.9 65.8 9.3 8.5 69.7 21.3 0.5 90.3 9.0 0.7 70.5 28.6 0.9 58.3 40.2 1.5 St. Marylebone 475 83.4 14.7 1.9 69.5 28.6 1.9 — 97.1 2.7 0.2 94.3 5.7 – 61.7 25.7 12.6 St. Pancras 1,239 56.5 40.7 2.8 17.1 72.6 10.0 0.3 82.7 17.1 0.2 74.9 23.6 1.5 30.3 47.8 21.9 Shoreditch 1,019 31.7 47.3 21.0 38.3 45.2 16.4 0.1 79.3 20.6 0.1 68.4 28.9 2.7 86.4 9.8 3.8 Southwark 1,719 13.3 66.4 20.3 22.1 62.0 15.6 0.3 78.0 21.7 0.3 34.9 57.4 7.7 41.6 43.1 15.3 Stepney 2,578 50.6 43.8 5.6 16.1 60.5 23.1 0.3 85.1 14.6 0.3 68.7 29.2 2.1 52.8 40.9 6.3 Stoke Newington 211 30.8 64.5 4.7 37.4 61.2 1.4 – 93.4 6.2 0.4 89.1 10.0 0.9 80.1 10.9 9.0 Wandsworth 1,946 62.2 33.6 4.2 14.6 80.3 5.0 0.1 93.4 6.4 0.2 84.7 14.0 1.3 68.3 15.1 16.6 Westminster 483 37.7 53.6 8.7 36.8 51.6 11.6 — 67.1 29.6 3.3 66.3 29.6 4.1 54.5 37.4 8.1 Woolwich 1,084 25.8 72.1 2.1 19.3 71.0 8.9 0.8 93.6 5.9 0.5 79.7 19.5 0.8 3.3 74.8 21.9 London County 31,643 47.5 45.4 7.1 22.0 62.2 15.5 0.3 87.1 12.3 0.6 72.0 25.1 2.9 51.4 36.6 12.0 GIRLS BORN IN 1905. City of London 105 61.9 37.1 1.0 18.1 69.5 11.4 1.0 61.9 36.2 1.9 73.3 24.8 1.9 47.6 34.3 18.1 Battersea 1,272 46.8 47.1 6.1 26.6 65.2 8.2 — 70.2 28.6 1.2 74.3 23.7 2.0 43.9 30.4 25.7 Bermondsey 1,103 54.4 40.4 5.2 27.0 57.8 14.8 0.4 71 8 26.7 1.5 52.8 41.0 6.2 56.2 30.2 13.6 Bethnal Green 1,249 35.2 57.0 7.8 11.3 48.0 40.2 0.5 50.5 42.0 7.5 54.1 42.4 3.5 51.5 44.5 4.0 Camberwell 2,075 68.1 30.8 1.1 26.6 62.0 11.0 0.2 68.9 29.1 2.0 73.5 23.0 3.5 71.2 22.2 6.6 Chelsea 298 35.2 48.3 16.5 32.9 49.0 17.8 0.3 63.4 25.9 10.7 60.1 32.9 7.0 58.1 31.5 10.4 Deptford 723 75.9 21.9 2.2 26.3 58.2 15.2 0.3 76.9 19.5 3.6 67.6 28.8 3.6 59.8 32.5 7.7 Finsbury 698 21.5 64.5 14.0 29.5 60.6 9.8 0.1 36.3 53.7 10.0 42.7 51.7 5.6 48.9 40.8 10.3 Fulham 1,201 55.4 43.3 1.3 31.5 52.7 15.6 0.2 83.4 16.5 0.1 89.4 10.4 0.2 45.4 33.7 20.9 Greenwich 804 41.6 57.5 0.9 33.8 58.5 7.2 0.5 68.9 30.0 1.1 71.1 28.0 0.9 23.8 75.1 1.1 Hackney 1,764 56.2 42.7 1.1 31.4 62.7 5.6 0.3 81.0 18.0 1.0 87.7 11.8 0.5 69.4 21.0 9.6 Hammersmith 543 95.0 5.0 — 9.9 80.1 9.8 0.2 79.9 20.1 — 97.8 2.2 – 39.2 44.6 16.2 Hampstead 294 33.0 61.9 5.1 26.9 60.2 11.9 1.0 81.0 19.0 — 92.9 7.1 – 15.3 61.9 22.8 Holborn 312 2430 63.2 12.8 9.3 84.0 6.7 — 50.0 41.7 8.3 73.7 26.0 0.3 47.8 28.8 23.4 Islington 2,371 52.9 43.6 3.5 18.3 58.4 23.0 0.3 59.3 38.3 2.4 82.9 14.4 2.7 57.7 27.8 14.5 Kensington 781 39.0 57.4 3.6 30.8 65.4 3.8 — 58.2 37.3 4.5 48.5 47.5 4.0 5.9 91.3 2.8 Lambeth 1,610 49.4 49.0 1.6 22.1 70.5 7.3 01 76.6 21.8 1.6 76.4 22.4 1.2 57.1 23.5 19.4 Lewisham 1,096 83.5 16.2 0.3 16.7 61.0 22.3 — 92.8 6.2 1.0 84.5 14.8 0.7 57.5 36.4 6.1 Paddington 819 60.1 36.9 3.0 54.1 40.1 5.7 01 76.7 21.2 2.1 77.4 20.2 2.4 47.7 40.4 11.9 Poplar 1,348 34.9 56.1 9.0 16.0 63.8 20.0 0.2 57.7 36.8 5.5 80.7 18.7 0.6 54.1 43.9 2.0 St. Marylebone 401 84.3 14.7 1.0 74.3 23.7 2.0 — 87.0 12.8 0.2 93.8 6.0 0.2 53.4 33.2 13.4 St. Pancras 1,328 58.2 38.5 3.3 18.4 71.6 9.3 0.7 63.5 34.6 1.9 82.4 16.9 0.7 35.7 45.2 19.1 Shoreditch 1,038 39.9 39.6 20.5 48.7 41.5 9.7 0.1 57.2 38.1 4.7 66.7 32.2 11 85.6 9.2 5.2 Southwark 1,634 17.4 70.0 12.6 16.3 66.3 17.0 0.4 48.1 50.4 1.5 39.5 54.4 61 41.0 43.0 16.0 Stepney 2,643 57.9 39.3 2.8 22.4 61.3 16.0 0.3 53.3 45.0 1.7 76.3 22.9 0.8 51.1 42.5 6.4 Stoke Newington 169 38.1 59.3 2.6 42.3 56.6 1.1 — 77.8 21.1 1.1 89.4 10.6 – 73.0 15.9 11.1 Wandsworth 1,964 66.7 31.1 2.2 190 76.5 4.4 0.1 79.3 19.6 1.1 83.9 15.2 0.9 67.1 17.2 15.7 Westminster 551 38.6 51.2 10.2 34.5 53.5 11.6 0.4 62.8 33.6 3.6 63.5 33.2 3.3 52.4 37.6 10.0 Woolwich 1,043 30.5 68.7 0.8 19.9 70.4 8.7 1.0 83.8 15.4 0.8 79.1 20.4 0.5 1.9 74.2 23.9 London County 31,257 51.4 43.9 4.7 25.1 61.4 13.2 0.3 67.3 30.3 2.4 73.7 24.2 2.1 51.6 36.3 12.1 Appendix I. V. APPENDIX I—(Contd.) Classification of children as to condition of clothing, nutrition, cleanliness and teeth. Percentage of children in each class. Number of children examined. Condition of clothing and foot.gear. Condition ns regards nutrition. Cleanliness of head. Cleanliness of body. Condition of teeth. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 BOYS BORN IN 1901. City of London 110 67.3 30.0 2.7 25.5 61.8 11.8 0.9 87.3 11.8 0.9 62.7 35.5 1.8 64.5 20.0 15.5 Battersea 1,148 50.0 42.9 7.1 17.7 70.4 11.8 0.1 97.5 2.4 0.1 83.0 15.7 1.3 33.5 44.5 22.0 Bermondsey 962 41.5 45.9 12.6 16.8 54.7 26.0 2.5 79.6 19.4 1.0 56.2 39.3 4.5 58.7 32.6 8.7 Bethnal Green 980 34.8 53.0 12.2 13.4 39.2 44.7 2.7 87.2 12.3 0.5 54.0 40.1 5.9 44.7 50.4 4.9 Camberwell 1,832 64.3 33.4 2.3 35.2 56.7 7.9 0.2 86.8 12.2 1.0 80.0 16.7 3.3 71.9 19.2 8.9 Chelsea 234 24.8 67.9 7.3 27.8 64.5 7.7 — 50.4 46.6 3.0 49.1 47.9 3.0 45.3 48.3 6.4 Deptford 655 43.7 52.2 4.1 25.1 58.9 16.0 92.1 7.6 0.3 78.9 18.5 2.6 66.9 24.9 8.2 Finsbury 718 18.9 63.8 17.3 24.8 62.7 11.1 1.4 73.4 26.2 0.4 45.3 49.0 5.7 36.6 54.3 9.1 Fulham 1,012 55.3 43.6 1.1 27.2 63.6 9.2 — 97.7 2.3 — 88.0 10.7 1.3 55.2 33.3 11.5 Greenwich 806 49.3 47.6 3.1 58.2 40.0 1.2 0.6 79.2 20.7 0.1 75.5 23.8 0.7 32.5 63.5 4.0 Hackney 1,533 45.4 51.5 3.1 25.2 61.6 12.8 0.4 85.5 14.2 0.3 72.9 25.1 2.0 54.7 38.4 6.9 Hammersmith 524 85.9 12.8 1.3 12.8 80.2 6.8 0.2 94.8 4.8 0.4 93.1 6.7 0.2 49.4 39.5 11.1 Hampstead 314 31.5 61.8 6.7 27.4 61.5 7.6 3.5 96.5 3.5 83.8 15.9 0.3 15.9 65.0 19.1 Holborn 287 28.2 58.9 12.9 13.9 72.1 13.6 0.4 87.1 11.8 1.1 66.9 31.0 2.1 64.1 22.0 13.9 Islington 2,021 54.6 41.1 4.3 18.0 58.0 22.9 1.1 94.2 5.3 4.5 87.1 10.8 2.1 56.1 33.7 10.2 Kensington 478 47.3 49.1 3.6 35.8 56.0 8.0 0.2 72.4 26.1 1.5 50.0 45.4 4.6 12.1 84.6 3.3 Lambeth 1,507 50.7 45.9 3.4 27.6 60.7 11.4 0.3 93.4 6.5 0.1 77.3 21.2 1.5 51.7 37.6 10.7 Lewisham 879 76.0 23.0 1.0 11.8 64.0 24.1 0.1 98.5 1.4 0.1 87.0 12.3 0.7 65.8 29.8 4.4 Paddington 669 83.7 14.8 1.5 62.4 33.5 4.0 0.1 97.0 3.0 — 90.5 8.5 1.0 47.7 40.8 11.5 Poplar , 982 30.0 63.3 6.7 19.6 62.3 18 1 — 88.4 10.9 0.7 70.1 28.9 1.0 33.4 65.7 0.9 St. Marylebone 436 76.1 23.4 0.5 70.9 27.7 1.4 — 92.0 7.8 0.2 91.3 8.5 0.2 60.5 29.6 9.9 St. Pancras 1,064 60.2 368 3.0 25.5 63.0 10.9 0.6 88.6 11.1 0.3 82.7 16.3 1.0 43.2 43.8 13.0 Shoreditch 967 11.1 85.4 3.5 20.1 67.9 11.1 0.9 55.9 43.6 0.5 52.2 44.8 3.0 89.0 6.3 4.7 Southwark 1,544 19.4 64.5 161 10.8 64.5 23.2 1.5 81.7 18.0 0.3 44.2 47.8 8.0 48.4 42.1 9.5 Stepney 2,281 50.2 43.5 6.3 35.3 48.9 13.5 2.3 87.3 12.3 0.4 63.9 32.4 3.7 30.1 55.5 14.4 Stoke Newington 189 51.8 471 1.1 40.7 56.1 3.2 — 95.8 3.7 0.5 92.6 6.9 0.5 64.0 26.5 9.5 Wandsworth 1,962 64.7 31.1 4.2 19.1 73.6 7.1 0.2 93.3 6.5 0.2 85.4 13.7 0.9 66.3 24.1 9.6 Westminster 313 22.4 72.5 5.1 22.7 72.2 4.8 0.3 47.0 49.8 3.2 47.6 49.2 3.2 48.9 43.1 8.0 Woolwich 736 60.1 39.4 0.5 47.3 48.1 4.6 — 93.0 6.9 0.1 86.2 12.9 0.9 7.2 72.8 20.0 London County 27,143 49.1 45.4 5.5 26.4 58.9 13.9 0.8 87.3 12.3 0.4 73.1 24.3 2.6 500 40.0 10.0 GIRLS BORN IN 1901. City of London 116 75.9 23.3 0.8 39.7 44.8 13.8 1.7 59.5 39.6 0.9 69.8 30.2 — 75.9 11.2 12.9 Battersea 1,026 54.3 39.6 6.1 20.8 64.4 14.3 0.5 76.1 22.0 1.9 78.6 20.0 1.4 37.8 45.6 16.6 Bermondsey 996 44.9 42.7 12.4 17.6 52.8 26.7 2.9 61.4 35.2 3.4 56.1 39.0 4.9 61.3 32.3 6.4 Bethnal Green 1,208 420 50.4 7.6 20.9 38.4 39.3 1.4 54.5 38.0 7.5 60.0 36.3 3.7 45.4 50.5 4.1 Camberwell 1,871 68.6 30.1 1.3 35.7 54.5 9.1 0.7 64.5 32.9 2.6 73.4 22.6 4.0 74.7 16.8 8.5 Chelsea 266 27.8 63.5 8.7 20.3 72.2 6.0 1.5 48.1 45.1 6.8 46.6 47.0 6.4 49.3 44.7 6.0 Deptford 625 50.9 47.2 1.9 25.1 60.2 14.2 0.5 73.3 24.5 2.2 73.1 22.9 4.0 61.8 29.2 9.0 Finsbury 749 19.1 71.7 9.2 32.8 56.4 10.1 0.7 44.7 47.5 7.8 52.9 43.5 3.6 40.0 52.9 7.1 Fulham 803 51.6 47.4 1.0 38.7 54.8 6.5 — 79.4 19.2 1.4 89.0 10.2 0.8 58.7 32.5 8.8 Greenwich 705 42.3 56.7 1.0 60.4 36.2 3.1 0.3 86.8 13.1 0.1 83.4 16.6 — 45.7 51.9 2.4 Hackney 1,600 44.9 53.3 1.8 25.9 60.9 13.1 0.1 62.1 36.9 1.0 69.6 28.4 20 56.6 38.1 5.3 Hammersmith 582 840 15.8 0.2 17.7 70.3 12.0 — 76.1 23.4 0.5 90.9 9.1 — 49.6 41.8 8.6 Hampstead 300 39.7 56.6 3.7 30.3 60.4 9.3 — 77.3 22.7 — 86.3 13.7 — 18.3 64.0 17.7 Holborn 238 30.3 60.5 9.2 19.3 71.9 8.4 0.4 46.2 48.8 5.0 81.9 16.8 1.3 75.2 15.1 9.7 Islington 1,987 52.1 44.9 3.0 22.0 53.0 24.5 0.5 62.8 34.2 3.0 86.0 12.1 1.9 59.8 30.9 9.3 Kensington 614 42.7 55.2 2.1 33.5 60.3 5.9 0.3 64.3 32.3 3.4 54.2 41.4 4.4 8.8 86.6 4.6 Lambeth 1,395 53.9 43.7 2.4 29.3 61.4 9.0 0.3 77.9 21.0 11 82.2 17.0 0.8 59.5 33.8 6.7 Lewisham 994 79.6 19.5 0.9 14.2 66.5 19.3 — 94.1 5.7 0.2 90.5 8.9 0.6 65.5 30.0 4.5 Paddington 748 82.5 16.8 0.7 72.7 25.4 1.9 — 86.9 11.2 1.9 91.2 7.6 1.2 57.2 34.4 8.4 Poplar 1,235 450 51.8 3.2 28.4 52.4 19.2 — 49.6 45.1 5.3 72.2 26.8 1.0 30.6 66.5 2.9 St. Marylebone 528 74.0 25.8 0.2 76.9 21.6 1.5 — 70.6 29.0 0.4 92.0 7.8 0.2 60.0 31.1 8.9 St. Pancras 1,199 58.6 39.6 1.8 27.2 64.0 8.0 0.8 64.1 34.6 1.3 87.9 11.5 0.6 49.2 36.6 14.2 Shoreditch 890 17.1 81.2 1.7 31.3 58.8 9.0 0.9 57.4 42.0 0.6 56.4 42.9 0.7 91.4 4.0 4.6 Southwark 1,485 24.9 66.0 9.1 12.7 60.9 24.9 1.5 52.9 45.0 2.1 54.8 39.9 5.3 49.0 41.4 9.6 Stepney 2,156 57.3 39.9 2.8 41.4 45.3 12.3 1.0 59.4 37.9 2.7 67.1 30.4 2.5 31.8 55.7 12.5 Stoke Newington 178 54.5 43.8 1.7 34.8 59.0 5.6 0.6 81.5 18.5 — 91.5 7.9 0.6 70.2 19.7 10.1 Wandsworth 1,721 66.5 31.7 1.8 25.3 67.3 7.1 0.3 81.5 17.3 1.2 87.5 11.9 0.6 73.7 19.3 7.0 Westminster 377 25.2 70.8 4.0 33.9 58.9 6.9 0.3 56.2 40.3 3.5 56.5 39.3 4.2 55.5 36.1 8.4 Woolwich 903 57.5 41.9 0.6 43.1 51.9 5.0 — 89.7 9.9 0.4 88.8 10.4 0.8 9.2 72.0 18.8 London County 27,495 51.8 44.8 3.4 30.6 55.1 13.7 0.6 67.2 30.4 2.4 74.8 23.1 2.1 52.4 39.0 8.6 23610 KK 2 vi. Annual Report of the London County Council, 1913. APPENDIX 1.—(Contd.) Table showing the number and percentage of children referred for treatment in each age group and in the three age groups taken together and the number and percentage of cases where the parent was present at the inspection. Entrants. Children aged 8. Children aged 12. Total. Number examined. Children referred for treatment. Per cent. Parents present. Per cent. Number examined. Children referred for treatment. Per cent. Parents present. Per cent. Number examined. Children referred for treatment. Per cent. Parents present. Per cent. Cases referred tor treatment. Per cent. City of London 222 56 25.2 172 77.5 234 96 41.0 162 69.2 226 116 51.3 163 72.1 268 39.3 Battersea 3,343 1,299 38.9 2,698 80.7 2,460 1,316 53.5 1,717 69.8 2,174 1,011 46.5 1,306 60.1 3,626 45.4 Bermondsey 2,887 934 32.4 2,317 80.4 2,223 860 38.7 1,650 74.2 1,958 983 50.2 1,126 57.5 2,777 39.3 Bethnal Green 2,743 568 20.7 2,152 78.5 2,476 1,008 40.7 1,657 66.9 2,188 865 39.5 1,125 51.4 2,441 33.0 Camberwell 5,219 1,091 20.9 4,306 82.5 4,072 1,173 28.8 2,869 70.5 3,703 1,372 37.1 2,189 59.1 3,636 27.8 Chelsea 900 224 24.9 676 75.1 702 228 32.5 498 710 500 205 41.0 275 55.0 657 31.3 Deptford 1,744 537 30.8 1,401 80.3 1,458 568 39.0 1,072 73.5 1,280 584 45.6 816 63.8 1,689 37.7 Finsbury 1,834 383 20.9 1,420 77.4 1,430 400 28.0 930 650 1,467 463 31.6 851 58.0 1,246 26.4 Fulham 2,695 849 31.5 2,146 79.6 2,432 942 38.7 1,602 65.9 1,815 607 33.4 1,005 55.4 2,398 34.5 Greenwich 2,273 446 19.6 1,834 80.7 1,622 494 30.5 1,160 71.5 1,511 482 31.9 894 59.2 1,422 26.3 Hackney 4,132 922 22.3 3,421 82.8 3,611 1,303 36.2 2,672 74.0 3,133 1,178 37.6 2,025 64.6 3.403 31.3 Hammersmith 2,140 396 18.5 1,665 77.8 1,316 384 29.2 863 65.6 1,106 241 21.8 599 54.1 1,021 22.4 Hampstead 848 235 27.7 688 81.1 550 203 36.9 385 70.0 614 224 36.5 314 51.1 662 32.9 Holborn 787 263 33.4 505 64.2 565 269 47.6 281 49.7 525 222 42.3 195 37.1 754 40.1 Islington 5,121 1,298 25.3 4,029 78.7 4,742 1,631 34.4 3,358 70.8 4,008 1,431 35.7 2,364 59.0 4,360 31.4 Kensington 2,106 388 18.4 1,503 71.4 1,489 381 25.6 807 54.2 1,092 313 28.7 527 48.3 1,082 23.1 Lambeth 4,944 2,053 41.5 3,893 78.7 3,236 1,735 53.6 2,262 69.9 2,902 1,500 51.7 1,710 58.9 5,288 47.7 Lewisham 2,478 316 12.8 2,013 81.2 2,391 644 26.9 1,689 70.6 1,873 580 31.0 1,202 64.2 1,540 22.8 Paddington 1,829 294 161 1,445 79.0 1,654 564 34.1 1,127 68.1 1,417 413 29.1 749 52.9 1,271 25.9 Poplar 3,205 1,226 38.3 2,504 78.1 2,692 1,367 50.8 1,777 66.0 2,217 1,399 63.1 1,381 62.3 3,992 49.2 St. Marylebone 1,285 242 18.8 906 70.5 876 246 28.1 529 60.4 964 308 32.0 448 46.5 796 25.5 St. Pancras 4,107 1,167 28.4 3,187 77.6 2,567 986 38.4 1,668 65.0 2,263 843 37.3 1,238 54.7 2,996 33.5 Shoreditch 2,251 920 40.9 1,808 80.3 2,057 1,092 53.1 1,405 68.3 1,857 950 51.2 1,058 57.0 2,962 48.0 Southwark: 4,504 2,124 47.2 3,755 83.4 3,353 1,926 57.4 2,209 65.9 3,029 1,719 56.7 1,736 57.3 5,769 53.0 Stepney 6,497 1,829 28.2 5,114 78.7 5,221 2,236 42.8 3,365 64.4 4,437 1,864 42.0 2,251 50.7 5,929 36.7 Stoke Newington 447 74 16.6 389 87.0 400 139 34.7 290 72.5 367 178 48.5 258 70.3 391 32.2 Wandsworth 5,408 2,059 381 4,428 81.9 3,910 1,975 50.6 2,876 73.8 3,683 1,617 44.0 2,339 63.7 5,651 43.5 Westminster 1,507 352 23.4 1,248 82.8 1,034 348 33.6 701 67.8 690 252 36.5 365 52.9 952 29.5 Woolwich 2,164 1,123 51.9 1,833 84.7 2,127 1,280 60.2 1,580 74.3 1,639 1,155 70.5 1,110 67.7 3,558 60.0 London County 79,620 23,668 29.7 63,456 79.7 62,900 25,794 41.0 43,161 68.6 54,638 23,075 42.2 31,619 57.9 72,537 36.8 vii APPENDIX II. SUMMARY OF MEDICAL INSPECTION. F— Denotes Defects found. (x)—Signifies Cases referred for treatment. Number of children examined. Clothing and footgear. Nutrition. Cleanliness and condition of skin. Skin. Teeth. Nose and throat. Eyes. Bars. Speech. Mental Condition. Heart. Lung defects. Diseases of Nervous system. Tuberculosis. Rickets. Deformities. Infectious diseases. Malnutrition. Glands (other than throat) Other defects. Cards Issued. Parents Present. Head. Body. 1. 3. Defects. Enlarged Tonsils. Adenoids. Tonsils or Adenoids. Other defects. Glands. Eye disease. Vision. Disease. Hearing. Stammering. Other defects. Heart disease. Anaemia. Phthisis. Other forms. 1. 2. 3. 1. 2. 3. 4. 1 2 3 1. 2. 3. Defect. Disease, (x) F. (x) f. f. (x) f. (x) f. (x) f. (x) 1. 2, 3. (x) f. (x) f. (x) f. (x) f. (x) 1. 2. 3. 4. M.D. F. (x) F. (x) F. (X) F. (X) F. (x) F. (X) F. (x) F. (x) F. (x) F. (x) F. (x) F. (x) Elementary Schools. Entrants Boys 40,017 21,565 16,984 1,468 12,272 23,414 4,200 131 34,761 5,010 246 31,056 8,262 699 859 846 418 24,860 11,099 4,058 14,739 5,425 5,478 3,863 3,316 1,830 275 4,966 188 1,821 1,099 ... ... ... ... 1,061 559 481 134 96 ... 547 12 ... ... ... ... ... 618 62 1,172 280 2,842 807 317 59 123 72 133 42 1,453 122 796 160 112 50 236 228 138 9 1,046 527 12,032 31,824 Girls 39,603 21,802 16,759 1,042 12,974 22,774 3,755 100 29,076 9,845 682 30,494 8,448 661 3,055 893 384 24,944 10,774 3,885 13,874 5,409 5,218 3,102 2,945 1,420 206 4,566 149 1,842 1,070 ... ... ... ... 1,050 585 506 143 40 1 366 4 ... ... ... ... 639 68 1,038 261 2,650 803 332 58 105 63 114 42 777 74 501 71 120 49 224 219 16 4 962 487 11,536 31,632 1905 Boys 31,643 15,016 14,383 2,244 6,959 19,682 4,905 97 27,574 3,888 181 22,790 7,946 907 537 594 256 16,257 11,589 3,797 14,654 5,891 3,523 2,122 1,942 1,329 207 3,387 118 1,228 550 11,244 13,295 6,092 4,164 622 300 587 199 139 3 345 5 3,097 24,860 3,126 465 95 699 68 1,022 207 1,265 293 421 64 148 67 117 40 679 15 673 99 27 10 154 146 29 10 809 410 12,683 20,837 Girls 31,257 16,079 13,722 1,456 7,839 19,199 4,131 88 21,043 9,449 765 23,035 7,569 353 3,348 518 169 16,106 11,357 3,794 14,703 6,162 4,011 1,831 1,956 1,001 163 3,322 106 1,287 544 9,747 13,980 6,577 4,511 693 346 589 233 46 ... 222 3 3,377 24,423 2,923 444 90 713 89 1,103 243 1,148 276 396 60 159 76 92 32 389 9 594 125 36 16 124 119 23 6 719 361 13,111 22,324 1901 Boys 27,143 13,346 12,308 1,489 7,177 15,987 3,762 217 23,683 3,339 121 19,850 6,599 694 479 445 177 13,579 10,864 2,700 11,732 5,211 2,626 1,323 1,447 1,059 204 2,162 80 914 382 13,813 7,073 6,134 4,191 617 319 580 246 238 11 243 8 5,336 18,666 2,804 321 16 715 105 717 217 1,065 213 317 55 139 59 95 35 630 17 663 101 15 3 250 248 35 5 557 261 11,361 14,199 Girls 27,495 14,248 12,312 935 8,400 15,156 3,770 169 18,490 8,351 654 20,571 6,346 578 2,623 437 155 14,421 10,734 2,340 11,286 5,013 3,250 1,226 1,590 801 125 2,248 67 996 393 12,013 8,380 7,045 4,767 681 333 686 278 66 4 216 7 4,787 18,941 3,321 424 22 952 141 1,024 321 981 238 396 81 135 56 72 17 284 9 808 181 13 3 222 218 57 5 664 289 11,714 17,420 Total, Elementary Schools 197,158 102,056 86,468 8,634 55,621 116,212 24,523 802 154,627 39,882 2,649 147,796 45,170 4,192 10,901 3,733 1,559 110,167 66,417 20,574 80,988 33,111 24,106 13,467 13,196 7,440 1,180 20,651 708 8,088 4,038 ... ... ... 17,633 4,724 2,442 3,429 1,233 625 19 1,939 39 ... ... ... ... ... 4,336 533 6,076 1,529 9,951 2,630 2,179 377 809 393 623 208 4,212 246 4,035 737 323 131 1,210 1,178 298 39 4,757 2,335 72,437 138,236 Mentally Defective Schools. 1901 Boys 714 205 413 96 151 413 143 7 538 166 10 398 265 51 30 21 11 294 317 103 339 143 81 61 49 60 7 89 2 43 17 241 218 217 97 40 19 29 7 10 ... 18 ... ... ... ... ... 36 3 29 11 56 10 27 6 5 1 4 1 38 1 37 5 ... ... 10 9 1 ... 19 6 313 405 Girls 505 171 281 53 158 264 81 2 230 245 30 278 198 29 65 17 5 237 215 53 221 92 66 40 33 47 8 41 3 38 15 161 162 156 83 20 12 24 6 ... ... 18 ... ... ... ... ... ... 38 3 20 4 25 7 25 6 2 2 2 ... 14 ... 33 3 ... ... 3 3 1 ... 13 6 231 342 1905 Boys 295 75 184 36 49 192 49 5 219 74 2 156 123 16 16 15 8 163 103 29 121 47 35 35 25 29 6 33 ... 29 13 76 103 55 16 11 8 14 6 2 ... 9 ... ... ... ... ... ... 7 ... 11 5 9 2 14 ... ... ... 1 1 17 ... 13 2 ... ... 5 5 ... ... 11 5 121 203 Girls 195 48 121 26 50 110 30 5 96 88 11 96 77 22 13 5 5 94 80 21 82 39 20 16 7 8 1 21 3 11 5 45 64 39 17 9 5 5 2 1 ... 3 ... ... ... ... ... ... 5 ... 8 1 16 3 4 1 1 ... 2 ... 10 ... 11 2 ... ... 6 6 2 ... 5 4 87 132 Schools for Blind. 1901 Boys 32 13 19 ... 9 21 2 ... 31 1 ... 28 4 ... 1 ... ... 10 14 8 8 7 1 ... ... 2 ... 2 ... 1 1 ... ... ... ... ... ... 3 1 ... ... 1 ... ... 24 7 1 ... ... ... ... ... 1 1 ... ... ... ... ... ... 3 1 1 1 ... ... ... ... ... ... ... ... 11 11 Girls 39 19 19 1 9 24 6 ... 30 8 1 29 8 2 2 ... ... 14 23 2 7 4 5 3 4 ... 3 ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... 28 11 ... 3 1 1 ... 3 1 ... ... ... ... 1 ... ... ... I ... ... ... 2 2 ... ... 1 ... 15 18 1905 Boys 27 17 9 1 3 19 5 ... 22 5 ... 24 3 ... 2 ... ... 11 13 3 7 4 1 3 ... 4 1 1 ... 5 1 ... ... ... ... ... ... ... ... ... 2 ... 1 16 6 2 2 1 ... ... ... 3 1 1 ... ... ... 1 ... 4 1 2 1 ... ... 2 2 ... ... 1 ... 9 17 Girls 13 7 6 ... 1 8 3 1 9 4 ... 9 4 ... 2 1 ... 3 8 2 7 2 ... 1 ... ... ... ... ... 1 ... ... ... ... 2 ... 1 ... ... ... ... ... ... 12 1 ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 I ... ... ... ... 3 7 Schools for Deaf. 1901 Boys 39 26 13 ... 8 23 8 ... 31 7 1 30 8 1 ... 1 ... 19 16 4 13 2 2 2 1 4 ... 3 ... 3 1 18 4 11 3 3 2 1 ... ... ... 3 ... 2 30 5 2 ... 2 ... 1 ... 1 ... ... ... ... ... ... ... 2 1 ... ... ... ... 2 2 ... ... 1 1 13 22 Girls 34 24 8 2 16 14 4 ... 23 11 ... 23 10 1 1 1 ... 22 10 2 12 1 2 1 ... 1 ... 3 ... ... ... 18 9 3 4 1 ... ... ... ... ... ... ... 3 31 ... ... ... 1 ... 2 ... ... ... 3 ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 7 21 1905 Boys 32 17 13 2 5 24 3 ... 23 8 1 18 12 2 1 ... ... 22 8 2 11 1 4 2 1 ... ... 5 1 1 1 12 6 2 1 3 2 ... ... ... ... ... ... 2 28 2 ... ... 3 ... 2 ... 3 ... ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... ... ... 5 9 Girls 26 16 8 2 9 14 3 ... 21 5 ... 18 6 2 1 ... 17 4 5 7 3 1 ... ... 2 ... 4 ... 4 1 9 3 1 ... ... ... 2 ... ... ... 1 ... 2 23 1 ... ... ... ... 1 1 ... ... ... ... ... ... ... ••• ... ... 3 1 ... ... ... ... ... ... 1 1 8 12 Urgent Cases, Elementary Schools. Boys 12,904 ... ... ... ... ... ... ... ... ... ... ... ... ... 21 1,189 1,015 ... ... ... 620 578 518 741 881 368 288 127 75 1,477 1,358 ... ... 998 905 925 828 297 232 10 5 36 10 ... ... ... ... 447 297 69 278 148 445 209 299 121 368 186 152 90 46 21 145 84 61 36 241 128 34 22 579 355 6,479 ... Girls 14,202 ... ... ... ... ... ... ... ... ... ... ... ... ... 40 1,164 853 ... ... ... 682 616 681 659 929 396 286 139 72 1,557 1,401 ... ... 1,374 1,231 911 828 326 255 11 2 25 3 ... ... ... ... 310 419 135 403 219 398 160 413 174 433 203 133 70 28 9 204 97 101 59 215 108 44 23 701 404 7,048 ... Total 226,215 ... ... ... ... ... ... ... ... ... ... ... ... ... 11,096 6,147 3,456 ... ... ... 83,125 34,650 25,523 15,031 15,126 8,361 1,777 21,122 864 11,258 6,852 ... ... ... 19,990 6,649 4,146 4,133 1,742 659 26 2,055 52 ... ... ... ... ... 5,148 744 6,833 1,918 10,911 3,024 2,965 685 1,618 785 919 370 4,376 280 4,487 933 485 226 1,697 1,444 380 84 6,089 3,117 86,787 ... APPENDIX III. viii. SUMMARY OF MEDICAL INSPECTION. AGE GROUP—ENTRANTS—BOYS. F. Indicates that a defect is found and (x) denotes cases referred for treatment. Borough. Number of children examined. Clothing and footgear. Nutrition. Cleanliness and condition of skin. Skin. Teeth. Nose and throat. Eye disease. Ears. Speech. Heart. Lung dcfects. Disease of nervous system Tuberculosis. Rickets. Deformities. Infectious diseases. Malnutrition. Glands (other than throat). Other defects. Cards issued. Parents present. Enlarged tonsils Adenoids. Tonsils or adenoids. Other. Glands. Head. Body. Defects. Disease. Hearing. Stammering. Other. Heart. Anaemia. Phthisis. Other forms. 1. 2. 3. I 2. 3. 4. 1. 2. 3. l. 2. 3. Def. Dis. (x) 1. 2 3. f. (x) f. F. (X) f. (X) f. (x) f. (x) f. (X) F. (x) f. J (x) f. j (X) F. (x) f. (X) f. 1 (x) f. (x) f. (X) f. (X) F. (X) F. (x) F. (x) F. (X) F. (x) F. (x) City 111 72 37 2 34 71 6 ... 96 15 ... 82 28 1 14 1 1 70 23 18 52 6 30 35 15 ... ... 14 ... 2 1 3 3 ... ... ... 1 1 ... 4 1 1 1 ... ... ... 1 ... 4 ... ... ... ... ... ... ... 1 1 23 81 Battersea 1,611 869 658 84 353 1,081 174 3 1,520 88 3 1,337 259 15 12 27 23 833 407 371 542 342 157 126 195 19 13 17 8 61 49 26 20 4 2 1 ... 3 1 6 1 58 44 40 35 ... ... 3 ... 4 1 3 1 13 7 2 2 2 2 3 1 45 43 592 1,338 Bermondsey 1,529 665 793 71 581 862 85 1 1,257 254 18 801 671 57 73 71 15 1,000 359 170 471 192 319 190 83 77 8 490 10 99 43 56 32 14 2 7 ... 25 1 30 3 124 17 248 111 16 6 1 1 4 ... 51 7 54 6 4 2 5 3 ... ... 139 49 517 1,225 Bethnal Green 1,294 579 592 123 243 655 386 10 1,185 101 8 945 330 19 5 21 4 866 383 45 410 64 101 14 48 118 40 69 4 65 49 20 16 7 2 2 ... 12 ... 31 ... 15 4 74 22 8 3 14 10 1 ... 36 3 14 9 2 ... 11 11 ... ... 26 13 287 1 031 Camberwell 2,094 1,885 745 64 995 1,469 223 7 2,323 336 35 2,128 485 81 20 34 22 2,107 466 121 560 147 144 147 160 129 19 37 5 116 64 56 38 35 10 5 ... 35 ... 19 2 53 33 171 33 10 3 12 9 4 ... 112 13 91 13 7 2 11 11 8 2 74 45 583 2,200 Chelsea 459 181 240 38 183 237 37 2 330 111 18 342 98 19 ... 8 3 325 118 16 62 43 64 41 45 7 3 31 3 14 7 7 5 3 1 ... ... 4 ... 14 3 9 1 44 8 4 ... ... ... 2 1 24 2 4 1 1 ... 3 3 ... ... 3 2 116 331 Deptford 868 571 279 18 314 460 93 1 795 63 10 715 139 14 61 50 13 508 233 127 370 189 131 50 24 44 199 5 36 15 20 8 7 3 2 ... 21 ... 11 ... 28 2 66 11 14 1 4 1 1 ... 22 ... 59 7 2 ... ... ... ... ... 22 14 270 668 Finsbury 947 266 584 97 324 537 82 4 687 241 19 497 414 36 30 25 9 503 315 129 428 43 131 159 94 25 2 188 3 59 22 34 22 15 4 2 ... 6 1 21 1 6 ... 25 2 6 1 1 1 4 1 51 0 17 2 4 ... 6 6 1 ... 25 7 201 714 Fulham 1,387 918 451 18 336 848 198 5 1,332 54 1 1,293 91 3 35 32 16 791 364 232 694 164 211 105 97 92 12 258 11 57 42 39 15 9 ... 1 ... 16 ... 14 2 25 9 134 29 6 2 7 3 8 1 43 4 50 8 13 7 12 11 ... ... 25 14 428 1,092 Greenwich 1,133 636 486 11 512 539 77 5 988 142 3 932 196 5 6 10 6 784 323 26 435 101 67 30 50 7 2 84 4 23 19 20 12 16 8 1 ... 7 ... 5 ... 5 3 48 12 6 2 2 1 ... ... 10 4 6 4 1 1 20 20 1 ... 11 6 235 912 Hackney 1,851 975 848 28 718 1,035 95 3 1,665 178 8 1,645 201 5 65 44 32 1,428 310 113 492 118 171 77 79 50 29 162 14 65 35 40 25 37 12 6 ... 7 ... 10 3 22 11 72 13 10 3 ... ... 4 3 127 7 12 2 5 4 17 17 ... ... 47 31 391 1,564 Hammersmith 1,070 974 93 3 145 865 58 2 1,034 36 ... 1,040 30 ... ... 11 5 569 332 169 633 45 144 145 97 47 ... 75 17 11 15 3 32 2 ... 2 ... 9 5 13 3 76 2 2 ... 5 2 1 ... 9 ... 16 7 1 ... 2 2 ... ... 16 9 195 811 Hampstead 427 198 199 30 191 200 32 4 409 18 ... 391 35 1 1 12 6 208 166 53 212 47 27 23 14 54 9 31 3 13 6 9 5 ... 1 ... 7 ... 11 1 6 3 52 16 3 1 ... ... ... ... 12 ... 30 3 ... ... 5 5 1 ... 13 5 120 346 Holborn 380 103 233 50 65 299 22 ... 327 53 6 317 66 3 13 20 11 218 79 89 246 86 127 190 30 25 ... 358 21 11 34 8 16 4 6 ... 28 ... 5 2 9 4 29 4 1 ... ... ... ... ... 24 8 1 .1 1 ... ... ... ... 9 ... 139 246 Islington 2,545 1,490 952 103 518 1,402 614 11 2,283 251 11 2,258 238 49 109 39 23 1,858 445 242 674 226 368 218 240 36 2 264 11 130 82 64 31 33 5 5 ... 18 ... 45 2 96 22 189 65 8 2 8 5 4 1 38 2 37 8 6 2 14 14 2 ... 30 12 665 1,989 Kensington 1,123 480 619 24 353 696 70 4 888 232 3 618 469 30 4 7 5 163 926 34 273 ... 184 106 98 53 2 263 3 50 30 24 7 8 3 1 ... 4 ... 8 ... 11 3 67 27 6 1 6 3 1 1 37 8 64 1 2 1 4 4 ... ... 17 11 205 797 Lambeth 2,490 1,275 1,143 72 509 1,764 214 3 2.355 133 2 2,030 419 35 19 34 22 1,617 444 429 884 670 385 241 277 28 11 146 7 107 78 48 41 25 8 2 ... 15 ... 49 2 13 8 52 19 7 3 2 1 4 2 58 4 14 1 1 ... 7 6 1 ... 53 28 1,023 1.966 Lewisham 1,272 920 347 5 357 718 195 2 1,247 25 ... 1,081 186 5 6 15 9 932 268 72 294 59 92 81 67 110 1 46 4 35 19 11 5 8 4 3 ... '16 ... 4 ... 17 2 32 3 3 ... 1 ... ... ... 15 1 6 1 3 ... 2 2 ... ... 8 3 169 1,012 Paddington 913 747 159 7 518 359 34 2 878 33 2 808 91 14 ... 9 3 577 302 34 173 24 88 40 57 26 3 96 5 41 29 12 4 2 1 1 ... .a ... 17 3 13 1 35 7 22 2 17 7 2 ... 28 3 11 3 2 ... 3 3 62 2 21 11 154 733 Poplar 1,651 481 1,089 81 454 972 224 1 1,445 197 9 1,332 305 14 2 18 12 1,038 581 32 539 425 169 91 113 63 15 85 5 74 62 50 34 26 11 2 ... 5 ... 25 4 8 2 110 23 9 3 7 4 6 1 71 4 29 22 4 ... 25 25 ... ... 51 23 661 1,270 St. Marylebone 593 479 110 4 422 160 11 ... 517 74 2 550 39 4 ... 7 1 431 117 45 151 42 38 25 31 3 53 3 29 21 8 7 1 ... 1 ... 17 4 21 4 37 8 21 ... 2 2 ... 11 3 2 ... 2 ... ... ... 49 1 33 10 125 405 St. Pancras 2,048 1,193 796 59 589 1,301 151 7 1,705 339 4 1,698 328 22 ... 69 32 1,137 603 308 908 267 430 540 81 169 12 1,069 8 96 57 144 22 47 5 17 ... 133 1 58 5 30 8 282 55 18 4 1 1 3 2 151 8 90 7 4 2 8 8 1 ... 79 18 599 ... Shoreditch 1,069 173 844 52 321 679 67 2 530 534 5 523 522 24 8 73 48 987 47 35 142 83 134 142 175 62 25 26 7 99 82 54 41 25 15 7 ... 23 .. 52 5 21 8 139 45 23 5 2 2 6 4 75 17 13 6 10 6 2 2 ... ... 66 49 456 859 Southwark 2,235 530 1,462 243 380 1,496 345 14 1,673 544 18 1,023 1,094 118 38 53 19 1,061 830 344 1,152 676 427 194 213 74 18 295 16 143 77 71 33 24 7 2 ... 23 6 53 4 72 14 242 105 15 3 2 I 6 1 55 9 37 9 5 2 15 14 1 ... 77 34 1,039 1,954 Stepney 3,321 1,928 1,298 95 1,441 1,431 421 28 2.861 429 31 2,420 836 05 294 75 28 1,840 1,167 314 1,443 343 517 285 319 423 22 437 16 219 92 109 66 16 7 ... 34 ... 71 3 399 15 381 55 51 1 14 9 41 9 209 1 60 8 16 5 29 28 1 1 74 40 934 2,606 Stoke Newington 235 88 146 1 97 134 4 ... 9.9.4. 10 1 215 18 2 1 4 3 180 47 8 30 3 16 11 16 10 4 8 8 2 2 2 1 ... ... ... 1 1 2 2 3 1 1 ... ... ... ... ... 18 ... 3 1 1 1 1 ... ... 6 ... 37 207 Wandsworth 2,844 1,990 809 45 559 2,131 150 4 2,586 254 4 2,507 317 20 32 32 15 2,138 382 324 2,099 716 388 285 327 50 17 86 19 73 40 48 27 22 15 2 ... 11 ... 9 1 60 37 72 21 19 ... 2 1 8 1 52 2 21 9 8 5 4 4 5 ... 39 25 1,105 2,279 Westminster 791 339 422 30 290 439 59 3 591 178 22 592 175 24 1 5 1 539 222 30 96 57 85 70 76 4 3 15 23 12 18 12 4 2 ... ... 3 ... 17 1 13 43 4 2 1 2 1 ... ... 30 2 9 1 1 ... ... 5 2 178 652 Woolwich 1,120 560 550 10 470 574 73 3 1,030 87 3 930 182 8 10 40 31 152 840 128 274 247 327 202 195 19 3 72 14 46 36 19 17 43 8 10 ... 85 2 5 4 19 19 78 71 25 12 8 7 19 13 80 17 22 14 5 4 27 25 2 2 31 22 585 965 Total 40,017 21,505 16,984 1,468 12,272 23,414 4,200 131 34,761 5,010 246 31,056 8,262 699 859 840 418 24,860 11,099 4,058 14,739 5,425 5,478 3,863 3,316 1,830 275 4,966 188 1,821 1,099 1,061 559 481 134 96 ... 547 12 618 62 1,172 280 2,842 807 317 59 123 72 133 42 1,453 122 796 160 112 50 236 228 138 9 1,046 527 12,032 31,824 Age group-entrants-girls. City 111 66 43 2 37 64 9 1 67 42 2 73 35 3 37 4 ... 70 26 15 57 11 27 25 17 1 18 1 8 5 5 3 ... ... ... ... 2 ... 2 1 2 ... 1 ... ... ... ... 1 1 ... ... ... ... ... ... 1 1 ... ... ... ... 33 91 Battersea 1,732 960 694 78 414 1,127 186 5 1 384 339 9 1,453 267 12 107 14 13 903 432 397 603 412 173 155 238 25 18 14 9 55 44 35 30 16 11 ... ... 3 1 6 1 29 28 37 26 3 ... 2 1 2 2 6 2 7 3 2 2 6 6 ... ... 51 46 707 1,360 Bermondsey 1,358 689 612 57 510 779 67 2 942 396 20 681 622 55 253 85 20 895 334 129 387 172 287 114 53 00 4 440 9 86 35 48 28 14 2 1 ... 12 ... 17 1 96 12 191 78 20 5 5 2 3 1 30 5 28 1 8 7 3 2 2 1 113 39 417 1,092 Bethnal Green 1,449 657 721 71 366 750 331 2 1 007 389 53 1,052 378 19 11 18 9 1,042 369 38 546 95 119 16 47 85 22 53 1 83 49 25 22 6 2 2 ... 1 ... 29 1 18 3 58 22 7 2 8 6 2 1 22 1 12 1 6 5 4 ... ... 21 6 281 1,121 Camberwell 2,525 1,776 717 32 942 1,377 198 8 L821 635 69 1,886 545 94 81 26 16 1,967 445 113 528 131 125 113 130 108 10 24 1 87 56 61 49 33 10 1 ... 18 ... 20 5 29 19 157 33 12 5 13 7 7 ... 39 4 53 4 8 5 11 10 1 ... 69 35 508 2,106 Chelsea 441 175 241 25 173 231 36 1 308 114 19 320 103 18 ... 7 3 306 113 22 54 37 55 29 37 2 1 29 1 16 4 7 5 8 4 ... ... 3 ... 15 ... 13 ... 32 5 7 ... 4 3 * 2 20 1 2 ... ... ... 1 1 ... ... 3 1 108 345 Deptford 876 632 235 9 331 471 72 2 716 146 14 094 172 10 209 30 5 554 225 97 365 170 156 54 22 40 ... 200 8 44 20 25 13 9 1 1 ... 15 ... 10 1 13 2 66 12 2 ... 4 1 2 ... 12 1 25 1 ... ... 2 2 ... ... 29 19 267 733 Finsbury 887 271 549 67 351 460 75 1 488 334 65 499 368 20 79 30 7 500 256 131 401 51 124 97 60 14 3 163 1 65 30 19 9 13 3 ... ... 8 1 17 ... 7 1 37 7 12 1 1 ... 3 2 28 ... 10 1 ... ... 3 3 1 ... 19 4 182 706 Fulham 1,308 916 383 9 365 755 185 3 1 140 156 12 1,222 79 7 181 21 14 683 384 241 665 178 177 90 90 01 9 235 5 51 30 54 20 14 2 2 ... 7 ... 22 1 23 10 105 33 6 ... 3 1 6 1 24 6 31 3 8 2 6 6 ... ... 21 12 421 1,054 Greenwich 1,140 540 598 2 581 511 46 2 932 199 9 985 151 4 5 22 11 812 317 11 458 87 76 16 41 7 3 44 1 34 23 22 17 20 10 ... ... 7 ... 4 3 4 3 36 10 11 4 2 2 ... ... 6 5 1 1 ... ... 11 10 ... ... 4 3 211 922 Hackney 2,281 1,144 1,119 18 989 1,187 95 10 1 719 556 6 1,848 423 10 273 49 32 1,730 418 133 590 134 246 110 120 47 25 241 7 96 62 53 39 49 10 3 ... 10 ... 25 4 19 9 133 36 18 4 4 3 5 2 86 8 16 3 6 3 19 19 ... ... 46 29 531 1,857 Hammersmith 1,070 992 75 3 158 852 59 j 916 150 4 1,053 16 1 2 12 8 555 366 149 647 56 130 124 88 28 ... 57 2 26 20 16 5 30 ... 1 ... 1 ... 9 1 12 8 70 5 8 ... 7 2 ... ... 3 ... 11 ... 2 1 1 1 ... ...... 15 11 201 854 Hampstead 421 214 191 16 140 239 39 3 394 26 1 389 32 ... 3 8 3 178 185 58 236 49 24 8 10 33 3 20 ... 17 12 11 7 3 ... 1 ... ... ... 13 ... 13 7 62 22 5 2 ... ... ... ... 16 ... 28 ... ... ... 4 4 ... ... 16 5 115 342 Holborn 401 113 253 35 83 300 17 1 243 144 14 320 78 3 27 10 2 251 79 71 273 68 132 173 22 24 ... 369 ... 41 22 43 7 10 1 ... ... 28 ... 2 2 4 2 27 6 1 1 1 1 ... ... 15 1 3 ... ... ... 1 1 ... ...... 7 3 124 259 Islington 2,576 1,527 985 64 529 1.427 610 10 1,820 713 43 2,272 248 56 365 56 20 1,869 479 228 686 216 349 188 235 29 3 225 6 111 65 44 29 34 12 2 ... 21 ... 47 3 108 22 209 73 8 ... 3 1 ... ... 16 ... 17 2 12 2 10 10 1 ... 41 23 633 2,040 Kensington 983 452 512 19 321 623 37 2 719 245 19 537 405 41 30 15 6 166 783 34 239 3 167 81 77 38 ... 222 7 48 26 19 9 5 2 ... ... 2 ... 9 1 7 3 51 25 7 ... ... ... 3 1 18 1 22 1 1 ... 7 7 ... ... 18 8 183 706 Lambeth 2,454 1,347 1,069 38 515 1,720 217 2 1,975 457 22 1,990 417 47 233 58 22 1,592 397 465 904 713 309 227 261 22 7 131 20 108 87 46 41 18 8 3 ... 8 ... 45 1 15 4 58 27 2 ... 3 3 4 1 36 1 10 ... 3 3 2 2 ... ... 42 27 1,030 1,927 Lowisham 1,206 910 291 5 414 651 140 1 1,140 62 4 1,060 142 4 22 21 5 914 238 54 256 50 103 66 55 91 2 24 28 12 9 5 9 4 ... ... 11 ... 7 15 2 23 7 1 1 1 ... 1 ... 5 ... 11 5 1 ... ... ... ... ... 6 1 147 1,001 Paddington 916 765 144 7 571 306 39 ... 841 70 5 817 91 8 13 13 5 578 280 52 175 32 89 42 48 11 1 89 5 34 17 15 10 ... 2 ... 2 ... 18 5 15 3 41 8 20 1 5 3 ... ... 15 1 10 ... 5 3 1 1 1 ... 18 8 140 712 Poplar 1,554 641 881 32 486 897 171 ... 899 586 69 1,242 300 12 9 42 21 1,020 508 26 528 383 121 62 75 44 15 71 3 78 53 47 32 31 14 2 ... 4 ... 21 3 20 3 83 23 17 5 7 4 6 2 24 3 12 6 9 4 29 29 1 ... 37 17 565 1,228 St. Marylebone 692 584 107 1 526 159 7 ... 602 90 ... 656 35 1 ... 9 ... 506 139 47 191 47 54 18 33 5 ... 57 3 16 10 11 5 1 ... 1 ... 1 ... 20 4 16 1 39 4 19 1 2 2 1 ... 4 1 5 ... 4 ... ... 4 ... 14 5 117 501 St. Pancras 2,059 1,218 792 49 589 1,304 157 9 1,459 578 22 1,659 379 21 1 52 23 1,134 627 298 847 274 395 417 68 139 9 973 5 92 46 136 21 40 6 9 ... 99 ... 77 7 40 19 287 67 20 4 1 ... 6 1 91 3 73 5 2 ... 12 12 ... ... 64 25 568 1,622 Shoreditch 1,182 257 873 52 457 658 67 ... 608 555 19 632 526 24 28 75 44 1,061 68 53 218 117 178 134 184 73 24 25 3 113 88 62 42 34 14 3 ... 8 ... 49 5 15 4 128 36 17 1 4 2 5 3 34 4 5 2 10 6 3 3 ... ... 62 36 464 949 Southwark 2,269 487 1,582 200 345 1,597 316 11 1,220 1,003 46 1,033 1,152 84 208 48 13 1,093 836 340 1,184 653 404 149 229 83 17 263 15 143 68 99 44 30 6 ... ... 11 ... 47 8 65 24 221 106 11 3 2 2 3 2 39 8 37 9 7 3 13 12 ... ... 108 52 1,085 1,801 Stepney 3,176 1,850 1,261 65 1,497 1,340 320 19 2,012 1,086 78 2,343 784 49 686 103 38 1,763 1,143 270 1,447 314 418 201 219 290 17 453 18 225 88 72 44 6 ... 1 ... 16 ... 85 5 362 17 341 58 60 6 18 12 39 14 99 ... 44 10 16 3 18 18 2 1 92 45 795 2,508 Stoke Newington 212 73 136 3 81 131 ... 160 49 3 187 24 1 10 2 2 162 42 8 33 2 17 7 16 5 2 2 ... 9 9 7 6 6 3 1 ... ... ... ... ... 2 1 2 ... ... ... ... ... ... ... 9 ... 2 1 ... ... ... ... ... ... 4 3 37 182 Wandsworth 2,564 1,753 788 23 542 1,918 103 1 2,140 402 22 2,243 299 22 114 32 18 1,998 319 247 982 633 310 174 203 28 8 57 10 66 42 31 22 17 9 ... ... 7 ... 14 2 32 18 70 20 11 3 ... ... 3 ... 21 3 12 4 5 1 1 1 1 ... 28 14 954 2,149 Westminster 716 280 381 55 263 396 56 1 478 213 25 497 192 27 15 7 5 472 221 23 102 69 71 45 50 7 ... 15 2 26 18 7 3 5 3 1 ... 3 1 7 1 11 3 34 5 1 ... 1 1 ... ... 15 ... 1 ... 1 ... 2 2 ... ... 1 3 2 174 596 Woolwich 1,044 513 526 5 398 544 100 2 926 110 8 851 185 8 53 24 19 170 739 135 272 247 262 167 151 14 3 52 6 36 29 21 18 45 6 3 1 58 1 2 2 33 33 51 49 26 9 4 4 9 6 44 15 13 8 4 4 52 52 2 2 11 8 538 868 Total 39,603 21,802 16,759 1,042 12,974 22,774 3,755 100 29,076 9,845 682 30,494 8,448 661 3,055 893 384 24,944 10,774 3,885 13,874 5,409 5,218 3,102 2,945 1,420 206 4,566 149 1,842 1,070 1,050 585 506 143 40 l 366 4 639 68 1,038 261 2,650 803 332 58 105 63 114 42 777 74 501 71 120 49 224 219 16 4 962 487 11,536 31,632 ix APPENDIX IV. SUMMARY OF MEDICAL INSPECTION. AGE GROUP.—1905.—BOYS. F. = Defects found and (x)=Defects referred for treatment. Borough. Number of children examined. Clothing and footgear. Nutrition. Cleanliness and condition of skin. Skin. Teeth. Nose and throat. Eyes. Ears. Speech. Mental condition. Heart. Lung defects. Diseases of nervous system. Tuberculosis. Rickets. Deformities. Infectious diseases. Malnutrition. Glands, (other than throat). Other defects. Cards Issued. Parents present. Enlarged Tonsils. Adenoids. Tonsils or Adenoids. Other defects. Glands. Head. Body. Defects. Eye diseases. Vision. Disease. Hearing. Stammering. Other. Heart defects. Ann Mnia. Phthisis Other forms. 1. 2. 3 1. 2. 3. 4. 1. 2. 3. 1. 2. - 3. Defect. Disease. (X) 1 2. 3 f. (X) f f. (X) f. (x f. (X) f. (x) 1. 2. 3. (x) f. (x) f. (x) f. (X) f. (X) 1. £- 3. 4. M.D. f. (x) f. j (x) f. (XI f. (x) f. (x) f. (X) f. (X) f. (X) F. (x) f. (X) f. (x) F. (X) City 129 82 41 6 22 94 13 ... 113 16 ... 95 29 5 5 4 2 67 43 19 66 18 13 21 9 1 ... 16 5 ... 33 53 42 32 1 ... 1 1 2 ... ... ... 1 127 1 ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 54 79 Battersea 1,188 538 568 82 219 864 103 2 1,115 73 ... 869 296 23 3 13 12 471 385 332 528 378 136 59 127 16 8 15 9 38 33 581 383 186 135 22 15 9 7 3 2 5 1 9 1,138 34 7 ... 13 2 16 15 14 8 2 1 1 1 1 4 ... 6 5 ... 2 2 ... 19 15 608 782 Bermondsey 1,120 478 549 93 284 634 199 3 956 159 5 670 363 87 35 33 8 685 310 125 359 146 171 80 30 51 5 235 1 72 23 448 405 260 166 51 23 20 3 5 ... 13 ... 193 767 151 7 2 34 5 81 7 84 19 17 2 3 2 3 ... 19 ... 32 5 1 1 6 3 4 1 107 48 420 797 Bethnal Green 1,227 356 671 200 81 511 625 10 970 249 8 564 634 29 3 24 6 605 582 40 602 176 78 11 38 99 40 73 5 58 13 309 579 304 221 14 8 20 14 11 ... 4 ... 200 742 217 65 3 25 1 11 6 9 1 7 3 5 4 5 4 20 ... 23 ... I ... 10 10 1 1 19 7 478 791 Camberwell 1,997 1,271 633 93 527 1,232 235 3 1,705 264 28 1,498 406 93 13 16 11 1,428 441 128 669 188 75 65 79 113 7 9 2 77 30 1,151 518 274 161 36 19 28 11 4 ... 22 1 37 1,859 95 4 2 17 1 53 31 47 6 14 4 20 6 ... ... 34 2 52 6 3 ... 4 3 2 1 38 27 553 1,318 Chelsea 404 151 194 59 137 203 64 ... 270 106 28 267 113 24 ... 8 1 217 163 24 85 35 60 29 33 7 ... 20 3 15 8 160 126 97 33 10 3 5 4 ... 2 ... 1 376 13 12 2 32 1 6 ... 34 5 10 1 ... ... 7 1 18 ... 10 2 1 ... ... ... ... ... 6 ... 126 267 Deptford 735 488 230 17 153 453 128 1 658 70 7 561 157 17 69 24 4 479 216 40 398 106 131 48 29 36 5 160 4 24 6 188 376 161 113 10 5 8 3 5 ... 6 ... 58 620 49 6 2 12 ... 14 3 29 6 9 ... 5 2 ... ... 10 1 57 7 1 1 1 1 2 ... 19 9 268 540 Finsbury 732 138 468 126 157 484 89 2 526 197 9 286 363 83 11 19 6 337 299 96 436 63 88 84 48 13 1 122 4 32 6 195 268 161 74 12 10 8 3 5 ... 8 ... 3 627 97 5 ... 17 2 5 ... 9 1 13 ... 1 ... 2 ... 7 ... 16 2 1 ... 1 1 ... ... 23 5 203 447 Fulham 1,231 578 607 46 322 657 248 4 1,188 42 1 1,079 145 7 20 20 9 559 405 267 813 216 141 53 67 35 7 186 8 47 21 573 411 229 189 15 6 22 1 9 ... 19 ... 42 1,120 61 ... 8 15 ... 29 9 62 18 8 2 6 2 8 1 13 1 39 5 6 2 5 4 ... ... 24 11 475 787 Greenwich 818 369 424 25 243 485 87 3 594 224 ... 499 304 15 2 13 10 171 631 16 504 70 47 20 31 7 4 47 ... 26 16 313 340 128 103 16 13 21 14 1 ... 8 ... 80 646 75 13 4 7 3 1 1 15 1 3 3 ... ... 1 ... 15 4 3 2 ... ... 7 7 ... ... 19 15 221 548 Hackney 1,847 939 849 59 511 1,164 166 6 1,748 95 4 1,665 171 11 76 20 12 1,270 394 183 890 248 126 123 73 57 25 114 2 65 31 571 916 332 196 32 19 52 19 9 ... 5 ... 600 1,026 187 32 2 23 4 22 14 50 7 6 ... 8 4 11 3 67 1 23 2 ... ... 18 18 ... ... 44 34 648 1,337 Hammersmith 773 677 94 2 80 607 82 4 757 16 ... 744 24 5 ... 17 6 294 359 120 544 59 108 97 51 16 1 51 3 12 5 372 278 105 85 12 4 19 1 2 ... 9 1 2 748 22 1 ... 7 4 11 4 23 2 5 1 9 8 ... ... 6 ... 20 1 ... ... 4 4 ... ... 18 11 223 488 Hampstead 256 78 161 17 86 128 41 1 246 10 ... 231 24 1 ... 2 1 48 147 61 203 56 17 1 6 11 2 11 3 5 ... 56 176 23 21 3 1 1 1 ... ... 2 ... 12 209 33 1 1 18 5 7 3 15 4 6 1 1 ... ... ... 6 ... 16 1 ... ... 1 1 ... ... 9 4 95 175 Holborn 253 48 149 56 16 225 11 1 204 43 6 178 70 5 12 8 3 117 75 61 206 57 72 66 6 24 ... 235 1 19 9 51 90 75 49 33 5 13 3 7 ... 12 ... 29 188 36 ... ... 1 ... ... ... 1 ... ... ... 1 1 1 ... 13 ... 12 2 ... ... 2 2 ... ... 1 ... 116 110 Islington 2,371 1,279 960 132 381 1,418 564 8 2,177 183 11 1,965 337 69 55 44 14 1,275 773 323 1,116 303 277 122 122 44 7 218 5 109 42 716 1,123 454 336 .36 11 70 26 9 ... 18 ... 125 1,810 378 52 6 57 7 78 5 45 16 16 2 5 2 3 ... 18 ... 37 3 1 ... 9 9 ... ... 59 20 810 1,654 Kensington 708 254 377 77 203 440 63 2 416 281 11 259 386 63 1 7 4 23 659 26 197 ... 83 48 53 29 2 195 21 10 165 299 179 98 7 3 12 3 3 ... 2 ... 69 526 108 4 1 2 ... 3 2 9 3 10 1 3 1 2 ... 30 1 26 ... ... ... 4 4 1 ... 16 7 188 329 Lambeth 1,626 817 741 68 346 1,135 133 12 1,507 117 2 1,242 358 26 ... 38 12 877 407 342 736 460 167 130 158 27 8 76 10 68 51 522 703 297 242 20 16 11 5 3 ... 5 ... 113 1,461 44 7 1 32 2 8 4 21 9 8 2 2 1 4 ... 36 ... 12 2 1 1 8 8 1 ... 24 15 879 1,073 Lewisham 1,295 943 328 24 200 823 272 ... 1,267 26 2 1,037 239 19 6 16 5 753 466 76 529 191 54 71 59 139 5 53 2 40 7 407 695 143 72 10 8 13 9 5 ... 2 ... 259 861 146 27 2 6 ... 40 6 9 1 1 ... ... ... 1 1 4 ... 9 3 ... ... ... ... ... ... 4 3 320 887 Paddington 835 506 299 30 400 357 78 ... 765 65 5 670 143 22 ... 7 5 377 375 83 297 81 84 40 55 22 3 117 1 21 7 308 293 211 131 7 2 7 1 1 ... 1 ... 43 748 32 7 5 19 1 4 ... 14 3 11 ... 5 3 ... ... 23 ... 19 1 ... ... 1 ... ... ... 26 8 277 552 Poplar 1,344 334 885 125 114 937 286 7 1,214 121 9 948 384 12 1 20 16 783 540 21 544 382 108 25 42 66 14 83 6 37 19 647 426 244 196 19 12 20 8 3 ... 9 ... 99 1,118 98 17 12 20 4 2 1 49 12 24 4 17 7 7 2 26 2 14 7 3 3 31 29 ... ... 30 16 671 831 St. Marylebone 475 396 70 9 330 136 9 ... 461 13 1 448 27 ... ... 4 ... 293 122 60 174 60 24 3 9 1 1 22 1 8 6 250 131 75 52 6 5 2 I ... ... 1 ... 158 306 7 1 3 7 ... 5 ... 10 2 5 ... 3 1 ... ... 2 ... ... ... 2 ... ... ... 2 ... 6 3 132 275 St Pancras 1,239 700 504 35 212 899 124 4 1,024 212 3 928 293 18 ... 38 18 375 593 271 867 263 237 199 37 142 11 618 2 58 25 425 605 173 137 104 23 40 7 14 ... 49 ... 89 988 138 11 13 42 6 20 9 95 21 27 4 4 1 4 1 59 ... 66 2 1 ... 5 5 4 ... 59 16 476 760 Shoreditch 1,019 323 482 214 390 461 10/ 1 808 210 1 697 294 28 3 60 34 880 100 39 239 110 104 76 102 50 17 35 5 53 37 252 488 254 212 21 18 41 26 6 ... 13 1 238 545 181 42 13 56 3 21 12 95 33 32 9 5 5 5 2 29 ... 8 4 1 ... 1 1 1 ... 65 35 524 689 Southwark 1,719 229 1,142 348 380 1,065 269 5 1,340 374 5 600 986 133 1 59 11 715 741 263 1,023 575 264 158 154 70 8 146 8 95 43 447 773 469 335 47 28 54 14 10 ... 19 ... 198 1,344 153 23 1 48 3 43 9 64 24 25 4 4 1 5 3 17 ... 66 9 ... ... 5 5 1 1 56 30 984 1,100 Stepney 2,578 1,306 1,128 144 416 1,559 596 7 2,192 377 9 1,771 752 55 197 35 14 1,362 1,053 163 1,028 420 390 222 222 206 11 399 18 130 43 776 1,096 642 418 43 20 37 6 7 ... 29 ... 141 1,756 588 85 8 148 4 461 6 351 28 120 8 24 6 23 8 115 1 57 5 1 1 6 6 5 2 53 26 1,076 1,604 Stoke Newington 211 65 136 10 79 129 3 ... 197 13 1 188 21 2 2 i 1 169 23 19 42 22 15 6 2 1 1 1 4 1 93 76 40 33 2 2 1 1 ... ... ... 169 31 11 ... ... ... ... 4 3 ... ... ... ... ... ... ... ... 16 ... 2 ... ... • •• ... ... 3 3 68 145 Wandsworth 1,946 1,211 653 82 283 1,563 98 2 1,818 125 3 1,647 273 26 12 16 6 1,328 295 323 1,035 758 176 96 140 30 10 32 7 45 25 832 821 239 170 11 6 12 7 1 ... 11 ... 35 1,857 44 8 2 19 5 28 13 33 6 16 3 3 1 2 1 21 ... 19 10 1 ... 2 2 2 1 32 23 996 1,375 Westminster 483 182 259 42 178 249 56 ... 324 143 16 320 143 20 ... 3 3 263 181 39 102 58 46 35 44 ... ... 21 1 9 5 207 180 93 47 4 2 6 4 ... ... 3 ... 1 476 5 1 12 2 5 ... 15 2 4 1 2 1 1 1 10 ... 4 . . . ... ... ... 4 3 165 308 Woolwich 1,084 280 781 23 209 770 96 9 1,014 64 6 864 211 9 10 25 22 36 811 237 422 392 231 134 116 16 4 77 7 35 28 196 667 202 107 18 13 34 1 9 1 68 1 93 840 122 27 2 9 3 44 44 63 55 22 8 11 7 21 12 41 2 25 13 2 1 21 21 3 3 25 16 629 789 Total 31,643 15,016 14,383 2,244 6,959 19,682 4,905 97 27,574 3,888 181 22,790 7,946 907 537 594 256 16,257 11,589 3,797 14,654 5,891 3,523 2,122 1,942 1,329 207 3,387 118 1,228 550 11,244 13,295 6,092 4,164 622 300 587 199 139 3 345 5 3,097 24,860 3,126 465 95 699 68 1,022 207 1,265 293 421 64 148 67 117 40 679 15 673 99 27 10 154 146 29 10 809 410 12,683 20,837 AGE GROUP.—1905.—GIRLS. City 105 65 39 1 19 73 12 1 65 38 2 77 26 2 9 ... ... 50 36 19 83 17 21 17 8 1 ... 6 ... 4 26 46 33 18 3 2 2 ... 1 ... 1 ... ... 103 2 ... ... 1 ... 3 ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... 1 1 ... ... 2 1 42 83 Battersea 1,272 596 599 77 338 829 105 ... 893 364 15 945 302 25 51 19 7 558 387 327 541 389 134 56 113 12 6 9 6 35 21 568 417 221 191 19 11 14 11 1 ... 3 ... 18 1,218 28 3 5 13 4 17 11 17 9 6 2 5 2 ... ... ... ... 12 3 ... ... ... ... ... ... 20 15 708' 935 Bermondsey 1,103 600 440 57 298 638 163 4 792 294 17 582 453 68 175 36 i n 6 620 333 150 429 187 194 57 32 35 6 218 4 85 22 352 423 299 188 41 23 18 2 2 ... 12 ... 250 694 152 5 2 28 2 81 6 73 14 21 6 5 5 1 10 38 5 2 1 5 4 3 ... 71 29 440 853 Bethnal Green 1,249 440 712 97 141 600 502 6 631 525 93 676 529 44 54 19 9 643 556 50 627 196 89 6 44 80 27 87 1 46 11 254 617 333 242 12 10 18 9 2 ... 4 1 246 746 212 42 3 35 ... 11 5 18 8 12 2 5 3 2 10 2 7 5 2 2 5 5 ... 15 8 530 866 Camberwell 2,075 1,412 640 23 553 1,285 232 5 1,430 604 41 1,526 477 72 104 21 o 8 1,477 460 138 712 264 87 65 74 96 7 11 1 61 27 1,133 604 288 168 24 19 31 10 2 ... 10 ... 71 1,856 134 10 4 15 1 62 34 49 16 25 2 16 8 3 1 22 1 43 2 2 1 4 4 2 ... 34 23 620 1,551 Chelsea 298 105 144 49 98 146 53 1 189 77 32 179 98 21 ... 3 1 173 94 31 68 30 54 33 36 4 2 7 ... 12 5 73 122 80 21 5 1 9 4 ... ... ... ... ... 283 12 3 ... 31 1 8 ... 29 2 6 ... 1 7 6 3 ... ... 1 1 ... ... 6 ... 102 231 Deptford. 723 549 158 lb 190 421 110 2 556 141 26 489 208 26 245 14 6 432 235 56 418 130 126 38 31 40 4 119 ... 37 5 145 388 190 136 15 4 10 2 3 ... 6 1 78 558 77 8 2 12 ... 10 1 17 1 9 ... 6 2 2 1 6 46 9 ... ... 3 3 8 ... 10 5 300 532 Finsbury 698 150 450 98 206 423 68 1 253 375 70 298 361 39 86 15 2 341 285 72 406 51 88 46 37 23 ... 101 2 40 7 215 243 156 79 12 7 13 6 ... ... 1 ... 11 606 75 6 ... 19 ...2 1 ... 7 1 14 ... 3 2 9 15 3 2 ... 1 1 ... ... 23 7 197 483 Fulham 1,201 665 520 16 55/8 633 188 55 1,002 198 1 1,074 125 2 216 13 1 545 405 251 816 227 141 58 72 26 3 175 9 47 25 547 426 205 165 18 5 27 5 2 ... 6 ... 33 1,114 49 1 4 19 3 18 7 45 11 8 1 6 1 8 1 7 51 4 7 2 5 4 1 1 24 14 467 815 Greenwich 804 335 462 7 372 470 58 4 554 241 9 572 225 7 8 10 oo 3 191 604 9 444 64 58 15 40 1 1 35 2 20 11 282 333 165 121 12 8 16 13 1 ... 13 ... 79 666 48 11 ... 8 3 3 3 14 1 4 3 2 2 1 1 2 2 ... ... 2 2 1 1 10 8 273 612 Hackney 1,764 991 753 20 554 1,105 99 6 1,429 317 18 1,547 208 9 326 32 11 1,55554 370 170 837 212 155 101 68 25 16 127 1 68 24 524 863 332 244 26 15 41 16 3 ... 4 ... 632 968 140 24 ... 26 6 39 21 43 8 12 2 3 2 12 5 49 ... 24 7 2 1 8 8 2 1 37 25 655 1,335 Hammersmith 543 516 27 ... 54 435 53 1 434 109 ... 531 12 ... 1 4 1 213 242 88 456 56 69 50 22 8 ... 25 1 15 5 224 206 98 70 10 5 8 ... ... ... 3 ... ... 523 14 1 5 5 2 13 8 9 1 3 ... 7 6 ... ... 2 ... 5 ... ... 1 1 ... ... 13 10 161 375 Hampstead 294 97 182 15 79 177 35 3 238 56 ... 273 21 ... ... 4 1 45 182 67 243 60 19 2 6 20 2 18 ... 8 2 54 204 33 24 4 ... 5 1 ... 1 ... 21 241 29 1 2 14 3 9 4 21 1 4 ... 1 ... 2 ... 18 ... 22 5 ... ... 3 3 ... ... 8 5 108 210 "Holborn 312 75 197 40 29 262 21 ... 156 130 26 230 81 1 39 9 5 149 90 73 247 72 97 62 12 25 1 289 ... 27 14 65 140 103 67 41 6 18 10 5 ... 7 ... 39 254 17 2 ... ... ... 6 4 8 ... 3 2 2 ... ... ... 9 ... 9 ... ... ... ... 1 ... 8 2 153 171 Islington 2,371 1,255 1,033 83 434 1,384 545 8 1,405 909 57 1,965 341 65 335 34 10 1,368 660 343 1,011 309 321 146 160 28 6 176 2 105 48 640 1,193 458 330 45 24 60 26 4 ... 18 ... 166 1,814 333 47 11 53 2 107 9 37 13 18 2 6 2 2 ... 9 ... 20 5 4 1 7 7 ... ... 40 22 821 1,704 Kensington 781 305 448 28 240 511 30 ... 455 291 35 379 371 31 43 7 4 46 713 22 265 4 108 57 56 37 2 221 6 26 11 165 416 156 90 11 4 15 6 1 ... ... ... 96 596 79 9 1 3 ... 8 3 13 7 6 1 1 1 2 1 22 1 14 1 ... ... 2 2 ... ... 18 6 193 478 Lambeth 1,610 796 788 26 356 1,134 118 2 1,234 351 25 1,230 361 19 200 19 9 919 379 312 699 515 223 130 163 17 6 56 2 51 32 450 782 321 248 26 24 14 10 ... ... 7 ... 124 1,417 59 6 4 22 4 9 6 12 6 4 1 5 2 ... 12 ... 7 2 ... ... 2 2 ... ... 15 11 856 1,189 Lewisham 1,096 915 178 3 183 668 245 ... 1,017 68 11 926 162 8 22 7 2 630 399 67 450 186 75 43 41 98 2 38 4 23 6 271 667 129 77 9 7 16 10 ... ... 1 ... 254 731 96 15 ... 6 ... 37 5 6 2 3 1 1 ... 2 1 ... 6 4 1 ... ... ... ... ... 6 4 324 802 Paddington 819 492 302 25 443 3558 47 1 628 174 17 634 165 20 18 13 2 391 331 97 257 88 61 18 30 23 4 73 4 30 15 248 337 217 132 13 8 3 1 1 ... ... ... 45 745 21 5 3 11 2 10 2 16 7 8 ... 7 2 3 1 5 ... 10 1 2 1 1 1 ... ... 21 4 287 575 Poplar 1,348 470 757 121 215 860 270 3 778 496 74 1,087 253 8 9 8 6 729 592 27 580 434 127 33 51 46 13 85 1 53 21 593 408 298 218 18 12 28 17 2 ... 6 1 87 1,133 107 15 6 22 4 13 5 38 9 26 7 7 3 3 • 1 12 ... 9 2 ... ... 23 22 ... ... 37 17 696 946 St. Marylebone 401 338 59 4 298 95 8 ... 349 51 1 376 24 1 ... 4 ... 214 133 54 186 50 21 3 10 ... ... 21 1 8 1 160 153 79 54 1 ... 1 1 1 ... ... ... 93 301 2 3 2 5 2 8 2 2 ... 7 ... ... ... ... ... 2 ... 1 1 1 1 ... ... ... ... 12 6 114 254 St. Pancras 1,328 772 512 44 245 951 123 9 843 460 25 1,094 224 10 5 27 7 474 600 254 910 236 312 160 46 78 12 663 4 38 14 358 716 214 147 125 26 39 8 8 ... 36 ... 105 1,095 119 6 3 63 7 32 22 78 15 15 2 2 1 2 ... 39 ... 79 11 ... ... 9 8 ... ... 46 15 510 908 Shoreditch 1,038 414 411 213 505 431 101 1 594 395 49 692 334 12 7 60 34 888 96 54 276 166 140 90 128 33 6 20 4 103 68 189 546 280 254 27 20 45 31 1 ... 10 ... 203 467 293 63 12 53 6 23 12 87 24 36 10 16 9 2 1 21 2 14 8 2 2 1 1 ... ... 71 40 568 716 Southwark 1,634 284 1,144 206 267 1,084 277 6 786 824 24 645 889 100 213 40 6 669 703 262 950 494 292 97 123 49 10 191 15 118 47 331 779 499 335 46 22 32 3 ... ... 8 ... 202 1,268 131 31 2 62 7 59 8 63 25 15 1 4 2 4 2 15 ... 47 11 ... ... 7 6 ... ... 60 26 942 1,109 Stepney 2,643 1,529 1,039 75 593 1,617 424 9 1,408 1,190 45 2,016 605 22 933 67 10 1,351 1,124 168 1,171 448 467 200 222 161 15 412 14 129 36 611 1,182 771 516 71 40 50 12 3 ... 29 ... 180 1,875 480 92 16 137 18 421 7 352 36 90 5 36 16 22 10 59 ... 55 6 5 2 8 8 1 ... 64 26 1,160 1,761 Stoke Newington 189 72 112 5 80 107 2 ... 147 40 2 169 20 13 1 ... 138 30 21 47 37 13 3 4 3 1 ... ... 3 2 45 102 36 25 9 7 4 2 ... ... ... ... 170 15 4 ... ... 2 1 3 2 1 ... 2 ... ... ... ... ... 5 ... ... ... ... ... ... ... ... ... 1 1 71 145 Wandsworth 1,964 1,310 611 4 3 373 1,503 87 1 1,557 385 22 1,648 298 18 172 9 2 1,319 337 308 1,000 715 268 103 190 19 7 51 2 36 20 778 857 290 224 23 13 8 5 ... ... 1 ... 40 1,862 51 11 ... 24 3 24 9 28 7 10 1 1 1 4 2 5 ... 25 6 2 1 1 1 1 ... 24 13 979 1,501 Westminster 551 213 282 56 190 295 64 2 346 185 20 350 183 18 6 4 1 289 207 55 122 85 43 26 34 2 24 3 18 10 249 186 97 42 8 7 8 6 1 ... 1 ... 38 502 10 1 ... 12 2 15 12 3 3 ... 1 ... 1 ... 3 ... 5 2 ... 2 2 ... ... 3 2 183 393 Woolwich 1,043 318 717 8 208 734 91 10 874 161 8 825 213 5 58 19 15 20 774 249 452 440 208 116 103 11 " 4 64 17 41 34 197 624 196 85 19 16 36 6 2 ... 34 ... 96 772 149 23 3 12 4 53 47 53 49 26 9 10 6 13 6 29 2 20 17 2 1 22 22 3 3 20 16 651 791 Total 31,257 16,079 13,722 1,456 7,839 19,199 4,131 88 21,043 9,449 765 23,035 7,569 653 3,348 518 169 16,106 11,357 3,794 14,703 6,162 4,011 1,831 1,956 1,001 163 3,322 106 1,287 544 9,747 13,980 6,577 4,511 693 346 589 233 46 ... 222 3 3,377 24,423 2,923 444 90 713 89 1,103 243 1,148 276 396 60 159 76 92 32 389 9 594 125 36 16 124 119 23 6 719 361 13,111 22,324 X APPENDIX V. SUMMARY OF MEDICAL INSPECTION. age group—1901—boys. F.— Defects found and (x)— Defects noted for Treatment. Borough. Number of children examined. Clothing and footgear. Nutrition. Cleanliness and condition of skin. Skin. Teeth. Nose and throat. Eyes. Ears. Speech. Mental condition. Circulation. Lung defects. Diseases of Nervous system. Tuberculosis. Rickets. Deformities. Infectious diseases. Malnutrition. Glands (other than throat). Other defects. Cards issued. Parent s present. Enlarged tonsils. Adenoids. Tonsils and adenoids. Other defects. Glands. Head. Body. 1. 2. 3. Defects, Eye diseases. Vision. Disease. Hearing. Stammering. Other Heart defects. Anaemia. Phthisis. Other forms. 1. 2. 3. 1. 2 3. 4. 1. 2. 3. 1. 2. 3. Defect. Disease. (X) f. (x) f. f. (X) f. (x) f. (x) f. (x) 1. 2. 3. (X) f. (X) f. (x) f. (x) f. (x) 1. 2. 3. 4. Mentally deficient. f. (X) f. (x) f. (x) f. (X) f. (x) f. (x) f. (x) F. (x) f. (x) f. (x) f. (x) f. (x) City 110 74574 33 3 28 68 13 1 96 13 1 69 39 2 12 1 1 71 22 17 64 34 14 56 13 14 1 ... 2 3 ... 4 1 44 28 38 27 2 1 1 1 ... ... 1 ... 25 82 2 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... 1 ... ... ... 1 1 ... ... ... ... 59 78 Bermondsey 1,148 399 492 8 203 808 136 1 1,119 28 1 952 181 15 3 14 11 384 511 253 353 278 119 39 72 14 11 86 3 18 12 621 295 233 27 17 11 27 25 5 ... 2 ... 125 971 48 4 ... 11 7 23 20 9 6 1 9 9 1 1 1 ... 6 5 ... ... 1 1 ... ... 10 6 560 616 Bermondsey 962 399 442 121 162 526 250 24 766 186 10 541 378 43 52 31 6 565 313 84 528 223 52 119 46 95 11 37 5 64 21 413 284 263 195 61 33 22 7 12 ... 9 2 247 500 194 20 1 bl 1 55 12 105 17 19 1 7 1 1 1 67 ... 46 7 ... ... 28 27 2 ... 30 15 470 539 Bethnal Green 980 341 519 120 131 384 438 27 854 121 5 529 393 58 10 17 8 438 494 48 498 198 72 14 23 76 14 13 1 37 19 404 276 282 180 8 5 14 8 8 ... 1 ... 321 455 165 39 ... 22 2 13 3 17 6 9 2 10 4 5 1 37 ... 14 1 1 ... 29 29 ... ... 11 4 415 464 Camberwell 1,832 1,178 612 42 644 1,039 145 4 1,591 223 18 1,466 306 60 14 11 5 1,317 352 163 471 318 13 69 85 82 12 1 ... 39 8 1,257 276 296 173 33 21 32 8 23 ... 13 ... 177 1,551 102 2 ... 14 1 28 21 32 9 6 1 5 2 2 I 21 1 66 3 1 ... 6 6 ... ... 41 19 660 973 Chelsea 234 58 159 17 65 151 18 ... 118 109 7 115 112 7 ... 1 1 106 113 15 46 43 81 2 8 1 1 37 1 5 3 90 87 50 211 2 2 ... ... ... ... 1 ... 14 206 13 1 ... 7 4 9 2 6 2 ... 2 2 ... 2 1 ... ... ... ... ... ... ... ... 95 98 Deptford 655 286 342 27 164 386 105 ... 603 50 2 517 121 17 17 29 4 438 163 54 299 137 67 31 16 32 ... 142 ... 43 3 280 1947 181 22 15 5 13 1 7 ... 6 ... 97 504 51 3 ... 14 1 5 2 20 1 8 1 1 ... 1 1 8 ... 60 ... ... ... ... 7 ... 5 2 271 388 Finsbury 718 136 458 124 178 450 80 10 527 188 3 325 352 41 10 17 3 263 390 65 401 76 117 25 25 31 4 84 4 34 10 354 171 188 111 11 4 17 6 3 ... 6 ... 28 674 14 2_ ... 24 ... 3 9 3 7 1 2 ... ... ... 24 1 18 2 2 1 6 6 2 1 25 6 235 368 Greenwich 1,012 560 441 11 275 644 93 10 989 23 ... 890 109 13 13 9 7 559 337 116 555 89 52 44 61 36 8 30 3 10 20 641 205 166 119 19 6 15 2 8 1 17 ... o Z you 30 ... ... 4 12 7 46 4 11 1 8 3 11 5 13 1 48 6 ... ... 1 1 ... ... 13 5 312 513 Fulham 806 397 384 25 469 322 10 5 638 167 1 608 192 6 ... 6 4 262 512 32 372 71 97 15 41 1 ... 30 2 26 10 507 165 134 95 9 9 17 13 6 4 4 1 310 406 86 4 ... ... 1 ... 6 3 3 2 ... ... 1 1 10 7 3 1 ... ... 6 6 ... ... 10 9 241 420 Hackney 1,533 696 790 47 386 944 196 7 1,311 217 5 1,117 386 30 102 14 11 838 589 106 330 201 54 67 53 46 12 58 5 5 17 877 314 308 98 27 18 43 17 9 ... 10 ... 654 675 189 15 ... 37 7 15 8 36 13 17 5 2 2 2 2 38 ... 28 6 1 ... 10 10 ... ... 48 25 573 873 Hampstead 524 450 67 7 67 420 36 1 497 25 2 488 35 1 102 3 ... 259 207 58 196 13 12 45 9 6 ... 13 ... 2 1 323 114 87 168 9 4 6 1 9 1 ... ... 18 499 7 ... ... 6 2 4 2 10 4 1 ... 3 ... 1 ... 4 ... 5 1 ... ... 1 1 1 ... 4 3 110 235 Hammersmith 314 99 194 21 86 193 24 11 303 11 ... 263 50 1 .... 11 3 50 204 60 258 56 89 2 9 22 ... 270 6 20 ... 94 174 46 49 5 4 3 ... 2 ... 2 ... 28 266 18 2 ... 14 3 4 ... 12 5 4 ... ... ... 1 1 11 ... 19 4 ... ... 12 12 1 ... 2 1 113 148 Holborn 287 81 169 37 40 207 39 1 250 34 3 192 89 6 7 11 1 184 63 40 217 40 214 33 7 37 ... 139 ... 81 10 109 93 82 27 38 5 23 8 22 ... 4 ... 105 159 22 1 ... 2 ... 1 ... 7 1 2 ... 1 ... 3 2 26 ... 31 4 ... ... 1 1 ... ... 5 1 127 93 Islington 2,021 1,104 830 87 364 1,173 462 22 1,903 108 10 1,761 218 42 27 54 16 1,134 680 207 852 207 57 92 6 35 12 61 6 7 30 1,024 496 484 70 40 15 73 27 23 ... 12 ... 322 1,288 310 97 4 41 3 54 18 44 18 17 3 10 5 3 ... 9 ... 35 2 ... ... 22 22 4 ... 26 8 692 1,113 Kensington 478 226 235 17 171 268 38 1 346 125 7 239 217 22 ... .... ... 58 404 16 222 6 202 23 108 30 1 187 5 32 ... 202 145 121 312 8 3 9 4 2 ... 2 ... 54 362 58 3 1 3 2 14 2 6 1 2 1 1 ... 19 ... 17 ... 1 ... 1 1 ... ... 18 6 125 208 Lambeth 1,507 764 692 51 416 915 172 4 1,408 98 1 1,164 320 23 12 32 16 780 566 161 749 534 41 67 24 34 7 25 3 23 827 367 309 86 12 11 12 7 5 3 6 ... 342 963 173 29 ... 52 12 9 8 10 4 8 3 2 1 3 1 8 ... 8 2 1 1 5 5 2 1 16 15 803 823 Lewisham 879 668 202 9 104 562 212 1 866 12 1 765 108 6 3 5 2 578 262 39 341 139 25 65 138 27 2 57 1 29 3 432 272 175 255 5 3 13 11 4 ... ... 257 538 74 10 ... 3 ... 8 ... 3 ... 3 ... ... ... ... ... 4 ... 4 1 ... ... 1 1 1 ... 8 3 277 526 Paddington 669 560 99 10 417 224 27 1 649 20 ... 605 57 7 2 1 1 319 273 77 271 67 53 11 43 11 ... 28 ... 6 5 366 151 152 99 6 3 2 1 2 ... 1 ... 47 594 Z5 3 ... 7 1 17 4 8 2 13 2 3 1 ... 14 ... 14 ... ... ... 1 1 1 ... 18 5 194 330 Poplar 982 294 622 66 192 612 178 ... 868 107 7 688 284 10 1 9 3 328 645 9 481 403 18 9 11 6 5 19 4 484 234 260 107 23 15 16 7 5 ... 2 ... 390 439 149 3 1 16 4 3 1 39 2 31 I 9 5 3 ... 16 4 8 2 1 ... 3 3 1 ... 22 5 597 519 St. Marylebone 436 332 102 2 309 121 6 ... 401 34 1 398 37 1 ... 8 2 264 129 43 183 48 lb 3 16 2 ... 4b 5 9 3 198 118 120 147 7 4 1 ... 3 ... 1 ... 59 360 14 2 1 5 2 9 1 5 ... 14 1 1 ... 2 2 ... ... 2 1 1 ... ... 2 ... 9 5 134 ... St. Pancras 1,064 640 392 32 271 670 116 7 943 118 3 880 173 11 4 24 5 460 466 138 427 109 175 60 8 104 6 467 2 47 14 573 285 190 70 90 14 39 5 21 ... 16 ... 301 684 78 0 1 52 2 25 9 76 14 28 3 2 ... 3 ... 73 1 72 3 ... ... 7 7 5 ... 39 12 ... ... Shoreditch 967 107 826 34 194 657 107 9 541 421 5 505 433 29 6 38 15 861 61 25 230 129 143 74 16 73 29 10 3 87 67 413 346 208 145 41 31 65 43 6 ... 36 217 585 158 5 2 54 5 12 6 107 35 23 8 13 5 6 4 15 1 8 2 1 ... 12 12 ... ... 62 41 ... ... Southwark 1,544 299 996 249 166 996 359 23 1,262 278 4 683 738 123 24 19 7 748 650 146 768 460 195 72 119 40 11 52 5 66 24 608 490 446 183 41 27 46 26 8 1 8 ... 303 1,070 155 16 ... 36 7 27 7 65 20 8 2 10 4 1 1 10 ... 41 15 ... ... 23 23 1 ... 30 14 ... ... Stepney 2,281 1,145 993 143 805 1,116 308 52 1,991 281 9 1,457 740 84 141 32 11 687 1,265 329 1,249 286 296 172 112 163 30 209 7 123 28 917 657 700 348 38 28 30 7 23 ... 38 ... 357 1,374 495 50 5 169 15 284 19 334 13 48 9 28 9 37 4 143 ... 59 3 3 ... 52 51 1 ... 58 20 ... ... Stoke Newington 189 98 89 2 77 106 6 ... 181 7 1 175 13 1 ... 1 ... 121 50 18 58 57 5 5 153 6 2 ... ... 1 1 71 79 49 470 2 2 2 ... ... ... ... 168 20 1 ... ... 1 1 4 3 ... ... 3 ... ... ... ... ... 10 ... 1 ... ... ... 3 3 ... ... 5 3 100 1 98 Wandsworth 1,962 1,268 611 283 374 1,445 139 4 1,831 128 3 1,675 269 18 16 23 12 1,301 472 189 833 551 1 /7 58 145 31 21 44 4 31 12 1,171 451 338 26 24 13 9 5 14 ... 6 ... 224 1,668 66 4 ... 15 4 42 32 20 4 16 3 6 4 2 2 8 ... 19 9 1 ... 4 4 4 3 22 12 869 1,156 Westminster 313 70 227 16 71 226 15 1 147 156 10 149 154 10 2 6 5 153 135 25 66 53 120 9 8 1 ... 2 ... 3 2 162 91 56 264 5 3 6 3 1 ... 1 ... 6 292 15 ... ... 8 ... 5 ... 6 ... ... ... 1 ... ... ... 3 ... 5 ... ... ... 1 1 ... ... 1 1 115 146 Woolwich 736 442 290 4 348 354 34 ... 684 51 1 634 95 7 1 18 17 53 536 147 414 385 76 76 15 6 29 4 33 31 351 212 172 107 19 19 24 3 7 1 38 3 58 581 92 5 ... 20 14 32 30 27 26 15 6 3 2 5 5 36 1 23 20 1 1 13 13 ... ... 19 15 510 453 Total 27,143 13,346 13,308 1,489 7,177 15,987 3,762 217 23,683 3,339 121 19,850 6,599 694 479 445 177 13,579 10,864 2,700 11,732 5,211 2,626 1,323 . 1,447 1,059 204 2,162 80 914 382 13,813 7,073 6,134 4,191 617 319 580 246 238 11 243 8 5,336 18,666 2,804 321 16 715 105 717 217 1,065 213 317 55 139 59 95 35 630 17 663 101 15 3 250 248 35 5 557 261 11,361 14,199 AGE GROUP—1901-GIRLS, City 116 88 27 1 46 52 16 2 69 46 1 81 35 ... 41 1 ... 88 13 15 62 34 14 7 7 3 1 3 ... 2 ... 43 32 41 25 ... ... ... ... ... ... ... ... 43 71 1 1 ... 1 ... 2 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 2 ... ... 1 1 57 85 Battersea 1,026 557 406 63 213 661 147 5 780 226 20 806 206 14 33 5 3 388 468 170 258 187 33 29 37 7 4 1 1 18 15 486 314 214 168 6 4 14 11 4 ... 4 1 52 894 73 6 1 20 12 22 22 12 9 ... ... 8 5 2 ... 1 ... 19 16 ... ... 5 5 1 1 13 11 451 690 Bermondsey 996 447 425 124 175 526 266 29 611 351 34 559 388 49 321 29 10 610 322 64 495 195 182 78 45 62 4 95 2 87 26 364 311 316 228 53 29 34 5 2 ... 11 ... 204 565 210 ... ... 76 7 60 8 99 27 14 4 4 2 4 1 32 4 48 12 ... ... 36 35 13 ... 25 9 513 587 Bethnal Green 1,208 507 609 92 253 464 474 17 659 459 90 724 439 45 45 15 4 549 610 49 534 210 86 23 36 78 10 61 3 49 21 367 452 407 260 15 11 26 22 ... ... 2 ... 311 644 231 ... 1 55 4 32 5 29 6 19 2 8 2 3 12 ... 20 7 ... ... 18 18 1 ... 16 7 450 661 Camberwell 1,871 1,284 562 25 668 1,019 171 13 1,207 616 48 1,374 422 75 92 19 9 1,398 315 158 432 306 89 73 99 73 7 25 1 42 17 1,133 366 372 257 36 18 48 15 4 ...... 9 ... 106 1,608 150 ... 18 1 66 43 39 15 15 4 5 3 5 ... 8 ... 71 6 ... ... 13 13 1 1 38 13 712 1,216 Chelsea 266 74 169 23 54 192 16 4 128 120 18 124 125 17 4 3 1 131 119 16 61 57 17 4 11 ... ... 7 1 10 6 108 80 80 42 3 3 1 ... ... ... ... ... 15 232 18 1 ... 6 ... 3 ... 5 ... 1 1 ... ... ... ... 1 ... 5 2 1 1 4 4 ... 2 1 110 177 Deptford 625 318 295 12 157 376 89 3 458 153 14 457 143 25 96 19 1 386 183 56 292 177 80 35 23 37 2 39 3 61 3 225 198 200 149 13 4 17 2 ... ... 12 ... 92 423 106 4 ... 13 1 9 3 19 1 17 2 ... ... 2 ... 8 ... 52 10 ... ... 4 4 15 ... 10 3 313 428 Finsbury 749 143 537 69 246 422 76 5 335 356 58 396 326 27 88 16 2 300 396 53 365 93 87 16 13 19 1 154 3 33 14 325 232 192 80 16 12 15 6 1 ... 4 ... 52 681 11 2 3 37 4 10 1 13 2 14 1 1 1 2 1 12 ... 31 1 1 ... 5 4 2 ... 53 5 228 483 Fulham 803 414 381 8 311 440 52 ... 638 154 11 715 82 6 105 25 12 471 261 71 438 70 117 24 53 11 2 70 5 45 29 458 177 168 116 23 13 15 2 3 ... 3 ... 27 728 48 ... ... 18 3 9 2 39 4 6 4 10 3 3 2 2 ... 54 6 2 ... ... ... 1 1 14 8 295 492 Greenwich 705 298 400 7 426 255 22 2 612 92 1 588 117 ... ... 5 4 322 366 17 339 69 63 6 39 1 1 23 ... 3 1 388 190 127 100 16 11 23 17 1 1 12 ... 177 425 90 13 ...... 11 8 1 1 7 1 5 4 ... ... ... 1 ... 4 1 ... ... 8 8 ... ... 4 2 241 474 Hackney 1,600 719 852 29 415 974 210 1 993 591 16 1,114 454 32 333 16 7 906 610 84 326 202 110 71 53 48 8 39 1 39 15 858 423 320 187 27 18 68 27 6 ... 9 ... 571 751 246 32 ... 44 8 30 17 41 24 30 10 1 1 3 1 13 ... 36 6 ... ... 9 9 ... ... 69 44 605 1,152 Hammersmith 582 489 92 1 103 409 70 ... 443 136 3 529 53 ... 2 2 1 289 243 50 324 29 51 28 13 3 ... 38 ... 2 ... 304 191 87 57 8 2 13 ... 1 ... 1 ... 4 570 8 ... ... 11 7 7 4 8 ... 3 2 l ... ... ... ... 4 2 1 ... ... ... 1 1 8 6 131 364 Hampstead 300 119 170 11 91 181 28 ... 232 68 ... 259 41 ... 5 8 3 55 192 53 224 53 19 6 9 17 4 9 1 10 2 89 142 69 30 13 9 2 1 1 ... 2 ... 41 245 13 ... 1 18 3 8 3 15 3 5 2 ... ... ... ... 7 ... 25 2 ... ... 2 2 1 ... 5 ... 111 166 Holborn 238 72 144 22 46 171 20 1 110 116 12 195 40 3 20 11 3 179 36 23 171 25 78 25 2 15 ... 207 ... 11 3 78 84 73 67 45 6 16 5 6 ... 7 ... 121 113 4 ... ... 4 2 9 2 5 2 2 1 ... ... 1 ... 3 ... 12 1 ... ... 1 1 3 ... 7 3 95 102 Islington 1,987 1,036 891 60 438 1,052 486 11 1,248 680 59 1,709 240 38 282 36 13 1,188 614 185 759 181 292 99 170 20 3 168 4 99 37 877 555 552 356 44 15 89 35 5 ... 19 ... 244 1,137 435 161 10 78 7 90 19 44 15 23 5 6 1 2 ... 13 ... 28 1 1 ... 11 11 1 ... 47 10 739 1,251 Kensington 614 262 339 13 206 370 36 2 395 198 21 333 254 27 51 7 ... 54 532 28 261 14 77 33 41 25 1 89 1 10 3 319 126 165 119 10 5 9 1 1 1 1 ... 82 462 70 ... ... 11 ... 15 3 10 1 10 2 2 l ... ... 9 ... 21 ... ... ... 4 4 1 ... 18 3 188 319 Lambeth 1,395 752 610 33 409 856 126 4 1,086 293 16 1,147 237 11 123 37 13 830 471 94 647 442 239 71 151 16 9 148 ... 39 31 667 388 336 257 23 20 14 10 1 1 3 1 336 870 160 29 ... 23 3 24 8 15 6 6 3 6 2 1 ... 1 ... 4 1 ... ... 4 4 1 ... 25 17 697 887 Lewisham 994 791 194 9 141 661 192 ... 935 57 2 900 88 6 45 5 ... 651 298 45 399 170 44 43 40 24 ... 35 1 15 3 431 363 200 109 6 3 10 5 1 ... 1 1 273 604 105 12 ... 9 ... 19 2 2 ... 3 ... ... ... 1 ... 1 ... 1 ... ... ... ... ... ... 5 ... 303 676 Paddington 748 617 126 5 515 190 14 ... 650 84 14 682 57 9 25 5 2 428 257 63 287 63 51 11 17 7 ... 65 3 14 6 370 205 173 98 9 6 3 ... ... ... 1 ... 36 665 41 6 ... 16 1 32 5 6 4 8 4 ... ... 6 ... 6 1 ... ... ... ... 2 1 16 8 219 419 Poplar 1,235 556 639 40 351 647 237 ... 613 556 66 891 331 13 3 12 8 378 821 36 618 487 135 28 41 14 6 31 4 37 7 423 390 422 268 28 8 28 8 ... ... 4 ... 396 610 225 4 ... 24 4 19 11 40 2 66 1 15 6 2 1 10 1 9 1 2 ... 2 2 ... ... 32 13 802 862 St. Marylebone 528 556391 136 1 406 114 8 ... 373 153 2 486 41 1 ... 2 ... 317 164 47 218 50 32 10 17 2 ... 76 2 15 8 221 159 148 89 6 2 ... ... 1 ... ... 80 442 5 ... 1 22 ... 17 7 9 1 15 2 ... ... 1 ... 4 ... 2 2 1 ... ... ... ... ... 10 6 174 269 St. Pancras 1,199 702391 475 22 326 767 96 10 768 415 16 1,054 138 7 1 10 2 590 439 170 535 128 265 66 12 84 4 582 4 55 16 532 399 264 185 111 18 48 19 14 ... 23 ... 371 768 52 8 ... 56 11 148 18 74 20 25 6 2 ... 6 2 41 1 119 11 2 ... 10 9 7 ... 46 15 472 773 Shoreditch 890 702152 723 15 279 523 80 8 511 374 5 502 382 6 19 28 13 813 36 41 207 111 123 63 100 45 17 5 ... 60 35 248 371 271 244 37 30 55 39 4 ... 12 ... 189 483 204 12 2 87 10 35 19 65 18 8 2 15 10 4 ... 8 1 25 5 ... ... 9 9 ... ... 61 35 474 546 Southwark 1,485 370370 980 135 189 903 370 23 786 668 31 814 592 79 174 43 7 729 614 142 651 410 222 54 110 27 6 84 9 63 22 542 510 433 346 48 25 45 21 1 ... 4 ... 291 1,007 165 22 ... 63 13 43 10 48 16 9 3 6 2 3 1 9 ... 34 13 ... ... 23 22 ... ... 43 25 821 947 Stepney 2,156 1,235 860 61 893 976 265 22 1, 281 817 58 1,448 655 53 516 27 10 686 1,200 270 1,096 272 355 129 172 130 13 140 8 91 15 681 722 742 499 30 20 35 3 5 ... 21 ... 286 1,410 409 49 2 172 12 218 19 267 13 55 4 32 11 21 3 40 1 59 8 ... ... 27 27 1 52 14 905 1,205 Stoke Newington 178 97 78 3 62 105 10 1 145 33 ... 163 14 1 15 3 2 125 35 18 326 31 15 3 7 6 4 ... ... 6 3 45 80 53 21 3 3 ... ... ... ... ... 151 25 2 ... ... 1 1 2 2 1 ... ... ... ... ... ... ... 3 ... ... ... ... ... 3 3 ... ... 5 3 78 130 Wandsworth 1,721 1,144 546 31 435 1,159 122 5 1,402 298 21 1,506 204 11 111 25 5 1,268 333 120 86 434 179 53 131 14 10 20 4 35 19 855 538 323 247 21 12 18 13 2 1 2 1 165 1,451 104 1 ... 32 11 28 24 14 3 11 6 5 4 ... ... 3 ... 51 15 ... ... 5 5 2 ... 22 13 748 1,183 Westminster 377 95 267 15 128 222 26 1 212 152 13 213 148 16 9 6 1 209 136 32 78 67 21 13 21 1 ... 3 1 8 2 180 93 82 45 6 4 6 3 1 ... 4 ... 6 343 27 1 ... 10 2 4 ... 7 1 ... 3 ... 17 6 1 1 1 1 ... ... 1 ... 137 219 Woolwich 903 519 379 5 389 469 45 ... 810 89 4 802 94 7 64 22 19 83 650 170 491 446 174 125 120 12 8 31 5 37 34 396 289 213 118 25 22 34 8 1 ... 45 3 65 714 108 15 1 16 6 62 62 48 44 26 12 3 1 6 5 33 1 51 45 1 1 16 16 3 16 14 645 657 Total 27,495 14,248 12,312 935 8,400 15,156 3 770 169 18,490 8,351 654 20,571 6,346 578 2,623 437 155 14,421 10,734 2,340 11,286 5,013 3,250 1,226 1,590 801 125 2,248 67 996 393 12,013 8,380 7,045 4,767 681 333 686 278 66 4 216 7 4,787 18,941 3,321 424 22 952 141 1,024 321 981 238 396 81 135 56 72 17 284 9 808 181 13 3 222 218 57 5 664 289 11.714 17.420 * xi. Appendix VI. APPENDIX VI. Statement showing the various hospitals and centres included in the Council's scheme, and the annual provision made as from the 1st January, 1914, for the treatment of the specified ailments. Hospital or centre. Eyes. Ear, Nose and Throat. Ringworm. Minor Ailments. Teeth. Total No. provided for in agreements. Belgrave Hospital 500 500 — — — 1,000 Charing Cross Hospital 250 500 70 — — 820 Deptford Children's Health Centre 440 880 — 660 3,520 5,550 Fulham School Treatment Centre 660 660 176 660 1,540 3,696 Hackney School Treatment Centre 880 880 — 660 1,540 3,960 Hammersmith School Treatment Centre — — — 660 1,540 2,200 Home and Infirmary, Lower Sydenham 250 250 — — — 500 Islington School Treatment Centre 880 880 264 660 1,540 4,224 London Hospital 3,000 3,500 350 1,540 8,390 Metropolitan Ear, Nose and Throat — 250 — — — 250 Metropolitan Kingaland road 500 500 — — — 1,000 Miller General 500 500 88 — — 1,088 Norwood School Treatment Centre 880 440 176 — 1,540 3,036 Pookham School Treatment Centre 660 880 176 1,320 1,540 4,576 Poplar Hospital — — — — 1,760 1,760 Poplar School Treatment Centre 880 1,320 176 660 – 3,036 Queen's Hospital — — — — 1,540 1,540 Rotherhithe Nursing Treatment Centre — — — 660 — 660 Royal Eye Hospital 4,000 — — — — 4,000 Royal London Ophthalmic Hospital 5,000 — — — — 5,000 St. Ceeilia's School Treatment Centre — — — 440 1,540 1,980 St. George's Dispensary — 440 176 — 2,640 3,256 St. George's Mission — — — 660 — 660 St. Marylebone General Dispensary — — — — 1,100 1,100 St. Marylebone Nursing Treatment Centre — — — 660 — 660 St. Mary's Hospital 500 500 176 — — 1,176 St. Pancras School Treatment Centre 880 880 — 660 1,540 3,960 Shoreditch School Treatment Centre — — — 660 – 660 South London School Treatment Centre — — — 1,320 1,540 2,860 Wandsworth School Treatment Centre 880 880 220 660 2,200 4,840 Western Dispensary — — — — 1,540 1,540 Woman's Hospital for Children 500 500 — 660 1,660 Woolwich School Treatment Centre 440 880 176 660 1,540 3,696 St. Mary's Ringworm School — — 66 — — 66 Totals 22,480 16,020 2,290 12,320 31,240 84,350 xii. Annual Report of the London County Council, 1913. APPENDIX VII. RETURN SHOWING THE RESULTS OF FIRST RE-INSPECTIONS OF CHILDREN DURING THE YEAR, 1913. Defects found requiring treatment. Number of defects under revision (outstanding from first reinspection) Form of treatment in cases in which treatment was obtained. Total numbers treated. No treatment received By private doctor or dentist. Under Council's scheme. At other hospitals or institutions. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured Total. Condition irremediable or treatment no longer considered necessary. Still requires treatment. (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) Refraction 16,698 58.4 11.1 30.5 377 62.6 26.9 10.5 6,713 63.2 20.7 16.1 2,249 62.6 24.7 12.7 9,339 509 6,850 220 42 115 4,202 1,804 707 1,420 466 363 5,842 2,312 1,185 4.0 71.9 24.1 56.0 30 410 Nursing treatment 7,770 82.4 11.9 5.7 1,060 67.1 22.4 10.5 2,311 65.1 22.1 12.8 1,661 69.7 20.1 10.2 5,032 1,363 1,375 874 126 60 1,551 518 242 1,081 367 213 3,506 1,011 515 21.1 45.9 33.0 64.8 17.5 17.7 Ear, nose and throat 16,000 58.0 16.9 25.1 617 83.1 11.1 5.8 4,056 75.9 14.2 9.9 2,464 78.4 12.7 8.9 7,137 1,451 7,412 358 104 155 3,371 450 235 1,870 351 243 34.5 5,599 905 633 8.6 56.9 44.6 9.1 46.3 Teeth 29,833 62.5 16.5 21.0 2,724 85.4 10.0 4.6 3,922 71.6 11.7 16.7 3,266 74.5 12.4 13.1 9,912 1,495 18,426 1,702 449 573 3,349 394 179 2,337 383 546 7,388 1,226 1,298 27.5 39.6 32.9 33.2 5.0 61.8 Other ailments 12,435 57.9 34.9 7.2 1,739 26.1 70.8 3.1 445 44.6 47.8 7.6 4,041 46.9 45.9 7.2 6,225 2,767 3,443 1,007 607 125 116 315 14 1,800 1,933 308 2,923 2,855 447 27.9 7.1 65.0 50.0 22.3 27.7 Total 82,736 63.8 20.4 15.8 6,517 72.2 19.9 7.9 17,447 62.2 25.6 122 13,681 67.1 22.1 10.8 37,645 7,585 37,506 4,161 1,328 1,028 12,589 3,481 1,377 8,508 3,500 1,673 25,258 8,309 4,078 17.3 46.4 36.3 45.5 9.2 45.3 xiii. Appendix VIII. APPENDIX VIII. Return showing under the various county electoral areas the results of first re-inspections held during the year, 1913, so far as these relate to defects dealt with under the Council's scheme, viz.:—eyes, ears, nose and throat ailments, and cases suitable for nursing treatment. COUNTY ELECTORAL AREA. Number of defects under review. Form of treatment in cases in which treatment was obtained. Total number treated. No treatment received. Percentage of defects treated. * By private doctor or dentist. Under Council's scheme. At other hospitals or institutions. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured.. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied,or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Condition irremediable, or treatment no longer considered necessary. Still requiring treatment. 1 2 3 1 2 3 1 2 3 1 2 3 Battersea 1,100 43 7 16 66 162 49 15 226 150 22 28 200 355 78 59 492 84 524 48.4 Bermondsey 918 20 5 6 31 66 35 20 121 117 56 57 230 203 96 83 382 82 454 45.7 Bethnal Green, N.E. 830 12 2 8 22 149 76 44 269 55 28 21 104 216 106 73 395 77 358 52.5 Bethnal Green, S.W. 636 21 — 1 22 163 77 20 260 31 23 7 61 215 100 28 343 64 229 60.0 Bow and Bromley 1,009 21 5 12 38 260 100 36 396 40 11 7 58 321 116 55 492 101 416 40.6 Brixton 621 18 5 4 27 162 32 11 205 61 14 6 81 241 51 21 313 54 254 55.2 Camberwell, N. 746 26 7 3 36 141 70 20 231 76 20 11 107 243 97 34 374 59 313 54.4 Chelsea 319 14 1 2 17 15 3 4 22 98 24 12 134 127 28 18 173 27 119 59.3 City of London 181 8 5 5 18 24 24 5 53 28 3 3 34 60 32 13 105 8 68 60.7 Clapham 1,413 63 5 21 89 238 76 26 340 171 45 25 241 472 126 72 670 63 680 49.6 Deptford 687 25 2 3 30 193 73 32 298 27 6 10 43 245 81 45 371 98 218 63.0 Dulwich 434 29 8 4 41 118 24 9 151 39 8 2 49 186 40 15 241 24 169 58.8 Finsbury, E. 401 17 2 5 24 58 24 10 92 64 29 20 113 139 55 35 229 22 150 60.4 Finsbury, E. 270 7 1 4 12 31 10 8 49 56 13 14 83 94 24 26 144 20 106 57.6 Fulham 1,673 146 12 10 168 392 84 39 515 221 60 28 309 759 156 77 992 205 476 67.6 Greenwich 624 20 17 4 41 176 82 12 270 27 16 6 49 223 115 22 360 72 192 65.2 Hackney, C. 417 25 3 3 31 100 46 23 169 33 13 4 50 158 62 30 250 43 124 66.9 Hackney, N. 569 27 5 5 37 157 43 22 222 49 12 4 65 233 60 31 324 55 190 63.0 Hackney, S. 1,360 52 6 8 66 466 139 43 648 125 29 18 172 643 174 69 886 96 378 70.1 Haggerston 982 15 2 6 23 163 71 33 267 102 30 31 163 280 103 70 453 114 415 52.2 Hammersmith 722 55 2 7 64 102 18 1 121 247 48 8 303 404 68 16 488 16 218 69.1 Hampstead 238 49 13 5 67 48 8 1 57 32 5 — 37 129 26 6 161 6 71 69.4 Holborn 519 32 4 5 41 24 17 25 66 98 27 58 183 154 48 88 290 35 194 59.9 Hoxton 1,020 15 2 9 26 114 82 34 230 145 55 53 253 274 139 96 509 92 419 54.8 Islington,E. 782 26 1 7 34 234 41 17 292 68 6 4 78 328 48 28 404 66 312 56.4 Islington, N. 603 7 — 4 11 148 29 23 200 85 4 10 99 240 33 37 310 42 251 55.3 Islington, S. 610 13 2 4 19 169 44 28 241 65 11 6 82 247 57 38 342 43 225 60.3 Islington, W. 631 10 — 6 16 165 29 45 239 72 16 8 96 247 45 59 351 67 213 62.2 Kennington 796 12 — — 12 183 25 22 230 122 22 10 154 317 47 32 396 68 332 54.4 xiv. Annual Report of the London County Council, 1913. APPENDIX VIII.-(Contd.) Return showing under the various county electoral areas the results of first re-inspections held during the year, 1913, so far as these relate to defects dealt with under the Council's scheme, viz.:—eyes, ears, nose and throat ailments, and cases suitable for nursing treatment. COUNTY ELECTORAL AREA. Number of defects under review. Form of treatment in cases in which treatment was obtained. Total number treated. No treatment received. Percentage of defects treated. * By private doctor or dentist. Under Council's scheme. At other hospitals or institutions. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Condition Irremediable, or treatment no longer considered necessary. Still requiring treatment. 1 2 3 1 2 3 1 2 3 1 2 3 Kensington, N. 970 21 14 2 37 186 137 20 343 136 72 20 228 343 223 42 608 56 306 66.5 Kensington, S. 191 8 4 – 12 17 10 1 28 60 26 4 90 85 40 5 130 3 58 69.2 Lambeth, N. 479 7 – 3 10 74 23 8 105 93 20 10 123 174 43 21 238 35 206 53.6 Lewisham 652 45 16 9 70 169 77 11 257 40 7 – 47 254 100 20 374 81 197 65.5 Limehouse 674 20 4 9 33 176 49 38 263 54 12 19 85 250 65 66 381 42 251 60.3 Marylebone, E. 123 4 – 1 5 20 4 – 24 35 5 8 48 59 9 9 77 6 40 59.8 Marylebone, W. 392 13 1 3 17 78 8 5 91 65 12 10 87 156 21 18 195 35 162 54.6 Mile End 488 8 – 6 14 151 34 34 219 7 3 8 18 166 37 48 251 23 214 54.0 Newington, W. 632 8 1 1 10 112 26 5 143 75 14 12 101 195 41 18 254 45 333 43.8 Norwood 816 25 2 10 37 273 47 18 338 47 7 5 59 345 56 33 434 75 307 58.6 Paddington, N. 677 15 1 5 21 227 33 9 269 70 13 5 88 312 47 19 378 66 233 61.9 Paddington, S. 226 5 5 – 10 57 28 7 92 31 7 2 40 93 40 9 142 12 72 66.4 Peckham 728 32 6 6 44 170 70 20 260 76 22 6 104 278 98 32 408 34 286 58.8 Poplar 825 12 1 – 13 261 60 18 339 58 7 7 72 331 68 25 424 90 311 57.7 Rotherhithe 674 9 3 9 21 79 34 14 127 84 41 33 158 172 78 56 306 88 280 52.2 St. George, Hanover-square 134 5 1 5 11 8 1 2 11 40 4 1 45 53 6 8 67 5 62 51.9 St. George-in the-East 856 11 3 7 21 268 96 72 436 39 7 16 62 318 106 95 519 34 303 63.1 St. Pancras, E. 593 53 11 7 71 76 21 23 120 112 33 39 184 241 65 69 375 25 193 66.0 St. Pancras, N. 447 35 8 – 43 122 20 5 147 106 29 5 140 263 57 10 330 5 112 74.7 St. Pancras, S. 329 13 – 3 16 36 4 16 56 59 12 29 100 108 16 48 172 13 144 54.4 St. Pancras W. 442 36 9 3 48 84 34 11 129 97 35 18 150 217 78 32 327 19 96 77.3 Southwark, W. 834 10 3 5 18 133 54 35 222 89 27 22 138 232 84 62 378 61 395 48.9 Stepney 1,111 13 3 20 36 349 94 52 495 25 9 13 47 387 106 85 578 46 487 54.3 Strand 153 3 2 1 6 27 3 5 35 25 5 2 32 55 10 8 73 14 66 52.5 Walworth 924 12 7 9 28 147 48 44 239 93 24 35 152 252 79 88 419 73 432 49.2 Wandsworth 2,073 86 17 16 119 654 108 41 853 79 20 6 105 819 145 63 1,027 227 819 55.6 Westminster 203 8 – 3 11 30 5 1 36 41 9 3 53 79 14 7 100 16 87 53.5 Whitechapel 718 16 1 8 25 192 90 24 306 62 22 8 92 270 113 40 423 51 244 63.2 Woolwich 1,993 91 25 2 118 527 123 17 667 69 24 2 95 687 172 21 880 240 873 50.2 Total 40,468 1,452 272 330 2,054 9,124 2,772 1,184 13,080 4,371 1,184 819 6,374 14,947 4,228 2,333 21,508 3,323 15,637 57.9 * In the calculation of these percentages, the cases reported "condition irremediable, or treatment no longer considered necessary," have been disregarded. XV. Appendix IX. 23610 IX APPENDIX IX. RETURN SHOWING THE RESULTS OF SECOND RE-INSPECTIONS OF CHILDREN DURING THE YEAR, 1913. Defects found requiring treatment. Number of defects under revision (outstanding from first reinspection). Form of treatment in cases in which treatment was obtained. Total numbers treated. No treatment received By private doctor or dentist. Under Council's scheme. At other hospitals or institutions. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Condition irremediable or treatment no longer considered necessary. Still requires treatment (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) Refraction 5,785 55.7 11.5 32.8 122 58.8 23.3 17.9 2,219 56.1 20.2 23.7 902 57.9 22.0 20.1 3,243 201 2,341 68 14 40 1,305 517 397 506 182 214 1,879 713 651 3.8 68.4 27.8 56.0 3.5 40.5 Nursing treatment 1,499 58.6 26.1 15.3 176 49.6 30.2 20.2 417 52.0 28.0 20.0 371 52.2 28.6 19.2 964 226 309 103 46 27 207 126 84 193 104 74 503 276 185 18.3 43.2 38.5 64.3 15.1 20.6 Ear, nose and throat 5,836 52.1 17.0 30.9 230 78.6 11.7 9.7 1,084 74.4 11.1 14.5 999 74.1 12.0 13.9 2,313 647 2,876 120 39 71 851 127 106 743 111 145 1,714 277 322 9.9 46.9 43.2 39.6 11.1 49.3 Teeth 9,980 62.1 15.0 22.9 1,110 86.2 6.2 7.6 1,061 69.5 9.2 21.3 1,055 72.4 10.2 17.4 3,226 890 5,864 690 166 254 914 66 81 733 97 225 2,337 329 560 34.4 32.9 32.7 32.3 8.9 58.8 Other ailments 3,548 57.1 34.2 8.7 494 38.1 54.7 7.2 194 44.8 44.8 10.4 1,285 47.3 43.1 9.6 1,973 664 911 282 169 43 74 106 14 576 576 133 932 851 190 25.0 9.8 65.2 55.6 18.7 25.7 Total 26,648 59.2 20.4 20.4 2,132 67.4 18.9 13.7 4,975 59.6 23.2 17.2 4,612 62.8 20.9 16.3 11,719 2,628 12,301 1,263 434 435 3,351 942 682 2,751 1,070 791 7,365 2,446 1,908 18.2 42.4 39.4 43.9 9.9 46.2 xvi. Annual Report of the London County Council, 1913. APPENDIX X. Return showing under the various county electoral areas the results of second re-inspections held during the year 1918, so far as these relate to defects dealt with under the Council's scheme, viz.:—eyes, ears, nose and throat ailments, and cases suitable for nursing treatment. COUNTY ELECTORAL AREA. Number of defects under revision (outstanding from first reinspection). Form of treatment in cases in which treatment was obtained. Total number treated. No treatment received. Percentage of defects treated. * By private doctor or dentist. Under Council's scheme. At other hospitals or institutions. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied, or from other causes uncured. Total. Condition irremediable, or treatment no longer considered necessary. Still requiring treatment. 1 2 3 1 2 3 1 2 3 1 2 3 Battersea 347 11 2 1 14 43 11 1 55 46 10 8 64 100 23 10 133 28 186 41.7 Bermondsey 200 — 2 4 6 7 11 4 22 32 16 19 67 39 29 27 95 14 91 51.1 Bethnal Green, N.E. 394 5 4 4 13 57 28 41 126 31 11 26 68 93 43 71 207 20 167 55.3 Bethnal Green, S.W. 240 7 2 1 10 52 37 11 100 9 3 3 15 68 42 15 125 14 101 55.3 Bow and Bromley 438 6 3 8 17 79 42 30 151 13 5 4 22 98 50 42 190 39 209 47.6 Brixton 143 3 3 2 8 26 2 2 30 11 2 2 15 40 7 6 53 24 66 44.5 Camberwell, N. 243 4 3 1 8 53 23 7 83 30 8 5 43 87 34 13 134 18 91 59.6 Chelsea 116 5 2 – 7 7 – 1 8 31 10 6 47 43 12 7 62 11 43 59.1 City of London 29 1 – — 1 2 2 2 6 2 1 1 4 5 3 3 11 – 18 37.9 Clapham 392 11 5 7 23 62 15 24 101 29 16 21 66 102 36 52 190 17 185 50.7 Deptford 176 5 – 3 8 42 10 12 64 8 4 1 13 55 14 16 85 32 59 59.0 Dulwich 138 11 4 — 15 34 5 3 42 7 9 3 19 52 18 6 76 8 54 58.5 Finsbury, C. 179 5 — 1 6 23 21 2 46 30 17 10 57 58 38 13 109 8 62 63.7 Finsbury, E. 118 1 1 — 2 16 10 5 31 22 12 6 40 39 23 11 73 7 38 65.8 Fulham 479 20 5 5 30 68 24 14 106 88 19 23 130 176 48 42 266 52 161 62.3 Greenwich 135 2 5 2 9 29 19 14 62 8 2 – 10 39 26 16 81 15 39 67.5 Hackney, C. 145 5 2 3 10 24 5 5 34 15 8 4 27 44 15 12 71 12 62 53.4 Hackney, N. 218 4 2 2 8 32 12 13 57 30 1 4 35 66 15 19 100 28 90 52.6 Hackney, S. 340 7 1 1 9 60 27 12 99 26 7 8 41 93 35 21 149 40 151 49.7 Haggerston 368 1 2 1 4 41 35 17 93 28 9 19 56 70 46 37 153 34 181 45.8 Hammersmith 267 11 1 4 16 23 8 2 33 90 12 7 109 124 21 13 158 10 99 61.5 Hampstead 46 6 2 2 10 6 1 — 7 14 – 1 15 26 3 3 32 2 12 72.7 Holborn 226 2 2 2 6 20 4 11 35 44 16 30 90 66 22 43 131 28 67 66.2 Hoxton 247 1 — 1 2 24 21 6 51 33 6 17 56 58 27 24 109 25 113 49.1 xvii. Appendix X. 23610 Islington, E. 357 5 6 11 61 17 9 87 21 5 6 32 87 22 21 130 25 202 39.2 Islington, N. 248 1 — 1 2 22 6 6 34 27 9 5 41 50 15 12 77 22 149 34.1 Islington, S. 265 2 1 2 5 51 17 21 89 25 4 3 32 78 22 26 126 28 111 53.2 Islington, W. 204 — — 2 2 22 9 12 43 21 11 10 42 43 20 24 87 15 102 46.0 Kennington 184 1 — — 1 35 3 10 48 33 2 4 39 69 5 14 88 11 85 50.8 Kensington, N. 267 5 5 1 11 57 29 19 105 33 13 17 63 95 47 37 179 14 74 70.8 Kensington, S. 61 2 1 1 4 2 2 – 4 23 11 2 36 27 14 3 44 3 14 75.9 Lambeth, N. 158 — 1 2 3 29 8 8 45 34 7 5 46 63 16 15 94 13 51 64.8 Lewisham 243 12 7 3 22 74 18 7 99 14 1 1 16 100 26 11 137 34 72 65.6 Limehouse 260 2 1 5 8 55 20 27 102 21 5 5 31 78 26 37 141 6 113 55.5 Marylebone, E. 57 1 1 — 2 8 1 1 10 8 1 3 12 17 3 4 24 3 30 44.4 Marylebone, W. 169 — — 1 1 28 5 3 36 35 3 5 43 63 8 9 80 19 70 53.3 Mile End 143 3 — 3 6 31 4 12 47 4 — 2 6 38 4 17 59 8 76 43.7 Newington 209 2 1 2 5 33 7 6 46 25 1 4 30 60 9 12 81 10 118 40.7 Norwood 161 2 2 3 7 36 8 7 51 9 1 1 11 47 11 11 69 13 79 46.6 Paddington, N. 134 1 — 2 3 37 5 3 45 16 3 1 20 54 8 6 68 12 54 55.7 Paddington, S. 60 2 1 – 3 18 8 4 30 5 4 3 12 25 13 7 45 1 14 76.3 Peckham 253 11 1 — 12 60 23 8 91 26 11 7 44 97 35 15 147 24 82 64.2 Poplar 291 1 — — 1 74 14 10 98 16 6 3 25 91 20 13 124 24 143 46.4 Rotherhithe 173 2 — 3 5 14 4 3 21 24 10 13 47 40 14 19 73 26 74 49.7 St. George, Hanover-square 46 2 — 1 3 5 — — 5 16 1 2 19 23 1 3 27 4 15 64.3 St. George-in-the-East 279 4 — 4 8 77 29 38 144 11 — 2 13 92 29 44 165 12 102 61.8 St. Pancras, E. 184 4 1 2 7 10 3 1 14 32 14 23 69 46 18 26 90 9 85 51.4 St. Pancras, N. 140 17 1 1 19 39 6 — 45 37 7 4 48 93 14 5 112 1 27 80.6 St. Pancras, S. 132 1 — 1 2 14 3 4 21 20 13 11 44 35 16 16 67 12 53 55.8 St. Pancras, W. 133 5 — 3 8 14 4 1 19 34 11 15 60 53 15 19 87 5 41 68.0 Southwark, W. 184 2 2 3 7 23 7 8 38 24 3 10 37 49 12 21 82 8 94 46.6 Stepney 390 7 1 6 14 92 25 33 150 8 1 7 16 107 27 46 180 16 194 48.1 Strand 26 2 — — 2 4 — 2 6 3 — 1 4 9 — 3 12 1 13 48.0 Walworth 235 5 1 3 9 33 5 15 53 34 4 13 51 72 10 31 113 7 115 49.6 Wandsworth 699 24 5 9 38 196 22 20 238 47 2 7 56 267 29 36 332 76 291 53.3 Westminster 75 1 — 2 3 16 4 2 22 8 6 1 15 25 10 5 40 6 29 58.0 Whitechapel 310 — 2 2 4 72 25 34 131 29 9 2 40 101 36 38 175 14 121 59.1 Woolwich 766 28 11 9 48 191 56 14 261 42 14 7 63 261 81 30 372 106 288 56.4 Total 13,120 291 99 138 528 2,363 770 587 3,720 1,442 397 433 2,272 4,096 1,266 1,158 6,520 1,074 5,526 54.1 LL 2 * In the calculation of these percentages, the cases reported "condition irremediable, or treatment no longer considered necessary" have been disregarded. xviii. xviii. Annual Report of the London County Council, 1913. APPENDIX XI. Return showing the final position of 46,365 defects, in respect of which first re-inspections were held in the year ended summer holidays 1913, and second re-inspections (where necessary) were held in year ended Christmas, 1913. (†) Defects found requiring treatment. Number of defects under revision. Defects found to have been treated. No treatment received. Completed and satisfactory. Still under treatment. Discontinued treatment before remedied or from other causes uncured. Total. Conditions irremediable or treatment no longer considered necessary. Still requiring treatment. Refraction 78.0 10.0 12.0 9,836 5,546 713 852 7,111 585 2,140 72.3 5.9 21.8 Nursing treatment 79.5 10.9 9.6 3,746 2,018 276 244 2,538 . 958 250 67.8 25.5 6.7 Ear, nose and throat 87.5 4.4 8.1 11,080 5,511 277 510 6,298 2,094 2,688 56.9 18.9 24.2 • Teeth 84.2 4.4 11.4 14,943 6,246 329 845 7,420 1,944 5,579 49.7 13.0 37.3 Other ailments 69.6 23.6 6.8 6,760 2,495 848 244 3,587 2,313 860 53.1 34.2 12.7 Total 80.9 9.1 10.0 46,365 21,816 2,443 2,695 26,954 7,894 11,517 58.1 17.0 24.9 (†) Of the total number, 19,717 were discharged at the first re-inspection. The outstanding 26,648 cases were seen for second time during the year 1913 (vide Appendix IX). xix. Appendix XII. xix. APPENDIX XII. Return showing under the various county electoral areas, the final position of 24,662 Council Scheme" defects (i.e., eye, ear, nose and throat ailments and cases suitable for nursing treatment) in respect of which first re-inspections were held in the year ended Summer Holidays, 1913, and second re-inspections (where necessary) were held in year ended Christmas, 1913. County electoral area. Number of defects under review. Defects found to have been treated. No treatment received. Percentage of defects treated.  Completed and satisfactory. Still under treatment Discontinued treatment before remedied or from other causes uncured. Total. Condition irremediable or treatment no lunger considered necessary. Still requiring treatment Battersea 629 301 23 27 351 109 169 68.8 Bermondsey 306 111 29 31 171 48 87 66.3 Bethnal Green, N.E. 660 284 43 78 405 95 160 71.7 Bethnal Green, S.W. 426 237 42 25 304 31 91 77.0 Bow and Bromley 767 321 50 48 419 145 203 67.4 Brixton 287 158 7 7 172 50 65 72.6 Camberwell, N. 455 247 34 19 300 70 85 77.9 Chelsea 212 112 12 8 132 38 42 75.9 City of London. 52 26 3 4 33 2 17 66.0 Clapham 733 401 36 69 506 59 168 75.1 Deptford 444 211 14 22 247 144 53 82.3 Dulwich 236 143 18 10 171 15 50 77.4 Finsbury,c. 352 172 38 26 236 67 49 82.8 Finsbury, E. 238 134 23 22 179 32 27 86.9 Fulham 980 544 48 53 645 185 150 811 Greenwich 342 180 26 20 226 81 35 86.6 Hackney, C. 310 151 15 19 185 70 55 771 Hackney, N. 418 201 15 26 242 93 83 74.5 Hackney, S. 795 462 35 31 528 126 141 78.9 Haggerston 578 187 46 54 287 127 164 63.6 Hammersmith 543 358 21 14 393 52 98 80.0 Hampstead 90 59 3 3 65 13 12 84.4 Holborn 350 161 22 57 240 57 53 81.9 Hoxton 386 160 27 39 226 62 98 69.9 Islington, E. 620 324 22 41 387 51 182 68.0 Islington, N. 442 208 15 17 240 58 144 62.5 Islington, S. 450 250 22 37 309 41 100 75.6 Islington, W. 392 196 20 30 246 50 96 71.9 Kennington 382 237 5 24 266 41 75 78.0 Kensington, N. 461 251 47 37 335 52 .74 81.9 Kensington, S. 105 68 14 3 85 6 14 85.9 Lambeth, N. 331 216 16 19 251 33 47 84.2 Lewisham 641 389 26 17 432 143 66 86.7 Limehouse 466 241 26 51 318 49 99 76.3 Marylebone, E. 73 33 3 6 42 3 28 60.0 Marylebone, W. 257 131 8 11 150 39 68 68.8 Mile End 247 125 4 21 150 25 72 67.6 Newington 365 175 9 19 203 51 111 64.7 Norwood 346 211 11 15 237 34 75 76.0 Paddington, N. 240 143 8 10 161 29 50 76.3 Paddington, S. 114 69 13 8 90 11 13 87.9 Peckham 447 259 35 20 314 56 77 80.3 Poplar 572 283 20 24 327 113 132 71.3 Rotherhithe 357 145 14 23 182 106 69 90.5 St. George, Hanover-square 80 51 1 6 58 10 12 82.8 St. George-in-the-East 507 304 29 70 403 28 76 84.1 St. Pancras, E. 333 156 18 45 219 48 66 76.8 St. Pancras, N. 298 227 14 5 246 25 27 90.1 St. Pancras, S. 184 74 16 23 113 25 46 71.1 St. Pancras, W 284 173 15 22 210 35 39 84.3 Southwark, W. 371 175 12 29 216 69 86 71.5 Stepney 725 390 27 66 483 68 174 73.5 Strand 53 33 - 3 36 4 13 73.5 Walworth 440 226 10 42 278 58 104 72.8 Wandsworth 1,328 772 29 45 846 200 282 75.1 Westminster 136 67 10 8 85 25 26 76.6 Whitechapel 565 340 36 61 437 30 98 81.7 Woolwich 1,461 812 81 36 929 250 282 76.7 Total 24,662 13,075 1,266 1,606 15,947 3,637 5,078 75.9 *In the calculation of these percentages the cases reported condition irremediable or treatment no longer considered necessary "have been disregarded. XX. xx. Annual Report of the London County Council, 1913. APPENDIX XIII. Return showing in percentages the results of first re-inspections for the four terms for which figures are available. Defects. Term. Number of defects under review. Form of treatment in cases in which treatment was obtained. Total treated. Untreated, but no longer requiring treatment Untreated and still requiring treatmen By private doctor. Under Council's scheme. At other hospitals. Refraction Autumn, 1912 6,304 4.6 68.0 27.4 54.4 4.6 41.0 Spring, 1913 5,052 4.2 69.4 26.4 55.8 2.3 41.9 Summer, 1913 7,449 3.8 72.6 23.6 56.6 3.0 40.4 Autumn, 1913 4,197 4.1 73.8 22.1 54.9 4.0 41.1 Nursing treatment Autumn, 1912 2,229 23.1 28.2 48.7 57.1 19.2 23.7 Spring, 1913 1,948 24.2 37.5 38.3 60.5 17.8 21.7 Summer, 1913 2,500 20.3 44.7 35.0 65.8 16.1 18.1 Autumn, 1913 3,322 200 51.4 28.6 66.4 18.5 15.1 Ear, nose and throat Autumn, 1912 7,651 11.2 41.3 47.5 40.4 13.5 46.1 Spring, 1913 5,091 9.3 53.7 37.0 44.1 9.5 46.4 Summer, 1913 4,931 7.6 57.5 34.9 43.7 8.9 47.4 Autumn, 1913 5,978 90 58.8 32.2 45.8 8.8 45.4 Teeth Autumn, 1912 7,749 26.7 24.7 48.6 30.5 7.3 62.2 Spring, 1913 9,813 26.5 37.9 35.6 35.0 5.4 59.6 Summer, 1913 10,538 28.7 35.8 35.5 32.7 4.9 62.4 Autumn, 1913 9,482 27.2 45.6 27.2 32.0 4.7 63.3 Other ailments Autumn, 1912 4,098 27.2 7.7 65.1 46.9 25.4 27.7 Spring, 1913 3,793 27.2 7.9 64.9 48.2 18.6 33.2 Summer, 1913 4,079 27.1 7.5 65.4 51.5 23.0 25.5 Autumn, 1913 4,563 293 6.2 64.5 50.3 24.6 25.1 All defects Autumn, 1912 28,031 16.2 38.9 44.9 43.1 12.0 44.9 Spring, 1913 25,697 17.6 43.8 38.6 44.8 8.5 46.7 Summer, 1913 29,497 16.3 47.4 36.3 46.0 8.6 45.4 Autumn, 1913 27,542 18.1 47.5 34.4 45.7 10.4 43.9 Return showing in percentages the results of second re-inspections for the three terms of the year 1913. Defects. Term. Number of defects under review (outstanding from first re-inspection). Form of treatment in cases in which treatment was obtained. Total treated. Untreated, but no longer requiring treatment Untreated and still requiring treatment By private doctor. Under Council's scheme. At other hospitals. Refraction Spring, 1913 2,106 4.0 69.3 26.7 56.9 2.9 40.2 Summer, 1913 1,557 3.4 65.6 31.0 54.3 3.3 424. Autumn, 1913 2,122 3.7 69.6 26.7 56.6 4.1 39.3 Nursing treatment Spring, 1913 512 19.7 46.1 34.2 65.6 12.7 21.7 Summer, 1913 360 15.1 39.1 45.8 62.5 14.4 23.1 Autumn, 1913 627 18.8 43.2 38.0 64.3 17.4 18.3 Ear, nose and throat Spring, 1913 2,110 11.7 46.9 41.4 38.0 10.5 51.5 Summer, 1913 1,526 7.6 44.4 48.0 38.4 9.4 52.2 Autumn, 1913 2,200 9.8 48.5 41.7 42.1 12.8 45.1 Teeth Spring, 1913 2,764 34.7 22.4 42.9 26.9 9.5 63.6 Summer, 1913 2,430 30.7 32.1 37.2 31.5 6.7 61.8 Autumn, 1913 4,786 35.9 37.8 26.3 35.9 9.7 54.4 Other ailments Spring, 1913 996 23.8 14.0 62.2 58.9 13.6 27.5 Summer, 1913 797 22.2 9.8 68.0 54.8 18.3 26.9 Autumn, 1913 1,755 27.1 7.3 65.6 54.1 21.8 24.1 All defects Spring, 1913 8,488 16.5 43.9 39.6 43.2 8.8 48.0 Summer, 1913 6,670 15.4 41.7 42.9 42.9 8.3 48.8 Autumn, 1913 11,490 20.9 41.9 37.2 45.2 11.5 43.3 Appendix XV. xxi. APPENDIX XV. Return showing in percentages the final positions of 46,365 defects, in respect of which first re-inspections were held in the year ended Summer Holidays, 1913; and second re-inspections (where necessary) were held in the year ended Christmas, 1913. Defects. Term in which second re-inspection took place. Number of defects under review. Percentage treated. Percentage untreated but no longer requiring treatment. Percentage untreated and still requiring treatment. Refraction Spring term, 1913 3,619 71.6 7.4 21.0 Summer term, 1913 2,672 72.2 5.1 22.7 Autumn term, 1913 3,545 73.1 5.0 21.9 Nursing treatment Spring term, 1913 1,276 67.5 25.7 6.8 Summer term, 1913 931 68.3 25.2 6.5 Autumn term, 1913 1,539 67.7 25.7 6.6 Ear, nose and throat Spring term, 1913 4,149 55.5 20.6 23.9 Summer term, 1913 2,888 55.0 18.9 26.1 Autumn term, 1913 4,043 59.5 17.2 23.3 Teeth Spring term, 1913 4,049 44.0 15.7 40.3 Summer term, 1913 3,590 49.5 11.1 39.4 Autumn term, 1913 7,304 52.9 12.5 34.6 Other ailments Spring term, 1913 2,080 51.3 36.6 12.1 Summer term, 1913 1,676 53.8 34.0 12.2 Autumn term, 1913 3,004 53.9 32.7 13.4 All defects Spring term, 1913 15,173 56.7 18.8 24.5 Summer term, 1913 11,757 58.1 16.1 25.8 Autumn term, 1913 19,435 59.2 16.3 24.5 xxii. Annual Report oj the London County Council, 1913. APPENDIX XVI. NUMBER OF CANDIDATES EXAMINED FOR THE PERMANENT SERVICE AND THE CONDITIONS FOUND. Status. 1 No. Examined. 2 No. of Examinations. 3 No. Fit. 4 Vaccination. Referred back. Rejected. 17 Withdrawnprior to re-examination or not yet reported. 18 Not vaccinated. 5 * No marks. 6 Want of cleanliness. 7 Throat. 8 Teeth. 9 Vision. 10 Heart. 11 Vaccination. 12 Sundry. 13 For one defect. 14 For two or more defects. 15 Total. 18 Head and assistant teachers and instructorsz M. f. m. f. m. f. M. f. u. f. m. f. m. f. m. f. m. f. m. f. m. f. M. 1'. M. f. m. f. m. f. M. f. M. f. 392 724 493* 9071 361* 736† 7 4 — 1 — 4 1 — 100 90 27 70 1 - 7 2 5 5 11l 141 15 15 126 156 — 5 38 16 Nurses, matrons, etc. — 16 — 18 — 15 ... ... ... ... — 2 - 3 ... ... ... — 1 — 2 — 3 ... — 1 Schoolkeepers, caretakers, etc. 47 — 52 — 41 — 1 — ... ... ... 7 — 2 — ... 1 — ... 8 — 1 — 9 — 2 — 4 — Totals 439 740 545* 925† 402* 751† 8 4 — 1 — 4 1 - 107 92 29 73 1 — 8 2 5 5 119 142 16 17 135 159 2 5 42 17 * In the case of 7 males (teachers), the figures for the first examination were included in the report for the 12 months ended 31st December, 1912. † in the case of 33 females (teachers), the figures for the first examination were included in the report for the 12 months ended 31st December, 1912. xxiii APPENDIX XVII. SCHOLARSHIP CANDIDATES EXAMINED AND THE CONDITIONS FOUND. Scholarships. 1 Number examined. 2 Number of examinations. 3 Fit. 4 Vaccination. Referred back. Rejected. 16 Withdrawn prior to re-examination or not yet reported. 17 Not vaccinated. 6 No marks. 6 Want of cleanliness. 7 Throat. 8 Teeth. 9 Vision. 19 Heart. 11 Sundry defects. 12 For one defect. 13 For two or more defects. 14 Total. 15 A.—County Scholarships. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. F. m. F. Junior County 821 814 1,269 1,289 814 796 39 52 13 13 2 67 19 22 337 303 132 156 ... ... 11 16 347 357 76 (2 for 3) 100 (7 for 3) 423 457 ... 6 7 12 Supplementary Junior County 133 154 187* 213 133* 148 16 ... 5 ... 1 7 1 1 43 40 12 15 ... 1 ... 2 44 47 6 (1 for 3) 9 (1 for 3) 50 56 ... 2 1 4 Intermediate County 139 60 183 74 137 58 6 ... ... ... 1 2 1 ... 29 8 18 6 ... 1 1 ... 36 15 7 1 43 16 ... ... 2 Senior County 35 18 40 25 35 15 2 1 ... ... ... ... ... ... 4 6 1 5 ... ... ... 1 5 8 ... 2 5 10 ... ... ... 3 Totals 1,128 1,046 1,679* 1,601 1119* 1017 63 53 18 13 4 76 21 23 413 357 163 182 ... 2 12 19 432 427 89 (3 for 3) 112 (8 for 3) 521 539 ... 8 10 21 B.—Trade Scholarships. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. M. f. M. f. Apprenticeships, dressmaking ... 19 ... 23 ... 17 ... 1 ... ... ... 2 ... ... ... ... ... 2 ... ... ... ... ... 4 ... 2 ... 6 ... ... ... 2 Artificers, Boy 22 ... 22 12 ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... 1 ... 3 ... ... ... 3 ... 7 ... 3 ... Beaufoy Institute 26 ... 38§ 27§ ... 2 ... 2 ... ... ... ... ... 10 ... 3 ... ... ... 1 ... 6 ... 4 ... 10 ... ... ... 1 ... Borough Polytechnic 20 ... 23 19 ... ... ... ... ... ... ... ... ... 3 ... 1 ... ... ... ... ... 4 ... ... ... 4 ... ... ... 1 ... Book production 11 ... 16 11 ... 2 ... ... ... ... ... ... ... 1 ... 2 ... ... ... ... ... 3 ... ... ... 3 ... ... ... ... ... Building 50 ... 72 48 ... 4 ... ... ... 1 ... 1 ... 17 ... 7 ... ... ... 1 ... 16 ... 5 (1 for 3 ... 21 ... ... ... 2 ... Carriage and motor - body building 6 ... 8 6 ... ... ... 2 ... ... ... ... ... 2 ... ... ... ... ... ... ... 2 ... ... ... 2 ... ... ... ... ... Cookery 5 11 8 22 5 11 2 2 ... ... ... 1 ... ... 2 7 1 2 ... ... ... ... 1 6 1 2 2 8 ... ... ... ... Corset making ... 10 ... 17 ... 8 ... 2 ... ... ... 2 ... ... ... 5 ... 2 ... ... ... ... ... 3 ... 3 ... 6 ... 2 ... ... Dressmaking ... 57 ... 83 ... 55 ... 5 ... ... ... 3 ... ... ... 15 ... 9 ... ... ... 1 ... 24 ... 2 ... 26 ... 1 ... 1 Domestic training (trade) ... 56 ... 80 ... 56 ... 1 ... ... ... 8 ... 1 ... 12 ... 6 ... ... ... 1 ... 18 ... 5 ... 23 ... ... ... ... Embroidery ... 17 ... 27 ... 15 ... 4 ... 1 ... 1 ... ... ... 8 ... 5 ... ... ... ... ... 9 ... 1 for 3) 2 ... 11 ... 1 ... 1 Engineering 71 ... l00‡ 69‡ ... 9 ... 2 ... ... ... ... ... 26 ... 5 ... ... ... 1 ... 28 ... 2 ... 30 ... ... ... 3 ... Free place (Imperial College of Science and Technology 2 ... 2 2 ... 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Furniture 25 ... 37 25 ... 3 ... 2 ... ... ... ... ... 9 ... 2 ... ... ... 1 ... 12 ... ... ... 12 ... ... ... ... ... Hackney Institute 2 ... 2 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Laundry work ... 13 ... is ... 13 ... ... ... ... ... 3 ... ... ... 1 ... 4 ... ... ... ... ... 3 ... 1 for 3) 2 ... 5 ... ... ... ... Millinery ... 10 ... 18 ... 10 ... 1 ... ... ... 1 ... ... ... 3 ... 4 ... ... ... ... ... 4 ... 2 ... 6 ... ... ... ... Painting and decorating 11 ... 15 ... 11 ... 1 ... ... ... ... ... ... ... 4 ... ... ... ... ... ... ... 4 ... ... ... 4 ... ... ... ... ... Photography 6 11 7 11 6 11 ... 5 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... ... 1 ... ... ... ... ... Beady-made clothing ... 34 ... 52 ... 29 ... 8 ... ... ... 3 ... ... ... 14 ... 6 ... ... ... ... ... 13 ... 5 ... 18 ... 5 ... ... Silversmithing 10 ... 13 10 ... ... ... ... ... ... ... ... ... 1 ... 2 ... ... ... ... ... 3 ... ... ... 3 ... ... ... ... ... Tailoring, ladies ... 41 ... 1" ... 37 ... 4 ... 1 ... ... ... ... ... 10 ... 3 ... ... ... ... ... 11 ... 1 ... 12 ... 4 ... ... Upholstery ... 29 ... 00 46 ... 27 ... 4 ... ... ... 3 ... ... ... 7 ... 5 ... ... ... 1 ... 11 ... (1 for 3) 2 ... 13 ... 2 ... ... Waistcoat making ... 11 ... 16 ... 10 ... 1 ... ... ... ... ... ... ... 3 ... 1 ... ... ... 1 ... 3 ... 1 ... 4 ... 1 ... ... Waiters 10 ... 14 10 ... ... ... ... ... ... ... ... ... 4 ... ... ... ... ... ... ... 4 ... ... ... 4 .... ... ... ... ... Woodcarving 3 ... 4 3 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... ... 1 ... ... ... ... ... Totals 280 319 381§‡ 468 266§‡ 299 24 38 9 2 1 27 1 1 83 89 23 49 ... ... 5 4 88 109 12 (1 for 3) 29 (3 for 3) 100 138 7 16 10 4 C.-Special Scholarships. m. F.. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. M. F. m. f. m. f. m. f. m. f. m. f. m f. Art 21 10 28 12 20 10 2 2 ... ... ... ... ... ... 7 2 2 ... ... ... ... ... 7 2 1 ... 8 2 ... ... 1 ... Blind 5 7 5 7 5 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... Cripple 4 11 4 11 4 9 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... Deaf 1 7 1 7 1 7 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... • • • ... ... ... ... ... ... ... Junior domestic economy ... 524 ... 802† ... 477† ... 56 ... 12 ... 68 ... 8 ... 189 ... 80 ... ... ... 3 ... 212 ... 64 (2 for 4) (4 for 3) ... 276 ... 22 ... 27 Science 15 ... 20 ... 15 ... ... ... 1 ... ... ... ... ... 5 ... ... ... ... ... ... ... 5 ... ... ... 5 ... ... ... ... ... Trust Fund 7 2 11 3 7 2 ... ... ... ... ... ... ... ... 3 ... 1 ... ... ... ... 1 4 1 ... ... 4 1 ... ... ... ... Totals 53 561 69 842† 52 511† 2 58 1 12 ... 68 ... 8 15 191 3 80 ... ... ... 4 16 215 1 64 (2 for 4) (4 for 3) 17 279 ... 25 1 27 * In the case of 1 male the figures for the first examination were included in the report for the 12 months ended 31st December, 1912. ‡ In the case of 1 male the figures for the first examination were included in the report for the 12 months ended 3lst December, 1912. § In the case of 2 males the figures for the first examination were included in the report for the 12 months ended 31st December, 1912. † In the case of 2 females the figures for the first examination were included in the report for the 12 months ended 31st December, 191. 23610 Appendix XVIII. xxiv 23610 APPENDIX XVIII. CANDIDATES EXAMINED FOR THE TEACHING PROFESSION AND THE CONDITIONS FOUND. Awards. Number examined. Number of examinations. Fit. Vaccination. Referred back. Rejected. Withdrawn prior to re-examination or not yet reported. Not vaccinated. No. marks. Want of cleanliness. Teeth. Vision. Heart. Vaccination. Sundry defects. For one defect. For two or more defects. Total. 1 2 3 4 5 6 7 8 9 12 13 14 15 16 17 m. f. m. f. m. f. m. f. M. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. m. f. Bursars 43 404 66 538† 43 384† ... 18 ... 1 ... 7 19 75 6 39 ... 1 ... 16 ... 4 19 110 3 16 22 126 ... 16 ... 8 Domestic economy training ... 9 ... 12 ... 9 ... ... ... ... ... ... ... 1 ... 2 ... ... ... ... ... ... ... 3 ... ... ... 3 ... ... ... ... Pupil teachers, handicraft 10 ... 16 ... 10 ... ... ... 1 ... ... ... 5 ... 1 ... ... ... ... ... ... ... 4 ... 1 ... 5 ... ... ... ... ... Student teacher's 53 421 73 507† 53 411† ... 6 ... ... ... 8 6 50 11 24 ... ... ... 1 2 3 17 78 1 4 18 82 ... 11 ... 2 Training college students 140 399 182* 485† 130* 388† 4 10 ... ... ... ... 37 46 11 42 ... ... 2 7 3 5 43 87 5 6 (1 for 3) 48 93 3 3 9 13 Totals 246 1,233 337* 1,542† 236* 1,192† 4 34 1 1 ... 15 67 172 29 107 ... 1 2 24 5 12 83 278 10 26 (1 for 3) 93 304 3 30 9 23 * In the case of 2 males (training college students) the figures were included in the report for the 12 months ended 31st December, 1912. † In the case of 12 females (4 bursars, 3 student teachers, 5 training college students) the figures were included in the report for the 12 mouths ended 31st December, 1912. MM xxv Annual Report of the London County Council, 1913, APPENDIX XIX. A. SCHOLARS—DEFECTS NOTED ON MEDICAL EXAMINATION. Institutions. No. examined. Defects. Teeth. Vision. Throat and Nose. Ears. Heart. Lungs. Anaemia. Back. Nutrition. Various. Defective Signs of Eye Strain. Hearing. Discharge. Bound. Curvature. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (i.) L.C.C. Training Colleges, Secondary and Trade Schools. Training Colleges. Males 80 6 22 — — — - 1 — — 3 1 — 1 Females 826 67 123 12 6 2 1 6 1 35 87 9 10 29 Secondary Schools. Males 880 159 130 11 18 10 — 23 3 22 35 15 6 29 Females 3,485 702 472 55 44 16 12 56 7 115 350 75 61 123 Trade Schools. Males 339 77 42 1 1 3 1 4 1 8 17 3 7 3 Females 462 115 56 11 9 2 1 4 1 35 117 18 22 13 (ii.) Secondary and Trade Schools, aided but not maintained by the Council. Secondary Schools. Males 1,207 226 223 3 6 5 4 23 3 13 19 11 11 7 Females 767 172 122 2 6 — 2 7 — 34 54 28 9 23 Trade Schools. Males 192 29 29 2 1 2 1 1 1 3 5 5 1 8 Females 443 121 50 8 7 1 3 9 3 15 31 19 3 16 B. SCHOLARS—DEFECTS REMEDIED. Institutions. Defeots. Teeth. Vision. Ears. Throat and Nose. Anaemia. Various. (i.) L.C.C. Training Colleges, Secondary and Trade Schools. Training Colleges. Males 1 1 — — — — Females 21 13 — 1 4 2 Secondary Schools. Males 21 10 3 5 - 2 Females 157 59 — 6 8 9 Trade Schools. Males 10 5 - - 1 Females 17 2 1 — 1 — (ii) Secondary and Trade Schools, aided but not maintained by the Council. Secondary Schools. Males 19 14 2 1 1 3 Females 25 6 — — 2 1 Trade Schools. Males 3 2 - - - 10 Females 18 15 — — - 1 APPENDIX XX. PROCEEDINGS OF LONDON SANITARY AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT, 1901. 23610 MM 2 xxvii xxviii APPENDIXXX. TABLE SHOWING PROCEEDINGS OF LONDON SANITARY AUTHORITIES UNDER THE FACTORY AND WORKSHOP ACT, 1901. Premises, Particulars, Class, &c. City of London. Battersea. Bermondsey. Bethnal Green. Camberwell. Chelsea. Deptford. Finsbury. Fulham. Greenwich. Hackney. Hammersmith. Hampstead. Holborn. Islington. Kensington. Lambeth. Lewisham. Paddington. Poplar. St. Marylebone St. Panoras. Shoreditch. Southwark. Stepney. Stoke Newington. Wandsworth. City of Westminster. Woolwich. 1. Inspections. Factories (including factory laundries) 3,071 487 163 124 306 4 188 499 158 65 45 1,043 98 242 615 344 2 72 115 92 180 43 858 202 215 54 934 73 120 Workshops (including workshop laundries) 3,663 1,588 374 4,149 1,883 739 310 1,525 375 303 2,074 1,133 561 793 2,561 2,234 94 1,293 3,544 878 3,009 192 4,167 1,139 4,741 201 3,185 2,963 271 Workplaces (other than outworkers' premises) 738 1,881 112 955 970 - 155 603 191 151 - 1,117 1,528 2,536 989 137 - 102 36 591 1,162 220 684 4,239 59 17 1,660 2,590 120 Total (Inspections) 7,472 3,956 649 5,228 3,159 743 653 2,627 724 519 2,119 3,293 2,187 3,571 4,165 2,715 96 1,467 3,695 1,561 4,351 455 5,709 5,580 5,015 272 5,779 5,626 511 2. Defects Found. Nuisances under the Public Health Acts. Want of cleanliness 702 91 52 606 93 15 146 92 42 123 253 91 51 90 256 86 51 45 89 556 108 85 229 655 753 7 188 859 36 Want of ventilation 111 10 4 23 — - 6 14 - - 30 1 5 7 30 29 5 13 7 2 26 2 3 36 94 - 8 333 11 Overcrowding 10 5 — 3 2 5 - 7 - 12 1 5 8 17 7 11 2 21 1 9 - 6 9 42 1 2 50 1 Want of drainage of floors — 7 9 1 3 l 130 1 - 2 4 14 1 — 34 — — - - - 6 2 - 7 7 3 3 18 - Other nuisances 861 134 138 1,097 88 7 1 168 5 21 100 149 50 114 170 65 243 15 68 168 86 4 516 723 293 - 277 742 12 Sanitary accommodation Insufficient 16 13 7 13 3 - 34 38 6 5 2 6 5 4 39 8 — — -— 2 9 6 9 23 24 2 7 47 - Unsuitable 2,911 75 50 375 71 2 - 231 12 7 79 30 5 60 432 80 73 57 1 — 70 8 222 35 166 - 86 461 12 Not separate for sexes 70 3 9 4 2 1 — 21 - - 13 1 1 13 12 6 1 — 1 — 14 4 5 4 19 1 2 l35 2 Offences under the Factory & Workshop Act. Illegal occupation of underground bakehouse (s. 101) - - - - - - - - - — — - - - - - - - - - - - - - - - - - Breach of special sanitary requirements for bakehouses (ss. 97-100) — 39 — — - 10 - - 7 11 — 85 — - - 42 - 21 - - 4 29 - - 76 - 16 2 - Other offences (excluding offences relating to outwork) — — — — - — — 48 — - — 14 9 - - - - - - - 2 - - - 50 - - - Total (defects found) 4,681 377 269 2,122 262 41 317 620 72 169 493 392 132 296 990 323 384 153 187 729 332 142 990 1,492 1,474 64 539 2,647 74 8. Homework. Outworkers' Lists (s. 107). Received twice in the year from employers Number of Lists 1,458 74 95 174 77 54 72 290 16 34 420 70 112 126 156 116 36 54 118 110 116 42 104 134 308 43 128 341 50 Outworkers, corresponding thereto Contractor 4,030 52 24 2,174 57 249 47 546 14 203 34 82 102 244 20 187 10 - 17 137 726 52 67 — 737 — 59 — — Workmen 12,060 323 870 1,697 369 446 4,182 44 4,481 98 211 521 1,180 607 405 144 546 1,698 984 187 1,515 1,044 3,434 293 357 4,644 747 Received once' in the year from employers Number of Lists Outworkers, corresponding thereto 60 7 1 18 13 1 1 33 5 1 36 16 6 16 94 6 6 16 6 18 1 7 6 22 28 — 2 34 4 Contractors 79 5 - 233 22 - - 65 6 5 - 14 — 35 3 — — — - 8 - - - - 12 - - - - Workmen 299 8 10 58 1 9 349 16 207 24 10 39 181 9 19 33 41 163 7 18 87 149 139 - 4 273 12 Number of addresses of outworkers received from other Councils 275 375 2,832 106 240 303 2,899 392 953 372 1,964 2,330 1,078 616 521 414 94 Number of addresses of outworkers forwarded to other Councils 16,025 181 1,452 619 101 2,287 613 530 243 359 1,051 1,229 656 194 276 4,747 119 Prosecutions Failing to keep lists or permit inspection thereof - - - 3 - - - - - — — - - - - - - - - - - - - - - - - - Failing to send lists - - - 3 - - 1 - - - - - - — — — — — — — — — — — — — — 1 — Outworkers' Premises. Number of inspections of outworkers' premises 37 808 1,167 2,245 1,316 107 400 444 128 2,183 308 1,068 192 192 408 1,301 1,963 822 5,484 408 465 969 363 Outwork in unwholesome premises (s. 108) Instances - 42 69 525 39 - 12 - 8 - - 12 - - 92 5 — — — - - — 94 — 452 — 27 328 18 Notices served - 35 61 872 18 - - - 8 - - 12 - — 35 5 — — — — — - 96 - 452 - 35 16 18 Prosecutions - - - - - - - - - - - - - — - — — — — — — — - —— - — - - — Outwork in infected premises (ss. 109,110 Instances - - - - - - - 10 - - - - - - 75 16 6 —- 8 —- — — 28 2 100 — 20 17 — Orders made (s. 110) - - - - - - - - - - - - - - - - - - - - - - - - - - - - Prosecutions (ss. 109. 110) - - - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Workshops. - Workshops on the Register at the end of 1913. Bakehouses (a) 19 71 72 86 154 33 62 57 72 52 28 62 32 32 237 80 214 91 51 83 75 132 74 107 175 23 122 84 40 Laundries 2,094 31 15 2,262 50 20 8 20 39 20 84 305 7 13 96 154 203 85 32 22 4,206 74 28 51 22 218 145 43 12 Other workshops 437 307 1,499 645 179 1964b 303 180 946 773 467 1,163 1,316 1,517 992 433 1,261 549 1,809 1,204 2,479 3,199 1,474 2,841 148 Total (number of workshops on the Register) 2,113 539 394 2,348 1,703 698 249 2,041 414 252 1,058 1,140 506 1,208 1,649 1,751 1,409 609 1,344 654 4,281 2,015 1,306 2,637 3,396 241 1,741 2,968 200 5. Other Matters. Mailers notified to H.M. Inspector of Factories. Failure to affix abstract of the Factory and Workshop Act (s. 133) 106 33 - 20 19 — 12 25 — — — — 36 9 155 53 — - 84 22 10 - - 1 26 16 35 135 4 Action taken in matters referred H.M. Inspector remediable under the Public Health Acts but not under the Factory and Workshop Act (s. 5). Notified by H.M. Inspector 28 2 10 110 15 27 5 23 6 - 62 12 3 29 16 31 6 7 9 — 31 54 24 16 360 5 10 94 2 Reports (of action taken) sent to H.M. Inspector 28 - 10 87 11 27 3 23 - 1 62 12 3 29 14 24 6 7 9 19 25 54 18 2 287 5 10 94 - Other 22 - - 1 - - 8 31 - - - 40 6 — - 3 5 — — 9 3 — — 2 73 2 — 4 — Underground Bakehouses (s. 101). Certificates granted during 1913 - - - - - - - - - - - — — - — — — — — — — — — - — - - - — In use at the end of 1913 20 26 32 26 65 28 24 34 48 14 51 27 20 21 94 73 72 20 48 25 75 101 38 40 61 18 48 68 14 (a) Including bakehouse not in use during the year. (b) Including workplaces. xxix xxx. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. APPEN DIX XXI. WORKING CLASS DWELLINGS ACCOUNTS, YEAR ENDED 31st MARCH, 1914. Dr. A-housing of the working classes act, 1890 Dr. EXPENDITURE. INCOME. PART 1. 1.-revenue account. PART 1. Working Expenses and Debt Charges (Details on pages xlvii. and xlviii,)— Boundary-street Estate (Bethnal Green and Shoreditch)— £ s. d. Income (Details on page xlvii.)— £ s. d. Tenements (including laundry) £21,314 12 11 Boundary-street Estate (Bethnal Green and Shoreditch)— Automatic gas supply 2, 818 10 1 24,133 3 - Tenements (including laundry £23,158 15 8 26,503 7 8 Cable-street Dwellings (Stepney) 2,721 7 9 Automatic gas supply 3,344 12 - 2,914 8 9 Shelton-street Dwellings (Holborn) 1,454 14 - Cable-street Dwellings (Stepney) 1,546 4 _ Millbank Estate (Westminster)—Proportion 5,316 18 6 Shelton-street Dwellings (Holborn) 6,515 1 5 Churchway Dwellings (St. Pancras) 3,199 - 5 Millbank Estate (Westminster 3,857 15 6 Hardy Cottages, Trafalgar-road, Greenwich 862 6 2 Churchway Dwellings (St. Pancras) 841 13 6 Duke's-court Dwellings (Westminster)—Proportion 1,534 11 - Hardy Cottages, Trafalgar-road (greenwich) 1,798 2 8 York-street Dwellings (Westminster)—Proportion 996 1 6 Duke's-court Dwellings (Westminster)—Proportion 1,124 18 11 Preston's-road Estate (Poplar)—Proportion 905 15 - York-street Dwellings (Westminster)— Proportion 685 15 5 St. Luke's Dwellings (Finsbury)— Preston's-roaa Estate (Poplar—Proportion Wenlake Buildings 1,679 13 2 St. Luke's Dwellings (Finsbury)— 1,892 8 6 Chadworth Buildings 2,871 - 3 Wenlake Buildings 3,043 5 8 Clerkenwell and Holborn Dwellings— Chadworth Buildings Mallory Buildings (Finsbury) 776 13 10 Clerkenwell and Holborn Dewllings- Mallory Buildings (Finsbury) 902 1 6 Nigel Buildings, etc. (Holborn) 5,666 12 - Nigel Buildings, etc. (Holborn) 5,907 15 11 Webber-row Dwellings (Southwark) 3,973 10 4 Webber-row Dwelling (Southwark) 4,783 4 - Dwellings on sites Compulsorily appropriated for rehousing, on the working of which a deficiency was anticipated owing to the character or situation of the site. Brook-street Dwellings (stepney) 1,044 9 8 Brook-street Dwellings (Stepney) 987 17 - Goldsmith's-row Cottages (Shoreditch) 484 18 8 457 6 6 Hughes-fields Cottages (Greenwich) 2,199 5 2 Goldsmith's-row Cottages (Shoreditch) Hughes-fields Cottages (Greenwich) 1,662 4 9 59,820 - 5 Dwellings in course of erection—Tabard-street 32 - 4 Difference between totals of debt charges on cash and stock basis 2,305 19 4 57 546 1 5 65,423 11 8 Surplus carried to Appropriation Account 8,258 16 2 Interest on cash balances (less income tax) 381 5 11 65,804 17 7 65,804 17 7 PART II. Working Expenses and Debt Charges (Details on pages xlvii. and xlviii.)— £ s. d. PART II. £ s. d. Cranley Buildings, Brooke's-market (Holborn) 241 18 3 Income (Details on page xlvii.)— Cranley Buildings, Brooke's-market (Holborn) 279 15 6 Borough-road Dwellings (Southwark) 1,737 16 8 Borough-road Dwellings (Southwark) 1,827 17 6 Cobham Buildings, Rushworth- (late Green-) street and Pocock-street (Southwark) 1,003 3 10 Cobham Buildings, Rushworth (late Green) street and Pocock-street (Southwark) l,118 13 - Ann-street Dwellings (Poplar) 1,923 17 9 Ann-street Dwellings (Poplar) 2,059 6 - Sylva Cottages, Mill-lane (Deptford) 415 10 10 Sylya Cottages, Mill-lane (Deptford) 463 5 6 5,322 7 4 Difference between totals of debt charges on cash and stock basis 101 19 10 5,220 7 6 5,748 17 6 Surplus carried to Appropriation Account 556 8 11 Interest on cash balances (less income tax) 27 18 11 5,776 16 5 5,776 16 5 PART III. PART III. (a) Dwellings. Working Expenses and Debt Charges (Details on pages xlvii. and xlviii.)— £ s.. d. (a) Dwellings. £ s. d. Parker-street House (Holborn) 3,156 - 3 Income (Details on page xlvii.) — Parker-street House (Holborn) 3,266 5 5 Carrington House (Holborn) 5,996 - 8 Carrington House (Deptford) 4,671 1 1 Dufferin-street Dwellings (Finsbury) 582 15 2 Dufferin-street Dwellings (Finsbury) 599 15 6 Rushworth- (late Green-) street and Boyfield-street Dwellings (Southwark) 1,575 7 11 Rushworth- (late Green) street and Boyfield-street Dwelling (Southwark) 1,716 15 6 Millbank Estate (Westminster)—Proportion 818 5 7 Millbank Estate (Westminster)—Proportion 975 11 5 Holmwood Buildings, 97, Southwark-street (Southwark) 360 11 - Holmwood Buildings, 97, Southwark-street (Southwark) 344 2 - Totterdown-fields Estate (Wandsworth) 26,811 4 7 Totterdown-fields Estate (Wandsworth) 29,117 14 5 Preston's-road Estate (Poplar)—Proportion 3,078 2 4 Preston's-road Estate (Poplar)-Proportion 2,638 11 1 Hughes-helds Dwellings (Deptford and Greenwich)—Proportion 1,201 14 4 Hughes-field Dwellings (Deptford and Greenwich)-Proportion 1,071 17 1 White Hart-lane Estate (Tottenham, Wood Green and Edmonton) White Hart-lane Estate (Tottenham, Wood Green and Edmonton) 20,540 - 11 Wessex Buildings, Wedmore-street (Islington) 3,823 5 10 Wessex Buildings, Wedmore-street (Islington) 4,037 19 8 Norbury Estate (Croydon) 10,415 - 2 Norbury Estate (Croydon) 11,005 12 - Caledonian Estate (Islington) 4,842 7 6 Caledonian Estate (Islington) 5,409 1 9 Briscoe Buildings (Lambeth) 2,441 11 - Briscoe Buildings (Lambeth) 2,444 2 3 Old Oak Estate (Hammersmith) 4,153 2 8 Old Oak Estate (Hammersmith) 4,797 15 2 88,227 - 9 Difference between totals of debt charges on cash and stock basis 603 2 7 87,623 18 2 92,629 5 8 Surplus carried to Appropriation Account 5,360 15 4 Interest on cash balances (less income tax) 355 8 3 92,984 13 6 92,984 13 6 xxxi Annual Report of the London Courty Council, 1913. Housing of the Working Classes—Accounts. xxxii. A—HOUSING OF THE WORKING CLASSES ACT, 1890-continued. EXPENDITURE. INCOME. PART III.-continued. I.-REVENUE ACCOUNT—continued. PART III.-continued. (b) Estates in Course of Development. Estates in Course of Development. Expenses and Debt Charges (details on pages xlvii, and xlviii.)- £ s. d. Income (Details on page xlvii.)— £ s. d. £ s d. White Hart-lane (Tottenham, Wood Green and Edmonton) 3,049 10 8 White Hart-lane (Tottenham, Wood Green and Edmonton) 470 1 11 Norbury (Croydon) 332 16 11 Old Oak (Hammersmith) 37 13 8 Old Oak (Hammersmith) 1,034 11 8 507 15 7 4,416 19 3 Less—Interest on overdrawn cash balances (after allowing for income tax) 44 1 10 Supervision 500 - - Difference between totals of debt charges on cash and stock basis 100 u 4 Revenue Account (Old Oak Estate) for transfer in respect of debt charges (interest £1,577 16s. 5d., sinking fund £282 9s. 10d.) on expenditure met out of the Acquisition of Lands Fund, applied towards deficiency arising under Part III.—Dwellings (part of £4,153 2s. 8d., page xxix.) 463 1,860 l.i 0 9 3 Deficiency carried to Appropriation Account (below) 4,292 11 2 Less—Transfer from Revenue Account (as above) ... 1,860 0 3 2,432 4 11 4,766 4 11 4,750 4 11 II—APPROPRIATION ACCOUNT. £ s. d. Amount brought from Revenue Account— Special Counts' Account for contribution to Rates, as contra 11,743 15 6 Surplus- £ s. d. Part I. 8,258 10 2 Part II. 556 8 11 Part III.—Dwellings 5,360 15 4 14,176 - 5 Less—Deficiency—Part III.—Estates in course of development (above) 2,432 4 11 11,743 15 6 11,743 15 6 11,743 15 6 III.- REPAIRS AND RENEWALS FUND Actual Expenditure— £ s. d. £ s. d. Balance—1st April, 1913 £ s. d. £ 8. d. Part I. 7,802 14 10 Part I.. 20,616 6 3 Part II. 741 15 6 Part II. 2,953 6 7 Part III 10,171 6 5 18,715 16 9 Part III 20,123 1 11 43,692 14 9 Expenses of Investment—Part III 19 1 6 Transfers from Revenue Account—(Details on page xlviii., column 12) 17,686 1 11 Balance—31st March, 1914 (of which £41,396 15s. 10d. is invested) carried to Balance Sheet (page xxxvii.)— Dividends on investments and interest on cash balances (less income tax)— Part I 577 18 6 Part I 19,603 12 7 Part II. 86 19 2 Part II. 2,891 10 3 Part III. 692 12 - 1,357 9 8 Part III. 21,606 5 3 44,001 8 1 62,736 6 4 62,730 0 4 23610 nn . Housing of the Working Classes—Accounts. xxxiv xxxiii. Annual Report of the London County Council, 1913. CLASSES ACT, 1890—continued Cr. A—HOUSING OF THE WORKING Dr. EXPENDITURE. INCOME. IV.—CAPITAL ACCOUNT PART 1 PART 1 Erection of Dwellings— £ s. d. Balance carried to Capital (Aggregate) Account £ s. d. 2,742 2 8 Clerkenwell and Holbom Dwellings—Nigel (late Union) Buildings 946 10 1 St. Luke's Dwellings—Chadworth Buildings 106 18 11 Tabard-street and Crosby row 1,688 13 8 2,742 2 8 2,742 2 8 PART III. A Acquisition and PART iii. Laying-out of Sites. White Hart-lane, Tottenham, Wood Green and Edmonton £ s. d. White Hart-lane, Tottenham, Wood Green and Edmonton—Amount receivable in respect of sale of land to Tottenham and Wood Green Burial Board £ s. d. £ s. d. 3,000 - - 2,455 - 11 Norbury, Croydon 4,173 7 2 Old Oak, Hammersmith—Amount transferred from Education Account in respect of value of site appropriated for an elementary school 4,130 - - Old Oak, Hammersmith 7,833 15 4 Totterdown -fields, Wandsworth 66 4 1 Working Class Dwellings Account for value of sites appropriated for dwellings— Totterdown-Fields Estate, Wandsworth 66 4 1 14,528 7 6 White Hart-lane Estate, Tottenham, Wood Green and Edmonton 2,217 - - Consolidated Loans Fund for transfer of land, contra 4,130 - - Norbury Estate, Croydon 6,315 - - Old Oak Estate, Hammersmith 5,816 - - 18,658 7 6 14,414 4 1 Balance carried to Capital (Aggregate) Account (below) 2,885 16 7 21,544 4 1 21,544 4 1 B Working Class Dwellings. £ s. d. £ s. d £ s. d. Totterdown-fields Estate, Wandsworth 1,326 3 6 Old Oak Estate—Acquisition of Lands Fund to meet part expenditure during year 10,878 12 - Add—Value of site appropriated for dwellings 66 4 1 1,392 7 7 Balance carried to Capital (Aggregate) Account 61,137 13 6 White Hart-lane Estate, Tottenham, Wood Green and Edmonton 10,688 8 9 Add—Value of site appropriated for dwellings 2,217 - - 12,905 8 9 Norhury Estate, Croydon 1,146 6 - Add—Value of site appropriated for dwellings 6,315 - - 7,461 6 - Old Oak Estate, Hammersmith 44,441 3 2 Add—Value of site appropriated for dwellings 5,816 - - 50,257 3 2 72,016 5 6 72,016 5 6 V.- CAPITAL (AGGREGATE) ACCOUNT. £ s. d. £ s. d. £ s. d. Balance—1st April, 1913 - Part I 884,417 8 - Balance—31st March, 1914, carried to Balance Sheet 2,278,374 16 7 Part II 80,014 6 7 Part III.— Estates in course of development 103,397 6 4 Dwellings 149,551 16 1 2,217.380 17 - Expenditure in 1913-14— Part I 2,742 2 8 Part III.— Dwellings 61,137 13 6 63,879 16 2 Less—Part III.— Estates in course of development (above) 2,885 16 7 60,993 19 7 2,278,374 16 7 2,278,374 16 7 23610 nn 2 XXXV xxxvi. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. A.- HOUSING OF THE WORKING Dr. CLASSES ACT. Cr. EXPENDITURE. INCOME. VI— LOAN ACCOUNT. (A) CONSOLIDATED STOCK. . , £ s. d. £ s. d. Balance— 31st March, 1914 (Stock at par value), carried to Balance Sheet 2,0394,846 13 9 Balance—1st April, 1913 2,094,846 13 9 (B) ADVANCES FROM CONSOLIDATED LOANS FUND. £ s. d. £ s. d. £ s. d. Amount repaid during year, including £'26 proceeds of sales (as below) 1,500 11 - Balance—1st April, 1913 108,583 1 3 Balance— 31st March, 1914, carried to Balance Sheet 223,631 8 10 Amount advanced during year— In respect of expenditure in 1911 12, previously met by London County Bills 55,554 19 - In respect of expenditure in 1913-14 60,993 19 7 116,548 18 7 225,131 19 10 225,131 19 10 VII— SINKING FUND [ Transactions of the Consolidated Loans Fund ACCOUNT (Accumulating). in respect of Dwellings under the Housing Act, 1890.] £ s. d. £ s. d £ s. d. Amount applied during year— Balance—1st April, 1913 161,958 3 9 Repayment of advances from Consolidated Loans Fund (as above) 1,500 11 - Amount provided during year for redemption— Balance— 31st March, 1914, carried to Balance Sheet 184,277 7 8 Sinking Fund instalments provided out of Revenue (Details on page xlviii. columns 16 and 17) 15,371 8 1 Less—In respect of expenditure met out of Acquisition of Lands Fund 282 9 10 15,088 18 3 Interest on accumulations of Sinking Fund 4,600 16 8 19,689 14 11 Transfer of land 4,130 - - 23,819 14 11 185,777 18 8 185,777 18 8 VIII.— ACQUISITION OF [Transfer of £50,000from the Thames Embankment Extension and Improvements at Westminster Account, under sec. 66 of the amount has been charged a sum of £6,441 1s. 6d. in respect of the proportion of expenditure on the Millbank lite relating LANDS FUND (PART III). L.C.C. (General Powers) Act, 1903, in respect of rehousing accomnodation provided on the Millbank Estate. Against this to the improvement. The balance of £13,558 18s. 6d. with interest thereon is available for the purposes of the fund.] CONTRIBUTION ACCOUNT, £ s. d. £ s. d. £ s. d. Outlay Account to close the Account, the balance of moneys available having been utilised during the year 55,324 4 9 Balance—1st April, 1913 55,041 1 11 Dividends on investment 251 13 4 55,324 4 9 Interest on uninvested portion (less income tax) 31 9 6 283 2 10 55,324 4 9 OUTLAY ACCOUNT. Balance—1st April, 1913 44,445 12 9 Contribution Account to close the Account, the balance of moneys available having been utilises during the year 55,324 4 9 Capital Account for amount transferred to meet expenditure curing year on Old Oak Estate— Erection of Dwellings 10,878 12 - 55,324 4 9 55,324 4 9 xxxvii. Annual Report of the London County Council, 1913. Hominy of the Working Classes—Accounts. xxxviii. Dr. A.- HOUSING OF THE WORKING CLASSES ACT, 1890 -continued. Cr. IX.— BALANCE SHEET 31ST MARCH, 1914. Liabilities. £ s. d. £ s. d. £ s. d. Assets and Capital Outlay. Loans raised and outstanding— Consolidated Stock—Par value— Metropolitan— Capital Outlay — Part I 887,159 10 8 2 ½ per cent. 237,179 10 - Part II 80,014 6 7 London Countv — Part III.— Dwellings 1,210,689 9 7 2 ½ per cent. 183,666 - 6 Estates in course of development 100,511 9 9 3 per cent. 1,211,503 5 8 2,278,374 16 7 3 ½ per cent. 462,497 17 7 2,094,846 13 9 Less—Proceeds of sales (Fart III.— Dwellings and estates in course of development) 16,814 16 3 Advances from Consolidated Loans Fund—Balances outstanding ... 223.631 8 10 2,261,560 - 4 2,318,478 2 7 Acquisition of Lands Fund—Moneys of the fund expended on the Old Oak Estate (£43,558 18s. 6d. with interest accumulations thereon) 55,324 4 9 Sundry Creditors 3,302 2 3 Repairs and Renewals Fund— Stock Issue Expenses, including difference between par value of stock outstanding and net cash proceeds 72,987 12 1 Part I. 19,503 12 7 Part II. 2,891 10 3 Part III. 21,606 5 3 Property (Permanent Assets) acquired otherwise than by capital expenditure— 44,001 8 1 Sir Samuel Montagu (Lord Swaythling) Gift (£10,000 with interest accumulations thereon)— Expended on the White Hart-lane Estate 12,041 8 - Appropriation Account (after taking into account net contributions from Rates amounting to £49,678 6s. 8d., page lvii.) - - - Sinking Fund Assets—Loans to local authorities and other investments 184,277 7 8 Excess of Assets and Capital Outlay over Liabilities— Advances repaid and Stock cancelled (cost) 32,884 6 1 Sundry Debtors 1,071 6 9 Sinking Fund balance £184,277 7 8 Less— Proceeds of sales, deducted from capital outlay (contra) 16,814 16 3 167,462 11 5 Investment Account—Investments at cost price— (Details on page lvii.)— Repairs and Renewals Fund 41,396 15 10 200,346 17 6 [Market value at 31st March, 1914, £36,900] Cash in Hand— Acquisition of Lands Fund (as contra) 55,324 4 9 Revenue Account 4,808 1 3 Property (Permanent Assets) acquired otherwise than by capital expenditure (as contra) 12,011 8 - Special Accounts— 267,712 10 3 Sir Samuel Montagu (Lord Swaythling) Gift Fund £1 14 6 Acquisition of Lands Fund (Part III.) 25 12 - 27 6 6 4,835 7 9 *Loans raised and outstanding 2,318,478 2 7 2,633,494 3 2 2,633,494 3 2 Lett—Sinking Fund balance 181,277 7 8 Net Debt 2,134,200 14 11 xxxix. xl. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. B. DWELLINGS UNDER IMROVEMENT ACTS. Note.- For statues under which these dwellings have been erected, see Appendix XXII., page lx. Dr., C EXPENDITURE INCOME. 1—REVENUE ACCOUNT. £ s. d. £ s d. Income (Details on page xlix.)— Working Expenses and Debt Charges— (Details on pages xlix. and 1.)— Battersea Bridge Dwellings (Battersea) 1,034 15 - Nattersea Nrodge Dwe;;omgs (Nattersea) 1,022 19 6 1,100 17 - Cotton-street Dwellings (Poplar) 1,061 8 11 Cotton-street Dwellings (Poplar) 1,237 9 9 Durham Buildings, York-road (Battersea) 1,602 13 10 Durham Buildings, York-road (Battersea) 599 7 7 Duke's-court Dwellings (Westminster)— Proportion 511 10 2 Duke's-court Dwellings (Westminister)-Proportion 374 19 7 York-street Dwellings (Westminster)— Proportion 332 - 9 York-street Dwellings (Westminster)— Proportion 2,747 - 6 Herbrand-street Dwellings (Holborn) 2,334 2 9 Herbrand-street Dwellings (Holborn) 7,553 4 - Bruce House, Kemble-street (Westminster) 7,008 6 6 Bruce House, Kemble-street (Westminster) 11,299 11 5 Millbank Estate (Westminster)— Proportion 9,221 10 5 Millbank Estate (Westminster)— Proportion 13,220 6 9 Bourne Estate (Holborn) 11,840 1 8 Bourne Estate (Holborn) 3,542 8 - Swan-lane Dwellings (Bermondsey) 4,107 3 9 Swan-lane Dwellings (Bermondsey) 1,635 9 - Valette Buildings (Hackney) 1,440 10 - Valette Buildings (Hackney) 535 18 6 Hughes-fields Dwellings (Deptford and Greenwich)— Proportion 600 17 2 Hughes-fields Dwellings (Deptford and Greenwich)— Proporton 823 9 9 Bearcroft Buildings (Fulham) 749 10 1 Bearcroft Buildings (Fulham) Dwellings on sites compulsorily appropriated for rehousing, on the working of which a deficiency was anticipated owing to the character or situation of the site. Council Buildings (Poplar) 981 6 10 762 Z 9 Council Buildings (Poplar) 1,280 16 - Westview, Armitage and Collerston Cottages (Greenwich) 1,740 3 7 Westview, Armitage and Collerston Cottages (Greenwich) 1,108 4 6 Idenden Cottages (Greenwich) 1,116 1 5 Idenden Cottages (Greenwich) 1,373 4 8 Barnaby Buildings, Leroy-street (Bermondsey) 1,384 18 10 Barnaby Buildings, Leroy-street (Bermondsey) 1,017 6 3 Brightlingsea Buildings, Ropemaker's-fields (Stepney) 1,005 19 3 Brightlingsea Buildings, Ropemaker's fields (Stepney) 1,219 10 6 Bekesbourne Buildings (Stepney) 1,229 6 8 Bekesbourne Buildings (Stepney) 704 12 6 Darcy Buildings, London Fields (Hackney) 705 19 1 Darcy Buildings, London-fields (Hackney) 896 3 - Wandsworth-road Dwellings (Lambeth) 847 4 11 Wandsworth-road Dwellings (Lambeth) 50,843 16 1 Difference between totals of debt charges on cash and stock basis 662 16 - 54,066 17 - 50,181 1 Interest on cash balances (less income tax) 247 12 1 Surplus carried to Appropriation Account 4,133 9 - 54,314 9 1 54,314 9 1 II.— APPROPRIATION ACCOUNT. £ s. d. £ s. d. Amount brought from Revenue Account—Surplus 4,133 9 - General County Account for contribution to Rates 4,198 7 8 Tramways Account for contribution to meet one-third of deficiency for year on Hughes-fields (Deptford) Dwellings, in respect of the rehousing of persons displaced by the Greenwich generating station 64 18 8 4,198 7 8 4,198 7 8 III- REPAIRS AND RENEWALS FUND. £ s d. £ s. d. Balance—1st April, 1913 19,316 10 9 Actual Expenditure 5,218 7 11 Transfers from Revenue Account (Details on page 1., column 12) 5,285 18 1 Balance— 31st March. 1914 (of which £19,103 4s. 2d. is invested), carried to Balance Sheet 20,004 14 9 Dividends on investments and interest on cash balances (less income tax) 620 13 10 25,222 2 8 25,223 2 8 23610 00 xli. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. xlii. B— DWELLINGS UNDER IMPROVEMENT ACTS— Dr. Cr. EXPENDITURE. INCOME. IV— CAPITAL ACCOUNT. £ s d. £ s. d. Erection of Dwellings— Rotherhithe Tunnel— Bekesbourne Buildings 186 18 4 Balance— 31st March, 1914, carried to Capital (Aggregate) Account 186 18 4 V.— CAPITAL (AGGREGATE ACCOUNT. £ s. d £ s. d. Balance—1st April, 1913 743,351 4 - Balance— 31st March, 1914, carried to Balance Sheet 743,538 2 4 Expenditure in year 1913-14 186 18 4 743,538 2 4 743,538 2 4 VI.— LOAN ACCOUNT. (A) CONSOLIDATED STOCK. £ s. d. £ s d. Balance— 31st March, 1914 (Stock at par value), carried to Balance Sheet 780,560 15 3 Balance— 1st April, 1913 780,560 15 3 (B) ADVANCES FROM CONSOLIDATED LOANS FUND. £ s. d. £ s. d. Amount repaid during year (as below) £ s. d. Balance- 1st April, 1913 425 5 7 14 2 2 Balance —31st March, 1914, carried to Balance Sheet 851 18 - Amount advanced during year— In respect of expenditure in 1911-12 previously met by London County Bills 253 16 3 In respect of expenditure in 1913-14 186 18 4 440 14 7 866 - 2 866 - 2 VII— SINKING FUND ACCOUNT (Accumulating). [Transactions of the Consolidated, Loans. Fund in respect of Dwellings under Improvement Acts.] Amount applied during year— £ s. d. £ s. d. £ s. d. Balance—1st April, 1913 59,875 10 4 Repayment of advances from Consolidated Loans Fund (as above) 14 2 2 Balance— 31st March, 1914, carried to Balance Sheet 66,839 1 7 Amount provided during year for redemption- Sinking Fund instalments provided out of Revenue (Details on page 1., cols, 16 and 17) 5,206 16 - Interest on Accumulations of Sinking Fund 1,770 17 5 6,977 13 5 66,853 3 9 66,853 3 9 23610 00 2 xliii Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. xliv. B— DWELLINGS UNDER IMPROVEMENT ACTS—continued. Dr. Cr. VIII.— BALANCE SHEET, 31ST MARCH. 1914. Liabilities. £ s. d. £ s. d. Assets and Capital Outlay. £ s. d. Loans raised and outstanding— Capital Outlay, including £8,614 19s. 8d. for Drake Buildings, Hughes Fields (rehousing in connection with Tramways) 743,538 2 4 Consolidated Stock—Par value— Lest—Proceeds of sales—Disposal of right of light (Bourne Estate) 1,000 - - Metropolitan— 2 ½ per cent. 64,363 12 5 742,538 2 4 London County— 2½ per cent. 31,930 9 6 Stock Issue Expenses, including difference between par value of stock outstanding and net cash proceeds 4,5,337 9 4 3 per cent. 632,254 5 9 3 ½ per cent. 52,012 7 7 Sinking Fund Assets—Loans to Local Authorities and other investments 66,839 1 7 780,560 15 3 Advances from Consolidated Loans Fund-Balances outstanding 851 18 *781,412 13 3 Sundry Debtors 526 14 7 SUNDRY CREDITORS 816 9 4 Repairs and Renewals Fund 20,004 14 9 Investment Account—Investments at cost price— (Details on page lvii.)— Repairs and Renewals Fund 19,103 4 2 Market value at 31st March, 1914, £17,158 ] Appropriation Account (after taking into account net contributions to Rates and from Tramways Account, amounting to £15,880 15s. 4d., page lvii.) Cash in Hand 1,191 5 4 Excess of Assets and Capital Outlay over Liabilities— Advances repaid and Stock cancelled (cost) 7,462 18 5 Sinking I and balance £66,839 1 7 Less—Proceeds of sales, deducted from capital outlay (contra) 1,000 - - 65,839 1 7 73,302 - - 875,535 17 4 375,535 17 4 * Loans raised and outstanding £781,412 13 3 Less—Sinking Fund balance 66,839 1 7 Net Debt 714,573 11 8 xlv. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. xlvi. C.- DWELLINGS UNDER THE HOUSING OF THE WORKING CLASSES ACT, 1890. AND IMPROVEMENT ACTS COMBINED. Dr. Cr. EXPENDITURE. INCOME. REVENUE ACCOUNT. (Apportionment calculated on basis of accommodation) Millbank Estate (Westminister)- Millbank Estate (Westminster)— £ s. d. £ s. d. £ s d £ s d, 18,790 4 3 Working expenses and debt charges 16,356 14 6 Income Less—Charged to the following accounts— Housing of the Working Classes Act, 1890— Less—Credited to the following accounts— Housing of the Working Classes Act, 1890— Part I. 5,316 18 6 Part I 6,515 1 5 Part III. 818 5 7 Part III. 975 1 I 5 11,299 11 5 Dwellings under Improvement Acts 9,221 10 5 Dwellings under Improvement Acts 18,790 4 3 15,356 14 6 - - - Duke's-court Dwellings (Westminster)— £ s. d Duke's court Dwellings (Westminister)- £ s. d. 2,397 10 3 Working expenses and debt charges 2 046 1 2 Income Lest—Charged to the following accounts— Housing of the Working Classes Act, 1890—Part I. 1,534 11 - Lest— Credited to the following accounts— Housing of the Working Classes Act, 1890—Part I. 1,798 2 8 Dwellings under Improvement Acts 511 10 2 Dwellings under Improvement Acts 599 7 7 2,397 10 3 2,046 1 2 - - - York-street Dwellings (Westminster)— £ s. d £ s. d. York-street Dwellings (Westminster)— Income 1,499 18 6 Working expenses and debt charges 1,328 2 3 Less—Charged to the following accounts— Housing of the Working Classes Act, 1890—Part 1 996 1 6 Less—Credited to the following accounts— Housing of the Working Classes Act, 1890—Part I. 1,124 18 11 Dwellings under Improvement Acts 332 - 9 1,328 2 3 374 19 7 1,499 18 6 - - - Preston's- road Estate (Poplar)— £ s. d. £ s. d. Preston's- road Estate (Poplar)— Income 3,324 6 6 Working expenses and debt charges 3,983 17 4 Less—Charged to the following accounts— Less-— Credited to the following accounts — Part I. 905 15 - Part I. 685 15 5 Part III. 3,078 2 4 3,983 17 4 Part III. 2,638 11 1 3,324 6 6 - - - £ s. d Hughes-fields Dwellings (Deptford)- £ s. d. Hughes-fields Dwellings (Deptford)— 1,607 15 7 Working expenses and debt charges 1,802 11 6 Income Less—Charged to the following accounts- Housing of the Working Classes Act, 1890—Part III. 1,201 14 4 Less—Credited to the following accounts— Housing of the Working Classes Act, 1890—Part III 1,071 17 1 Dwellings under Improvement Acts 535 18 6 1,607 15 7 600 17 2 1,802 11 6 - - - xlvii. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. xlviii. d. details of revenue account. Dwellings. 1 Income. Expenditure. Result of Year's Working, 1913-14. Surplus ( + ). Deficiency (-) 20 Deductions. Net Rental. 7 Supervision and Collection of Rent. 8 Maintenance and Management. Debt Charges. Gross Rental. 2 Empties. 3 Caretakers' Quarters. 4 Amounts irrecoverable. 5 Total. 6 Rates and Taxes. (i) 9 Lighting, Heating, Water and Insurance. 10 Stores and Incidentals 11 Transfer to Repairs and Renewals Fund. 12 Total. 13 (f) Interest (gross). Sinking Fund. Total. 18 Total. (Columns 13 and 18.) 19 Land. 14 Buildings. 15 Land. Buildings. 17 1.—Housing of the Working Classes Act, 1890 (pages xxlx. to xxxii.). Part i. £ s. d. £ s. d. £ s. d. £ s. d £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Boundary-street (Including laundry) 23,463 2 11 156 11 5 142 16 - 4 19 10 304 7 3 23,158 15 8 1,710 13 8 4.057 19 10 Do. Automatic Gas Supply 3,345 5 - - - - 13 - - 13 - 3,344 12 - 170 - - - 1,362 2 2 15 - 9 2,140 - - 9,285 16 5 1,899 9 6 7,919 13 5 405 4 7 1,804 9 - 12,028 16 6 21,314 12 11 + 1,844 2 9 Cable-street 2,963 1 - 22 1 - 25 - - 1 11 3 48 12 3 2,914 8 9 137 9 6 594 18 6 2,223 1 6 - 3 6 150 - - 2,543 5 - - 222 9 - - 52 16 1 275 5 1 2,818 10 1 + 526 1 11 Shelton-street 1,574 11 6 2 15 - 24 15 6 _ 17 - 28 7 6 1,546 4 - 70 - 7 270 9 5 104 5 - 6 6 321 - - 1,157 19 11 112 14 — 1,158 16 7 25 14 9 266 2 6 1,563 7 10 2,721 7 9 + 193 1 - Hill bank (proportion) 6,582 9 1 36 4 3 30 5 7 - 17 10 67 7 8 6,515 1 5 323 11 3 1,099 17 6 56 13 9 1 - - 147 - - 545 3 9 153 - - 578 15 5 36 11 4 141 3 6 909 10 3 1,454 14 - + 91 10 - 208 1 10 - 607 9 4 2,238 19 11 335 3 6 2,229 16 4 62 15 5 450 3 4 3,077 18 7 5,316 18 6 + 1,198 2 11 Churchway 3,905 9 — 20 1 - 27 7 6 - 5 - 47 13 6 3,857 15 6 203 17 1 696 15 6 Hardy 878 17 _ 12 17 6 16 19 - 7 7 - 37 3 6 841 13 6 36 - 2 6 121 3 - 351 - - 1,372 13 10 277 17 6 1,248 17 5 53 3 4 246 8 4 1,826 6 7 3,199 — 5 + 658 15 1 Duke's-court (proportion) 1,818 9 4 2 - 1 16 12 3 1 14 4 20 8 2 8 89 7 13 6 27 11 - 128 - - 348 13 5 32 10 398 4 9 6 4 4 76 13 8 513 12 9 862 6 2 — 20 12 8 York-street (proportion) 1,143 4 11 1 11 2 16 12 3 - 2 7 18 6 - 1,124 18 11 55 4 7 174 1 3 55 4 8 - 191 5 - 635 10 2 136 10 - 613 9 7 26 2 5 122 18 10 899 - 10 1,534 11 - + 263 11 8 Preston's- road (proportion) (a) 821 13 4 120 2 9 10 4 5 5 10 9 135 17 11 685 15 5 46 - 6 199 5 9 35 16 11 - 102 15 - 367 17 9 101 5 - 424 - 2 19 13 1 83 5 6 628 3 9 996 1 6 + 128 17 5 St. Luke's— 28 3 3 - 2 2 113 13 4 387 4 6 47 12 4 389 15 4 72 3 8 905 — -219 19 7 Wenlake 1,929 12 6 12 9 - 24 15 - - 37 4 _ 1,892 8 6 99 18 7 333 - - Chadworth 3,398 13 5 319 14 3 22 3 6 13 10 - 355 7 9 3,043 5 8 151 15 8 469 4 6 62 15 5 - 179 - - 674 14 _ 175 - - 672 10 5 31 15 7 125 13 2 1,004 19 2 1,679 13 2 + 212 15 4 Clerkenwell and Holborn— 93 11 - 275 - - 989 1 1 260 - _ 1,342 - 11 50 16 11 229 1 4 1,881 19 2 2,871 - 3 + 172 5 5 Mallory 927 7 6 1 15 6 23 9 6 _ 1 - 25 6 - 902 1 6 38 - - 105 3 1 Nigel, etc. 6,141 4 2 158 12 6 54 15 - 20 - 9 233 8 3 5,907 15 11 287 7 1 935 13 2 23 6 1 - 64 - - 230 9 2 60 15 - 402 14 9 10 5 11 72 9 — 546 4 8 776 13 10 + 125 7 8 Webber-row 4,929 12 _ 82 - - 62 11 6 1 16 6 146 8 _ 4,783 4 - 284 10 5 869 11 3 183 11 - 481 - - 1,887 12 2 545 12 6 2,683 10 11 92 9 7 457 6 10 3,778 19 10 5,666 12 — + 241 3 11 143 13 8 - 431 - - 1,728 15 4 316 17 6 1,592 6 11 61 19 5 273 11 2 2,244 15 - 3,973 10 4 + 809 13 8 63,822 12 8 948 15 5 498 7 59 6 10 1,506 9 3 62,316 3 5 3,703 15 11 10,262 15 3 4,728 9 8 16 12 11 5,682 2 8 24,393 16 5 4,454 6 10 1 21,877 1 11 891 15 10 4,474 5 11 31,697 10 6 56,091 6 11 + 6,224 16 6 Dwellings on sites compulsorily appropriated for rehousing, on the working of which a deficiency was anticipated owing to the character or situation of the site. Brook-street 1,016 15 6 9 6 6 19 11 - - 1 - 28 18 6 987 17 - 41 3 9 182 7 8 Goldsmith's- row 483 9 6 6 1 6 19 11 - - 10 6 26 3 - 457 6 6 19 - - 89 14 11 34 7 4 - 145 - - 402 18 9 55 10 - 470 3 2 12 4 5 103 13 641 10 11 1,044 9 - 56 12 5 Hughes-fields (cottages) 2,053 15 4 6 16 19 13 7 3 391 10 9 1,662 4 9 71 - - 360 18 10 17 16 2 - 55 - - 181 11 1 30 - - 213 14 11 1 52 10 7 7 484 18 -27 12 2 69 1 4 - 230 - - 731 - 2 111 12 - 1,072 4 11 26 8 258 - 5 - 5 -537 -- 8 3,554 - 6 376 12 6 56 1 - 13 18 9 446 12 3 3,107 8 3 131 3 9 633 1 5 121 4 10 430 - 1,315 10 - 197 2 - 1,756 3 - 45 14 4 414 4 2 2,413 3 6 3,728 13 6 — 621 5 3 Difference between totals of debt charges on cash and stock basis - - - - - - - 172 17 8 Dwellings in course of erection( Tabard street) - - - - - - - 1 19 8 - - - 172 17 8 487 8 11 2,476 6 2 77 19 9 406 18 4 2,478 17 - 2,305 19 4 + 2,305 19 4 Interest on cash balances - - - - - - - - - - - 1 19 8 - 34 - _ - - - 34 - - 32 - 4 - 32 - 4 67,376 13 2 l,325 7 11 554 8 - 73 5 7 1,953 1 65,423 11 3,834 19 8 11,066 8 - - - - - - - - - - - + 381 5 11 4,849 14 6 16 12 11 6,112 2 8 25,880 4 5 4,163 19 11 21,190 18 9 1,015 9 11 5,295 8 5 31,665 17 - 57,546 1 5 + 8,258 16 2 Part II. Cranley 289 8 - 9 4 6 - - 8 - 9 12 6 279 15 6 18 9 8 51 3 Borough-road 1,869 6 6 15 7 6 26 1 6 - 41 9 1,827 17 6 107 6 2 335 11 7 9 2 - - 10 - 28 - - 107 15 11 22 10 - 88 13 2 4 10 5 18 8 9 134 2 4 241 18 3 + 37 17 3 Cobham 1,131 15 - 13 — 6 - - 1 6 13 2 - 1,118 13 - 69 5 3 210 5 12 3 - 165 - - 667 10 162 10 - 725 7 6 32 3 11 150 5 3 1,070 6 8 1,737 16 8 + 90 - 10 Ann-street 2,136 8 - 50 5 - 19 11 - 7 6 - 77 2 - 2,059 6 - 132 2 7 485 18 7 34 5 5 - 104 - - 418 7 1 68 5 - 422 14 7 12 19 2 80 18 - 584 16 9 1,003 3 10 + 115 9 2 Sylva 469 5 6 5 5 - - - 15 - 6 - - 463 5 6 20 - - 98 5 7 62 2 3 - 247 - - 927 3 5 73 9 - 756 13 4 14 1 1 152 10 11 996 14 4 1,923 17 9 + 135 8 3 Difference between totals of debt charges on cash and stock basis - - - - - - 5 6 - 12 18 2 - 49 - - 180 3 9 33 15 - 162 18 10 6 11 32 2 3 235 7 1 415 10 10 + 47 14 8 Interest on cash balances - - - - - - - - - - 5 6 13 - 7 77 16 6 2 5 7 14 3 2 107 5 10 101 19 10 + 101 19 10 - - - - - - - - - - - - - + 27 18 11 5,896 3 - 93 2 6 45 12 6 8 10 6 147 5 6 5,748 17 6 347 3 8 1,187 12 5 178 - 1 - 10 - 593 - - 2,306 6 2 347 8 5 2,078 10 11 68 - 420 2 - 2,914 1 4 5,220 7 6 + 556 8 11 Part III. Dwellings. Parker-street House (b)3,274 8 11 8 3 6 - 8 3 6 3,266 5 5 896 6 - 353 16 9 Harrington House (c) 7,689 11 7 (f)2,927 10 6 91 - - - 3,018 10 6 4,671 1 1 1,582 6 9 595 16 4 14 11 70 4 5 397 - - 2,150 2 1 110 9 10 704 12 4 24 19 1 165 16 11 1,005 18 2 3,150 - 3 + 110 5 2 Dufferin- street 630 18 6 7 15 - 22 16 - - 12 - 31 3 - 599 15 6 60 7 8 122 18 1 13 8 103 18 4 - - 3 742 15 74 5 - 1,811 15 10 14 8 3 352 16 6 2,253 5 7 5,996 - 8 — 1,324 19 7 Rushworth (late Green)-street and Boyfleld-street 1,789 6 - 49 9 6 22 3 - - 18 - 72 10 6 1,716 15 6 94 6 331 3 2 24 11 3 - 136 - - 343 17 55 19 8 138 18 2 12 12 10 31 7 6 238 18 2 582 15 2 + 17 - 4 18 6 - 188 - - 668 2 2 115 16 - 623 10 10 30 - 8 137 18 3 907 5 9 1,575 7 11 +141 7 7 Millbank (proportion) 985 13 2 5 8 5 4 10 8 - 2 8 10 1 9 975 11 5 48 9 - 163 11 4 10 Holmwood 384 11 - 21 11 - 18 5 - - 13 - 40 9 - 344 2 - 18 8 1 77 18 6 31 3 2 - 90 19 3 334 2 9 67 17 9 335 11 4 12 14 3 67 19 6 484 818 5 7 + 157 5 10 Totterdown- fields 29,427 5 11 222 4 9 73 9 6 13 17 3 309 11 6 29,117 14 5 1,332 6 7 5,145 9 - 12 15 7 - 61 - - 170 2 2 12 18 9 144 15 11 2 15 1 29 19 1 190 8 10 360 11 - -16 9 - Preston's- road (proportion) (d)3,161 8 8 462 4 9 39 6 7 21 6 3 522 17 7 2,638 11 1 177 1 9 787 16 2 803 6 - - 12 4 3,448 - - 10,729 13 11 2,575 18 5 10,995 19 7 475 5 8 2,034 7 — 16,08 10 8 26,811 4 7 + 2,306 9 10 Hughes-fields (dwellings) (proportion) 1,278 3 7 179 4 8 11 6 - 15 15 10 206 6 6 1,071 17 1 58 2 11 236 5 7 108 7 4 - 8 2 437 6 8 1,511 - 1 183 3 11 1,137 10 9 34 9 6 211 18 1 1,56 2 3 3,078 2 4 - 439 11 3 White Hart-lane 20,695 9 2 (g) 68 19 6 76 5 - 10 3 9 155 8 3 20,540 - 11 1,091 18 3 4,949 13 7 42 13 2 - 13 4 156 13 4 494 8 4 28 17 1 569 1 4 5 7 11 103 19 8 707 6 - 1,201 14 4 -129 17 3 525 - 8 1 18 4 2,421 - - 8,997 10 10 1,791 18 1 6,680 1 — 325 7 2 1,175 10 11 18,971 1 9 +1,568 19 2 Wessex 4,153 7 2 90 8 6 23 9 _ 1 10 - 115 7 6 4,037 19 8 224 - 1 745 1 - Norbury 11,117 1 6 57 4 - 52 3 - 2 2 6 111 9 6 11,005 12 - 523 4 1 1,778 17 - 132 11 6 - 1 - 394 - - 1,495 13 7 384 5 4 1,574 6 2 73 11 7 295 9 2 2,32 12 3 3,823 5 10 + 214 13 10 Caledonian 5,584 10 - 152 lb 6 29 19 6 - 7 9 182 8 3 5,402 1 9 301 18 7 1,040 8 5 3 1 - 10 4 - - 4,036 1 4 1,053 2 4,370 8 4 18' 13 6 766 9 8 6,378 8 8 10,415 - 2 + 590 11 10 Briscoe 2,537 8 - 65 3 9 27 7 6 - 14 6 93 5 9 2,444 2 3 141 7 9 471 8 2 181 2 5 1 1 - 525 - - 2,049 10 5 491 6 - 1,865 5 2 98 15 2 338 - 9 2,793 7 1 4,842 17 6 + 559 4 3 Old Oak 4,884 6 10 (g) 31 17 8 54 6 6 - 7 6 86 11 8 4,797 15 2 281 18 3 771 13 8 84 3 8 - 253 - - 949 19 7 241 9 2 1,023 12 1 45 3 181 7 2 1,49 11 5 2,441 11 - +2 11 3 Difference between totals of debt 19 7 10 6 9 537 - - 1,716 18 3 410 17 2 1,652 2 10 75 - - 298 4 b 2,43 4 4,153 2 8 + 644 12 6 charges on cash and stock basis - - - - - - - 56 9 Interest on cash balances - - - - - - - - 56 3 9 177 3 785 12 9 12 247 5 1 65 6 4 603 2 7 + 603 2 7 - - - - +355 8 3 97,593 10 - 4,350 2 - 546 7 3 67 15 6 4,964 4 9 92,629 5 3 6 831 16 3 17,628 - 6 - - - - - - - Total for dwellings 170,866 6 2 5,768 12 5 1,146 7 9 149 11 7 7,064 11 9 163,801 14 5 11,013 19 7 29,882 7 7 3,816 4 6 189 14 - 10,980 19 3 39,446 14 6 7,422 5 1 32,841 18 11 1,474 16 3 6,438 3 5 48,177 3 8 87,623 18 2 + 5,360 15 4 8,843 19 1 206 16 11 17,686 1 11 67,633 5 1 11 933 13 5 56,111 8 7 2,558 6 2 12,153 13 10 82,75 2 - 150,390 7 1 + 14,176 - 5 Part iii. Estates in course of development. 68,045 2 - 14,712 14,712 - - White Hart-lane 470 1 11 - - - - 470 1 11 - 107 7 9 Norbury - - - - - - - 16 17 9 - 77 1 - - 30 6 9 2,638 0 - - 44 8 5 - 3,070 17 5 3,040 10 8 -2,579 8 9 Old Oak 37 13 8 - - - - 37 13 8 - 6 15 3 - 2 1 - - 14 16 9 304 18 11 - 42 14 9 - 347 13 8 332 16 11 — 332 16 11 Supervision, etc. - - - - - - 500 - - - - 3 15 8 - 2 19 7 993 13 6 - 4: 17 9 - 1,03 11 3 1,034 11 8 996 18 - Interest on cash balances - - - - - - - - - - - 500 - - - - - 500 - - 500 - - Sundry estates (Acquisition of Lands Fund) (e) 1,860 6 3 - - - - (e) 1,860 6 3 - - - - - - - - - 44 1 10 - - + 1,860 6 3 Difference between totals of debt charges on cash and stock basis - - - - - - - - — - - - 18 1 10 2,368 1 10 - - 2,368 1 10 500 - 112 18 11 - - - 18 1 10 310 4 - 131 7 2 178 16 2 160 14 4 +160 14 4 - 82 17 8 460 18 9 3,626 18 1 - 659 8 1 - 4,286 6 4,756 4 11 — 2,432 4 11 Total—Housing of the Working Classes 173,234 8 - 5,768 V? 5 1,146 7 9 149 11 7 7,064 11 9 166,169 16 3 11,513 19 7 29,769 8 8 Act, 1890 Add-Interest on cash balances 720 11 3 (h) 8,841 19 1 289 14 7 17,686 1 11 68,103 3 10 15,560 11 6 56,11 8 7 3,217 14 3 12,153 13 10 (k)87,043 8 2 155,146 12 - + 11,743 15 6 166,890 7 6 (*) 71,672 - 1 (k) 15,871 8 1 (a) Including £1 7s. 3d. receipts for baths. (6) Including £25 14s. 5d. miscellaneous receipts for baths, storage of parcels, etc. debt charges on expenditure met out of Acquisition of Lands Fund as on page xxxii. (/) Excluding £4 2p., rebate on weekly tickets, (i) After deducting tax on interest on debt recovered, see Dote (j). (j) Tax on interest recovered is deducted from rates and taxes (col. 9) Revenue Account (as page xxxii.) in respect of expenditure met out of Acquisition of Lands Fund—Interest £1,577 16s. 5d . Sinking Fund £282 9s. 10d. (e) Including £34 10s. 1d., as in note (6). (d) Including £5 4s. 9d. as in note (a). (e) Transfer from revenue account in respect of (g) Including new cottages handed over on completion. (h) Local wages of caretakers, etc., £4,636 4s. 6d. central office, 15s. 1d. see note (i). (k) Comprising : (1) Transfers to Consolidated Loans Fund—Interest, £70,094 3s. 8d., Sinking Fund £15,088 18s. 3d., (2) Transfers to Dwellings 23610 PP xlix. Annual Report of the London County Council, 1913. Housing of the Working Classes—Accounts. D.-DETAILS OF REVENUE ACCOUNT-continued. Dwellings. Gross Rental. Income. Maintenance and Management. Expenditure. Result of Year's Working, 1913-14. Surplus (+ ), Deficiency ( - ). Deductions. Net Rental. Debt Charges. Total. (Columns 13 and 18.) Empties. Caretakers Quarters. Amounts irrecoverable. : Total. supervision and Collection of Rent. Rates and Taxes (d) Lighting, Heating, Water and Insurance. Stores and Incidentals Transfer to Repairs and Renewals Fund. Total. (e) Interest (gross). Sinking Fund. Total. Land Buildings. Land. Buildings. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 II.- Improvement Acts, (pages xxxix. and xi.). £ s. d. £ s. d. £ B. d £ s. d. £ s.. d. £ s. d £ s. d. £. s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s d £ s d. £ s d. £ s. d. £ s. d. £ s. d. £ s. d. Battersea bridge 1,138 1 6 79 15 6 21 11 6 1 19 6 103 6 6 1,034 15 — 44 — — 151 4 6 40 7 3 - 129 - - 364 11 9 43 17 6 508 - 8 8 7 11 98 1 8 658 7 9 1,022 19 6 + 11 15 6 Cotton-street 1,184 18 6 61 10 6 20 17 _ 1 14 — 84 1 6 1,100 17 — 69 12 6 271 14 6 35 1 8 - 143 - - 519 8 8 40 5 - 412 8 3 8 4 - 81 3 - 542 - 3 1,061 8 11 + 39 8 1 Durham 1,598 17 6 337 7 3 17 13 _ 6 7 6 361 7 9 1,237 9 9 67 16 1 184 5 9 44 6 9 - 196 - - 503 8 7 80 6 6 843 16 - 15 11 10 159 10 11 1,099 5 3 1,602 13 10 — 365 4 1 Duke's-court (proportion) 606 3 2 — 13 5 5 10 9 — 11 5 6 15 7 599 7 7 29 15 8 99 17 10 18 8 2 - 63 15 - 211 16 8 45 10 - 204 9 10 8 14 1 40 19 7 299 13 6 511 10 2 + 87 17 5 York-street (proportion) 381 1 7 — 10 4 5 10 9 — — 11 6 2 — 374 19 7 18 8 2 58 - 6 11 19 - - 34 6 - 122 12 8 33 15 - 141 6 10 6 17 - 27 15 3 209 8 1 332 - 9 + 42 18 10 Herbrand-street 2,775 6 _ 5 4 3 22 3 — — 18 3 28 5 6 2,747 — 6 145 1 9 472 10 2 87 8 2 - 268 - - 973 - 1 236 5 - 906 3 7 45 2 2 172 16 11 1,361 2 8 2,334 2 9 + 412 17 9 Bruce Bouse (a) 7,672 — 1 (b) 14 16 1 104 _ _ — 118 16 1 7,553 4 — 2,207 — 1 743 19 2 1,021 9 6 100 6 2 587 - - 4,659 15 2 331 2 6 1,657 19 3 56 17 5 303 7 2 2,348 11 4 7,008 6 6 + 544 17 6 Millbank (proportion) 11,416 8 9 62 16 1 52 10 3 1 11 — 116 17 4 11,299 11 5 561 3 6 1,907 11 10 360 18 2 - 1,053 11 5 3.883 4 11 581 6 4 3,867 6 9 108 17 5 780 15 - 5,338 5 6 9,221 10 5 + 2,078 1 - Bourne 13,473 13 9 141 2 6 114 11 — 2 6 6 253 7 — 13,220 6 9 696 17 10 2,069 13 11 424 11 - - 1,063 - - 4,253 2 9 1,430 - - 4,942 11 3 271 17 8 942 10 - 7,586 18 11 11,840 1 8 + 1,380 5 1 Swan-lane 4,119 6 — 540 14 6 19 11 — 16 12 6 576 18 _ 3,542 8 — 199 — 4 858 11 5 138 3 9 1 - - 473 - - 1,669 15 6 177 4 6 1,871 15 4 28 16 9 359 11 8 2,437 8 3 4,107 3 9 — 564 15 9 Valette 1,676 17 — 15 8 6 23 9 6 2 10 — 41 8 — 1,635 9 — 82 6 — 290 14 5 53 15 11 - 151 - - 577 16 4 112 10 - 615 12 3 19 1 4 115 10 1 862 13 8 1,440 10 - + 194 19 - Hughes-fields (dwellings) (proportion) 639 1 9 89 12 4 5 13 — 7 17 11 103 3 3 535 18 6 29 1 5 118 2 10 21 6 7 - 6 8 78 6 8 247 4 2 14 8 6 248 10 9 2 14 - 51 19 9 353 13 - 600 17 2 - 64 18 8 Bearcroft 879 4 6 31 15 9 23 9 6 — 9 6 55 14 9 823 9 9 35 — — 156 - 7 27 - 3 - 80 - - 198 - 10 26 5 - 356 1 8 4 9 - 64 13 7 451 9 3 749 10 1 + 73 19 8 47,561 — 1 1,381 7 - 436 10 3 38 6 — 1,856 3 3 45,704 16 10 4,185 3 4 7,382 7 8 2,295 16 2 101 12 10 4,318 18 1 18,283 18 1 3,152 15 10 16,612 2 5 585 4 7 3,198 14 7 23,548 17 5 41,832 15 6 + 3,872 1 4 Dwellings on sites compulsorily appropriated for rehousing on the working of which a deficiency was anticipated owing to the character or situation of the site. council 799 7 6 35 13 9 — 1 11 — 37 4 9 762 2 9 51 3 3 169 16 - 28 6 10 - 101 - - 350 6 1 18 12 7 492 4 9 4 4 7 115 18 10 631 - 9 981 6 10 — 219 4 1 Westview, etc. 1,311 8 — 28 13 _ — 1 19 — 30 12 — 1,280 16 - 56 4 8 218 15 9 45 12 2 - 179 - - 499 12 7 34 9 1 968 17 2 7 4 2 230 - 7 1,240 11 - 1,740 3 7 — 459 7 7 Idenden 1,135 14 — 5 6 6 22 3 _ — 27 9 6 1,108 4 6 47 - - 208 19 10 35 3 10 - 125 - - 416 3 8 45 - - 513 17 - 11 13 5 129 7 4 699 17 9 1,116 1 5 — 7 16 11 Barnaby 1,431 6 — 35 18 - 20 17 — 1 6 4 58 1 4 1,373 4 8 73 18 11 329 7 7 44 15 11 - 143 - - 591 7 5 97 - 7 573 9 4 18 4 2 104 17 4 793 11 5 1,384 18 10 - 11 14 2 Brightlingsea 1,086 17 — 47 11 — 19 11 — 2 8 9 69 10 9 1,017 6 3 47 - - 194 13 10 37 10 10 - 5 - 125 - - 404 4 8 33 15 - 474 17 5 6 7 1 86 15 1 601 14 7 1,005 19 3 + 11 7 - Bekesbourue 1,244 2 6 2 14 - 22 3 — — 5 — 24 1?, — 1,219 10 6 65 12 - 220 10 7 41 12 2 - 134 - - 461 11 9 36 8 - 636 6 8 7 2 4 87 17 11 767 14 11 1,229 6 8 — 9 16 2 Darcy 743 — 6 16 5 _ ?,?, 3 — — — 704 12 6 30 - - 132 3 6 25 6 6 - 71 - - 258 10 - 42 3 9 335 11 4 7 18 11 61 15 1 447 9 1 705 19 1 — 1 6 7 Wandsworth-road 921 12 — 3 6 - 22 3 — — 25 9 — 896 3 - 38 - - 169 14 5 27 17 11 — 89 - - 324 12 4 54 12 - 386 2 3 9 11 2 72 7 2 522 12 7 847 4 11 + 48 18 1 8,673 7 .6 175 7 3 1 9 — — 7 — 1 311 7 4 8,362 - 2 408 18 10 1,643 18 6 286 6 2 5 967 - - 3,306 8 6 362 1 - 4,381 5 11 72 5 10 888 19 4 5,704 12 1 9,011 - 7 — 649 5 Difference between totals of debt charges on cash and stock basis _- - - - + 662 16 - Interest on cash balances — — — — — - - 69 13 - - — — 69 13 - 171 5 - 1,022 15 8 63 18 3 397 13 5 732 9 - 662 16 - + 247 12 1 56,234 7 7 1,556 14 3 565 10 3 45 6 1 2,167 10 7 54,066 17 — - - — — - Add-Interest on cash balaces. 247 12 1 4,594 2 2 9,095 19 2 2,582 2 4 101 17 10 5,285 18 1 21,659 19 7 3,343 11 10 19,970 12 8 712 8 8 4,485 7 4 28,521 - 6 50,181 - 1 + 4,133 9 - 54,314 9 1 23,314 4 6 5,206 16 - (a) Including £72 7s. 2d., miscellaneous receipts for baths, storage of parcels, etc. (b)Excluding £585 7s., rebate on weekly tickets, (e) Tax on interest on debt recovered is deducted from rates and taxes (col 9). See note (d). (e)Local wages of caretakers, etc., £2,475 11s. 9d.; central office £2,118 10s. 5d. (d) After deducting tax on interest on debt recovered (see note e). ii. lii. Annual Report of the London County Council. 1913. Housing of the Working Classes Accounts. E..STATEMENT SHOWING PERCENTAGES ON GROSS RENTAL OF THE SEVERAL ITEMS OF INCOME AND EXPENDITURE IN RESPECT DWELLINGS IN THE DETAILED REVENUE ACCOUNT (PAGES xlvii. TO I.). Dwellings Income. Expenditure. Result of Year's Working ing interest on cash balances). Gross Rental. Deductions. Net Rental. Maintenance and Management. Debt. Charges. Total (cols. 13 and 18) (d) Interest (gross.) Sinking fund. Total. Empties. Caretaker's Quarters. Amounts irrecoverable. Total. Supervision and Collection of Rent. Rates and Taxes, (c) Lighting, Heating, Water and Insurance. Stores nd Incidentals. to Repairs and Renewals Fund. Total. Land. Buildings. Land. Buildings. Surplus. Deficiency. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 1..Housing of the Working Classes Act. 1890 Part I. £ % % % % % % % % % % % % % % % % % % % Boundary.street (including laundry) 23,463 .67 .61 .02 1.30 98.70 7.29 17.29 5.81 .06 9.12 39.57 8.10 33.75 1.73 7.69 51.27 90.84 7.86 — Do. (automatic gas supply) 3,345 — — .02 .02 99.98 5.08 — 66.45 .01 4.48 76.02 - 6.65 - 1.58 8.23 84.25 15.73 — Cable.street 2,963 .75 .84 .05 1.64 98.36 4.64 20.08 3.52 .01 10.83 39.08 3.80 39.11 .87 8.98 52.76 91.84 6.52 — Shelton.street 1,575 .18 1.57 .05 1.80 98.20 4.45 17.18 3.60 .06 9.34 34.63 9.72 36.76 2.32 8.96 57.76 92.39 5.81 — Millbank 6,582 .55 .46 .01 1.02 98.98 4.92 16.71 3.16 — 9.23 34.02 5.09 33.88 .95 6.84 46.76 80.78 18.20 — Churchway 3.906 .51 .70 .01 1.22 98.78 5.22 17.84 3.10 — 8.99 35.15 7.11 31.98 1.36 6.31 58.45 81.91 16.87 — Hardy 879 1.46 1.93 .84 4.23 95.77 4.10 17.88 3.13 — 14.56 39.67 3.70 45.:31 .71 8.73 49.44 98.12 - 2.35 Duke s.court 1,819 .11 .92 .09 1.12 98.88 4.91 16.48 3.04 — 10.52 34.95 7.50 33.74 1.44 6.76 54.95 84.39 14.49 — York.street 1,143 .14 1.45 .01 1.60 98.40 4.83 15.22 3.14 — 8.99 32.18 8.86 37 09 1.72 7.28 63.11 87.13 11.27- — Preston's.road 822 14.62 1.24 .68 16.54 83.46 5.60 24.25 3.43 .01 13.83 47.12 5.80 47.44 1.09 8.78 52.08 110.23 - 26.77 St. Luke's— Wenlake .65 1.28 1.93 98.07 5.18 17.26 3.25 — 9.28 34.97 9.07 34.85 1.65 6.51 55.37 87.05 11.02 — Chadworth 3,399 9.41 .65 .40 10.46 89.54 4.47 13.80 2.74 — 8.09 29.10 7.65 39.49 1.49 6.74 58 90 84.47 5.07 — Clerkenwell and Holborn— Mallory 927 .19 2.53 .01 2.73 97.27 4.10 11.34 2.51 — 6.90 24.85 6.55 43.43 1.11 7.81 61.53 83.75 13.52 — Nigel, etc 6,141 2.58 .89 .33 3.80 96.20 4.68 15.24 2.99 — 7.83 30.74 8.88 43.70 1.50 7.45 45.54 92.27 3.93 — Webber.row 4,930 1.66 1.27 .04 2.97 97 03 5.77 17.64 2.92 — 8.74 35.07 6.43 32.30 1.26 5.55 63.10 80.61 16.42 — Brook.street 1,017 .92 1.92 — 2.84 97.16 4.05 17.94 3.38 — 14.26 39.63 5.46 46.24 1.20 10.20 62.75 102.73 - 5.57 Goldsmith's.row 484 1.26 4.04 .11 5.41 94.59 3.93 18.57 3.68 — 11.37 37.55 6.20 44.21 1.47 10.87 71.49 100.30 - 5.71 Hughes.fields Cottages 2,054 17.59 .82 .65 19.06 80.94 3.46 17.57 3.36 — 11.20 35.59 5.43 52.21 1.29 12.56 3.68 107.08 - 26.11 Difference between totals of debt charges on cash and stock basis — — — — — — — .26 — — — .26 .72 368 .12 .60 3 68 3.42 3.42 - Part II. Cranley 3.19 .14 3.33 96.67 6.39 17.87 3.14 .17 9.68 37.25 7.77 30.64 1.56 6.37 46.34 83.59 13.08 — Borough.road 1,869 .82 1.40 — 2.22 97.78 5.74 17.95 3.19 — 8.83 35.71 8.70 38.80 1.72 804 57.26 92.97 4.81 — Cobham 1,132 1.15 — .01 116 98.84 6.12 18.63 3.02 — 9.19 36.96 6.03 37.35 1.15 7.15 51.68 88.64 10.20 — Ann.street 2,136 2.35 .92 .34 3.61 96.39 6.18 22.74 2.91 — 11.56 43.39 3.44 35.42 .66 7.14 46.66 90.05 6.34 — Sylva 469 1.12 — .16 1.28 98.72 4.26 20.95 2.75 — 10.44 38.40 7.19 34.72 1.40 6.84 50.15 88.55 10.17 — Difference between totals of debt charges on cash and stock basis — — — — .09 . — — .09 .22 132 .04 .24 1.82 1.73 1.73 — Part iii. Parker.street House 3,274 .25 .25 99.75 27.37 10.81 13.22 2.14 12.12 65.66 3.37 21.52 .76 5.07 30.72 96.38 3.37 17.23 Carrington House 7,690 38.07 118 — 39.25 60.75 20.58 7.75 10.45 1.35 8.55 48.68 .96 23.56 .19 4.59 29.30 77.98 2.70 — Dufferin.street 631 1.23 3.61 .10 4.94 95.06 9.57 19.48 3.89 — 21.55 54.49 8.87 22.02 2.01 4.97 37.87 92.36 7.90 — Rushworth (late Green) street and Boyfield.street 1,789 2.76 1.14 .05 4.05 95.95 5.25 18.51 3.07 — 10.51 37.34 6.47 34.85 1.68 7.71 50.71 88.05 15.96 — Millbank 986 .55 .46 .01 102 98.98 4.92 16.59 3.16 — 9.23 33.90 6.89 34.04 1.29 6.90 49.12 83.02 - 4.23 Holmwood 385 5.60 4.75 .17 10.52 89.48 4.79 20.27 3.32 — 15.86 44.24 3.36 37.65 .72 7.79 49.52 93.76 7.84 - Totterdown.fields 29,427 .75 .05 1.05 98.95 4.53 17.48 2.73 — 11.72 36.46 8.75 37.37 1.62 6.91 54.65 91.11 - 13.90 Preston's.road 3,161 14.62 1.24 .68 16.54 83.46 5.60 24.92 3.43 .01 13.83 47.79 5.80 35.98 1 09 6.70 49.57 97.36 - 10.16 Hughes.fields Dwellings 1,278 14.02 .8S 1.24 16.14 83.86 4.55 18.48 3.34 .05 12.26 38.68 2.26 44.52 .42 8.14 55.34 94.02 7.58 — White Hart.lane 20,695 (a) .33 .37 .05 .75 99.25 5.28 23.92 2.54 .01 11.73 43.48 8.66 32.28 1.57 5.68 48.19 91.67 5.17 — Wessex 4,153 2.18 .56 .04 2.78 97.22 5.39 17.94 3.9 — 9.49 36.01 9.25 37.91 1.77 7.11 56.04 92.05 5.17 — Norbury 11,117 .51 .47 .02 100 99.00 4.71 16.00 4.6 .01 11.43 36.31 9.48 39.31 1.69 6.89 57.37 93.68 5.32 — Caledouian 5,585 2.74 .54 .01 3.27 96.73 5.41 18.63 3.24 .02 9.40 36.70 8.80 33.40 1.77 6.05 50.02 86.72 10.01 — Briscoe 2,537 2.57 1.08 .03 3.68 96.32 5.57 18.58 3.32 — 9.97 37.44 9.51 40.34 1.78 7.15 58.78 96.22 .10 — Old Oak 4,884 (a) .65 1.11 .01 1.77 98.23 5.77 15.80 2.38 .21 10.99 35.15 8.41 33.83 1.54 6.10 49.88 85.03 13.20 — Difference between totals of debt charges on cash and stock basis — — — — — — — .06 — .06 .18 .81 .06 .25 .68 .62 .62 — Total for Housing of the Working Classes Act, 1890 .. 170,866 3.38 .67 .09 4.14 95.86 6.44 17.49 5.18 .12 10.35 39.58 6.98 32.84 1.50 7.11 48.43 88.01 7.85 — II.-Imporvement Acts. Battersea.bridge 1,138 7.01 1.90 .17 9.08 90.92 3.87 13.29 3.55 — 11.33 32.04 3.85 44.64 .74 8.02 57.85 89.58 100.24 3.33 22.84 Cotton.street 1,185 5.19 1.76 .14 7.09 92.91 5.88 22.93 2.96 — 12.07 43.84 3.40 34.80 .69 6.85 45.74 84.39 14.49 — Durham 1,599 21.10 1.10 .40 22.60 77.40 4.24 11.53 3.46 — 12.26 31.49 5.02 52.77 .98 9.98 68.75 11.27 _ Dukes.court 606 .11 .92 .09 112 98.88 4.91 16.48 3.04 — 10.52 34.95 7.50 33.74 1.44 6.76 49.44 York.street 381 .14 1.45 .01 1.60 98.40 4.83 15.22 3.14 — 8.99 32.18 8.86 37.09 1.72 7.23 54.95 84.10 14.88 — Herbrand.street 2,775 .19 .80 .03 102 98.98 5.23 17.02 3.15 — 9.66 35 06 8.51 32.65 1.65 6.23 49.04 91.35 7.10 18.20 Bruce House 7,672 (b) .19 1.36 — 1.55 9S.45 28.77 9.70 13.31 1.31 7.65 60.74 4.32 21.61 .73 3.95 30.61 80.78 10.24 ■— Millbank 11,417 .55 .46 .01 1.02 98.98 4.92 16.71 3.16 — 9.23 34.02 509 33.83 .95 6.84 46.76 87.88 13.71 Bourne 13,474 1.05 .85 .02 1.88 98.12 517 15.36 3.15 — 7.89 31.57 10.61 36.68 2.02 7.00 56.31 99.71 Swan.lane 4,119 13.13 .47 .40 14.00 86.00 4.83 20.84 3.36 .03 11.48 40.54 4.30 45.44 .70 8.73 59.17 85.91 11.62 — Valette 1,677 .92 1.40 .15 2.47 97.53 4.91 17.34 3.21 — 9.00 34.46 6.71 36.71 44.52 1.14 6.89 51.45 94.02 8.41 1016 Hughes.fields Dwellings 639 14.02 .88 1.24 16.14 83.86 4.55 18.48 3.34 .05 12.26 38.68 2.26 40.50 .42 8.14 55.34 85.25 Bearcroft 879 3.62 2.67 .05 6.34 93.66 3.98 17.75 3.07 — 9.10 33.90 2.99 61.58 .51 7.35 78.94 122.76 — 27.42 Council 799 4.47 _ .19 4.66 95.34 6.40 21.24 3.55 —— 12.63 43.82 2.33 73.88 .53 14.50 94.60 132.70 98.27 . 35*03 .69 Westview, Armitage and Collerston 1,312 2.18 — .15 2.33 97.67 4.29 16.68 3.48 — 13.65 38.10 2.63 45.25 .55 17.54 61.63 96.76 .82 Idenden 1,136 .47 1.95 — 2.42 97.58 414 18.40 3.10 — 11.00 36.64 3.96 40 07 1.03 11.39 55.44 Barnaby 1,431 2.51 1.46 .09 4.06 95.94 5.17 23.01 3.13 .02 9.99 41.32 6.78 43.69 1.27 7.32 55.37 92.56 1.04 — Brightlingsea 1,087 4.38 1.80 .22 6.40 93.60 4.32 17.91 3.46 — 11.50 37.19 3.11 51.15 .56 7.98 61.71 98.81 — .79 .18 Bekesbourne 1,244 .22 1.78 .02 1.98 98.02 5.27 17.71 3.35 — 10.77 37.10 2.93 45.16 .57 7.06 60.22 95.01 5.31 — Darcy 743 2.19 2.98 *— 517 94.83 4.04 17.79 3.41 — 9.55 34.79 5.68 41.90 1.07 8.31 56.71 91.93 Wandsworth.road 922 .36 2.40 — 2.76 97.24 4.12 18.41 3.03 — 9.66 35.22 5.92 1.04 7.85 1.13 118 — Difference between totals of debt charges on cash and stock basis — . — — — — — .12 — — — .12 .30 182 .11 .71 1.30 — Total for Improvement Acts 56,235 2.77 1.00 .08 3.85 96.15 8.17 16.18 4.59 .18 9.40 38.52 5.95 35.51 1.28 7.93 50.72 89.24 6.91 — Total for dwellings 227,101 3.23 .75 .09 4.07 95.93 6.87 17.16 5.03 .14 10.12 39.32 6.73 33.50 1.44 7.33 49.00 88.32 7.61 (e — (a) See note (g) on page xlvil. (b) Excluding 7. 63 for rebate on weekly tickets (c) After deducting income tax on interest on (d) See N'ote (e) (e) Percenage on surplus £17,297 5s. 3d., which excludes interest on cash balances amounting to £1,012 5s. 2d. capital outlay (cola 14 and 16). liii. liv Annual Report of the London County Council, 1913. I Housing of the Working Classes—Accounts. F.-SUMMARY OF FINANCIAL RESULTS. Dwellings Borough Accommodation (persons (*) Persons in occupation 31st March 1914. Date of opening. Aggregate Capital Expenditure to 31st March, 1914. Aggregate Balance on Revenue Account, 1st April. 1913. Surplus ( + ) Deficiency (—). Result of Year's Working. Surplus (+) Deficiency (—) ' page xlviii. col. 20). Aggregate Balance on Revenue Account, 31st March, 1914 Surplus (+) Deficiency (—). Accumulations of Sinking Fund to 31st March, 1914, (including proceeds of Sales). Repairs and Renewals Fund. Unspent Accumulations on 1st April, 1913. 1913-14 Unspent Accumulations on 31st March, 1914. Transfers from Revenue Account (page xlviii., col. 12) Actual Expenditure. Difference, being further amount set aside. Land. Buildings. Total. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1.—Housing of the Working Classes Act, 1890. Part i. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. 1. £ s. d. Boundary-street Bethnal Green and 5,380 4,444 1895-1900 62,010 - - 275,526 6 _ 337,536 6 _ + 24,073 3 2 + 2,370 4 8 + 26,443 7 10 48,999 10 2 15,820 5 - 6,112 2 8 7,802 14 10 1,690 12 2 14,129 12 10 Cable-street Stepney 798 610 1896, 1901 3,660 _ _ 37,592 8 7 41,252 8 7 + 1,932 3 6 + 193 1 _ + 2,125 4 6 6,613 9 2 Shelton-street Holborn 284 231 1896 5,100 - - 19,292 7 5 24,392 7 5 + 363 3 7 + 91 10 - + 454 13 7 4.438 11 6 Millbank (Proportion) Westminster (City) l,536 1,035 1899-1902 11,906 12 - 70,390 13 1 82,297 5 + 14,292 16 1 + 1,198 2 11 + 15,490 19 _ 8,417 17 7 Churchway St. Pancras 832 614 1901-2 8,550 - - 39,126 14 - 47,676 14 - + 8,058 2 2 + 658 15 1 + 8,716 17 3 4.396 9 - Hardy Greenwich 306 234 1901 1,000 . 12,298 9 - 13,293 9 - 1,034 13 4 — 20 12 8 — 1,055 6 1,243 5 - Duke's court (proportion) Westminster (City) 458 347 1902 4,200 _ - 19,193 16 1 23,393 16 1 + 2,982 4 10 + 263 11 8 + 3,245 16 6 2,101 17 _ York-street (proportion) Westminster (City) 293 220 1903 3,000 - - 12,950 6 7 15,950 6 7 + 1,285 9 8 + 128 17 5 + 1.414 7 1 1,232 14 5 Preston s-road (proportion) Poplar 268 186 1904 1,433 14 1 11.412 17 5 12,846 11 6 — 2,706 8 1 — 219 19 7 — 2,926 7 8 894 3 7 St. Luke's— Wenlake Finsbury 496 353 1905 5,000 19,774 2 7 24,774 2 7 3 3 + 212 15 4 + 1 963 18 7 1,535 18 4 Chadworth Finsbury 720 572 1907 8,000 - - 36,004 14 2 44,004 14 2 + 897 3 6 + 172 5 5 + 1,069 8 11 2,169 7 3 Clerkenwell and Holborn— Mallory Finsbury 164 110 1906 1,620 - - 11,479 2 3 13,099 2 3 + 780 16 10 + 125 7 8 + 906 4 6 703 16 11 Nigel,etc. Holborn 1.260 895 1908 14,550 - _ 72,719 8 6 87,269 8 6 + 238 7 10 + 241 3 11 + 479 11 9 3,408 14 4 Webber-row Southwark 1,143 804 1906-7 9,750 - - 43,041 8 1 52,791 8 1 + 4,268 19 5 + 809 13 8 + 5,078 13 1 2,640 13 1 Dwellings on sites compulsorily appropriated for rehousing, on the working of which a deficiency was anticipated owing to the character or situation of the site. Brook-street Stepney 308 236 1894, 1900 1,800 - - 15,314 - 9 17,114 - 9 -2,030 3 11 - 56 12 8 - 2,086 16 7 2,951 2 2 Goldsmith's-row Shoreditch 144 106 1895 1,000 - _ 7,128 8 11 8.128 8 11 -569 14 9 — 27 12 2 — 597 6 4 1,009 14 10 Hughes fields cottages Greenwich 666 507 1895 3,720 - - 35.756 1 1 39,476 1 1 — 10,669 5 2 — 537 - 5 — 11,206 5 7 7,917 12 4 Difference between totals of debt charges on cash and stock basis — - - - - + 2,305 19 4 + 2,305 19 4 17,980 9 9 Part ii. Cranley Holborn 60 47 1897 750 - - 3,017 8 10 3,767 8 10 + 652 4 5 + 37 17 3 + 690 1 8 506 7 11 2,359 19 - 59 - - 741 15 6 148 15 6 2,211 3 6 Borough-road Southwark 400 292 1900 5,000 _ _ 24,014 4 1 29,014 4 1 + 1,029 10 9 + 90 - 10 7 Cobham Southwark 279 202 1900 2,100 _ - 13,007 1 5 15,107 1 5 + 1,029 10 9 + 115 9 2 + 1,534 10 2. 1,553 3 8 Ann-street Poplar 630 429 1901-2 2,260 _ - 23.812 4 8 26,072 4 8 - 733 5 7 + 135 8 3 — 597 17 4 2,324 2 2 Sylva Deptford 144 88 1903 1,000 - - 5,053 7 7 6,053 7 7 + 603 17 3 + 47 14 8 + 651 11 11 481 17 2 Difference between totals of debt charges on cash and stock basis — — — — - - - + 101 19 10 + 101 19 10 123 - 10 Part III. Dwellings. Parker-street House Holborn 345 345 1893 3,750 - - 23,159 9 - 29,909 9 - + 694 6 7 + 110 5 2 + 804 11 9 5,510 16 - Carrington House Deptford 814 505 1903 2,200 - _ 54,936 17 7 57,136 17 7 - 13,685 - 3 — 1,324 19 7 — 15,009 19 10 4,405 15 1 17,318 1 7 10,980 19 3 10,17 1 80 9 12 10 18,127 14 5 Dufferin -street Finsbury 174 137 1892 1,900 _ 4,714 10 11 6,614 10 11 - 82 12 6 + 17 - 4 - 65 12 2 1,481 - 3 Rusliworth (late Green) street and Boyfieldstreet Southwark 418 301 1897 3,860 - - 21,074 18 4 24,934 18 4 + 2,137 15 3 + 141 7 7 + 2,279 2 10 3,850 17 9 Millbank (proportion) Westminster (City) 230 155 1899-1902 2,411 14 5 10,540 5 3 12,951 19 8 +1,976 8 3 +157 5 1 + 2,133 14 1 1,331 - 2 Holmwood Southwark 72 45 1900 450 - - 4,777 13 6 5,227 13 6 -309 5 - — 16 9 - — 325 14 - 580 9 8 Totterdown-fields Wandsworth 4,807 1903—11 **77,606 — 9 317,616 _ 2 395,252 - 11 + 2,881 13 8 + 2 306 9 10 + 5,188 3 6 21,909 13 2 Preston's-road (proportion) Poplar 1,030 714 1904 5,516 5 1 33,552 19 10 39,069 5 9 - 6,690 7 11 — 439 11 3 — 7,129 19 2 2,765 2 7 Hughes-fields-dwellings (proportions) Deptford and 440 306 1904 855 6 8 16,374 12 9 17,229 9 5 — 2,068 14 4 — 129 17 3 — 2,198 11 7 1,128 1 6 White Hart-lane Tottenham, Wood Green and Edmonton (U.D.C.) 6,883 3,403 1904-14 **52,404 - - 195,010 18 - 247,414 8 - — 4,180 19 4 + 1,568 19 2 — 2,612 - 2 13,084 - 7 Wessex Islington 1,050 743 1904-5 11,818 13 ?. 46.060 9 11 57 879 3 1 - 953 6 5 + 214 13 10 — 738 12 7 4,072 9 1 Norbury Croydon 3,472 1,734 1906-12 **35,338 - - 127,09(i 11 2 162,434 11 2 - 469 9 1 + 590 11 10 + 121 2 9 6,290 16 10 Caledonian-road Islington 1,384 1,010 1906 15,763 12 7 53,192 8 68,955 3 3 + 976 - 6 + 559 4 3 + 1,635 4 9 4,115 - 9 Briseoe Lambeth 718 378 1906 7,154 7 2 27,971 17 1 35,126 4 3 - 1,544 18 1 11 3 - 1,542 6 10 1,955 - 7 Old Oak Hammersmith 2,124 1,188 1912-14 **19.957 - - 33.595 4 9 53,552 4 9 - 44 15 11 + 644 12 6 + 599 16 7 992 19 1 Difference between totals of debt charges on cash and stock basis - - - — — — — — + 603 2 7 + 603 2 7 2,831 18 - Total—Dwellings •• — 28,333 - 398,395 6 9 1,777,610 - - 2,176,005 6 9 + 25,521 12 5 + 13,443 7 8 + 38,965 - 1 167,796 15 6 35,493 5 7 17,686 1 11 18,71 5 1 1,089 1 10 34,468 10 9 Interest on cash balances - - — + 3,527 1 11 + 764 13 1 + 4,291 15 - — — — — - - Dwellings in course of erectionPart I. 398,395 6 9 1,777,610 - - 2,176,003 6 9 + 29,048 1 4 + 14,208 - 9 + 43,256 15 1 - - - - - 1,858 1 1 858 - 1 — 6,613 17 1 — 32 - 4 — 6,645 17 5 - - - - - Part III — - — 5,601 17 3 - — 5,601 17 3 — — — - - - Dividends (less expenses of investment) and interest (Repairs and Renewals Fund) - 1,958 - 1 1,858 - 1 — 12,215 14 4 — 32 - 4 —12,24' 14 8 — — — — - 398,395 6 9 1,779,468 - 1 2,177,863 6 10 + 16,833 - _ + 14,176 - 5 + 31,009 - 5 _ — — — — — — — — - 8,194 9 2 - —1,338 8 2 1,338 8 2 9,532 17 4 Part iii. Estates in course of development §100,511 9 9 — § 100,511 9 9 — 78,255 2 2 — 2,431 4 11 —80,68 7 1 121,62 - 5 — -- — - - 498,906 6 6 1,779,468 - 1 2,278,374 1 6 7 — 61,422 2 2 + 11,743 15 6 —49,67 9 8 189,423 15 11 43,692 14 9 17,636 1 11 17,377 8 7 308 13 4 44,001 8 1 Add—Net contributions from rates to 31st March, 1914 49,678 6 8 * The accommodation Is arrived at generally by calculating two persons to a room. The enumeration in March 1914 showed an average of £32,287: Norbury, £20,656; Old Oak, £10,174 †After deducting expenditure of £43,204 -s. 10d. met out of the' Acquisition of Lands' Fund 1.28 persons per room. **These figures include the following charges for roads and sewers—Totterdown, £32,973 1s. 8d; White Hart Lane, £19.863 13s. These figures represent the balance of the cost of land and development not yet transferred to the accounts of the dwellings † After deducting expenditure of £12,120 3s. 11d. as in note †. § White Hart-lane £78,650 19s, 3d.; Norbury £1,991 17s. 6d.; Old Oak of the amount applied in repayment of debt (Consolidated Loans Fund Advances £5,146 8s. 3d.) † Including proceeds of sales. ¶ The total accumulations (£189,423 10s 11d.) shown in this column do not take account IV. lvi Annual Report of the London County Council, 1913.Housing of the working classes-Accounts. F-SUMMARY OF FINANCIAL RESULT—(continued). Dwellings. Borough Accommodation (persons (*) Persons in occupation 31st ' March 1914. Date of opening Aggregate Capital Expenditure to 81st March, 1914. Aggregate Balance on Revenue Account, 1st April, 1913. Surplus ( + ) Deficiency (—). Result of Year's Working. Surplus ( + ) Deficiency (—) (page 1., col. 20). Aggregate Balance on Revenue Account, 3lst March, 1914. Surplus (+) Deficiency (—). Accumulations of Sinking Fund to 31at March, 1914, (including proceeds of Sales). Unspent Accumulations on 1st April, 1913. Repairs and Renewals Fund. 1913-14. Unspent Accumulations on 31st March, 1914  Transfers from Revenue Account (page l.,col. 12) Actual Expenditure. Difference,being further amount set aside Land. Buildings. Total. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 II.-Improvement Acts, £ s. d £ s. d. £ s. d. £ s. d. £ s d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £- s d. £ s. d. Battersea Bridge Battersea 286 201 1901 1,350 - - 15,704 7 8 17,054 7 8 + 513 10 1 + 11 15 6 + 525 5 7 1,595 5 - 15,657 * 7 1 5,286 18 1 5,218 7 11 67 10 2 15,725 3 5 Cotton-street Poplar 360 236 1901 1,400 _ - 12,768 12 5 14,168 12 5 - 521 11 8 + 39 8 1 — 482 3 7 1,412 18 9 Durham Battersea 536 336 1904 2,: 580 _ _ 24,684 13 - 27 064 13 - — 4,098 2 7 — 365 4 1 —. 4,463 6 8 1,940 2 4 Duke's Court (proportion) Westminster (City) 152 115 1902 ] .400 _ 6,397 18 9 7,797 18 9 +994 2 - + 87 17 5 + 1.081 19 5 700 11 7 York-street (proportion) Westminster (City) 97 73 1903 1,000 - - 4,316 15 5 5,316 15 5 + 428 9 5 + 42 18 10 + 471 8 3 410 18 10 Herbrand-street Holborn 680 549 1904 7,000 26,659 2, 2 33,659 9, 2 + 3,828 7 - + 412 17 9 + 4,241 4 9 2,488 7 2 Bruce House Westminster(City) 715 715 1906 8,830 - - 47,109 3 1 55,939 3 1 + 4,887 7 - + 544 17 6 + 6,432 4 6 2,858 8 6 Millbank (proportion) Westminster(City) 2,664 1,796 1899-1902 20,650 10 - 122,083 15 11 142.734 6 1 + 24,831 11 10 + 2,078 1 - + 26,909 12 10 14,599 14 5 Bourne Holborn 2,642 1,662 1902-4 44,000 _ _ 149 363 18 6 193,363 18 6 + 9,543 1 1 + 1,380 5 1 v 6 2 114,999 1 9 Swan-lane Bermondsey 1,270 998 1902-4 5,000 - - 55,870 5 - 60,870 5 - - 9,561 16 2 - 564 15 9 — 10,126 1 1 11 4,399 14 6 Valette Hackney 416 286 1905 3,000 - - 18,172 11 1 21,172 11 1 + 954 17 7 + 194 19 - + 1,149 16 7 1,252 10 2 Hughes-fields(dwellings) (proportions) Deptford and Greenwich 220 153 1904 427 13 4 8,187 6 4 8,614 19 8 - 1,034 7 3 - 64 18 8 — 1,099 5 11 564 - 2 Bearcroft Fulham 220 115 1906 700 - - 9,566 17 4 10,266 17 4 — 114 19 7 + 73 19 8 — 40 19 11 507 9 5 Dwellings on sites conipulsonly appropriated for rehousing, on the working of which a deficiency was anticipated owing to the character or situation of the site. Council Poplar 240 150 1894 621 _ _ 16,420 7 _ 17,041 7 - — 4,817 10 3 — 219 4 1 — 5,036 14 4 3,474 8 1 Westview, etc. Greenwich 464 313 1894 1,148 9 3 32,307 14 11 33,456 4 2 — 8,939 8 11 — 459 7 7 — 9,398 16 6 6,800 4 9 Idenden Greenwich 400 248 1896 1,500 - - 17,156 10 6 18,656 10 6 -854 15 1 — 7 16 11 — 862 12 - 3,445 8 2 Barnaby Bermondsey 400 330 1904 2,875 — - 16,516 17 1 19,391 17 1 — 191 7 5 — 11 14 2 1 7 1,291 12 11 982 8 10 Brightlingsea Stepney 340 233 1904 1,000 - - 13,671 5 10 14,671 5 10 -1,640 4 5 + 11 7 - — 1,628 17 5 876 4 9 Bekesbourne Stepney 380 246 1907 1,120 — - 17,282 14 1 18,402 14 1 - 347 17 4 -9 16 2 — 357 13 6 750 8 1 Darey Hackney 190 133 1904 1,250 _ _ 9,741 12 3 10,991 12 3 -175 12 2 -1 6 7 — 176 18 9 814 11 6 Wandsworth-road Lambeth 238 148 1905 1,560 _ _ 11,343 1 3 12,903 1 3 +321 10 4 +48 18 1 + 370 3 5 Difference between totals of debt charges on cash and stock basis — — - — — — — + 662 16 - + 662 16 - 696 7 10 Total—Dwellings in occupation .. — 9,236 — 108,212 12 9 635,325 9 7 743,538 2 4 + 14,005 3 6 + 3,885 16 11 + 17,891 - 5 66,860 17 6 15,657 13 3 5,28 5 18 1 5,218 7 11 67 10 2 15,725 3 5 Interest on cash balances — — — + 1,639 10 7 + 247 12 1 + 1,887 2 8 — — — — — — Dwellings in course of erection — — +15,644 14 1 + 4,13S 9 - + 19,778 3 1 — — — — — — — 3,897 7 9 — — 3,897 7 9 Dividends (less expenses of investment) and interest (Repairs and Renewals Fund) — + 11,747 6 4 + 4,133 9 - + 15,880 15 4 — 3,658 17 6 — — 620 13 10 620 13 10 4,279 11 4 108,212 2 9 635,325 9 7 743,538 2 4 + 11,747 6 4 + 4,133 9 - + 15,880 15 4 66.860 17 6 19,316 10 9 5,28 5 1 4,597 14 1 688 4 — 20,004 14 9 Deduct-Net contributions to rates, after deducting contributions from Tramways Account, to 31st March '.914 15,880 15 4 - - - * The accommodation is arrived at generally by calculating two persona to a room. The enumeration in March, 1914, showed an average of 1.28 persons per rooms, †Including proceeds of sales ‡ The total accumulations (£66,860 17s. 6d.) shown in this column do not take account of the amount applied in repayment of debt (consolidated Loans fund Advances, £21 15s, 11d.). Ivii Annual Report of the London County Council, 1913. G.-REPAIRS AND RENEWALS ACCOUNT-DETAILS OF INVESTMENTS (PAGES XXXVIII. AND XLIV.). Name of Stock. Amount of Stock. Cost Price. Housing of the Working Classes Act, 1890. Dwellings (Improvement Acts). Total Market Value on 31st March, 191. Part. I. Part II. Part III. Total. London County Consolidated- £ s. d. £ 8. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ 2½ per cent 24,570 14 9 12,693 9 1 1,000 _ _ 1,603 16 9 15,297 5 10 5,702 14 2 21,000 _ _ 16,401 3 per cent 12,246 9 8 1,000 — - 500 - - 4,500 - - 6,000 - - 5,000 - - 11,000 - - 9,889 Now South Wales Government— 3½ per cent. Inscribed (1918) 11,148 17 2 3,000 - - 500 - - 4,000 _ - 7,500 . - 3,500 - - 11,000 _ — 11.065 Dominion of Canada— 3½ per cent. Registered (193050) 13,026 4 1 3,000 - - — — — 5,500 - - 8,500 - - 4,500 - - 13,000 - - 12,131 London, Brighton and South Coast Railway Company— 5 per cent. Consolidated Guaranteed 1,500 - - 801 - - 400 10 - 400 10 - 1,602 - - 400 10 - 2,002 10 - 1,836 Madras Railway Annuity (Class " B ") £135 of annuity — — 2,497 10 - 2,497 10 - — 2,497 10 - 2,734 20,494 9 1 2,400 10 - 18,501 16 9 41,396 15 10 19,103 4 2 60,500 - - *54,056 *Housing Act, 1890, £36,900; Improvement Acts, 17,156. H.-STATEMENT AS TO CONTRIBUTIONS FROM AND TO RATES. Year Housing of the Working Classes Act, 1890. Dwellings (Improvement Acts) Total. Part I. Part II. Part III. Dwellings. Estates in Course of Development. Contributions from Rates. £ s. d. £ s. d. £ s. d. £ s, d. £ s. d. £ s. d. 1894-5—1912-13 3,167 17 6 — 30,579 14 7 79,645 10 8 5,097 5 4 118,490 8 1 1913-14 — — 2,432 4 11 — 2,432 4 11 3,167 17 6 — 30,579 14 7 82,077 15 7 5,097 5 4 120,922 13 Contributions to Rates. 1894-5—1912-13 42,725 2 1 3,388 10 _ 4,467 _ _ †l,390 8 6 17,995 8 1 69,966 19 6 1913-14 8,258 10 2 556 8 11 5,360 15 4 — — — 4,198 7 8 18,374 8 1 350,983 18 3 3,944 18 11 9,827 15 4 †1,390 8 6 22,194 6 7 88,341 7 7 Net Contributions— From rates 20.751 19 8 80.687 7 1 32,581 5 5 To rates 47,816 - 9 3,944 18 11 — — 17,097 1 3 Contributions from Tramways account. Proportion of deficiency on Hughes-fields (Deptford) Dwellings, Drake Buildings, allocated for rehousing persons displaced by the Generating Station, Greenwich— To 31st March, 1913 1,151 7 3 1,210 5 11 64 18 8 Net contributions from Rates and Tramways Account— Housing of the Working Classes Act, 1890 49,678 6 8 33.797 11 4 Less—Dwellings under Improvement Acts 15,880 15 4 † In respect of Norbury Brickfield, being amount charged to the Brickfield Account in 1907-8 for interest on outlay in previous years met out of rates. lviii Housing of the working Classes—Accounts. J.-STATEMENT OF CAPITAL EXPENDITURE ON CLEARANCE SCHEMES UNDER THE HOUSING OF THE WORKING CLASSES ACT, 1890. Note.—The receipts are derived from sales of land and rents and include amounts transferred from the accounts of the dwellings for the housing values of the sites appropriate. for that purpose. Under Part II. they include contributions from Local Authorities. Clearance Scheme. Date of Act sanctioning Scheme Capital Expenditure to 31st March, 1914. Gross. Receipts applied to Capital Expenditure. Net. (a) housing of the working classes act, 1890. Part I. £ s d. £ s. d. £ s d.. Whitechapel and Limehouse 1876 187,557 18 6 35,795 1 4 151,762 17 2 Holborn — 1,728 14 7 — 1,728 14 7 Goulston-street and Flower and Dean-street, Whitechapel 1877 371,607 5 5 87,635 15 7 283,971 9 10 Elizabeth-place, King-street and Mint-street, St. George-theMartyr, Southwark „ 66,785 10 8 14,342 5 9 52,443 4 11 Bedfordbury, St. Martin-in-the-Fields „ 87,212 8 4 11,701 14 4 75,510 14 _ Great Wild-street, St. Giles-in-the-Fields „ 124,278 7 10 18,627 15 9 105,650 12 1 Pear Tree-court, Clerkenwell „ 27,426 6 5 6,556 11 6 20,869 14 11 Whitecross-street, St. Luke „ 391,302 19 2 76,360 5 3 314,942 13 11 High-street, Islington „ 44,775 11 3 6,588 16 7 38,186 14 8 Old Pye-street, Westminster „ 79,389 4 10 29,493 - 4 49,896 4 6 Bowman's-buildings, St. Marylebone 1878 52,348 6 6 15,889 15 6 36,458 11 _ Essex-road, Islington „ 115,108 - - 17,209 6 2 97,898 13 10 Little Coram-street, Bloomsbury 1879 14,358 19 3 871 8 8 13,487 10 7 Wells-street, Poplar „ 75,771 8 7 11,651 19 8 64,119 8 11 Great Peter-street, Westminster „ 235 5 3 22 12 7 212 12 8 Tench-street, St. George-in-the-East 1883 52,636 16 4 645 17 9 51,990 18 7 Brook-street, Limehouse „ 23,794 14 11 3,988 2 6 19,806 12 5 Windmill-row, Lambeth „ 13,212 5 8 3,433 12 11 9,778 12 9 Trafalgar-road, Greenwich „ 20,700 4 - 3,023 12 8 17,676 11 4 Tabard-street, Newington 1885 18,629 13 7 10,400 7 8 8,229 5 11 Hughes-fields, Deptford „ 91,978 3 5 8,083 5 10 83,894 17 7 Cable-street, Shadwell 1887 46,390 10 6 5,155 8 2 41,235 2 4 Shelton-street, St. Giles „ 79,553 13 6 11,134 12 9 68,419 — 9 Boundary-street, Bethnal Green 1891 353,439 8 5 74,442 7 10 278,997 _ 7 Goldsmith's-row, Shoreditch „ 4,885 7 10 1,090 17 6 3,794 10 4 Churchway, Somers Town, St. Pancras 1897 43,200 11 7 8,699 _ _ 34,501 11 7 Clare-market, Strand „ 414,015 8 2 353,850 — 2 60,165 8 - Ayiesbury-place, Clerkenwell, and Union-buildings, Holborn 1900 194,193 12 6 18.948 4 6 175,245 8 _ Burford's-couit, Tucker's-court and Favonia-strect, Poplar „ 16,829 7 3 5,530 10 — 11,298 17 3 Garden-row, Roby-street, Baltic-street and Honduras-street, „ 120,815 12 10 13,860 11 6 106,955 1 4 St. Luke Webber-row, Wellington-place and King's Bench-walk, „ 108,574 11 10 10,293 9 _ 98,281 2 10 Southwark Nightingale-street, St. Marylebone „ 702 1 - 702 1 — — Providence-place, Poplar 1902 12,752 3 6 145 7 1 12,606 16 5 Tabard-street and Grotto-place, Southwark, and Crosby-row, — 45,835 15 6 — 45,835 15 6 General - 449 3 7 — 449 3 7 Total for Part I 3,302,475 12 6 866,173 17 10 (a)2,436,301 14 8 Part ii. (i.) Schemes carried out by the Council— Brooke's-market, Holborn 1892 8,929 15 6 3,857 14 10 5,072 8 Mill-lane, Deptford 1894 23,341 1 11 14,174 16 4 9,166 5 7 Ann-street, Poplar „ 11,089 10 5 6,735 2 _ 4,354 8 5 Falcon-court, Borough 1898 50,951 6 10 15,798 10 1 35,152 16 9 (ii.) Contributions to schemes carried out by the Local Authorities— Green-street and Gun-street, Southwark 1893 1,568 14 10 — 1,568 14 10 Moira-place and Plumber's-place, Shoreditch 1894 27,500 — — — 27,500 — — Queen Catherine-court, Ratclift 1895 2,787 2 8 — 2,787 2 8 London-terrace, St. Georgc-in-the-East „ 682 8 _ — 682 8 — King John's-court, Limehouse 1899 6,429 — 8 — 6,429 _ 8 Fulford-street and Braddon-street, Rotherhithe 1900 14,560 — - — 14,560 _ _ Brantome-place and Prospect-terrace, St. Pancras 1904 15,600 - - — 15,600 _ _ Norfolk-square, Islington „ 3,986 19 8 — 3,986 19 8 Total for Part II 167,426 - 6 40,566 3 . 3 (a)126,859 17 3 Total for Parts I. and II. 3,469,901 13 — 906,740 1 1 2,563,161 11 11 (a) Before deducting proceeds of sales carried to Consolidated Loans Fund. 23610 QQ 2 lix. Annual Report of the London County Council, 1913. K.-STATEMENT AS TO THE COMMERCIAL AND HOUSING VALUES OF SITES UTILISED FOR THE ERECTION OF WORKING CLASS DWELLINGS. Statement showing difference between the commercial value and the housing value of sites (a) sold by the Metropolitan Board of Works to Dwellings Companies and others, with the obligation to erect dwellings for the working classes thereon, or (6) acquired or appropriated by the Council for the erection of working class dwellings. Note- The figures in the column headed Commercial value, except in the few instances where actual cost is given, represent the estimate of the Council's Valuer of the amount which would have been obtained in the open market at the time of the disposal of the re-housing site for the site as cleared land free from all restrictions. The figures in the column headed "Housing value" represent in statement (a) the sums actually received from Dwelling Complanies and others for the sites restricted to the erection of working class dwellings, and in statement (i.) the estimated housing value as determined by the Council on the advice of the Valuer, and charged (a) Sites sold by the Metropolitan Board of Works to Dwelling Companies and others, with the obligation to erect dwellings for the working classes thereon. (6) Sites acquired or appropriated by the Council for the erection of working class dwellings. Clearance scheme or street improvement Commercial value. (Estimated). Housing value. (Cash received from Dwellings Companies.) Difference charged to clearance scheme or improvement (cost of writing down value of cleared site). Dwellings. Commercial value. (Estimated.) Housing value. (Estimated.) [Amounts charged to Dwellings Accounts, pages liii. and lv., col. 6.] Difference charged to clearance scheme or improvement (cost of writing down value of cleared site). HOUSING OP THE WORKING CLASSES ACT, 1890. £ £ 1 £ Housing op the Working Classes Act, 1890. Part I £ £ £ Part I-Clearance Schemes. Boundary-street 131,670 62,010 69,660 Goldsmith's-row (Supplemental to Boundary Street) *4,795 1,000 3,795 Whitechapel and Limehouse 73,000 24,900 48,100 Cable-street 8,500 3,660 4,840 Goulston-street and Flower and Dean-street, Whitechapel 80,000 32,106 47,894 Shelton-street 24,465 5,100 19,365 Elizabeth-place, King-street and Mint-street, St. George- the martyr, Southwark 27,000 12,300 14,700 Clare Market— Mill bank *16,202 11,907 4,295 Bedfordbury, St. Martin-in-the-Fields 15,000 7,886 7,114 Duke's-court *61,181 4,200 53.981 Great Wild-street, St. giles-in-Fields 35,000 15,840 19,160 York-stree 3,000 Pear Tree court, Clerkenwell 12,000 5,925 6,075 Ghurchway 25,000 8,550 16,450 Whitecross-street, St. Luke 105,000 36,882 68,118 Hardy 4,000 3,000 High-street, Islington 11,000 5,650 5,350 Preston's-road 1,434 1,434 Old Pye-street, Westminster 40,000 20,410 19,590 St. Luke's—Wenlake 25,900 5,000 20,900 Bowman's buildings, St. Marylebone 16,000 10,000 6,500 Do. Chadworth 20,800 8,000 12,800 Essex-road, Islington 30,000 13,306 16,694 Clerkenwell and Holborn — Mallory 10,000 1,620 8,380 wells-street,Poplar 12,000 5,000 7,000 Do. Nigel, etc 53,000 14,550 38,450 Windmill-row, Lambeth 6,000 3,050 2,950 Webber-row 28,500 9,750 18,750 Tabard-street, Newington 7,000 4,200 2,800 Parker-stree 14,035 3,750 10,285 Hughes-fields, Deptford 2,000 1,460 1,140 Brook-street 3,600 1,800 1,800 Total for Clearance schemes 472,100 108,915 273,185 Hughes-fields 7,760 3,720 4,040 Part. ii. Cranley 1,500 750 750 Borough 8,146 5,000 3,146 Cobham 6,466 2,100 4,366 Ann-street 2,850 2,260 590 Sylva 2,166 1,000 1,166 Carrington House 3,834 2,200 1,634 465,804 163,361 302,443 Street Improvements §dwelltngs under improvement acts. Battersea-bridge 4,000 1,350 2,650 Metropolitan Street Improvements Act, 1872- Cotton-street 2,500 1,400 1,100 Bethnal Green-road *7,220 4,280 Durham 5,000 2,380 2,620 Old Street to oxford (Clerknwell road and Theobald's road) 11,500 10,860 27,540 Duke's-court *20,668 1,400 18,268 Willow-walk, Great Eastern-street 38,400 12,033 York-street 1,000 Metropolitan Board of works (various Powers) Act, 1876- Herbrand-street 41,836 7,000 34,836 Appold-street (Sun-street), Shoreditch 26,305 14,272 850 Bruce House 63,000 8,830 54,170 Metropolitan Street Improvements Act, 1877- 1,250 Bourne *201,469 44,000 157,469 Camberwell and Peckham 2,100 *33,715 900 Millbank *27,901 20,651 7,250 Charing cross road and Shaftesbury avenue 1,500 14,335 43,285 Swan-lane 6,850 5,000 1,850 Gray's Inn-road (including Elm-street, Acts of 1884 and 1887)- 22,739 5,300 8,395 Valette 8,600 3,000 5,600 Jamaica road 10,700 5,300 5,400 Hughes-fields *428 428 Kentish Town road 2,500 2,300 260 Beareroft 2,229 700 1,529 Marshalsea-road (Southwark Bridge-road) 4,200 1,900 2,300 Council 3 000 Tooley-street 20,000 *10,000 10,000 Westview, Armitage and Collerston 4,900 1,148 3,752 Metropolitan Street Improvements Act, 1883- Indenden 4,400 1,500 2,900 Green-street, Bethnal Green 3,500 2,030 1,570 Barnaby 6,100 2,875 3,225 Upper-street, Islington 2,500 950 1,550 Brightlingsea 4,100 1,000 3,100 Hampstead, High-street 2,500 1,500 1,000 Bekesbourne 2,350 1,120 1,230 Metropolitan Board of works (Various Powers) Act, 1885- Darey 2,350 1,250 1,100 Rosebery-a venue 30,000 24,775 5,225 Wandsworth-road *4,596 1,560 3,036 Total for street Improvements 255,435 131,007 124,428 416,277 108,213 308,064 Total 727,535 329,922 397.613 882,081 271.574 610.507 * Wholly or partly based on the capitalisation ;of annual ground rents. * Actual cost of site purchased for re-housing purposes. † Erected as a lodging house under Part III, but provides accomodation in connection with shelton-street, Schema. ‡Erected as a lodging house under Part III., but provides accommodation in connection with Mill-lane. Deptford, Scheme § For Statutes under which these dwellings are erected, see page lvii lx Housing of the Working Classes—Accounts. APPENDIX XXII. STATEMENT SHOWING STATUTES UNDER WHICH DWELLINGS UNDER IMPROVEMENT ACTS WERE ERECTED. Dwellings. Act. Battersea Bridge Dwellings Bridges Acts of 1881 and 1884. Council Buildings Blackwall Tunnel Acts, 1887 and 1888. Westview, Armitage and Collerston Cottages Idenden Cottages Cotton-street Dwellings Barnaby Buildings L.C.C. (General Powers) Act, 1897—Long-lane and Tabard-street widening. Durham Buildings L.C.C. (General Powers) Act, 1898— York-road, Battersea, Improvement—and L.C.C. (Tramways and Improvements) Act, 1901—Red Lion-street to Tooting High-street Improvement. Duke's-court Dwellings L.C.C. (Improvements) Acts, 1899—Holborn to Strand Imj rovement. York-street Dwellings Herbrand-street Dwellings Bruce House Millbank Estate L.C.C. (Improvements) Act, 1899—Holborn to Strand Improvement—and L.C.C. (Improvements) Act, 1900—Thames Embankment Extension and Westminster Improvements. Bourne Estate L.C.C. (Improvements) Act, 1899—Holborn to Strand and Southampton-row Improvements — L.C.C. (Improvements) Act, 1900—St. John-street, Clerkenwell, and Goswell-road Improvements—and L.C.C. (General Powers) Act, 1901—Central-street, St. Luke, Improvement. Swan-lane Dwellings L.C.C. Thames Tunnel (Rotherhithe and RatclifE) Act, 1900. Brightlingsea Buildings Bekesbourne Buildings Darcy Buildings L.C.C. (Improvements) Act, 1900—Mare-street, Hackney, Improvement. Valette Buildings Wandsworth-road Dwellings L.C.C. (Improvements) Act, 1900—Nine Elms-lane widening. Hughes-fields Dwellings L.C.C. (Tramways and Improvements) Act, 1902—Tramways— Greenwich generating station. Bearcroft Buildings L.C.C. (Tramways and Improvements) Act, 1902—Fulham Palaceroad and High-street widening. xi Annual Report of the London County Council, 1913. Housing of the Working Classes—Statistics. xii APPENDIX XXIII. A —Number of Tenements Comprised in the Dwellings in Occupation on 31st March, 1913, together with Particulars of the Dwellings Opened between that date and 31st March, 1914. Dwellings. Metropolitan Borough. Date opened. Number of tenements of Total tenements Total rooms. Cubicles Number of persons provided for. Shops Workshops. Sheds. Cupboards 1 room . 2 rooms 3 rooms 3 rooms with small additional bedroom. 4 rooms 4 rooms with.small additional bedroom 5 rooms 6 rooms. Total number of tenements, etc. in occupation on 31st March, 1913 •• •• 208(a) (e) 3,485 3.887 310(b) 1,131 12(c) 474 3 9,510 27,051 1,874 55,589 108 97 224(d) 39 Dwellings opened during the year 1st April, 1913, to 31st March, 1914— Old Oak Estate— Hammersmith Ducane-road June, 1913 •• •• •• •• 4 •• 14 •• 18 86 •• 172 •• •• •• •• Erconwald-street July, 1913 to Oct., 1913 •• •• 11 •• 11 2 1 •• 25 92 •• 182 3 •• •• •• Fitzneal-street July, 1913 to Dec., 1913 •• •• 37 8 24 1 7 •• 77 279 •• 549 •• •• •• •• Foliot-street July, 1913 to Nov., 1913 •• •• 17 8 7 2 8 •• 42 161 •• 312 •• •• •• •• Old Oak-lane Nov., 1913 to Mar., 1914 •• •• 6 •• 8 2 16 •• 32 140 •• 278 •• •• •• •• 71 16 54 7 46 194 758 1,498 3 10 White Hart-lane— Tottenham Tower-gardens-road •• May., 1913 to Mar., 1914 •• 26 •• 16 •• •• •• 42 142 •• 284 •• •• •• •• Waltheof-row June, 1913 to Oct., 1913 •• •• •• •• •• • • •• •• •• •• •• 5 •• •• •• 26 16 42 142 284 5 Total number of cottages, etc., opened during year to 31st March, 1914. •• •• •• •• 97 16 70 7 46 •• 236 900 •• 1,777 8 •• 10 •• Separation of number of 5 room lettings providing accommodation for 9 persons only •• •• •• •• •• •• •• + 65 —65 •• •• •• •• •• •• •• •• •• Alteration to cottage flats at Totterdown Fields Estate •• •• •• +2 –2 •• •• •• •• •• •• —2 •• —4 •• •• •• •• •• •• •• 2 5 16 70 72(c) —19 •• 236 898 •• 1,773 8 •• 10 •• Total number of tenements, etc., open on 31st March, 1914. 208(a) (e) 3,487 3,982 326(b) 1,201 84(c) 455 3 9,746 27,949 1,874(f) 57,362 116 97 234(d) 39 (a) Five of these tenements also contain a bed recess and each is reckoned as accommodating three persons. (b) These cottages are reckoned as containing 4 rooms, accommodating 7 persons. (c) These lettings are reckoned as containing 5 rooms, accommodating 9 persons. (d) Including 12 stables at Costermongers' dwellings. (e) Sixteen of these lettings also contain a bed recess, and each is reckoned as accommodating 2 persons (Housing Committee, 8th December, 1909). (f) Including 17 cubicles occupied by staff. xiii Annual Report of the London County Council, 1913. Housing of the Working Classes—Statistics. xiv. 23610 RR B.—Accommodation Provided in all the Council's Dwellings open on 31st March, 1914. Dwellings. Metropolitan Borough. Date opened. Number of tenements of Total tenements Total rooms. Cubicles. Number of persons provided for. Shops. Workshops. Sheds. Cupboards. 1 room. 2 rooms. 3 rooms. 3 rooms with small additional bedroom. 4 rooms 4 rooms with small additional bedroom. 5 rooms 6 rooms Ann-street-dwellings— Poplar Adelaide-buildings Sept., 1901 .. 25 15 .. .. .. .. .. 40 95 .. 190 Melbourne-buildings Nov., 1902 .. 30 10 .. .. .. .. .. 40 90 .. 180 Sydney-buildings Dec., 1902 .. 35 20 .. .. .. .. .. 55 130 .. 260 90 45 185 315 630 Barnaby-buildings Bermondsey Sept., 1904 .. 40 40 .. .. .. .. .. 80 200 .. 400 Buttersea-bridge-buildings Battersea Oct., 1901 10 44 15 .. .. .. .. .. 69 143 .. 286 .. .. 12 Bearcroft buildings Fulham Sept., 1906 .. 10 30 .. .. .. .. .. 40 110 .. 220 .. .. .. 1 Bekesbourne-buildings Stepney July, 1907 .. 45 20 .. 10 .. .. .. 75 190 .. 380 .. .. .. Borough-road-dwellings— Southwark Gardiner-buildings May, 1900 .. 8 .. .. .. .. .. .. 8 16 .. 32 Hunter-buildings May, 1900 .. 20 20 .. .. .. .. .. 40 100 .. 200 Murphy-buildings Oct., 1900 .. 24 12 .. .. .. .. .. 36 84 .. 168 52 32 84 200 400 Boundarv-street estate— Streatley-buildings Bethnal-green April, 1895 .. 32 24 .. .. .. .. .. 56 136 .. 272 .. 12 .. 4 Cleeve-buildings Shoreditch July, 1896 .. 7 12 .. 12 .. 1 .. 32 103 .. 206 8 16 8 Culham-buildings Bethnal-green Nov., 1896 15 20 .. .. .. .. .. .. 35 55 .. 110 Sonning-buildings „ Nov., 1896 .. 10 15 .. 15 .. .. .. 40 125 .. 250 Hurley-buildings „ Jan., 1897 .. 5 5 .. .. .. .. .. 10 25 .. 50 Sandford-buildings „ Jan., 1897 .. 5 5 .. .. .. .. .. 10 25 .. 50 Henley-buildings „ March, 1897 .. 45 25 .. .. .. .. .. 70 165 .. 330 .. .. .. 5 Walton-buildings „ March, 1897 .. 40 35 .. .. .. .. .. 75 185 .. 370 .. .. .. 6 Marlow-buildings „ March, 1897 .. .. 12 .. 17 .. 5 .. 34 129 .. 258 6 17 .. Shiplake-buildings „ March, 1897 .. .. .. .. 25 .. .. 1 26 106 .. 212 4 Taplow-buildings „ May, 1897 .. 25 25 .. .. .. .. .. 50 125 .. 250 Chertsey-buildings „ July, 1897 .. 6 14 .. .. .. .. .. 20 54 .. 108 Sunbury-buildings „ Aug., 1897 .. 50 25 .. 5 .. .. .. 80 195 .. 390 .. 32 .. 2 IfHey-buildings „ March, 1898 .. 5 5 .. 5 .. .. .. 15 45 .. 90 Clifton-buildings „ Jan., 1899 .. 27 36 .. 7 .. .. 2 72 202 .. 404 Molesey-buildings „ March, 1899 .. .. 18 .. 2 .. .. .. 20 62 .. 124 Wargrave-buildings „ May, 1899 .. 45 15 .. .. .. .. .. 60 135 .. 270 Cookham-buildings „ July, 1899 .. 21 22 .. 10 .. 1 .. 54 153 .. 306 Benson-buildings „ April, 1900 .. 30 10 .. .. .. .. .. 40 90 .. 180 Hedsor-buildings „ April, 1900 .. 50 35 .. .. .. .. .. 85 205 .. 410 Abingdon-buildings „ May, 1900 .. 75 10 .. .. .. .. .. 85 180 .. 360 Laleham-buildings „ May, 1900 .. 35 40 .. .. .. .. .. 75 190 .. 380 15 533 388 .. 98 .. 7 3 1044 2690 .. 5380 18 77 8 17 % Bourne-estate— Holborn .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Denys-buildings Oct., 1902 .. 40 15 .. .. .. .. .. 55 125 .. 250 Frewell-buildings Jan., 1903 .. 40 15 .. .. .. .. .. 55 125 .. 250 Scrope-buildings Jan., 1903 .. 50 5 .. .. .. .. .. 55 115 .. 230 Skipwith-buildings Feb., 1903 .. 40 15 .. .. .. .. .. 55 125 .. 250 Ledam-buildings March, 1903 .. 50 5 .. .. .. .. .. 55 115 .. 230 25 Shene-buildings May, 1903 .. 30 .. .. .. .. .. .. 30 60 .. 120 25 Redman-buildings Oct., 1904 11 31 58 .. 27 .. .. .. 127 355 .. 710 Radclifi-buildings June, 1904 5 25 54 .. 21 .. .. .. 105 301 .. 602 23 .. 16 306 167 48 537 1321 2642 23 50 Union-buildings area— Holborn Buckridge-buildings Oct., 1908 .. 10 20 .. 10 .. .. .. 40 120 .. 240 Kirkeby-buildings Aug., 1908 .. 10 15 .. 20 .. .. .. 45 145 .. 290 Laney-buildings April, 1908 4 29 32 .. 5 .. 1 .. 71 183 .. 366 15 14 2 Nigel-buildings Dec., 1907 11 20 29 .. 11 .. .. .. 71 182 .. 364 15 69 96 46 1 227 630 1260 15 14 2 Brightlingsea-buildings Stepney Sept., 1904 5 20 35 .. 5 .. .. .. 65 170 .. 340 Briscoe-buildings Lambeth Oct., 1906 .. 10 73 .. 30 .. .. .. 113 359 .. 718 15 Brook-street-dwellings— Stepney Beachcroft-buildings .. Sept., 1894 .. 20 20 .. .. .. .. .. 40 100 .. 200 Cranford-cottages July. 1900 .. .. 18 .. .. .. .. .. 18 54 .. 108 20 38 58 154 308 Cable-street dwellings— Stepney Bewley-buildings March, 1896 .. 20 30 .. .. .. .. .. 50 130 .. 260 Deliow-buildings March, 1896 .. 20 30 .. .. .. .. .. 50 130 .. 260 Lowood-buildings May, 1901 (a) 11 29 .. .. .. .. .. .. 40 69 .. 139 Chancery-buildings Mav, 1901 (a)11 29 .. .. .. .. .. .. 40 69 .. 139 22 98 60 180 398 798 Caledonian-estate— Islington Burns-buildings July, 1906 .. .. 30 .. .. .. .. .. 30 90 .. 180 Scott-buildings July, 1906 .. .. 30 .. .. .. .. .. 30 90 .. 180 Wallace-buildings July, 1906 .. 40 30 .. .. .. .. .. 70 170 .. 340 Knox-buildings July, 1906 .. 36 26 .. 4 .. .. .. 66 166 .. 332 Bruce-buildings Oct., 1906 6 40 30 .. .. .. .. .. 76 176 .. 352 6 116 146 4 272 692 1384 Chadworth-buildings Finsbury April, 1907 .. 58 68 .. 10 .. .. .. 136 360 .. 720 19 Churchwav-dwellings— St. Pancras Wellesley-buildings March, 1901 .. 60 20 .. .. .. .. .. 80 180 .. 360 Seymour-buildings July, 1902 2 48 10 .. .. .. .. .. 60 128 .. 256 Somerset-buildings Aug., 1902 .. 16 20 .. 4 .. .. .. 40 108 .. 216 2 124 50 4 180 416 832 (a) One of the one-roomed tenements in each of these buildings contains abed recess, and is reckoned as accommodating three persons. xv. Annual Report of the London County Council, 1913. Housing of the Working Classes—Statistics. xvi. B.—Accommodation Provided in all the Council's Dweliings open on 31st March, 1914—(continued). Dwellings. Metropolitan Borough. Date opened Number of tenements of Total tenements Total rooms. Cubicles. Number of persons provided for. Shops Workshops Sheds Cupboards 1 room. 2 rooms. 3 rooms. 3 rooms with small additional bedroom 4 rooms 4 rooms with small additional bedroom. 5 rooms 6 rooms Cobham-buildings Southwark Oct., 1900 (a)l 39 20 .. .. .. .. .. 60 139 .. 279 Cotton-street-dwellings— Poplar Montreal-buildings Sept., 1901 .. 25 25 .. .. .. .. .. 50 125 .. 250 Toronto-buildings Sept., 1901 .. 5 15 .. .. .. .. .. 20 55 .. 110 30 40 70 180 360 Council-buildings, Popiar Poplar April, 1894 .. 30 20 .. .. .. .. .. 50 120 .. 240 Cranley-buildings Holborn Oct., 1897 .. 6 6 .. .. .. .. .. 12 30 .. 60 Darov-buildings Hackney July, 1904 .. 25 15 .. .. .. .. .. 40 95 .. 190 Dufferin-street dwellings Finsbury April, 1892 29 23 4 .. .. .. .. .. 56 87 .. 174 .. .. 24 (d) Duke's-court -dwellings— Westminster .. Fletcher-buildings April, 1902 .. 35 15 .. .. .. .. .. 50 115 .. 230 Beaumont-buildings May, 1902 10 15 5 .. 10 .. .. .. 40 95 .. 190 Sheridan-buildings Aug., 1902 .. 25 15 .. .. .. .. .. 40 95 .. 190 10 75 35 10 130 305 610 Durham-buildings Battersea July, 1904 .. 56 52 .. .. .. .. .. 108 268 .. 536 East Greenwich cottages— Greenwich Collerston-cottages May, 1894 .. 12 8 .. 4 .. .. .. 24 64 .. 128 Armitage-cottages June, 1894 .. 12 8 .. 16 .. .. .. 36 112 .. 224 Westview-cottages Aug., 1894 .. 6 4 .. 8 .. .. .. 18 56 .. 112 30 20 28 78 232 464 Goldsmith's-row-cottages Shoreditch Sept., 1895 .. 8 12 .. 5 .. .. .. 25 72 .. 144 Hardy-cottages Greenwich July, 1901 .. .. 51 .. .. .. .. .. 51 153 .. 306 Herbrand-street-dwellings— Holborn Coram-buildings Feb., 1904 .. 50 .. .. .. .. .. .. 50 100 .. 200 Dickens-buildings March, 1904 20 30 10 .. .. .. .. .. 60 110 .. 220 Thackeray-buildings March, 1904 .. 20 30 .. .. .. .. .. 50 130 .. 260 .. .. 28 20 100 40 160 340 680 28 Holmwood-buildings Southwark April, 1900 .. 12 4 .. .. .. .. .. 16 36 .. 72 Hughes-fields-cottages Greenwich Jan., 1895 .. 71 61 .. 2 .. .. .. 134 333 .. 666 Huehes-fields-dwellings— Drake-buildings Deptford Sept., 1904 .. 10 30 .. .. .. .. .. 40 110 .. 220 Raleigh-buildings Nov., 1904 .. 18 24 .. 8 .. .. .. 50 140 .. 280 .. .. .. 1 Benbow-buildings Greenwich Oct., 1904 .. 10 20 .. .. .. .. .. 30 80 .. 160 .. .. .. 1 88 74 8 120 330 660 2 Idenden-cottages Greenwich Aug., 1896 .. .. .. .. 50 .. .. .. 50 200 .. 400 Malory-buildings Finsbury July, 1906 1 15 17 .. .. .. .. .. 33 82 .. 164 5 Millbank estate— Westminster Hogarth-buildings May, 1899 .. 21 22 .. 10 .. 1 .. 54 153 .. 306 .. .. .. 2 Millais-buildings June, 1900 .. 15 10 .. .. .. .. .. 25 60 .. 120 .. .. .. 1 Leighton-buildings July, 1900 .. 15 10 .. .. .. .. .. 25 60 .. 120 .. .. .. 1 Romney-buildings Nov., 1900 .. 35 25 .. .. .. .. .. 60 145 .. 290 .. Turner-buildings Dec., 1900 .. 43 39 .. 3 .. .. .. 85 215 .. 430 .. .. .. 3 Ruskin-buildings March, 1901 .. 43 39 .. 3 .. .. .. 85 215 .. 430 .. .. .. 4 Rossetti-buildings April, 1901 .. 35 25 .. .. .. .. .. 60 145 .. 290 .. .. .. 1 Reynolds-buildings Oct., 1901 .. 39 40 .. .. .. .. .. 79 198 .. 396 .. .. 12 Mulread y-build ings Dec., 1901 .. 20 25 .. .. .. .. .. 45 115 .. 230 Maclise-buildings Feb., 1902 .. 50 16 .. .. .. .. .. 66 148 .. 296 .. .. .. 1 Landseer-buildinsrs March, 1902 .. 20 25 .. .. .. .. .. 45 115 .. 230 .. Lawrence-buildings April, 1902 .. 50 16 .. .. .. .. .. 66 148 .. 296 .. .. .. 1 Morland-build ings May. 1902 .. 30 30 .. .. .. .. .. 60 150 .. 300 .. .. 18 Wilkie-buildings July, 1902 .. 30 30 .. .. .. .. .. 60 150 .. 300 .. .. 18 Gainsborough-buildings Aug., 1902 2 38 40 .. .. .. .. .. 80 198 .. 396 .. .. 12 2 484 392 16 1 895 2215 4430 60 14 Norbury estate— Croydon Bavant-road Mav, 1906.. .. .. 8 9 16 4 2 .. 39 154 .. 295 Bulkeley-road Feb., 1908.. .. .. .. 16 .. 4 16 .. 36 164 .. 308 Newlands-rcad May, 1906.. .. .. 62 16 9 .. 8 .. 95 326 .. 636 4 Northborough-road April, 1906 .. .. 30 .. 103 .. 12 .. 145 562 .. 1124 Norton-gardens Oct., 1910 .. .. 4 13 24 .. .. .. 41 160 .. 307 Palmers-road Feb., 1906 .. .. .. 6 8 2 .. .. 16 66 .. 124 Tylecroft-road June, 1910 .. .. 42 38 20 .. .. .. 100 358 .. 678 146 98(b) 80 10(c) 38 472 1790 3472 4 Old Oak-estate— Hammersmith Ducane-road May, 1912 .. .. .. .. 13 5 19 .. 37 172 .. 340 .. .. .. .. Erconwald-street July. 1912 .. 7 19 .. 20 2 3 .. 51 176 .. 346 5 5 .. .. Fitzneal-street April, 1912 16 20 58 9 31 1 7 .. 142 430 .. 848 .. .. .. 3 Foliot-street Julv, 1913 .. .. 17 8 7 2 8 .. 42 161 .. 312 .. .. 10 .. Old Oak-lane Nov.. 1913 .. .. 6 .. 8 2 16 .. 32 140 .. 278 .. .. .. .. Preston's-road estate— Poplar 16(e) 27 100 17(b) 79 12(c) 53 304 1079 2124 5 15 3 St. Lawrence-cottages March, 1904 .. .. 14 .. .. .. .. .. 14 42 .. 84 Ottawa-buildings March, 1904 .. 25 25 .. .. .. .. .. 50 125 .. 250 Baffin-buildings March, 1904 .. 20 4 .. .. .. .. .. 24 52 .. 104 Ontario-buildings Aug., 1904 .. 25 5 .. .. .. .. .. 50 125 .. 250 Hudson-buildings July, 1934 .. 20 5 .. .. .. .. .. 25 55 .. 110 Winnipeg-buildings Sept., 1904 .. 25 2 .. .. .. .. .. 50 125 .. 250 Quebec-buildings Sept., 1904 .. 23 25 .. .. .. .. .. 50 125 .. 250 140 123 263 649 1298 23610 RR 2 (a) The one-roomed tenement at these buildings also contains a bed recess and is reckoned as accommodating three persons. (b) These cottages are reckoned as containing 4 rooms, accommodating seven persons. (c) These cottages are reckoned as containing 5 rooms, accommodating nine persons. (d) Inclnding 12 stable*. (e) These cottages contain a bed recess, and each cottage is reckoned as accommodating two persons (Housing Committee, 8th December, 1909. xvii. Annual Report of the London County Council, 1913. Housing of the Working Classes—Statistics xviii. B.—Accommodation Provided in all the Council's Dwellings open on 31st March, 1914—(continued). Dwellings. Metropolitan Borough. Date opened Number of tenements of Total tenements Total rooms. Cubicles. Number of persons provided for. Shops. Workshops. Sheds. Cupboards. 1 room . 2 rooms. 3 rooms. 3 rooms with small additional bedroom 4 rooms 4 rooms with small additional bedroom. 5 rooms 6 rooms Rushworth-street and Boyfield-street (late Greenstreet and Gun-street) dwellings— Southwark Albury-buildings June, 1897 6 24 6 • • • • • • • • • • 36 72 • • 144 Clandon-buildings June, 1897 6 18 6 • • • • • • • • • • 30 60 • • 120 Merrow-buildings Aug., 1897 • • 12 6 • • • • • • • • • • 18 42 • • 84 Riplev-buildings Aug., 1897 1 17 • • • • • • • • • • • • 18 35 • • 70 • • • • 8 13 71 18 102 209 418 8 Shelton-street-d wellings— Holborn Aldwych-buildings Aug., 1896 • • 30 • • • • • • • • • • 30 60 • • 120 • • 7 Cotterell-buildings Aug., 1896 • • • • • • • • 4 • • • • • • 4 16 • • 32 Lindssy-buildings Aug., 1896 1 5 • • • • • • • • • • • • 6 11 • • 22 • • 9 Powis-buildings Sept., 1896 • • 6 9 • • • • • • • • • • 15 39 • • 78 • • 4 Wimbledon-buildings Oct., 1896 2 4 2 • • • • • • • • • • 8 16 • • 32 3 45 11 4 63 142 284 20 Swan-lane-dwellings— Bermondsey Winchelsea-buildings Oct., 1902 • • 35 30 • • • • • • • • • • 65 160 • • 320 Rye-buildings April, 1903 • • 20 20 • • • • • • • • • • 40 100 • • 200 Sandwich-buildings May, 1903 • • 20 20 • • • • • • • • • • 40 100 • • 200 Hythe-buildings May, 1904 • • 40 25 • • 5 • • • • • • 70 175 • • 350 Seaford-buildings Dec., 1904 • • 20 20 • • • • • • • • • • 40 100 • • 200 135 115 5 255 635 1270 Sylva-cottages Deptford March, 1903 • • • • 24 • • • • • • • • • • 24 72 • • 144 Totterdown-fields estate— Wandsworth Blakenham-road Aug., 1903 • • • • 26 • • 8 • • • • • • 34 110 • • 220 Church-lane May, 1905 • • • • • • • • 11 • • 16 • • 27 124 • • 248 Coteford-street June, 1903 • • • • 165 82 1 • • • • • • 248 827 • • 1572 Cowick-road May, 1903 • • 50 226 8 1 • • • • • • 285 814 • • 1620 Derinton-road Aug., 1903 • • • • 159 64 67 • • 23 • • 313 1116 • • 2168 Franciscan-road Jan., 1907 • • • • • • • • • • 23 18 • • 41 205 • • 387 4 Lessingham-avenue May, 1903 • • • • 18 • • 113 32 63 • • 226 981 • • 1930 Ruislip-street May, 1903 • • • • 29 • • 4 • • • • • • 33 103 • • 206 Okeburn-road Oct., 1909 • • • • • • 54 • • • • • • • • 54 216 • • 378 50 623 208(b) 205 55(c) 120 1261 4496 8729 4 V alette-buildings Hackney May, 1905 • • 39 34 • • 7 • • • • • • 80 208 • • 416 Wandsworth-road-dwellings— Lambeth Lennox-buildings May, 1905 3 17 20 • • • • • • • • • • 40 97 • • 196 Clere-cottages May, 1905 • • • • 7 • • • • • • • • • • 7 21 • • 42 3(g) 17 27 47 118 238 Webber-row estate— Southwark - Delarch-buildings Nov., 1906 • • 20 25 • • • • • • • • • • 45 115 • • 230 Overy-buildings Nov., 1906 • • 20 25 • • • • • • • • • • 45 115 • • 230 Algar-buildings Dec., 1906 • • 20 25 • • • • • • • • • • 45 115 • • 230 Dauncy-buildings Jan., 1907 1 18 26 • • • • • • • • • • 45 115 • • 230 Mawdley-buildings March, 1907 3 13 16 • • 3 5 (c) • • • • 40 114 • • 223 10 4 91 117 3 5(c) 220 574 1143 10 Wenlake-buildings Finsbury March, 1905 25 46 • • 15 • • • • • • 86 248 • • 496 Wessex-buildings Islington Oct., 1904 5 140 80 • • • • • • • • • • 225 525 • • 1050 White Hart-lane estate— Tottenham • • Awlfield-avenue May, 1909 • • • • • • • • 16 • • 11 • • 27 119 • • 238 Balliol-road July, 1910 • • • • 29 • • • • • • • • • • 29 87 • • 174 Benington-road Feb., 1911 • • • • • • • • 32 • • • • • • 32 128 • • 256 Chesthunte-road Sept., 1904 • • • • 44 • • • • • • • • • • 44 132 • • 264 Cumberton-road April, 1910 • • • • 34 • • • • • • • • • • 34 102 • • 204 Kevelioc-road Apr., 1909 • • • • • • • • 18 • • 22 • • 40 182 • • 364 Risley-avenue Sept., 1904 • • • • 44 2 105 2 57 • • 210 855 • • 1706 Shobden-road March, 1907 • • • • • • • • 22 • • 15 • • 37 163 • • 326 Siward-road Feb., 1907 • • • • 46 • • • • • • • • • • 46 138 • • 276 Spigurnell-road Oct., 1906 • • • • 24 • • 16 • • 4 • • 44 156 • • 312 Teynton-terrace Aug., 1904 • • • • 11 • • 7 • • • • • • 18 61 • • 122 Tower-gardens-road July, 1904 • • • • 73 1 91 • • 71 • • 236 942 • • 1883 Walden-road Nov., 1912 • • • • • • • • 8 • • • • • • 8 32 • • 64 Waltheof-a venue June, 1906 • • • • • • • • • • • • 37 • • 37 185 • • 370 Waltheof-row June, 1913 • • • • • • • • • • • • • • • • • • • • • • • • 5 Wateville-road Oct., 1904 • • • • 12 • • 9 • • 18 • • 39 162 • • 324 317 3(b) 324 2(c) 235 881 3444 6883 5 York-street dwellings— Westminster Stirling-buildings June, 1903 5 20 15 • • • • • • • • • • 40 90 • • 180 Siddons-buildings June, 1903 5 10 20 • • 5 • • • • • • 40 105 • • 210 10 30 35 5 80 195 390 Bruce House Westminster July, 1906 • • • • • • • • • • • • • • • • 715(f) 715 3 Carrington-house Deptford Nov., 1903 • • • • • • • • • • • • • • • • • • • • 814(f) 814 3 Parker-street-house Holborn Jan., 1893 • • • • • • • • • • • • • • • • • • • • 345 345 2 Totals 208(a) (e) 3,487 3,982 326(b) 1,201 84(c) 455 3 9,746 27,949 1,874(f) 57,362 116 97 234(d) 39 Note.—In reckoning the number of rooms in the cottages on the Totterdown-fields, White Hart-lane and Norbury estates, kitchen sculleries have been omitted. (a) Five of these tenements also contain a bed recess, and each is reckoned as accommodating three persons. (b) These cottages are reckoned as containing 4 rooms, accommodating seven persons (c) These lettings are reckoned as containing 5 rooms, accommodating 9 persons. (d) Including 12 stables. (e) Sixteen of these lettings also contain a bed recess, and each is reckoned as accommodating 2 persons. (f) Including 8 cubicles at Bruce House and 9 at Carrington House, occupied by staff. (g) Two of these tenements also contain a bed recess, and each is reckoned as accommodating three persons. xix. Annual Report of the London County Council, 1913. Housing of the Working Classes—Statistics. xx. C.—Rents Charged at the Council's Dwellings. Dwellings Borough. Rent per week of tenements. Rent per night of cubicles. Rent per week of workshops Rent per week of sheds. Rent per week of cupboards. rent per annum on 31st March, 1914. 1 room. 2 rooms. 3 rooms. 3 rooms with small additional bedroom. 4 rooms. 4 rooms with small additional bedroom. 5 rooms. 6 rooms. Ann-street-dwellings Poplar 5/- to 6/- 6/6 to 7/6 £ 8. d. 2,129 8 - Barnaby-buildings Bermondsey 5/6 & 6/- 7/6 & 8/- . • 1,427 8 - Battersea-bridge-buildings Battersea 5/- 6/- to 7/6 8/- to 9/- . . , . ., 3d. 1,232 8 - Bearcroft-buildings Fulham 5/9 to 8/6 to 9/6 . . # , 3d. 876 4 - Bekesbourne-buildings 3tepney ft/- to 6/- 6/6 to 7/6 8/- & 8/6 . . 1,242 16 - Borough-road-d wellings Southwark 6/6 to 8/- 9/6 & 10/- . . 1,864 4 - Boundary-street-estate 3ethnal-green 3/-to 4/- 5/- to 8/- 7/- to 10/6 9/- to 13/- . . 10/6 to 14/- 12/6 & 13/ 6 3/6 to 6/ 6 6d. 3d. 23,117 6 - Bourne estate (including shops) lolborn 4/6 to 6/- 7/6 to 8/6 9/6 to 11/- . . 11/—to 13/- . . , . 3d. 13,394 10 - Brightlingsea-buildings i Stepney 3/6 & 4/- 5/- & 5/6 6/6 to 7/6 8/- & 8/6 . . . # • • 1,084 8 - Briscoe-buildings jambeth 6/6 & 7/- 7/6 to 8/6 . . 10/-to11/6 9 # 3d. 2,: 30 9 - Brook-street-dwellings Stepney 5/6 7/-to 8/- . . . . # . 1,014 - - Bruce-house (including shops) Westminster . • . . 6d., 7d. • • 7,672 - 1 1/-&1/ 2 Cable-street-dwellings ! Stepney 4/6 & 5/41 5/6 to 6/6 7/6 . . . . , , 2,955 4 - Caledonian-estate ! slington 1/6 & 5/- 6/6 to 7/6 8/- to 9/6 11/6 " 5,569 4 - Carrington-house ing shops) Deptford . . . . , . 6d. anc 7,689 11 7 Chadworth-buildings 1/- ' cluding shops) ] Tinsbury 6/- to 7/- 8/- to 9/6 . . 10/-to11/- . . # # 3,386 14 - Churchway-dwellings 3t. Pancras 4/6 & 5/- 7/- to 8/- 9/6 to 10/6 11/6 # # 3,893 10 - Cobham-buildings Southwark 6/- 6/- & 6/6 8/6'& 9/- , . . . m # 1,128 8 - Cotton-street-dwellings ' 'oplar 5/6 7/- to 8/- , . . , # m 1,181 14 - Council-buildings, Poplar >oplar . . 5/- to 5/9 7/- & 7/6 , , m B 796 18 - Cranley-buildings ] lolborn 8/- 10/6 # , . , . , # # 288 12 - Darcy-buildings ] dackney 6/- & 6/6 7/6 to 8/6 , , . . . . 741 - - Dufferin-street-dwellings j tfinsbury 2/3 to 2/9 4/6 to 5/- 6/6 & 7/- . . . . i/-&'i/e * 629 4 - Duke's-court-dwellings 1 Westminster 4/- 6/6 8/6 . # 10/6 . > / 2,418 - - Durham-buildings ' Jattersea . . 5/- to 6/- 6/- to 7/6 # , 1,738 2 - East Greenwich-cottages i Greenwich . . 5/- 6/- & 6/6 , , 8/- & 8/6 m # 1,307 16 - Goldsmith's-row-cottages shoreditch . . 5/6 7/6 to 8/6 . . 10/- 481 13 - Hardy-oottages < Greenwich . , 6/- to 7/- . # 876 4 - Herbrand-street -dwellings lolborn J }/6 & 4/- 6/- & 6/6 8/- & 8/6 . . . . # # 3d. 2,767 14 - Holmwood-buildings 1 I southwark 1 8/- & 9/- L0/6&11/6 383 10 • Hughes-fields-cottages Greenwich 5/- & 5/6 6/- to 6/6 V- 2d. £ s. d. 2,044 18 - Idenden cottages Greenwich 8/6 & 9/- • • 1.132 12 - Mallory-buildings ing shops) Holborn 5/- 6/- to 7/- 8/6 to 9/6 • • • • 930 16 - Millbank-estate Westminster 4/6 & 5/- 6/- to 8/6 8/- to 10/6 12/- to 13/- 12/6 3d. 3d. 18,931 18 - Norbury-estate (including 10/6 to shops) Croydon If- to 8/- 8/6 to 9/- -8/6 to 10/6 11/6 10/6 toll/6 11,089 18 - Old Oak-estate (including 116 to shops) Hammersmith 4/- 4/6 & 5/- 6/6 to 9/6 9/- to 10/- 9 /6 to 11/- 12/6 11/6 to 13/- • • 2d. & 3d. 7,425 18 8 Parker-street-house cluding shops) Holborn . . . • . . • ♦ 6d. • • 3,274 8 11 Preston's-road-estate Poplar • , 4/6 & 5/- 6/6 to 8/- • <- • • 3,965 - - Raleigh, Drake and Ben- Greenwich bow-buildings (Hughes- and fields-dwellings) Deptford 5/- <fc 5/6 6/- & 6/6 7/- & 7/6 • • • • • • • • • • 1,911 3 4 Rushworth-street and < - s» Boyfield - street (late 1 Green-street and Gun - street) dwellings Southwark . 4/6 & 5/- 6/6 & 7/- 8/- & 8/6 . . . . . . . • •. 6d. • • 1,783 12 - Shelton-street-dwellings Holborn 5/- 6/6 to 8/- 9/6 . . 11/- k 11/6 s . 4/6 to 6/- •. 1,56) 14 - Swan-lane-dwellings Bermondsey 4/6 to 5/6 6/6 to 8/- 8/- to 9/- . , 4,108 - - Sylva-cottages Deptford 7/6 . . • • . . •. 468 - - Totterdown-fields-estate 9/- to 10/6 to (including shops) Wandsworth 6/6 6/6 to 9/- 10/. 9/- to 11/- 11/- 10/6 to 14/- . • 29,346 16 - Dnion-buildings ing shops) Holborn 4/6 & 5/- 7/- to 8/- 9/- to 10/- . . 10/6toll/6 . . 12/- 4d. 3d 6,264 10 8 Valette-buildings Hackney 6/6 & 7/- 8/- to 9/- # . 10/6 . . 1,673 2 - Wands wcrth - road - dwellings Lambeth 5/6 6/- & 6/6 8/- & 8/6 . . . . 919 2 - Webber-row estate cluding shops) Southwark 5/- 5/6 to 7/6 8/- to 10/- , . 9/- 11/6 # . ., ,, ,. . . 4,903 18 - Wenlake-buildings Finsbury 6/6 & 7/- 8/6 to 9/6 . # 10 /- &10/6 . . ,, ,. . . 1,920 2 - Wessex-buildings Islington 4/- & 4/6 5/6 to 7/- 8/- to 9/- # # . . . . ., . . 4,141 16 - White Hart - lane estate (including shops) Tottenham 6/6 to 9/- 9/- 8/6 to 11/6 11/- 9/3 to 13/- ,, 21,152 - - York-street-dwellings Westminster 4/6 6/6 8/6 10/6 •• •• • • •• 1,519 6 Total £22 6,294 11 3 * Bent per week of stables. xxi. Annual Report of the London County Council, 1913. D.—Accommodation Provided in the Council's Dwellings, and the Gross Rent per annum on 31st March, 1892, and each subsequent Year. Year. Tenements. Rooms. Cubicles. Persons provided for. Gross annual rent. 1892 56 87 — 174 £ 629 s. 4 d. — 1893 56 87 324 498 3,577 12 — 1894 56 87 324 498 3,577 12 — 1895 358 871 324 2,066 8,119 11 8 1896 602 1,485 324 3,294 12,910 1 8 1897 984 2,603 324 5,530 22,020 9 8 1898 1,263 3,261 324 6,846 27,943 5 8 1899 1,355 3,525 321 7,374 30,062 5 8 1900 1,523 3,966 324 8,256 33,832 5 8 1901 2,346 5,936 324 12,196 51,241 17 8 1902 2,951 7,368 324 15,060 62,780 6 8 1903 3,881 9,552 324 19,428 81,087 19 8 1904 4,666 11,661 1,147 24,469 103,090 10 2 1905 5,929 15,098 1,147 31,343 129,129 12 6 1906 6,326 16,352 1,147 33,853 136,315 7 6 1907 7,474 19,879 1,845 41,648 166,949 10 10 1908 7,880 21,085 1,845 44,060 177,487 14 7 1909 8,196 22,210 1,845 46,310 186,096 13 7 1910 8,539 23,578 1846 49,00 194,019 15 - 1911 8,947 25,006 1,849 51,856 207,340 17 4 1912 9,272 26,291 1,856 54,141 213,589 16 2 1913 9,510 27,051 1,856 55,571 218,925 17 10 1914 9,746 27,949 1,874* 57,362 226,294 11 3 * Seventeen occupied by staff. E—Number of Persons Rehoused by the Council after being Displaced by Improvement Education or Clearance Schemes. Dwellings. Metropolitan Borough. Number of displaced persons re-housed. Before 31st March, 1913. During year 1913-4. Total. Ann-street-dwellings Poplar 25 Nil. 25 Bekesbourne-buildings Stepney 37 37 Boundary-street estate Bethnal-green 45 45 Borough-road-dwellings Southwark 50 50 Bourne estate Holborn 222 222 Brightlingsea-buildings Stepney 4 4 Brook-street-d wellings Stepney 9 9 Duke's-court-dwellings Westminster 516 516 Herbrand-street-dwellings Holborn 91 91 Millbank estate Westminster 174 174 Preston's-road-dwellings Poplar 8 8 Rushworth-street and Boyfield-street (late Green-street and Gun-street) dwellings Southwark 13 13 Swan-lane-dwellings Bermondsey 186 186 Russell-court-dwellings Westminster 323 323 Webber-row estate Southwark 12 12 Wenlake-buildings Finsbury 41 41 Totals 1,756 1,756 xxii. Housing of the Working Classes—Statistics. F.—Number of Lettings effected, the number of Tenants who Vacated their Tenements and the number of tenants who were transferred to other tenements in the Council's Dwellings during the Year 1913-1914. Dwellings. Metropolitan Borough. Number of tenements Number of lettings effected. Number of vacations, less transfers. Number of Transfers (not included in number of lettings or vacations) Tenant's notice. Council's notice. Total. Percentage. Ann-street-dwellings Poplar 135 56 49 4 53 39 2 Barnaby-buildings Bermondsey 80 25 23 2 25 31 4 Battersea-bridge-buildings Battersea 69 24 24 2 26 38 7 Bearcroft-buildings Fulham 40 9 8 1 9 22 2 Bekesbourne-buildings Stepney 75 7 6 1 7 9 1 Borough-road-dwellings Southwark 84 13 12 1 13 15 2 Boundary-street-estate Bethnal-green 1,044 251 208 42 250 24 69 Bourne-estate Holborn 537 140 114 24 138 26 78 Brightlingsea-buildings Stepney 65 32 30 4 34 52 4 Briscoe-buildings Lambeth 113 48 49 1 50 44 3 Brook-street-dwellings Stepney 58 19 18 1 19 33 2 Cable-street-dwellings Stepney 180 35 35 35 19 4 Caledonian-estate Islington 272 101 91 4 95 35 68 Chadworth-buildings 'Finsbury 136 25 24 1 25 18 2 Churchway estate St. Pancras 180 40 38 2 40 22 7 Cobham-buildings Southwark 60 11 10 1 11 18 Cotton-street-dwellings Poplar 70 24 19 4 23 33 1 Council-buildings, Poplar Poplar 50 24 20 3 23 46 Cranley-buildings Holborn 12 5 4 1 5 42 Darcy-buildings Hackney 40 13 12 1 13 32 1 Dufferin-street-dwellings Finsbury 56 6 5 1 6 11 4 Duke's-court dwellings Westminster 130 5 4 1 5 4 7 Durham-buildings Battersea 108 26 30 4 34 31 1 East Greenwich-cottages Greenwich 78 17 16 1 17 22 1 Goldsmith's-row-cottages Shoreditch 25 3 3 3 12 Hardy-cottages Greenwich 51 6 5 1 6 12 Herbrand-street-dwellings Holborn 160 11 9 2 11 7 Holmwood-buildings Southwark 16 3 3 3 19 Hughes-fields-cottages Greenwich 134 29 25 4 29 22 2 Hughes-fields-dwellings Deptford 120 26 18 3 21 17 3 Idenden-cottages Greenwich 50 5 5 5 10 Mallory-buildings Finsbury 33 6 6 6 18 Millbank-estate Westminster 895 164 163 3 166 19 48 Norbury estate Croydon 472 59 57 1 58 12 11 *01d Oak estate Hammersmith 304 221 25 1 26 8 4 Preston's-road estate Poplar 263 97 82 7 89 34 31 Rushworth-street and Boyfield-street dwellings (late Greenstreet and Gun-street) Southwark 102 28 26 2 28 27 1 Shelton-street-dwellings Holborn 63 2 2 2 3 Swan-lane-dwellings Bermondsey 255 109 80 11 91 36 4 Sylva-cottages Deptford 24 7 7 7 29 Totterdown-fields-estate Wandsworth 1,261 351 313 29 342 27 79 Union-buildings Holborn 227 19 18 1 19 8 7 Valette-buildings Hackney 80 11 11 11 14 Wandsworth - road - dwellings Lambeth 47 11 11 11 23 Webber-row-estate Southwark 220 38 34 1 35 16 2 Wenlake-buildings Finsbury 86 15 15 15 17 Wessex-buildings Islington 225 75 69 4 73 32 7 * White-Hart-lane estate Tottenham 881 168 119 7 126 14 48 York-street-dwellings Westminster 80 3 3 3 4 1 Totals 9,746 2,423 1,958 184 2,142 22 524 * New cottages were opened at theae estates during the year. 23610 s s xxiii. Annual Report of the London County Council, 1913. G.—Percentage of Total Outgoings for Maintenance on the Rent Receivable for the last Five Years. Dwellings. Metropolitan Borough. 1909-10. 1910-11 1911-12. (b) 1912-13. (b) 1913-14. (b) Ann-street-dwellings Poplar 45 45 41 42 43 Barnaby-buildings Bermondsey 44 43 40 40 41 Battersea-bridge-buildings Battersea 40 39 30 (c) 23 32 Bearcroft-buildings Fulham (c)21 (c)23 34 34 34 Bekesbourne-buildings Stepney 39 39 37 37 37 Borough-road-dwellings Southwark 42 41 36 35 36 Boundary-street estate Bethnal-green 42 42 38 39 40 Bourne estate Holborn 35 35 31 31 32 Brightlingsea-buildings Stepney 41 40 37 36 37 Bruce house Westminster 54 58 58 59 61 Briscoe-buildings Lambeth 41 40 39 37 37 Brook-street-dwellings Stepney 43 44 40 41 40 Cable-street-dwellings Stepney 41 41 39 39 39 Caledonian estate Islington 37 37 39 36 37 Carrington house Deptford 47 47 47 46 49 Churchway-dwellings St. Pancras 37 37 35 35 35 Clerkenwell & Holborn-dwellings Mallory-buildings Holborn 30 37 25 25 25 Union-buildings 34 32 31 30 31 Cobham-buildings Southwark 43 43 39 37 37 Cotton-street-dwellings Poplar 44 44 40 42 44 Council-buildings, Poplar Poplar 45 47 41 44 44 Cranley-buildings Holborn 40 41 37 37 37 Darcy-buildings Hackney 40 38 35 36 35 Dufferin-street-dwellings Finsbury 59 58 53 53 54 Duke's-court dwellings Westminster 37 36 34 35 35 Durham-buildings Battersea 39 40 30 (a)22 31 East Greenwich-cottages Greenwich 41 40 35 37 38 Goldsmith's-row-cottages Shoreditch 42 41 36 36 38 Hardy-cottages Greenwich 40 40 37 39 40 Herbrand-street-dwellings Holborn 37 37 35 34 35 Holmwood-buildings Southwark 49 48 40 42 44 Hughes-fields-cottages Greenwich 42 34 32 34 36 Hughes-fields-dwellings Deptford 39 36 33 36 39 Idenden-cottages Greenwich 38 37 34 36 37 Millbank estate Westminster 36 36 34 33 34 Norbury estate Croydon (a)34 (a) 35 (a)33 (a)36 36 Old Oak estate Hammersmith . . . . . . 44 (a)35 Parker-street house Holborn 67 69 64 65 66 Preston's-road-dwellings Poplar 41 40 36 41 47 Rushworth-street and Boyfieldstreet (late Green-street and Gun-street) dwellings Southwark 43 42 39 38 37 Shelton-street-dwellings Holborn 37 37 34 35 35 St. Luke's-dwellings— Wenlake-buildings Finsbury 38 37 34 34 35 Chadworth-buildings 32 32 29 29 29 Swan-lane-dwellings Bermondsey 43 43 36 37 41 Sylva-cottages Deptford 40 40 36 39 38 Totterdown-fields estate Wandsworth (a)35 (a)33 (a)31 35 36 Valette-buildings Hackney 38 37 34 35 34 Wandsworth-road-dwellings Lambeth 33 38 35 35 35 Webber-row estate Southwark 40 39 35 34 35 Wessex-buildings Islington 39 39 36 36 36 White Hart-lane estate Tottenham (a)(c)24 (a)(c)25 (a) 37 (a)43 (a) 43 York-street-dwellings Westminster 35 34 32 32 32 (a) New buildings were opened during this year. (b) After deducting income tax on interest on capital outlay from maintenance outgoings. Formerly such tax was deducted from debt charges. (c) Rates paid by tenants direct to local authorites. xxiv. Housing of the Working Classes—Statistics. II.—Population of the Council's Dwellings According to the Enumeration taken in March, 1914. Dwellings. Metropolitan Borough. Accommodation. Number of persons in occupation (including children) Number of children under 14 years of age in dwellings. Tenements. Rooms. Boys. Girls. Ann-street-dwellings Poplar 135 315 429 63 70 Barnaby-buildings Bermondsey 80 200 330 60 68 Battersea-bridge-buildings Battersea 69 143 201 38 28 Bearcroft-buildings Fulham 40 110 115 17 17 Bekesbourne-buildings Stepney 75 190 246 30 41 Borough-roadd wellings Southwark 84 200 292 42 51 Boundary-street estate Bethnal-green 1,044 2,690 4,444 842 809 Bourne estate Holborn 537 1,321 1,862 274 265 Brightlingsea-buildings Stepney 65 170 233 46 52 Briscoe-buildings Lambeth 113 359 378 69 73 Brook-street-dwellings Stepney 58 154 236 44 48 Bruce-house Westminster . . (a) 715 715 . . . . Cable-street-dwellings Stepney 180 398 610 114 79 Caledonian estate Islington 272 692 1,010 175 190 Carrington-house Deptford . . (a) 814 505 . . . . Chadworth-buildings Finsbury 136 360 572 94 77 Churchway-dwellings St. Pancras 180 416 614 96 85 Cobham-buildings Southwark 60 139 202 25 41 Cotton-street-dwellings Poplar 70 180 236 33 39 Council-buildings, Poplar Poplar 50 120 150 30 20 Cranley-buildings Holborn 12 30 47 10 4 Darcy-buildings Hackney 40 95 133 25 15 Dufferin-street dwellings Finsbury 56 87 137 24 14 Duke's-court-dwellings Westminster 130 305 462 61 62 Durham-buildings Battersea 108 268 336 61 52 East Greenwich-cottages Greenwich 78 232 313 66 58 Goldsmiths'-row-cottages Shoreditch 25 72 106 10 10 Hardy-cottages Greenwich 51 153 234 48 71 Herbrand-street-dwellings Holborn 160 340 549 96 92 Holmwood-buildings Southwark 16 36 45 9 1 Hughes-fields-cottages Greenwich 134 333 507 102 103 Hughes-fields-dwellings Deptford 120 330 459 110 84 Idenden-cottages Greenwich 50 200 248 52 42 Mallory-buildings Finsbury 33 82 110 13 8 Millbank estate Westminster 895 2,215 2,986 460 454 Norbury estate Croydon 472 790 1,734 305 288 (b)Old Oak estate Hammersmith 304 1,079 1,183 247 210 Parker-street-house Holborn • • • (a) 345 345 Preston's-road estate Poplar 263 649 900 160 172 Rushworth-street and Boyfield-street (late Green-street and Gun-street) dwellings Southwark 102 209 301 37 47 Shelton-street-dwellings Holborn 63 142 231 36 36 Swan-lane-dwellings Bermondsey 255 635 998 211 190 Sylva-cottages Deptford 24 72 88 15 15 Totterdown-fields estate Wandsworth 1,261 4,496 4,807 937 886 Union-buildings Holborn 227 630 895 133 150 Valette-buildings Hackney 80 208 286 43 44 Wandsworth-road-dwellings Lambeth 47 118 148 21 23 Webber-row estate Southwark 220 574 804 132 135 Wenlake-buildings Finsbury 86 248 353 44 38 Wessex-b uildings Islington 225 525 743 110 121 (b)White Hart-lane estate Tottenham 881 3,444 3,403 641 646 York-street dwellings Westminster 80 195 293 43 49 Totals . . . . 9,746 29,823 (c) 37,569 6,357 6,173 (a) Cubicles (including those occupied by staff). (b) New cottages were opened at these estates during the year. (c) Including 1,874 cubicles at lodging houses. xxv. Annual Re-port of the London County Council, 1913. J.—Particulars of Cases of Infectious Diseases Reported by Superintendents and Caretakers as having been Removed from the Council's Dwellings during the Year ended 31st March, 1914. Dwellings. Metropolitan Borough. Erysipelas. Measles. Scarlet Fever. Consumption Diphtheria. Chickenpox. Typhoid or Enteric Fever. Cerebro meningitis. Ann-street-dwellings Poplar . . 2 . 2 . . . Barnaby-buildings Bermondsey . . 1 . 3 . . . Battersea-bridge-buildings Battersea . . 1 . . . . . Bearcroft-buildings Fulham . . . . . . . . Bekesbourne-buildings Stepney . . . . . . . . Borough-road-dwellings Southwark . . 1 . . . . . Boundary-street estate Bethnal-green . . 17 . 14 . . 1 Bourne estate Holborn . . 4 . 2 . . . Brightlingsea-buildings Stepney . . . . 1 . . . Briscoe-buildings Lambeth . . . 1 . 2 1 . Brook-street-dwellings Stepney . . 1 . . . . . Cable- street-dwellings Stepney . 1 1 . . . . . Caledonian estate Islington 1 . 3 . 3 . . . Chadworth-buildings Finsbury . . 1 . . . . . Churchway-buildings St. Pancras . . 1 . . . . . Cobham-buildings Southwark . . . . . . . . Cotton-street-dwellings Poplar . . . . . . . . Council-buildings Poplar . . 1 . . . . . Cranley-buildings Holborn . . . . . . . . Darcy-buildings Hackney . . . . . . . . Dufferin-street-dwellings Finsbury . . . . . . . . Duke's-court-dwellings Westminster . . 3 1 1 . . . Durham-buildings Battersea . 1 . . 1 1 . . East Greenwich-cottages Greenwich . . . . . . . . Goldsmith's-row-cottages Shoreditch . . 1 . . . . . Hardy-cottages Greenwich . . 1 . 1 . . . Herbrand-street-dwellings Holborn . . . . . . . . Holmwood-buildings Southwark . . . . . . . . Hughes-fields-cottages Greenwich . 1 3 . . . 1 . Hughes-fields-dwellings Deptford . 5 2 . 1 . . . Idenden-cottages Greenwich . . . . . . . . Mallory-buildings Finsbury . . . . . . . . Millbank estate Westminster . . 1 . 6 . . . Norbury estate Croydon . . 2 . 3 . . . (a)Old Oak estate Hammersmith . . 3 . . 1 . . Preston's-road estate Poplar . . . . . . . . Rushworth-street and Boyfield-street (late Greenstreet and Gun-street) dwellings Southwark . . . . . . . . Shelton-street-dwellings Holborn . 1 1 . . . . . Swan-lane-dwellings Bermondsey . . 2 . . . . . Sylva-cottages Deptford . . . . 1 . . . Totterdown-fields estate Wandsworth . . 2 . . . . . Union-buildings Holborn . . 3 . . . . . Valette-buildings Hackney . . . . 1 . . . Wandsworth-road-dwollings Lambeth . . . . 1 . . Webber-row estate Southwark . . 4 . . . . . Wenlake-buildings Finsbury . . 6 . 1 . . Wessex-buildings Islington . . 8 . . . . (a)White Hart-lane estate Tottenham . . 17 . 4 1 1 York-street-dwellings Westminster . . 4 . 1 . . Totals . . 1 9 97 2 47 5 3 l (a) New cottages at these estates wore opened during the year. Ixxvi. Housing of the Working Classes—Statistics. K.—Particulars of Births and Deaths in the Council's Dwellings during the Year ended 31st March, 1914. (a) Dwellings. Borough. Births. Deaths. Occurring in the dwellings. Occurring in institutions. . Ann-street-dwellings Poplar 19 6 6 Barnaby-buildings Bermondsey 11 2 2 4 Battersea-bridge-buildings Battersea 4 Bearcroft-buildings Fulham 1 Bekesbourne-buildings Stepney 9 1 1 2 Borough-road-dwellings Southwark 10 1 1 Boundary-street estate Bethnal-green 112 9 15 24 Bourne estate Holborn 56 10 9 19 Brightlingsea-buildings Stepney 5 1 1 2 Briscoe-buildings Lambeth 7 Brook-street-dwellings Stepney 9 1 1 2 Bruce-house Westminster 1 28 29 Cable-street-dwellings Stepney 22 5 4 9 Caledonian estate Islington 23 8 5 13 Carrington house Deptford 17 17 Chadworth-buildings Finsbury 15 2 6 8 Churchway estate St. Pancras 22 3 3 6 Cobham-buildings Southwark 7 1 2 3 Cotton-street-dwellings Poplar 9 1 2 3 Council-buildings, Poplar Poplar 7 4 1 5 Cranley-buildings Holborn 1 1 Darcy-buildings Hackney 4 1 1 Dufferin-street-dwellings Finsbury 1 4 5 Duke's-court-dwellings Westminster 11 6 7 13 Durham-buildings Battersea 6 2 2 East Greenwich-cottages Greenwich 7 2 1 3 Goldsmith's-row-cottages Shoreditch Hardy-cottages Greenwich 7 2 2 Herbrand-street-dwellings Holborn 8 1 1 2 Holmwood-buildings Southwark 3 Hughes-fields-cottages Greenwich 8 1 1 Hughes-fields-dwellings Deptford 15 5 5 10 Idenden-cottages Greenwich 3 1 1 Mallory-buildings Finsbury 1 Millbank estate Westminster 45 15 21 36 Norbury estate Croydon 58 6 3 9 Old Oak estate Hammersmith 8 Parker-street house Holborn 18 18 Preston's-road-dwellings Poplar 28 9 2 11 Rushworth-street and Boyfield-street (late Green-street and Gun-street) dwellings Southwark 9 3 3 Shelton-street-dwellings Holborn 5 Swan-lane-dwellings Bermondsey 40 5 8 13 Sylva-cottages Deptford 2 1 1 Totterdown-fields estate Wandsworth 56 15 14 29 Union-buildings Holborn 20 7 1 8 Valette-buildings Hackney 4 1 1 Wandsworth-road-dwellings Lambeth 6 1 1 Webber-row estate Southwark 16 7 3 10 Wenlake-buildings Finsbury 3 4 2 6 Wessex-buildings Islington 11 1 5 6 White Hart-lane estate Tottenham 122 14 14 York-street-dwellings Westminster 7 2 6 8 Totals 861 166 202 368 (a) The particulars comprised in this table for estates within the County have been supplied by the Medical Officer of Health, and for estates outside the county by the registrars of the districts. 23610 t t xxvii. Annual Report of the London County Council, 1913. L.—Occupations op the Tenants. Nature of occupation. No. Agent 60 Artist and draughtsman 38 Attendant 140 Baker and confectioner 106 Barman and barmaid 25 Basket and brush maker 16 Boilermaker 14 Bookbinder 52 Bootmaker 93 Boxmaker 16 Brass finisher 31 Brewer 10 Bricklayer, mason 70 Butcher 67 Butler 24 Cabdriver 15 Cabinet maker 210 Carman 200 Carpenter and joiner 184 Carpet planner 17 Case maker 12 Cellarman . 24 Charwoman and cleaner 294 Checker 40 Chemist 15 Cigar and cigarette maker 147 Clergyman and churchworker 18 Clerk, etc 594 Coach and motor builder 26 Coachman 20 Collector 25 Commercial traveller 126 Commissionaire 65 Compositor 117 Conductor 123 Cook 86 Cooper 10 Costermonger 21 Cutter 58 Decorator, painter etc. 164 Domestic and hotel servant 47 Dressmaker and milliner 111 Dustman and scavenger 23 Electrician 69 Engine and crane driver 64 Nature of occupation. No. Engineer 136 Engraver 18 Factory worker 22 Farrier 36 Fireman 41 Fitter and plumber 192 Florist 16 Foreman 76 Furrier 27 Gardener and park keeper 37 Gas worker 21 General dealer and hawker 57 Glazier and glassworker 17 Goldsmith and silversmith 41 Hairdresser 33 Harness maker and sadler 12 Hat and cap maker 37 Horsekeeper 38 Housekeeper 65 Independent 112 Inspector 51 Instrument maker 49 Jeweller 19 Journalist 14 Labourer 570 Lamplighter 11 Laundry Worker 13 Leather worker 27 Machinist and machine minder 71. Manager and manageress 55 Mechanic 45 Messenger 71 Metal worker 58 Milkman and dairyman 40 Miscellaneous 99 Mission worker 17 Motorman 239 Musician and artiste 44 Newsagent 32 No occupation 115 Nurse 50 Nature of occupation. No. Packer 132 Pavior 11 Pensioner 100 Platelayer 17 Police constable and sergeant 387 Polisher 51 Porter 365 Portmanteau maker 15 Postman 152 Printer 187 Railway worker, guard and signalman 56 Reader 12 Salesman 248 Sawyer 18 Seaman 36 Shipwright 26 Soldier 18 Sorter and Post Office Worker 77 Stevedore 34 Stoker 72 Storekeeper 64 Superintendent and caretaker 70 Tailor and tailoress 219 Teacher 39 Telegraphist 37 Theatre worker 27 Timekeeper 27 Tinsmith 23 Turner 19 Umbrella and stickmakers 18 Upholsterer 37 Waiter and waitress, steward, etc. 144 Warehouseman 211 Watchmaker 19 Watchman 41 Waterman, boatman, and lighterman 76 Wheelwright 15 Wireman and linesman 34 Woodcarver 28