London County Council. LCC 26 •v : REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1917. 2, Savoy Hill, Victoria Embankment, London, W.c. 2. July, 1918: Printed for THE LONDON COUNTY COUNCIL by odhams limited And may be purchased, either directly or through any Bookseller, from P. S. KING & SON, Ltd., 2 and 4, Great Smith-street, Victoria-street, Westminster, S.W. l. Agents for the sale of the Publications of the London County Council. No 1930 Price Is., post free, Is. 2d. 500—11. 7. 18— 43316 3236 ADMINISTRATIVE COUNTY OF LONDON. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. W. H. HAMER) FOR THI YEAR 1917. Part I.—General. Introduction. The health of London during the year compares not unfavourably with that of 1916, itself a year of low mortality. The long period of very cold, though dry, weather early in 1917 took its toll among the aged, but on the other hand, wet weather in July and August and the consequent absence of high temperatures, was favourable to infant life, the mortality from summer diarrhoea being low. In the autumn also, except during the closing weeks of the year, the conditions were favourable, the mortality from respiratory diseases and influenza being below the quarterly average. Thus, once again, the elements were on the whole, propitious. In last year's Annual Report (p. 36) the question of the possible relation of gunfire on the westerr front to rainfall in South East England, and indirectly to the comparative freedom from scarlet fever prevalence in London was referred to. The subject has been much debated by meteorologists in the last few months, and the view taken has been summarised as follows:— "Much stress has been laid or the relative wetness of the years 1915 and 1916 in the South East of England, but this fact must be considered in connection with the fact that 1917, when the war was at its intensest phase, was a year ol nearly normal fall."* Mr. Fredk. J. Brodie in an analysis of the records (loc cit. December, 1917) writes as follows:— "It may be after all a mere coincidence that the repeated discharge on a wholly unprecedented scale of vast quantities of the most violent explosives ever known to mankind, should have been accompanied in this country by an excess of rain which was far more pronounced in districts lying-contiguous to the seat of war than in any other part of the United Kingdom." . . . "In 1914-17 England, S.E., stands out boldly as the wettest part of the country, with an excess of rainfall amounting to no less than 26 per cent." ..."There can be no question that for so extended a period as three years, an excess of rainfall amounting to as much as 26 per cent, is extremely large and it seems to me very doubtful whether it would be possible to find its equal in the records for any consecutive period of thirty-six months." The relation of rainfall to disease has for long been a subject of great interest, and the phenomenal wetness in South East England since the outbreak of war, whether due or not to gunfire, is unquestionably in part responsible for some of the comparatively low death rates of London during the past three years. The number of marriages registered was somewhat below that for 1916; the marriage-rate is estimated to have been 17 per 1,000, as compared with 19 0 in 1916. The Registrar-General estimates the birth-rate in 1917 at 17 9 per thousand, as compared with 21.5 in 1916. Part of the decline in the rate must be attributed to the sudden fall in the marriage-rate after the first quarter of 1916, a reaction following upon the abnormal increase in 1915. An increase in the proportion of births occurring in institutions is noted, and undoubtedly a change in this direction connotes a diminution in childbirth fatalities both to the mothers and their offspring. Deaths. The death-rate among civilians in 1917 is estimated by the Registrar-General to have been 15.7 per thousand, the corresponding figure for 1916 being 14.6. The higher death-rate of 1917 is accounted for mainly by the high mortality among children between one and five years of age, resulting from the prevalence of measles during the winter and the late autumn. The infant mortality in 1917 was 104 per 1,000 born, as compared with 89 in 1916. The rate was considerably above the average in the first quarter and again at the close of the year, the cause in each case being the adverse climatic conditions. Some comments upon the suggestion which has been made that atmospheric pollution is a prominent if not predominant factor in the causation of infant mortality, are submitted. The Teasons for the fluctuations in infant mortality during the last 50 years are also considered (pp. 3-4). Infectious diseases. The prevalence of the notifiable infectious diseases was, generally speaking, remarkably low in 1917, the only exceptions being diphtheria and cerebrospinal fever, each of which, however, showed a slight decline upon last year's incidence. The number of cases of scarlet fever notified in 1916 and in 1917 was far below any previous annual record since 1890, the first year of notification. It is noteworthy, t hat despite the exceptional circumstances of war there was no serious outbreak in London of smallpox, typhus or typhoid fevers. Early in 1918 smallpox obtained for a time just a footing, but up to May it had not succecded in establishing itself. Only one case of typhus was notified in London, but early in 1918 a small prevalence of this disease was reported among gypsies in Surrey and Sussex. The behaviour of dysentery was carefully watched and two small groups of cases were noted among children in Chelsea and in South Islington; isolated cases were reported, moreover, in various parts of the town, but there was no serious spread of the disease. Upon typhoid fever attention was of course specially focussed. Small outbreaks occurred in asvlum populations drawing patients from London, and certain more extensive asylum outbreaks were recorded in other parts of the country. The prevalence of intestinal diseases and the raised general death-rate among the insane throughout the country, seemed to indicate that in this section of the population the effect of war conditions was being felt. Typhoid fever in the population of London as a whole, remained at the low level of the preceding year, itself low in comparison with 1915. As pointed * Symons' Meteorological Magazine, Feb., 1918. 43316 A 2 out last year, in contradistinction to anything that may have happened in the Army abroad, it cannot be claimed that protective inoculation has had any appreciable influence in maintaining during the war the remarkably low level of typhoid fever reached 14 or 15 years ago in the civilian population. At the end of the year a group of cases among consumers of a certain batch of oysters was recorded. Some increase in the number of deaths registered from phthisis has been apparent for 5 or 6 years past and the reasons for this are considered on p. 6. Towards the end of 1917 and in 1918 there was a new development which has special interest in connection with observations made in London in the last four years with regard to influenza and cerebrospinal fever. It should be premised that in the Annual Reports of 1914, 1915 and 1916, statistical evidence to the effect that epidemics of there two diseases occur concurrently and also in a certain sequence to one another was adduced. Reference was also made to the relationship between poliomyelitis, cerebrospinal fever, and influenza. In 1916 there was a considerable outbreak of poliomyelitis in New York, and in London in that year and again in 1917 there was synchronised prevalence of cerebrospinal fever and of influenza. The recent "obscure disease with cerebral symptoms." At the close of 1917, however, a distinct change of type was manifested. In December, and in the early months of 1918, cases of illness with pulmonary, gastro-intestinal or cerebral symptoms were prevalent, and it soon afterwards became apparent that a special epidemics inference was at work At first the suspicion of some observers fell upon focd, and "botulism" and "solanism" were invoked as the sources of the trouble, but no evidence of this was forthcoming, and it was then agreed that, most of the illnesses with obscure cerebral symptoms must be regarded as cares of polioencephalitis due to special epidemic influence. In Paris, M. Netter described similar cases, and he pointed out that like, prevalences had been noted following immediately upon the pandemic influenza of 1889-90 ; in these epidemics,which appeared in Italy and Hungary, lethargy was a striking symptom, just as here in London the outbreak was described under the title of "epidemic stupor" ; M. Netter also referred to similar prevalences in Austria in 1916-17 of a disease known as "Schlafkrankheit." Polioencephalitis was, moreover, found during the spring of 1918 to be prevalent in epidemic form in other parts of the world, e.g., Germany and South Africa; it further transpired that influenza was raging in Spain and a " new disease " in Sweden. Probable nature of the outbreak. The phenomena of the particular epidemic constitution of 1917-18 arc considered on pp. 7-10; it must suffice here to state that just as encephalitis, febrile cerebritis, influenza and sweats prevailed in Europe 400 years ago and have periodically done so since that time, so, history repeating itself, they have again recently spread widely in the old and new worlds. Thus it would appear that the events of the past few months once more strikingly illustrate the "posting character," the unexpected manifestations and the protean behaviour of "influenza" ; and incidentally, the close connection between polioencephalitis, poliomyelitis, cerebrospinal meningitis and influenza now seems to be established. Often out of a great evil a great good is born, says the proverb, and it may be that recent events will place a limit upon the too exacting claims of causal organisms, and lead to some exercise of the recognised principle known as the Law of Parsimony in considering additions to the list of new diseases. The want of such recognition during the last four years has made the work of administration difficult, and during the past few months there has been quite an outbreak of ephemeral new diseases which, on enquiry, have turned out to be old foes, with faces new only to those not versed in the. history of epidemics. As these pages are passing through the press numerous groups of cases of influenza have been reported from various parts of London, the type of disease now manifested being similar to that observed in the pandemic of 1889-90; the provisional diagnosis above made may be said therefore to be now definitely confirmed. Administration. The tuberculosis scheme adopted by the Council in May, 1914, was continued in operation and was extended during 1917. At the end of the year, arrangements had been made for the use of 231 children's beds and 100 beds for adults in voluntary institutions and in addition beds were available in the institutions of the Metropolitan Asylums Board. As regards children, these numbers were increased to 300 in May, 1918. The number of cases receiving treatment during 1917 included 670 adults and 933 children. Treatment in 37 dispensaries is provided under the borough council schemes. The Invalid Children's Aid Association by agreement with the Council provides some 400 beds for convalescent cases. They assist in supplying surgical instruments and arrange the after care of children treated. There arc 29 interim care committees and one borough committee (Chelsea) supervising the home life of the patients and obtaining for them extra nourishment and suitable employment. On 1st January, 1917, the scheme for the diagnosis and treatment of venereal disease came into force, and during the ensuing twelve months over 12,000 London patients were seen at the London clinics. The administrative work under Part I. of the Children Act, 1908, was transferred to the public health department as from 1st April, 1917, and an account of the work done is given on page 15. Mention was made in last year's annual report (page 3) of depletion of sanitary staffs, and it. was recorded that the assistance of the Local Government. Board had been asked for in this matter. During 1917 it was found necessary again to call attention to delay in the removal of house refuse, and later, improvement was effected. Statements appear on page 16 with regard to the work of the chemical branch of the department and on page 14 on the administration of the Mental Deficiency and Midwives Acts. It. may also be here mentioned that a census in February, 1917, revealed only 24 homeless persons as compared with 370 in the February preceding the outbreak of war. Population. A.—Vital Statistics. The population of London County at the census of the 3rd April, 1911, was 4,521,685, and it was estimated by the Registrar-General from the records of births and deaths to have decreased to 4,518,021 3 by the middle of 1914. From 1915 onwards, estimates of the civil population of London have been made annually by the Registrar-General from the records of the National Register compiled in August, 1915. In preparing the estimates for 1917 the effect of the revision of the Register early in 1918 has, of course, not been taken into account, and consequently the estimate of 4,026,901 civilians in 1917 is probably less accurate than the figures of the two preceding years. The considerable amount of material collected in connection with food rationing schemes should afford a more accurate basis for estimating the recent populations, and perhaps at a later date this material may be made available. The population of the Metropolitan Boroughs in the middle of 1917, as estimated by the RegistrarGeneral, is given in his 14th weekly return of 1918 and is reproduced in table II. appended to this report. Marriages. The marriages registered in London numbered about 39,400 as compared with 43,855 in 191G» 58,354 in 1915 and 43,373 in 1914. During the first half of the year the marriages recorded are about equal to the numbers in 1911-14. The marriage rate for the year 1917 is estimated at 17 per 1,000, the corresponding estimates for 1916 and 1915 being 19 and 26 respectively. The average for the pre-war period 1911-14 was 18.5. Births. The births in London daring 1917 numbered 80,550 as against 99,336 in 1916. The average anuual number born in the four pre-war years 1911-14 was 110,951. The decline in 1917 upon the average for 1911-14 was greatest in the socond half of the year, and amounted to over 30 per cent. The Registrar-General estimates the London birth-rate for 1917 at 17.9, comparing with 21.5 in 1916, and 24 5 in 1911-14. Deaths (all causes). The deaths among the civil population of London during 1917 numbered 63,406 as compared with 62,325 in 1916. The Registrar-General gives the death rate as 15 7 per 1,000 as against 14.7 in 1916. The distribution of the deaths by ages, in 1917 and the three preceding years, is shown in the following table:— Year. 0- 1— 2— 5- 10— 15— 20— 25— 35— 45— 55— 65 + All ages. 1914 11,477 3,189 2,654 1,511 916 1,188 1,36; 3,647 5,365 7,445 8,597 18,687 66,037 1915 11,464 4,044 3,413 1,772 998 1,231 1,369 3,450 5,515 7,859 9,524 21,754 72,393 1916 8,864 2,622 2,298 1,402 866 1,161 1,171 3,206 4,736 6,780 8,628 20,591 62,325 1917 8,400 3,133 2,839 1,407 908 1,294 1,188 3,139 4,747 6,897 8,699 20,755 63,406 Increase ( + ) decrease (—) —464 +511 + 541 + 5 + 42 +133 + 17 — 67 + 11 + 117 + 71 + 164 + 1,081 1917 over 1916 The extremely cold weather experienced in the first, quarter of the year caused a considerable number of death? among persons over 65 years of age, the total deaths at that age during this quarter being more than 20 per cent. above the quarterly average for the preceding six years. On the other hand the favourable weather conditions later in the year resulted in a remarkably low autumnal mortality at all age.3. The prevalence of measles is responsible for the greater proportion of the excess inmortality at ages between one and five years in 1917, as compared with 1916 ; apart from the mortality at this age, the two years show remarkable similarity. Infant mortality. The reduction in mortality among infants under one year of age apparent in the above table, is due in a large measure to decrease in the number of births ; but the death-rate did not exceed 104 per 1,000 born. This relatively small death-rate is largely due to the low mortality from infantile diarrhoea during the summer, when no abnormal heat was experienced. The corresponding mortality rates for 1916 and 1915 were 89 and 112 respectively. In comparing the figures for 1917 with those for the year 1916 (when the infant mortality was the lowest recorded) it is found that the greater part of the excess in 1917 occurred in the first quarter of the year, (115 as compared with 92 in 1916) when the climatic conditions were unusually severe. The mortality from whooping cough was much below the average although in the closing weeks of the year the prevalence due in 1918 was clearly foreshadowed. The death-rate from this cause in the first quarter of 1918 exceeded the rate in any year since 1896. The effect of restriction in the sale of intoxicants in decreasing mortality from overlying was discussed in last year s report; the decline noted is maintained in 1917 exccpt in the first quarter when the deaths, which in the corresponding quarter of 1916 were 47, rose to 72. This marked increase in these fatalities is probably attributable to the abnormally cold weather in this quarter. A similar increase in overlying mortality occurred during the exceptionally cold winter of 1890-91. The Medical Research Committee issued in 1917 a report on " The Mortality of Birth, Infancy and Childhood," which includes an analysis by Dr. W. A. Brend of " The Relative Importance of Prenatal and Post-natal Conditions as Causes of Infant Mortality." Dr. Brend briefly reviews the causes 43316 A 2 4 to which the marked excess of infant mortality in urban over rural districts are commonly ascribed and, eliminating those which lie regards as largely common to both, is led to conclude that the urban excess has little relation to pre-natal conditions, but is due to some factor or factors peculiar to urban districts, "of which possibly the most important is a polluted state of the atmosphere." In proof of his thesis, Dr. Brend relies upon the fact that " in most large cities there is a steady rise in the infant mortality rate as we go from the periphery to the central parts which never receive a wind that has not passed over a smoke-laden area." He selects as a case in point the London area, which he divides into (i) a central part, comprising Finsbury, Shoreditch, Bethnal Green, the City, Southwark, Bermondsey, Stepney and Poplar, the infant mortality in this area in 191+ being 124; (ii) a surrounding area, in which the rate was 97; and finally (iii) an outlying fringe which, north of the Thames, is outside the county boundary, with a rate of 74. In the heart of Dr. Brend's "London area" is the City, where certainly no wind blows that has not passed over an air-polluting district, yet the rate there in 1911-14 was only 98. Moreover, in the Council's dwellings on the Boundary-street area, Bethnal Green, the rate is consistently low, but before the clearance of the area it was altogether excessive. The relatively low rate of infant mortality in the city is consistent with the conditions indicated by the number of persons per room in tenements, which at the last census was only 107 on the average, while in the other districts of Dr. Brend's central area the figure varies from 133 in Poplar to 1G2 in Finsbury. Dr. Brend, in conclusion, advocates, inter alia, the clearance of slums as a remedy for excessive urban infant mortality. Practically all the slum areas of London are situated in just the very boroughs which comprise his central area of maximum atmospheric pollution, and the London figures therefore are of little value in support of his {hypothesis that atmospheric pollution is " possibly the most important " factor in the excess of mortality in the central areas of large towns. The marked decline in infant mortality of recent years has been attributed to the increased attention given to infant welfare. Examination of the third section ("Deviation from an even rate of decline") of the accompanying diagram. however, shows that the fluctuations in mortality at ages 0-5 during more than forty years past broadly follow those at ages 35-75. It would appear therefore that no theory to account for the behaviour of the mortality at the youngest ages can be complete which fails to explain the correspondence shown to exist at the other extreme of life. Smallpox. Infectious Diseases. No cases of smallpox occurred during 1917. Three suspected cases were under observation, but proved not to be cases of smallpox. During February to May 1918, an outbreak of smallpox has occurred in London, comprising 35 cases, and in addition there were 3 cases in East Ham, 4 cases in Dartford and 1 case in Mitcham. The outbreak originated in a very poor area in the borough of Stepney frequented by British and foreign sailors. The first case was not recognised as smallpox, and a crop of 8 cases occurred between the 2nd and 6th March. The unrecognised case was that of a female child, aged six, who died on the 13th February from "pneumonia" accompanied by a profuse eruption. The source from which this child was infected has not been traced, but it is surmised that a sailor from abroad must have visited the house whilst suffering from a modified attack of the disease. There is no doubt that the prompt vaccination and removal of the contacts to observation shelters during the period of quarantine were responsible to a very large extent for restricting spread of the disease. Chicken-pox was made a notifiable disease in London for a period of three months dating from the 27th March, 1918. During the period under review 87 suspected cases of smallpox were seen by Dr. Brincker or his assistant, 6 of which proved to bo smallpox. 5 Typhus fever. One case was notified during the year in Stepney, that of a woman iet. 50, originally notified to be suffering from typhoid fever. Typhoid fever. During 1917 (52 weeks) there were 446 cases of typhoid fever in London as compared with 461 cases in 1916. The number reported in each quarter of the year, except the third, showed decrease upon the corresponding quarter of 1916, and the slight increase in the third quarter is probably merely the reflection of the slightly increased incidence of diarrhoea and enteritis in 1917. On the other hand, the deaths, which in 1916 numbered 75, increased in 1917 to 101, the increase being mainly in the second (8) and third (15) quarters. An analysis of the age and sex incidence of deaths shows that the increase occurs chiefly in the age group 20—45 years and among females. The number of cases in which particulars were obtained by borough medical officers of health as to possible sources of infection was 183. Fish, shellfish, etc., are mentioned in 51 instances; 16 cases were those of soldiers or sailors; in 27 cases the disease was said to have been contracted outside London; 42 were ascribed to contact infection (this number included 9 nurses—there were 3 groups of 2 each and 3 single cases; one of the last-named was almost certainly an oyster case); 5 cases were attributed to river bathing and 1 to a fall into four feet of sewage water; 3 to drainage; 5 to drinking water and 3 to "air raids." In the latter months of the year suspicion was thrown upon oysters as the source of certain cases of typhoid fever, and in some eleven or twelve London cases there is considerable probability that polluted oysters obtained from one particular locality were implicated. Attention was first directed to oysters as the possible source of recent cases by a letter received on the 26th November from a county medical officer regarding a case occurring after a visit to London where oysters were consumed at a certain restaurant. The restaurant in question being situated in Westminster, the letter was forwarded to Dr. Allan and as a result of Dr. Allan's inquiries in connection with this and earlier cases in which oysters came into question, the Fishmongers' Company caused samples of oysters from a certain locality to be submitted to Dr. Klein, who reported them to be not clean. Investigations made by the Company's inspector revealed the fact that some consignments from the source in question had not been relaid for the proper period for cleansing, but had been consigned directly from a polluted source. The circumstances were investigated and confirmed by Dr. McEwen, of the Local Government Board, who succeeded in tracing a number of cases in addition to those occurring in London to oysters from this particular source and took the necessary steps to prevent further mischief. A series of cases has been recently noted in two of the London county asylums, and in the provinces two outbreaks of some severity in asylums have occurred. In none of these cases can it be ascertained that oysters were implicated. Plague. No cases of plague occurred in the administrative county during the year, but on two occasions vessels arrived in the Port of London from the East with cases of plague on board. In one case (the S.S. Sardinia), five of the crew were suffering from the disease when the boat arrived on 2nd May, whilst two had been buried at sea ; the patients were removed to Denton Hospital, together with a suspect case, and three of them subsequently died. On the second occasion ten cases of plague were reported on the S.S. Matiana. All necessary precautions were taken by the Port of London Authority. Anthrax. Six cases of human anthrax occurred in London during 1917, of which two proved fatal. In each instance the patient was engaged in handling skins or hides, which doubtless were the means of conveying the infection. Outbreak of illness of a dysenteric nature. A localised outbreak of severe illness associated with dysenteric symptoms occurred in Chelsea. During the period 4th August to 2nd October, 28 cases were reported, the majority occurring in a circumscribed area comprising six adjoining streets in a poor part of the borough contiguous to the river. The outbreak was investigated by Dr. Palgrave in consultation with Dr. Louis Parkes, the Medical Officer of Health, and Dr. McNalty of the Local Government Board. It was shown that in the fatal cases the disease had a very rapid course, about five or six days, and post-mortem examinations revealed extensive intestinal ulceration and swelling of the mesenteric glands. The bacteriology of the disease was not conclusively cleared up. Of the 28 cases noted during the period specified, 8 died. Young children were mostly affected, although several cases occurrcd among older children and young adults. Ten of the cases occurred in one household. Enquiries into the food and water supply, sanitary arrangements, etc., did not throw any light on the origin of the cases. It was ascertained that a soldier who had recently suffered from dysentery stayed at the house of one of the families attacked, and it is now considered that the whole outbreak originated from this soldier. A similar outbreak was reported about the same time in Islington, where seven cases occurred in two adjoining houses in the same street. A discharged soldier was living in the house occupied by the family originally infected. Within two weeks of the soldier's appearance two adults in the house contracted an acute form of diarrhoea resembling dysentery in certain features. About a week later two children in the family developed a similar condition. They were removed to Great Ormond-street Hospital, where they subsequently died- Post-mortem examinations showed all the appearances of dysentery. In the next house three cases of a like nature occurrcd about the same period. In addition, 12 other deaths in different parts of London were registered as being due to dysentery, but only in two instances were the patients known to have been in closc relationship with soldiers, and none of the soldiers in question were known to have suffered from dysentery. It is important, however, in view of the extensive epidemics of this disease recently reported in the Central Empires and in Eastern Europe, that vigilance should be exercised with a view to preventing outbreaks occurring in this country through the medium of military cases. Malaria. On the 1st August, 1917, intimation was received that a number of Australian munition workers had arrived at Plymouth on board two vessels, the Ulysses and Banalla and that a number of them had 6 been taken ill after landing. One had been admitted to St. George's Hospital as a case of malaria and died a few days later ; another was found to be in St. Mary's Hospital, where he was seen by one of the Council's medical officers, who was of opinion that the man was suffering from pernicious malaria; a third had been admitted to hospital at Ramsgate, where he subsequently died with acute malarial fever ; the fourth was admitted to an institution at Grimsby whilst a fifth patient was treated in the infirmary at Dundee as a case of enteric fever. The last two cases were also reported subsequently to have malaria. A number of deaths from malaria also occurred amongst the troops after their arrival at Salisbury Plain. Upon further enquiry it was ascertained that the vessels had come from Sydney and had called at Sierra Leone en route, where they stayed for four nights. These vessels and several others which arrived about the same time carried Australian troops, in addition to munition workers who were contracted out by the Australian Commonwealth to the Ministry of Munitions for labour in all parts of the country. No further developments arose in the London area. The Local Government Board later issued a memorandum for the information of medical officers of health throughout the country, dealing with indigenous cases of malaria in England. Tuberculosis. Phthisis. The number of deaths from pulmonary tuberculosis in the civil population of London during 1917 was 6,908, compared with 6,491 in 1916 and 6,875 in 1915 There has, therefore, during the course of the war been a serious increase in the mortality from phthisis, the average annual number of deaths during 1911-14 being only 6,286 in the total population. For nearly 50 years the phthisis mortality in London has, with occasional years or short periods of exception, persistently fallen ; the first indication of a pause in the decline was in 1914. The hardship and exposure of war directly and immediately affected the mortality of males of military age; but as there has also been an increase in the female mortality during the war period, other causes must be looked for. It has been pointed out in previous reports that one of the consequences of notification of tuberculosis would be to increase the recorded death-rate, the reason being that in the case of a notified phthisic dying from some concurrent disease, the phthisis history would be less likely to bo overlooked in certifying the cause of death. This influence would attain a maximum effect some time after the introduction of compulsory notification (1st Feb., 1913) and of National Insurance (15th July, 1912); and some proportion of the recorded increase may be attributed to more accurate death-certification. Emigration to the colonies, and resort to Continental sanatoria must largely have been arrested on the outbreak of war, and simultaneously the great increase of sanatorium treatment in the United Kingdom under the Insurance Acts must have led to the retention in this country of a certain number of phthisics ; doubtless, deaths among these which before the war would have been recorded elsewhere, are now included in London records. Lack of food and disturbance of the normal dietary are both factors tending to increase susceptibility to phthisical infection, but during the years 1915 and 1916, neither can have been largely operative. In 1917, however, many articles of popular dietary were either scarce or expensive and to this cause some share of the increased phthisis rate of that year may be attributed : at any rate, while the increase in 1915 was undoubtedly augmented by the adverse climatic conditions and the prevalence of pneumonia, etc., this cause did not largely affect the year 1917. Turning to the consideration of special classes of the population it is noteworthy that there has been a marked increase in the deaths from phthisis among inmates of lunatic asylums. The increase is remarkable because of its great excess above that observed in the general population, for while in the country as a whole the female deaths increased by 261 in 1916 over 1915, in asylums alone the increase was 133. The asylums increase was greatest between 30 and 60 years of age, the female deaths at this age period being 623 in 1915 and 719 in 1916, while in England and Wales as a whole the deaths declined from 8,698 to 8,627. On the other hand at ages below 30 years the female deaths in asylums increased from 196 to 230 and in England and Wales from 8,173 to 8,570. The following paragraph appears in the Annual Report of the Board of Control for 1916, p. 13: " The continuance throughout the year of war conditions, led to great and increasing difficulties in the administration of asylums, mainly through the diminution of the staffs by the withdrawal of large numbers of the most efficient officers for military service, and through the curtailment of accommodation by the conversion of several institutions into war hospitals and consequent overcrowding of those which remained in use as asylums." Reference is made elsewhere in the same report (p. 60) to similar consequences of the war in Poor Law Institutions, but "there lias been during the period a marked decrease in the ordinary workhouse population, many of the country workhouses having very few inmates." It is possible therefore, that the conditions have been less unfavourable in Poor Law Institutions on the whole, than in asylums, and the absence of a correspondingly marked increase in them of the phthisis mortality may be thus accounted for. Tuberculosis, other than pulmonary, caused 1,575 deaths among London civilians in 1917, the figures for 1916 and 1915 being 1,514 and 1,681 respectively. The number of " primary " cases of tuberculosis notified during 1917 (52 weeks) was 18,735, as compared with 17,631 in 1916 and 18,661 in 1915. Of these, 14,871 were pulmonary, and 3,864 other forms of tuberculosis, the corresponding figures in 1916 being 13,547 and 4,084 respectively. These figures, differing from those given elsewhere in this report, include cases among soldiers and sailors. Notification of tuberculosis 7 The following is an analysis of the cases notified in London in 1917 (52 weeks). Form of tuberculosis notified. Sex Notifications on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, infra). 0- 1— 5— 10— 15— 20— 25— 35 — 45 — 55— 65 + Age not stated Total. Pulmonary tuberculosis M. 21 127 444 310 683 887 2,227 2,154 1,272 615 182 15 8,937 F. 16 132 333 412 606 737 1,397 1,104 525 272 137 — 5,671 Other tuberculosis M. 91 380 530 325 163 71 83 69 51 23 17 2 1,805 F. 76 336 457 309 156 94 128 52 30 22 17 — 1,677 All forms of tuberculosis M. 112 507 974 635 846 958 2,310 2,223 1,323 638 199 17 10,742 F. 92 468 790 721 762 831 1,525 1,156 555 294 154 – 7,348 Form of tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools). Notifications on Form C. (Secondary notifications from institutions receiving cases). 0— 5— 10— 15 + Total. Poor law. Other. Pulmonary tuberculosis M. 4 81 46 3 134 1,760 2,045 F. 3 70 54 2 129 949 1,397 Other tuberculosis M. 5 136 54 1 196 259 73 F. 1 105 79 1 186 210 78 All forms of tuberculosis M. 9 217 100 4 330 2,019 2,118 F. 4 175 133 3 315 1,159 1,475 Influenza, Bronchitis and Pneumonia. Ever since the first institution of registration these causes of death have shown increase from time to time, as though in response to the stimulus of an epidemic influence; in other words, the great influenza outbreak of 1847–48; the succeeding minor prevalences of 1851, '55, '58, '62-63, '69 and '75; the then following pandemic of 1890, with the subsequent epidemic waves of 1891, '92, '95 and 1900 ; and the lesser waves of 1908-09 and of more recent years, have each and all been accompanied by noteworthy increase in the number of deaths returned as due to "bronchitis" and "pneumonia." Again, in addition to the well-known type with respiratory complications, influenza has been found to present from time to time distinct gastro-intestinal and nervous types, and during recent years, in London, the welling up in each first quarter of the year of deaths attributed to influenza and to respiratory diseases has been accompanied by a corresponding increase in the number of deaths ascribed to cerebro-spinal fever. It should further be noted that there has been apparent in London for some years past an approximation or merging into one another of the prevalences of illness attributed in the earlier months of each year to cerebro-spinal fever and later in the summer months diagnosed as poliomyelitis. The question was thus seen to arise, and has been discussed in the Annual Reports for 1914, 1915 and 1916, as to the need from an epidemiological point of view for associating the prevalence of influenza not only with illnesses in which respiratory and gastro-intestinal complications are present, but also with illnesses in which disturbances affecting the central nervous system predominate. It has, in fact, become apparent that, it is now necessary to consider the desirability of enlarging the present connotation of the term influenza. The varieties of influenza Influenza, Cerebro-spinal Fever and Poliomyelitis. Dr. Franklin Parsons, in his report on the influenza epidemic of 1889-90, wrote as follows :— By many observers throe forms of influenza have been recognised, viz. :— "(a) Nervous- The prevalent form in the epidemic of 1889-90, characterised by groat depression and severe pains in the head, spinal region and muscles." (He adds, some distinguish a rheumatic form characterised especially by pains in the muscles and joints.) "(b) Catarrhal—Marked by coryza and tendency to congestion of the respiratory mucous tract. "(c) Gastric—Especially noticed in children and marked by vomiting, diarrhoea and other symptoms of gastro-intestinal disturbance. "These three forms have all been observed in cases occurring together under the same roof and are evidently mere varieties of the same disease," 8 The change of view brought about by study of bacteriology In his further report, published in 1893 he has a note on "clinical features of the later epidemics," in which he specially refers to the "greater tendency to lung complications" and to "profound disturbance of nutrition of the nervous system," and he adds, "some practitioners in the eastern counties have observed influenza to have been accompanied or followed in the later epidemics by symptoms resembling those of cerebro-spinal meningitis." He also quotes Dr. Bezley Thome to the effect that " influenza essentially consists of symptoms caused by toxic influences exerted upon the cerebro-spinal meninges." It may be added that Graves believed " the poison which produced influenza acted on the nervous system in general," and he quotes Dr. Peyton Blakiston's statement that "influenza is an affection of the nervous system." The position taken up by Dr. Parsons was the result of the experience of the pandemic of 1890-92 studied in the light of the epidemiological teaching current at that time. But then came a change of outlook associated with the rapid development of the study of, bacteriology. Quite at the outset a "causal germ," Pfeiffer's bacillus, was invoked as producing the at that time, common type of influenza; then at a later date the part played by other germs was considered, and at length, in 1887, the meningococcus of Weiehselbaum was identified and declared to be ' the causal organism of cerebro-sninal fever. The easy descent was already in full progress at the close of the century. Thus, in Dr. Bruce Low's paper on Epidemic Cerebro-spinal Meningitis, of 1889, reference is made to the fact that this disease and influenza not infrequently concur and that the one may be mistaken for the other, and then follows this striking passage : " Some authorities, indeed, have advanceel the view that these two diseases are one and the same. But it is now generally admitted that epidemic influenza is associated with a special organism, the bacillus of Pfeiffcr, and as will shortly be seen, cerebro-spinal fever is now known to be associated with a special diplococcus. So that to the bacteriologist in future we shall have to look to settle the diagnosis in doubtful cases." The outcome • of this sale of the birthright of epidemiology has been serious enough, and the trouble would never have arisen if more attention had been paid to the epidemiological teaching. Sydenham wrote in the second chapter (On Epidemic Diseases) of his Medical Observations " Nothing, in my opinion, strikes the mind that contemplates the whole and open domain of medicine with greater wonder than the well-known varied anel inconsistent character of those diseases which we call epidemic. It is not so much that they reflect and depend upon different conditions of climate in one and the same year as that they represent different and dissimilar constitutions of different and dissimilar years." The contrast with the modern point of view may be illustrated by comparing Sydenham's description of the new fever of 1685 with the bacteriological study of the epidemic visitation of 1915. Account is given of the former in Sydenham's "Schedula Monitoria" and the description closely tallies (see Proc. Roy. Soc. Med. Vol. 8) with that of the epidemic which prevailed in London three years ago. Sydenham states that his epidemic "commenced in February and the patient often had chills and flushes by turns and frequently complained of pain in his head and joints and generally had a cough. There was pain also in the neck and fauces, the fever was continued, and the patient might determine the. fever to the brain and convert it to a frenzy " ; petechia? and purple blotches, perspirations and peripneumonies are all referred to, and it is added that "of all the fevers this attacked the brain most and could not bo detached from it without great trouble and danger." All this repeated itself in February 1915, but the bacteriologists could not see the wood bccause of the trees and hencc roferrcd each particular symptom complex as it presented itself to its supposed appropriate "causal organism." It was impossible therefore to avoid surmising that Sydenham, if he were back here among us, would laugh when he was told that the influenza-like cases of the 1915 outbreak were due to Pfeiffer's bacillus and the sore throats were due to the micrococcus catarrhalis, and certain other conditions were due to pneumococci and streptococci and others to meningococci and yet others to parameningococci. He would surely eleclare that the germs which the bacteriologists were demonstrating were nothing more than " associated organisms " or " sccondary invaders." The relation between cases of cerebrospinal fever and poliomyolit:s and the so-called abortive cases, many of which are described as cases of influenza. In London, cerebrospinal fever was first made notifiable in 1907 and poliomyelitis in 1911. Study has been made of the confusion which has arisen between epidemics of cerebrospinal fever and influenza for over twelve years, attention being first called to it by the occurrence of "an epidemic simulating influenza " in East Herts in the winter of 1904-05. This was described as a " new disease," and influenza throughout the entire history has, of course, been commonly designated by that name. In 1906-07 an " outbreak simulating influenza " occurred in an institution in Holborn. At that time it seemed obvious that the cases which were being described as cerebrospinal fever in Glasgow and Belfast had at any rate some counterpart in the influenzas then prevailing in London. It was also then quite clear that, as Dr. Parsons had already pointed out in 1891, different forms of influenza might occur under the same roof and were evidently mere varieties of the same disease. Two or three years after this Dr. Brorstrom's report upon epidemic poliomyelitis in Sweden was published. In this volume, " Akute Kinderlahmung und Influenza," Leipzig, 1910, the epidemiological relationship of the cases of poliomyelitis and of influenza was plainly demonstrated. But the same question had already been seen to arise in London with regard to cerebrospinal meningitis and influenza, and, furthermore, the differentiation between poliomyelitis anel cerebrospinal fever, though a simple enough task, bacteriologically speaking, was found by clinicians and epidemiologists when the relation of case to case came to be stuelieel to present great difficulties. In point of fact, in the light of the classification into varieties of poliomyelitis acuta formulated by Wickman, a classification accepted by later authorities, the supposed clear signs of distinction between poliomyelitis and cerebrospinal meningitis, from the epidemiological point of view, disappear. The difficulty of diagnosis was being experienced, it was found, not only in London, but throughout the country, by inspectors of the. Local Government Board, and in order temporarily to meet the official requirements of the case it was arranged that in London all reports relating to 9 The epidemic constitution of 1917. myelitis should be made upon blue forms and all reports relating to cerebro-spinal fever upon white forms. Peace reigned under this dispensation until early in the present year, when it was found that the "well-known varied and inconsistent character" of the epidemic disease, recognised 250 years ago by Sydenham, was being yet again exhibited, and now the places both of cerebrospinal meningitis and of acute poliomyelitis were being usurped by a closely related polioencephalitis, for the recording of cases of which a new form distinct from the blue and white forms became necessary. Brief reference to this new variety of epidemic disease, which curiously enough, was at first confused with " botulism " will be made later. But first it is necessary to consider the epidemic constitution of the early part of 1917. In previous annual reports statistical evidence to the effect that cases of cerebrospinal fever and cases of influenza were associated one with another to a greater extent than mere chance could explain, has been adduced. In a paper on " The Epidemiology of Cerebrospinal Fever " (Proc. of the Roy. Soc. Med. Vol. X.) the time relationships of prevalences of pandemic influenza and prevalences of cerebrospinal fever were set out, and examination was made of the hypothesis that cerebrospinal fever must be regarded as "a complication or sequela of influenza, it being assumed that owing to special circumstances some individuals, when attacked by influenza, develop cerebrospinal fever." Shortly after this paper appeared it was ascertained that an important epidemiological enquiry had been conducted during the preceding two years, the outcome of which was the demonstration of the occurrence in association with cases of cerebrospinal fever of abortive forms of illness described as influenza, pneumonia, catarrh, etc. The report on the results of this enquiry has not yet been published, and it is therefore only possible to say here that it proves the existence between cerebrospinal fever and so-called influenza of a relationship similar to that shown by Brorstrom to obtain between acute poliomyelitis and influenza. It may be added that reports of 1917 from bacteriologists of the Medical Research Committee and of the Local Government Board reveal some divergences of view, the one school places reliance mainly upon serological, the other exclusively upon cultural tests ; and from this there now emerges a disposition to approach the epidemiological standpoint and to invoke the doctrine of " temporarily • enhanced virulence," due to " the action of some unknown influence, telluric, climatic, or other, which becomes operative under conditions of which we remain ignorant." There is thus an approximation to the attitude of those who hold that the meningococcus is not the causal organism of cerebrospinal fever, although it may assume importance as a secondary invader when activated by some "unknown influence" temporarily endowing it with virulence. This view, which has always been urged in these annual reports, has at least the merit of being reconcilable with field observations. The hypothesis is examined further elsewhere (Vol. X. Proc. Roy. Soc. Med). It is urged, in brief, that the reaction between the epidemic influence and the individual attacked, may vary at diflierent phases of major waves of prevalence ; and that the epidemic form of cerebrospinal fever represents the particular type assumed in " trailing epidemics " of influenza, in those members of the community who have not acquired any sort of protection at a previous date. The bearing of (he foregoing argument and its application to the now {May, 1918) prevailing type oj epidemic influence. Influenza, epidemiologically speaking, has always had three striking characteristics. (i.) its " posting character " involving large areas of the inhabited globe and prevailing in each affected community for some three or four months ; (ii.) its power of impressing the mind of observers as being a "new disease." (iii.) its ''protean manifestations." These three characteristics are to be preferred in making the epidemiological diagnosis to indications such as the presence in particular cases of sweats, or primary and secondary rashes, or even of Kernig's or Babinsky's signs. After a main epidemic or pandemic outbreak of influenza, in the explosive violence of which nearly the entire community is affected, and in which symptoms of involvement of the cerebrospinal nervous system are apt, as Dr. Bezley Thome pointed out, to predominate, the outbreak may settle down, particularly in large urban communities, and become endemic, affecting then mainly specially susceptible individuals. In them the prevalence may assume, particularly in cold countries, the respiratory type—"the mistborn spectre" type—so common in the early nineties in Northern Europe, or, on the other hand, gastro-intestinal outbreaks may occasionally be observed, or gastro-intestinal symptoms maybe encountered in individual instances among groups of persons attacked by the disease in one of its more usual forms ; or again, cerebrospinal meningitis, poliomyelitis, polioencephalitis, or other manifestations of involvement of the central nervous system may present themselves. The habitual sufferer from recurring attacks learns to appreciate the protean character of the disease affecting him, according as one or other type prevails, or as one or other locus minoris resistentiae is involved ; he may present in one attack a pharyngeal catarrh, or an otalgia, a catarrh of some other mucous surface, a myalgia (stiff neck, lumbago, sciatica) or, again, herpetic or other eruptions; but while the system of such sufferers is invaded in the outworks, so to speak, the patients seem to enjoy a kind of protection of vital organs against the more severe manifestations of influenza. After 15 or 20 years the prevalence again becomes widespread, and it is possible now, in the light of study of the intervening " trailing epidemics " and of some knowledge of epidemiologyf to recognise the cloven hoof. Thus, the sweating sicknesses of the middle ages, the dengue of the tropics, the cerebritis, encephalitis, brain fever, etc., outbreaks of the older records, are all extraordinarily true to one or other type of influenza, and all manifest the three main characteristics above described. 43316 B 10 The outbreak which has recently aroused much attention had doubtless been brewing since the end of 1917. As early as December of that year certain anomalous cases of suddenly appearing stupor, in which suspicion arose as to pneumonia, cerebrospinal meningitis, typhus, etc., were noted ; and there can be no doubt that during the early months of 1918 in addition to the ordinarily occurring influenzas of the winter season there were numerous attacks of unusual severity in which much difficulty arose as to diagnosis from typhus and spotted fever, from encephalitis, cerebrospinal fever and acute pneumonia. The Lancet, of April 7, 1918, published two papers in which the "new disease" was declared to be botulism, and later other articles of food than sausages were held to be suspect. There was at no time, however, any actual evidence pointing to food origin of the outbreak, and it speedily became clear that the prevailing type was a polioencephalitis of the kind described in recent years by Wickman, Brorstrom, and many others, as occurring in association with outbreaks of acute poliomyelitis. But here, again, the "posting character" of the prevalence, the creation of the impression of its being a "new disease" * and its "protean manifestations" were all to hand; and the association of cases of polioencephalitis in the early stages of the outbreak with cases of influenza, bronchitis and pneumonia, and later with cerebrospinal fever and poliomyelitis, can leave no doubt but that the prevailing epidemic was identical with all the other posting and protean "new diseases" of the last five centuries, in fact with what, in the absence of knowledge of its essential cause, can perhaps best be described as the influence —influenzaf. It should be noted as a question of possible importance that at the time when a pandemic prevalence of influenza might perhaps have been forecasted in this country, in the light of the epidemiological history, the number of persons landing from abroad was to a large extent limited to soldiers or to persons engaged on special military duties. Thus, the place of the large numbers of civilian migrants and transmigrants coming to London at the time of the last pandemic, 1889-90, has been for the most part filled by Colonial and more recently by American soldiers; there has been in addition, of course, the arrival of men on leave from the front and of wounded. The question arises, therefore, as to whether the recent epidemic influence has in the main been derived from the east or the west. As regards the former, little had been heard up to May of influenza on the continent, though that disease and polioencephalitis are said to have prevailed in Germany and recent accounts are forthcoming of influenza from Spain and of polioencephalitis from Paris ; furthermore some suspicion may attach to the " pyrexias of unknown origin "and perhaps to some of the cases ascribed to "trench fever" among British troops. It is in particular deserving of note in this connection, that according to a recent paper by Captains Sundell and Narkivell, in the Lancet, March 16, 1918, three types of onset of trench fever are observed: "1 General, with prostration, etc.; 2. Abdominal; 3. Cerebrospinal. This last type forms roughly 1 per cent. of the cases." This classification applied to a "new disease" at least arouses some suspicion. As regards origin from the west, it is known that in New York in 1916 there was a considerable prevalence of poliomyelitis, and for some time before this, cerebrospinal meningitis was reported from the States and from Canada ; it may be, therefore, that infection has been transmitted preponderatingly from the west during the war period and that this fact is in part responsible for the special type of disease hitherto observed here. (See footnote +). An examination of the recorded outbreaks of influenza in this country shows, however, that when the epidemic has prevailed in the spring and summer, cases of nervous type have predominated. Thus, in 1658, in April, there was " much cephalic affection," followed in the summer by a new fever in which the sufferers were " ill in their brain and nervous stocks." Creighton notes that " spots " were commonly observed, and that "those who died passed away in a stupor." lie says the account given of the exanthem "reminds one rather of the rash of sweating sickness and of dengue (break bono fever) than of the spots of typhus." Again in 1710, 1743, 1767, 1803, 1831 and 1833, great epidemics prevailed in the spring and "nervous disturbance* and "affection of the head" predominated. It will be seen, therefore, that the present type of epidemic prevalence (May, 1918) is in no way aberrant, though it differs from the respiratory type of influenza obtaining in winter with which the present generation of practitioners is especially familiar. Cerebrospinal meningitis. During 1917, 430 cases of cerebrospinal fever and post basic meningitis were notified in London including 25 military cases. Of these 38 proved subsequently not to be cases of cerebrospinal meningitis. On the other hand, 15 cases came under observation, which were not officially notified. Thus 382 actual cases were known to have occurred during 1917 among the London civilian population, of which 227 proved fatal. The following table is of interest as showing the number of cases notified during the past 10 years. No. of cases notified 1908. 1909. 1910. 1911. 1912. 1913. 1914. 1915. 1916. 1917. 85 111 115 101 105 92 73 627a 425a 382a a Not including military cases. * Epidemics of influenza have generally taken the world by surprise and they have been initially described as "new disease," "new delight," "new acquaintance," or in the older phraseology as "stop gallant," "stop, knave, and know thy master," etc.; or, again, recently as the "mystic disease," or "a new and strange outbreak the germ of which has not yet been discovered." † Since writing the above, the question has been decisively cleared up by the widespread occurrence of groups of cafes of influenza of the type commonly observed in the great prevalenco of 1889-90. 11 Poliomyelitis. Detailed particulars on a uniform schedule concerning 387 notified cases were received during the year from borough medical officers and were circulated in accordance with the customary practice. The Council's experts have been called in consultation in 55 suspected cases of the disease and lumbar punctures were performed in 43 cases. Of these 16 were confirmed bacteriologically, whilst of those in which the meningococcus was not isolated 2 were ultimately notified as cases of cerebrospinal meningitis, 6 proved to be tuberculous, 2 serous, 1 septic, and 1 post-basic, meningitis ; the remainder were associated with various other conditions. During 1917, 53 cases of poliomyelitis or polioencephalitis were notified in London, but in 3 instances the diagnosis was subsequently withdrawn. This number is the lowest recorded since the disease was made notifiable in 1911. Detailed particulars respecting 49 cases were received from the borough medical officers. The cases were fairly evenly distributed throughout the year; the usual increase in the late summer was not experienced. B.—Administkation. Certain statistical information available is summarised in Table II. appended to this report. Tuberculous Milk.—L.C.C. (General Potcers) Act, 1904, Pari V., and 1907, Part IV. The Council's inspectors obtained 416 samples from churns of milk consigned from the country to tho various London railway termini, and these were submitted to the Lister Institute for bacteriological examination. The milk was sent to London from 27 counties. Of 409 completed examinations, 42, or 10.3 per cent., yielded tubercle bacilli, as against 8 7 per cent. in 1916, 6 5 per cent. in 1915 and 7 9 per cent. in 1914. In connection with these samples the veterinary inspector visited 41 farms and examined 1,770 cows. It was found that 22 cows, i.e., 12 per cent., showed signs of tuberculosis in one or more of its forms, or were otherwise unhealthy. In the case of each cow suffering from tuberculosis, the farmer undertook to have the animal slaughtered and meanwhile not again to use the milk. In addition, the inspector re-visited 148 farms, and inspected 5,845 cows ; all the animals examined at these re-visits were found to be in a satisfactory condition. During the period 27th January to 26th November, 1917, there were three inspections of the cows kept in the 145 London cowsheds. In all, 5,649 examinations were made. No cases of tuberculosis of the udder were detected, but in 61 cases other unhealthy conditions of the udder were found. Two cows were found presenting symptoms of pulmonary or general tuberculosis, and these were slaughtered or disposed of by tho owners. The number of cows examined in London cowsheds during the first quarter of 1914 was 2,676, while at the last quarter of 1917 the number was 1,771. Housing of the Working Classes Acts. Owing largely to conditions brought about by the war, the provisions of section 17 of the Housing and Town Planning Act have not been utilised to any great extent during the year. The action taken by the metropolitan borough councils under the Act with regard to the making of representations and closing orders is shown in the following table—the figures for the years 1914, 1915 and 1916 being included for comparison. Metropolitan borough. No. of representations. No. of closing orders. No. of houses demolished. 1914. 1915. 1916. 1917. 1914. 1915. 1916. 1917. 1914. 1915. 1916. 1917. Battersea 185 38 – – – – – – – Bermondsey — — — — — — — — 36 — — — Bethnal Green 31 3 31 — 25 3 16 — — 2 Camberwell — — — — — — — — — — — — Chelsea 3 — — — — — — — — — 8 Deptford 5 5 2 — 5 5 2 — 6 2 — Finsbury — 2 — 15 — 2 — 15 — — — — Fulham — 1 — — — 1 — — — — — Greenwich 193 — — — — — — — — — Hackney — 29 — — — 29 — — — — — — Hammersmith 37 26 — — 6 26 12 — — 3 22 • Hampstead 9 3 4 — 9 3 4 — 5 — — — Holborn 2 3 — — 2 1 — — — — Islington 21 8 — — 1 8 — — 6 1 — — Kensington 13 9 — — 3 9 — — — — — — Lambeth 7 — — — 7 — — — 7 — — — Lewisham — 6 — 3 3 12 4 3 6 — l'addington 5 1 1 — 5 1 — — — — — — Poplar 10 17 5 7 10 17 5 7 2 — — — St. Marylebone 1 3 — — — 2 — — 6 — — — St. Pancras 37 18 15 2 — 29 9 4 — — Shoreditch — 3 — — — 3 — — — — 7 Southwark — — — — — — — — — — 32 Stepney 6 23 — — 6 23 34 2 — — — 2 Stoke Newington — — — — — — — — — — — — Wandsworth — — — – — — – — — — 6 Westminster, City of — 2 4 — — 4 1 — 11 8 31 Woolwich 18 11 6 4 9 9 4 4 7 — 4 1 43316 B 2 12 Depletion of Sanitary Staffs. The difficulties referred to in last year's Report as being still outstanding in two boroughs were satisfactorily dealt with early in 1917. In the early part of the year the attention of the Local Government Board was again drawn to difficulties experienced by several of the metropolitan borough councils with regard to collection and disposal of house refuse due to the depletion of staffs, shortage of labour and restricted transport facilities. In several instances the intervals between collections were as long as four weeks, and accumulations of collected refuse remained on wharves or at railway sidings owing to the absence of barges or scarcity of trucks. By midsummer considerable improvement had been effected in the collection and disposal of house refuse throughout the metropolis. National Insurance Acts 1911-13—Treatment of Tuberculosis. The scheme for the treatment of tuberculosis in London adopted by the Council in May, 1914, and the arrangements approved in June of the following year for the appointment of interim care committees continued in operation during the year 1917. Shortly stated, this scheme places the responsibility for dispensary treatment upon the borough councils, with financial assistance from the Council to the extent of 25 per cent. of the cost of treatment of uninsured persons ; the Council further makes at its own expense arrangements for the treatment in residential institutions of uninsured persons by taking beds in voluntary hospitals and sanatoria, and it provides by arrangement with the Metropolitan Asylums Board for the use of beds in their institutions, the cost of the latter being borne by the Board. In the case of children treated in residential institutions, the parents are asked to pay to the Council a small sum roughly representing the cost of the child's maintenance at home. In adult cases free treatment is provided where the income does not exceed £160 a year. Where the income of the patient or the person responsible for the patient's maintenance exceeds this amount a contribution may be asked for towards the cost of treatment. The London Insurance Committee deals with insured persons both in respect of dispensary treatment and treatment in residential institutions. Dispensary treatment for insured persons is provided as part of the schemes of borough councils by agreement between the London Insurance Committee and the respective borough councils. The use of the dispensary at Victoria Park Chest Hospital (for the borough of Bethnal Green in addition to part of Hackney commenced in October, 1917), brings the total number of schemes in operation, including that of the City of London, to 27. The Stepney Borough Council have now completed an agreement for the use of the three voluntary dispensaries which have been at work in this borough for some years. The borough of Hammersmith has recently adopted a scheme for the provision of a tuberculosis dispensary. When this scheme is in operation dispensary provision for the whole of London will have been made. The total number of dispensaries at work at the end of 1917 was 37, some of the boroughs having provided more than one dispensary. A summary of the dispensary work during 1917 is given in the table on page 13. With regard to the residential treatment of uninsured persons, the Council renewed authority for the use of 231 children's beds and 100 adult beds in voluntary institutions and for the acceptance of such beds as were available in the institutions of the Metropolitan Asylums Board, the latter including a small number of beds for advanced cases, at St. George's Home (women) and at Downs Sanatorium (men). At the end of May, 1918, the number of children's beds had been increased to 300. The total number of cases treated during 1917, inclusive of those under treatment at the end of the previous year, was 224 men, 446 women, 933 children. In addition the Council continued, with certain administrative modifications, the scheme of co-operation with the Invalid Children's Aid Association which commenced in November, 1915, under which beds available, through them, in institutions are used principally for cases requiring " convalescence " rather than treatment in sanatoria. These are, generally speaking, gland cases, surgical cases requiring open-air life and surgical dressings following operations, and children requiring convalescence after sanatorium treatment. Some 400 beds were obtained in this way and more than 1,000 children benefitted. The agreement with the Invalid Children's Aid Association also includes financial assistance in the provision of surgical instruments and other accessories to treatment and after care of children dealt with in hospitals and sanatoria at the instance of the Council. The Council continues to receive the active co-operation of the 29 interim tuberculosis care committees appointed by t he Council throughout London, pending the appointment by the Metropolitan Borough Councils of borough carc committees, constituted in accordance with the model scheme adopted by the Council on the 15th June, 1915; the Borough of Chelsea is the only borough at present which has appointed its own committee representative of the various local agencies in the borough. The interim care committees are principally concerned with the home life of the patients and with obtaining for them extra nourishment and suitable employment. They are frequently able to influence patients who would otherwise refuse to do so, to attend regularly at the dispensaries or to undergo treatment in residential institutions; this is particularly the case in respect of parents who are loath to part with their children for the long periods necessary for effective sanatorium treatment. They also visit the homes and ensure that parents understand the instructions given to them as to arrangements for institutional treatment. In quite a large number of cases the "after care" reports indicate that considerable improvement has been effected in home conditions as the direct result of the activities of the interim tuberculosis care committees. Children who, prior to treatment, slept with others, are provided on return with separate beds and even separate bedrooms. Not infrequently parents have been induced to remove to more healthy dwellings. The interim care committees also suggest the assessments for the consideration of the Public Health Committee of the Council, and collect the contributions of parents for the residential treatment of their children. The services rendered by these committees in the directions indicated have been most valuable in the efficient working of the Council's tuberculosis scheme. 13 Tuberculosis Dispensaries—Analysis of Returns in 1917. 1 2 3 4 5 6 7 8 9 10 11 12 Borough. Examined for the first time. No. included under (2). Suffering from Pulmonary Tuberculosis. No. included under (2). Suffering from NonPulmonary Tuberculosis. No. included under (2). Found to be NonTuberculous. No. included under - when Diagnosis Doubtful. Total Attendances at Dispensary, including those under column 2. Attendances included in column 7 at which systematic examination and records were made. Visits to homes made by Dispensary Medical Officers. Visits to homes made by Dispensary Nurses. Referred to hospitals to which Dispensary affiliated. Specimens of sputum examined. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Unin sured Insured. Unin sured. Insured. Unin sured. Insured. Unin sured. Insured. Unin sured. Insured. in. sured. M. F. M. F. Chldn. M. F. M. F. Chldn. M. F. M F. Chldn. M. F. M. | F. Chldn. M. F. M. F. Chldn. City of London 79 33 29 9 24 29 7 12 1 2 1 ... ... ... 1 38 23 11 6 19 11 3 6 2 2 1339 614 220 129 4 1 113† 196† 10 7 84 29 Battersea 343 92 23 245 766 130 22 5 42 125 1 1 ... 3 6 148 33 7 141 380 64 36 11 59 255 1500 [4848 364 655 146 546 474 2074 1 3 123 53 Bermondsey 208 55 18 79 274 118 31 8 30 37 4 4 1 ... 29 42 10 5 25 121 44 10 4 24 87 1230 6864 441 993 4 109 111 496 ... 1 114 78 Bethnal Green (a) 70 20 12 27 68 41 9 8 12 1 – – 7 25 7 2 14 53 3 4 2 1 8 199 178 100 128 4 – – – 2 7 72 21 Camborwell 549 160 117 374 1157 237 77 4 0 89 93 12 3 5 6 106 168 36 4 172 622 132 44 23 107 336 4229 20442 1552 3971 —25 56h— 73 76 136(g) 96(g) Chelsea (b) 52 28 16 60 112 25 12 11 17 12 ... 1 6 14 8 4 32 81 13 8 1 10 13 272 518 ... ... 1 3 220 535 ... ... 70 108 Deptford 197 47 31 114 388 107 22 14 43 81 ... 4 2 9 34 82 10 15 47 225 8 11 ... 15 48 1492 3745 470 763 29 25 1221 2671 4 22 269 86 Finsbury 138 42 24 46 198 92 24 15 24 32 ... ... ... ... 10 26 13 6 18 135 20 5 3 4 21 712 1157 245 417 43 70 546 576 – – 65 32 Fulham 260 128 47 227 750 111 42 15 50 65 3 2 ... ... 8 73 54 15 117 454 73 30 17 60 223 1052 6528 501 1496 151 745 727 1977 – 202 214 Greenwich 137 49 12 79 451 103 23 5 34 43 ... ... ... ... 57 25 15 5 19 225 9 11 2 26 126 1150 6173 262 669 – – 1165 2928 20 5 86 66 Hackney 473 314 153 376 983 212 73 76 45 31 10 8 1 2 51 212 201 59 296 819 39 32 17 33 82 3445 4160 1157 1936 16 84 1207 1280 51 36 565 229 Hammersmith (i) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Hampstead 74 36 60 60 153 53 24 37 30 9 2 5 4 4 18 14 7 11 22 114 5 ... 8 4 12 348 1334 180 536 4 1 137 619 30 110 94 97 Holbom 99 23 33 17 32 26 13 7 6 2 ... ... ... ... 1 28 1 9 1 13 45 9 17 10 16 652 604 264 205 11 – 544 582 – 3 64 43 ! Islington (c) 513 132 106 156 426 294 67 60 70 45 8 1 1 3 24 181 48 38 65 295 30 16 7 18 62 3027 3543 874 1038 126 129 1124 1222 2 148 941 Kensington 135 73 40 87 268 55 30 14 22 36 2 3 — 2 8 46 18 16 28 90 32 22 10 35 134 1248 4703 253 551 121 482 571 1578 — – 150 211 Lambeth (e) 520 217 90 300 465 191 72 31 61 30 10 19 3 17 190 143 68 15 123 150 176 58 41 99 95 5131 8134 1301 1693 9 73 10 29d l18 122 419 236 e237 367 Lewisham 156 45 43 70 234 77 23 11 28 9 4 5 1 8 28 69 16 29 30 186 6 1 2 4 11 859 1456 201 347 17 19 995 1174 10 13 68 49 Padding ton 210 117 56 122 356 73 26 8 22 30 11 3 5 50 83 60 35 59 175 43 28 13 34 101 1949 5769 311 791 171 357 706 3523 16 46 64 49 Poplar 196 58 57 312 826 85 32 19 72 47 2 2 1 81 42 14 19 87 314 67 10 19 152 384 983 8964 276 1439 24 87 133 887 1 6 186 183 St. Marylebone 151 82 54 78 183 74 35 19 24 40 6 7 1 2 g 44 26 19 34 55 28 13 15 18 79 1528 2828 247 ;15 4 62 334 299 1397 9 13 138 74 St. Pancras 250 85 65 89 265 178 52 42 54 53 6 5 3 2 35 g 10 3 8 49 58 18 17 25 128 1434 2989 551 990 55 33 430 978 35 61 86 66 Shoreditch 219 104 43 119 392 131 41 27 22 31 1 2 13 56 51 12 72 283 : 31 10 4 25 65 2307 4682 550 1301 51 76 713 1310 ... ... 143 77 Southwark 372 238 37 194 891 221 71 14 64 85 3 5 3 76 118 141 15 118 666 30 23 5 10 64 3798 3515 1213 1151 12 12 1332 1416 ... 14 75 37 Stepney (j) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Stoke Newington 61 9 17 18 40 32 5 8 7 8 1 1 1 7 21 1 6 5 10 7 2 3 5 15 319 438 106 110 — 146 220 1 2 45 109 Wandsworth 250 97 83 204 585 157 56 44 50 34 5 6 2 23 66 27 28 135 503 22 8 11 17 25 2883 9486 605 1427 9 ... 757 1209 2 8 151 175 W eatminster 186 83 37 69 343 86 47 15 31 35 2 3 3 2 26 45 15 7 27 187 53 18 12 9 95 888 1464 573 1038 46 151 712 1780 3 1 99 29 Woolwich 322 201 66 185 707 135 54 16 43 67 3 19 7 20 19 108 72 23 84 412 76 56 20 38 209 3279 5217 1138 2032 226 214 510 1017 5 1 194 64 (a) Bethnal Green Dispensary opened 1st October, 1917. (b) Chelsea—April to December, 1917. (c) Islington Northern Dispensary opened 1st May, 1917. (d) Records have not distinguished between insured and uninsured. (e) The figures supplied from this Branch Dispensary are for six months. (J) In addition 53 visits were made to insured and uninsured persons for nursing purposes. (g) Only refers to sputum rent to borough bacteriologist for examination. (h) This number is incomplete. (i) No scheme in operation in 1917. Provision of municipal dispensary approved by the London County Council, May, 1918. (j) Scheme of borough council approved by London County Council, May, 1918. Work previously done by three voluntary dispensaries now included in Scheme of borough council. 14 Mental Deficiency Act, 1913. Information was received by the Clerk of the Asylums and Mental Deficiency Committee, from various sources, of alleged mental defect in 435 cases during 1917, and 347 of these were dealt with by the local authority. The remainder were still under consideration at the end of the year or were otherwise disposed of. Among the 347 cases dealt with, 165 were sent to institutions, 170 were placed under supervision, 8 were placed under guardianship, 26 were sent to places of safety pending the presentation of a petition, and 12 were referred to the Poor Law. During the year 284 cases were examined with the following results :— Males. Females Totals. Males. Females Totals. Idiot 14 8 22 Mora] Imbecile 1 1 2 Imbecile 90 62 152 Not Defective 4 8 12 Feeble-minded 36 58 94 Insufficient evidence — 2 2 Midwives Act, 1902. The number of midwives with London addresses excecds 5,000, of whom 554 notified their intention to practise in the county during the year. Of these, 359 were enrolled as a result of examination, 150 held a certificate of training, granted before the passing of the Midwives Act, and 45 were in bona fide practice for at least a year before the Act was passed. During the yfcar the title of the inspectors of midwives was changed to that of "medical inspectors" and the number increased from 2 to 4. 1,662 inspections were made during the year. The number of births notified under the Notification of Births Act, 1907, by ceitified midwives during the period under review was 37,822, and 3,159 notifications were received by the Council that, medical aid had been advised by ceitified midwives. The occurrence of 551 stillbirths was reported, the foetus in 305 cases being macerated and in 234 cases not macerated ; in 12 cases no particulars were given. During the year inquests were held on the bodies of 3 women and 77 children, arising out of cases in which certified midwives had been in attendance. Under the Order made by the Council extending the provisions of Section 55 of the Public Health (London) Act, 1891, to ophthalmia neonatorum, 641 notifications were received, 238 being in respect of cases in the practice of certified midwives. Of this number 215 were curcd, impairment of vision resulted in 7 cases, 5 infants died and in 11 instances information could not be obtained owing to the removal of the parents. In all, 199 cases of puerperal fever were notified in the county, and the Registrar-General records 115 deaths from puerperal septic disease. Of the notified cases, 75 proved fatal, the remaining 40 deaths recorded by the Registrar-General not having been notified. If these 40 cafes be added to the 199 notified cases, a total of 239 cases is obtained, 71 of which occurred in the practice of certified midwives. The Registrar-General also records 163 deaths from other accidents of childbirth, of which 14 were in the practice of midwives. The establishment of prima facie cases of negligence and misconduct on the part of 14 midwives was reported to the Central Midwives Board, the names of nine being subsequently removed from the roll of midwives. The remaining five were cautioned, subsequent reports as to the conduct and methods of practice of four of them being required by the Board at the expiration of three months and again at the expiration of six months from the date of the hearing of the charges. One midwife voluntarily surrendered her certificate of enrolment. The name of a midwife who had on a previous occasion been cautioned by the Board and against whom further irregularities were alleged, was removed at her own request from the roll, the Council raising no objection to this course on the understanding that her name would not at any future period be restored to the roll without the Council's knowledge. The name of a midwife was removed from the roll in consequence of her conviction for an offence. At the end of the year, 222 lying-in homes remained on the register, 45 having been added during the year and registration in respect of 6 having either been cancelled or the use of the premises having been discontinued. Maternity and Child Welfare. In 16 boroughs voluntary schemes are in operation ; in one an official scheme, and in 11 both official and voluntary schemes. In connection with this work some 49 whole time and 23 part time health visitors are employed by the borough councils, and in addition the various voluntary agencies contribute a large staff of workers. Ante-natal work is undertaken in practically all the boroughs and arrangements are made for hospital treatment where necessary. The work of the Council's inspectors under the Midwives Act stands in close relation to that, of the several Maternity and Child Welfare Centres, and the Local Government Board recognises this work for the purposes of grant. Census of Homeless Persons. In accordance with the practice which has obtained for several years, a census of homeless persons in the county of London was taken on the night of 9th February, 1917. The area covered was practically coincident with the area covered at previous censuses. The night was moonlight and frosty. As on previous occasions the homeless persons were mostly found in the more centrally-situated districts. Persons sheltering under arches or on staircases totalled four—all females—the lowest number yet recorded The homeless persons in the streets also showed a considerable reduction. On the night in question, 19 men and 5 women were found, as compared with 21 men and 16 women in 1916, and 296 men and 76 women in the early part of 1914 before the war. 15 The common lodging-house population was less numerous than on any previous occasion, there being 13,679 inmates as compared with 15,254 in 1916, and 20,173 in the early part of 1914. In the free shelters and labour homes, not licensed as common lodging-houses, there was also a great reduction in the number of inmates, 04 men, 159 women and 7 children being accommodated, as compared with 91 men, 218 women and 2 children in 1910. The number of persons in London casual wards on the night in question was 89, as against 123 at the time of the last census, and in Rowton Houses 3,950 as agaiqst 4,219. Scheme for the Treatment of Venereal Diseases. The scheme for London and the Home Counties for the diagnosis and treatment of venereal disease, referred to in last year's report, came into force on 1st January, 1917, and was continued throughout the year. Clinics were established at 22 of the London general hospitals where arrangements were also made for in-patient treatment. During the year the number of persons who made use of the facilities was 15,385, viz., 9,648 males and 5,737 females, and their attendances totalled 120,659. The number of "in-patient" days of treatment given was 63,923, and 7,056 persons were treated with salvarsan substitutes. Of those dealt with for the first time, 12,211 were London patients of whom 6,057 were suffering from syphilis, 174 from soft chancre, 4,098 from gonorrhoea and 1,882 not suffering from venereal disease. Pathological examinations of material from patients attending the clinics totalled 13,988, and 3,649 examinations for medical practitioners were made in the laboratories. The total examinations include 12,342 Wassermann tests. During the year 108 medical practitioners submitted evidence of their experience in the administration of arseno-benzol preparations in accordance with the regulations of the Local Government Board and were placed on the Council's approved list, entitling them to supplies of these drugs free of cost. Of the 3,649 pathological examinations made on behalf of private practitioners, 3,310 Were Wassermann tests. In order to assist practitioners in arriving at a proper interpretation of the Wassermann reaction, a pamphlet embodying the views of a number of well-known pathologists was issued on the subject. In considering the arrangements for the year 1918 certain districts not conveniently served by the existing facilities for treatment were provided for by the inclusion in the scheme of three additional hospitals. Provision was also made at hostels for certain persons who, whilst undergoing treatment at the hospitals, continued in employment, and whose lodgings did not permit of the requisite privacy. The need for special facilities for treatment for infected pregnant women was also considered, and the authorities of the large lying-in hospitals were approached on the subject, but they came to the decision that shortage of staff and the need for additional accommodation precluded them from participating in the scheme during the ensuing year. Children Act, 1908—Part I. The Council on the 20th March, 1917, transferred the work arising out of the administration of this part of the Act from the Public Control Department to the Public Health Department as from the 1st April, 1917. This part of the Act provides that where a woman undertakes for hire or reward the nursing and maintenance of an infant under the age of 7 years, apart from its parents, notice of such reception must be given within 48 hours. The Act further provides for notice to be given of the change of address of a foster-mother and of the death or removal of a nurse infant within 48 hours of such change of address or removal taking place. Penalties are provided for failure to comply with these requirements and for obstructing visitors duly appointed by the local authority in the performance of their duties. The outdoor staff employed by the Public Control Department consisted of 10 female and 2 male visitors, whose duties comprised supervising the infants in respect of whom notice had been given, advising the foster-mothers as to the care of such infants, and, in the case of the male visitors, the tracing of unregistered foster-mothers, etc. On 1st April, 1917, the number of notified houses on the register was 3,054 and the number of nurse-infants was 4,002. When the work was transferred to the Public Health Department, London had been divided into 10 districts giving about 300 notified houses per visitor ; the instructions to visitors provided that houses where more than one notified infant was kept should be visited at intervals of at least 4 weeks, while other notified houses were to be visited at intervals to be decided upon after a consideration of the age, health and general conditions under which the infants were being maintained. The experience of the Public Control Department proved that the staff was insufficient to carry out this instruction, and in January, 1917, the Public Control Committee expressed the opinion that the staff should be strengthened to cope with the work. The Council in December, decided to increase the visiting staff by the appointment of 5 additional women visitors. It has been possible with the increased staff to devote a considerable amount of attention to the homes from a health point of view. 1,195 homes were specially visited. In 725 cases the conditions were satisfactory; in 220 sanitary defects were found ; in 144 there was overcrowding ; and in 38 overcrowding and sanitary defects. The sanitary authorities were informed in all cases where unsatisfactory conditions were found. In cases where overcrowding existed a re-arrangement of the sleeping accommodation was found sufficient in many cases to establish healthy conditions, but in others the foster-mother had either to give up the nurse-infant within a specified period or find other and more suitable accommodation. Careful supervision is maintained over the health of the foster-children, and where an infant is found to be in need of medical treatment the visitor generally advises the foster-mother to take it to the 16 local infant welfare centre or to a hospital, and follows up the case to see that treatment is obtained. In difficult cases it is the practice to call in the assistance of one of the women medical inspectors in this department, and this practice has often proved to be most helpful; if the infant is attending school and is suffering from such complaints as ringworm, verminous head, etc., with which the school medical officer can deal, steps are taken to secure the necessary treatment. Arrangements have been made for notifying the Care Committees when foster children reach the age of 7. The number of notified houses on the register at the end of the year was 2,995 and the number of notified infants 3,900. The number of infringements of the Act during the year was 474. Cautions were sent in 434 of these cases and legal proceedings were taken and convictions obtained in 30 cases. Work of the Chemical Branch. The work conducted at the analytical laboratories at Savoy Hill includes the examination of samples received under the Fertilizers and Feeding Stuffs Act, 1906, the Petroleum Acts, London County Council (General Powers) Act, and the London Building Acts. A large number of milk and other meals supplied to necessitous children in Council schools have been systematically submitted for chemical examination as to adulteration or adequacy. Many analyses have been made of materials used in connection with works undertaken by or for the Council. The chemical and ealorimetric examination of all coal delivered to Greenwich Generating Station is, under the conditions of contract, the basis of price to be paid for such coal. In addition to these analyses daily examinations of coal actually burnt under the boilers are made in the laboratory, and chemical investigation of various problems concerning fuel economy is being undertaken in cooperation with the electrical staff, with a view to assisting in the use to the best advantage of the necessarily curtailed quantity of suitable fuel now available. Systematic investigations as to the condition of the water of the River Thames have been continued, as well as daily examinations of the sewage effluent and sludge. The analytical work in connection with these and allied matters has been carried out in the laboratories at the Northern and Southern Outfalls. The special investigation of the river has continued for four years. In each of these years the treatment of sewage has been modified during varying periods, partly for experimental reasons and partly owing to war conditions. Considerable economy has incidentally been effected and so far no inconvenience has been caused. Since the sewage effluent enters the tidal portion of the Thames at points below that at which the river leaves the county, it is clear that the general effect of the flow of the river is for the water which has become mixed with effluent to pass seawards away from the county. The tides are, however, sufficiently strong for a marked upward movement of water to occur every flood tide, that is, twice every day. The effect of a movement towards the metropolis of a vast volume of water carrying with it the liquid and finer solid portions of the sewage of a population of some millions should clearly be carefully studied when the treatment of sewage is in any way altered. During the four years in question the rainfall in the Thames valley has been well above the average, and in three of them the flow of the river has also been high. A very large proportion of the rainfall of 1914 fell in December ; its effect was, therefore, observed in 1915 rather than in 1914 The following table based on returns from the Thames Conservancy shows how very great was the flow of the river in 1915 and 1916. 1914. 1915. 1916. 1917. Average of 33-34 years. Rainfall in inches 32.75 38.3 36 30.07 26.58 Daily flow in thousand million gallons 11.9 26.35 26.9 15.3 12.35 The problem of dealing with sewage effluent therefore presents less difficulty during such years than in dry periods. In the summer of each of these years water which contained so much salt as definitely to point to mixture with sea water was found in the course of the investigation at places well above Westminster. In 1914 (September) such water reached Barnes, eleven miles above London Bridge, in 1915 (October) and 1916 (August) it was found at Putney, but in 1917 (June) only as high as Battersea ; the heavy rains of July-August of the last year account for salt water not having reachcd beyond this point. The fact of an excess of salt being found so high up the river in summers when the fresh water flow was much above the average, raises the question as to occasional passage of polluting matter from the outfalls through the county and as to the possibility of nuisance being caused. The fresh water reaching the tideway from the upper river is by no means unpolluted. It has received the sewage, more or less treated, of a population of from half to one million. Although inoffensive to the senses it yields chemical evidence of pollution and is unfit for drinking. In the tideway itself it receives the effluent from the sewage of several suburban districts in Middlesex and Surrey before it reaches the county of London. A gradual deterioration is observed from Tcddington downwards. It has not therefore been found possible to assign precise limits to the effects of the various sources of pollution, although it is evident from the investigation that the region of maximum pollution oscillates, with the tide, in the neighbourhood of the outfalls. The flow of the river having been high and the summers cold in the years under consideration, it has not been found possible so far, during this investigation, to ascertain the maximum effect on the upper part of the tideway of the upward passage of water from the 17 lower and more polluted reaches. These years would appear to have been particularly favourable to the success of the reduced treatment which war conditions necessitated. At the present stage it is possible to arrive at tentative conclusions only, but the chemical results so far obtained show that the continued inoffensive condition of the river, about which there can be no question, has not been due to the absence of sources of pollution or to the fact that the dilution has been so great as to lead to a clean and well oxygenated stream. The evidence of unoxidised polluting matter in the water is at times apparent, more particularly in the neighbourhood of the outfalls and the proportion of dissolved oxygen has frequently been low over considerable stretches of river. The state of equilibrium, which the co-existence of such conditions with inoffensiveness indicates, appears to be due to the fact that those natural processes of purification which go on continually in any body of polluted water, do so at a particularly high rate in the Thames where, owing to the tidal movement, the mixing and agitation of water and of mud deposited at slack water is very rapid. This acceleration of processes of oxidation leads to a reduction in the proportion of oxygen in solution, which might be held to indicate a serious state of affairs in stagnant water or in a slowmoving or non-tidal river. It is evident from the facts, and is capable of explanation on theoretical grounds, that such results in a swift tidal stream demonstrate that purification is going on at a very rapid rate. The continued oxidation of matters in suspension or of mud which is not allowed to accumulate permanently, no doubt largely accounts for the small proportion of dissolved oxygen frequently found in the Thames water. This is a much more satisfactory condition than has been found in more slowly moving waters, where relatively high aeration was found to be accompanied by the presence of a fermenting river bottom. It was suggested to the Council towards the end of 1916 that pollution of portions of the Thames estuary which had been observed at times, might be due to the travel of sewage matter from the altered area of discharge. The area which it was suggested might be affected was therefore examined under the supervision of the Chemist, by two officers in his branch of the department, Messrs. J. W. H. Biggs and E. R. Andrews, in January and February, 1917, under very adverse weather conditions, which were, however, of the kind which had been considered most likely to lead to pollution from the discharging area used by the Council and other bodies. The investigation included a bacteriological and some chemical examination of samples of water taken under varying conditions of tide and of mud collected at certain selected places in the area. As the outcome of this investigation, it was found that the results were not compatible with the hypothesis that contaminated material is brought inshore by the combined action of the wind and tide in the manner suggested, and this, notwithstanding the fact that during the investigation the prevailing winds and conditions generally were theoretically favourable to such a movement. 43516 C 18 TABLE I. COUNTY OF LONDON. Vital statistics for the several metropolitan boroughs and the County of London in the year 1917. (Rates per 1,000 of civil population), Metropolitan borough. (In topographical order). Estimated civil population. 1917. | Births. Deaths. Infant mortality (per 1.000 births). Measles. Scarlet lever. Diphtheria. Whooping cough. Typhoid fever. Diarrhœa and Enteritis age 0-2 (per 1,000 births). Phthisis. Cancer. Cases of notifiable infectious disease.* Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Puerperal fever (per 1,000 births). Cerebrospinal fever. Western Paddington 122,507 15.5 16.8 130 .95 .02 .11 .16 .02 24.6 1.52 1.64 1.00 1.85 .09 .54 3.3 .07 Kensington 151,535 14.6 16.4 127 .67 .02 .06 .08 .03 21.0 1.18 1.37 1.10 1.08 .14 .44 .8 .11 Hammersmith 114,952 17.8 14.3 111 .34 .01 .10 .10 .05 14.9 1.68 1.29 1.21 1.33 .17 .45 .09 Fulham 145,186 18.4 13.9 111 .52 .03 .12 .15 .01 24.2 1.38 1.23 1.61 1.62 .08 .34 5.0 .14 Chelsea 57,368 15.6 16.0 80 .12 – .05 .03 .02 25.1 1.34 1.36 1.76 .94 .1 7 .42 4.0 .07 Westminster, City of 122,046 11.3 15.7 106 .19 .02 .09 .06 .03 11.7 1.61 1.78 1.60 1.29 .11 .37 4.5 .10 Northern St. Marylebone 92,796 14.6 17.0 125 1.08 — .09 .10 01 17.2 1.52 1.73 .99 1.81 .05 .55 •7 .06 Hampstead 75,649 13.2 12.3 82 .16 — .04 .01 .04 9.0 1.00 1.48 .83 1.77 .16 .37 – .05 St. Pancras 186,600 18.3 17.0 106 .63 .02 .13 .16 .03 19.9 1.95 1.54 1.32 2.41 .12 .65 2.4 .13 Islington 297,102 17.6 15.8 99 .50 .01 .12 .16 02 15.2 1.70 1.51 1.60 1.88 .08 .57 2.7 .10 Stoke Newington 47,426 14.6 15.5 84 .42 — .19 .17 11.7 1.18 1.94 .82 2.32 .08 .51 2.6 .11 Hackney 196,598 17.1 14.7 94 .09 .04 .11 .13 .03 18.9 1.64 1.22 1.56 1.56 .10 .63 2.4 .09 Central Holborn 35,303 14.5 19.5 107 1.05 — .03 .03 15.8 2.49 1.47 .82 1.93 .06 .45 – .14 Finsbury 68,011 20.7 21.1 121 1.53 .03 .13 .15 .01 18.4 2.56 1.13 1.71 2.43 .04 .49 4.5 .07 London, City of 16,138 6.4 14.1 70 .06 .12 .06 1.92 1.12 1.12 1.74 – .25 – – Eastern Shoreditch 89,675 22.8 22.2 152 1.53 .06 .29 .22 .01 36.0 2.71 1.28 1.84 3.04 .08 1 .26 1.8 .17 Bethnal Green 107,362 22.8 15.8 112 .63 .03 .16 .09 .02 21.6 2.21 .96 2.29 3.24 .09 .91 2.2 .22 Stepney 232,010 22.9 17.2 99 .49 .03 .26 .13 .02 23.8 2.32 1.03 1.71 3.05 .19 .84 2.7 .06 Poplar 143,443 23.4 16.8 94 .62 .03 .18 .24 .03 20.3 1.88 .88 1.42 2.54 .27 .81 4.0 .06 Southern Southwark 167,936 22.1 18.7 111 .46 .04 .28 .21 .03 21.1 2.42 1.47 1.63 3.46 .06 1.01 2.9 .11 Bermondsev 107,635 22.6 19.4 130 .71 .01 .18 .32 .05 31.7 2.06 1.48 2.89 3.85 .07 .69 1.5 .06 Lambeth 272,038 17.3 15.7 101 .40 .02 .18 .15 .01 17.0 1.72 1.40 1.21 1.92 .06 .44 2.5 .09 Battersea 150,023 17.7 15.2 101 .49 .03 .09 .22 .05 15.2 1.68 1.37 1.63 1.23 .09 .47 1.4 .11 Wandsworth 300,787 14.4 12.8 91 .44 .04 .12 .10 .03 12.8 1.17 1.35 1.85 1.54 .15 .34 2.9 .09 Camberwell 239,461 18.0 15.4 99 .46 .02 .16 .19 .02 17.9 1.68 1.54 1.40 1.71 .11 .50 1.5 .10 Deptford 103,527 20.4 16.1 101 .29 .02 .21 .19 — 23.8 1.81 1.23 1.15 2.53 .13 1.05 1.3 .09 Greenwich 90,440 19.8 16.0 102 .50 .01 .30 .09 .02 18.5 2.01 1.14 1.71 3.56 .14 .56 1.5 .09 Lewisham 161,405 14.9 11.0 88 .07 — .14 .04 .04 11.2 1.14 1.25 1.78 1.39 .06 .36 3.0 .09 Woolwich 131,942 18.5 11.9 79 .23 .01 .13 .08 .03 9.6 1.33 .99 1.04 2.05 .09 .58 4.0 .11 London 4,026,901 17.9 15.7 104 .50 .02 .15 .14 .03 19.0 1.72 1.35 1.52 2.06 .11 .58 2.5 .10 * Small pox.—There were no cases during the year. 19 43316 C 2 TABLE II. COUNTY OF LONDON. Statistics of the administrative work carri^l out during the year 1917. Sanitary Authority. Cowsheds. Slaughterhouses. Offensive Trades. Smoke nuisances. Underground rooms. Overcrowding. Housing of the Working Classes Acts. Houses let in lodgings. Common lodging houses. Cleansing of persons and rooms. Water supply. Milk- shops. Ice cream premises. Other food places. No licensed. No. of inspections. No. licensed No. of inspections. No. licensed. No. of Inspections. Observations. Complaints. Notices. No. illegally occupied. No. closed or otherwise remedied. Instances found. No. remedied. Houses inspected. Representations made. Closing orders. Remedied without closing orders. No. on register. No. of inspections. Prosecutions. Houses licensed. Authorised lodgers. Adults. Children. Premises or rooms. Tenement houses extra supply. No. on register. No. of inspections. No. on register. No. of inspections. No. of places. No. of inspections. City ot London — — * * — — 143 14 – l – 1 1 493 — 191 473 — 1 455 8 16 5 – 580 1,481 43 110 † 1028 1,575 Battersea 2 6 3 436 3 16 1 1 1 12 12 31 31 1,661 — — 996 114 149 — 2 147 320 2,620 99 54 145 489 177 313 168 1,033 Bermondsey 1 1 28 13 145 67 14 14 — — 10 10 — — — — 223 60 — 4 1,196 48 — 1,908 273 815 95 66 910 8,393 Bethnal Green 12 62 3 15 1 3 17 8 — — — 25 25 13 6 6 — 235 964 — 8 400 13 — 3,400 1 220 670 95 180 254 1,134 Camberwell 7 109 6 98 2 7 — 4 8 — — 51 51 — — — — 292 39 — 5 466 126 5,178 138 — 544 1,121 276 338 380 1,642 Chelsea 3 9 — — 3 2 2 — — 5 5 — — — — — — 4 236 8 72 615 — 99 140 28 30 99 140 Deptford — 2 55 5 18 — — — — — 3 3 — — — — 438 363 — 8 1,231 — 943 3,781 — 247 353 136 74 117 222 Finsbury 1 3 2 59 1 12 13 13 1 5 5 13 13 15 15 15 — 908 2,564 — 3 228 8 — — — 156 165 2 44 223 223 Fulham 2 50 — — — 8 4 4 4 22 22 — — — — — — 2 98 — 163 122 15 96 520 54 96 — 946 Greenwich .. .. .\. 3 12 5 10 3 — 93 — — 5 5 18 18 — — — 247 251 — 3 121 1,105 171 — 124 137 105 61 — _ Hackney 13 40 19 73 1 1 — 12 13 — — 38 38 — — — — 470 185 — 5 416 68 2,091 — 3 288 151 29 29 — Hammersmith 7 294 — 20 7 3 — — 12 12 — — — 2,693 600 — 3 387 — 982 2 306 734 234 153 — 3,715 Hampstead — 4 37 — — 38 2 4 10 10 4 4 73 4 4 — 405 970 — — — 7 444 41 30 94 205 72 109 465 1,443 Holbom 1 3 — — 14 4 3 4 4 5 5 — — — — 623 780 — 17 1,247 54 — £0 — 165 113 58 49 467 1,535 Islington 3 29 23 1,025 7 89 33 4 2 6 6 14 — — — — — 26 1,134 4 4,001 17 12 586 948 235 27 559 10,308 Kensington 1 55 6 416 — — 365 4 3 2 2 16 16 32 6 6 2 2,065 7,459 3 12 625 131 1,889 296 — 190 978 190 132 634 2,046 Lambeth 6 12 14 180 3 36 — — — 49 49 76 76 — 372 446 — 5 645 .— — 465 18 255 1,530 — — 462 428 Lewisham 9 86 11 121 — — 19 1 2 — — 10 10 193 3 3 41 4 12 — 1 30 — — 45 — 147 198 — — 60 60 Paddington.. . , 1 4 5 232 — — 119 13 — — — 52 49 63 8 8 — 1,404 5,308 9 3 221 — — 105 4 108 133 43 76 302 444 Poplar 10 34 11 80 6 35 — 19 13 — 171 171 9 7 7 2 1,265 4,510 1 7 994 185 4,761 1,139 •— 265 698 76 51 263 966 St. Marylebone 5 18 3 14 2 12 211 6 6 15 15 5 5 1,167 — — 1,158 1,202 6 10 1,102 2,914 3,075 1,866 25 203 195 117 6 395 1,186 St. Pancras 4 30 12 163 2 46 4 8 3 19 19 38 38 1,625 2 4 1,623 2,364 5,917 — 5 504 413 4,098 902 26 223 481 129 111 — 4,331 Shoreditch 3 10 3 10 1 10 — — 3 — — 70 70 656 — — — 283 435 — 7 464 — – — . — 272 1,724 59 89 166 525 Southwark 3 34 5 57 3 15 11 6 4 6 6 126 126 — — — — 1,349 2,323 16 27 3,173 82 8,024 729 7 362 1,321 205 14 461 1,165 Stepney 29 65 5 13 6 24 56 6 23 16 16 188 188 — 2 — 741 972 36 5,370 162 1 2,858 — 456 1,793 96 212 429 1,477 Stoke Newington 1 — 4 — 12 — — — — 1 1 326 — — 259 — 1 37 4 251 — 4 65 96 — — — 387 Wandsworth 11 44 13 239 4 110 34 19 3 — 26 26 844 — — 668 292 851 — 6 185 59 — 176 21 412 725 330 309 213 287 Westminster 1 4 — 1,230 66 44 3 3 13 13 3,070 — — — 1,240 3,640 5 6 1,606 64 522 191 36 486 693 155 239 1,200 3,413 Woolwich ... .. 15 39 9 33 — — 2 2 1 2 2 95 95 4,251 4 4 — 435 609 18 518 17 2,783 568 — 96 112 46 – 128 153 Note.-—In the columns above a dash signifies a nil return. Common lodging houses: Licensed number, 235; lodgers, 23,236: visits-day, 18,240, night, 652; prosecutions, nil. Seamen's lodging houses: Licensed number, 7 in Bermondsey, 1 Deptford, 13 Poplar, 36 Stepney; lodgers, 1461; visits-day, 1,637, night, 142; convictions, 6; penalties, £97 Prosecutions: Milkshops—Chelsea 5, Hammersmith 2, Paddington 1, Bethnal Green, 1; water supply—St. Marylebone 3, Southwark 2; smoke nuisances—Stepney 1, Westminster 1 ; offensiv^rades—Bermondsey 4, Wandsworth 4 ; overcrowding—Bethnal Green 1. * Continuous supervision during the regular hours of slaughter. When slaughtering is required at other hours, the Slaughterhouse Bye-laws provide for notice being given to the Medical Officer of Health in order that arrangements may be made for an Inspector to be present, t In addition to these premises, there are Cold Stores, Butchers' Shops and the Central Meat Market, all of which are kept under constant supervision. 20 REPORT OF THE SCHOOL MEDICAL OFFICER (Dr. W. H. HAMER) FOR THE YEAR 1917. PART II.—EDUCATION. Introductory Note. In last year's Report it was possible to cite the continued improvement in the results obtained at medical inspections, during the years 1913-16, as a proof that the war " had not been allowed to interfere with the growth of that solicitous care for the welfare of the children which has distinguished recent years." It will be seen immediately that this improvement has been maintained; moreover, an indication of the favourable economic conditions prevailing during 1917 is afforded by the fact that the number of necessitous children receiving free meals continued to decline below the already very remarkable figures of the preceding year. These are exceedingly satisfactory results after three years of war ; on the other hand, there have not been wanting indications that certain possible sources of trouble should now be considered. Thus, during 1917 the suspicion was aroused in the minds of a few observers that particular symptoms of illness were attributable to eating war-bread ; this view has not so far been supported by any conclusive published evidence. A more serious difficulty has been that of checking fraudulent adulteration. This practice has become so common in the case of milk that comment was recently made by the writer of London "Charivaria" on a statement that in South Wales "samples of water examined had been found to contain 45 per cent. of milk." The Education Committee has had under its consideration the poor quality of much of the milk supplied to necessitous school children in London. The results of analysis were at certain times of the year unpreccdentedly unsatisfactory inasmuch as more than half the samples taken were found to contain added water. The question is being further investigated. In spite of difficulties of this sort, an enquiry made by Dr. C. J. Thomas into the number of malnourished children found at medical examinations, shows improvement and not deterioration. Over and above the food difficulties there remains to be mentioned the mischief of quite another kind which was undoubtedly caused in the autumn by nervous excitability associated with air raids, and there was even a suspicion that spread of infection was caused by the undue crowding which took place late in the year in some of the places of shelter (see p. 37). Broadly speaking, setting aside certain small and localised outbreaks of dysentery in North and North-west London—and apart from the comparatively speaking minor difficulties mentioned above, there were only two serious interferences with the children's health during 1917 directly attributable to war conditions ; in the first place there was notable increase in the prevalence of scabies, doubtless largely introduced by soldiers returning from abroad ; and seoondly, less satisfactory results as regards treatment of the ailments of school children were obtained, owing partly to a marked falling off in the facilities afforded at certain hospitals, and partly to a further increase in the difficulty ex. perienced in " following-up," due in some degree to mothers going out to work, but mainly to diminution in the number of voluntary care committee workers. In the latter part of the year arrangements were made for nurses to render further assistanco in home visiting, and in a few selected schools, in which the need was most urgent, nurses were made responsible for the medical following-up work (see p. 29). Medical inspection. In last year s Annual Report it was shown that the scheme, approved by the Council in November, 1915, under which the detailed examination of entrants was replaced by a preliminary inspection followed by a detailed inspection of those apparently ailing, had led to the detection of fewer ailments than in previous years. As a result the Council, on the 31st July, 1917, decided to revert to the former method of examining all the entrants in detail. During the year 228,124 children in the age groups were examined by the school doctors in elementary schools, and of this number 89,171 were found to require treatment for one or more defects. A further 1,727 children in the age groups were inspected in special schools, and 53,334 elementary school children not in the age groups were specially examined, giving a total of 283,185. In addition, the school medical staff inspected 4,458 children for scholarship awards, 8,800 students in secondary schools and training colleges, and 13,904 children in connection with their specific defect in special schools. A detailed analysis of the results of the examination of elementary school children has been made by Dr. C. J. Thomas and is given on pages 22—27. Medical treatment. The facilities provided by the Council for the medical and dental treatment of school children have been considerably increased during the year, five new centres being opened and the provision at many of the existing centres being extended. The number of children who received treatment under the Council's arrangements was 122,765, as compared with 111,456 in 1916. Details as to the number of children treated under each class of ailment and of the results of treatment are given on page 27. Under the arrangements approved for the year commencing 1st April, 1918, authority has been given for schemes which will provide treatment for some 164,500 children annually. Re-inepection. The number of defects noted at primary inspections for treatment or observation coming under review was 177,742. It was found that in the case of defects requiring treatment 36 9 per cent. of the cases had received treatment within six months, a falling-off compared with 1916, when the figure was 41.7. 15.2 per cent. of the cases were deemed to be no longer in need of treatment, and in 47.9 per cent, 21 treatment was still required. The delay in obtaining treatment is to be attributed partly to the engagement of care committee workers in other directions, partly to the decreased facilities at hospitals not included in the Council's arrangements, and in some degTee to the employment of mothers on war work. At six centres arrangements have been made under which the same premises are used for the purposes of school treatment centres and infant welfare centres, to the mutual benefit of the Council and the authorities of the infant welfare centres. Further schemes of co-operation are under consideration. Co-operatioa with Infant Welfare Centres. The grant awarded by the Board of Education under Part I. of the Medical Grant Regulations for the year ending 31st March, 1918, amounted to £49,082 3s. 4d., and was again assessed at the maximum rate, representing 50 per cent. of the Council's expenditure on medical inspection and treatment and ancillary work during the previous year. Under Part II. £754 10s. was awarded in respect of the open-air schools at Kensal House, Birley House and Shooter's Hill, and under Part III. £599 4s. 5d. was allowed for physical education, both amounts being calculated at the maximum rate. GoTernment grant. The open-air schools at Birley House and Shooter's Hill were both continued; formerly they were hold throughout the year, but in 1917 they were closed for the Christmas holidays. The Kensal House school for tuberculous children has been continued, and some of the play-ground classes were, as in the past, held in the public parks. Open-air schools. In all 5,566 examinations were conductcd with a view to admission to special schools. Of these 2,768 were certified as suitable for admission, and the remainder were either returned to elementary schools or found to be unsuitable for any of the Council's institutions. The results of the periodical examination of children in the schools for the mentally and physically defective are shown in the roport (p. 39). Special schools. The report contains results of analysis of samples of meals supplied to the schools, and attention has been particularly directed to the question of the adequacy and quality of the food supplied. Save as regards milk, as already mentioned above, there has been no departure from the accepted standard. Supervision of dietaries, etc. The Council s cleansing schemes have been amended so as to permit of the compulsory stage being reached at an earlier date. There are now 25 cleansing stations, including one opened in January of this year (1918) at the camp school, Wellington-street, Deptford; at 21 of these treatment has been extended by the inclusion of scabies. 798,643 examinations of children were made, and in 19,506 cases the children were found to be verminous, 8,506 children were cleansed by the parents, and 11,000 children were cleansed by the Council and the borough councils. 6,940 children suffering from scabies were given in all 30,317 baths. This is a large increase on the number shown last, year, and the cause is no doubt infection introduced into the homes, mainly from abroad. Attention is drawn to the closer co-operation between the Council and the hospitals and treatment centres for the following-up of the cases. Personal hygiene, The year was especially notable for the extent to which attention was arrested by and concentrated upon the problems arising out of verminous conditions. The great improvement in this respect brought about since 1870 and particularly during the last thirty years is appreciated by everyone who has had experience of London children extending over that period, but the campaign against vermin has. unfortunately, until quite recently not excited much general enthusiasm, and those whose immediate duty it has been to endeavour to combat the prevailing indifference with regard to cleanliness, more particularly the Council's nurses, have often had a very difficult and at all times a much criticised task to perform. It is now, however, becoming realised that the banishment of plague from Europe in the seventeenth century was in all probability closely bound up with altered conditions affecting prevalence of one or other species of vermin, and the practical extinction of typhus and relapsing fever in this country, dating from nearly 50 years ago, diseases until then regarded as " almost necessary incidents of existence " in the oase of poor people, stands in close relationship with general improvement in the condition of the population as regards infection with body lice. This has been brought about in part by action such as that taken under the Baths and Wash-houses Act (1846) with regard to public provision of conveniences for washing, and in part by the influence exerted by isolation and cleansing of infected persons in hospitals. It is well known that infestation by body vermin was not uncommonly experienced, even in the higher ranks of society, until within a century or two ago, and during the. past 70 or 80 years, even in carefully tended homes, the invasion of houses by bugs was a, frequent source of annoyance ; the published letters of Jane Welsh Carlyle bear witness to this and enable readers of to-day to appreciate the serious importance assumed by "small beings," as Mazzini termed them, in domestic life in Chelsea less than a century ago. In many poor homes the problem is still a very serious one. It was noted more than 500 years ago by John de Trevisa that in this country the flea "Wexeth slowe and faylcth in colde time and in somer tyme it wexeth quiver and swifte and spareth not kynges." Since 1909 the seasonal prevalence of fleas throughout each year has been carefully studied in London and from 1913 onwards the statistical records have been based on examination of school children, and the resulting flea curves have been published in successive annual reports. The amount of discomfort caused by flea-bites in the child population has incidentally been revealed, but it is not possible to allow the question to rest at this point. Of late years study of plague and of the part played by insect parasites in its spread has greatly emphasised in India the importance to be attached to fleas, and it may be that it is now necessary to look nearer home. Reference is made on page 15 to the results of the enquiries carried out during the last nine years in London with regard to the relationship between the flea curve and the ourve of scarlet fever, and the case in favour of a flea hypothesis of causation of scarlet fever is, it may now be claimed, one which calls for close examination. Dr. Russell, in his recently published monograph on the flea, points out that, contrary to the general belief, monkeys have no Verminous conditions and infectious disease. 22 fleas, and indeed he protests against the assumption that it is possible for so clean an animal to be so affected, save as the result of chance infection from a human being; the question, therefore, arises whether a standard which obtains in the case of this animal should not constitute an ideal to be aimed at in London elementary school children. This is the more to be desired if it should transpire that the flea actually transmits disease from child to child. One thing is clear, the demonstration of the association of veimin with the spread of infectious disease has done more than had ever before been accomplished in arousing serious interest in what had hitherto been regarded merely as an unpleasant subject. During the past year the fact that one London elementary school girl in three is found, on surprise medical examination, to have nits in her hair, has been repeatedly commented upon as being a condition of things for which a Temcdy must be found. The spread of verminous conditions amongst soldiers and the dissemination throughout the country of scabies have enforced the moral, and it is to be hoped therefore that the attempt to cope more effectively with what is now recognised as a public danger will meet with general support. The Results of Medical Inspection. Owing to the demonstration that the cursory examination of entrant children was not giving such satisfactory results as did the full examination in detail, the Council on 31st July, 1917, decided to revert to the latter practice. During the first two terms of the year therefore the cursory examination of entrants was still carried out, but those entrants falling due for examination in the third term were examined in detail. The total number of children of all ages inspected during the year according to the Board's schedule was 283,185; these comprised 30,492 entrants cursorily inspected, 55,012 entrants examined in detail, 34,487 boys and 33,715 girls examined in the intermediate age group, 34,260 boys and 34,158 girls examined in the leaver age group, 24,930 boys and 28,404 girls mainly outside the age groups examined as urgent or special cases, and 1,727 children seen in their age groups in special schools. Number of children referred for treatment. Tho percentage of ohildren referred for treatment as a result of routine inspection was on the whole higher than in the previous two years:— Intermediate Age Group. Leavers. Boys, Girls. Boys. Girls. 1915 34.2 40.2 38.7 40.5 1916 40.0 41.2 39.2 40.2 1917 44.0 44.7 41.8 43.0 Attendance of parents at the inspections. The falling off in the attendance of parents at the inspections which was pointed out in 1915 has not proved a progressive feature. In 1915 a parent was present in 56 6 per cent. of the inspections, in 1916 this fell a little further to 55.2, but in 1917 was raised again to 56.2. The parents are much more interested in the examination of their children when entrants than at the older ages, and the percentage of oases in which a parent was present at the inspection of entrants was 71 9. This is, of course, a very strong argument for making the entrants' examination as full and comprehensive as possible. Indiccs of the effects of economic conditions. 1 he yearly individual examination of & quarter of a million children in London affords a measure of the social condition of the people with which formerly there was nothing to compare. It has been shown in.my recent-annual reports that important conclusions in relation to the effects of economic conditions can be drawn from the classified figures relating to the condition of clothes and footgear, cleanliness and nutrition. The Chief Medical Officer of the Board of Education referred in his last annual report, to the steady, unwavering, incontrovertible nature of these statistics. Very remarkable are the figures relating to cleanliness :— Cleanliness Cleanliness or Head. Cleanliness or Body. Intermediate age group. Leavers. Intermediate age group. Leavers. Year. Clean. Nits. Verminous Clean. Nits. Verminous Clean. Nits. Verminous Clean. Nits. Verminous Boys 1913 87.1 12.3 0.6 87.3 12.3 0.4 72.0 25.1 2.9 73.1 24.3 2.6 1914 86.9 12.6 0.5 88.5 11.2 0.3 75.3 22.9 1.8 75.1 23.0 1.9 1915 88.4 11.4 0.2 90.9 8.9 0.2 76.6 22.0 1.4 77.9 20.9 1.2 1916 89.2 10.6 0.2 90.6 9.2 0.2 79.3 19.7 1.0 79.2 19.8 1.0 1917 89.4 10.4 0.2 90.7 9.2 0.1 79.8 19.1 1.1 79.2 19.5 1.3 Girls 1913 67.3 30.3 2.4 67.2 30.4 2.4 73.7 24.2 2.1 74.8 23.1 2.1 1914 66.3 31.6 2.1 68.8 29.3 1.9 77.8 20.8 1.4 78.0 20.7 1.3 1915 69.2 29.4 1.4 72.6 26.2 1.2 77.6 21.4 1.0 80.7 18.5 0.8 1916 68.8 29.9 1.3 70.8 28.1 1.1 80.5 18.8 0.7 81.7 17.8 0.5 1917 68.8 | 29.9 1.3 70.2 28.7 1.1 80.9 18.3 0.8 81.7 17.6 0.7 The condition of the children in each age group has remained quite stationary as regards cleanliness during 1917, the figures only varying by a slight fraction in any particular group or category. 23 This remarkable fact supports the view that observations taken on this large scale can be relied upon to give accurate results, since no coincidence could explain the similarity of the figures, and it warrants the conclusions presently to be made upon the figures for the other indices. The maintenance of the status quo ante in regard to cleanliness has only been achieved by constant vigilance on the part of the nurses, and is remarkable in the face of continued introduction of parasitic infection and the increased employment of married women. The amount of work in this connection performed bv the school nurses is detailed later in the report under the heading of personal hygiene. Clothing. The figures for clothing and footgear show that while the percentage of children ill-shod and insufficiently clothed has remained low, but almost stationary, there has been an appreciable, though not groat, diminution in the number well dressed and shod as contrasted with those only fairly well provided for. It would appear that economic conditions have operated here and that the parents are now beginning to spend less upon clothes and more upon other necessities. It is perhaps as well that the tendency has been checked to expend the surplus of wages upon finery in apparel, so conspicuous a feature in the first years of the war. Nutrition. It is mainly to the figures for nutrition that one turns for information about the effects of the war upon the physical condition of the children and, ex pede Ilerculem, upon the general condition of the people. Close scrutiny has, therefore, been paid to these figures for the past year, and in the following tables the figures for each term of the years 1916 and 1917 have been separately worked out:— Intermediate. Leavers. Boys. Girls. Boys. Girls. Year. Good. Fair. Poor. Hood. Fair. Poor. Good. Fair. Poor. Good. Fair. Poor. 1913 22.0 62.2 15.8 25.1 61.4 13.5 26.4 58.9 14.7 30.6 55.1 14.3 1914 19.9 70.1 10.0 22.8 68.2 9.0 26.4 61.1 12.5 29.9 58.6 11.5 1915 21.1 69.8 9.1 23.3 69.0 7.7 29.0 63.8 7.2 32.8 60.9 6.3 1910 23.6 67.0 9.4 26.4 65.6 8.0 29.4 63.8 6.8 31.4 62.3 6.3 1917 20.9 70.6 8.5 22.3 70.2 7.5 27.1 66.7 6.2 28.5 65.2 6.3 1916, 1st term 22.5 67.0 10.5 26.2 65.4 8.4 29.7 63.8 6.5 31.7 62.5 5.8 2nd , 24.3 66.4 9.3 25.8 65.6 8.6 28.5 64.0 7.5 30.6 63.0 6.4 3rd ,, 24.2 68.1 7.7 26.6 66.3 7.1 30.1 63.0 6.9 31.5 61.8 6.7 1917 1st term 20.1 69.9 10.0 22.3 69.7 8.0 27.0 66.4 6.6 28.4 65.0 6.6 2nd „ 19.4 72.3 8.3 21.0 71.1 7.9 27.7 66.1 6.2 28.6 65.1 6.3 3rd „ 22.8 69.4 7.8 23.5 69.7 6.8 26.2 68.6 5.2 29.3 65.7 5.0 The progressive reduction in the number of the children found with poor nutrition has been maintained, the figures in this respect being better for 1917 than 1916 and less than half the pre-war figures. It is noteworthy that this reduction has been continued right up to the end of 1917 and that the figures for the third term of that year are the best in this respect that have ever been attained. On the other hand, the percentage of children returned as of good nutrition as opposed to fair nutrition only has showed diminution. This is no doubt to be explained by the anxiety of many parents to fall in with the voluntary rationing schemes suggested by the Food Controller. The above results were reported to the Education Committee, were carefully considered by them, and were upon 13th February, 1918, made the subject of a special report to the Council in the following terms:— "The question of the physical condition of children in London schools is one which during the war has received our close and continuous attention. The number of necessitous children fed at school remains at an extremely low level compared with the number fed before the war. The school medical officer's annual reports since 1914 have given the results of medical inspection based upon an annual examination of some 200,000 children. He has pointed out that there has been an all-round improvement in the physical condition of the children during the war, and that the number of children found at medical inspections to be under-nourished has greatly decreased. The results for 1917 have now been presented by the school medical officer, and they show that the improved conditions have been fully maintained. During the third term of 1917 the inspection of all the entrant children, which had been discontinued from the beginning of 1916, was again resumed, and the results of this term's examinations are the best that have ever been attained, the percentage of children found in a poorly nourished condition being considerably less than half the percentage found in 1913, the year before the war." "It is with profound satisfaction that we find ourselves able to report these facts, showing, as they do, not only that the horrors of war have not been allowed to affect adversely the general condition of the children, but that, on the contrary, the general well-being of the children has, up to the present continually improved in spite of the war." Examination of Entrants The resumption in the third term of 1917 of the examination of entrants in detail which had remained in abeyance during 1916 enables similar figures to be given once more for these as for the 24 older children. In every detail these figures supplement and confirm the inferences drawn from the statistics relating to the older children. Especial attention is drawn to the very favourable condition of the entrants in regard to nutrition during the third term of 1917 :— Clothing and Footgear, Nutrition. Cleanliness of Head. Cleanliness of Body. Year. Good. Fair. Poor. Good. Fair. Poor. Clean. Nits. Verminous. Clean. Dirty. Verminous. Boys 1913 53.9 42.5 3.6 30.7 58.5 10.8 86.6 12.8 0.6 77.7 20.6 1.7 1914 56.3 40.4 3.3 31.2 60.7 8.1 88.0 11.0 0.4 81.7 17.3 1.0 1915 57.8 39.9 2.3 32.1 62.4 5.4 90.0 9.7 0.3 82.0 17.2 0.8 1917 55.7 42.2 2.1 31.1* 64.1* 4.8* 90.0 9.8 0.2 82.9 16.3 0.8 Girls 1913 55.1 42.3 2.6 32.7 57.5 9.8 73.4 24.9 1.7 77.0 21.3 1.7 1914 56.7 40.7 2.6 32.2 60.6 7.2 73.5 24.7 1.8 81.3 17.7 1.0 1915 58.0 40.5 2.0 32.3 62.5 5.1 76.2 22.4 1.4 81.1 18.0 0.9 1917 55.5 42.8 1.7 31.3* 64.1* 4.6* 74.7 24.4 0.9 81.6 17.6 0.8 Condition of the teeth. The Council's scheme for dental treatment is based primarily upon the inspection of the children at the age of 6 to 8 in the schools by dental surgeons attached to the local treatment centres. The figures dealt with in this paragraph relate only to the examination of the children in the age groups examined by the school doctors. They are valuable as an annual stocktaking. The total amount of dental decay present in the children in the schools remains, unfortunately, very great. It is satisfactory, however, that the measures taken by the Council, although not yet complete, result in a continuous improvement of the dental condition of the children throughout school life, as shown by the better condition of the leaver children as compared with the eight-year-old group, and of the latter as compared with the entrants. Each successive year, too, the examination of leaver children presents better results than the previous year. The percentage of entrants with severe caries or oral sepsis was during 1917—Boys, 23'8 per cent.; girls, 23 3 per cent.; in the eight-year-old group—Boys, 14 0 per cent. ; girls, 13-1 per cent. ; in the leaver group, boys, 6.2 per cent.; girls, 5.5 per cent. Corresponding improvement occurs in each successive age group in regard to children noted with sound dentures. Of course it would not be fair to claim the whole of this improvement as a result of medical inspection and treatment during school life, as some part of it is due to the decay of the milk dentition of the entrants, but the practice of concentrating effort upon the worst cases of dental disease in the older children must materially have reduced the number of cases of serious defect at the oldest age. The percentage of leaver children with good teeth was in 1917, boys, 55.2 ; girls, 564 ; 1916, boys, 53.1 ; girls, 55.0 ; 1915, boys, 53.1; girls, 555 ; 1914, boys, 51.9 ; girls, 541 ; 1913, boys, 50 0 ; girls, 52.4 ; 1912, boys, 47.3 ; girls, 50.6. There is therefore not only an improvement noticeable in any one year when the younger children are compared with the older children actually in the schools, but there has been since 1912 a steadily increasing percentage of children leaving school with sound teeth. Unfortunately, the children entering school show no improvement from year to year, and the seeds of decay are already present before the school service of medical care has an opportunity of stepping in. Although the effect of the care of children's teeth during sohool life is making itself felt, it is of course unsatisfactory that nearly 45 per cent. of the leavers should be reported as having some degree of caries, but it must be remembered that this includes all eases in which even the slightest decay is recognised, and it must further be remembered that the children enjoy two years of school life subsequent to the leaving examination, and further improvement no doubt takes place during this period. Diseases of the Nose and Throat. There was a slight increase during 1917 in the number of children referred for treatment for adenoid growths and enlarged tonsils, the eight-year-old, as usual, providing a larger percentage than the leaver group. The incidence upon the sexes of these throat conditions remains in each group practically identical. Amongst the eight-year-old children, 5.9 per cent. of the boys and 5.7 per cent. of the girls were referred for treatment for these conditions, and amongst the leavers 3.8 per cent. of the boys and 3 9 per cent. of the girls. Although slightly higher than the percentages for 1916, which were the lowest on record, the figures remain lower than they were in former years. For instance, the percentage of the eight-year-old group referred for treatment in 1912 was boys, 8.9 ; girls, 8.6 ; and of leavers, boys, 7.9 ; girls, 8.7. The progressive reduction at the leaver age as compared with the eight-year-old group is undoubtedly due to the care in medical matters exercised over the children while at school. One of the important influences in improvement of these conditions in children is the attention paid to correct breathing and the provision of breathing exercises as part of the physical education in school. Unfortunately, there is some confusion owing to the existence of two sets of breathing exercises, one designed to promote correct and healthy breathing habits and the other used as a drill preparatory to singing lessons. Contrary directions are given in the two sets of exercises, and it has been pointed out that the exercises for voice are liable to promote undesirable habits of ordinary breathing. The * Figures for 3rd term only. 25 case is further complicated by the fact that in the infant school it is the breathing for voice which alone is, in general, practised, and therefore at this impressionable period the children do not benefit by the corrective whioh the general breathing exercises would supply. The condition 01 the throat nas such a preponderant innuence upon me development or ear disease and deafness that it is convenient to deal with the latter conditions next, in order. Ear disease, defective hearing and speech defects. The percentage of children of the eight-year-old group referred tor treatment tor ear disease was 11 in the case of both boys and girls and at the leaver age nearly the same. The percentage of children examined at the earlier age referred for treatment for deafness was 0 5 per cent, in both sexes, and at the later age boys 0.6 and girls 0 .5. The equal incidence upon the sexes of ear disease and deafness is in consonance with former experience and with the equal incidence of unhealthy throat conditions. The percentage was slightly lower than that of last year and considerably lower than those of former years. In fact, the reduction in the number of children found in school to be suffering from deafness and ear disease has prooeeded pari passu with the reduction pointed out above in unhealthy throat conditions. In October, 1916, it was reported to the Children's Care (Central) Sub-Committee that during 1915 a special inspection centre for ear cases had been arranged in the south-western division and that a special scheme of following up was in the summer term of 1916 extended to the north-western division also. Dr. A. G. Wells, who has been responsible for the special inspections in the two districts named, reports that at each inspection an assistant organiser is present to consult with the parents as to the means of obtaining the special treatment indicated by the doctor. Note is made upon a special record card of the condition found and the treatment advised. The School Care Committee in each case is notified for the purpose of following up. Each assistant organiser has a list of the special ear cases attending the hospital or centre at which she attends and reports to the Care Committee, without delay, any irregularity in attendance or failure to carry out directions given. Much better results are obtained, as might be expected, in cases which attend under the Council's scheme. From June, 1915, to June, 1916, 190 cases were seen in the south-western division, and 23.4 per cent, were discharged as cured; from June, 1916, to June, 1917, 145 cases were seen and 30.8 per cent, were discharged as cured. Thus the total number of cases was reduced and a larger proportion wero cured in the second year. As a result of the success of the special inspection in these two divisions it was agreed to extend the scheme to the other three divisions. In my report of October, 1916, the need for in-patient treatment for some of the cases of ohronic ear discharge was pointed out, and the Sub-Committee recommended that the Council should enter into negotiations with the authorities of one or two hospitals in London with a view to arranging for the reservation of five beds for this purpose at an expenditure not exceeding £260 a year. The Board of Education did not see their way to agree to this proposal, which therefore fell through. The need of such provision is, of course, just as urgent as it was, and the Council, at the close of 1917, asked the Board to reconsider their decision There has been no change noticeable in the proportion of children of either sex in each age group found to be suffering from heart defects or anaemia, and the percentage referred for treatment for these conditions is identical with that of the previous year. 1,222 boys (3.5 per cent.) and 1,258 girls (3.7 per cent.) at the age of eight years, and 1,197 boys (3.5 per cent.) and 1,542 girls (4-5 per cent.) were noted as suffering from defects of the heart. 1,652 boys (4.8 per cent.) and 1.646 girls (4.9 per cent.) were noted as suffering from anaemia at the earlier age, and 1.146 boys (3.3 per cent.) and 1,453 girls (4.3 per cent.) at the later age. The excess of the incidence of both these conditions at the older age upon girls corresponds with what has been experienced in all previous years and the explanation is to be sought in the practice, towards the end of school life, of employing girls at home on household drudgery while their brothers escape this to a greater degree and are free to engage in outdoor sports and nastimes. Heart defects and ansemia. There is no alteration apparent in the distribution of lung complaints other than tuberculosis, which are found in about 4 per cent, of the younger and 3 per cent, of the older children, the incidence being slightly higher at each age upon boys than girls. The number of cases found suffering from phthisis in the course.of the routine age examination Lung complaints, phthisis and other forms of tuberoulosis. remains exceedingly small. 296 children were found, forming a total of 0.1 percent, of those examined. On the other hand, 438 additional children were discovered with phthisis at special and urgent examinations. It is clear, therefore, that phthisis in school is detected at a relatively early stage, and the children are placed under treatment before arriving at their next routine age group examination. Tuberculosis of other organs than the lungs was found in 465 children in the age groups, or 0.2 per cent. ; as in the case of phthisis, a larger number were found at urgent and special examinations, viz.. 511. Contrary to the view expressed by some to the effect that air raids would be found to increase generally the incidence upon school children of nervous complaints, there is no evidence at all in the results of the age group examinations that there has been any general strain arising from this cause falling upon the mass of the children, the figures being in all respects comparable to previous years. That a limited number of children have been immediately affected is no doubt true, and this is reflected in the figures of urgent and special inspections apart from the age group examinations. At such special inspections 586 boys and 754 girls were reported to be suffering from nervous complaints, compared with 508 boys and 606 girls similarly reported upon in 1916. It is unsafe to extend the results obtained by one or two observers working in a limited and special field to the general mass of the population and it can still safely be said that up to the end of 1917 there is no evidence that any portion of the strain of war conditions had been allowed to fall upon the children of school age generally in London. 43316 u Nervous complaints. 26 The number of children found to stammer amongst the eight-year-old group was 130 boys and 35 girls (0.4 per cent. and 0.l per cent. respectively), amongst the leavers there were 160 boys and 52 girls (0.5 per cent. and 0.2 per cent. respectively). The number of boys in the earlier age group suffering from other speech defects was 214 (0.6 per cent.) and girls 148 (0.4 per cent.), at the later age the numbers were 138 boys (0.4 per cent.) and 122 girls (0.4 per cent.). In the Annual Report for 1916 attention was drawn to the classes for adults provided by the Council and taught by teachers of the deaf by oral methods, to the instruction of the students in the training colleges in the theory and practice of speech, and to the "speech clinic" conducted by the authorities of St. Thomas's Hospital. These facilities were continued during the year, and an experi- mental class in remedial exercises for stammering children attending elementary schools is about to be conducted under the auspices of the Westminster Health Society at Greek Street, Soho; the results of this experiment will be recorded in the report for the ensuing year. The number of children noted as having enlarged glands of the neck was higher than in the previous year, reaching 11.6 per cent. in the case of boys and 10.5 per cent. in the case of girls at the eight-year-old period and 8.1 per cent. in the boys and 8.4 per cent. in the girls at the older age. These figures, however, include all degrees of enlargement, and it is necessary to add that there was no increase noted in the number of cases in which the enlargement was such as to necessitate reference for treatment, i.e., in severe cases, which remained practically identical with the numbers of the previous year, viz., 0.4 per cent. boys and 0.2 per cent. girls at the eight-year-old age and 0.2 per cent. for boys and girls alike in the leaver group. The percentage of children at the age of eight found with normal vision was 37.9 boys and 34.6 girls, at the age of twelve this had increased to 51 per cent. boys and 45.4 percent. girls. Attention is therefore once more directed to the excess of the incidence of visual defect upon girls as compared with boys. The number of eight-year-old boys referred for treatment for vision was 3,716, or 10.8 per cent., and of girls 4,017, or 11.9 per cent., and of older children 5,409 boys (15.8 per cent.) and 5,539 girls (16.2 per cent.). These, although differing not materially from those of the previous year, are high percentages; a considerable amount of visual defect appears to be inseparable from the conditions of modern civilised life; how far the condition is due to hereditary causes and how far due to defective hygiene and too early application to fine work at school and home is not decided, but the special incidence upon girls suggests that the second factor is a very important one in the production of visual defect. Percentage of boys and girls at the age of 12 found with perfect vision with or without glasses. 1913. 1914. 1915. 1916. 1917. Boys 51.1 54.3 57.4 54.4 51.0 Girls 43.8 47.3 51.3 48.4 45.4 The above table shows that ground has been lost during the last two years. This is due to a variety of causes, including preoccupation of parents, the increasing cost of spectacles and the closing down of eye departments at many of the general hospitals. It is probable that the last of these causes is the most important, as previous to the war a large number of children obtained relief from these departments. The proportion of children found suffering from the effects of rickets was slightly lower than that of the previous year. The absence of complete figures for the entrants, however, makes any general statement upon this point impossible. 1,080 (1.6 per cent.) children of the eight-year-old group, equally divided between the sexes, were reported as suffering from deformities other than the result of rickets, while 705 (2.1 per cent.) boys and 969 (2.8 per cent.) girls at the leaver age were so reported upon; corresponding with the higher incidence of heart defeat and anaemia in older girls the excess of deformities in girls reported at the leaver age must be attributed to their occupation at home upon household tasks. The greater difficulty experienced in keeping children in a cleanly condition, owing to the enforced or voluntary absence of the mothers from home during a great part or the whole of the day is referred to elsewhere in the report. This is reflected in slight increases in the percentage of children in the age groups found to be suffering from skin disease and external eye disease, both of which in general may be taken to belong to the category of "dirt" diseases. Still more is it seen in the numbers of children suffering from these diseases presented for urgent and special examinations. There were no less than 6,614 children so presented found to be suffering from skin diseases in 1917 compared with 2,646 in 1916. This is a very significant increase. The number of children presented for special and urgent examinations continues to increase. During 1917 reports on 53,334 special examinations were received, as compared with 39,425 in 1916. Owing to the facilities accorded to teachers and Care Committee workers for presenting special cases and to the frequent presence in the schools of the doctor and nurse, it is increasingly the case that few cases of serious disease remain undetected. Were it not for these special facilities by which children are seen early and brought under treatment the results of the routine inspections would be far worse. As has already been pointed out, it is rare for a case of phthisis to be first detected at a routine age group examination, and this also applies in slightly less degree to cases of skin disease and external eye disease. The extension of the routine age group inspections to the children in schools for the mentally defective admits of a comparison being made between them and the normal children. That the mentally defective are derived from the more degenerate stocks physically, is shown by the excessive incidence upon the mentally defective children of every one of the tWenty-two diseases comprised in Stammering children. Enlarged glands of the neck. Defective vision. Rickets and other deformities. Skin diseases and external eve diseases. Special and urgent examinations. Physical cmdition of mentally defective children. 27 the official schedule. Among the more pronounced instances of this the following may be cited. While 42 per cent. of the children in the ordinary elementary schools are found to have perfect vision, only 25 per cent. of those in the special schools attain it. While 1.1 per cent. of the elementary school children are reported as having impairment of hearing, 4.1 per cent. of the mentally defective are reported for the same condition. Nervous diseases which affect 1 per cent. of the ordinary school children are found in 3.6 per cent. of the special school children, and speech defects of all kinds which are exhibited by 0.6 per cent. of ordinary school children are found in 4.l per cent. amongst the mentally defective. Medical and Dental Treatment. A considerable increase has been made in the provision for the medical and dental treatment of school children during the year. Five new centres have been opened, at Popham-road, Islington (for teeth and minor ailments); Rye-lane, Peckham (for eyes, throat, teeth and minor ailments); Lancing-street, St. Pancras (teeth and minor ailments); Marylebone (teeth); and Whitechapel (teeth and minor ailments), and the work at many of the existing centres has been extended. The numbers under the agreements in force during the year were as follows:—Eyes, 25,432; ear, nose and throat, 13,105; ringworm, 2,015; minor ailments, 23,024; teeth, 60,845—total, 124,421. In addition several extra sessions were arranged, especially for vision cases, at the Council's centres, owing to the inability of certain of the hospitals to continue to deal with school children. The total number of children who attended the centres as new cases during the year was 122,765. The numbers have been somewhat affected by air raids, as very few children have presented themselves on the mornings following the raids. This has been specially the case in the E. and N.E. of London. Defective Vision.—The number of children dealt with under the Council's arrangements was 27,062, or 157 more than in the previous year. Spectaoles were prescribed for 21,423 children, and 17,343 children obtained spectacles. Ear, Nose and Throat Defects.—The decline in the number of children treated which has been noted in previous reports has continued. The number of children treated was 9,375, or 990 less than in 1916. The reduction this year, however, is not due to the lower number found on inspection to require treatment, but to the difficulties of following up the cases. Ringworm.—1,284 children were referred to the Council's centres for the treatment of ringworm, as compared with 1,466 in the previous year. X-ray treatment was applied in 1,157 cases. Minor Ailments.—The deficiency which exists in the accommodation for the treatment of minor ailments is being gradually met. Arrangements for such treatment were made at four new centres, and the provision at some of the existing centres was increased. During the year 28,131 new cases were treated as compared with 22,876 in 1916. The new cases, together with the cases under treatment at the beginning of the year made 525,030 attendances at the centre. 16,479 home visits were paid by the nurses to the children's homes, and in 6,183 cases arrangements were made for convalescent treatment or other forms of after care. It was represented to the Council that the allowance of £100 a year made to the District Nursing Associations for the services of a full-time nurse did not now meet the necessary expenses, and the Council has agreed to increase the allowance to £115 a year. Dental Treatment.—Mr. C. Edward Wallis reports that during the year steady progress has been maintained in the development of the scheme for dental treatment. In spite of the difficulties of obtaining staff and premises, five new centres have been established during the year, located respectively in Lancing-street, Euston-road; Earl-street, Lisson-grove ("Lissonia"); Popham road, Islington; Rye-lane, Peckham; and Whitechapel. The number of centres at which dental treatment was given at the end of the year was 36. Children have been examined in the schools by the Council's inspecting dentists, and of the 90,000 children seen 71,000, or 79.4 per cent. were found to require treatment. Of these, 57,000 have received treatment at the Council's centres, as compared with 50,000 in the year 1916. The results of dental treatment for the year 1917 are as follows :— Total number of children attended 56,913 No. of other operations, e.g., scaling, immediate No. of attendances 83,907 regulation, application of AgNO3, etc. 9,561 No. of teeth or roots extracted— No. of general anæsthetics— Temporary 109,332 Nitrous oxide 12,164 Permanent 30,727 Ethyl chloride 8,856 No. of stoppings 45,839 Other general anæsthetics 743 The shortage of dentists owing to war circumstances has to some extent been alleviated by the appointment of women dentists to five of the dental centres; the supply of women dental surgeons is, however, extremely limited. The Council has considered the general position in regard to the supply of dentists in the future, having regard to the fact that so few students are now undergoing training. With a view to encouraging suitable girls to enter the dental profession a letter was addressed to the head mistresses of the Council's secondary schools giving information as to the prospects afforded and pointing out that the Intermediate and Senior County Scholarships could be used for the purpose of obtaining the necessary training. At several of the dental centres arrangements have been made with the local committees for use of the Council's dental equipment in connection with infant welfare centres and the treatment of expectant and nursing mothers; this scheme, which is gradually developing, marks an advance as regards the health of mothers; it should, moreover, indirectly affect the health of the children themselves. Already the school medical inspectors report a great improvement in the oral conditions and 43316 D 2 28 general health of the children of London as the result of the school dental treatment now being systematically carried out. For the year 1918-1919 eight additional centres have been sanctioned, making a total of 44 centres, which will provide facilities for the dental treatment of 90,000 children annually. Reinspections of Ailing Children. The measure of success of the Council's schemes for following up and securing treatment for the children found at inspection to be ailing is given by the results of reinspection. As the primary inspection is a point and the remedial action is a process, it is obviously impossible to present the actual position at any given moment in the form of a balance-sheet of profit and loss with a surplus or remainder to be carried on from year to year. What can be done is to give the proportion of ailing children whose treatment has actually been commenced at given dates after the first discovery of their defects. During 1917, 177,742 reports were made upon the re-examinations of ailing children, compared with 181,035 in the previous year. 21,511 of these reports related to children kept under observation, but not referred for treatment, 94,660 to children seen six months after their primary inspection, and 61,571 to children referred for treatment and found not to be relieved at their reinspection in the previous year and now again reinspected. It was found that treatment had been commenced or the conditions otherwise satisfactorily dealt with in the case of 45.3 per cent. of the children reinspected for the first time during the year, and in 49.1 of those who had not been satisfactorily dealt with at the time of their first reinspection in 1916 or 1917, so that on the results of the year 67.6 per cent. of the children requiring treatment were eventually receiving it, or otherwise being satisfactorily dealt with. The corresponding figure for 1914 was 75 per cent. The results at first and second reinspections in 1915, 1916 and 1917 may be seen from the following statement. Percentage of ailments noted amongst children reported to have been brought under treatment or discharged as not requiring treatment. Cases noted as requiring observation at first reinspection are counted as discharged at second reinspection if in the opinion of the examining doctor no treatment is advisable:— First Reinspection. Second Reinspection. 1915 51.9 53.7 1916 51.6 52.4 1917 45.3 49.1 This falling off is to be ascribed to war conditions operating through three factors (a) the full occupation of the parents, including the absence of mothers from home on munition and other work; (b) the withdrawal of many voluntary workers from the work of following up in favour of voluntary work connected with soldiers and sailors and munition workers; and (c) the shutting down of facilities for treatment at voluntary hospitals in consequence of the number of wounded soldiers being dealt with and in consequence of staffing difficulties. How serious the last factor has become is shown by the fact that whereas in 1914 22.6 per cent. of the children obtaining treatment for visual defect went to voluntary hospitals, the proportion doing so in 1917 was only 6.2 per cent. The opportunities for treatment outside the Council's scheme have, therefore, owing to war conditions dwindled almost to negligible proportions and a consequent greater strain has been imposed upon the Council's arrangements. Somewhat similar difficulties have been experienced in regard to operations for throat diseases, and the percentage of children found at first reinspection not to have been dealt with for these conditions has increased from 44.8 in 1916 to 53.0 in 1917. The Council has done what was possible to cope with these difficulties by endeavouring to fit in extra sessions for treatment at the centres. It is obviously difficult to start new centres tinder war conditions, when shortage of materials and labour is so acute, and it is possible that, in localities near hospitals, the need may be transient, for upon the restoration of peace the facilities at voluntary hospitals now denied may again become available. The highest percentage of failure to obtain treatment occurs in cases of dental defect. It is admitted that there is not, nor has there ever been, sufficient provision either of a voluntary or of a public nature to deal with the mass of dental defects in children. The scheme of dental amelioration favoured by the Board of Education deals in the first instance exclusively with younger children. The cases now under consideration are not those amongst younger children who are subject to the special inspection of the Council's dental staff, but those of older children for whom inadequate facilities are provided seen by the school doctors as part of the routine age group examinations. The war, of course, has seriously hampered the rate of extension of the Council's provision of dental centres, although steady progress at a reduced rate has been made. If the dental figures are subtracted from the total results of following up the position is a more favourable one than has been reported above. It is possible to claim that when dental cases are excluded some 74 per cent. of the children referred for treatment were eventually being brought under treatment or discharged as satisfactory during 1916-17. Special Examinations of Children at Minor Ailments Centres. The school doctors have attended at ten of the minor ailment centres for a short time after school hours on certain fixed days for the purpose of inspecting children reported by care committee 29 workers, teachers, school nurses and attendance officers, with a view to securing that the necessary action should be taken in each case and that those urgent cases found to be suitable for treatment under the Council's scheme should be referred immediately to the proper department. The number of cases dealt with in this way during the year was 6,115, and the conditions found as a result of these examinations were as follows Conditions of skin (3,328), including scabies, impetigo, eczema, septic wounds, etc.; conditions of the eye (783), conjunctivitis, blepharitis, corneal ulcers, etc.; conditions of ear, nose and throat (674), otorrhcea, enlarged glands, tonsils, adenoids; conditions of teeth (101); other cases (880), including mumps, anaemia, tubercular diseases, lung defects, etc, while in 349 cases the child had already been under treatment and at the time of examination was found to have been cured. These facilities for the special examination of children have been so much appreciated that it has been decided to extend the arrangements to 15 additional centres, making 25 in all. "Following-up." During the year the reinspections showed a considerable falling off in the proportion of children who had obtained the necessary medical treatment. The committee therefore considered as to the steps to be taken to effect an improvement. The following notice was inserted in the L.C.C. Gazette of 14th January, 1918 :— "In order to assist care committees where the lack of voluntary workers is specially acute it has been decided that, as a temporary measure, a portion of the routine work of 'following-up' after medical inspections and reinspections may be done under certain conditions by the school nurses. In view of the great demands already made on the time of the nurses, it will be understood that extra visiting by the nurse can only be undertaken where the care committee is satisfied that it is impossible to arrange in any other way for ths carrying on of the medical work. "The following instructions have been issued to assistant medical officers and school nurses:— "(1) Where the parent of a child needing treatment is present at the inspection or reinspection and consents to obtain treatment, but neither the Care Committee representative nor the head teacher is available to make the necessary arrangements, the school doctor shall send the following-up card, suitably endorsed, to the divisional medical officer, who will take the necessary action. "(2) Where the parent of a child needing treatment is not present at the inspection it has been the practice hitherto for the school nurse to deliver the advice card M.0.49 at the home. In future, except in specially urgent cases, the nurse should not visit the home in cases of dental defect, but in these and other cases in which it is decided that the nurse need not visit the M.0.49 should be sent home by the child. Some of the nurses'time will thus be saved, and in future at the inspection or reinspection in cases in which no parent is present the school doctor (after consultation with the Care Committee representative, if present, or head teacher), shall select cases for home visitation by the nurse. In these cases the nurse will take the advice card M.0.49 or M.0.49 (R) to the home and will make every effort to see the parent and report the result of her visits to the divisional medical officer upon the following-up cards. "(3) In a tew specially selected schools the nurse will undertake the further following-up of cases until the necessary treatment is obtained. "With regard to (1), in order that the Care Committee may be kept fully informed, the nature of any action taken will be communicated to the district organiser. It will, of course, be understood that in the event of the Care Committee worker not being present at a particular inspection or reinspection, but sending word that she wishes to take the necessary action, the following-up cards will be left at the sohool for her. "With regard to (2), where it has been the practice of the Care Committee representative to deliver M.0.49 at the home, this procedure should not be altered. When the nurse visits, the result of her visit will be reported by the Divisional Medical Officer to the District Organiser for the information of the Care Committee, or, alternatively, where this can be mutually arranged, the nurse will send the result direct to the honorary secretary of the Care Committee. The nurse will not follow up those cases which the Care Committee representative has indicated that she will undertake. In connection with the selection of cases for home visitation by the nurse, the Care Committee representative, if present, will, of course, bear in mind the question as to whether the social condition of the child is such as to warrant treatment under the Council's scheme. "With regard to (3), by a temporary arrangement in a few selected schools where the dearth of voluntary workers has been especially felt, a portion of the nurse's time has been set apart for the routine'following-up'of cases requiring medical treatment until such time as the Care Committee can be re-inforced. "This has involved considerable re-arrangement of the nurses'work, and the small amount of time available for 'following-up' work will not allow of any further claims on the nurses' services in this connection. "It is recognised that Care Committees are experiencing great difficulty in carrying on the'following-up'work owing to war conditions, which take so many mothers from their homes all day. It must, however, be understood that, in view of the very limited time at the disposal of the nurses, help can only be given in very special cases and not as a matter of course. It is, therefore, hoped that the Care Committee will endeavour to the utmost of their ability to carry on the work of 'following-up' the children requiring medical treatment and observation." 30 Co-operation between School Medical Service and Factory Surgeon. In October, 1917, the Children's Care (Central) Sub-Committee agreed to allow the final reports of the school doctors on "school leavers" to be sent to the City factory surgeon. The following report has been received from the City factory surgeon on the working of the arrangement:— "It was arranged that when a child, on leaving school, obtained work in a factory, the labour exchange should send me Form A. stating the child's name and address, and an abstract of the school doctor s report, as well as the name of the factory, under confidential cover. Although this arrange- ment has been in operation for a few weeks only the results have been most satisfactory. I have obtained a number of reports about the young persons starting work in the City of London, and in many instances I have been able to continue the treatment of defects instituted by the school doctors. Sometimes the reports sent me by the labour exchanges have shown that girls were under treatment at school for chlorotic anæmia. I have been able to see that their treatment has been continued while in the factory, have sent many such cases to their own doctors, have obtained the co-operation of the employers and the assistance of the overlookers in seeing that these girls go on obeying their doctors' instructions and they are given time to do so. In several instances defects which were not remedied at school have been remedied now owing to this arrangement, while at work in the factory. Sometimes parents refuse to follow the recommendations of the school doctors as to operation for adenoids, tonsils, carious teeth and even the supply of spectacles, or to teach their children cleanliness. Yet, in many instances, these refractory parents have given way when they found that their children might not be able to earn wages until their physical defects, discovered years before at school and always deferred treatment, were removed; for they know that the certifying surgeon has the power to refuse certain defective young persons for certain employments under the Factories Acts. In most cares persuasion has succeeded, when the parents discovered that I was in accord with the school doctors and co-operating with them to obtain the proper medical treatment of the children. Many children on leaving school obtain employ- ment in London through sources other than the labour exchanges. On finding such children in the factories I send their names, addresses and school attended to the labour exchanges nearest their homes on Form B. This form is returned to me with the full doctor's report attached, and on my next visit to the factory I am able to continue the treatment or observation of the conditions (if any) of such young persons in the same way as those placed at work by the labour exchanges. In the event of a young person being found unsuitable to work in any particular trade, industry, or factory, and I refuse a certificate of fitness, it has been arranged that the same procedure should be adopted, and the name and address is sent to the labour exchange. The Local Juvenile Advisory Committee then proceeds to obtain more suitable employment. Already several cases have been dealt with in this way. Cases of quiescent pulmonary tuberculosis have been transferred from London printing works to better occupation in the country, deformed children have been referred to various organisations for the supply of apparatus and to centres for physical training, suitable work has been found for cripples, and even adults have been dealt with in this way." Education (Provision of Meals) Act. The arrangements set out in previous reports for the supervision of dietaries have continued throughout the year. The total samples of milk meals examined amounted to 565-of this number 218 (nearly 39 per cent.) could not be considered satisfactory, 46 being described by the chemist as of "poor quality," whilst the remainder, 172, were definitely "unsatisfactory" either by reason of the addition of water or a deficiency of fat. The maximum addition of water (41 per cent.) was found in the supply to a school at Poplar, whilst a sample from a school at Stepney was reported as being deficient in fat to the extent of 43 per cent., showing also the addition of 7 per cent. of water. Another sample was found to contain extraneous matter (dirt) to such an extent as to render it unfit for food. The most serious adulteration was found early in the year, and arrangements were made for a larger number of samples to be taken and for further enquiry concerning unsatisfactory samples. Following upon this action a great improvement in quality occurred. This, however, has not been maintained, and recent results are again very unsatisfactory; thus, of 70 samples examined last January, 53 (over 75 per cent.) were unsatisfactory, and during February 67 out of 72 samples examined (93 per cent.) were unsatisfactory. Of these 5 in January and 11 in February which may have contained added water up to 5 per cent. may be classed as of "poor quality." Setting these apart, it is found that of the remainder no less than 40 per cent. in January and 54 per cent. in February contained 10 per cent. or more of added water. An improvement was observed in March, i.e., leaving out of consideration 12 samples which may be described as being of "poor quality," only 8, or 13½ per cent., of the remainder showed the addition of 10 per cent. or more of water. Effort has been and is being made to remedy these conditions, and the medical officers of the local authorities in whose districts the sellers' premises are situated are asked to co-operate with a view to samples being collected under the Sale of Food and Drugs Acts and a considerable number of convictions have been obtained. Of 35 samples of meals, other than milk meals, supplied to necessitous children, one only was reported after analysis as "unsatisfactory" as to quality. In many cases recommendations were made as regards restoring the balance of the various ingredients and increasing the amount of available nourishment. Supervision of dietaries. 31 Children Out oj School for Long Periods. . The arrangement has continued whereby the attendance branch of the Education Officer's depart nient submits each month to the School Medical Officer medical certificates concerning all children out of school for a period of three months on account of ill-health. The total number of children who were thus reported as absent from school on the 1st November 1917 was 2,311, and the conditions from which they were suffering were as follows:—Rheumatism, including heart disease and chorea, 285 (12.33 per cent.); nervous disorders, 209 (9.04 per cent.); tuberculosis, 465 (20.12 per cent.); anæmia and debility, 207 (8.96 per cent.); ringworm, 142 (6.14 per cent.); other diseases, 961 (41.59 per cent.); unsatisfactory certificates, 42 (1.82 per cent.). It will be noted that whereas formerly the rheumatic group accounted for the greatest percentage of the total number of children absent for long periods, the premier place is now taken by tuberculosis. This is not due to any alteration in the incidence of the two groups of conditions but to the extended care and attention now being given to tuberculosis, whereby a larger number of sufferers from this condition are discovered and followed up. All cases of tuberculosis and epilepsy are still being registered, and apparently unsatisfactory or doubtful conditions are being followed up, especially such conditions as ringworm, scabies, and minor ailments. Tuberculosis. During 1917 authority was renewed for the use of 231 sanatorium and hospital beds for children in voluntary institutions at the expense of the Council and for the acceptance of beds as available in Metropolitan Asylums Board institutions. During the year 784 children were treated in residential institutions. In addition, through the I.C.A.A., with financial assistance from the Council, some 400 beds were available. Returns from 22 out of 27 local tuberculosis dispensaries show that upwards of 10,300 child patients from babyhood to sixteen years of age were in attendance during the year; of these 7,590 including 3,839 boys and 3,751 girls were of compulsory school age. A new development during the year has been the establishment of day sanatoria attached to certain of the tuberculosis dispensaries. The work carried out under the tuberculosis scheme of the Council is dealt with in detail in the general section (Part I.) of this report. Open-air Schools. The Council's open-air schools at Birley House and Shooter "s-hill have been continued, and individual records of health and progress have been maintained. The arrangements for the medical inspection of the children have been set out in previous reports. The records show that the improvement of the children in general condition, mental and physical, has been well marked. The physical measurements present the same features as in former years, demonstrating the immense benefit to debilitated and anaemic children which accrues from an open-air education accompanied by generous and wise feeding. The majority of those in attendance are children in whom the onset of tuberculosis was feared, or children returned from sanatorium treatment with the disease in an arrested state. Further co-ordination of the work of the schools with that of the tuberculosis dispensaries has been effected during the year with advantage to the children. At Birley House school, improvement, in many instances great, was recorded in 101 out of the 103 children in attendance, and similar good results are evidenced by the school doctor's detailed reports upon individual children in the case of Shooter's-lxill school. The school has been under the regular supervision of Dr. R. S. Walker, who is also the medical officer of the Paddington Tuberculosis Dispensary, from which the children are drawn. The number of children on the roll on 1st January was 105 and on 31st December 91—the average for the year was 100. There was a marked variation in the average attendance from month to month, the lowest being 71 in December and the highest 84 in February. During the year 47 children left the school; of these 19 returned to ordinary elementary schools, 12 were excused further attendance after attaining the age of 14 years, 9 left the district, 5 were excluded by the medical officer on medical grounds, 1 went to a sanatorium and 1 to Greenwich Hospital. 35 children were referred for treatment—dental treatment, 20; throat treatment, 3; defective vision, 4; defective hearing, 2; ringworm, 1; whooping cough, 2; diphtheria, 1; measles, 1; scabies, 1. Careful measurements were taken, and it was reported that children who attended the whole year gained considerably in weight. Play-ground, Classes. During the year two classes of type "A" 38 of type "C," and 16 of type "D" were conducted. Particulars in regard to these different types have been set out in previous reports. Of the 56 classes, 16 were held in parks or open spaces and the remainder in school play-grounds; 5 were discontinued before the summer holidays. Detailed reports have been received from assistant medical officers upon 24 of the classes. As in former years, it was found that the children placed in classes of type "C" generally contained a larger percentage of those who are delicate or dull or backward than is to be found in the remaining classes of the school. This has to be borne in mind when comparisons are made between the progress physically and mentally of the children in the play-ground classes and those remaining in the ordinary classrooms. The universal testimony of the doctors is that the general improvement in colour and nutrition amply confirms the value of the arrangements made, and that the open-air life is a deciding factor in producing physical and mental alertness in these particular children. Reference to the happier, brighter and more ready response to all stimuli are found in all Kensal House School. 32 the reports. The times have been very trying and the progress oi the children has been ufiected thereby. The main trouble has been undue fatigue at times, and the doctors attribute this to loss of sleep rather than to any nervous tension directly brought about by shock or fear. This, of course, has affected all the children equally, whether in play.ground or in ordinary classes. Special mention should be made of the "open.air classroom" at the Jews' infant school, Commercial.street. Good results have been obtained in this class by intensive attention paid to the physical condition of the children, including the provision of cot hammocks for resting purposes, and special arrangements for feeding, by which every child gets milk at school during the morning session. The children are all delicate and are selected for admission by the school doctor, remaining in the class until discharged by him. The class is not limited to the summer months, but is carried on throughout the year. The results obtained in this class are comparable to those obtained in the regular open.air schools, and the increase in physical measurements is at a higher rate than in the play.ground classes generally. This emphasises the need for careful attention to the nutritional state of the children in all the classes. Personal Hygiene. The duties of the school nurses with regard to cleansing were steadily pursued throughout the year, but the absence on war duty of a large number of the more experienced nurses has naturally affected the work to some extent. The duties consist of a general inspection of the children and the application of the Council's schemes for dealing with those who are found to be (1) verminous in body and clothing; (2) suffering from scabies. The schemes have been set out in detail in previous reports. The scheme for dealing with verminous heads only is no longer operative, as it is now possible for children attending schools in outlying districts to be conveyed t6 the cleansing stations by means of the Council's motor ambulance. Careful consideration has been given to the question as to whether any improvements could be effected. It was found that some parents abused the privileges accorded to them, allowing their children to relapse from time to time into a verminous condition after repeated voluntary cleansings. It has therefore been decided to amend the scheme. Hitherto it has been the practice to send a warning notice (see A below) to parents stating that children may attend voluntarily at the cleansing station, and this notice is repeated if. after being cleansed, the children again become verminous. On a further relapse occurring a more drastic notice (see C below) is served, and this is repeated before the warning as to police court proceedings is issued. It is now thought that these notices should not be issued more than once, and the scheme has been varied accordingly. The modifications are shown below, the portions to be omitted being printed in italics :— CLEANSING SCHEME (PERSONS AND CLOTHING). Slight cases. Advice given. I Severe cases. Remedied by parents. Unremedied. A Card given offering voluntary baths at cleansing station. Local Medical Officer of Health informed. Opportunity accepted. Opportunity neglected. B Three voluntary baths given Child cleansed. In case of relapse 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. Parents now come voluntarily to station. 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 Child examined within 24 hours oy nurse and conveyed to station for compulsory bath. Child cleansed in one operation. Local Medical Officer of Health informed. E Divisional Superintendent asked to serve statutory notice in which no opportunity of voluntary bath in given. G If the child again becomes verminous 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. Cleansed by parent. In case of relapse begin again at E. No steps taken by parent, proceed under F. A complete record of the number of examinations by the school nurses and of the conditions found was made, and the following figures show the amount of work done: Number of examinations, 2,130,186; number found clean, 1,601,528; number found verminous, 528,658; percentage found verminous, 24.8 per cent. The number found verminous includes all degrees of unsatisfactory conditions, from the case of a few nits on the hair to cases of head, body and clothing infested with pediculi. Rota visits General inspection. 33 The need for cleansing work has, owing to war conditions, become more acute; how acute is shown by the great increase in numbers of children brought to the cleansing stations; thus from 41,458 cleansings in 1913, 42,557 in 1914, and 43,884 in 1915, the numbers have increased to 54,945 in 1916 and 80,755 in 1917. There are now 25 stations for the cleansing of verminous children, a new one having been opened at the open.air camp school, Wellington street, Deptford. The total number of examinations made by the nurses under the cleansing scheme proper was 798,643, and 19,506 children were found verminous; of these 8,506 were cleansed by the parents, the remainder 11,000 children were dealt with at the cleansing stations; 31,124 cleansings were carried out at the Council's stations and 49,631 at stations of the local sanitary authorities This number is an increase of 25,810, or 47 per cent, when compared with the number for 1916. The parents of 124 children were prosecuted, and fines varying from 2s. to 10s., with costs, were imposed. Of the total number of children cleansed, 1,792 were conveyed by the Council's motor ambulance. At each stage under the scheme a notice indicating the condition in which the child is found is sent to the local sanitary authority in order that action may be taken with regard to clothing and bedding in the home under the London County Council General Powers Act, 1904, Part IV. The arrangements for the bathing of chddren suffering from scabies were continued. total milliner dealt witn during tne year was 6,940, an increase of 3,727 when compared with the figures of the previous year; and there was an increase of 30,317 in the total number of baths given. Cases in which the family has been found infected after the visit of a soldier have come under notice. All the cases in school children have been speedily followed up, and in older that there should be no interference with the treatment, baths were given at the stations throughout the summer recess. The co.operation between the Council and the hospitals and treatment centres was further facilitated by the use of a specially prepared card, which was handed at the hospital or treatment centre to the parent, who was advised to take it, together with the child, to the nearest cleansing station. The school nurses again assisted the executive Committee of the Children's Country Holiday Fund by examining for any infectious disease (e.g., ringworm) or any form of uncleanliness the children whom it was proposed to send to the country. The personal hygiene scheme in girls' secondary schools and kindred institutions has continued in operation. The scheme was applied also to one boys' school, where only one verminous head was found. The proportion of verminous heads found in the girls' schools was 4.0 per cent., a decrease of O.1 per cent, when compared with the figures for 1916. The scheme in force during 1917 provided that all pupils found on examination to be defective as regards personal hygiene should be given three opportunities for remedying the unsatisfactory condition, a period of one month elapsing between the first and last of the series of examinations. The preliminary examinations in all cases are carried out by the school nurses, and pupils in whom unsatisfactory conditions remain unremedied are seen by an assistant superintendent of nurses, upon whose report action is taken. In exceptional cases awards are withdrawn from scholarship holders and fee. paying pupils are permanently excluded from the institutions. Experience has proved that a certain number of the scholars and pupils, found to have remedied the condition at the third examination, relapse again during the holiday periods. The Higher Education Sub.Committee considered whether it would be possible to further safeguard the pupils in secondary schools from infection by verminous children, and it was suggested that if a child were once found verminous any scholarship or award should be refused or terminated. Upon this I reported that serious hardship might result if this rule were strictly enforced, and the Council has since decided that, in the year 1918 and subsequently, it shall be a condition of the award and tenure of the Council's scholarships, exhibitions and free places, that the candidate or scholar shall not be found unclean or verminous (apart from accidental infection). Provided that a reasonable interpretation is placed upon the last four words this scheme should be productive of good results. The scheme in force at the institutions has, therefore, been amended so as to give effect to the Council's decision. Examinations of Candidates and Medical Inspection in Higher Education Institutions. The total number of candidates medically examined was 4,965, a decrease of 431 when compared with the figures for 1916. In addition to the foregoing examinations, 1,614 references in regard to the health of employees in the Council's service were considered. This number shows an increase of 194 when compared with the figures for the previous year. Arrangements were also made for the examination of discharged soldiers and women who proposed taking up the specialised courses of training for munition students at the Council's Brixton and Shoreditch Munitions Training centres. 52 men and 1,211 women were examined; of these 12 men and 232 women were found to be unfit. The women, whose ages varied from 18 to 35 years, were drawn from a very wide field, including various parts of London, the provinces and Scotland. The medical inspection of pupils in L.C.C. training colleges and secondary and trade schools and of pupils in attendance at non.maintained secondary schools was continued, and the results are given in the Appendix. Infectious Diseases—Schools. In 1917, as in the preceding year, these diseases, and especially the former, were but little prevalent. The season was again an exceptionally wet one, and this circumstance, together with the fact that a major wave of scarlet fever attained a maximum in 1914 and was due to ebb to a minimum about 1917 affords a partial explanation of the phenomena. In the trough of the preceding wave, i.e., 43316 E Cerminous persons and clotliing. The Scabies. Country Holiday Fund. Secondary schools. Scarlet lever and diphtheria. 34 in 1910, the number of notifications was the smallest recorded up to that date, some 10,SCO; in 1916, however, only 8,778 cases (excluding military cases) were notified; the total for 1917 was lower still, only just over 6,000 cases of scarlet fever; there were, however, nearly 8,600 cases of diphtheria. The relation of flea prevalence to that of scarlet fever has been commented upon from time to time in these reports. There was an increase in flea prevalence in 1913 and 1914, corresponding with the culmination of the major wave of scarlet fever, and since then there has been diminution. (See Diagram). The reasons, so far as they were then appreciated, for claiming that a flea hypothesis of causation of scarlet fever should be carefully examined were first set out tentatively in 1908, and a first "flea curve," based on examination of common lodging.house beds, was obtained in 1909 and published in the following year (Appendix IV., Ann. Rep. Med. Off., 1910). The close correspondence in the seasonal curves of scarlet fever and of flea prevalence was thus made apparent, and the important fact that maximum flea prevalence antedates maximum prevalence of scarlet fever was revealed. In the annual report for 1911 the seasonal curves of 3 years were exhibited, and the need for further study of"the special incidence upon children, and particularly upon children in schools, and the evidence as to fomites and the alleged clinging of infection to houses or rooms, or in schools to particular departments or even classrooms," was considered. Moreover, reference was made to the need for closer examination of the return case problem. The first of these two lines of enquiry was taken up in 1912, and Diagram C, Annual Report for 1912, illustrates the tenacity of hold of scarlet fever and diphtheria upon particular elementary schools. As noted originally by Dr. Niven, the phenomenon suggests the clinging of infective property to the premises rather than to the children, and the possible influence of dust was hinted at by him in this connection. In 1913 the curve of seasonal prevalence of fleas was established upon a more satisfactory basis "by the inclusion of material made available by the examination of elementary school children," a more satisfactory test than that previously afforded by examination of common lodging.house beds. The curves for 5 years, including the children's curve for 1913, are given in the Annual Report for 1913, find in 1914 the curves for 6 years were shown; the fact was now clearly demonstrated that the maxima for scarlet fever always "lagged somewhat (three or four weeks) behind those for flea prevalence." The subject of "school influence" was, in 1914, further studied (see D iagram E., Ann. Rep. Med. Off.), and it was made clear"that some condition, closely associated with poverty, determines an earlier incidence of scarlet fever in the poorest areas," and that "when, moreover, children attended elementary schools some condition (presumably the same condition) exerts its influence and determines in even higher incidence of scarlet fever upon the comparatively unprotected'less poor than upon the partially protected'poorest'children."It was added that" it is quite possible that one of the factors sperating in the schools is the presence of vermin, and this is true despite the fact that the evidence of scarlet fever at school ages is appreciably less in schools where the children are badly than in those where they are less badly flea bitten." The seasonal curves obtained year by year have continued to reveal the phenomenon of ante. lating of the disease maximum by the flea prevalence maximum, and this fact has been illustrated n successive Annual Reports (see also the composite curve, inset in upper Diagram facing page 35). In the Annual Report for 1915 reference was made to the influence of cycles of dry years upon cycles of scarlet fever prevalence, and also to the respective "geographical ranges" of the flea and of scarlet fever; and in the Annual Report for 1916 the close epidemiological relationships between scarlet fever and diphtheria were referred to, the extent to which variations in nomenclature had confused the issues was noted, and in this connection closer study was made of the distribution of diphtheria and scarlet fever in various parts of the country during the past seventy years. There can, of course, be no question that the marked decline, during that period, of scarlet fever has been accompanied by greatly increased attention to the importance of cleanliness and disinfection, and also by decline in prevalence of fleas. The relation of variations in flea prevalence to the recent major waves of throat illness, which culminated in 1907 and in 1914, was also considered. The Diagram illustrates the fact that the corre. pondence between the figures for flea prevalence and for scarlet fever is closer when the common lodging. louse population is used as an index to flea prevalence than it is when school children are so used. This nay be in part due to special war conditions. During the past year the attempt has been made to examine further the altered behaviour of scarlet fever in recent times, and special study has been made of the "return case problem." This question is one which has been much studied during the last 20 years. The large mortality caused luring the major waves of scarlet fever in the sixties and seventies had been followed by very notable Jecline throughout the eighties and nineties, and a still lower level has been attained during the present century. This. very satisfactory condition of things was not unnaturally attributed to the influence of isolation hospitals, but it was noted, just before the close of last century, that although the mortality Erom the disease had so appreciably diminished there was some ground for thinking its prevalence had been maintained. Inquiry with regard to this subject was greatly stimulated by a report by Dr. J. T. Wilson, who pointed out that the decline of mortality was not confined to the larger towns, which had led the way in active prevention, but was shared by other towns and by rural areas. He argued, therefore, that it was "to be feared that the prophylactic value of isolation is by some authorities overrated."Upon this it may be observed that Dr. Wilson's enquiry, which related to Scotland, clearly showed that the decline was, as a matter of fact, manifested in the larger urban communities shortly prior to its appearance in the smaller town and rural districts. Moreover, even if the "prophylactic value" against attack by scarlet fever might conceivably be held to be open to some question, there could remain no doubt whatever as to the correspondence in time between growth of hospital isolation and the marked decline of severity of attack. History of the enquiries made in London with regard to the flea hypothesis of causation of scarlet fever. Hospital isolation and the decline of scarlet fever. London 1909.17. Diagram showing the seasonal and annual prevalence of fleas over a series of years and the incidence of searlet fever in the corresponding period. Diagram showing the dates of air raids {dotted vertical lines}, the notifications of scarlet fever and measles, and the proportions of flea.bitten children for the weeks ending 1st. september 1917 to 23rd March 1918. {The air raids associated with special crowding in shelters are lettered A.B and C; possible corresponding curve relationship are similarly lettered.} 35 At about the same date the possibility that even a prejudicial influence might be exerted by hospital isolation was mooted, and this subject was very fully investigated by Mr. T. W. Thompson (Trans. Epidem. Soc., Lond., 1895.6; and Report Local Gov. Board, 1896). He examined certain instances in which return cases had been ascribed to hospital influence, and he says,"In a certain proportion of instances, though by no means in all, a returned hospital patient is found upon examination to exhibit some evidence of desquamation, or to be suffering from discharge from the nose or from the ears, a discovery which is naturally held to strengthen the belief in his having reintroduced infection into the household."On the other hand, as Mr. Thompson pointed out, the occurrence of the fresh case may have been a mere coincidence, or have been due to failure to disinfect the dwelling, or may have"probably owed its origin to the unpacking, in preparation for the home.coming of the hospital patient, of some garment which had been worn by that patient prior to his removal to hospital, and which had, upon his departure from home, been packed away in a drawer or box out of reach of any aerial disinfection which might have been subsequently employed." He concluded that while"the occurrence of a further case of scarlatina in a household shortly after the return of a patient from hospital is sometimes merely a coincidence ... a proportion of alleged cases are really due to infection in some way re.introduced into the dwelling by the patients themselves."He doubted whether such patients operated merely as mechanical carriers of infection; he questioned the sufficiency of the"infected breath"theory; and he thought the influence of desquamation required"very careful study,"as also that of"the influence of catarrhal conditions of the nose, ear and throat."His enquiry elicited, however, the important fact that there was a special incidence of secondary invasion"upon the hospital class of households"; there was a suggestion that milk outbreaks may sometimes play a part; or, again,"that one factor of the kind in question had perhaps been furnished by attendance at particular schools"; and on the whole it appeared probable"that some unknown proportion of the so.called return cases had in this instance been due, not to the return of the patients from hospital, but to the cause or causes which had contributed to the excessive incidence of secondary invasion generally upon households of the hospital isolation class."He decided, therefore, that in connection with the occurrence of return cases there are in all probability some obscure factors at work,"/actors perhaps closely bound up with the natural history of scarlatina." A like appreciation of the complex character of the problem is shown in the annual reports of Dr. Niven. In 1901 he suggested that the autumnal wave of scarlet fever must be associated with"a growth of the specific germ in the soil"; he was, moreover, impressed then with the importance of"overlooked cases,"and he said"it is impossible not to be roused to a strong suspicion that in the more insanitary parts of the City, where the people are poorest, there is a considerable proportion of such cases"; he referred too to the"possibility of scarlet fever receiving a reinforcement from growth of the infection outside the body."In the following year he recurs to this, and suggests that"flies or some other medium of communication may be more active in one year than another."In 1903 he questioned the infectivity of particles of skin and was already at that time in doubt about mucous discharges; he noted that the disease may"reach considerable proportions in one department of a school yet not spread to another having a separate playground and offices,"and that it"does not spread aerially from scarlet fever wards to others in the same grounds."He surmises that the vehicle of infection"must be comparatively heavy,"and that the infection may"actually multiply in clothing under certain conditions."Then later, in 1907, he says"instances arise when it seems to be carried by an intermediate agent not affected with the disease,"and adds,"a collection of such cases might throw considerable light on what happens when return cases occur"; further, he now declares, concerning mucous discharges, that there is no evidence that they"materially add to the infectiousness of discharged cases."These deductions and speculations of Dr. Niven are profoundly interesting when regarded in the light of the hypothesis of flea communication of scarlet fever, and they would certainly for the most part be justified if the truth of that hypothesis were firmly established. The questions raised by the important papers of Dr. Wilson and Mr. Thompson and by the writings of Dr. Niven and others were much discussed. As regards the supposed malefic influence of hospitals, the evidence collected in the last'20 years has certainly not proved convincing; no doubt the criticisms made have been, in quite a minor degree, beneficial, but despite the most rigid precautions return cases continue to occur. As regards desquamation, opinion has steadily veered in the direction of discrediting altogether the view that the powdered cuticle is itself the vehicle of infection. For example, a striking table, on p. 60 of Dr. Ken's Annual Report for 1909, gives the outcome of an enquiry concerning 26 children found to be peeling in school; harm resulted in only 3 instances, and it is thus clear that"secondary cases seldom occur in school, even although the affected child has been in constant attendance."Careful study has, moreover, been made, particularly in the last 10 yeaTs. of the infectivity of mucous discharges, and here again the result by no means always accords with popular belief. Professor Simpson suggested that these discharges may act as the vehicle of infection, but are not specifically infectious. This view has not, however, been materially supported by later observations. Newsholme held that such discharges might not infrequently be at fault, but agreed that though the proportion of cases"in which there are no mucous discharges is smaller, their occurrence is undoubted."Cameron attached importance to these discharges, but pointed out that the figures relating to occurrence of return cases, ir metropolitan boroughs, seemed to suggest that home environment was largely concerned as well as the condition of the patient. This question was carefully followed up in the"Observations on Dr. Cameron's Report bv the Medical Superintendents of the Board's Fevei Hospitals,"and the conclusion was reached that"it is even possible that home conditions are more important tha i hospital conditions in determining the infectivity rate."Dr. F. M. Turner's carefully collected statistics (see Annual Report of M.A.B.. p. 265) throw considerable doubt upon the serious character 43316 £ 2 The return case problem. 36 of the influence exerted by mucous discharges, and Dr. Arnold, who had worked with Dr. Niven in Manchester, in a paper read before the Epidemiological Society in 1912, conclusively demonstrated"the'paramount importance of housing conditions in relation to the occurrence of return cases"; he showed, after taking full account of the fact that there are twice as many susceptible persons per house in the homes of the hospital cases as in the homes from which the patients are not removed to hospital, that there still remains a big gain in the hospital group during isolation of the case in hospital; and, more important still, his figures show conclusively that the conditions to which the hospital patients return are, in comparison with the home.treated cases, very favourable for the production of further infections. Dr. Seaton's figures, published in his"Infectious Diseases and their Preventive Treatment,"confirm these conclusions, and his diagrams exhibit the time relations of return cases in home treated and hospital treated cases in a particularly instructive fashion. Dr. Shadick Iliggins, when at Birmingham, carefully investigated the question of return cases, and he read a paper before the Epidemiological Society, in 1913, on the relationship of the presence of the diphtheria bacillus to persistence of scarlatinal infectiveness. During the latter part of 1915 and in 1916 he very kindly furnished me with particulars concerning all the return cases occurring in St. Pancras, and study has been made of these in the light of the observations detailed above. Some fifty possible return cases have come under review; for the most part, in those occurring after a long interval, the evidence is far from conclusive; consideration has been limited, therefore, to the 26 return cases affecting children of school age within four weeks of the return of the supposed infecting ease; they were all elementary school children, and 8 occurred in one, and 7 others in another of two of the poorest areas in St. Pancras, in which scarlet fever was especially prevalent during the period under review. In a third notably poor area in the borough the disease was little prevalent, and there was a corresponding absence of return cases from that area; it should be noted, however, that this third area had suffered severely from scarlet fever shortly prior to the months to which the present statistics relate. It is not possible to give exact figures as to the school populations involved, but roughly they may be divided into three groups :— (a) Nearly one.sixth (i.e., some 5,500) of the total number of children at risk belong to the group which includes children not attending elementary schools; these had far less than their share of scarlet fever (some 40 cases), and only one was suspected of causing a return case. (b) More than one.half (i.e., some 18,000) of the elementary school children at risk lived outside the two especially affected areas; these children yielded some 290 cases of scarlet fever, and there were 11 return cases. (c) The two especially affected areas, with rather more than one.third (i.e., 6,000 plus 5,500, or 11,500) of the elementary school children at risk yielded some 270 cases of scarlet fever, and there were 15 return cases. Among the schools in (b) two were particularly heavily attacked, and if the figures for these two be added to those for the schools in (c) the group of schools thus constituted yielded 360 cases and 21 return cases. It is important to note that in the large majority of the supposed infecting cases neither desquamation nor mucous discharges were present at the time when the mischief was presumably caused. It will be seen, therefore, that the predominant influence of home environment, first hinted at by Mr. Thompson in 1895, and which has been gradually coming more clearly into view as desquamation, mucous discharges, etc., have receded into the background is very clearly brought out by analysing the St. Pancras results. The children in the better homes escape lightly both as regards scarlet fever and as regards return cases; the children in the elementary schools generally suffer in both respects to a much greater extent; but the children in the two special areas, which include most of the poorest schools in the borough, have still more pre.eminently suffered both from attack by scarlet fever and from incidence of return cases. These facts, it may be submitted, are compatible with the hypothesis that the predominating agency in promoting the occurrence of return cases of scarlet fever is closely related to some special influence concerned in producing cases of scarlet fever generally; it is to be sought in some hitherto unrecognised operative factor in the home environment and not in any of the conditions hitherto suspected, such as conveyance of infection in particles of skin or in mucous discharges, for the infecting child often fails to exhibit any evidence of desquamation or of mucous discharges. As regards the so.called"recrudescence of infection,"it may be surmised that it is the needed conjunction of the convalescent child and the insect carrier rather than any variation of infectivity of the child that determines whether or no infection may occur. It had been hoped that clear light would have been thrown by the St. Pancras figures on the relative extents to which home and school environments are responsible for favouring return cases. But here it is essential that, two facts should be kept carefully in mind—in the first place the home is, perhaps naturally, more likely to fall under suspicion than the school, and hence there is a tendency to underestimate school influence in this respect; and secondly, a system of keeping back the returned hospital child from school attendance until it had been examined by one of the school doctors was strictly carried out. in St. Pancras; thus the return of the child to school was generally two or three weeks and sometimes longer still after the return home; this would, of course, tend to reduce the number of return cases ascribed to school influence. As a matter of fact it was found that there was, generally speaking, no reason for doubting that, the suspected return cases were really infected at home, for only quite exceptionally was there any reason to think it possible that infection could have been introduced from the school into the home inasmuch as no recognised scarlet fever had recently occurred in the school. Analysis of results obtained on examination of return cases in St. Pancras. Is the return case infected at home or in school. 37 On the other hand, in only four instances was there good ground for supposing that an infecting case, suspected of causing mischief at home, had at a later date also done so at school, and in these four the interval between return to school and development of the supposed secondary case was in one instance less than 24 hours, and in the other three instances the intervals varied from ten days to three weeks; in these three instances, moreover, scarlet fever was at the time prevalent among children attending in those departments of the schools in which the secondary cases occurred. The St. Pancras evidence generally confirms the view, which other considerations tend to support, that the duration of potential infectivity in scarlet fever is not as a rule appreciably marked after three or three and a half months from the date of original attack; it would further appear from the St. Pancras experience that so far as return cases are concerned the mischief is as a rule done at home and not at school—the part played by school infection is thus, at any rate under the St. Pancras conditions, exercised rather through mild and missed than through recovered cases of scarlet fever. The result of the nine years'study of the hypothesis that scarlet fever is commonly transmitted by the flea is as follows :— (i) There is very close correspondence in form between the last nine seasonal curves of scarlet fever and of flea prevalence, and the autumnal maximum of the latter has invariably ante.dated that of the former, the ante.dating being by periods of from one to eight or more weeks. (ii) There is some correspondence between the contour of the curve of the latest major wave of scarlet fever and that of the corresponding curve depicting annual flea prevalence. (iii) Both scarlet fever and flea prevalence stand in close relationship with cycles of dry or wet years. (iv) Study of school influence in scarlet fever leads to the conviction that some factor, other than immediate or direct personal infection from child to child, is concerned is maintaining the hold which the disease not infrequently obtains upon particular departments or classrooms.* (v) Study of the relation of scarlet fever to social status shows that among the well.to.do, attack by scarlet fever may be often deferred until adolescence or adult age; in the best elementary schools infection is common in the higher departments; in the poor schools the infants'departments especially suffer; in the poorest schools it is not uncommon to find that the child has already suffered from scarlet fever before coming to school at all. One of the conditions closely associated with this grading of intensity of attack rate by scarlet fever is liability to suffer from fleabites. (vi) In striking contrast to dissemination of scarlet fever in homes and in schools stands the absence of any marked ability to spread in hospital wards, where susceptible children are undoubtedly often present, but where flea prevalence is reduced practically to a vanishing point. (vii) Study of return cases shows that the influence of hospitalism has been unduly exaggerated. There is no doubt that cases of scarlet fever discharged from hospital, even when presenting no signs of desquamation or of mucous discharge, are capable of producing return cases. As Mr. Thompson originally pointed out and as Or. Arnold has conclusively shown, there is a special risk of return cases in the poorer and more overcrowded homes, The St. Pancras figures strikingiy confirm the existence of this special risk, and thus strengthen the conviction that some factor bound up with the natural history of scarlet fever, the existence of which is not rendered apparent until the return of the hospital case supplies the necessary materies morbi, must be present in these homes. It is submited that Mr. Thompson's"obscure factor"may quite well have been the presence of fleas in several of the households supplying return cases, and the close correspondence between the special extent of incidence ol primary cases upon these poorer households and the special incidence of return cases upon them, is compatible with the view that one and the same agency was concerned in the original diffusion of scarlatinal infection and also in its later spread to return cases. (viii) The supposed"recrudescence of infection"and the spread of infection by fomites or by apparently healthy persons may find their real explanation on an appeal to a flea hypothesis. (ix) Study of the geographical distribution of scarlet fever and of that of the human flea reveah a general correspondence in the present day allocation of both; moreover, both have apparently spread from Europe to other parts of the globe pari passu with the gradually increasing facilities of intercommunication which have become available. (x) The distribution, in time, of the fall in mortality from scarlet fever corresponds, so far as the facts can be ascertained, with diminution of prevalence of fleabites in children. The period of decline corresponds also, however, with increasing use of hospital isolation, so that the two factors, and not one or the other exclusively, should be credited with the great improvement effected. The question of possible influence of crowding in shelters in favouring spread of vermin and of infectious disease was raised when, at the close of 1917, large use was made of tube railway stations and other places of shelter on the occasion of air raids. This influence was especially suspected in connection with the raids of September 24th—October 1st, the Zeppelin raid of October 19th.20th, the raids of October 31st. November 1st, and those of the 5th, 6th and 18th of December; it has also been examined in connection with those occurring, in 1918, on January 28th and 29th, on February 16th, 17th and 18th, and on March 7th. The flea curve constructed from the data available from medical inspections showed a rise in 1917 during the weeks ending 29th September and 6th October; again a slight rise in the week ending 27th October, possibly maintained in the following holiday week; again in the weeks ending 1st December and 8th December; and then later a marked rise culminating in the week ending the 9th * It may be incidentally mentioned that in London, during the past six years, special importance has been attached to the adequate washing of floors in schools or class.rooms where persistent infection i>y scarlet fever or diphtheria has been observed. Summary. Spread of tleas and of infectious disease in connection with crowd. inginshelters during air raids. 38 February. These rises stand in close relationship with the dates of full moons and the crowding associated with the corresponding air raids. Notifications relating to measles, scarlet fever and diphtheria have been examined, and the results are set out in detail in the accompanying diagram and also in the following Table. In the former the operating series of raids and the corresponding rises in the disease curves are indicated by the letters A, B, C. The earliest raids were not accompanied by any considerable use of shelters. In the later raids the crowding was less marked. The dates given in the Table are those of the full moons at the end of each month, those of the principal air raids, and those ending the weeks in which overcrowding in underground shelters especially occurred; the weeks in which evidence of flea prevalence was observed are noted and the behaviour of the three principal infectious diseases in the first, second and third weeks following the overcrowding is described. Dates ending the Behaviour of the Behaviour of infectious diseases in successive weeks during flea prevalence weeks following the two specified weeks. Dates of which tho use of curve in the two Full Moon. Air Raids. underground weeks of preced. shclters was ing column. 1st week 2nd week. 3rd week, specially marked (1) (2) (3) (4) (5) (6) (7) 30th Sept. 24,25,28,29, 29 Sept. Marked rise in S.F. Slight J/. Rise. S.F. Marked 30 Sept. 6 Oct. both weeks. rise rise. 1 Oct. D. Marked D. Slight rise. rise. 30th Oct. 20 Oct. 27 Oct. Slight rise in D. Rise S.F. Marked M. Rise Main. 31st Oct. and 3 Nov. former and M. Commenc. rise tained. 1 Nov. possibly in ing rise M. Rise main. latter weeks* tained. 28 Nov. 3, 6, Dec. 1 and 8 Dec. Marked rise in M. Rise. both weeks. 28th Dec. 18 Dec. 22 and 29 Dec. Xo data avail. M. Rise M. Rise con. (weather was able S.F. Slight tinues. rough in latter rise. S.F. Rise week and shel. D. Slight rise maintained ters were not much used) 27th Jan. 28 and 29 Jan. 2 and 9 Feb. Marked rise in M. Rise M. Rise niain. both weeks. tained. S.F. Rise. 25th Feb. 10, 17, 18 Feb. 23 Feb. and Rise in latter M. Rise. S.F. Rise M. Rise. 7 Mar. 2 Mar. week. S.F. Rise maintained / > Rise * Schools closed during half.term holiday. S.F.—Scarlet Fever. D.—Diphtheria. M.—Measles. It will be seen from the Table that in each instance in which the data were available (col. 4) there was an immediate rise in the flea curve corresponding with the period in which the use of underground shelters was especially marked. In the next following week (col. 5) there was, generally speaking, a slight rise in cither scarlet fever or diphtheria, and twice a commencing rise of measles. In the next week (col. 6) there was always a rise of measles and twice a rise in scarlet fever. In the next week (col. 7) there was, following upon the first set of raids in the Table, a rise in scarlet fever and in diphtheria. It will be observed that the measles rises (col. 6) followed the special crowding after an interval which would have allowed time for incubation and notification. In the case of scarlet fever, and still more in that of diphtheria, the behaviour was less regular, and a rise sometimes appeared earlier and sometimes later than in the case of measles. If these rises in prevalence are in any way associated with the special crowding it is clear, in view of the fourteen days incubation period of measles and the distinctly shorter incubation period of scarlet fever and diphtheria, that the measles rise must be looked upon as a direct and immediate effect of the crowding, and the scarlet fever rise as being brought about in some instances more indirectly. It may perhaps have occasionally resulted from a cumulative influence, only becoming manifest after a lapse of time sufficient to enable the infection to be mediately transmitted, and it is, of course, possible that increased diffusion of the disease, brought about by a preliminary spread of fleas among children congregated together at the time of special crowding may have played a part here. An analogy for such indirect influence is afforded by the relationship noted as having been generally observed, during the last nine years in London, between development in point of time of maximum prevalence of fleas and maximum prevalence of scarlet fever. The total number of cases of measles and German measles reported as occurring among school children during 1917 was 27,828, as compared with 76,121 among persons of all ages notified in accordance with the Public Health (Measles and German Measles) Regulation, 1915. The prevalence of the disease was most marked during the late winter months and in the spring. During the month of May and throughout the summer there was a sharp decline, and during the succeeding autumn and winter measles was practically quiescent. During the year one infants'department and 35 classrooms were Measles and German measles. 39 closed, and in 41 schools children under 5 years were excluded for appropriate periods, whilst unprotected children were excluded from 1,215 classrooms. Whooping cough was less prevalent during 1917 than at any time during the past 5 years, only 7,117 cases having been reported as occurring among school children. Whooping cough is compulsorily notifiable in the boroughs of Greenwich, Lambeth and Holborn. The progressive decline in the number of cases of ringworm occurring among school children during the past few years continued during 1917. The total number of fresh cases discovered was 2,824, the lowest number recorded since 1911; the number of children cured was 2,964, of these 53 per cent, were treated by X.rays. At the end of the year only 992 school children were known to be suffering from the disease. The number of hair specimens submitted by school nurses for microscopical examination was 2,401, of which 1,193 were found to contain ringworm fungus, and 15 showed the presence of favus. Only three fresh cases of favus were reported during the year. The standard of health, so far as infectious illness is concerned, in the Council's residential special and industrial schools has been generally satisfactory. Cases of epidemic diseases such as scarlet fever, measles, chicken pox and mumps, and of contagious skin diseases, such as ringworm and scabies, have occurred in certain institutions, but the preventive measures taken have been successful in averting their spread. The principal conditions noted among the children in the places of detention were scabies and ringworm, as might be expected considering the type of children passing through these institutions. A small outbreak of measles (6 cases) and an outbreak of mumps (7 cases) occurred at Ponton.road place of detention, but otherwise there is nothing noteworthy to record. [ Defective Children. During the year two new schools have been opened for physically defective children, and nine classes for myopic children. Two schools for mentally defective children have been closed. The total number of examinations conducted under the special Acts during the year was 5,566, as compared with 5,422 for 1916. Of these, 1,108 were deemed suitable to attend elementary schools, 60 a blind school, 278 schools for myopes, 930 P.D. school, 1,318 M.D. school, 21 open.air school, 66 hard of hearing school, 95 a deaf school, 1,054 were epileptic, 507 invalided from school attendance, 108 imbecile, 4 feeble.minded ineducable, and 17 idiots. The following table shows the nature of the conditions found among the children certified suitable or admission to physically defective schools at the admission examinations during the year:— Certified. No. attending School. Certified. No. attending School. Boys. Girls. Total. Boys. Girls. Total. Infantile paralysis 1ll 69 180 Heart disease 100 147 247 Cerebral paralysis 21 15 36 Congenital deformities 25 17 42 Various paralysis Tubercle 3 7 10 Various deformities 39 57 96 140 123 272 Other diseases 25 22 47 The special schools were visited at least once a quarter, and every child present was seen at least once during the year. During these visits the scholars were re.classified : 293 were transferred to elementary schools, 3 to blind and myope schools, 27 from physically defective to mentally defective schools, 2 from mentally defective to physically defective schools, 32 were excluded from mentally defective schools as imbecile, 36 were invalided on medical grounds, and 37 over 14 years of age were excluded as no longer certifiable. In addition, 1,441 special examinations were made of children already on the rolls of special schools, in connection with applications for non.enforcement of attendance'at special schools, committals to industrial schools, reformatories, etc. The following return gives the numbers of defective children recorded on 31st December, 1917 — Blind and partially blind. Deaf and hard of hearing. M.D. excluding imbeciles and idiots. Physically Defective. 83 12 31 3 Attending certified special schools 670 713 7,106 3,716 Not at a schools 6 . 5 11 In the age groups, out of a total of 228,124 examined, the following were found to be the mental conditions of the children : Dull or backward age group 8.9 years, boys, 6.5 per cent., and girls, 5.3 per cent.; leavers, boys, 8.2; girls, 8.3 per cent.; mentally defective, age group 8.9 years, boys and girls, 0.2 per cent.; leavers, boys and girls, 0.3 per cent. During the year there were referred by the local education authority to the local authority undeT the Mental Deficiency Act, 1913, 229 cases, of which 77 were feeble.minded, 132 imbeciles, 19 idiots, and 1 was a moral imbecile. Whooping cough. Ringworm and Favus. Residential speoial and industrial schooli and places of detention. Admiasion examination!. Rota viiits. Mental Deficiency Act, 1913. 40 There are 8 residential and industrial schools, 2 reformatories, 0 residential schools (2 for blind, 3 for deaf, and 1 for mentally defective children), with a total accommodation for 2,097 residential and 252 day scholars. To each institution is allocated a medical olliccr and a dentist, whose duties have been set out in previous reports. The dentists made 132 visits to the schools, conducted 2,576 examinations, and treated 1,176 cases. During the year 893 boys were admitted to Harrow.road place of detention, 1,662 boys to Pentonville.road place of detention, and 809 girls and infants to Ponton.road. The teeth of children attending the Council's blind, myope, deaf, and hard of hearing schools are examined and attended to by a dentist specially engaged for the purpose by the Council. The dentist visits each day school twice a year, and the consent of the parents is obtained in all cases before children receive treatment. Where accommodation permits, facilities for tooth.brush drill are also provided. During the year the dentist made 1,611 examinations, and treated 684 cases, but some of the children were treated more than once. Objections to inspection or treatment or both were received in 181 cases. In addition to this work, the dentist also made 76 examinations in connection with children boarded out from industrial schools, and treated 39 cases. During the year 27 children were scheduled as suitable for admission to epileptic colonies. On the 31st December, 1917, 77 children were attending certified schools for epileptics and 17 were on the waiting list for admission to special schools or colonies. A register is now being kept of all children found in the course of the examinations to be epileptic, and, on the 31st December, 1917, contained 711'names (340 boys and 371 girls). At, the time of the examination 368 (175 boys and 193 girls) were out of school. APPENDIX I SCHOLARS—DEFECTS NOTED ON MEDICAL EXAMINATION. Defects. Institutions. No. examined. Vision. Throat and nose. Ears. Back. Teeth. Defective. Signs of eye.strain. Hearing. Discharge. Heart. Lungs. Ansemia. Round. Curvature. Nutrition. Various. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (131 (14) (15) (i.) L.O.C. Training Colleges, Secondary and Trade Schools. Training colleges. Males 37 — 1 — — — — — — — — — — 9 Females 1,085 140 261 25 10 5 2 10 6 48 90 30 27 81 Secondary schools. Males 590 120 53 12 29 5 4 26 2 72 11 2 6 89 Females 4,673 1,168 870 108 166 31 22 01 18 120 473 195 201 482 Trade Schools. Males 434 07 71 10 5 5 1 4 2 1 16 0 15 28 Females 361 83 54 9 11 5 1 8 — 16 28 13 4 31 (ii.) Secondary and Trade Schools, Aided but not maintained by the Council. Secondary schools. Males 138 43 36 18 — — 6 1 1 15 4 5 15 Females 501 05 114 8 10 2 1 6 4 11 22 14 8 30 Trade schools Males 516 160 68 3 27 3 4 13 2 3 3 1 — 29 Females 465 83 87 6 11 6 2 17 1 12 32 12 — 49 Residential institutions. Dental inspection and treatment of children in blind, myope, deaf and hard of hearing classes. Epileptics. 41 APPENDIX II.—Table showing the results of medical inspection. Elementary schools. Special schools. Entrants. Intermediate. Leavers. Total. Urgent and special. Myope. Deaf. Mentally defective. *Boys. * Girls. † Percentage of total number seen. Boys. Girls. Boys Girls. Boys. Girls. Boys and Girls. Boys and Girls. Boys and Girls. Number examined 27,839 27,173 91,504 34,487 33,715 34,260 34,158 228,124 24,930 28,404 97 — 137 1,493 % % % % % % % % % Skin diseases (f) 933 740 1.8 779 2.3 553 1.6 572 1.7 452 1.3 4,029 1.8 3,447 3,167 3 3.1 6 4.4 36 2.4 (x) 577 435 1.1 462 1.3 310 0.9 351 1.0 237 0.7 2,372 1.0 2,714 2,531 — 4 2.9 21 1.4 Teeth (x) 10,738 10,611 23.3 9,049 26.2 9,024 26.8 7,751 22.6 7,884 23.1 55,057 24.1 1,131 1,203 13 13.4 12 8.8 386 25.9 Tonsils Enlarged (f) 5,313 5,111 114 4,105 11.9 4,447 13.2 3,106 9.1 3,704 10.8 25,786. 11.3 593 708 7 7.2 7 5.1 143 9.6 Adenoids (f) 2,757 2,151 5.4 1,972 5.7 1,568 4.7 968 2.8 849 2.5 10,265 4.5 569 444 4 4.1 4 2.9 130 8.7 Tonsils or adenoids (x) 2,63G 2,421 5.5 2,024 5.9 1,936 5.7 1,286 3.8 1,341 3.9 11,644 5.1 711 744 2 2.1 1 0.7 88 5.9 Other nose & throat defects If) 1,089 773 20 1,163 3.4 798 2.4 946 2.8 664 1.9 5,433 2.4 391 377 6 6.2 5 3.7 106 71 (x) 247 169 0.5 264 0.8 176 0.5 237 0.7 175 0.5 1,268 0.6 266 . 265 — — 12 0.8 Enlarged glands of neck (/) 3,529 3,380 7.5 4,015 11.6 3,552 10.5 2,769 8.1 2,858 8.4 20,103 8.8 282 285 5 5.2 12 8.8 138 9.2 (x) 134 111 0.3 138 0.4 83 0.2 66 0.2 70 0.2 602 0.3 146 127 1 10 2 1.5 3 0.2 Vision (x) 3,716 10.8 4,017 11.9 5,409 15.8 5,539 16.2 18,681 13.9 1,212 1,478 — 1 0.7 222 14.9 External eye disease ... (!) 1,76S 1,708 3.8 1,284 3.7 1,233 3.7 905 2.6 905 2.7 7,803 3.4 1,187 1,396 13 13.4 2 1.5 93 6.2 (x) 1,163 1,119 2.5 591 1.7 523 1.6 377 11 334 10 4,107 1.8 991 1,041 — 1 0.7 40 2.7 Ear disease (!) 804 787 17 618 1.8 665 2.0 628 1.8 645 1.9 4,147 1.8 1,120 1,043 3 31 — 62 4.2 0X) 516 475 11 369 11 368 1.1 383 11 356 10 2,417 11 841 806 1 10 — 38 2.5 Defective hearing (!) 227 234 0.5 540 1.6 478 1.4 541 M 443 1.3 2,463 11 320 270 3 31 — 61 41 (x) 54 63 01 182 0.5 163 05 189 06 164 05 815 0.4 204 163 1 10 — 30 20 Stammering (J) 47 25 01 130 0.4 35 01 160 0.5 52 0.2 449 0.2 30 9 — — 14 0.9 (X) 1 00 8 00 2 00 7 00 1 00 19 00 11 3 — — Other speech defects ... (!) 207 133 0.4 214 0.6 148 0.4 138 0.4 122 0.4 962 0.4 20 20 1 10 3 2.2 48 3.2 (x) 5 1 00 6 0.0 2 0.0 — — 2 0.0 16 00 4 3 — — Mental defects ... (f) 73 0.2 65 0.2 13 0.0 10 00 161 01 619 508 — 1 0.7 Heart defects ... (f) 849 721 1.7 1,222 3.5 1,258 3.7 1,197 3.5 1,542 45 6,789 30 361 587 4 41 5 3.6 72 4.8 (■r) 28 40 01 56 0.2 54 0.2 65 0.2 93 0.3 336 01 79 112 — — 5 0.3 Anaemia ... (f) I,6:i4 1,650 3.6 1,652 4.8 1,646 4.9 1,146 3.3 1,453 4.3 9,181 4.0 473 643 3 31 11 8.0 66 4.4 (x) 547 j 519 12 435 13 486 1.4 254 0 7 424 1.2 2,665 1.2 299 388 1 10 3 2.2 12 0.8 Lung complaints (/ 2,131 1,976 4.5 1,503 4.4 1,380 41 1,110 3.2 1,000 2.9 9,100 40 552 575 6 6.2 8 5.8 79 5.3 (x\ 594 536 1.2 287 0.8 282 0.8 175 0.5 151 0.4 2,025 0.9 241 234 3 31 1 0.7 16 11 Nervous diseases (!) 350 345 0.8 398 12 456 1.4 351 10 422 1.2 2,322 10 586 754 1 10 2 1.5 54 3.6 (z) 40 50 01 56 0.2 59 02 53 0.2 50 01 308 01 249 292 — — 9 0.6 Phthisis (!) 34 42 01 68 0.2 66 02 45 01 41 01 296 01 189 249 — — 4 0.3 (x] 16 ! 11 00 32 01 28 01 14 0.0 15 00 116 01 89 98 — — 1 01 Other tubercular disease (!) 83 65 0.2 75 0.2 80 0.2 74 0.2 88 0.3 465 0.2 272 239 2 21 2 1.5 9 0.6 (x) 28 24 01 29 01 29 01 21 01 25 01 156 01 129 106 1 10 — 1 01 Rickets ... (!) 1,044 627 1.8 670 1.9 357 1.1 448 1.3 250 07 3,396 1.5 69 45 2 21 — 68 4.6 (x) 149 93 0.3 10 0.0 7 0.0 7 00 7 00 273 01 35 24 — — Deformities (f) 311 240 0.6 551 1.6 529 1.6 705 21 969 2.8 3,305 1.4 219 227 6 6.2 3 2.2 55 3.7 (x) 69 52 0.1 114 0.3 117 0.3 129 0.4 250 0.7 731 0.3 116 131 — — 6 0.4 Infectious disease (f) 71 60 0.1 18 0.1 24 0.1 5 00 13 00 191 01 72 96 — — 2 01 (x} 46 36 01 7 0.0 14 0.0 2 00 6 00 111 00 43 51 — — 1 01 Malnutrition (!) 175 204 0.4 236 0.7 245 0.7 119 0.3 131 0.4 1,110 0.5 98 70 1 10 — 20 1.3 (x) 107 133 0.3 120 0.3 134 0.4 59 0.2 69 0.2 622 0.3 66 42 1 10 — 12 0.8 Other defects ... <f) 1,048 802 2.0 907 2.6 864 2.6 728 2.1 1,003 2.9 5,352 2.3 1,284 1,502 1 10 — 69 4.6 (x) 590 434 11 456 1.3 405 1.2 311 0.9 380 11 2,576 1.1 900 984 — — 31 21 No. noted for treatment 15,301 14,608 32.7 15,184 44..0 15,060 44.7 14,325 41.8 14,693 430 89,171 391 9,630 10,331 23 23.7 29 21.2 728 48.8 No. of cases where parent wa< present 19,849 19,697 71.9 18,253 52.9 19,875 59.3 13,327 38.9 16,605 48.6 107,606 56.2 — — 19 19.6 49 35.8 550 36.8 • Examined In detail. t Including preliminary examinations. (/) Signifies defects found. <x) Cases noted as requiring treatment. 43316 42 / APPENDIX III. Percentage of children classified in each group as regards condition of clothing, nutrition, cleanliness, teeth, vision and mental capacity. Clothing and Footgear. Nutrition. Cleanliness of Head. Cleanliness of Body. Condition of Teeth. Visual Acuity, Mental Condition. 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Entrants— Boys 55.7 42.2 2.1 30.0 64.2 5.8 .03 90.0 9.8 0.2 82.9 16.3 0.8 40.5 35.7 23.8 — — — — — — Girls 55.5 42.8 1.7 29.6 64.8 5.5 .07 74.7 24.4 0.9 81.6 17.6 0.8 39.2 37.5 23.3 — — — — — — Intermediate—Boys 51.7 44.8 3.5 20.9 70.6 8.5 .03 89.4 10.4 0.2 79.8 19.1 1.1 46.2 39.8 140 37.9 41.8 20.3 93.3 6.5 0.2 Girls 53.5 44.3 2.2 22.3 70.2 7.5 .02 68.8 29.9 1.3 80.9 38.3 0.8 46.9 40.0 13.1 34.6 43.2 22.2 94.6 5.3 0.2 Leavers—Boys 51.1 45.1 3.8 27.1 66.7 6.2 .02 90.7 9.2 0.1 79.2 19.5 1.3 55.2 38.6 6.2 51.0 26.5 22.5 91.8 8.2 0.04 Girls 55.3 43.3 1.4 28.5 65.2 6.3 .04 70.2 28.7 1.1 81.7 17.6 0.7 56.4 38.1 5.5 45.4 30.3 24.3 91.8 8.3 0.03 Total 53.7 43.8 2.5 26.2 67.1 6.7 .03 80.6 18.8 0.6 81 .0 18.1 0.9 47.9 38.4 13.7 42. 4 35.3 22.3 92.8 7.1 0.1 Special Schools 31. 3 61.5 7.2 19.5 63.6 16.5 0.4 68.3 30.0 1.7 62.9 33.6 3.5 45.2 41.1 13.7 25.2 45.7 29.1 — — — The classification 1, 2, 3, refers to good, fair or poor in regard to clothing, cleanliness and condition of teeth 4 in nutrition = malnutrition. In vision l=normal vision f in both eyes, 2=6/9 in either eye, and 3=6/12 or worse in either eye. In mental condition l=good or fair, 2—dull or backward, 3 = mentally defective. 43 APPENDIX IV. Result of re.inspections carried out during 1917. 1st Re.inspections. Class of Ailment and Number of Cases re inspected. Treated Cases. Untreated Cases. By private doctor. Under Council's scheme. At other hospitals. Discharged. Requiring observation. Still requiring treatment. Cured. Not cured. Cured. Not cured. Cured. Not, cured. Refraction (21,733) 149 0.7 91 0.4 5,403 24.9 2,699 12.4 862 4.0 482 2.2 840 3.9 1,427 6.5 9,780 45.0 Nursing treatment cases (7,263) 248 3.4 57 0.8 1,526 21.0 642 8.8 616 8.5 257 3.5 1,675 23.0 499 6.9 1,743 24.0 Bar, nose and throat cases (11,531) 90 0.9 41 0.4 1,981 17.2 227 2.0 821 7.1 135 1.2 822 7.1 1.294 112 6,111 53.0 Teeth (43,150) 1,372 3.2 779 1.8 10,502 24.3 815 1.9 1,313 3.0 518 1.2 2,455 5.7 615 1.4 24,781 57.4 Other ailments ... (10,983) 443 4.0 170 1.5 119 11 162 15 1,258 11.5 1,243 11.3 2,128 19.4 2,614 23.8 2,846 25.9 Total (04,660) 2,311 2.4 1,138 10,531 1.2 20.6 4,545 4.8 4,870 5.1 2,635 2.8 7,020 8.4 6,449 6.8 45,261 47.9 2nd Re.inspections. Class of Ailment and number of Cases re.inspected. Treated Cases. Untreated Cases. By private doctor. Under Council scheme. At other hospitals. Treatment no longer necessary. Still requiring treatment. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction (14,034) 80 0.6 58 0.4 2,486 17.7 1,798 128 471 3.4 372 2.7 2,077 14.8 6,683 47.6 Nursing treatment cases (4,568) 77 1.7 44 10 692 15.2 556 121 288 6.3 103 4.2 1,415 31.0 1,304 28.5 Ear, nose and throat cases (9,050) 54 0.6 20 0.3 1,032 114 175 1.9 522 58 118 1.3 2,264 25.0 4,865 53.7 Teeth (26,210) 834 3.2 543 2.1 3,928 15.0 525 20 830 3.2 333 1.3 2,578 9.8 16,639 63.5 Other ailments ... (7,700) 150 2.1 109 1.4 50 0.8 107 14 779 101 028 120 3,728 48.4 1,831 23.8 Total (61,571) 1,213 2.0 783 1.3 8,107 13.3 3,160 5.1 2,800 4.7 1,044 3.1 12,062 19.6 31,322 50.9 43316 . t 2