43 LCC 27 London County Council. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1918. 2, Savoy Hill, Victoria Embankment, London, W.C. 2. July, 1919. Printed for THE LONDON COUNTY COUNCIL bv odhams limited And may be purchased, either directly or through any Bookseller, from P. S: KING & SON, Ltd., 2 and 4, Great Smith-street, Victokia-street, Westminster, S.w. 1. Agents for the sale of the Publications of the London County Council. No- 1968. Price 1s. 9d. 500 10.7.19—50129 O.C 34537 ADMINISTRATIVE COUNTY OF LONDON. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. W. H. HAMER) FOR THE YEAR 1918. PART I.—GENERAL. Introductory Note. In 1918, for flhe first time in records going back nearly a century, the deaths in London exceeded the births. Two causes contributed to this result, namely, the reduction in berths brought about by the war, and the heavy death-roll from the two epidemics of influenza. The deaths among civilians alone during the??? red the births by nearly 5.000, and to this figure there must be added a number of deaths ??? on active service. In the first week of November when the second epidemic of influenza reached its height, the death-rate in London was 55.5 per 1,000. This is the highest rate recorded in any week since 184.9, the cholera year, in the 36th week of which 3,183 deaths were registered, giving a rate of over 72 per 1,000. The weather conditions during 1918 were, generally speaking, not unfavourable. The winter was mild, except during the early weeks in January. July and August were not marked by any periods of high temperature, and the mortality among infants from summer diarrhoea was consequently low. The rainfall in July was exceptionally heavy and there was also much rain in September; and owing to the excess in these months the rainfall for the year was some five inches above the average. Except during the course of the influenza epidemics of June and July and of October to December, the mortality was low. Marriages. Ihe number ot marriages registered showed some increase, the estimated marriage rate being 19 per 1,000 living as against 17 in 1917. Births. The Registrar-General estimates the birth-rate in 1918 to have been 160 per 1,000 as compared with 17.9 in 1917. The decline in the birth-rate upon the pre-war rates was evenly distributed among the four quarters of the vear, and taking 1914 as the standard, amounted to about 35 per cent. Deaths. Ihe death-rate among civilians is estimated by the Kegistrar-lTeneral to ha\e been 19.2 as compared with 15.7 in 1917. The total number of deaths, ainorg civilians only, numbered nearly 76,000 and of this total it is estimated that not fewer than 18,000 were due to the influenza epidemics. The infant mortality in 1918 was 108, showing a slight increase upon that recorded in 1917 of 104 per 1,000 births. The increase chiefly occurred in the first quarter, when the mortality from whooping Cough was verv high: there was also a considerable number of deaths from respiratory diseases. Infectious disease. Ihe remarkably low prevalance of notifiable infectious disease in London in recent years was maintained in 1918. Several groups of smallpox cases, however, gave cause for anxiety but happily in each instance prompt measures of isolation were effective in limiting the mischief. Diphtheria was less prevalent than in 1917, and while there was a slight increase in the number of cases of scarlet fever, the total for the year was nevertheless far below the average. Only one case of typhus occurred in London. Dysentery deaths showed an increase to 313 as compared with 290 in 1917. The increase was in the female deaths, the male deaths showing a decline. There were no recognised outbreaks due to importation of the disease from abroad such as occurred in two boroughs in 1917. The incidence of typhoid fever was remarkably low. In an instance in which five members of one household were attacked suspicion fell upon some cockles which had been brought from Southend. A considerable proportion of the cases notified in the autumn occurred among persons recently returned to London from other parts of the country. As in the last few years there were still manifest in 1918 high mortality rates from tuberculosis, dysentery and typhoid fever among certain asylum populations in several parts of England, as well as in London, and a special memorandum on the "Increased Annual Death Rate in Asylums" was issued by the Board of Control in January, 1919. Up to the time of the armistice there was steadily growing evidence that the prejudicial effects of war conditions were being experienced in various ways by asylum populations. Cerebrospinal fever was less prevalent than in 1917. Polioencephalitis and poliomyelitis were at a comparatively low ebb; there were, however, a few cases of encephalitis lethargica which might formerly have been described as polioencephalitis. Influenza The three widespread and fatal influenza epidemics of 1918-19 are the subject of a special report which will be found in the Appendix. The epidemiology of influenza is discussed in that report and reference is made to the same question on p. 8. The "obscure disease with cerebral symptoms " which in some places ushered in the great influenza was alluded to in last year's report and is here further considered under the head encephalitis lethargica and in the special report on influenza. 50129 2 Tuberculosis, There was some increase in the number of cases of pulmonary tuberculosis notified, both among males and females, mainly in the first half of the year. The mortality is also higher than in 1917, but this increase is largely due to the influenza epidemics. There can be little doubt that restriction of movement of population due to the war has had some influence in raising the case rate of tuberculosis. A suggestion that the differing age incidence of phthisis mortality in various parts of Great Britain is to be accounted for by the existence of different types of pulmonary tuberculosis is discussed in the section dealing with tuberculosis (p. 6), and it is pointed out that the influence exerted bv movement of population needs to be carefully considered in this connection. Administration. The tuberculosis scheme of Mav, 1914, was further extended during 1918. The number of cases treated during the year included 739 adults and 1,050 children. Two boroughs which had not completed their dispensary schemes in 1917 did so in 1918. The arrangements made with the Invalid Children's Aid Association were continued and the work of the Tuberculosis ('are Committees was further developed. The scheme for London and the Home Counties for the diagnosis and treatment of venereal diseases, inaugurated on 1st January, 1917, was continued in operation throughout 1918. Provision was made for the inclusion of three additional hospitals, a total of 25, and three special hostels for women were added. In all 16,372 persons (of whom 12.538 were London patients) made use of the facilities, as compared with rather more than 12,000 in 1917. An arrangement was entered into with the National Council for Combating Venereal Disease with a view to making more generally known the nature of the facilities provided. During the year a large amount of work was undertaken in connection with the preparation of reports upon housing schemes (see p. 11). Reference is made to the work under Part I. of the Children Act, 1908 (p. 15), under the Midwives Act (p. 15), and the Mental Deficiency Act (p. 14). The risks of introduction of infectious diseases from abroad made it necessary to keep close watch upon common and seamen's lodging houses and upon soldiers' rest homes (p. 17). Account of the work in the chemical branch of the department is given on p. 18. Population A.—Vital Statistics. The population of London County at the census of 3rd April. 1911, was 4,521,085, and it was estimated by the Registrar-General to have declined to 4,518,021 in the middle of 1914. Since then annual estimates of the civil population have been made by the Registrar-General on the basis of the National Register of August. 1915, supplemented, during the last two vears by information collected in connection with the rationing of food. Since the early months of 1915 there has been little migration from England and Wales and such growth of civil population as has occurred results from the excess of births over deaths. This natural increase did not amount by the middle of 1918 to more than one-fifth of the number of civilians enlisted in the meantime. London has, however, been throughout the centre of all military administration and hence the decrease in total population by the middle of 1918 was less relatively than in England and Wales as a whole. The Registrar-General estimates the total population at 4,430,929. So many circumstances influenced the movements of the population to and from and in London during the war that the annual average population deduced from data relating to a particular time of the year must necessarily be uncertain. The frequent air raids upon London in the autumn of 1917 led to an exodus on a large scale from certain districts ; subsequently a reaction set in, and at the present time the total population of London, so far as may be judged from the existing demand for accommodation, must be as great as if not greater than it was in 1914. Bv the end of this year the distribution of population will have become more normal owing to demobilisation and the closing of munition works. The civil populations of the Metropolitan Boroughs in the middle of 1918, estimated by the Registrar General, are shown in Table I., page 20. Marriages. The marriages registered in London in 1918 numbered 42,875 as compared with 39,352 in 1917. The marriages in the first quarter were considerably above the average, and this no doubt is associated with the increase in enlistments during this period. The marriage rate for 1918 is estimated at 19 as compared with 26, 19 and 17 in the years 1915-17, and an average of 18*5 in the period 1911-14. The total number of marriages in the four war years 1915-18 exceeded those in the pre-war period 1911-14 by more than 17,000. Births. The births in London during 1918 numbered 70,976 as against 80,550 in 1917, and a yearly average of 110,951 during the pre-war period 1911-14. The Registrar-General estimates the birth-rate at 16 0 per 1,000 of the total population. The average annual number of births during the four war years 1915-18 was 88,000, a decline of 23,000 on the pre-war average ; hence the war has resulted in the loss of about 90,000 births in London. The percentage reduction in the number of births is found in London to be greatest in the poorest class of population. The decline in a representative group of the poorer class populations comprising Stepnev. Bethnal Green, Shoreditch, Finsbury and Bermondsey, amounts to 42 per cent, upon the 3 1914 births, while in the aggregate for Hampstead, Lew is ham and Wandsworth the decline was 32 per cent. The reduction in births registered also varies, however, with the decrease in civil population resulting from enlistment and migration ; thus in the Metropolitan Borough of Woolwich, where the civil population in 1918 is estimated bv the Registrar-General to exceed the total population in 1914, the decline in the birth-rate is only 10 per cent., considerably below that found in any other borough. The greatest decrease, 49 per cent, occurred in Shorediteh. Deaths. The deaths among the civil population of London during 1918 numbered 75,928 as compared with 63,406 in 1917. The Registrar-General gives the death-rate as 19'2, the rates during the years 1915-17 being 16-8, 14 6 and 15'7 respectively. The distribution of the deaths by ages in 1918 and the five 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 1918 7,659 3,925 4,337 2,352 1,563 2,358 2,708 6,935 6.237 8,106 9,085 20,663 75,928 Increase ( + ) decrease (—) [—741 + 792 + 1,498 + 945 + 055 + 1,064 + 1,520 + 3,796 + 1,490 + 1,209 + 386 — 92 + 12522 1918 over 1917 Infant mortality. The excessive mortality in 1918 shown in this table is almost entirely due to the two influenza epidemics; they are dealt with in a separate report, which is appended. During the course of these epidemics the deaths from pneumonia, bronchitis, diseases of the heart and circulatory system, and phthisis were considerably increased. Of other causes of death not affected by influenza mention must be made of whooping-cough, the mortality from which, allowing for the decrease in child population, was higher than in any year since 1896. The deaths from diseases of the respiratory system in the first quarter of the year were also high. The reduction in the mortality from cirrhosis and alcoholism is remarkable; it will be recollected that a decline was recorded in 1917 and was associated with the control of the liquor traffic. The death rate among infants under one year of age was 108 per 1,000 births, the corresponding rates in 1915-17 being 112, 89 and 104 respectively. Influenza caused 259 deaths, and there are indications of an increase in the number of premature births during the course of the influenza epidemics; but the cause principally responsible for the somewhat higher infant mortality Was whooping-cough, from which 499 deaths were recorded. The reduction in mortality from overlying commented upon in recent reports and associated with decrease in drunkenness was maintained in 1918, being 93 as compared with 150 in 1917. Smallpox. Infectious diseases. A small outbreak of smallpox during the Spring of 1918 is described in Part II. of this Report.! It must be added here that between 7th December, 1918, and 31st March, 1919, 18 cases of smallpox occurred in the Boroughs of St. Pancras (12). Islington (2), Battersea (2). Holborn (1), and Westminster (1), which were all directly or indirectly connected. The first of the series was a man, G. N., aged 63 years, living at 59, Red Lion-square, Holborn. A few days later, on lltli December, an Australian soldier who attended the medical inspection room at Horseferrv-road, Westminster, was also found to have smallpox. On making enquiries it was found that this man had stayed at 59, Red Lion-square previously referred to ; it was ascertained that these premises were frequented by overseas soldiers, and that smallpox had occurred among a party of soldiers who had psissed through London previously. The Australian stayed with other friends at 40, Burton-street, St. Pancras, a night or two before reporting for medical inspection on 11th December, with the result that three further cases occurred among the occupants of that house between 28th December, 1918, and 6th January, 1919. The long interval gave rise to suspicion that an intermediate unrecognised case must have occurred. The first of the St. Pancras group of cases that of 28th December, was reported from 9, Se\erus-road, Battersea, where the patient was staying for the Christmas holidays, and two other persons in that house developed the disease on 13th and 15th January respectively. Concurrently with the later cases of this group another set occurred, originating in a child E. B., aged 13, living at 6, Dewsbury-terrace, St. Pancras, who was at first thought to be suffering from chicken-pox in the early part of January. It was not until after her mother was removed to hospital on 25th January that Dr. Shadick Higgins, Medical Officer of Health of St. Pancras, saw the child and concluded that she was recovering from smallpox. The source of infection could not be discovered and no connection with any of the cases in the group previously referred to could be traced. Although the child had not been to school during her illness, in view of this and other possible unrecognised cases the children attending schools in the neighbourhood were kept under close observation by the Council's medical officers. 50129 2 4 No further cases were notified until 4th March, when Dr. Shadick Higgins was called to see a woman (P. U.), aged 42, living at 12, Ceuntess-road, who was found to have smallpox, the rash having appeared 3 days before. l)r. Higgins discovered that a woman next door (E. B.) and her two children (F. B., aged 6 months and F. K., aged 9) had been and were still suffering from the disease. The mother (E. B.) only had the scars remaining, the rash having first appeared 3 weeks previously, whilst as regards the children the rash had been out 7 days and 2 days respectively. E. B.'s husband was employed as a disinfecting officer by the Borough Council, and on 20th January he had disinfected 6, Dewsburyterrace. The man remained in good health and had no sign of rash, but as no other source coidd be discovered it was assumed that he must have been the means of infecting his wife, who in turn infected her own childrer, P. U. living next door, and another child, D.H. (aged 6), 54, Leverton-street, Kentish Town, who had visited the house. Two of these children attended Burghlev-road and Raveley-street, L.C.C. schools respectively, and the pupils and staff at both schools were offered vaccination: large numbers a\ailed themselves of the facilities and this, no doubt, helped to check the spread of the disease. Two other pupils from Burghley-road School, living at 25, Tremlett-grove, Islington, developed smallpox on the 6th and 29th March, respectively, but in both cases the children had ceased attending school before the onset of illness. A medical practitioner in attendance on these cases also contracted the disease. The disquieting feature of this outbreak was the large proportion of cases not recognised as smallpox until some time after the rash appeared. In 12 out of 18 cases which occurred, varying periods of between 2 and 21 days had elapsed before the diagnosis was mad"1 and the patient removed to hospital. The Council decided, therefore, to circularise all the medical practitioners1 in London in April, 1919, drawing attention to the fact that the services of the Council's smallpox expert were at their disposal in suspected cases. Measles, scarlet fever dihtheria, whooping- cough. Typhus fever. At the time of writing this Report cases of smallpox are occurring in different parts of the country, mainly imported from abroad. During the war epidemics of smallpox and other diseases have been reported in foreign countries but fortunately the spread of infection has, so far, been kept within close bounds. The resumption of intercourse with all parts of the world as soon as hostilities ceased has undoubtedly greatly increased the dangers of spread of epidemic illness. During 52 weeks of 1918, 45,115 cases of measles, 6,807 of scarlet fever and 8,173 of diphtheria were notified, the deaths (365 days) being 1,649, 120 and 669 respectively. Whooping-cough was very prevalent and caused 1,687 deaths. The case incidence and mortality rates from the principal notifiable infectious diseases in the Metropolitan boroughs are shown in Table I. appended to this Report (p. 20). One case of typhus fever occurred in London (Borough of Bermondsey) in September, 1918The patient was removed to the S.E. Hospital where the diagnosis was confirmed. The source of infection was not traced. An outbreak of typhus fever among gipsies in Surrey, Sussex and Kent, was reported in May. A gipsy woman Mas admitted very ill on 3rd May to the Hambledon Union Infirmary. Surrey. She was seen bv Dr. T. Henry Jones, County Medical Officer of Surrey, who diagnosed typhus fever. Eight days later an old man who had been in the infirmary for 14 years fell ill with typhus. It was later ascertained that three gipsies had been admitted to the Infirmary during April and had died, the cause of death being certified as broncho-pneumonia. The old man referred to helped to put them in their coffins. On 13th May another gipsv woman admitted to West Hampnett (W. Sussex) Hospital was found to have the disease. Dr. Manby of the Local Government Board instituted inquiries and traced a long series of cases of illness, among the gipsies in that part of the country, described principallv as " pneumonia," dating back to the early part of February and even as far back as Christmas among the gipsies at Eastbourne. Typhoid fever. Particulars of two families, contacts of previous cases, whose later movements could not be traced by Dr. Manbv were, on receiving the information from the Local Government Board, communicated to the Borough Medical officers, with the result that both families were discovered in gipsy haunts in S.W. London. Fortunately no developments arose in London as a result of this outbreak. During 1918, 357 cases of typhoid fever were notified as compared with 449 in 1917, 4-61 in 1916, 607 in 1915, and 789 in 1914. It is clear that even after allowing for the absence of men of military age on war service, there have been appreciably lower case rates in 1916, 1917 and 1918 than in 1915, and the rate for that year represents a distinct fall as compared with the years immediately preceding. Thus excluding all men at ages 15-45 the numbers of notified cases in the rest of the London population for the years 1912 to 1918 are as follows—470, 530, 504, 453, 333, 366, 271. In all 20 cases, including three military cases, were desciibed as paiatyphoid fever. In June two groups of cases were notified as paratyphoid fever. The fiist included a matron and seven nurses in an infirmary; a nurse sickened on June 9th, and the remainder for the most part within a few days of that date; the last of the group was notified on July 13th. The patients exhibited an irregular temperature for a week or more, tendency to diarrhoea, abdominal discomfort, and in two instances profuse sweating; there was no cutaneous eruption. The diagnosis on the strength of a not very marked agglutination reaction was held to be paratyphoid B. At about the same time five cases in Wandsworth and two in Battersea also suspected to be paratyphoid B were notified; all had taken meals at a particular dining table. None of the illnesses in these groups were of a severe character. In the light of the fact that the summer influenza prevalence was just commencing in London at the time, the question of course aiises as to whether these two groups of cases might have been examples of the gastro-intestinal vaiiety of that disease. 5 The number of cases of typhoid fever attributed to-fish or shellfish was 49, constituting a rather lower percentage of the total cases than usual. Five cases occurred in persons who had eaten cockles said to have been obtained from Southend. In the Annual Report for 1916 it was pointed out that from 1912 onwards, accompanying the decline in the annual case rate, there had been a marked smoothing out of the autumnal rise of typhoid fever in London; 1917 and 1918 exhibit the same phenomenon; it is difficult- to explain on the carrier hypothesis and more in accord with the rival theory of food causation. Reference was made to the steady improvement as regards elimination of dangerous shellfish, and to the Council's representations to the City Corporation-in 1906 as to the need for regarding small ungutted dabs or plaice as a possible source of danger. It was further pointed out that a particular area in the North Sea not far from the mouth of the Elbe, from which in earlier years large numbers of small plaice were derived, had not been visited at all by English boats since 1912 With the advent of the war the supply of foreign shellfish was practically cut off from this country and very great interference with the fishing industry in the North Sea also resulted. The Fish Trades Gazette noted on May 17th, 1918, that "apart from an occasional cargo of Government 'ish. practically no Water borne fish has reached this (Billingsgate) market." The Billingsgate steamer were again at work during that month and, in 1919, "the services between Grimsby, Holland, Belgium and the Netherlands were resumed, and on several occasions resulted in large supplies of Dutch ,sh at Grimsby and Billingsgate. . . . Steamer fish, of course, often accounted for nearly half the annual deliveries at Billingsgate in pre-war times, but at present (May, 1919) the daily arrivals—all u il borne—often equal the combined land and waterside supplies recorded prior to 1915." Plague and cholera. The low incidence of typhoid fever in soldiers during the war has been widely ascribed to inoculation. The low" incidence in the civil population of London cannot, of course, be thus explained. In view of the correspondence in time between the marked falling away in typhoid fever incidence, and alteration in the extent of consignment to London of foreign shellfish and of ungutted flat fish from the German bight, it is clearly desirable that a close watch should be kept upon the behaviour of the disease, especially now that there is the possibility that one or both of these sources of supply may again come into operation. No cases of plague or cholera occurred in London during 1918. Six cases of plague, however, were removed to the Isolation Hospital of the Port Sanitary Authority at Denton, Gravesend; two of these were on board the s.s. Somali from Bombay, which arrived at Gravesend on 19th May, and both patients died after admission to hospital. One was a storekeeper who had killed several rats during the voyage and who had found several dead rats in the store room. Many of the passengers and crew came to London and were kept under observation, but none of them contracted the disease. One of the persons on board the vessel, who proceeded to Rochester, subsequently died of plague. On 8th August the s.s. Hector arrived at Gravesend from Calcutta with four cases of plague on board which were removed to Denton Hospital. There were no passengers, and the crew* were only partially paid off; the only two members of the crew who came to London stayed at the Scandinavian Sailors' Home and were kept under observation bv the Council's inspectors. Anthrax. During 1918, seven cases of anthrax occurred in London. The affected persons were all engaged Al in occupations associated with the handling of imported hides, furs or hair, i.e., five of the patients were employed in dealing with imported skins at riverside wharves, one was a furrier working on the hair of the South American fox, and the other was engaged as a labourer in a leather factory handling goat skins from India and South America. The Departmental Committee of the Home Office appointed in November, 1913, to enquire into the dangers from infection by anthrax in the processes of sorting, willeying, washing and combing, and carding wool, goat hair and camel hair, reported in August, 1918, and their report was published later in the year. The Committee recommended that the principle of compulsory disinfection of animal skins, wool and hair, of defined kinds and from specified sources, should be substituted for the policy of attempting to control the danger of infection by factory regulations. It was further proposed that a "Disinfection Authority should be constituted by the Government with powers for bringing into operation and enforcing disinfection of wool and hair, that steps should be taken to secure the co-operation of all organised countries for this purpose, and that the capital cost of disinfection should be provided by the British Government to be repaid by a charge imposed on all material disinfected. The main object of the Committee was to ensure that all dangerous or potentially infective material should be disinfected before being exported to this country. With this object it was recommended that central disinfection stations should be established under expert supervision at the various ports abroad from which the material is exported. A Bill has since been prepared with the object of giving effect to the Committee's recommendations by Orders in Council. At the time of writing the Bill has already passed the House of Commons and is awaiting the second reading in the Lords. When passed into law it will be cited as the Prevention of Anthrax Act, 1919. Tuberculosis. The deaths from pulmonary tuberculosis in the civil population of London during 1918 numbered 7,048 as compared with 6,908 in 1917 and 6,491 in 1916. The increased mortality in 1918 occurred in the latter half of the year and is associated with the epidemics of influenza, th^ excess in the phthisis mortalitv during the summer epidemics being about 130 deaths and in the autumn about 570, or in all 700. Tuberculosis, other than phthisis caused 1,398 deaths in 1918 and 1,575 in 1917. There has been a steady decrease in mortality among children under five years of age for many years past. 6 Notification of tuberculosis. The number of "primary" cases of tuberculosis notified in London during 1918 (52 weeks) was 19,178, the corresponding figures for the years 1915-17 being 18,061, 17,031 and 18,735 respectively. These figures do not relate exclusively to the civil population. Of.the total "primary" cases of tuberculosis notified in 1918, 15,661 were pulmonary, and 3,517 were other forms of tuberculosis. The following is an analysis of the cases notified in London in 1918 (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 9 107 405 339 763 924 2 480 2,278 1,286 556 193 14 9,354 F. 8 106 352 408 592 789 1,544 1,166 611 281 124 3 5,984 Other tuberculosis M. 49 341 487 292 138 69 97 61 28 19 10 1 1,592 F. 40 257 418 279 174 102 111 80 41 22 20 — 1,544 All forms of tuberculosis M. 58 448 892 631 901 993 2,577 2,339 1,314 575 203 15 10,946 F. 48 363 770 687 766 891 1,655 1,246 652 303 144 3 7,528 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. 6 78 1 150 1,301 2,597 F. 5 95 72 1 173 863 1,271 Other tuberculosis M. 8 138 61 207 150 59 F. 6 102 65 1 174 148 60 All forms of tuberculosis M. 14 216 126 1 357 1,451 2,656 F. 11 197 137 2 347 1,011 1,337 The Medical Research Committee's Report on the Epidemiology of Phthisis. The Medical Research Committee issued in 1918 a report (No. 18, Special Report Series) embodying the results of a statistical investigation by Dr. Brownlee into the epidemiology of phthisis in Great Britain and Ireland. Dr. Brownlee premises that "in all diseases which are definite clinical entities the curves of age-distribution follow definite laws." Applying this hypothesis to the age-incidence of phthisis mortality he finds remarkable divergencies from a definite law in different areas of the United Kingdom ; and he therefore concludes that phthisis is not one " definite clinical entity," but, so far as ages abo\e 10 years are concerned, a combination of three entities. The three types of phthisis are thus differentiated by the contour of the curves representing the age-incidence of mortality. Type I., predominant in Ireland and the Shetland Islands is characterised by a sharp rise to a maximum between 20 and 25 years of age and then declines, and this is the " young adult " phthisis. Type II. exemplified in the London mortality, has a maximum between 45 and 50years of age, and is the " niiddle-age " phthisis. Type III. exhibited in the mortality rates of miners attains a maximum incidence betw een 55 and 65 years, and is the " old age " phthisis. Dr. Brownlee recognises that there may possibly be other means of accounting for the divergencies observed in the phthisis mortality curves for different localities ; he refers to the need for considering environment, occupation and climate, and also the effect of the elimination of susceptible persons by natural selection, and proposes to discuss the influence of each of these conditions in a later note, but he says, " at this moment it may be stated that none affords any adequate explanation of the phenomena observed." No mention, curiously enough, is made of the effect of movement of population upon the phthisis mortality at different ages. In a paper on " The' Influence of Migration upon the Phthisis death-rate " (Proc. of the Roy. Soc. Med. Vol. VI.), it was suggested that no inconsiderable influence upon phthisis mortality had been exerted by migration. The growth of urban populations at the expense of surrounding rural areas, and emigration in numbers to America and the Colonies, involve changes in the residual populations not only in age and sex-constitution, but also in regard to vitality, since no stock can be continuously depleted of its most virile elements without deterioration ; again, some countries have sent away their phthisics, and of these in varying proportions some have died abroad and others have returned to die at home. 7 As a case in point mention may 1m; made of the County of Cornwall, which, as Dr. Brownlee says, furnishes "an example of conditions observed in no other county in England. Cornwall differs from all other counties (except Huntingdon) in that its population began to decline as far back as the sixties. At the census of 1861 the population was 369,390, and this by 1901 had fallen to 322,334. Since then there has been an increase to 328,098 in 1911, not unconnected perhaps with a partial revival in this period of the tin mining industry. The ages mainly affected by the migration which the decline in population implies will be seen from the following figures quoted from the census of 1911 (Vol. VIL, p. xxiv.), showing the number of persons in various age-groups in Cornwall compared with England and Wales taken as 100 .— Sex. Age-group. 15— 20— 25— 30— 35— 40— *45— 50— 55— 60— 65— 70— 75— 80— 85— 90— Males 107 94 82 80 82 91 102 106 109 114 128 142 160 171 192 217 Females 102 97 93 92 98 106 119 121 128 133 147 168 177 195 217 264 The 1911 census thus shows a marked deplet ion in the Cornish population of males at ages between 20 and 40 years and also, though in much less degree, a deficiency at those ages among females. Cornish miners have a world-wide reputation, and hence young adults after an apprenticeship in Cornish tin mines emigrate to other mining districts of the world. The reduction in the number of tin-miners aged 20-25 upon those aged 15-20 is shown in the Registrar-General's occupational statistics for 1900-02 and is far in excess of the corresponding reduction in the number of coal-miners of these ages. On the other hand, in the age-group 65 and over, while among tin-miners about 45 per cent, of the total were " retired or unoccupied miners," the corresponding figure for coal-miners was about 30 per cent. Obviously, with so clear an indication of migration of tin-miners in the occupational statistics, the mortality rates must be regarded with reserve, especially in contrast with other mining occupations. It is thus clear that young miners, probably the ablest and fittest of them, when sufficiently trained emigrate to other mining centres of the world, returning later in life to live upon their earnings ; but they do not necessarily in all instances return to the tin-mining registration districts ; and, elsewhere, the more prosperous of them are not described at death as retired tin-miners. Thus the phthisis mortality of Cornwall for the age-period 20-25 appears to be based upon a residual population ; while, on the other hand, deaths among the returned tin-miners of high age are added to a mortality already loaded with an excess of phthisis. The absence of any second "hump" in the mortality curve for females in Cornwall seems finally to dispose of the possibility of the Cornish "old age " phthisis being, as Dr. Brownlee contends, peculiar to the district, and not due to the tin-mining industry. With regard to the curves for Ireland and the Shetland Isles, the volume of emigration from Ireland to America and from the Shetland Islands to the shipbuilding areas of the mainland, and of young seamen into the Navy, cannot be disregarded, the effect being to exaggerate the phthisis mortality among the residual young adults. The effects of migration upon the contour of the phthisis mortality curves were clearly shown in the Annual Report for 1913 in the diagram facing page 42, where Urban and Rural Counties are contrasted. Between the ages 15 and 30 the rural mortality slightly exceeds the urban, and this is at any rate in part accounted for by the addition to the urban districts of those "selected" from rural areas by the attractions of urban life, and, in part also, by the return of those dying from phthisis to their country homes. On the other hand from age 30 onwards the urban phthisis mortality is greatly in excess especially among males. To account for this urban excess it must be premised that from the earliest times the beneficial effect of an outdoor life upon those suffering from or pre-disposed to phthisis has been recognised and has been the foundation of treatment. Tn rural counties the predominant male occupation is outdoor work, mainly farming ; in urban counties, on the other hand, it is mainly indoor work. The divergence between urban and rural mortality or between fanners and industrial workers is much more likely to have affected the curves than the assumed influence of three or more " types " of phthisis. If, indeed, any proof were wanted of the soundness of the former explanation it is afforded in the similarity in the mortality curves for females in the rural and urban areas since, in the case of females, the working conditions do not offer anything like the same contrast, the bulk of female occupation in both areas being of an indoor nature. The effects of movement of population are broadly exemplified in the mortality contours for males in England and Wales since 1841 which Dr. Brownlee gives (Diagram II.). The volume of total emigration was large up to the end of the sixties and in this period the phthisis mortality is maintained, especially at the age-period chiefly affected, i.e., 20-25 years. Thereafter, the total quantity of emigration declined and with it the mortality rate, the decline being proportionately far greater at the age period mentioned than in later years of life. It must be borne in mind, moreover, that with increase in the total number of emigrants there has undoubtedly been up to five or ten years ago a steadily increasing exodus of phthisical persons, owing to cheapened means of transit and the opening up of countries having the reputation of being suited for consumptives. 8 Tt should be added that throughout, the 60 years to which the contours in Diagram II. relate urbanization has steadily proceeded at the expense largely of rural districts and rural occupations; so that finally the striking contrast between the shapes of the curves for 1861-70 and for 1901-10 shows remarkable approximation to that presented in the shapes of the curves for rural counties and urban counties in 1891-1900 reproduced in the Annual Report for 1913 (page 42). Evidence of tubercular infection is found post mortem in so high a proportion of cases examined that it is beyond doubt that susceptibility rather than infection is the determining factor in phthisis mortality, and certain occupations are known to increase the susceptibility to particular diseases. That occupations such as tin-mining and file-cutting should gradually undermine the natural resistance to phthisis is no more difficult of explanation, therefore, than that farming on the other hand should diminish susceptibility; and granted that the phthisis mortality may be thus controlled for periods of years the resulting variations in the mortality contours can no longer be ascribed to the existence of different "clinical entities." There is a general similarity in the age-incidence of phthisis mortality among coal miners in different counties, and such divergencies as are observed appear to be governed by the varying incidence of mortality from respiratory diseases, and also from the differing mortality from all causes. Climatic conditions undoubtedly influence mortality from respiratory diseases, notably bronchitis, and it would thus be expected that at higher ages, at the point where the phthisis mortality is decreasing, and the bronchitis mortality rapidly increasing, some confusion between the two might result in an over-statement of the phthisis mortality at that age. This possibility was discussed in the Annual Report for 1913, page 43. Dr. Brownlee in considering the high mortality from phthisis in Ireland in 1851 to 18 0 concludes that "the obvious interpretation of the statistics is that at high ages a considerable amount of bronchitis was classed as phthisis."If this possibility is borne in mind in dealing with occupational statistics much of the " old age " type of phthisis maj be accounted for. Dr. Brownlee thinks that his hypothesis of three "clinical entities" may explain his never having seen any " demonstrable benefit " from tuberculin treatment in Glasgow. The tuberculin, he says, may have been prepared in London where middle age phthisis is "prevalent," while in Glasgow " there is little phthisis of the middle age type." The figures upon which he relies are given in Public Health, March, 1916, and relate to the four years 1909 12, for he says " piior to 1909 no statistics of any value with regard to phthisis exist for Glasgow and Edinburgh." He citcs in a section headed "Phthisis in Scotland, 1860-1910," an example of the kind of misunderstanding which has arisen with regard to the Edinburgh statistics. His Glasgow figures are, it is tine, more recent, but they are not critically examined with a view to learning how far they may be affected by migration. Further study of these figures with this consideration in mind would, t! orefore, seem desirable. Dr. Brownlee concludes with a review of the mortality from phthisis in London since 1631 as disclosed in the "Bills of Mortality" under the heading "consumption." As compared with the total deaths, "consumption "claimed an increasing proportion from about the beginning of the 18th century to its close, the proportion thereafter declining. Dr. Brownlee suggests as the easiest explanation of the facts " that an epidemic wave of phthisis spread steadily over London in the 18th century, culminated about 1800 and has since declined." Further investigation of the data is foreshadowed, and this would seem desirable, for many epidemiological and social factors may have been operative during 200 years in a way which might tend to disturb the relationship between the total deaths and those classed to "consumption," even if this heading can be considered to have had the same meaning throughout the period under review. The depletion of the vitality of stocks bv the continued withdrawal of the fittest and by in-breeding, and the invigoration of stocks by cross-breeding, are effects which, presumably, have influenced the general death-rate as Well as phthisis mortality since the beginning of last century. Some share in all this may well be assigned to the increasingly greater freedom of movement in the population from about that time. This factor may have specially affected, too, the changing proportion of " consumption " to all deaths in London since 1631. Influenza Influenza, cerebrospinal fever, poliomyelitis and polioencephalitis (including encephalitis lethargica). Influenza in pandemic phase has usually given rise to the impression that it is a " new disease." The pandemic of 1918 was no exception to this rule, and the first spectre raised, that of Botulism, was only laid to be replaced by so-called encephalitis lethargica or epidemic stupor, and to be followed by the insubstantial theory of the Spanish origin of influenza. Such phantoms of the imagination could, perhaps, only have been bodied forth in an age of specialism, for the present epoch clearly has the defects of its qualities. But epidemiology refuses to stress unduly the " here and now," for it can recognise no limits to its enquiries save those of the inhabited world and of the historical period. The technique and newly-acquired knowledge of the specialist can be of but little service in comparing a current epidemic with earlier prevalences, possibly of a closely related character ; moreover, the critics of epidemiological methods sometimes fail to appreciate that they are designed for distinguishing epidemics and not individual cases from one another. Fourteen years ago in the Milrov Lectures of 1906 the relation of influenza to English sweat and the accompanying phrenitis, cerebritis, pleuritis, etc., of the 15th and 16th centuries, and to the dengue of more recent centuries, was discussed and the attempt was made in the light of the facts elicited to distinguish between the pandemic and the inter-epidemic phases of influenza. Starting from the salient epidemiological characters common to both influenza and dengue in pandemic phase (sudden onset, tendency to relapse, establishment of immunity, "posting character," etc.) the attenip' was made to 9 follow up the transformations p-esented and to measure the instability resulting, as it was presumed, from inter-action between a germ and its environment. Further study was made of the subject when the Glasgow and Belfast cerebrospinal fever outbreaks occurred, in 1906, and when Brorstrom and others at about the same time directed attention to the influenzal nature of the poliomyelitis outbreaks of Scandinavia. Later, in the annual reports from 1914 onwards, the relation between cerebrospinal fever and influenza in London was studied in detail; and it transpired in 1916 that similar observations had been made by Lt.-Col. Dorgan in army camps. Thus, already; prior to 1918, it was apparent, as was stated in the report for 1917 published last year, that London was once again being subjected to an epidemic influence eminently protean in its behaviour, and then at length (in June and July, 1918) the "posting character" of declared pandemic influenza became clearly manifested; incidentally, as Was then observed, "the close connection between polioencephalitis (including of course encephalitis lethargica), poliomyelitis, cerebrospinal meningitis and influenza now seemed to be established." Similar lines of enquiry have been followed by Dr. F. G. Crookshank in his Chadwick lectures and in his writings on Epidemic Encephalitis. In the special report on influenza, which is appended, the attempt is made to show that the theory above outlined derives further support from studv of earlier writings on the historv of epidemics. Cerebrospinal fever lhere was a marked diminution in the prevalence of cerebrospinal fever during 1918, only 265 ( cases having been notified, as compared with 430, 432 and 674 cases in 1917, 1916 and 1915 respectively.8 Of the 265 cases, 31 proved ultimately not to be cerebrospinal fever. Of the 265 cases, 31 proved ultimately not to be cere brospinal fever. The monthly distribution is shown in the following table :— Month. Jan. Feb. Mar. April May. June. July. Aug. Sept. Oct. Nov. Dec. Number of cases 23 31 34 23 31 14 18 13 10 13 14 10 The age distribution was as follows:— Age. Under 3. 3—5. 5—10. 10—20. 20—30. 30—40. 40—50. 50—60. Over 60 ♦Number of cases 81 19 31 58 17 17 4 4 3 In 202 cases forms containing detailed information Were received from borough medical officers and were circulated in accordance with the usual practice. The services of the Council's expert medical staff were requisitioned on 70 occasions, either for visiting suspected cases and making lumbar punctures, or for examining specimens of cerebrospinal fluid or other material. Of these 22 were actual visits to the homes of the patients and in these cases 10 lumbar punctures were performed; only 4 proved to be cases of cerebrospinal fever, the remainder being influenza (1), tubercular meningitis (3) and poliomyelitis (2). The 12 remaining cases included cerebrospinal fever (1), chronic post basic meningitis (1), poliomyelitis (1), febricula (2), toxaemia resulting from pyorrhoea (1), cerebral abscess (1), influenza (3), pneumonia (1), and erythema simplex (1). In addition to these visits 48 specimens of fluid or other material were received for bacteriological examination, mainly from infirmaries. Of these seven contained meningococci, 15 were shown to be tubercular meningitis and the remainder proved to be encephalitis (7), meningismus (7), pneumococcal meningitis (2), septic meningitis (1), cerebral abscess (1), influenza (1); whilst in seven cases there was neither evidence of meningitis nor any indication to assist in a diagnosis; one specimen proved to be contaminated and no result could be obtained. During the year 77 persons in contact with cerebrospinal fever were examined, of whom four were found to be carrying the meningococcus, and were kept under observation. In each case, however, a negative result was obtained on a second examination about a fortnight later. Under the Public Health (Cerebro-Spinal Fever) Regulations, 1918, issued by the Local Government Board on the 1st April, 1918, the Council of any Administrative County or of any County Borough is empowered to provide or arrange (1) for the provision of serum for the treatment of cases or suspected cases of cerebrospinal fever occurring among the inhabitants of the County or Borough, together with the necessary apparatus for the use of the serum, and (2) for the examination of any person who is suspected to be suffering from the disease. With reference to (2) the Council had already in 1915 made the necessary arrangements. As regards (1) provision had been made in London for the supply of antimeningococcal serum in the hospitals of the Metropolitan Asylums Board, the general hospitals, infirmaries, etc. The requirement of the regulations, as far as London was concerned, is therefore limited to those cases which are treated at home. In this connection the Council agreed on 30th July, 1918, to provide serum for the treatment of cases of cerebrospinal fever seen in consultation with the Council's medical staff, and arrangements have been made wherebv a supply of serum will be available in such cases. Encephalitis lethargies Detailed particulars w ere obtained concerning 78 cases wh ch came under the observation of the Council s medical staff, but of these only 49 presented the characteristic group of symptoms ; the remainder were found on examination to be due to tubercular meningitis, cerebrospinal meningitis, or to various other c> iditions. With regard to the general symptomatology of these 49 cases, it may be said that the onset of illness Was characterised by lethargy, accompanied by high temperature and * Not including cases in which the diagnosis was withdrawn. 60129 B 10 headache, followed in a large proportion of instances by interference with the nervo-muscular system of the eve, resulting in a variety of eye manifestations, such as ptosis, squint and nystagmus ; in others there was an interference with the nervo-muscular system of the face, producing a characteristic masklike appearance, or later a varying amount of permanent paralysis of the face or neck muscles. A predominant feature was involvement of the lumbosacral enlargement producing constipation and retention of urine. Other features of nervous origin such as delirium, tremors, vomiting, sweats, rashes, were also frequently observed. The symptoms in many of the instances were mild and it may be assumed that a number of cases missed identification. Of the 49 which came under observation by the Council's medical officers, 12 died within 14 days of the date of onset. In severe cases, owing to extensive injury or destruction of nervous tissue, recovery was very slow, in some cases the illness lasted six weeks or even longer. The paralysis observed in the more severe cases remained permanent even after recovery. The chief characteristics of the cerebrospinal fluid taken from the 49 cases were as follows:—The fluid was usually quite clear and colourless and was contained in the canal under considerable pressure. The albumen content was usually very small and the fluid reduced Fehling's solution very slightly. The centrifuged deposit contained very few cells, mainly lymphocytes, and no micro-organisms were demonstrated either microscopically or by culture. The monthly distribution of the 49 cases which presented the characteristic group of symptoms was as follows. As the disease was not at the time notifiable the dates of onset of illness have been selected for the purpose of this table. No cases came under observation between August and the end of the year:— Month .. .. February. March. April. May. June. July. August. Number of cases 1 8 14 19 6 — 1 On 19th December the Local Government Board issued an Order requiring the compulsory notification of cases of encephalitis lethargica under regulations which came into force on 1st Januarv, 1919. Poliomyelitis During the past two years the prevalence of poliomyelitis and polioencephalitis has been the lowest recorded since these diseases were made notifiable in 1911. viz.. 53 in each of the two vears recorded since these diseases were made notifiable in 1911, viz., 53 in each of the two years. The following table shows the number of notified cases each year since 1911 :— 1911, from 1st Sept 1912. 1913. 1914. 1915. 1916. 1917. 1918. Number of cases 66 132 145 93 97 197 53 53 Of the 53 cases notified in 1918, four proved subsequently not to be poliomyelitis, reducing the total to 49. Detailed particulars Were received from borough medical officers respecting 47 of these cases and were circulated for information. Month Jan. Feb. Mar. April May. June. July. Aug. Sept. Oct Nov Dec. Nu mber of cases — — 1 — 9 8 7 4 5 11 1 3 The subjoined table shows the age incidence .— Age Under 3 3—5. 5—10. 10—20. 20—30. 30—40. 40—50. 50—60. Over 60. Number of cases •• 81 19 31 58 17 17 4 4 3 B.—Administration. Certain statistical information available is summarised in Table II., see page 21. Tuberculous Milk.—L.C.C. (General Powers) Act, 1904, Part V., and 1907, Part IV. The Council's inspectors obtained 654 samples from churns of milk consigned from the country to the various London railway termini, and these were submitted to the Lister Institute for bacteriological examination. The milk was sent to London from 33 counties. Of the 620 completed examinations, 46, or 7'4 per cent., yielded tubercle bacilli, as against 10 3 per cent, in 1917, 8'7 per cent, in 1916, and 6'5 per cent, in 1915. In connection with these samples the veterinary inspector visited 50 farms and examined 1,839 cows. It was found that 36 cows, i.e., 2 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 182 farms and inspected 7,781 cows ; all the animals examined at these re-visits were found to be in a satisfactory condition with the exception of 15 which appeared to be tuberculous. In each instance the owner undertook to have the animal removed. During the period 26th November, 1917, to 25th November, 1918, there were three inspections of the cows in the 132 London cowsheds. In all, 5,466 examinations were made. No cases of tuberculosis II of the udder were detected, but in 80 cases other unhealthy conditions of the udder were found. One cow was found presenting symptons of pulmonary tuberculosis ; this was slaughtered by the owner. The number of cows examined in London cowsheds during the first quarter of 1914 Was 2,676, while in the last quarter of 1918 the number was 1,843. Housing of the Working Classes Acts. The action taken by the metropolitan borough councils under the provisions of section 17 of the Housing and Town Planning Act with regard to the making of representations and closing orders is shown in the following table—the figures for the years 1914, 1915, 1916 and 1917 being included for comparison. for comparison. It will be noticed that owing largely to conditions brought about by the war, these provisions have not been utilised to any great extent during recent years. Metropolitan borough. No. of representations. No. of closing orders. No. of houses demolished. 1014. 1015. 1016. 1017. 1918. 1314. 1015. 1916. 1917. 1918. 1914. 1915. 1916. 1917. 1918. Battersea 185 — — — — 38 — — — — — — — — — Bermondsey — — — — — — — — — 36 — — — — Bothnal Croon 31 3 31 — — 25 3 16 — — — 2 — — — Camhorwell — — — — — — — — — — — — — — — Chelsea 3 — — — — — — — — — 8 — — Deptford 5 5 2 5 5 2 — 6 2 — — — Finsbury — 2 — 15 — — 2 — 15 — — — — — Fulham — 1 — — — 1 — — — — — — — Greenwich 103 — — — — — — — — — — — — — — Hackney — 29 — — — — 29 — — 5 — — — — — Hammersmith 37 26 — — 6 26 12 — — 3 22 — — Hampstead 9 3 4 — 4 9 3 4 — 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 — — — 3 Paddington 5 1 1 — 3 5 1 — — 3 — — — — — Poplar 10 17 5 7 10 17 5 7 — 2 — — — 1 St. Marylebone 1 3 — — 13 — 12 — — 13 6 — — —' — St. Pancras 37 18 15 2 2 — 29 9 4 2 — — — — — Shoreditch — 3 — — — 3 — — — — 7 — — Southwark — — — — — — — — — — 32 — — Stepney 6 23 — — — 6 23 34 2 — — — — 2 — Stoke Newington Wandsworth — — — — — — — — — — — — 6 — — Westminster, City of — 2 4 — 1 — 4 1 — 1 11 8 31 — — Woolwich 18 11 6 4 12 9 9 4 4 12 7 — 4 1 — During the year the Council had under consideration the question of the sufficiency of housing accommodation in and near London. In considering the latter the Council had before it, so far as greater London was concerned, the material which had been obtained by the Local Government Board in reply to a circular letter on the subject addressed by the Board to local authorities. As a result of its investigations the Council in October, 1918, issued a report on "Housing After the War," from which the following extracts are taken. "The Council has now in hand the clearance of one insanitary area—Tabard-street, etc., South walk —and is committed to the clearance of another area—Brady-street, Bethnal Green * In 1911 the Medical Officer of Health for the County of London stated that there were throughout London about 1,900 groups of three or more houses which were either insanitary or so congested, badly arranged, or badly situated, that they required to be dealt with." The number of dwellings in these groups was 25,734, occupied, it was estimated, by about 195,000 persons. .By far the greater number of these groups of houses was in East London and in the older and more central parts of the boroughs south of the river. "Apart from certain technical difficulties under the Housing Acts, the main difficulty in dealing with undesirable houses or congested areas has in the past been that of re-housing. Of the 25,734 houses above referred to, 1,564 have since been demolished and the estimate of 195,000, as given above, can therefore be reduced to about 184,000, but only 217 of these 1,564 houses have been replaced by domestic buildings for persons of the working class. "There is evidence of a strong disinclination on the part of working people to reside further from their work than they need. Local authorities are consequently reluctant to displace residents in their districts unless it be possible to re-house them in the neighbourhood. In the more central districts it is impossible to provide upon the cleared sites new accommodation on economic lines for the persons displaced; and, even when, by valuing sites as restricted to the special purpose of re-housing accommodation, they can be used for re-housing purposes it is only practically possible in most cases to provide 50129 B 2 12 for a portion of the number who previously occupied the old houses. There may, however, be some insanitary areas in the outlying districts, where the houses are only two storeys high arid have a fair amount of space at the rear, on the cleared sites of which it would be possible to provide new accommodation for a number equal to that of the persons displaced. In the Walworth district houses of this class have been demolished and three-storey block dwellings erected; the space between and around the blocks is well paved so that there is no exposed polluted soil, and this class of dwelling has obvious advantages over that built upon the old damp sites with unpaved spaces at the rear in which animal and vegetable matters accumulate and pollute the soil. "The second section of unsuitable accommodation comprises certain large areas in portions of London, principally in the older parts, where the continued occupation of the houses is, on health grounds, undesirable, for one or more of the following reasons, namely, age, defective construction, decay, dampness or dilapidated and verminous condition. There are no detailed particulars in the Council's possession as to the extent of this class of accommodation, but it can hardly be doubted that it is considerable." On 3rd June, 1919, the Housing of the Working Classes Committee submitted to the Council a report in which the nature and extent of existing evils were outlined and a summary of the proposals under consideration or in contemplation was given. In this report the work to be done was divided into four heads— (i.) Development of existing estates; (ii.) Acquisition of new estates; (iii.) Clearance of insanitary areas; (iv.) Improvement of unhealthy dwellings. As regards (i.)—the development of existing estates—it was pointed out that the Council has three estates, two of them situated outside the County, which are not as yet fully developed. These have a total area of 106.53 acres on which will be erected about 2,000 cottages containing 8,412 rooms with accommodation for some 10,000 persons. As regards (ii.)—the acquisition of new estates—the report called attention to the recent decision to purchase an estate of 143 acres on which it was proposed to accommodate about 6,000 persons in some 1,200 cottages; while with the maturing of other proposals for purchase it was estimated that, apart Irom the rebuilding on cleared insanitary areas, it is probable that from 25,000 to 20,000 cottages could be erected with accommodation for approximately 130,000 persons, making, with the accommodation under item (iii.) an approximate total of 29,000 cottages with accommodation for 145,000 persons. In dealing with (iii.)—clearance of insanitary areas—two schemes have been decided upon, one 6f which is now in course of execution. These will provide accommodation for 3,460 persons. In addition there are 22 other areas with a population of about 40,000 which, in the opinion of the Housing Committee, should be dealt with. It was also pointed out in the report that there were many small areas or groups of houses which would naturally receive the attention of the borough councils. With regard to (iv.)—improvement of unhealthy dwellings—the Committee put forward no programme as this was a sphere of activity appertaining primarily to borough councils, and the existence of alternative accommodation was necessary before any effective action could be taken. The Committee further pointed out that any proposals then made must be regarded not as a programme of final and complete reform, but as intended to meet the pressing requirements of the present time, and they presented to the Council the following recommendations which were adopted :— (a) That a scheme be made and submitted to the Council without delay for the provision by the Council of dwellings for the working classes and the improvement of housing conditions in London on the following basis— (i.) The provision within a period of five years from the date of the approval of the scheme by the Local Government Board of a total of not fewer than 29,000 new dwellings, exclusive of those to be erected upon the cleared sites of insanitary areas, to accommodate a population of approximately 145,000 persons upon condition that the financial assistance of the' State shall not be limited to work completed in any part of this period, and provided that the Council shall not lose such assistance if the Council fails to complete within the time limit through circumstances beyond its control, such as labour, materials and difficulties with regard to sites, after showing reasonable diligence in prosecuting the scheme. (ii.) The provision, if possible, of not fewer than 10,000 of the dwellings referred to in (i.) before 31st March, 1921, to accommodate about 50,000 persons. (iii.) Immediate steps for securing the clearance of certain of the worst remaining insanitary areas containing a population estimated at 40,000. (b) That before the end of the period of five years mentioned in the foregoing scheme the Council do reconsider the position, having regard to the then existing conditions of the supply and demand of houses and to the existing sanitary conditions, and do thereafter decide what further steps should be taken to meet those conditions. Offensive trades. In November, 1918, legal proceedings were instituted by the St. Pancras Borough Council against a tallow melter, whose works were situated in the borough, for having caused effluvium nuisance. The hearing of the case was adjourned in order that the defendant might carry out at the premises certain works of improvement which it was hoped would remove cause for complaint. 13 An order, known as the Horseflesh (Sales) Order made by the Food Controller nnder the Defence of the Realm Regulations came into operation during the year, by which the slaughter of horses, whether the flesh was used for human consumption or not, was prohibited except in premises the owner or occupier of which held a licence from the Food Controller. A similar order—The Slaughterhouses (Licensing) Order—was made by the Ministry of Food requiring the licensing by the Food Controller of all persons using a slaughterhouse for cattle. In each instance the powers of the Food Controller were in addition to, and not in substitution for those possessed by the Council in respect to the regulation of the business of a knacker and of a slaughterer of cattle or horses. One application was received for a licence, under section 53 of the London County Council (General Powers) Act, 1903, of a depot for the reception of dead horses or horses for slaughter, but the licence was not granted. Application was also made for the Council's sanction to the establishment anew of the business of a slaughterer of horses, the flesh of which would be used for human consumption, and an order sanctioning the establishment of the business was in due course made. Removal of house refuse. The difficulties in securing an efficient collection of house refuse in the several metropolitan boroughs, to which reference was made in last year's annual report were again experienced in 1918. At the time of writing this report a weekly collection had been resumed in many of the boroughs, but the Council was in communication with certain borough councils as to delay in removal or disposal of refuse. A special case of delay in removing house refuse collected in the borough of Islington to shoots situated outside the county was brought to the notice of the Local Government Board in order to strengthen the hands of the borough council who had already called the Board's attention to the subject. The Board conferred with the Borough Council, the Home Office and the Ministry of National Service, and steps were taken to provide the labour necessary for handling the accumulation. In connection with the general question of the possibility of further depletion of the staff engaged on this work owing to the passing of the Military Service Act, 1918, with consequent increase in the delay in collection, the Council expressed to the Local Government Board the hope that in the consideration of claims upon the staffs of the borough councils for military service, the Board would take such steps as might seem necessary to secure due recognition being given to the requirements of the public health and sanitary services in London. Depletion of sanitary staffs. There were in May, 1919, only 10 male sanitary inspectors remaining on war service. At that time there were 363 male sanitary inspectors actually employed in the several metropolitan boroughs, five of whom were temporary officers ; in addition four men and a woman were employed as war substitutes. There were also 28 female sanitary inspectors, of whom two were temporarily employed, as well as 91 permanent and two temporary health visitors, while 16 women performed the dual functions of sanitary inspector and health visitor. National Insurance Acts, 1911-13—Treatment of tuberculosis. Two boroughs which had not completed their tuberculosis dispensary schemes at the end of 1917 did so in 1918, and dispensary schemes comprising 33 dispensaries are now in operation in all the metropolitan boroughs and the City of London. A summary of the work of these dispensaries during 1918 is given in table III. on page 22. During the year the Hammersmith Borough Council appointed a Tuberculosis Care Committee, representative of all the agencies in the borough connected with the welfare of the tuberculous population, in accordance with the principles laid down in the model scheme passed by the London County Council on 15th June, 1915, dealing with the appointment and duties of Tuberculosis Care Committees; the Interim Committee appointed temporarily by the London County Council was accordingly dissolved after having done much useful work, for which the Council has expressed to the members its appreciation. The only other borough in which a Borough Care Committee is in operation is that of Chelsea. In the remaining boroughs the Council still has the advantage of the co-operation and assistance of the Interim Tuberculosis Care Committees set up throughout London to perform the functions ultimately to be discharged by Care Committees to be appointed by the metropolitan borough councils. These Committees play an important part in the work of ameliorating the lot of the tuberculous population, particularly in such matters as improving the home conditions and provision of suitable employment, etc. They also collect contributions made by parents towards the cost of the treatment of their children. With regard to treatment in residential institutions, provision is made by the Council for the treatment of uninsured persons and children, insured persons being the concern of the London Insurance Committee. The Council authorised the use of maxima of 100 beds for adults and 300 beds for children in voluntary institutions, and such beds as may be available at the institutions of the Metropolitan Asylums Board, including a limited number of beds for advanced cases at St. George's Home, Milmanstreet, Chelsea (Women), and at Downs Sanatorium (Men). A comprehensive scheme, under which the Council would be responsible for the provision of institutional treatment for both insured and uninsured persons, is now under consideration. 14 The subjoined table indicates the numbers, inclusive of advanced cases, under treatment in residential institutions during the year :— Men. Women. Total. Children. Boys. Girls. Total. Number remaining under treatment on 31st December, 1917 39 125 164 191 185 376 Number admitted during 1918 144 431 575 388 286 674 Total number treated during 1918 183 556 739 579 471 1,050 In addition to the foregoing, the Council has again had the advantage of beds made available through the I.C.A.A. as the result of a contribution from the Council to the funds of the Association amounting to £1,500. These beds were used principally for cases requiring "convalescence" rather than treatment in sanatoria. In this way, including 200 children under treatment on 1st January, 1918, 737 children received the benefit of treatment in convalescent homes, and, in addition, 23 children were provided with such surgical apparatus as had been ordered by the surgeon in attendance. The question of the provision of open air schools for tuberculous children has received careful consideration. A small experiment was started in 1917 by the establishment of five such schools attached to tuberculosis dispensaries accommodating about 25 in four cases and 50 in the other case. The Council has provided the teacher and the educational equipment. Two of these schools (Battersea and Hammersmith) have now been closed, the remaining three (Camberwell, Bermondsey and Fulham) being continued for another 12 months. For some years an open air school has been conducted at Kensal House, Paddington, in connection with the Paddington Tuberculosis Dispensary. The work at this school is dealt with in the Education Section of this report. The Council has recently decided to establish open air schools under the Elementary Education (Defective and Epileptic Children) Act, 1899, throughout the County of London. The children will be selected by the Medical Officer, as they are now selected for residential institutions for the treatment of tuberculosis, and it is hoped that in some cases this may obviate the necessity for sanatorium treatment, while in other cases the schools will be beneficial in breaking the otherwise too sudden change from sanatorium conditions to those of home and ordinary school life. One school was opened at Springwell House on the north side of Clapham Common early in the year 1919, and the 50 children from Battersea (see above) were transferred there. This school will ultimately have accommodation for 100 children. It is expected that several of these new open air schools for tuberculous children will be opened in 1919. Mental Deficiency Act, 1913. Information was received by the Asylums Officer, from various sources, of alleged mental defect in 445 cases during 1918. During the period under review 166 defectives were sent to institutions, 205 were placed under supervision, 8 were placed under guardianship, and 43 were sent to places of safety pending the presentation of a petition. On the 31st December, 1918, of the 1,443 cases being dealt with at the expense of the Council there were—In institutions, 504; under guardianship, 10; under supervision, 923; in places of safety waiting other action, 6. There remained 1,341 out of the total number (2,784) of cases of alleged mental defect of which notice has been received since the Act came into operation. These cases include 210, in which no action could be taken; 383 ascertained not defective or not to be London cases; 262 dealt with through the poor law; 228 removed from the register (died, discharged or removed to lunatic asylums), and 258 still under consideration. During the year 361 cases were examined with the following results .— Males. Females Totals. Males. Females Totals. Idiot 15 10 25 Moral Imbecile 3 5 8 Imbecile 74 50 124 Not Defective 12 15 27 Feeble-minded 84 86 170 Insufficient evidence 3 4 7 Medical examinations—Staff. The Council decided that so long as the appointment of Sir John Collie, as the Council's medical examiner, was in abeyance while he continued his duties under under the Ministry of Pensions, examinations for which the medical examiner was formerly responsible should be conducted in the Public Health department. The work actually began in the Public Health department on the 15th April, and continued until the 1st February, 1919. During that period, of 9£ months, 5,604 examinations were conducted at the head office, 37 at homes, on three occasions the examiner had to attend County Court compensation cases, on one occasion the examiner had to attend a post-mortem examination, 982 certificates were furnished to police authorities and 167 reports were made upon cases not necessitating examination. The volume of work varied considerably from day to day but it was always possible to finish all on the same day, the results being telephoned immediately in urgent cases and the written reports posted each evening to the head of the department concerned. 15 Midwives Act, 1902. Tlie number of certified midwives with London addresses exceeds 5,000, of whom 535 notified their intention to practise in the county during the year, a decrease of 19 on the previous year. During the year the four medical inspectors in the Public Health department made 2,406 inspections of the work of the certified midwives. The number of births notified under the Notification of Births Act, 1907, by certified midwives during the period under review was 34,976, and 2,738 notifications were received by the Council that medical aid had been advised by certified midwives in the following circumstances—Pregnancy, 170; lying-in, 480; labour, 1,089; child, 999. Notifications were also received as to the occurrence of 30 deaths in the practice of certified midwives, four cases of liability to be a source of infection and 16 cases of laying out a dead body. The occurrence of 535 stillbirths was reported, the foetus in 243 cases being macerated, and in 252 cases not macerated, while in 40 cases no definite particulars were given. During the year inquests were held on the bodies of 13 women and 48 infants arising out of cases in which certified midwives had been in attendance. 613 cases of ophthalmia neonatorum were notified by medical practitioners, under section 55 of the Public Health (London) Act, 1891, 332 being in respect of cases in the practice of certified midwives. Of this number 314 were cured, impairment of vision resulted in four cases, seven infants died, and in seven instances information could not be obtained owing to the removal of the parents. 158 cases of puerperal fever were notified in the County and the Registrar-General records 95 deaths from puerperal septic disease. 61 of these occurred in the practice of certified midwives. The RegistrarGeneral also records 121 deaths from other'accidents of child birth, of which 6 were in the practice of midwives. A new Midwives Act was passed duirng the year, but did not come into force until 1st January 1919. It provides, inter alia, for the payment by the local supervising authority of the fees of medical practitioners in cases where midwives summon medical assistance in accordance with the rules of the Central Midwives Board, and empowers the local authority to recover the fee from the patient or other person liable unless evidence is forthcoming that such person is too poor to pay. The Act also empowers local supervising authorities to supply midwives gratis with all books and forms which they are required to fill up or use, and stamped envelopes where necessary. Section 12 of the Act repeals the provisions of section 8 of the Act of 1902 which enabled County Councils to delegate their powers and duties to district councils. The establishment of prima facie cases of negligence and misconduct on the part of five midwives were reported to the Central Midwives Board, the name of one being subsequently removed from the roll of midwives. The remaining four were cautioned, subsequent reports as to the conduct and methods of practice of three 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. At the end of the year 272 lying-in homes remained on the register, 67 having been added during the year and registration in respect of 17 having either been cancelled or the use of the premises for confinements having been discontinued. Children Act, 1908—Part I. The work arising under this part of the Act was transferred to the Public Health Department in March, 1917. Part I. of the Act provides that if a person undertakes for hire or reward the nursing and maintenance of an infant under the age of seven years, apart from its parents, due notice of such reception must be given to the local authority—in London the Council—within 48 hours. A similar requirement is imposed in the case of the change of address of a foster parent, or the removal or death of the infant. There is also an obligation to notify the local coroner in the case of the death of an infant, but such notification must be given within 24 hours. At the beginning of 1918 the number of notified houses on the register was 2,995, and the number ot nurse infants was 3,900. At the end of the year the figures had dropped to 2,654 houses, and 3,461 infants. Since the war began there has been a gradual reduction in the number of houses and infants, due mainly to the fact that it has been possible for foster parents to obtain lucrative employment, and they feel indisposed to be burdened with the care of nurse infants. In this connection it may be noted that the charges have gradually risen, and although before the war it was possible to find a home for an infant at 5s. a week, the amount now asked is, on an average, 12s. 6d. and upwards; but there are, of course, a few cases where for special reasons foster parents can be induced to take an infant at a lower sum. It is hoped that the powers in the Maternity and Child Welfare Act, 1918, given t6 borough councils to assist foster mothers financially, may result in an increase in the number of suitable homes and foster mothers available. At present it is an exceedingly difficult matter to find a suitable home for a young infant so greatly has the number of applications for such homes increased. The applicants are either unmarried and must work to live, or are married and find it more profitable to go to work and place infants out to nurse. The homes for infants are also finding it necessary to refuse applications. The staff charged with the duty of carrying out this part of the Act comprises 15 female visitors, and two male inspectors. The female visitors are required to visit the foster mothers, to see that the infants are receiving proper care and attention and to advise foster mothers as to the best method of feeding, etc., the particular infants in their care. The two male inspectors watch advertisements in the Press, trace unregistered foster mothers, verify removals of infants from foster parents outside London to parents or relatives in London in cases where the outside authority advises the Council of such removals, assist the visitors in tracing infants or foster mothers who have removed without notice being given, and render assistance to visitors in difficult cases. 16 The Act provides for the removal of an infant to a place of safety—i.e., a workhouse—in cases where either the foster mother is by reason of negligence, ignorance, inebriety, immorality, criminal conduct, or other similar cause, unfit to have charge of it, or the premises are overcrowded, dangerous, or insanitary, or if the infant is being kept by any person or in any premises in contravention of the provisions of the Act. During the year there have been 48 such removals. The Act also permits the local authority to exempt either partially or wholly such premises as in their opinion are so conducted as to make regular inspection unnecessary. During the year partial exemption, limited to one or two visits a year, has been granted in five cases. Particular attention is paid to the sanitary condition of the homes in which the infants are kept. Every new notification is reported upon from a sanitary standpoint, apart from the condition of the infant or the suitability of the foster mother; similar action is taken if a foster mother removes or if in the opinion of the visitor the condition of the premises is likely to prove harmful to the infant. During the year 1,441 such reports were made. In 848 cases the conditions were satisfactory, in 299 sanitary defects were found, in 238 overcrowding and in 56 both overcrowding and sanitary defects were discovered. In 85 cases the infant had been removed before the visit could be paid. The attention of the sanitary authorities has been drawn to cases in which serious sanitary defects existed. In instances of overcrowding it was found possible in many cases to re-arrange the accommodation so as to remedy this, but in others it was necessary for the foster mother to be required either to obtain other and more suitable premises or to give up the infant. The shortage of labour has, of course, contributed largely to the difficulty in securing that the necessary work of renovation is carried out. Careful supervision is maintained over the health of the infants, and foster parents are encouraged to take ailing infants to the local Infant Welfare Centre. If the case is sufficiently serious the hospital is advised, and in all cases the visitor follows up to see that the treatment is carried out. In certain cases where the infant does not appear to be progressing one of the Council's medical inspectors pays a special visit and submits a report upon the case. This practice has been attended with very useful results. Nurse infants on reaching the age of 5 years usually become school children, and in cases where treatment is necessary use is made of the school medical treatment scheme. During the year there were 103 deaths, in 10 of which inquests were held, the verdicts in each case being Death fron Natural Causes. Infringements of the law were discovered in 446 cases, in 420 of which Written cautions were sent. In 25 cases legal proceedings were taken and convictions obtained, and one case was adjourned sine die on a point of law. Diagnosis and Treatment of Venereal Disease. The scheme for London and the Home Counties for the diagnosis and treatment of venereal disease which came into force on 1st January, 1917, Was continued throughout 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. The number of clinics—22 in 1917—established at London general hospitals was thus increased to 25. Provision was also made at three hostels for women who, whilst undergoing treatment at the hospitals, continued in employment, and whose lodgings did not permit of the requisite privacy. During the year the number of persons who made use of the facilities was 16,372, viz., 10,069 males and 6,303 females, and their attendances totalled 169,485. The number of "in-patient" days of treatment given was 66,095 and 6,649 persons were treated with salvarsan substitutes. Of those dealt with for the first time 12,538 were London patients of whom 5,167 were suffering from syphilis, 96 from soft chancre, 5,222 from gonorrhoea, and 2,053 not suffering from venereal disease. Pathological examinations of material from patients attending the clinics totalled 25,973 and 6,380 examinations for medical practitioners were made in the laboratories. The total examinations included 21,360 Wassermann tests. Since the inception of the scheme, 178 medical practitioners have submitted evidence of their experience in the administration of arseno-benzol preparations in accordance with the regulations of the Local Government Board and have been placed on the Council's approved list, entitling them to supplies of these drugs free of cost. In considering the arrangements for the year 1919, the need for special facilities for treatment for infected pregnant women was considered and the authorities of the large lying-in hospitals were approached on the subject, with the result that it is probable that at least one of these institutions will participate in the Scheme during the ensuing year. To assist in bringing these facilities for treatment to the notice of the public, the Council entered into arrangements with the National Council for Combating Venereal Disease, who undertook in return for financial assistance the organising of lectures and meetings in the several metropolitan boroughs, the distribution of free literature, and the issuing of advertisements in the daily press calling attention to the dangers of infection, the desirability of early treatment and the means for obtaining the same. Posters giving the location, days and times of attendance at the clinics, were also displayed in public conveniences and, where the necessary permission could be obtained, in large business premises. Common Lodging Houses. The administration of the Common Lodging Houses Acts devolved upon the Council in 1894. By the passing of the London County Council (General Powers) Act, 1902, the Council obtained powers to licence common lodging houses annually. New by-laws for t'no regulation of such houses came into force on the 1st October, 1903. 17 In the following table will be seen the number of houses, the authorised number of lodgers, the number of convictions, with the penalties inflicted and other particulars, during each year since the outbreak of war :— Year. No. of houses licensed. Authorised number of lodgers. No. of day visits by inspectors. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. No. of cases of infectious disease. £ s. d. 1914 308 26,308 24,210 1,708 5 5 14 10 0 11 1915 295 25,426 25,827 1,696 3 3 8 11 0 5 1916 252 24,308 21,190 1,028 1 1 0 15 0 4 1917 234 22,781 18,240 652 — — — — 1918 211 20,818 16,703 441 3 3 43 0 0 — Seamen's Lodging Houses. In 1901 the London County Council made by-laws under section 214 of the Merchant Shipping Act, 1894, dealing with the inspection, sanitary condition and well-ordering of seamen's lodging houses. In 1909 the by-laws were amended in certain particulars and a new series came into force on 1st January, 1910. In February, 1910, powers were conferred on the County Council for the licensing of seamen's lodging houses, and since that year all such houses have been annually licensed. In June, 1917, the by-laws were further amended to permit of a wider interpretation of the definition of a " seaman," as the then existing by-laws were restricted in their application to houses where seamen who had service as such within the preceding four weeks were lodged; great difficulty was experienced in proving sea service within this period, and the four week limit was therefore eliminated in the new by-laws. In compliance with the suggestion of a Thames Police Court Magistrate, posters and handbills in English, Chinese, Yiddish and Arabic were displayed and distributed in the districts catering for seafarers, warning lodging house keepers as to the heavy penalties they would be liable to on conviction for accommodating seamen without a licence. In the following table will be seen the number of houses, the authorised number of lodgers, the number of convictions, with the penalties inflicted and other particulars, during each year since these houses were licensed by the Council.— Year. No. of licensed houses. Authorised number of lodgers. No. of day visits. No. of night visits No. of prosecutions. No. of convictions. Penalties and costs. No. of cases of infectious diseases. £ s. d. — 1910 37 1.157 2,404 197 15 14 90 9 0 — 1911 36 1,173 1,465 204 7 6 52 13 0 — 1912 41 1,066 1,079 210 18 13 81 12 0 — 1913 44 1,120 1,814 237 15 4 29 16 0 — 1914 35 1,043 1,247 174 4 4 59 13 0 — 1915 43 1,186 1,660 255 11 8 76 16 0 1 1916 53 1,271 1,422 193 26 17 313 0 0 — 1917 57 1,461 1,637 142 7 6 97 0 0 — 1918 59 1,486 1,666 85 15 12 139 2 0 — Soldiers' Rest Houses. In February, 1916, the Council was asked by the Army Council to render assistance by its officers in connection with the supervision of the sanitary arrangements and other kindred matters affecting shelters provided for troops in London. Certain officers of the Public Health department were detailed for this work, inspections being made as far as possible twice weekly by day and less frequently at night. Close co-operation between the Council's officers and the Inspector of Rest Houses, Colonel Valentine Matthews, acting under the Officer Commanding the London District, has been effective in securing great improvements in the conditions obtaining in these rest houses. By working to a standard of sanitary requirements, overcrowding was practically abolished, adequate w.c. and lavatory accommodation was secured and regard was paid to the necessity for cleanliness and ventilation. Further assistance was rendered in securing the prompt removal of cases of sickness, the cleansing of inmates found in a verminous condition and the keeping of contacts of infectious illness under observation. In 1916 these houses numbered about 40, with accommodation for about 4,000 men, but by the end of the year 1918 the number of houses and accommodation had increased threefold. Following upon the armistice particulars were received concerning repatriated prisoners returning to this country and were forwarded to the borough medical officers of health. 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 15th February, 1918. Owing to war conditions only the central, eastern and northern parts of the county, where such persons are usually found, were 50129 n 18 visited. The night was fine and cold. Only two persons, both females, were found sheltering under arches or on staircases—the lowest number yet recorded. In the streets, the number of homeless persons also showed a considerable reduction. On the night in question 1 man and 6 women were found, as compared with 19 men and 5 women in 1917, and 296 men and 76 women in the early part of 1914. The common lodging house population was less numerous than on any previous occasion, there being 12,522 inmates as compared with 13,679 in 1917, 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 reduction in the number of inmates, 32 men and 74 women being accommodated, as compared with 64 men, 159 women and 7 children in 1917. The number of persons in London casual wards on the night in question was 82 as compared with 89 at the time of the last census, and in Rowton Houses 4,108 as against 3,950. Work of the Chemical Branch. The work of the chemical branch of the department is carried out at the central laboratory at Savoy Hill and at the laboratories at the two sewage outfalls at Barking and Crossness. During the year under consideration a laboratory has been partly equipped at the Greenwich generating station in order that systematic work and technical investigations required by the Highways Committee may be undertaken. Central laboratory.—The work at the central laboratory normally includes the examination of samples received under such statutes as the Fertilisers and Feeding Stuffs Act, 1906, the Petroleum Acts, the London Building Act and certain of the Council's General Powers Acts. In connection with the administration of the Petroleum Acts, 69 analyses were made of gases used for creating a definitely non-explosive atmosphere in certain dry cleaning and de-greasing plants in which petroleum spirit is used. Monthly samples of rainwater collected in special gauges at six open spaces in the county were examined in connection with the work of the Atmospheric Pollution Committee, in which the Council is co-operating with other bodies all over the country. The results of the examination of upwards of 800 samples of milk are dealt with in the school section of this report. Two samples of dried milk, both guaranteed full cream, were examined. One was found to be genuine dried whole milk. The other was dried separated milk. Owing no doubt to the food shortage and the difficulty of enforcing requirements as to quality, only very few samples of foods supplied to the Council's residential institutions were received for examination. Previous experience as well as that obtained with milk in the year under consideration shows, however, that the knowledge that deliveries will be submitted to examination has a wholesome effect on the quality of the supply, apart from the actual detection of inferior materials. The chemical examination and determination of the heating value of coal supplied to the Council's generating station at Greenwich has for many years been carried out by the chemical stafE. The results obtained in 1918 have shown that a great deal of very low grade coal is now on the market. Samples yielding as much as 19 per cent, of ash were received on many occasions, the greatest amount found in the year being 28 per cent. Recently this figure has been exceeded. The use of coke at the generating station owing to the shortage of coal has been attended with considerable success. This material varies much less in its general properties than the coals from which it is made. The examination of 90 samples has, however, shown that coal of very high ash content is now used in gas making, leading to the formation of a less valuable and more difficultly combustible coke. The examination of such more or less abnormal samples of coal and coke has presented some experimental difficulties which have been successfully overcome by the various new devices adopted by the chemical staff. In all 752 samples of solid fuel were examined, 662 samples of coal and 90 samples of coke. An investigation for the Public Control department of the inflammable properties of aeroplane " dope " (celluloid varnish) involved a considerable amount of experimental work. An investigation into the cause and prevention of corrosion of lead sheathing for electric conductors is being carried out in collaboration with the electrical branch of the tramways department. The results, so far obtained, seem to indicate fairly clearly the most important cause of such corrosion, but the matter is not yet fully investigated. The Outfalls.—The work at the laboratories at the two outfalls includes the routine daily examination of sewage effluent and sludge and of river water collected at high and low water at both outfalls. A long series of records, dating back to the beginning of the present system of sedimentation, is thereby continued and data are available, not only for daily information as to the quality of the materials in question, but for larger problems which may at any time arise. In 1918, 730 samples of sewage, 730 samples of effluent and 2,154 samples of sludge were examined at the two outfalls, as well as 395 samples of lower river and estuary waters. Examination of the tideway.—Allusion was made in last year's report to the systematic examination of the tideway of the River Thames, which was undertaken as a means of observation of the effect of varying treatment of sewage at the Council's outfalls, and with a view to solving certain problems connected therewith. The results so far obtained have been recently summarised and tentatively discussed in a report to the Main Drainage Committee of the Council. They are very briefly presented below :— I. Results obtained— The various chemical tests, more particularly the percentage saturation with dissolved oxygen, show that there is very little deterioration of the water coming down from the nontidal portion of the river until, say, Isleworth is reached, and no marked deterioration above Putney. From this point down to Greenhithe, the average saturation with dissolved oxygen 19 is below 50 per cent. during most of the summer, a minimum being reached in the neighbourhood of the outfalls. Below Greenhithe the quality of the water rapidly improves and beyond the Nore practically fully aerated water is usually found. II. Factors affecting the river— (i.) The progressive deterioration of the upper tideway appears to be due to local causes rather than to the Council's operations. It does not seem to be due to the immediate effect of up-river pollution, but rather to the inoffensive oxidation of organic matter in the mudbanks exposed to air at low-water but stirred up by the rising tide. (ii.) The summer condition of the important commercial area area London Bridge to the outfalls is less satisfactory. Results of examination of daily samples of river water collected at the outfalls, at both high and low water, point to a falling off of dissolved oxygen since the year 1911, which was remarkable both for being hot and dry and that also in which the total effluent discharged from the two outfalls reached a maximum. (iii.) The influence of certain natural and other factors upon the river generally:— (а) Fresh water flow was much higher during the summers 1911-1918 than in the preceding summers of this century. The average daily flow was below 500 million gallons in 32 months from 1901-10, in 4 months in 1911, and in only 7 months from 1912-1918. Other data referring to flow confirmed the existence of relative dryness in the earlier years. (b) The temperature differences in the water during the summers of the two periods were not of such an order as to suggest that greater biochemical activity caused the more marked deterioration in the later summers. (c) An important change began to take effect in the neighbourhood of 1911. The Port of London Authority carried out an extensive and necessary dredging programme which must have had, inter alia, two effects—(1) much matter must have been brought up from the river bed which required oxidation; (2) the increased tidal flow, due to the increased volume of the river, must have led to the agitation and commingling with the water of mud which would otherwise have been undisturbed. If the view be accepted that low aerations are, in part at least, attributable to dredging, then, in so far as this has led to the oxidation of matters which unoxidised would be a potential source of nuisance, its effect must have been on the whole good although obtained at the expense of an apparent deterioration in the summer condition of the river. (d) It might be suggested, in regard to the treatment of sewage, that the omission of " chemical " treatment was a possible cause of low aerations, but as these were observed when chemical treatment was carried out as well as when it was omitted this view cannot be maintained. (e) The amount of effluent discharged into the river from the outfalls has increased almost continuously up to 1911, when a maximum seems to have been reached. The relative importance of the various factors suggested above has not yet been determined, partly owing to the very complicated nature of the problems involved, but largely owing to the fact that some of these factors, e.g., those dependent on meteorological conditions, cannot be controlled but only observed, and an adequate study of a series of observations extending over a number of years is necessary. 50120 20 TABLE I. COUNTY OF LONDON. Vital statistics for the several metropolitan boroughs and the County of London in the year 1918. (Rates per 1,000 of civil population). Metropolitan borough. (In topographical order). Estimated civil population. 1918. 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 Dirths). Phthisis. Cancer. Cases of notifiable infectious disease. Smallpox. Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Puerperal fever (per 1,000 births). Cerebrospinal fever. Western Paddington 117,517 15.4 19.2 116 .36 .00 .17 .46 .00 11.3 1.24 1.41 — 1.28 2.22 .11 .47 1.0 .03 Kensington 154,814 14.2 17.8 91 .09 .05 .07 .23 .01 17.5 1.31 1.33 — 1.44 1.13 .07 .31 1.6 .09 Hammersmith 115,833 15.5 17.3 102 .39 .02 .05 .24 .03 15.9 1.65 1.34 — 1.49 1.19 .13 .32 1.5 .10 Fulham 143,211 16.7 17.5 109 .32 .03 .09 .40 .04 22.8 1.50 1.11 — 1.60 1.45 .11 .32 4.5 .06 Chelsea 56,741 13.0 19.5 88 .25 — .09 .19 .02 9.7 1.50 1.66 — 1.18 .81 .07 .34 7.3 .02 Westminster, City of 126,215 10.3 16.5 108 .08 .02 .09 .21 .02 15.2 1.51 1.45 — .73 1.06 .16 .28 2.8 .02 Northern St. Marylebone 98,526 12.5 18.7 113 .12 — .11 .26 .02 25.5 1.75 1.49 — .79 1.61 .09 .47 4.4 .04 Hampstead 71,815 11.1 14.3 77 .01 .04 .10 .21 .04 8.9 1.04 1.46 — .73 1.54 .15 .35 — .03 St. Pancras 175,716 16.9 22.3 102 .40 .04 .18 .50 .03 14.1 2.37 1.54 — 1.88 2.26 .10 .64 1.5 .05 Islington 286,400 16.3 20.5 110 .40 .03 .15 .52 .02 13.2 1.84 1.40 .01 1.51 1.81 .09 .49 .8 .05 Stoke Newington 44,195 12.8 18.1 93 .18 — .41 .09 .07 11.0 1.47 1.27 — 1.11 2.50 .02 .34 1.6 .09 Hackney 195,804 14.9 18.9 112 .21 .03 .27 .29 .04 18.7 1.72 1.26 .02 1.38 2.42 .15 .50 2.4 .03 Central Holborn 36,769 12.1 22.7 147 .16 — .14 .35 .08 20.1 2.61 1.12 .03 .63 2.21 .05 .27 — .03 Finsbury 66,492 17.8 23.9 109 .62 .05 .15 .81 — 11.3 2.39 1.35 — 2.52 1.82 .03 .39 .8 .05 London, City of 15,923 5.7 18.8 158 .19 — .06 .06 — 39.6 1.95 1.19 — 1.13 1.20 — .44 — .06 Eastern Shoreditch 87,645 18.2 24.2 163 .89 — .13 1.08 .01 35.3 2.51 1.02 .01 1.78 2.20 .06 1.02 1.7 .05 Bethnal Green 103,403 19.2 23.9 129 1.68 .09 .23 1.45 .02 17.5 2.61 1.22 .02 2.88 3.27 .14 1.12 1.3 •09 Stepney 230,943 18.6 20.9 113 .64 .03 .26 .40 .02 17.5 2.59 1.06 .10 1.95 3.36 .07 .59 1.2 •08 Poplar 139,530 20.2 22.7 110 1.09 .01 .23 .47 — 15.5 2.06 1.04 .01 1.66 2.20 .09 .68 3.8 •06 Southern Southwark 161,968 19.0 23.5 126 .88 .09 .25 .79 .01 13.9 2.48 1.32 — 4.04 3.11 .05 .93 3.5 •04 Bermondsey 108,406 20.1 22.2 134 .67 .03 .21 .80 — 15.1 1.71 1.33 — 2.16 3.48 .06 .44 .8 •06 Lambeth 262,275 16.1 19.3 97 .50 .05 .20 .33 .02 14.8 1.76 1.56 .00 2.00 1.67 .05 .37 3.6 ■06 Battersea 149,951 16.1 18.7 99 .38 .03 .15 .39 — 14.8 1.52 1.35 — 1.69 1.48 .05 .50 .7 •08 Wandsworth 292,408 13.5 15.2 95 .15 .01 .12 .21 .02 17.3 1.31 1.31 — 1.89 1.69 .13 .38 3.6 •06 Camberwell 233,833 16.2 18.3 102 .37 .02 .17 .36 .02 14.1 1.71 1.44 — 1.47 2.35 .06 .64 .9 •06 Deptford 102,036 19.0 18.0 98 .20 .03 .12 .53 .02 11.0 1.83 1.15 .01 1.89 2.28 .14 .68 .9 •04 Greenwich 89,939 17.9 19.5 118 .50 .01 .18 .50 .06 17.2 1.67 1.42 — 1.85 2.72 .16 .47 .6 •03 Lewisham 151,793 13.9 14.8 72 .07 .05 .21 .21 .03 8.5 1.12 1.34 — 1.32 2.11 .04 .36 2.1 •04 Woolwich 134,453 16.9 15.6 106 .16 .03 .19 .22 .01 13.0 1.48 1.23 — 1.58 1.80 .10 .43 5.1 •07 London 3,954,554 16.0 19.2 108 .42 .03 .43 .02 15.8 1.78 1.33 .01 1.73 2.07 .09 .51 2.2 •06 TABLE II. COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1918. Sanitary Authority. Cowsheds. Slaughterhouses. Offensive Trades. Smoke nuisances. Underground rooms. Overcrowding. Houses let in lodgings. Common lodging houses. Cleansing of persons and rooms. Water supply. Milkshops. lce 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 occupicd. No.closed or otherwise remedied. Instances found. No. remedied. 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 of London — — 7 * — — 138 11 — — — 1 1 191 764 — 1 455 4 73 11 — 124 754 — — 1,098 984 Battersea 1 4 3 329 3 — — 3 — 3 3 7 7 88 380 — 2 147 317 3,153 816 22 140 306 — 16 — 1,093 Bermondsey — — 1 15 13 110 22 5 5 — — 23 23 223 446 — 3 1,153 52 — 1,740 — 281 693 95 28 849 — Bethnal Green 12 63 3 4 1 — — — — — — 1 1 238 258 — 8 400 32 — 3,689 — 215 494 199 72 215 100 Camberwell 4 90 6 98 2 8 57 — — — — 21 21 292 — — 5 466 75 5,080 67 — 484 1,163 256 247 320 1,380 Chelsea — — 3 12 — — 4 2 2 — — 3 3 — — — 4 236 — — 582 — 98 129 24 24 96 118 Deptford — — 2 47 5 21 — — — — — 9 9 289 578 — 6 1,160 4 1,042 402 32 227 269 134 3 113 168 Finsbury 1 2 2 60 1 22 — — — — — 25 25 1,019 3,783 — 3 228 6 — — — 153 184 68 76 238 259 Fulham — — 2 6 — — — 4 2 2 2 32 26 — — — 2 98 12 177 672 12 112 245 36 85 — 1,280 Greenwich 3 12 4 71 3 — 24 — — 1 1 13 13 247 69 — 2 90 — 1,064 516 8 126 160 103 72 125 251 Hackney 13 17 19 50 1 1 18 11 7 — — 36 36 470 117 — 5 416 198 2,291 138 7 272 138 106 — 44 50 Hammersmith — — 7 122 — — 40 6 10 — — 12 12 2,695 270 — 2 341 — — 100 — 307 661 234 24 — 8,810 Hampstead — — 4 31 — — 14 2 — 24 18 12 12 405 781 — — — 130 669 — 27 90 269 72 86 465 1,872 Holborn — — 1 1 — — 9 4 3 1 1 3 3 622 573 — 16 1,194 117 — 60 11 158 66 — 13 400 2,294 Islington 4 18 21 889 7 69 16 1 1 1 1 8 8 — — — 24 844 9 4,226 13 1 586 805 235 6 456 8,007 Kensington 1 50 6 371 — — 300 3 6 3 3 42 42 2,065 4,988 2 11 539 178 1,351 258 — 184 1.073 189 28 735 2,281 Lambeth 5 16 13 190 3 36 — — — 58 58 84 84 372 4,464 — 5 582 — — 539 4 274 1,644 — — Lewisham 7 71 10 123 — — — — — — — 3 3 2 9 — 1 30 — — 80 2 148 264 — — 58 58 Paddington 1 4 5 423 — — 25 5 — — — 13 13 1,404 3,616 21 3 165 — — 63 1 99 125 — — 308 776 Poplar 10 14 10 62 6 56 — 4 4 — — 22 22 1,442 4,632 — 7 998 159 4,457 1,123 — 237 623 68 18 285 901 St. Marylebone 5 21 3 12 2 8 6 2 2 14 14 29 29 1,152 1,164 — 5 763 3,116 2,723 60 4 183 326 117 — 341 356 St. Pancras 4 8 10 153 2 52 36 5 — 3 3 37 37 2,364 6,619 — 4 358 480 4,501 854 19 214 502 129 49 — 3,543 Shoreditch 3 3 3 8 1 — — — — — — 19 19 283 319 — 6 373 — — 253 — 256 2,118 — — 209 474 Southwark 3 24 5 52 3 13 6 1 1 5 5 168 168 1,349 2,090 29 26 3,139 60 983 1,452 6 545 1,026 203 1 456 1,348 Stepney 29 62 5 11 6 23 90 20 20 9 9 154 154 741 975 — 31 4,789 223 38 1,243 1 433 1,603 94 118 334 673 Stoke Newington 1 3 5 14 — — 10 2 1 — — 1 1 259 259 — 1 37 3 76 65 — 65 67 — — — 1,145 Wandsworth 10 48 12 131 4 33 29 6 6 — — 33 33 292 783 1 6 173 76 — 195 — 416 611 313 208 218 279 Westminster 1 6 — — — — 436 19 19 6 6 26 26 1,190 3,309 7 6 1,606 105 684 157 500 481 1,373 155 30 1,563 4,637 Woolwich 14 33 9 36 — — 2 — — — — 52 52 448 656 — 17 493 *** 17 3,667 463 — 84 104 46 — — 104 Note.—In the columns above a dash signifies a nil return. Common lodging houses, licensed number, 212 ; lodgers, 21,273 ; visits—day, 16,703, night, 441 ; prosecutions, 3 ; penalties and costs, £43. Seamen's lodging houses, licensed number: Bermondsey, 7 ; Deptford, 1 ; Poplar, 13 ; Stepney, 38 ; lodgers, 1,486. Visits—day, 1,666; night, 85; convictions, 12 ; penalties, £139 2s. Prosecutions—Milkshops ; Bermondsey, 28 ; Hammersmith, 1 ; Hackney, 1. i . Offensive trades; Bermondsey, 5; Wandsworth, 2, * Continuous supervision during slaughtering. Overcrowding : Stepney, 1. Ice Cream.: Hammersmith, 2. to 1 3 4 5 6 7 8 9 10 11 12 Borough. 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 2 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 hospital to which Dispensary affiliated. Specimens of sputum examined. Insured. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Unin sured Insured. Unin sured. Insured. Unin sured. Insured. Unin sured. Insured. Unin sured. Insured. Un- in. sured. 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 ... 75 26 36 29 7 16 9 1 1 1 36 15 22 8 31 10 4 4 q i fins 7ftft qq4. 99A i nn„ ooo~ 1 A Battersea 420 123 509 ! 188 32 15 26 77 1 __ 2 109 51 10 132 310 122 4.0 1 4 74. o i on 1 «JUO 1 700 < oo A nitii 004 A OK ZZO too 1 yy a Zoo(l 1U 8 85 46 Bormondsoy 154 70 298 103 38 7 24 27 4 i 20 21 13 6 24 148 26 18 9 i 4 34 lou 1 nq 1 l\)A Q49 4Uy4 4yo •}fl9 Ooo Q40 191 1 A 414 OO 1022 2154 1 1 145 55 Bethnal Green 355 103 234 176 53 59 35 7 10 5 2 24 147 31 34 103 178 32 14 15 27 IUO 26 1843 O Oo- 1991 OvZ 673 J'to 682 10 28 oz 1 9 50 745 5A fiA 95 39 Cambenvell 502 183 1253 259 76 42 87 123 10 6 5 83 (16 18 20 158 748 167 83 42 124 299 4047 l an** I659 4nqn (h\ 1Z {j. \ QOA oooc 1 1 A ou t A A 456 207 Chelsea 60 39 105 26 8 5 11 10 __ 3 7 8 3 8 48 27 23 10 49 44 720 1 OUOO Q7Q on 4 iuOU Sdfi \0) K (0) oZU zoy o A FTC 110 I4U 208 138 Deptford ... 152 39 300 79 28 20 34 50 r> 2 1 5 31 50 5 10 57 j 50 l ft A o Ol CO V 1 v OO A 1 ^-U4 OiO TO/? o o 400 ooo — 136 125 Finsbury 139 59 231 100 28 22 27 35 4 16 23 4 13 166 I O 23 1 8 0 1 ol 4. 0.3 26 1509 1Q9A oo91 1 747 458 qafi 73o qaa 10 15 QK 1300 1 Al A 2371 3 17 207 137 Fulham 195 103 454 80 44 15 42 53 2 3 9 89 45 26 67 252 24 11 5 21 140 1 JZiXj 1993 1 /4 / ft4fip; ooo 9ftl ooo 771 04 1 4 OO OK„ 1U14 1 rtl O 1029 OOAO noTre *~ 69 25 Greenwich ... 130 52 396 84 33 8 27 25 56 29 12 11 23 210 17 7 5 33 105 1ZZO 1377 OfOO 6889 Z Ol 272 Ml 658 14 Notg oOG iven lUlz 951 zzyy 2742 19 corded 10 182 99 45 68 Hackney 434 258 831 233 41 114 46 31 9 8 3 1 43 142 173 69 245 637 50 36 19 79 1 9q Oftfift A 771 OQO 1 AO! 90 Hammersmith (<Z) ... 59 24 72 | 44 18 1 14 29 4 0 1 1 8 7 3 1 5 26 4 3 q / Z q 1 ZO o OoOo 9qa 4 / / 1 97Q yyz ii-< 14Z 1 1 KA ZO A A 102 .1298 1319 79 99 350 256 Hampstead 74 38 136 50 20 27 38 8 3 6 " 15 16 11 18 29 99 5 1 K O V 1 A. Z 04 Z <o 1 A 1 14 1 QO 104 A KQ 44 46 16 50e notaffi liated 18 7 Holborn 69 33 40 i 37 15 7 5 0 I 1 1 5 1 3 0 16 9ft 1 7 «.» A O ^ K 14 OO oOO 14b0 loo 40© 1 68 229 (c) (c) 54 99 Islington 537 160 495 351 88 63 70 74 4 3 4 4 23 155 54 34 89 348 97 j. < l *± K 0 07 Zo PA 880 569 271 197 10 1 520 360 1 1 36 13 Kensington 176 87 380 ! 83 24 17 35 24 2 6 2 31 45 19 21 37 126 Z 1 46 lO 38 o 23 37 50 199 4706 94ftl 5603 Aafiq 1112 j.nq 1340 Q9Q 133 9AQ 164 O 1579 2241 3 1 272 129 Lambeth 548 233 479 228 78 44 64 25 24 11 2 13 112 130 49 26 84 122 166 95 37 Of 78 220 *>416 OOOo Qfil 4 4U0 1 *5*57 i'zy 2196 ZOJ7 Olo 565 1490 ~\A """ 1 87 70 Lewish&m ... 165 55 179 102 28 32 31 23 6 5 2 4 24 54 18 17 31 118 3 4 i 1 A JT 1. \J qcl I/DIT 1 oco 1 OO l OO A q 2 o 04 107 150 6 20 Paddington 189 110 384 1 50 21 7 21 11 5 9 3 1 47 100 55 37 87 222 34 25 7 i 98 14 1 fi4 OOl 977 1 looz zzO ooo 297 oftr O 1 AC 5 1103 1210 5 1 70 39 Poplar 249 63 817 127 30 21 65 63 3 3 1 1 73 44 11 11 94 308 75 19 21 ZO 163 1U* 373 Z i I 1 1042 oy4o 8388 ooZ 383 »yo 1237 lOo 12 362 38 1097 100 3142 755 13 52 55 255 46 245 St. Marylebone 167 109 247 81 35 14 22 16 2 1 2 4 13 47 QO 91 J.A 70 q7 o x St. Pancras 280 1 94 327 200 50 26 55 66 g o q lO O A 1 o o o ^ 1 i /y o / OO 13 35 139 1587 4616 206 470 178 693 467 1411 6 17 201 126 Shoreditch ... 207 103 406 155 41 25 39 59 3 Z 2 o o4 7 11 33 9 45 1 4 10 74 43 289 63 16 33 17 17 q 42 *ji 184 pr 1 1684 9COA 4469 KO1 O 735 KOI 1590 94 KH 69 460 755 14 22 65 35 Southwark ... 464 ;205 902 238 70 15 51 65 4 *5 2 8 70 181 100 6 123 643 41 30 O 5 ol 17 Ol 124 ZooU 3455 oo 1 o 3368 ool 1206 857 1396 O / 13 83 9ft 1216 loin 1870 1 A7A OA 115 62 AA Stepney 822 : 94 2106 382 29 142 82 60 9 5 1 63 132 38 140 473 1225 299 27 199 190 758 7323 37924 4.A 47*> 99 ZO iziy 1U /U CO/i 3 zu 136 yo Stoke Newington ... 69 18 55 54 16 27 13 13 4 1 9 9 2 4 21 2 3 3 12 fiqQ 701 Qft 4/e oo o OB 94 Oz^ 10 159 t e 68 le Wandsworth 295 124 614 192 68 55 90 42 10 2 1 r> 51 69 43 35 111 501 24 11 7 15 20 coy 4057 to 1 13228 yo 789 yo 1494 7 A A/IO 1 HAH 7 15 32 1 7A 23 1 OA Westminster 177 105 352 97 59 32 36 27 3 2 7 18 21 20 14 22 212 56 24 19 15 11 in 9A47 K\I LtZi-t 1 OAA 4 1 O A 04y 1UOU l 0 1 ID loO Woolwich ... 319 167 637 177 66 12 30 60 1 5 2 10 30 51 40 6 51 314 90 50 52 35 JO 233 11 lu 3629 Z04 / 5680 /u / 953 loUO 1704 Oo 379 lo4 358 918/ 982 1744f 957 5 3 8 127 156 83 86 23 REPORT OF THE SCHOOL MEDICAL OFFICER (Dr. W. H. HAMER) FOR THE YEAR 1918. PART II.—EDUCATION. Introductory Note. The comparison of town and country children. The wonderful years, as they have been termed, of the war, having extended over 1,560 days, came to a close with the armistice on the 11th November, 1918. The " most wonderful year," it has been said, was 1914, when the country, after persistently and earnestly fighting for peace, pledged itself to carry out its obligations and entered upon the war; but the year 1918 was " wonderful also for the material victory by which this vow was accomplished." Incidentally, it may be noted that an outward sign of material victory, so far as school medical work throughout the country is concerned, is to be seen in the Education Act, 1918. Already prior to, and during the years of war, however, something material had been accomplished in London, as will be realised on referring to the Annual Report for 1917 of the Chief Medical Officer of the Board of Education. The results of a typical medical inspection carried out by Dr. C. J. Thomas with the help of Dr. R. H. Norman, " by the courtesy and good offices of the authorities of the London County Council," are set out in that report and described by Sir George Newman as " of exceptional value and extraordinary interest," and likely to be " studied with care in town and country throughout the kingdom." The main conclusions reached by Dr. Thomas (pp. 29 and 30 of Sir George Newman's report) bring to light differences between the London and country children " due in the main to the facilities of treatment, cleansing and supervision provided by the London County Council, which are not similarly available for the country children." The "substantial evidence of the value of organised medical treatment" thus supplied by Dr. Thomas was based upon the favourable position of the town children as regards sound dentition, absence of affections of the nose and throat, and freedom from vermin; these results, which it should be noted were recorded during the final stages of the war, were set out in abstract in the "London County Council Gazette " for the information and encouragement of members of the school care committees and the teachers and officers of the Council. It should be added that an important share in bringing about the results must be ascribed to the steady work during several years past, of the committees with which the Council had made agreements under its treatment scheme, and of the medical men and dentists concerned. The numerous difficulties, mainly arising directly out of the war, encountered during recent years in connection with the scheme—the shortage of doctors, nurses, organisers and voluntary workers, the numerous changes of personnel, the claims made that the school organisation or parts of that organisation should be commandeered for other uses—all these have been set out in previous annual reports ; it is, perhaps, needless to say that the year 1918 brought with it intensification of many of these difficulties. Now that the grave menace of the dangers of war has been replaced by new difficulties associated with " the return to peace," it is possible to look back with a sense of relief upon the unique experiences of the early months of 1918, upon the steady aggravation of food difficulties as the year advanced, and upon the growth in severity of the successive waves of influenza, culminating in the very fatal prevalence of November and December which followed hard upon the armistice reioicings. Medical inspection During the year 206,938 children in the age groups were examined by the school doctors ir elementary schools and of this number 91,074 were found to require treatment for one or more defects A further 1,579 children in the age groups were inspected in the special schools and 47,114 elementarj school children not in the age groups were specially examined, giving a total of 255,631. In addition, th< school medical staff inspected 4,835 children for scholarship awards, 7,953 students in secondary schools and training colleges and 12,365 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 b> Dr. C. J. Thomas and is given on pp. 25—28. Medical treatment. Five new centres have been opened and the provision at many ot the existing centres has been extended. The total number of children who received treatment was 143,539 as compared with 122,765 in 1917. Under the arrangements approved for the year commencing 1st April, 1919, authority has been given for schemes which will provide treatment for some 185,000 children annually. Re-inspection. The number of defects noted at primary inspections for treatment or observation coming under review was 123,082. It was found that in the case of defects requiring treatment 36 5 per cent, of the cases had received treatment within six months, almost the same proportion as in 1917. 17 0 per cent, of the cases were deemed to be no longer in need of treatment, and in 46.5 per cent, treatment was still required. Co-operation with Welfare Centres. Wherever possible, co-operation is established between the Council s centres and the infant welfare centres. On p. 30 Mr. C. E. Wallis describes the dental work which is carried out at the " Lissonia " Centre, where the Council's work is associated with the work of the infant welfare centre. Government grant. The grant awarded by the Board of Education under Part 1. of the Medical Grant Regulations for the year ending 31st March, 1919, amounted to £57,132 4s. 1d., representing 50 per cent, of the Council's expenditure on medical inspection and treatment and ancillary work during the previous year. Under Part IT. £1,002 10s. was awarded in respect of the open air schools at Kensal House, Birley House and Shooter's Hill and under Part III. £640 l1s. 5d. was allowed for physical education. 24 Supervision of dietaries, etc. As in 1917, the number of children receiving free meals remained phenomenally low, but the presence of food restrictions was becoming increasingly felt. In last year's report the unprecedentedly unsatisfactory results of analysis of milk supplied to necessitous school children were referred to. Doubtless in part as the outcome of the action taken, improvement was noted in the latter part of 1918. Followingup. The following-up difficulty, in cases referred tor medical treatment by the school doctors, Dwing to the continued shortage of voluntary care committee workers, became especially acute in 1918. rhe help of school nurses, in selected schools, under the arrangement adopted at the end of 1917, was continued throughout 1918 with successful results. Personal hygiene. The growing sense ot the need tor securing an improved standard of cleanliness among school children, was further strengthened and developed during 1918. Various influences contributed to this— the broadening of the views held as regards safeguarding the health of children, the increasing appreciation of the part played by verminous conditions in the dissemination of disease, the clear evidence of the spread of scabies by soldiers returning from the front—these factors were all operative. The lessons learnt were, however, especially borne in upon the minds of the parents and relations of the thousands of young men who became verminous, and suffered the attendant discomforts and disabilities, despite all practicable effort on their own part, owing to the stern exigencies of life in the trenches. There has resulted from all this a marked change in the point of view with regard to vermin. For many years past there had been unwillingness on the part of many people, even to countenance reference to the subject and certainly to face the obvious facts, with a resulting disposition on the part of parents of the poorest children either to accept infestation as inevitable, or at any rate, to ignore or even resent, the proffer of the facilities provided by the Council. The findings of the doctor or nurse were again and again called in question, the advice given with a view to remedying the conditions found vas not welcomed, and when the procedure sanctioned by law was invoked, the demonstration of nits was looked upon in the light of an insult, the cutting of hair necessary in neglected cases was resisted as a violation of the liberty of the subject, and the Council's nurses were not infrequently subjected to actual ill-treatment. The scheme of procedure originally adopted was tentative and hesitating, but despite this fact, it was very difficult in the early days to secure convictions even in the most extreme cases of neglect. By the adoption of persuasion and of conciliatory measures and by the exercise of great patience, steady improvement has been brought about, and the cleansing scheme has from time to time been amended with a view to expediting the procedure. There is now general agreement as to the necessity for taking prompt and effective action in bad cases, and the difficulties in securing enforcement of statutory notices have materially lessened during the past three or four years. In the course of 1918 valuable help was given to the Council by Mr. Bacot, F.E.S., Entomologist to the Lister Institute ; further modifications in the cleansing scheme are, partly at his instance, again being made, and Mr. Bacot has prepared a memorandum which is being circulated by the Council for the information of teachers and parents. In the following report (p. 35) reference is made to an attempt to promote larger use by school children of the public baths of London. It is a striking fact that at the present time these baths are not used up to anything approaching their maximum capacity. The existing provision no doubt needs further supplementing, but even as it stands, if fully used throughout the day as well as in the evening, it should be capable of giving a warm bath to every member of the population who would be likely to require it, say once a month. The actual number of warm baths given in recent years has only been about 4½ millions, the 3,300 baths being thus used on an average only some four times a day and the number of these baths taken by each member of the London population being thus on the average only one per annum. There are now 25 cleansing stations, and it is hoped that two additional stations will be opened during the year . At 22 of the stations arrangements have been made for children suffering from scabies to attend for baths and sterilisation of clothing In all, 516,566 examinations of children were made, and in 13,237 cases the children were found to be verminous, 4,912 children were cleansed by the parents, 8,325 were cleansed at the cleansing stations and 9,624 children suffering from scabies were also given baths. The total number of cleansings at the stations was 95,003. Early in the year an investigation was made by medical officers of the Board of Education into the working of the Council's arrangements for medical inspection and treatment. The results of their inquiries were communicated to the Council in a letter dated 27th March, 1918. This letter and the subsequent communications between the Council and the Board raised many important questions, especially in regard to the "following-up" of children requiring medical treatment. The whole correspondence is set out on pp. 36—43. Epidemic diseases. In 1917, two small localised outbreaks of dysentery, mainly affecting children, were reported one in north and one in north-west London. No further development of dysentery prevalence was noted in the general population in 1918 ; both this disease and other diseases associated with war and privation were, however, encountered in certain institutions in London and in other parts of the country. Smallpox just obtained a footing in London on more than one occasion, and in connection with these occurrences, attempts were made to protect, by means of vaccination, children who might possibly have been in contact with sufferers from the disease. This offer of vaccination was, as a rule, gladly accepted by the parents and no cases of conscientious objection were met with. Reference is made on p. 44 to the prevalences of influenza occurring during the year in relation to their effect upon the schools. The mortality during the prevalence of November and December, in the population generally, was phenomenally high and there can be little doubt that the wholly exceptional conditions prevailing in the great centres of civilisation were contributory to this. In last year's report the effects in promoting spread of measles and scarlet fever of crowding in underground places 25 of shelter during air raids were considered. Fortunately the special opportunities for continuing these observations no longer occur, but there can be no doubt that among the factors contributing to the phenomenal spread and fatality of influenza during 1918 in London, congestion and crowding, such as for example have prevailed in tube railways, have played a part. Study has been made during the last 8 years of the flea hypothesis of causation of scarlet fever. The conclusions reached were set out in last year's report. During 1918, however, it has been necessary to consider further a criticism which has been made. Thus, it has been urged that the incidence of scarlet fever is in some instances greater upon well-to-do than upon poor populations ; this contention is undoubtedly justified at certain times and in certain places, but it is not generally true. The opportunity has been taken to assess, as accurately as may be, the qualifications and limitations to be put upon such a statement, and incidentally the influences exerted by age incidence, school attendance, movement of population and the protection afforded by previous attack have been carefully considered. The results of this enquiry have been illustrated diagrammatically and are set out on pp. 45-48 and in diagrams A and B. It may be stated broadly that the facts thus summarised strengthen rather than militate against the flea hypothesis, but it needs to be borne in mind that the children in the slums are attacked as a rule at an early age, and that when the disease spreads to the surrounding areas the latter may present the appearance of suffering more heavily from the disease, the poor areas having purchased comparative immunity at the price of earlier exposure. The results of medical inspection. Number of children inspected. The inspection in detail of entrant infants was resumed in the autumn term of 1917, and continued throughout 1918. Full facilities for inspection were therefore provided for all entrants and leavers, and, in addition, for the inspection of all elementary school children at the age of eight. 206,938 children were inspected in the age groups in the elementary schools, 1,579 in the special schools, and, in addition, 47,114 children not in the age groups were officially examined, owing to some indication of ill health noticed by teachers, school nurses, or care committee workers, or were submitted for examination by the attendance officers on account of absence from school. The total number of children inspected during 1918 was therefore, 255,631, as compared with 283,185 in 1917. The detailed results are shown in tables A and B, pp. 53 and 54. Attendance of parents at inspection. The percentage of parents attending at routine inspections as in tne previous year, was 56. The greater solicitude felt by the parents for the entrant infants was again manifest, as the percentage o1 parents attending in the case of these was over 70. The least concern was shown for leaving boys to the examination of whom only 36 per cent. of parents came. Number of chi dren referred for treatment. The proportion of children inspected who require medical attention in one form or another remains very high. At routine inspections advice cards were issued to 91,474 children, or 44 per cent. of those examined by the doctors. This percentage is higher than in the previous year, but this, to some extent, is explained by the fact that during the first part of 1917, entrant infants were not all examined in detail and many defects therefore were not detected. The comparative figures given in the accompanying tables are worthy of careful study. They are percentages worked out for each year of the results of the examination of more than 200,000 children in the age groups. They refer to those index conditions which are most affected by economic changes in the life of the people, and they tell the story of the war as reflected in the condition of the elementary school children of London. The story is one of which London may be proud, for it is one of continuous amelioration throughout the whole period of the war. Whether judged from the state of the children's clothing, from their health as expressed by their nutritional well-being or from the conditions found as regards cleanliness, the result is the same, practically steady improvement in each particular. ENTRANT INFANTS. Clothing and Footgear. Nutrition. Cleanliness (Body). Cleanliness (Head). Year. Good. Fair. Poor. Excellent normal. Subnor mal. 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 1914 56.3 40.4 3.3 31.2 60.7 8.1 88.0 11.6 0.4 81.7 17.3 1915 57.8 39.9 2.3 32.1 62.4 5.4 90.0 9.7 0.3 82.0 17.2 *1917 55.7 42.2 2.1 31.1 64.1 4.8 90.0 9.8 0.2 82.9 16.3 1918 58.0 40.3 1.7 31.4 63.9 4.7 92.9 7.0 0.1 89.7 9.8 0.4 Girls 1913 55.1 42.3 2.6 32.7 57.5 9.0 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 1918 57.5 40.9 1.6 31.3 64.3 4.4 79.6 19.8 0.6 88.6 10.9 0.5 * The figures for 1917 are for the third term only, when inspection of entrants in detail was resumed after its discontinuance in 1916. 50129 D 26 INTERMEDIATE AGE GROUP (aged 8). Clothing and Footgear. Nutrition. Cleanliness (Head). Cleanliness (Body). Year. Good. Fair. Poor. Excellent Normal. Subnor mal. Clean. Nits. Verminous. Clean. Dirty. Verminous. Boys 1913 47.5 45.4 7.1 22.0 62.2 15.8 87.1 12.3 0.6 72.0 25.1 2.9 1914 47.8 45.9 6.3 19.9 70.1 10.0 86.9 12.6 0.5 75.3 22.9 1.8 1915 51.4 44.6 4.0 21.1 69.8 9.1 88.4 11.4 0.2 76.6 22.0 1.4 1916 52.4 44.1 3.5 23.6 67.0 9.4 89.2 10.6 0.2 79.3 19.7 1.0 1917 51.7 44.8 3.5 20.9 70.6 8.5 89.4 10.4 0.2 79.8 19.1 1.1 1918 51.3 45.6 3.1 19.7 73.1 7.2 91.6 8.3 0.1 85.6 13.8 0.8 Girls 1913 51.4 43.9 4.7 25.1 61.4 13.5 67.3 30.3 2.4 73.7 24.2 2.1 1914 51.6 45.0 3.4 22.8 68.2 9.0 66.3 31.6 2.1 77.8 20.8 1.4 1915 55.0 43.0 2.0 23.3 69.0 7.7 69.2 29.4 1.4 77.6 21.4 1.0 1916 55.6 42.8 1.6 26.4 65.6 8.0 68.8 29.9 1.3 80.5 18.8 0.7 1917 53.5 44.3 2.2 22.3 70.2 7.5 68.8 29.9 1.3 80.9 18.3 0.8 1918 54.5 43.7 1.8 21.3 72.2 6.5 71.3 27.8 0.9 85.4 14.0 0.6 LEAVERS (aged 12). Boys 1913 49.1 45.4 5.5 26.4 58.9 14.7 87.3 12.3 0.4 73.1 24.3 2.6 1914 52.6 41.9 5.5 26.4 61.1 12.5 88.5 11.2 0.3 75.1 23.0 1.9 1915 52.5 43.4 4.1 29.0 63.8 7.2 90.9 8.9 0.2 77.9 20.9 1.2 1916 54.3 42.2 3.5 29.4 63.8 6.8 90.6 9.2 0.2 79.2 19.8 1.0 1917 51.1 45.1 3.8 27.1 66.7 6.2 90.7 9.2 0.1 79.2 19.5 1.3 1918 51.2 45.2 3.6 25.2 69.5 5.3 91.8 8.1 0.1 84.0 15.2 0.8 Girls 1913 51.8 44.8 3.4 30.6 55.1 14.3 67.2 30.4 2.4 74.8 23.1 2.1 1914 55.9 40.8 3.3 29.9 58.6 11.5 68.8 29.3 1.9 78.0 20.7 1.3 1915 58.2 40.1 1.7 32.8 60.9 6.3 72.6 26.2 1.2 80.7 18.5 0.8 1916 58.9 39.8 1.3 31.4 62.3 6.3 70.8 28.1 1.1 81.7 17.8 0.5 1917 55.3 43.3 1.4 28.5 65.2 6.3 70.2 28.7 1.1 81.7 17.6 0.7 1918 54.6 43.7 1.7 26.9 67.8 5.3 72.8 26.4 08.1 85.3 14.2 0.5 Clothing and Footgear. Insufficiency of clothing fell continuously throughout the war until in 1918 the number of children found insufficiently clad was less than half the number discovered in 1913. The infants and the girls are always found to be better clad than the boys. A larger percentage of especially well clad children of both sexes and at all ages was found in 1915 and 1916 than in the years preceding and following. There was a tendency in those years for surplus wages to be expended in clothing for the children, but with increasing prices in the last two years of the war. it is clear that expenditure on clothing gave place to expenditure on food. Nutrition. In both sexes and at all ages there was a continuous decline in the percentage of children returned as poorly nourished and in each section the number of such children was in 1918 less than half the number found in 1913. The entrant infants continue to be better nourished than their elder brothers and sisters. The extremely close correspondence of the figures for the infants in the third term of 1917 with the figures for 1918 is noteworthy. Although the reduction in the percentage of poorly nourished children is a striking fact, it should be noted that there was also a general reduction, though of smaller dimensions, in the number of children especially well nourished. The main increase was therefore in the middle group comprising those with normal nutrition. The effect of the war is thus seen to have been an equalising one; to this no doubt rationing, voluntary and compulsory, contributed and the result is a testimony to the wisdom and fairness of the arrangements made in this country, which resulted in an equitable distribution of the available supplies of the more important food stuffs to all sections of the population. Cleanliness. In 1917 there was a disappointing check to the progress which had been made year by year in the condition of the cleanliness of the children. The percentages in each group remained almost identical with those found in 1916. The work of the school nurses was greatly increased owing to the repeated subjection of families to infestation by lice through return of men on leave from the front; there was also a very serious outbreak of scabies which overwhelmed the cleansing stations and prevented the nurses from paying so much attention as would otherwise have been possible to the other parasitic conditions. Much concern was expressed and much attention was given by the children's care sub-committee to this state of affairs. By the introduction of special measures, combined with a timely increase in the number of the nurses, these difficulties were in part overcome; and it is especially encouraging to be able to record that progress in this respect is being resumed. From the results which are given in the table it is seen that the leeway has been made up and a greater improvement has taken place between 1917 and 1918 than in any preceding year. Whether entrants, middle-age group, or leavers, whether boys or girls are concerned, and whether judged by the state of the hair or the clothing, the conditions as regards cleanliness are better than ever attained before. It is, of course, far from satisfactory that 27 per cent. of the girls in the schools should present traces, however slight, of infestation by lice; but while a substantial reduction has been effected this 27 year in the number of girls found with nits in the hair, the percentage attending school in a condition in which live vermin were to be found has in 1918, for the first time, been reduced to below one per cent. As for boys, the number has been reduced so far as the hair is concerned, to one in a thousand ; the percentage of boys found with verminous clothing has been almost halved and for the first time less than one per cent, are reported to be in this state. Condition of the teeth. It has been pointed out in previous reports that the continuous increase in the provision under the Council's scheme of facilities for dental treatment, has produced in London an appreciable amount of improvement in the condition of the children's teeth, when examined at the oldest age group. The percentages of children found during 1918 with severe caries and oral sepsis were : entrant boys, 19.9; entrant girls, 19.3; eight year old boys, 19.3 ; eight year old girls, 18.8 ; twelve year old boys, 7.3; twelve year old girls, 6.9. The corresponding figures over a series of years for the leaver group of children are as follows:—Boys, 1913, 10 per cent; 1914, 9.2 per cent.; 1915, 7.2 per cent.; 1916, 6.5 per cent.; 1917, 6.2 per cent. Girls, 1913, 8.6 per cent.; 1914, 7.7 per cent; 1915, 6.7 per cent.; 1916, 5.8 per cent.; 1917, 5.5 per cent. The results therefore are not so good in 1918 as in the years immediately preceding ; during the war it has been found progressively more difficult to persuade parents to have the necessary attention paid to the condition of the children's teeth. On the whole, girls are found to have better teeth than the boys; it is much easier to persuade a girl to clean her teeth regularly than it is to persuade a boy. When slighter cases of dental caries are added to the severe cases mentioned above, the vast amount of dental defect that exists becomes manifest. Fifty-five per cent, of infants when they enter school already have manifest caries; 60 per cent, of the eight year old group and 50 per cent, of the twelve year old children are in like case. By the use of mirror and probe for examination in the hands of a skilled dentist these figures, large as they are would be still further increased. In sheer bulk therefore, the problem of dental hygiene remains the most important of all the problems to be solved in relation to the health of the children. Nose and throat diseases. The percentage of children referred for treatment for enlarged tonsils and adenoid growths again showed a slight increase during 1918. Amongst the eight year olds 6.8 per cent. of the boys and 6.4 per cent. of the girls, and amongst the leavers 4.1 per cent. of the boys and 4.3 per cent. of the girls were so referred. Although higher than the percentages for 1916, which were the lowest on record, these figures are much lower than they were in earlier years, and the reduction is greater in the case of the older children than the younger, showing that the improvement is largely due to the facilities for treatment which the Council has instituted. In this respect reference may be made to the results of a model inspection of town and country children, set out by Sir George Newman in his annual report. In that investigation, 5.5 per cent. of the London children were found to have enlarged tonsils and adenoid growths, while 20.5 per cent. of the country children presented these conditions. This difference, it was suggested, was largely due to the facilities for treatment provided in London, which were wanting in the country. Further evidence of the difference between London and country children in this respect is to be found in a comparison of the figures for London with those for Lancashire as given by Dr. John Priestley. In the latter county over 30 per cent, of leavers were found to have enlarged tonsils, whereas for London the percentage is 10. Bar disease and hearing step by step with the reduction of the percentages of children found with unhealthy conditions of the throat, there has been a corresponding decrease in the percentages of those found with discharging ears and hardness of hearing. At the routine inspections 2.4 per cent. of the entrants, 2.0 per cent. of the eight year olds and 1.9 per cent. of the twelve year olds are found with discharging ears, while .9 per cent, of entrants, 1.3 per cent. of eight year olds and 1.4 per cent. of leavers are reported to be hard of hearing. It is probable that if more time were available and the school doctors were able in each case to apply special tests for hearing, the numbers last quoted would be greater. It is remarkable how many intelligent children are able to hide from their nearest associates the fact that they are hard of hearing and are considered even by their parents and teachers to be peculiar or dull. In the investigation into the physical condition of town and country children quoted above, as the result of particularly careful individual tests, it was found that 8 per cent, of London children had less than one half of normal hearing. Vision. The higher percentage of girls with defective vision as compared with boys, remains most marked. The fact that the difference is greater at the leaver age than it is at the eight year old age, once more directs attention to the causes which lead to deterioration of vision during school life and particularly to those conditions which press more heavily upon the girls. Amongst these no doubt is to be included the practice of sewing classes in school being held in the late afternoon, while the light is at its worst, necessitating in the winter months the use of artificial lighting. While the percentage of children failing to reach normal vision with each eye tested separately at eight years of age (62 in the case of boys and 65 in the case of girls) remains practically identical with that found in the previous year, there is a slight improvement in the twelve year old group, in which the percentages were 47.4 in the case of boys and 53.2 in the case of girls, as compared with 49 and 54.6 respectively in 1917. Even these high percentages do not tell the whole story as children with serious short sight are transferred to special schools and children whose vision is corrected by glasses are not counted as defective. Squint and external eye diseases. The percentage ol children with external eye disease or squint remained the same as in the previous year as regards the two other age groups, but was distinctly higher in the case of entrant infants. In general it may be stated that though abundant evidence is forthcoming that, owing to the greater care and attention paid to children of school age, an appreciable amelioration of their condition is to be found, the entrant children do not show a corresponding improvement. 50129 d2 28 With regard to squint, Mr. Bishop Harman found a year or two ago that 2 per cent. of good class elementary school children squinted, that squint was twice as common in girls as in boys and was commoner amongst infants than older children. Heart defects and anæmia. The percentages of defects of the heart, functional and organic, recorded during the year are in all respects similar to those of the previous year, but the percentage of children found with anæmia is fractionally less. The heavier incidence of these conditions upon the older girls as compared with boys, in again emphasised : boys, heart defects, 3.4 per cent; anæmia, 3 per cent. ; girls, heart defects, 4.6 per cent., anaemia 4 per cent. This difference, repeated year after year, calls for insistent warning that the conditions under which the girls are brought up, lack something that is enjoyed by the boys. It is the more striking when it is considered that difference in the incidence of heart defect between boys and girls does not exist in the eight year old group, and is therefore developed during four years of school life. There can be no doubt that the effect is due to the denial of opportunities to the girls which are open to boys for participating in outdoor games and sports. " She grows as a flower does,—she will " wither without sun; she will decay in her sheath, as a narcissus will, if you do not give her air enough." Lung diseases. There was a notable increase in the number of children found with lung complaints ; 5.2 per cent. was recorded as against 4.0 per cent. in the previous year. The explanation no doubt is to be sought in the widespread prevalences of influenza which occurred in the summer and autumn. By far the heaviest incidence was upon entrant infants, nearly eight per cent. of all those examined being found with some degree of lung trouble. Tuberculosis The percentage of children found suffering from phthisis and other forms of tuberculosis remains low, 0.16 per cent. from phthisis, or less than two in a thousand, and rather more than two in a thousand From other forms of tubercular disease. During 1917 the number of cases of phthisis found was 0.13 per cent., but the difference in the two years is not more than might be explained on accidental grounds, rhe cases are equally distributed over all ages and in both rexes. Nervous diseases. Diseases of the nervous system were recorded in 1.2 per cent., as compared with 1 per cent. in 1917, the girls showing more nervous defect than the boys. There is here little confirmation of the nervous fears of some that the children have been subjected to greatly excessive strain owing to war conditions. Dr. Chaikip, the acting di visional medical officer in the East End of London made throughout the year a careful study of all school children nominated for special examination at inspection centres, with the object of determining the proportion of children who were seriously affected by the effects of hostile air raids. Out of a total of 1,707 special cases, only 66 were of a nervous character and of these only 12 were attributable to air raids. In particular he notes the case of one child whose hair was turning grey from nervous shock. Stammering children. The number of children found to stammer amongst the eight year old group was 64 boys and 33 girls (.20 per cent. and .10 per cent. respectively), amongst the leavers there were 152 boys and 46 girls (.47 per cent. and .14 per cent. respectively). The number of boys in the earlier age group suffering from other speech defects was 178 and girls 94 (.56 and .30 per cent.) and at the later age boys 109 and girls 82 (.34 and .24 per cent.) In previous reports 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 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 experimental class in remedial exercises for stammering children attending elementary schools has been conducted under the auspices of the Westminster Health Society at Greek Street, Soho. Rheumatism Rheumatism is not separately taken out and recorded in statistical form, but Dr. Kerr, the Council's Research Medical Officer, has analysed a special enquiry made some time ago by the school doctors, with a view to the detection of rheumatic signs. Returns were obtained relating to 3,286 children. 336 were considered to be definitely subjects of rheumatic conditions, or ten per cent. The incidence appeared to double in intensity during school life, increasing from 7 per cent. at age seven to 13 per cent. at age thirteen. Rickets anc other deformities. Exactly twice as many infant boys as girls admitted to school presented signs ot rickety deformities, the percentage being 3.1 in the case of boys and 1.6 in the case of girls. The number of children in whom specific rickety defects are noted, rapidly declines during school life, but no doubt many cases of stunted growth in after life are due to rickets, although the specific signs of that disease may have quite disappeared. Deformities, other than rickety, on the other hand show an increase during school life, especially affecting the girls between eight and twelve years. 2.8 per cent. of leaver girls were recorded as presenting such deformities, as against 1.8 per cent. of boys. Attention is thus again directed to the conditions mentioned above under the heading of heart defects and anæmia. Physical condition of mentally defective children. Attention last year was drawn to the greater incidence of many of the more serious detects upon the children in the schools for the mentally defective. This is again strikingly brought out in this year's returns. Thus external diseases of the eyes are twice as common amongst the mentally defective as amongst the normal children ; the percentage of mentally defective with good vision is less than half that of normal children; disease of the ears is one and a half times as common in the mentally defective and hardness of hearing four times as frequent. The special incidence upon the children classed as mentally defective of defects of the sense organs raises the question whether, if these defects could be prevented, fewer children would need to be relegated to the special schools. 29 special examinations of children at Minor Ailments Centres. The school doctors have attended at twenty-four 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 workers, teachers, school nurses and attendance officers, with a view to securing that any necessary action should be taken 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 seen in this way during the year was 6,527, and the conditions found as a result of the examinations were as follows :— Conditions of skin (3,286) including scabies, impetigo, eczema, septic wounds, etc.; conditions of the eye (725), conjunctivitis, blepharitis, corneal ulcers, etc.; conditions of ear, nose and throat (1,019) otorrhcea, enlarged glands, tonsils, adenoids; conditions of teeth (89); other cases (937), including mumps, anaemia, tubercular diseases, lung defects, etc. Children out of school for long periods. The arrangement has continued whereby the attendance branch of the Education Officer s department submits each month to the school medical officer, medical certificates concerning all children out of school for a period of 3 months on account of ill-health. The total number of children who were thus reported as absent from school on the 1st November, 1918, was 2,487 as compared with 2,311 for the corresponding month of the previous year. The conditions from which the children were suffering in November, 1918, were as follows:—Rheumatism, including heart disease and chorea 325 (13.07 per cent.), nervous disorders 227 (913 per cent.), tuberculosis 566 (22.76 per cent.), anaemia and debility 180 (7.24 percent), ringworm 136 (5.47 per cent.), diseases of the eyes 179 (7.20 per cent.), other diseases 838 (33.68 per cent.), unsatisfactory certificates 36 (1.45 per cent.) As pointed out in last year's report, the premier place is now taken by tuberculosis, which shows an increase of 101 or 21.72 per cent., as compared with the figures for November, 1917. This increase is no doubt due to the extended care and attention now being given to tuberculosis, whereby a larger number of children suffering from this condition are discovered. All cases of tuberculosis and epilepsy are still being registered, and apparently unsatisfactory or doubtful conditions are being followed up, especially such for example as ringworm, scabies, and minor ailments. Medical and Dental Treatment. There is again a considerable increase to be recorded in the provision made for medical and dental treatment. The centres, including hospitals, open and at work on 31st December, 1918, numbered 54, and provided for the treatment of 160,070 cases, viz., eyes 28,760; ear, nose and throat 12,610; ringworm 2,050; minor ailments 29,970; and teeth 86,680. The most marked increase is in the provision for minor ailments and dental defect and the proposed arrangements for the year 1919-20 further raises the numbers for minor ailments and for teeth to 37,840 and 100,980 respectively. Defective Vision.—The number of children dealt with under the Council's arrangements was 27,200 or 138 more than in 1917. Spectacles were prescribed for 20,668 children, and 16,716 children obtained spectacles. Ear, Nose and Throat Defects.—For several years past the number of children requiring treatment has steadily decreased. During 1918, however, there was an increase of 1,532 over the 1917 figures, the total number receiving treatment being 10,907. In the last annual report, it was noted that the decrease in that year was not due to the lower number found on inspection to require treatment, but to the difficulties of following up the cases and the cessation of other facilities for treatment. Apparently, therefore, the higher numbers receiving treatment in 1918 are due to improvement in following up. Ringworm.—1,602 children were referred to the Council's centres, as compared with 1,284 during 1917. 1,280 children received X-ray treatment. Minor Ailments.—35,423 children received treatment for minor ailments at 32 centres, or 7,292 more than the previous year. The new cases, together with those imder treatment at the beginning of the year made 651,982 attendances. The visits paid by the nurses to the children's homes numbered 18,515, and in 1,399 cases arrangements were made for convalescent treatment or other forms of aftercare. Dental treatment. Dental Treatment.—Mr. C. Edward Wallis reports that in spite of many difficulties contingen upon the war the number of dental centres in London has increased from 38 to 43, affording provisio at the end of the year for about 90,000 new cases annually, and as six further centres are authorise by the Board of Education for the year 1919 there will shortly be provision for some 101,000 cases. The results of dental treatment for the year 1918 are as follows :— Total number of children attended 68,445 Number of attendances 107,472 Number of teeth or roots extracted— Temporary 254,215 Permanent 29,726 Number of stoppings 51,496 Number of other operations, e.g., scaling, immediate regulation, application of Ag NO:l, etc. 12,881 Number of general anaesthetics— Nitrous oxide 14,062 Ethyl chloride 13,834 Other general anaesthetics . 1,060 The principle underlying the scheme of school dental treatment in elementary schools as carried out in London is that prevention and treatment should be developed side by side. Thus the dental inspection sessions, which are held at the schools themselves, are utilised not only for instructing such parents as attend, but also for instructing elder children in the care of the teeth. Mr. Wallis refers to the preventive methods in use in Bridgeport, Connecticut, in which city specially trained dental nurses go from school to school and it is claimed that as a result the incidence of dental decay has appreciably diminished. If difficulty were experienced in London in obtaining a sufficient number of suitably qualified dentists, it might be necessary to consider whether such a scheme should be applied in the county. 30 Sale of tooth brushes, etc. In addition to the routine work of dental inspection and treatment carried out in London, arrangements have been made for supplying at cost price tooth brushes, tubes of tooth paste and small tablets of permanganate of potassium for making an antiseptic mouth wash when required. Selection of age groups for dental inspection and treatment. It is becoming generally recognised that the age group 6.8 is really too advanced and that the earliest age possible should be selected if the temporary teeth are to be kept healthy and the permanent teeth treated on the first sign of caries; first permanent molars erupted at 5 to 5½ may be already extensively carious by the time the child is dentally inspected at perhaps 6 to 7 years of age. Secondary schools. Reference is made on page 31 to the arrangements under section 18 of the Education Act, 1918, for the inspection and treatment of scholarship holders in secondary and trade schools. Physically defective children. a scheme has been prepared for treating these children at the dental centres, ana careful regulations have been drawn up to ensure that each child is thoroughly examined before any dental treatment or administration of an anaesthetic takes place. It is intended that each child shall be conveyed to and from the dental centres in one of the Council's ambulances accompanied by the school nurse. The supply of dentists. Difficulty was experienced in 1918 in obtaining experienced dentists to replace those called up for naval or military service. The success of a dental centre is of course largely dependent upon the dentists engaged. Frequent changes of dentist are undesirable, and though for the successful working of a centre the question of the annual renewal of the appointments is considered by the Council, it is, as a general rule, the practice to reappoint the dentist if possible. Dental scholarships. With a view to increasing the supply of dentists for school dental work a letter has been sent to head teachers of secondary girls' schools pointing out the suitability of this work for women and its advantages as a career for them. The use of scholarships for the purpose should ultimately lead to an increase of available trained dentists. Dental anaesthetics The use of ethyl chloride for dental anaesthesia continues to give great satisfaction, and though nearly 14,000 administrations have taken place during the last few years, no cause for alarm of any kind has occurred ; the gain in duration of anaesthesia is such that practically every case is finished at one sitting, and this is not possible when nitrous oxide is used. The disadvantages of ethyl chloride in skilled hands may be regarded as almost negligible ; there is merely a tendency to sickness which is preventable by proper preparation beforehand ; moreover, recovery from the anaesthetic is somewhat more protracted than is the case with nitrous oxide. Owing to the growing proportion of older children now attending the centres the original fortnightly anaesthetic session has proved insufficient and additional anaesthetic sessions will be needed in future. Unregistered and unqualified dental practitioners. A special investigation was carried out by Mr. Walls at the Stockwell Practising School where some of the parents were known to have been attracted by the advertisements of dental companies trading in the South London District. Out of 87 girls at this school who received dental treatment, as the result of recommendations by the school inspecting doctors. 48 per cent. were treated by qualified and registered dentists, 12 per cent. were treated at hospitals, and 40 per cent. went to unqualified and unregistered practitioners. All the above were inspected with a dental probe and mirror, and it was found that while the 40 per cent, who had been treated by unregistered dentists had been mulcted in fees often in considerable excess of those charged by the properly qualified dentists, the quality of the stopping work done was shameful to a degree and many children declared that their stoppings fell out soon afterwards. Oral sepsis, too, had been passed over as of no account, and where the extractions required presented any considerable difficulty the teeth were either broken or left in situ with their pulp chambers open and full of septic material, leading to the infection of glands of the neck and general toxasmia. Another serious result of treatment of this kind is that children have been so frightened that great difficulty arises in persuading them to have their teeth attended to again. The children referred to were as a rule of 13 and 14 years of age, and therefore at that time, not admissible under the Council's dental scheme. A certain proportion had, however, obtained treatment at the Stockwell Centre and the condition of their teeth was in strong contrast with that of those treated by unregistered Welfare centres (mothers and infants). An important development of the Council's Dental scheme has been its association with the work of Infant and Mothers Welfare Centres in various parts of London. Although the Council is not in any way responsible for the dental work performed on others than school children, the mutual association brought about by the use of the school treatment centres by the welfare centres is of great advantage to both parties. A good example of this association is to be seen at the Lissonia Centre, where on one weekly session, mothers and infants are seen and treated, the Council allowing the use of the dental equipment for these cases. The serious state of oral sepsis of many of the expectant and nursing mothers calls for extensive extraction operations upon septic and necrosed unsaveable teeth and roots. At this welfare centre a small charge is made by the Committee for all work done, and where provision of dentures is undertaken the necessary fee is arranged for by a system of instalments. Medical and dental treatment— General. The total number of children attending treatment centres as new cases during the year was 143,539. The returns of numbers treated are less than were expected mainly owing to the air raid menace in the early part of the year, and later to the influenza epidemics. It may be mentioned that the numbers fell below the weekly averages of the year to the following extent in certain periods :— January 26th (2 weeks) 409 ; February 9th (2 weeks) 275 ; April 20th (2 week's) 243 ; July 7th (2 weeks) 219; November 23rd (4 weeks) 891, the figures stated representing the average defect each week. The maximum intensity of the influenza epidemic is clearly reflected in the low numbers for the period ended November 23rd. 31 It has been necessary for the Council as the result of representations from the contracting authorities concerned to increase the payments made in respect of the services of dentists and nursing associations and to make special allowances for rent and drugs. It is estimated that the increased cost under these heads during the forthcoming year will be about £2,500. Education Act, 1918. Section 18 of the Education Act, 1918, extends the powers and duties of the Council in regard to medical inspection and treatment to include children and young persons attending secondary schools maintained by the Council. The Council already makes provision for the medical inspection of pupils in secondary and trade schools, and it is not proposed at present to vary the existing arrangements in this respect. With regard to treatment, it has been a condition of the award of the Council's scholarships that any defects from which scholars may be suffering shall be remedied before the scholarships are taken up. A large number of the pupils, however, are found to require some dental treatment during the tenure of their scholarships. Some also require their vision corrected, and a few need attention for ear, nose and throat defects. The extent to which it is found impracticable to obtain medical treatment for scholarship children under existing conditions varies very much in different schools, but from particulars which have been ascertained it is clear that this difficulty is acutely felt in some instances at the present time. It has, therefore, been decided that in future the scholarship holders in secondary and trade schools shall, if unable to obtain treatment privately, be eligible for treatment at the hospitals and treatment centres at which special arrangements have been made under the scheme hitherto restricted to children attending public elementary schools. The Council has also decided that the scheme for dental inspection of the children shall be applied to the secondary and trade schools. Reinspection of children noted as requiring treatment. The measure of success of the Council's schemes for following up and securing treatment of the children found at inspection to be ailing, is given by the results of reinspection. The primary inspection is a point in time, but the remedial action is a process which takes a considerable time to complete. It is therefore difficult to present the actual position at any given moment in the form of a balance sheet. What can be done is to give the proportion of ailing children whose treatment has commenced at given dates after the first discovery of their defects. During the year, 199,114 reinspection reports were made upon children previously found to be ailing. 39,307 of these were upon children kept under observation, but not referred for treatment, 97,766 upon children seen six months after their primary inspection and 62,041 upon children already once reinspected, whose condition had not been entirely alleviated at the time of the first reinspection. Detailed figures of the reinspection results are given in Table C on page 55. It was found at first reinspections that 45,479 or 46.5 per cent. of the children in need of treatment had not commenced to receive it after a six months' interval; at the second reinspection roughly half of those previously left over had commenced treatment. The total result of the year's work was that 69 per cent. of those requiring it had been brought under treatment by the time of their second reinspection. This is an improvement upon the results in 1917, when the corresponding percentage was 67.6. Quite half the cases under consideration, however, relate to children with dental defects discovered by the school doctor. And it is precisely these cases which fail to obtain treatment in the highest degree. It must be remembered that adequate provision has never yet existed for the treatment of the mass of dental defect presented by the children in elementary schools and that the dental centres under the plan laid down by the Board of Education deal when they are first opened with children within specified age limits examined by the school dentists and only to a minor degree with the cases found to require treatment by the school doctors. If the dental figures be taken out, the results of following up are correspondingly improved, for in all other classes of defect, more adequate facilities for treatment are provided and perhaps less disinclination to undergo the ordeal of treatment exists. That the last mentioned factor is one to be reckoned with is shown by the fact that the next class of ailments in order of " leakage " is that in which operations for enlarged tonsils and adenoids are concerned. It has always been the Council's policy not to press for treatment to the point of prosecution in ordinary cases where an operation is involved. The considerations involved are of course, very complex, but in the long run education and persuasion are more likely to be effectual than more Draconian methods. Evidence is available which shows that the parents are now readier to receive and act upon the advice of the school doctor than was the case a few years ago, and a harsh and threatening spirit would destroy the growing trust of the parents. Following up. In last year's annual report some account was given of the measures adopted to combat the falling off in the percentage of children who had obtained the necessary medical treatment for ailments found on inspection. In a few specially selected schools, arrangements had been made for the school nurse to undertake the following-up of cases until treatment was obtained. The thirty-seven schools in question were those in special need of attention owing to the lack of voluntary workers, and these schools have derived very great benefit from the assistance afforded by the Council's nurses. At the close of the Summer term, 1918, a report was presented to the Central Care Committee in the following terms :— The re-inspection for the present term is now nearly completed, and the returns to hand for these 37 schools, where 75 per cent, of the children have been re-inspected, show that of 1,319 cases 32 re-inspected 854 cases have received treatment, are receiving treatment, or are no longer in need of it, and 465 cases still remain untreated. Thus 35.3 per cent. of the cases at these schools are outstanding. The corresponding percentage for last term for the whole of London was 47.1. The greatly improved result for the 37 schools is highly satisfactory, more especially when it is borne in mind that most of these schools previously had an abnormally high percentage of untreated cases. The exceptionally good results obtained in particular schools are deserving of note. Thus at Addington-street the precentage of outstanding cases in the last term of 1917 was 70.9, and this has now been reduced to 16.3. The corresponding figures at Warple-way are 55.5, reduced to 14.3 ; at Arthur-street 70.1, reduced to 25.0 ; and at St. Leonard's-road 50.0, reduced to 14.3, The treatment results obtained in the last term of 1918 in the selected schools, compared with London for the whole year, may be stated as follows:— London, per cent. Selected schools, per cent. Cases completed at first re-inspection 36.9 47.8 Cases completed at second reinspection 32.1 31.2 Total percentage of completed cases 69.0 79.0 Thus not only did more children ultimately obtain treatment in the selected schools, but a higher proportion had already obtained that treatment antecedent to the first reinspection. The total number of home visits paid during the whole year, by the nurses concerned with Johanna-street and Warple-way, were no fewer than 715 and 947 respectively, and as a result the large majority of the outstanding cases were reported as cured. With a view to obtaining additional voluntary workers for various parts of London, in which the following-up difficulty was acute, the Council on the 30th July, 1918, appointed 12 temporary assistant organisers for recruiting purposes. Education (Provision of Meals) Act. Supervision of dietaries. The arrangements set out in previous reports for the supervision of dietaries have continued throughout the year. The total samples of milk examined amounted to 849. Of this number 260 (30.6 per cent.) were found to be unsatisfactory, 205 by reason of the addition of water and 55 owing to removal of fat (skimming). A noticeable feature with regard to the unsatisfactory samples was that 64 per cent. were received during the first three months (January—March) a period not usually associated with low quality milk. The least satisfactory samples were received during February last when nearly 92 per cent. of the samples examined contained added water ; in nearly half these cases the addition of water exceeded 10 percent. and in one case reached 37 per cent. After the first quarter of the vear the quality of the milk supply generally improved, until in October less than 3 per cent. of the samples were found to be unsatisfactory. In each case in which 3 per cent. of added water or abstraction of fat is indicated by the result of analysis, the Medical Officer of the Borough concerned is communicated with and prosecutions under the Sale of Foods and Drugs Act have resulted and convictions have been obtained. Of 27 samples of meals, other than milk meals, supplied to necessitous children, only two were 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. Tuberculosis. During 1918 the Council increased from 231 to 300 the number of sanatorium and hospital beds for children paid for by the Council in voluntary institutions, and continued the authority for the acceptance of beds available in Metropolitan Asylums Board institutions. On the 1st January, 1918, 186 boys and 185 girls were under treatment in residential institutions and 393 boys and 373 girls were sent away during the year. The total number treated during 1918 was therefore 1,137. In addition, through the Invalid's Children's Aid Association, with financial assistance from the Council, 686 children were treated in convalescent homes, the average number of beds in occupation at one time being 271. The Council further continued during the year the assistance given during 1917 in respect of the day sanatoria attached to certain of the tuberculosis dispensaries. This assistance took the form of the supply of a teacher and the necessary educational equipment. The work carried out under the tuberculosis scheme of the Council is dealt with in detail in Part I. of this report; it may be stated here that further provision of day schools for tuberculous children is being made. Open Air Schools. Birley House and Shooter's Hill. 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. These 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, although difficulty was experienced in connection with the dietary and the regularity of attendance was affected by the outbreaks of influenza and difficulties in travelling. Many 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. Kensal House School. The school has been under the regular supervision of Dr. R. S. W alker, who is also the medical officer of the Paddington Tuberculosis Dispensary from which the children are mainly drawn. The number of children on the roll on the 1st January was 91, and on the 31st December, 102; the average 33 for the year was 98. As noted in previous reports there was a marked variation in the average attendance from month to month, the lowest being 65 in October, when there was an epidemic of influenza, and the highest 84 in September. During the year 28 children left the school, of these 9 were returned to ordinary elementary schools, 8 were excused from attendance after attaining the age of 14 years, (3 left the district, 2 went to a sanatorium and 3, two of whom were sent to hospital, were excluded by the medical officer on medical grounds. Careful measurements were taken and the children who attended throughout, the whole year gained considerably in weight. Playground classes. During the year two classes of type " A, 36 of type "C, and 20 of type "D,' were conducted. Particulars in regard to these different types have been set out in previous reports. Of the 58 classes, 10 were held in parks or open spaces and the remainder in school playgrounds. Detailed reports have been received from assistant medical officers upon 21 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 home in mind when comparisons are made between the progress physically and mentally of the children in the playground classes and those remaining in the ordinary classrooms. The unanimity of the doctors in reporting general improvement ir colour and nutrition is complete evidence of the value of the arrangements made, and clearly shows 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 stimuli are found in all the reports. The times have been very trying and the progress of the children has been affected thereby. Particularly disturbing were the waves of influenza prevalence, although it appears that in the June outbreak the children in the open air classes suffered to a less extent than those in the ordinary classes. It was again noted that the children from the same school who attended classes in parks and open spaces did better than those who merely used the playground, the radiant colouring of the former children when seen at the height of the summer, in spite of the influenza wave, being quite remarkable. Physical measurements of a similar number of children from the same school doing their lessons in the park, in the playground and in the school itself, showed a regular gradation in the weekly increase in weight, the girls attending the class in the park doing best and those meeting in the school doing worst. Unfortunately, although making children blighter and healthier, there are limits to the degree of improvement to be achieved by an open air life. Living in the open air does not itself remove hypertrophied adenoid growths and tonsils, cure discharging ears or turn a mentally deficient into a normal child. It is clear from the reports that hopes that even these miracles might be performed, seem to have been entertained, for some classes were largely composed of children who should properly have been submitted for statutory medical inspection for entrance to schools for the mentally deficient. Such an instance is seen in the case of one school where the criterion of selection for the open air class appeared to consist entirely in backwardness. So many of the children were in reality mentally defective, that Dr. Morrish, while commenting on the excellent physical results, reports that no corresponding mental improvement was noticeable and he was obliged to recommend 15 members of the class for statutory examination. At another playground class it was reported that many defects were present, including squint, defective vision and enlarged tonsils and adenoids, but unfortunately owing to war conditions, there had been a cessation of care committee visiting and these defects were not attended to. Personal Hygiene. The general inspection of children by the school nurses and the application of the Council's schemes for dealing with those found in an unclean or verminous condition or suffering from scabies were continued in 1918. The scheme had been modified in 1917 with a view to speeding up the process of cleansing. The modifications have had the desired effect of bringing pressure to bear in certain cases, but in practice it has been found that the modifications are not sufficiently drastic and further amendments are under consideration. The following figures show the amount of work done: Number of examinations, 1,921,762; number found clean, 1,456,154; number found verminous, 465,608; percentage found verminous, 24.2. 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. The continuance of war conditions accentuated the need for cleansing work. This is evidenced by the increase in the number of children brought to the cleansing stations, the average for the years 1913 to 1916 being 45,711 as compared with 80,755 in 1917 and 95,033 in 1918. There are now 25 cleansing stations and it is hoped during the present year to complete arrangements for opening additional stations in the districts of Old Ford and Shoreditch. The Council has entered into agreements with 16 of the 29 local authorities, including the Cities of London and Westminster, and with two committees for the use of their cleansing stations. In addition the Council has 7 stations of its own. By these means the Council has made provision for cleansing children throughout London, but in Fulham, Hammersmith, Lambeth, Lewisham and Shoreditch, no provision has been made for dealing with adults under the Cleansing of Persons Act by the borough councils concerned. The total number of examinations made by the nurses under the cleansing scheme proper was 516,566 and 13,237 children were found verminous ; of these 4,912 were cleansed by the parents, the remaining children were dealt with at the cleansing stations ; 34,030 cleansings were carried out at the Council's stations and 61,003 at stations of the local sanitary authorities. 50129 E 34 This number is an increase of 14,278 or 17.7 per cent. when compared with the number of 1917. The parents of 117 children were prosecuted and fines varying from 1s. to 10s. with costs, were imposed. Of the total number of children cleansed 2,793 were conveyed by the Council's motor ambulance from outlying schools. The scheme contemplates that at each stage a notice indicating the condition in which the child is found shall be 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. In the annual report for 1914 a table was given showing the action taken in the homes by the local authorities and it was noted that upwards of 10,000 houses were visited and rooms, or bedding, or both were disinfected in more than 2,000 cases. Since the outbreak of war, representations were made by borough medical officers of health that it was impossible to continue to carry out the necessary home visits in a large number of instances, and the practice of sending out notices in cases in which the head alone was verminous was discontinued. The number of home visits has steadily declined, but it is now hoped that the cordial co-operation obtaining between the Council and the borough councils in 1914 will again be fullv re-established, and even further extended. Scabies. Arrangements for bathing children suffering from scabies were continued. The number of cases dealt with was 9,624, an increase of 2,684 over the number for 1917. As in the previous year cases have come under notice of infection in a family subsequent to a visit from a soldier from overseas. All cases in school children have been speedily followed up, and baths were given throughout the summer holidays. The hospitals and treatment centres closely co-operated with the Council, and the card referred to in the annual report for 1917 resulted in expediting the arrival of the children at the cleansing stations and their consequent return to school after the condition had been cured. The need for baths for school children. Up to the present time the Council has been concerned almost exclusively with cure rather than prevention, and the general question of cleanliness apart from infestation by lice has not been specifically dealt with.. The personal habits of the people in relation to cleanliness lie at the roots of national health and well being, and it is now, more than ever before, becoming recognised that the duties of the Council in regard to the personal hygiene of the children in the schools and to the inculcation of the principles of cleanliness generally must be adequately filled. This can only be satisfactorily accomplished if cleansing is regarded as a part of the curriculum of the schools comprising not only precept but practice. It is unfortunately true that adequate provision for maintaining the body in a necessary state of cleanliness does not exist in the homes of the poorer classes, and it may be assumed that a quarter of a million school children in London are brought up in ignorance of and without the possibility of that minimum of attention to hygienic requirements which should now be necessary in every civilised community. In the third week of the Easter term an enquiry was carried out by the Divisional Medical Officers into the condition of cleanliness of school children. Poorer schools were selected from every part of London, and 954 boys and girls were examined and interrogated as to cleanliness and home bathing arrangements. 789 children, or 82.8 per cent., claimed to have a satisfactory bath at least once a week; the remaining 165 (17.2 per cent.) admitted that there were no satisfactory arrangements at home nor did they use the public provision. A more careful examination of the question of adequacy of bathing arrangements in the home, however, revealed that in a large number of cases the above statements made by the children were unreliable. Of the children examined by Dr. Argles in the S.W. division, 89.5 per cent. claimed to have a satisfactory weekly bath, but more than 60 per cent. of the children confessed that only with difficulty was it possible to sit down in the washing tub, and 96 per cent. said that the bath-water was not changed, but was used by all the members of the family one after another. Dr. Lewis in the N.E. division, says the usual thing is for the child to be placed in a tin bath in front of the fire once a week, the whole of the family using the same water, and although they say they " sit down " in the bath, it is unlikely that the bath is large enough for them to be properly washed. Dr. Kidner, too, speaking of the S.E. division, says " there can be no doubt that there is a considerable improvement in cleanliness and also that it is more the rule than the exception for children to have a bath of some sort in their homes at more or less regular intervals. The bath taken is, however, not of a thorough nature, and considerable further improvement would follow the use of public baths." One child out of 200 examined in the East End had a " real" bath at home. Examination of the condition of the children supported the view that the provision in the home for the maintenance of cleanliness was inadequate in a greater number than would be gathered from the replies of the children. Dr. Kidner remarks on the disparity between the subjective replies of the children and the objective facts revealed by examination of their condition. Quite forty per cent, of the children seen were not in a satisfactory state of cleanliness, 33.6 per cent. were found with nits in the hair, and another 3.6 per cent. with live vermin. 30.2 per cent. had unsatisfactory conditions of bodily cleanliness, in addition to 3.2 per cent, whose bodies were verminous. In 39.9 per cent, the underclothing was in an unsatisfactory condition ; in 32.4 per cent. there were flea marks on the underclothing, and in 23 per cent. lice were seen. The provision of bathing accommodation in connection with the building of public elementary schools has been advocated. The Board of Education have in their official reports signified their sympathetic approval of the establishment of such provision, and the Council has had before it reports of the officers on the subject. Although the special schools of the Council are pretty generally 35 equipped with bathing facilities no provision exists in the elementary schools except in one or two accidental, and, in practice, negligible cases. Under the Public Baths and Washhouses Act, 27 local sanitary authorities in London have installed 3,344 baths at 51 centres. In 1914, two members of the Education Committee (Miss Mary Beeton and Dr. Sophia Jevons) were appointed to report on the general question of cleansing of verminous children. These members submitted a statement on the 18th December, 1914, in which it was suggested, in order that the habit of cleanliness should be encouraged alike in the children who were bathed at the stations and in the older members of the families, that the Council should arrange with the borough councils for the sale at the stations at reduced rates (and in necessitous cases the free distribution) of tickets of admission to the public baths ; it was pointed out, moreover, that from the figures published by the borough sanitary authorities it was clear that on an average an individual in London used the baths about once a year, whereas if full advantage of the facilities were taken it would be possible for at least six times as many baths to be taken. The two members stated that they attached the utmost importance to larger use of the existing facilities being made. It was decided that children and other members of the family who had been cleansed should be encouraged to attend at the public baths at regular intervals for a hot bath, by the issue of vouchers admitting them at a reduced rate. This recommendation was forwarded to the Public Health Committee, who (29-4-15) decided to ask the metropolitan borough councils whether the}- were prepared to grant facilities to adults and children to use the public baths at rates not exceeding 1d. a bath, at times when the baths were not fully utilised, and to supply the Council with vouchers in book form for admission of suitable cases. Favourable replies were received in several instances, but enquiries have elicited that the facilities have hardly, if at all, been utilised. This experience appears conclusively to show that little progress can be made unless the attendances at the baths are made part of the school curriculum and demonstrates the need of comprehensive and general action. The public baths referred to have been established in neighbourhoods where the need is greatest and they are well distributed over the county area. With a relatively small number of exceptions the schools where the provision is most necessary are within a convenient distance. The baths provided have hitherto by no means been used by the public to their full extent, and in many cases the provision stands idle for a large proportion of the available time. It is probable that most of the accommodation and at all events the second class bath provision could be reserved for the exclusive use of classes of children from the elementary schools during school hours. If the whole of the accommodation could thus be reserved it would be possible to bath upwards of 150,000 children once a week or 300,000 children once a fortnight. It may be pointed out that the swimming bath accommodation of the same authorities is already used by the school organisation and some 133,000 children are annually instructed in swimming during the summer months, payment being made by the Council to the local authorities. It cannot be contested that the inculcation of cleanliness is even more important than the teaching of swimming and the utilisation of the existing bathing accommodation of the local authorities offers the readiest means to hand for effecting this purpose, as it can be introduced without delay and without costly expenditure upon installation of special baths at the schools themselves. An additional advantage over the installation of school baths lies in accustoming the children to the use of the public provision during school life and the formation of habits which will ensure the fuller use of this provision after leaving school. These facts were considered by the Central Care Sub-Committee, who received a deputation of representatives of the teaching staff, and discussed the whole matter with them. As a result of this interview, it was decided not to adopt the proposal that children should be taken to washing baths as part of the school curriculum and organisation. It was, however, resolved (1) that when a school is being built or enlarged the question of making provision in the building for baths should be considered on its merits; (2) that should it be considered that school baths are necessary in a particular district enquiry should be made as to the practicability of adapting the basements of old schools for the purpose ; and (3) that tickets should be sold in the schools and cleansing stations enabling children to obtain voluntary baths at reduced rates. 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. Secondary schools. During the present session an amended scheme was introduced. The amendments arose out or the decision of the Higher Education Sub-Committee that 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), and the greater stringency resulted in 35 children, as compared with seven in 1917, being excluded from school or losing their awards. The scheme provides that school nurses shall examine pupils, and, differentiating between accidentally and habitually verminous cases, advise the head teachers to exclude the latter from school. Those found to be verminous as a result of presumably accidental infection are given opportunities for remedying the unsatisfactory condition, a period of three weeks elapsing between the first and last of the series of examinations. The assistant superintendent of nurses makes the last examination, and if the unsatisfactory condition continues, the pupil is excluded from school, and the medical record cards showing the results of the examination are forwarded to the school medical officer, who certifies that the pupil is unfit (a) to be in attendance at school, or (b) to hold the award, 50129 b 2 36 Examination of candidates and medical inspection in higher education institutes. The total number of candidates medically examined was 5,333, an increase of 368 when compared with the figures for 1917. In addition to the foregoing examinations, 1,778 references in regard to the health of employees in the Council's service were considered. This number shows an increase of 161 when compared with the figures for the previous year. The medical inspection of pupils in London County Council 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 Table D on page 56. The arrangements made last year were continued 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. 348 men and 1,37ft women were examined ; of these 101 men and 324 women were found to be unfit. Correspondence between the Board oj Education and the Council. Early in the year the Board of Education made an investigation into the working of the arrangements for medical inspection and treatment. The following letters are the outcome of this enquiry :— 27th March, 1918. The Board's letter of 27th March, 1918. Sir, 1. The Board have had under consideration the report received from Dr. Eichholz and Dr. Crowley, two of their medical officers, on the recent inspection of the working of the arrangements made by the authority for the school medical service. 2. The Board desire, in the first place, to express their appreciation of the efforts successfully made by the authority to maintain the work of medical inspection and treatment, in spite of the absence on military service of a large number of their medical officers and nurses, and other difficulties arising out of the war. In particular, the Board note with satisfaction that the full medical inspection of the intermediate and leaver groups has been continued throughout, and that, while some curtailment was deemed to be necessary for a time in the case of the entrants group, it has now been found practicable to resume the normal medical inspection of the whole of this group also. They also note that the provision made under the authority's scheme for the treatment of the principal types of malady affecting school children, which before the war was expanding, has continued to grow steadily during the war, the total number of cases of all types of defect for the treatment of which provision is made under the arrangements for 1918-19 (152,744) being about half as many again as in 1914 (98,976). In addition, the arrangements for the systematic re-inspection of children, who are found to be defective in the course of medical inspection and require treatment or to be kept under observation, have been maintained unimpaired. 3. These achievements in the face of exceptional difficulties are most gratifying, and indicate a strong desire on the part of the authority to maintain and develop their arrangements for the welfare of the children of London. At the same time I am to express the hope that the need for still further increasing the provision for all or almost all the various forms of treatment undertaken, particularly for the treatment of " minor ailments " will be constantly borne in mind. From the experience of other areas the Board would expect the number of children requiring treatment annually for " minor ailments " to be not less than 65,000 (10 per cent, of the total number of children in average attendance), so that the existing provision needs to be at least doubled in order to be comprehensive. Similarly, it would appear that, while the arrangements already made for dealing with defects of eyesight cover the greater part of the ground, some extension of the arrangements is required in order to make them thoroughly comprehensive. In this connection the Board observe from the school medical officer's report for 1916 that at the second re-inspections carried out, during that year upwards of 5,000 refraction cases were found still to require treatment. 4. The Board are also glad to learn from their medical officers' report of the measures taken since the last inspection in 1913 to meet the suggestions then made, particularly the introduction of a considerable amount of variety into the work of the assistant school medical officers—the permanent full time assistants at any rate- and the development of the arrangements for the inspection of special cases and inspection clinic work generally. The use of the schools, offices of the divisional medical officers and treatment centres for inspection clinic purposes, however, has certain disadvantages—the disturbance of the routine of the schools at irregular intervals, the congestion of the premises of the divisional offices, and similarly the fact that the accommodation of the treatment centres is limited and is frequently used up to its maximum capacity for treatment work. The Board accordingly look forward to a time when inspection branch clinics will be provided by the authority in the different districts in adequate premises of their own (as has been done in most other large urban areas), with which will be associated the work of a minor ailments clinic carried out by the authority's school nurses under the supervision of the authority's medical officers in accordance with the practice now almost universally adopted. Such branch clinics would constitute medical (as distinct from administrative) centres of the kind referred to in paragraph 7 of the Board's letter of 24-6-13 " serving a comparatively small area, from which the school medical work might radiate and a continual supervision over individual children, so far as necessary, might be exercised." The authority should realise in this connection that they are now practically the only authority out of all those undertaking treatment who debar their medical officers from taking any part in the actual work of treatment. Further, while it appears that the school attendance officers perform useful service in bringing large numbers of cases to the notice of the medical department, it is desirable that co-ordination between the school attendance and medical departments should be developed as opportunity occurs. 37 As an instance in point, reference may be made to the delay in visiting cases of measles among young children. It would appear that at present, in the case of children attending infant schools, as much as a month may elapse before the school attendance officer visits. The fact should be realised that a large part, probably the larger part, of the absences from school are on medical grounds real or alleged. Much of the supervision entailed by such absences is naturally best carried out by school nurses; but, whatever the detailed arrangements made may be, the broad principle should be borne in mind that school attendance and school health are problems which are intimately related and cannot be dissociated without detriment to both departments of the work. 5. The Board's medical officers state that the following up of ear cases has received considerable attention since the last inspection, and they refer to the scheme adopted in two divisions for the supervision of such cases by one of the authority's medical officers who possesses special experience of ear, nose and throat work. The Board understand that it is hoped to extend the scheme to other divisions shortly. They regret to learn, however, that there is inadequate opportunity at present for the general daily nursing treatment of such cases at the treatment centres, and that the existing facilities for treatment, viewed as a whole, cannot be regarded as satisfactory. Parents take their children to the hospitals or treatment centres and carry out for a time the instructions given them as to syringing, but are disappointed at the absence of immediate results and too often discontinue treatment. It would appear that, while some improvement has been effected, the whole question needs further consideration, in view of the serious risk to the child from the neglect of such defects. (5. While the provision for medical inspection and treatment has, as already stated, been generally well maintained and even extended, in spite of the war, it would seem that, largely owing to war conditions, which have led to a depletion of the personnel of the care committees, the arrangements for following up have suffered a serious loss of efficiency, and in certain cases have even broken down altogether. The seriousness of the situation is increased by the fact that the falling off is most marked in those districts where the need for following up and treatment is greatest. The Board's medical officers report that in a number of schools in such districts the proportion of children obtaining treatment has sunk to a very low figure, and that in some schools practically no treatment is secured, whether under the Council's scheme or otherwise. The Board gather that the authority are endeavouring to meet the difficulty by utilising their nurses for following up in 30 or 40 of the schools which have suffered most. It would appear, however, that this measure is inadequate to the needs of the case, and that, in view of the prolongation of the war and the probability that even after the war there will be a shortage of suitable voluntary workers, the whole question of the present arrangements for following up should be reconsidered with a view to placing the employment of the authority's staff of school nurses in the work of following up on a wider and more permanent basis. The Board recognise and appreciate the admirable and devoted work which has been carried out by many of the care committees, as well as by the organisers appointed by the Council to assist the voluntary workers, and they are anxious that these energies should be retained as far as possible for the benefit of the children. They suggest, however, for the authority's consideration that the time has come to include the main burden of the work of following up among the duties performed by the school nurses under the direct supervision of the school medical officer, as is done in nearly all other large areas, reserving the care committees for cases of special difficulty or cases which require particular forms of treatment, such as convalescent treatment Or other assistance which such committees are specially qualified to procure or provide. In this connection I am to direct the attention of the authority to the limitations at present imposed on the work of the nurses, which, except in so far as arrangements have now been made for the nurses to undertake the following up of dental cases, is practically confined to attendance and assistance at routine medical inspection, cleanliness work, and the following up of children suffering from ringworm or scabies, and to the failure to make the best use of capacity and experience which results from the employment of fully-trained nurses in duties such as clerical assistance at routine medical inspection or leaving notices at the homes of parents who are not present at the medical inspection of their children—duties which could equally well be performed by untrained persons. I am also to draw attention to the delays which, it is understood, frequently occur under the present arrangements. Thus, as regards defects of eyesight, while it appears that treatment is obtained ultimately in the majority of cases, it would seem that delays extending to 12 months occur in some cases before treatment is secured. Similarly, the Board's medical officers state that there may be a delay of six months before a child recommended for milk actually begins to receive it. Long delays detract considerably from the value of following up, and in certain cases the results to the child may be serious. From the point of view of the working of the authority's scheme generally, it is clear that it is of no avail for the authority to extend their provision for treatment unless the arrangements for following up are, such as to provide the children requiring treatment and with reasonable expedition. 7. It is important that efforts to improve the cleanliness of the children should not be allowed to diminish owing to the work necessitated by the considerable increase of scabies in the area, which has been caused by war conditions. The Board observe, from the school medical officer's report for 1916, that approximately one-third of the girls examined at routine medical inspection suffered from uncleanliness of the head to a greater or less extent. They are aware that, as the nurses examine the children for cleanliness at a preliminary visit of which the parents have no knowledge, the children are not prepared as they usually are more or less when examined for cleanliness at routine medical inspection, and also that, as a result of the war, there has probably been some relaxation of parental care. It is obvious, however, that a condition of things in which practically one out of every three girls in the elementary 38 schools of the metropolis is unclean cannot be regarded as satisfactory, and every effort should be made to secure a considerable further improvement. 8. The Board observe, from the school medical officer's report for 1916, that, while spectacles were prescribed during that year for 20,597 children, they were obtained in only 17,389 cases. I am to remind the authority that it is a condition of the Board's sanction to arrangements for dealing with defects of eyesight that steps will be taken to secure that children for whom spectacles are prescribed actually obtain them, and afterwards to ascertain whether the spectacles are being worn properly and with satisfactory results. The Board understand that at present spectacles are not provided by the authority in necessitous cases, but that assistance in obtaining them is given by the local associations of care committees, under the general guidance of the London Central Spectacles Committee. In view of the increased cost of spectacles at the present time, the difficulties under which care committees are working, and the apparent failure in a considerable number of cases actually to obtain the spectacles, I am to suggest that the present arrangements should be reconsidered with a view to the authority themselves undertaking the provision of spectacles in cases in which the parents are not in a position to pay for them, as is now done by practically all the authorities who make provision for dealing with defects of eyesight. Such cases should not be numerous; but it is important that the children should not suffer by the withholding of the spectacles, which they require, and that the waste of the specialist's time which occurs when spectacles are prescribed but not obtained, should not be allowed to continue. The Board assume that arrangements have been made by the authority to enable parents who are in a position to pay for spectacles to obtain them at contract rates ; but they will be glad to be informed exactly what the position is in regard to this matter. In this connection, attention is invited to paragraph 186 of the report for 1913 of the Board's chief medical officer. 9. The Board desire to invite the attention of the authority to the following matters— (1) It is very important that the whole of the authority's arrangements for securing the medical treatment of cases requiring it should be under the direct supervision of the school medical officer, whether the treatment required in a particular case is treatment for the provision of which the authority is responsible, or whether it has to be obtained outside the authority's own scheme of treatment. It will be observed that article 4 of the Medical Grant Regulations applies to treatment generally and draws no distinction between treatment provided by the local education authority and treatment not so provided. The scope of the school medical officer's supervision should extend to the administration of the Education (Provision of Meals) Acts. (2) It is regrettable that the authority's arrangements for open air education show no development. As pointed out on page 76 of the report for 1916 of the Board's chief medical officer, there is perhaps no form of treatment so needed at the present time, and none so certain in its remedial effects as the open air school; yet there are still only two open air schools accommodating about 200 children for the whole of the metropolis. The Board realise the difficulties of this nature, but in view of the great importance of provision for open air education I am to suggest that the practicability of establishing additional day open air schools should be considered even though it be necessary during the war to utilise existing premises or temporary buildings which may not be altogether satisfactory for the purpose. Attention is invited in this connection to paragraph 137 of the chief medical officer's report for 1916. (3) Closely connected with the question of open air education is that of provision for backward children which needs much further attention than it has hitherto received, though valuable investigations preliminary to action have, it is understood, been carried out by the Council's psychologist. It is probable that the total number of children affected in the area is not less than 50,000 to 75,000. Even if under present conditions it is impracticable to put a scheme into operation—at any rate full operation— it is very desirable that the authority should give serious consideration to the problem and the various methods of dealing with it through medical supervision, open air education, provision of meals, special educational treatment (e.g., manual and physical training), etc., so that on the return of more normal conditions it may be possible to take action without delay. (10) Owing to war conditions it was impossible in the course of the recent inspection to form an opinion as to the working of the system of quarter-time assistant school medical officers appointed temporarily and employed solely for medical inspection in the public elementary schools in the districts allotted to them. The authority will be aware that the Board have always entertained considerable doubts as to the expediency of this system. Should the Council decide to adhere to it after the war the Board will watch its working closely, and will arrange for a further inspection to be made which would have regard to this point particularly. 11. I am to add that, in view of the general character of the report of their medical officers, the Board have decided that they would be justified in sanctioning payment of grant for the year which ended on the 31st March, 1917, at the maximum rate, and they will also be prepared to pay grant at the full rate for the current year. In determining the rate of grant for subsequent years, however, the Board will have regard to the action taken by the authority in view of the suggestions and criticisms contained in the present letter, and in particular to the measures adopted to place the arrangements for following up on a more satisfactory basis. I am, Sir, Your obedient Servant, (Signed) E. H. Pelham. The points raised by the Board were dealt with by the Council in the following letters of the 11th July and 8th August, 1918. The Council's reply of 11th July. 1918. 11th July, 1918. Sir, 1. The Council has had under consideration Mr. Pelham's letter of 27th March last (M. 49.18) with reference to the London School Medical Service, and notes with satisfaction the expression of the Board's appreciation of the thoroughness with which medical inspection of school children is conducted in London, and of the increased facilities made by the Council for the treatment of the principal types of malady. At the same time the Council observes that certain criticisms and suggestions with regard to the School Medical Service are made by the Board, and that an intimation is given that in determining the rate of grant in the future the Board will have regard to the action taken by the Council to meet these points. The suggestions made have received careful consideration, and I am directed to submit the following observations thereon 2. Minor ailments and eyesight—In paragraph 3 the Board state that from the experience of other areas they would expect the number of children requiring treatment annually for "minor ailments" to be not less than 65,000 (10 per cent. of the total number of children in average attendance), and that therefore the existing provision needs to be at least doubled in order to be comprehensive. With reference thereto I am to point out that, during the year 1914, 14,634 children received treatment for "minor ailments" at 25 centres, whereas the arrangements sanctioned for 1918-19 provide for the treatment of 30,410 children at 38 centres. In addition there would be a considerable number of children who would be treated at hospitals not included in the Council's arrangements, and by private practitioners. Thus very substantial progress has been made in spite of the difficulties of the present time. As opportunities occur further schemes for adding to the facilities will be considered by the Council. The Board also draw attention to the need for some extension of the arrangements for dealing with defects of eyesight. With regard to this point, the Board are probably aware that during the last two years the authorities of several of the hospitals have found themselves unable to continue to treat school children owing to the demands made upon them by military requirements, with the result that the facilities for the treatment of school children have been considerably reduced. The deficiency has been met, to some extent, by arranging for extra sessions to be worked at the Council's centres, and, wherever possible, steps are being taken to increase the provision in this way. 3. Branch inspection clinics—The Council note the views expressed in paragraph 4 of the Board's letter with reference to the desirability of establishing branch inspection clinics in London. Whatever may be the merits of this suggestion, the Council feels that in present circumstances, its adoption would involve very considerable practical difficulties which will readily be appreciated by the Board. Meanwhile the Council is extending the arrangements by which special and urgent cases are seen by the school doctors at the treatment centres, and authority was recently given by the Council for these facilities to be extended to 15 centres in addition to the 10 centres at which they were already accorded. It appears to the Council to be more desirable to continue to knit together the inspection and treatment arrangements, wherever possible, by such means than to embark upon a policy of erection of special centres for medical inspection which would tend in the direction of separating inspection from treatment. 4. Treatment by Council's medical staff—With regard to the question of the Council's medical staff taking part in treatment work, I am to point out that at the Whitechapel and Wapping centres, arrangements have been made for the treatment of minor ailments to be directed by the Council's staff, and that the extension of this practice at particular centres will receive the careful consideration of the Council. 5. Co-ordination between school attendance staff and School Medical Service— With regard to the Board's observations also in paragraph 4 as to the delay in visiting cases of measles amongst young children, the Council thinks that the Board hardly realise the amount of co-operation which exists between the attendance staff and the school medical service. As indicating the desire of the Council that there should be as complete co-ordination as possible between the attendance staff and the school medical service, it may be mentioned that, in addition to the ordinary methods adopted for dealing with such cases, in 1913 an experimental scheme was put into operation in the electoral areas of Southwark, W., Walworth and Bermondsey, with the object of receiving earlier information of cases of measles, through the co-operation of attendance officers, and thus securing more efficient control of the disease in infant schools. Special arrangements were made whereby all children absent from infant departments of schools were visited by the attendance officers within a week from their last day at school. During the earlier period of the operation of the scheme there were clear indications that the special methods employed in visiting absentees enabled the school medical officer, in many instances, to take preventive measures at the school more promptly than would have been the case under normal arrangements. The intervention of the war and the consequent difficulties, however, have prevented the full working of the scheme in the experimental areas, but the question will be again considered as to what extent the special methods adopted could be employed in other areas when measles becomes more prevalent, and if it becomes necessary the Council will be prepared to apply this scheme to all parts of London. It is difficult, however, for the Council to understand how, even under the ordinary system of visitation it would be possible for a case of measles to remain unvisited for so long a period as a month. I am, therefore, to invite the Board to be so good as to give particulars of any cases which have come to their knowledge. 39 40 The number of cases dealt with by the Council's medical officers (both central and divisional) on reference from the attendance staff is increasing at a very rapid rate. There is also a very close co-operation between the attendance staff and the nurses in regard to the cleansing and other cases. The general aim kept in view is that the greater the co-ordination between attendance staff, care committee organisers, medical officers, and nurses, the more effective the work is likely to become. 6. Cleanliness of school children—In paragraph 7 the Board point out that efforts to improve the cleanliness of the children should not be allowed to diminish owing to war conditions, and they refer to the special problem presented by scabies. In reply. I am to inform the Board that, so far from relaxing its efforts, the Council has given the greatest attention to this matter, and many improvements in the scheme have recently been effected. Some months ago the scheme of procedure was carefully re-examined and amended in certain respects with a view to expediting the work. In addition, the Council has recently approved expenditure for the instalment of new baths, the provision of a new motor ambulance and the employment of additional nurses for cleansing work. By these means it is hoped to secure a considerable measure of improvement. It may also be mentioned that it has been made 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). 7. Provision of spectacles—Paragraph 8 of the Board's letter deals with the provision of spectacles, and the Board assume that spectacles can be obtained at contract rates, and ask to be informed exactly what the position is in regard to this question. In reply, I am to state that in the case of the special schools, spectacles are supplied through the Council's stores to children requiring them, and the cost or such part of the cost as the Council may determine, is recovered from the parents. In the case of the ordinary schools voluntary committees have been formed in order to assist parents in obtaining the spectacles. In some districts one committee deals with all the schools in the district, while in others each school care committee deals with its own school. The procedure as regards supplying glasses and collecting contributions varies in different districts, but an endeavour is made to provide that, whenever a loan is asked for, the glasses are ordered at once, a grant being given in the necessitous cases. "Where payment is to be made by instalments it is expected that at least Gd. a week, and, if possible, 1s. or 1s. 6d. a week should be paid. Under such a scheme long periods of waiting for glasses are avoided. The Council agrees that it is very important that the delay incidental to obtaining glasses should not be increased by a preliminary delay through waiting while small weekly instalments are being collected. The terms upon which glasses are obtainable by London school children are in practice contract rates. and compare not unfavourably with those mentioned in paragraph 186 of the chief medical officer's report of 1913. There has, however, of course, been a rise in prices owing to the war, though the prices are still below the non-contract prices referred to in paragraph 186. In view of all the circumstances the Council is of opinion that of children requiring glasses the percentage who obtain them is extremely satisfactory. 8. Supervision of medical treatment—It is observed that in paragraph 9 the Board state that "it is very important that the whole of the Council's arrangements for securing the medical treatment of the cases requiring it should be under the direct supervision of the school medical officer, whether the treatment required in a particular case is treatment for the provision of which the authority is responsible or whether it has to be obtained outside the authority's own scheme of treatment." With regard to this point, I am to state that the Council is in agreement with the Board, and that the work has been organised on this basis. The following up of children for whom it is proposed to obtain treatment other than through the Council's treatment scheme, is accomplished in the main by care committee workers whose activities are directed by the members of the organising staff working under the control of the school medical officer. The children concerned, moreover, are subject to re-examination from time to time by the school doctors. The supervision of medical treatment is, however, under reconsideration. 9. Provision of meals and school medical service In the same paragraph the Board refer to the importance of supervision by the school medical officer in connection with the Provision of Meals Acts. On this point I am to remind the Board of the statement made by the Council on Form 9 M (Question 2) in which the arrangements for co-ordinating the work in connection with provision of meals with that of the school medical service are set out. For convenience of reference the statement referred to is set out below— "The school teachers, the school care committee, and the school doctors are closely associated in the matter of the selection of the necessitous children. On the one hand school medical records of individual children are referred to by the care committee, and, on the other hand the attention of the doctor is called, at the time of the routine or other medical inspections, to children about to be inspected who are on the feeding list, in order that he may give any special advice as to the kind of meal which should be given. The menus of the meals are submitted to and approved by the school medical officer, and the dining centres are visited and reported on by the school doctors, in regard to questions of diet and hygiene. In addition, samples of the meals are taken from time to time, without notice to the caterers, and submitted to the school medical officer for chemical analysis. In the case of milk meals, the school medical officer from time to time takes samples for analysis, and local medical officers of health are notified in those cases in which the sample of milk is found to be unsatisfactory, in order that they may obtain samples and prosecute if necessary." While dealing with this matter, I am to refer to the statement towards the end of paragraph 7 of the Board's letter, in which it is assumed that there may be a delay of six months before a child recommended for milk actually begins to receive it. With reference thereto I am to state that careful enquiry 41 has not revealed any case of the kind, and, as the Council's regulations regarding the selection of necessitous children are expressly framed with a view to avoiding delays, I am to enquire whether the Board will be so good as to supply specific instances for investigation. 10. Open-air schools. With reference to paragraph 9 (2) of the Board's letter, the Council would remind the Board that there is ample evidence of the fact that the Council has for many years fully appreciated the need for open-air treatment of children, and that even before the Administrative Provisions Act was passed, or general attention drawn to the subject, the Council had established an open-air school in Bostall Woods in 1207. The fact that the Council has, at the present time, only two open-air schools is due to a variety of causes chiefly arising from the special and peculiar needs of an open-air school. Many proposals have been made for the establishment of such schools, but on examination and enquiry it has not been found practicable to adopt any of them. It may be added that a provisional sum has been included in the estimates for the current year for the establishment of additional schools, but, in view of the difficulties as regards labour and materials and the shortage of teaching staff, it is very improbable that this money will be spent during the year. On the other hand, the Council has inaugurated and developed a system of open-air or playground classes. A large number of such classes have been held during the summer months (usually from about the beginning of May till about the end of October) in connection with the elementary schools maintained by the Council. These classes are held either in parks or open spaces or in the school playgrounds In 1914 the number of such classes was more than 100, but owing to various causes resulting from the war this number has declined to 56. In two cases the classes are composed of delicate children specially selected from various schools by the school medical officer, and in many other cases some attempt is made by the head teachers of schools where such classes are held to place the more delicate or backward children in the open-air class. The head mistress of one school (Kilburn-lane (G), Paddington, N.), has arranged, with the Council's approval, for all the classes of her school to work in Queen's-park for at least half of every week during the summer of 1918. It should be added that the Education Committee of the Council has recently had under consideration the whole question of the education and treatment of tuberculous and pre-tuberculous children and of other children needing open-air treatment, and that a Joint Sub-Committee of the Education and Public Health Committees of the Council has been appointed to consider the matter and submit recommendations with a view to the settlement of the principle of dealing with these classes of children. 11. Backward children.—As regards the education of backward children, a report on this subject by the Council's Psychologist, Mr. Burt, was submitted to the Committee in January last. As the report was full of suggestions which, it was thought, would be of value to teachers, copies of it were sent to the head teachers of all the schools maintained by the Council. Further consideration by the Committee of the report and of the general question of making special provision for such children was postponed until after the summer recess. 12. The Council has still under consideration paragraphs 5 and 0 relating to the question of discharging ears and following up, and will send a reply to the Board on these points at the earliest opportunity. 13. I am to express, on behalf of the Council, the hope that from the information given above, the Board will be satisfied that the Council is taking every reasonable step to secure the efficiency of its school medical service. I am, Sir, Your obedient servant, (Signed) R. Blair, Education Officer. The further reply of the Council, dated 8th Aug., 1918. Sir,— 8th August, 1918, In continuation of my letter dated the 11th ultimo, I have to state that the Council has given careful consideration to paragraphs 5 and 6 of the Board's letter of 27th March, 1918, relating to the questions of discharging ears and " following up." 1. Discharging ears.— As regards discharging ears, the Board on the 24th June, 1913, in reviewing the arrangements for the medical inspection and treatment of children in London, stated that, having regard to the fact that a certain proportion of the cases of discharging ears were of a serious nature, it seemed desirable, with a view to ensuring adequate treatment, that facilities should be provided for an examination by an expert aural surgeon where that appeared to be necessary. With regard to this suggestion, the Board were informed that careful consideration had been given to the question, and that it was intended that provision should be made for certain of the school doctors, who had had special experience, to pay special attention to this side of the work. Since that date, special attention has been given to the matter by one of the school doctors, and careful records have been kept of the results of examinations and re-inspections. The means which have been adopted have resulted in a steady improvement in the number of children who attend for treatment, and in the number whose ear defects are satisfactorily cured, and the Council proposes to arrange that the school doctor who is at present giving five sessions a week to this work, should devote his whole time to it. 50129 D 42 One considerable difficulty has, however, been experienced, namely, that of obtaining suitable treatment for children who require radical operations for the purpose of curing the disease, and who should be admitted to hospitals as in-patients. It has been felt for some time that no arrangement, for the treatment of ear cases can be complete or satisfactory which does not include some such provision. In this connection, the following observations of the School Medical Officer are important:— "Ear discharge amongst children is very common in this country. It is a frequent sequel of the common infectious diseases such as measles or scarlatina, but apart from this it often results from frequent colds and is often associated with the overgrowth of tonsils and adenoids. The medical inspection of school children quickly demonstrated the wide prevalence of the condition, and its serious effects upon the capacity of the children to profit educationally by school attendance. It was already well known to the medical profession that chronic ear discharge is a serious menace to life itself, and a large number of deaths from diseases originating in discharging ears takes place amongst the child population yearly. Every medical man knows that a patient with chronic discharging ears is always on the blink of a precipice, and that it is impossible to exaggerate the gravity of the condition. Whenever a child patient dies in hospital from blood poisoning or from meningitis for which there is no obvious cause, the pathologist always examines the middle ear in the expectation of there finding a neglected and perhaps unknown focus of inflammation, and in the majority of cases his expectation is justified. In addition to the toll of child life exacted by this condition, the results in loss of hearing amongst the survivors are most serious, and the condition is moreover productive of chronic ill-health with much loss of school attendance. "The results of school medical inspection show that more than 12,000 children with discharging ears are in attendance at school; there is, in addition, a number which cannot be estimated who are not attending. There are some 7,500 children attending elementary schools who have some easily appreciable deafness, and there are in addition 800 children attending deaf schools or "hard of hearing" classes. From 100 to 150 children of school age die in London annually from diseases closely associated with ear disease. "A large proportion of children attending minor ailment centres and aural departments of treatment centres suffer from chronic ear dischaige. In a great many cases no cure can be expected by syringing and other local methods although these must be maintained in the absence of facilities for radical treatment in order to limit, so far as possible, the ofiensiveness of discharge and danger of spread of the disease to vital organs. "Owing to the prevalence of the condition and the lack of facilities at London hospitals for dealing with the cases, it was one of the first for which the Council found it incumbent upon it to provide at treatment centres. "The need for beds at hospitals arises directly out of the Council's work. It is practically impossible to obtain in-patient treatment for those needing it at London hospitals ; the beds which are in existence are fully occupied with acute cases, many of which have been left too late for anything effective to be done to save hearing or even life. All these cases should have had earlier attention. The result of want of this provision is that the centres are congested with the accumulation of cases which cannot be cured by local measures, and the work of the centres becomes more and more difficult to carry on." From a consideration of the above facts, the Council are strongly of the opinion that an arrangement should be made with the governing bodies of one or two hospitals in London, whereby five beds could be reserved for the in-patient treatment of children suffering from serious ear trouble and referred under the Council's school medical treatment scheme, in the same way that beds are reserved by the Council under the tuberculosis scheme. The time required for treatment would be on an average one month for each case, so that 60 cases a year could be treated in this way. As regards cost, the Council is advised that it could probably be arranged to reserve the five beds for a sum of £1 a week for each bed, or £260 per annum. As some negotiation will be necessary, it will probably be impracticable to put the scheme into operation before 1st January, 1919, in which event the expenditure during the current financial year would not exceed £65. Before taking further steps in the matter, the Council will be glad to receive the Board's approval of the proposed arrangements and to receive an assurance that the expenditure involved will be allowed to rank as approved expenditure for annual grant. 2. "Following up."- With regard to the Board's remarks on this subject, the Council is prepared to agree that it is unfortunately the fact that owing to the depletion of School care committees in consequence of the war, medical " following up " has, in common with other important work concerning the welfare of school children inevitably suffered. In order to meet the situation, the Council has decided to appoint, as from 1st September next, 12 additional temporary organisers at a rate of pay of £3 weekly, and to raise from amongst successful care committee members a mobile corps of voluntary workers who will work in six detachments in various parts of London where care committee activity is at a very low ebb. Six of the temporary assistant organisers will be placed in the Public Health Department and a similar number in the Education Officer's Department, and the work of the staff will be co-ordinated by the principal organiser. It is hoped that the Board will agree that the appointment of this additional staff will result in materially improving the standard of the medical "following up" work. I am, Sir, Your obedient Servant, (Signed) R. Blair, Education Officer, 43 The Board's letter of 9th August] 1918. The following is the reply received from the Board:— 9th August, 1918. Sir,—With reference to Sir Robert Blair's letter of the 11th ultimo, I am directed to state that the Board are glad to learn that the various questions raised in their letter of the 27th March last are receiving the consideration of the Council, and that in certain directions some action is being taken. They will be glad to learn in due course what is decided in regard to those questions which are stated to be still under consideration. The Board are strongly of opinion that the Council should not restrict their consideration of the problems of their school medical service to what is practicable within the limits imposed by existing abnormal conditions and circumstances, but that they should take an early opportunity of reviewing the whole of their arrangements with a view to the adoption of a broad policy of reconstruction and development as soon as more normal conditions are restored. For the moment the Board do not consider that they can usefully add to the full statement of their views which was contained in their letter of 27th March last. There are, however, a few points raised in Sir Robert Blair's letter which may be briefly referred to— (а) The Board fully concur with the view of the Council expressed in paragraph 3, that the work of inspection clinics should not be divorced from that of treatment centres. As stated in paragraph 4 of their letter of the 27th March, they considered it especially important that the work of inspection clinics should be closely allied with that of minor ailments centres. What the Board desired to emphasise was that the end in view would not be attained if the establishment of inspection clinics at treatment centres tended to congestion and to interference with the . efficient working of the centre. (b) In answer to the inquiries made in paragraphs 5 and 9 of the letter, I am to inform the Council that the references made in the Board's letter of the 27th March to the possibility of delay in following up cases of measles and in the supply of milk, were based upon information furnished to the Board's officers during their inspection, the evidence of which of course is in the possession of the Council and not the Board. I am to add that the Board's officers did not take particulars of such cases, but the Board are assured that if the authority will examine the returns in their possession they will find that the statement as to the possibility of delay is fully justified. (c) As regards the provision of spectacles dealt with in paragraph 7 of Sir Robert Blair's letter, while it may not be practicable for the Council under existing conditions to secure that a larger proportion of the children who require spectacles actually obtain them, the Board cannot regard the present position as a satisfactory one. The question is in some respects closely allied with that of the maintenance of an efficient system of " following up." (Signed) E. H. Pelham. Smallpox. Infectious Diseases. An outbreak of smallpox occurred during the months of March and April, mainly in the East End. On the 2nd March, a case was discovered in Stepney, and the same day four additional cases were found in neighbouring houses. The patients were at once removed to hospital, and all precautions were taken, including vaccination of contacts, and their removal to the borough council's shelter for observation. Subsequent investigations brought to light two further cases during the next few days in the same area. The rash in each instance had appeared some days before the case was discovered. On the 5th March, Dr. Brincker, one of the Council's smallpox experts, was asked to see a man (H.W.) aged 33, of 71, Albion-road, Hackney, and found that he was suffering from smallpox. It was ascertained that the patient was the undertaker who made arrangements for the funeral of the original sufferer in Stepney, by whom he was no doubt infected. The patient's wife and child contracted the disease during the course of the next two weeks. On the 6th March a case was discovered in Bethnal Green in the person of one of the female employees (aged 17) at the Sussex Laundry, Commercial-road, where it was stated some of the washing from Stepney was dealt with. From 12th to 14th March, eight contacts in the borough council's shelter were removed to hospital, and there is no doubt that the prompt detection and removal of these and other cases later on whilst under observation at the shelter averted a more extensive outbreak and possibly an epidemic. A total of 34 cases occurred during the course of the outbreak, including 24 in the Borough of Stepney, 3 in Ilackney, 2 in Poplar, 2 in Bethnal Green, 1 in Deptford, 1 in Lambeth, and 1 in Islington. All the cases which occurred outside the Stepney area were attributed, directly or indirectly, to the original focus of infection, and owing to the prompt measures taken the outbreak was restricted. Only 8 out of these 34 cases were elementary school children, and of these two attended St. Mark's School, Royal Mint-street (Whitechapel), two were at Tower Hill (R.C.) School (Whitechapel), one each at Somerford-street (Bethnal Green, S.W.), Queen s-road (Hackney, C.), Malmesbury-road (Bow and Bromley), and Fairclough-street (St. George's-in-the-East). No secondary cases occurred among the pupils at these schools; in fact, in only one out of the eight school cases referred to above was it possible for the child to have been infectious when last at school prior to removal to hospital. Vaccination was widely offered to. the pupils and staff of the schools, as well as to large numbers of other inhabitants in infected areas, who freely availed themselves of the facilities thus afforded. There is no doubt that this protective measure, by immunising a considerable proportion of the local population, was in part instrumental in suppressing the outbreak. All the schools in the neighbourhoods affected were kept under close observation by the Council's medical staff, and special attention was paid to the following-up of absentees in co-operation with the borough medical officers and the school attendance staff. 50129 d 2 44 [???]fluenza. The widespread epidemic of influenza which visited this country during 1918 occurred in two distinct epidemic waves, viz.. June-July and October-December, followed by a third wave early in 1919. Similar widespread epidemics of the disease were reported in this country in 1803, 1833, 1837-8, 1847-8, and 1889-92. It is difficult to say how far the epidemics of the last twelve months were influenced by the special conditions arising out of the war, but increased traffic, closer aggregation of persons, and the movements of population, both civil and military, no doubt contributed in assisting spread of the disease. It is significant in this connection that the population of London, which was largely increased and seriously congested as a result of the war, suffered a higher death rate from influenza on the average during the autumn epidemic than the remainder of the large towns in England. Already early in 1918 attention had been arrested by the occurrence of a series of fatal cases of pneumonia in a reformatory school, and it became quite clear later, when the prevalence of "epidemic lethargy" was noted in April, that a special epidemic influence was at work. The first intimation of the presence of "influenza" in London in epidemic form was on the 15th June, 1918, when sudden explosive outbreaks of illness were reported to have occurred in certain factories, one situated in Finsbury and the other in Chiswick; a similar outbreak was reported among the staff of one of the Customs and Excise Offices. The two first-named outbreaks were investigated by the Council's medical staff, and it was found that the symptoms complained of closely resembled those met with in previous epidemics of influenza. Following upon these outbreaks reports were received from schools in various parts of the county which demonstrated conclusively that the epidemic was established in London. The average attendance at many of the schools was reduced in the next few weeks by as much as 30 per cent. and more in some cases. The teaching staff were also attacked in considerable numbers and in one or two instances, schools were forced to close owing to lack of staff. The question of closing the schools as a preventive measure was carefully considered, particularly as this course was being adopted in certain other parts of the country, but the conclusion was arrived at that, in view of the widespread nature of the epidemic, and the numerous opportunities of contracting infection from outside sources, school closure would serve no useful purpose as a preventive measure. Head teachers were enjoined to pay special attention to free and continuous ventilation of classrooms, to prohibit unnecessary grouping of the children, and to send home at once all ailing children. Appropriate notices were issued in the London County Council Gazette with these objects in view. In illustration of the difficulties experienced in particular instances, the outbreak of illness among children on a "school journey" may be referred to Thirty-six girls and three teachers left London on the 3rd July and joined four girls, belonging to a previous party, in a village some dozen miles away. In all, nine children became acutely ill, seven with undoubted influenza; two others were believed to have had scarlet fever. It became necessary to improvise arrangements for the treatment of the children away from their homes and thanks to the energy shown by the teachers and the medical help available locally, the emergency was successfully met. The first epidemic wave in the summer did not approach in virulence the second epidemic wave, which commenced in October and reached its culminating point about the end of October and the early part of November. The heavy death toll exacted during the autumn and winter was to a large extent attributable to complications due to secondary infections, mainly pneumonia. [???]sles and [???]man [???]sles. I he total number of cases of measles and German measles reported as occurring among school children during 1918 was 25,880, as compared with 45,000 (uncorrected) first cases occurring in families notified in accordance with the Public Health (Measles and German Measles) Regulations, 1915. During the year one classroom was closed for a short period, and unprotected children were temporarily excluded from 780 classrooms, whilst in 9 schools all children under 5 years of age were excluded for appropriate periods. [???]ooping [???]gh. The number of cases of whooping cough reported as occurring among school children was higher than usual, viz., 11,671, as compared with 7,117, 8,595, 10,959, 9,977 and 9,762, during the years 1917, 1916, 1915, 1914, 1913 respectively. Whooping cough was compulsorily notifiable in Greenwich, Lambeth and Holborn. [???]gworm Favus. There has been a marked decline in the number of cases of ringworm occurring among school children during the past few years, mainly due to the successful results of X-ray treatment and to the strict control exercised by the school medical and nursing service. In 1911 there were 6,214 fresh cases of ringworm reported from the schools but in 1918 the number of cases had diminished to 2,639. During the year 2,555 cures were effected, of which 51 per cent. were by means of X-rays. At the end of the year only 979 school children were known to be still suffering from the disease. The number of hair specimens submitted by school nurses for microscopical examination was 1,945, of which 1,026 were found to contain ringworm fungus and 9 showed the presence of favus. Only six fresh cases of favus were reported during the year. The standard of health so far as infectious diseases, such as scarlet fever, diphtheria, measles etc., is concerned in residential, special and industrial schools and places of detention, has been satisfactory. On occasions when such ailments have been introduced preventive measures have been taken and outbreaks have been averted. In common with the rest of the population, influenza attacked several of the institutions during the epidemic, but on the whole it may be said that the Council s residential schools and places of detention were less affected in proportion than the elementary schools and many other classes of the community. [???]let [???]er and [???]theria. These two epidemic diseases have fortunately during the last few years been at a low ebb. Tiltimportance of this fact has, as noted in previous reports, been great, inasmuch as the claims made upon hospital accommodation for isolation purposes have in consequence been comparatively limited and 45 beds have, therefore, during the war, been available for other much needed uses. Scarlet fever and diphtheria reached the crest of one of their epidemic waves in 1907, and in that year scarlet fever was just three times as prevalent as diphtheria. After the lapse of some seven years the next wave swelled to a maximum in 1914; since that time both epidemic diseases have declined, but scarlet fever has diminished more than diphtheria, so that in 1917 the scarlet fever notifications, for the first time on record, were less in number than those of diphtheria; the same phenomenon was observed in 1918. In recent reports the relationship of scarlet fever to rainfall and flea prevalence was discussed. The experience of 1918 has been in keeping with the views previously expressed with regard to these Questions. (See p. 37 of the Annual Report for 1917.) Comparison of seasonal prevalence of Fleas and Scarlet Fever The seasonal variations in the prevalence of fleas and scarlet fever are illustrated in diagram "A" The seasonal incidence of diphtheria is also shown for purpose of contrast. The diagram is divided into two sections, the first shows the monthly prevalence of fleas in relation to the monthly case rates of scarlet fever and diphtheria during the ten years 1909-1918. A small inset diagram gives the mean monthly rates for the ten years ; and, as the maximum seasonal incidence of scarlet fever cases is about one month later than the maximum prevalence of fleas, the case rates are ante-dated one month to facilitate comparison. The second section of the diagram is designed to illustrate how far a deviation from the quarterly average of flea prevalence is associated with a corresponding deviation from the average quarterly incidence of scarlet fever, as well at all ages as in certain age-groups; the averages for diphtheria at all ages being also shown. The contour of flea prevalence is based upon figures which post-date by one month the figures for cases of scarlet fever and diphtheria. The first section of the diagram shows a greater measure of association of the annual prevalence of fleas with scarlet fever than with diphtheria. The three years of highest prevalence of scarlet fever and fleas (1913-15) are followed by three years of relatively low incidence, but in diphtheria the correspondence is not so close. In some years there is a secondary prevalence of diphtheria following the normal autumnal incidence, and in 1914 it will be seen that the February case rate of diphtheria exceeded the normal autumnal maximum of the preceding October. There is no evidence of any similar secondary prevalence in the case of scarlet fever, although the decline after the normal autumnal maximum is not equally regular in all years. The common lodging-house records are continuous throughout the period of ten years ; in the case of school records the continuity is disturbed by holidays at Christmas, Easter, Whitsun and in August. It will be noted that the former records correspond more closely than the latter with the scarlet fever curve. In the second section of the diagram the average figures for each quarter are taken as a basis in order to eliminate the wide fluctuations of monthly records. The diagram shows the extent of deviation in any first quarter from the average of nine first quarters in the period of 1910-18, and so on for other quarters. The general similarity of the contours of the flea and scarlet fever prevalences is significant, especially in view of the less marked correspondence shown in the case of diphtheria. Reverting to the interval, of one month or so, between the maxima of flea and scarlet fever prevalence, the question arises whether this interval points to the fact that there are two distinct phenomena controlled by one factor, (such, for instance, as meteorological conditions) or whether a part of that interval can be taken to represent evolution of a scarlet fever germ. In either case the facts imply that the conditions which favour flea prevalence are either identical or intimately associated with those influencing prevalence of scarlet fever, and a presumption is raised that steps directed to the elimination of fleas may loosen the foothold of scarlet fever. Effect is as far as practicable being given to this view in London at the present time. Thus, as a case in point, reference deserves to be made here to a prevalence of scarlet fever in Southwark in the summer of last year. The outbreak occurred at a time when the amount of scarlet fever in London as a whole was exceptionally low. The area affected was very limited but the incidence within the area was very high. Application was made to the borough council to disinfect the infants' department of the Council's school central to the area, the records of which showed a greatly excessive proportion of flea-bitten children. This was done, and in addition the officers of the borough council visited homes and disinfected rooms and bedding associated with scarlet fever cases. This action was followed by marked reduction of prevalence of scarlet fever. The prevalence of scarlet fever in relation to standards of cleanliness A point of some importance with regard to the flea hypothesis of causation of scarlet fever is the fact that there is an undoubted tendency, at certain times and in certain localities for the disease to occur in households and in schools in which the standard of cleanliness is not a low one. The question was considered in the Annual Report for 1914, but, as it has especial importance as affecting the flea hypothesis, further study has been devoted to it. Examination of the literature shows that there is considerable difference of opinion with regard to the relation of the incidence of scarlet fever to "social condition." There is apparently general agreement that mortality rates are almost always hgher among the poor, but in the case of incidence rates, the facts are more difficult of ascertainment. In the Annual Report for 1914 it was pointed out that the question is much complicated by the influences of age and of school attendance and the conclusions reached may be briefly summarised. (a) Contrasting poor with well-to-do boroughs the incidence of scarlet fever is excessive in the former at ages under 5, but after that age the incidence in the two classes of boroughs is almost exactly the same, indeed after 12 or 13 it becomes, if anything, higher in the richer than in the poorer boroughs. 46 (b) When comparison was made, between 20 good elementary schools and 20 poor elementary schools, the apparently anomalous result was obtained that the former had suffered more severely than the latter. In order to throw further light upon these school figures the records of medical examinations of "entrants" and children of the intermediate age (8-9 years) in the two groups of 20 schools have been analysed. In some 1,700 cases, among "entrants" in the good schools, 3.5 per cent. were stated by the parents to have suffered from scarlet fever, and of 2,030 children of the age 8-9, 8.4 per cent. had been attacked. For the group containing the poorest schools the corresponding figures were 4.3 per cent. and 6.5 per cent. respectively. It appears, therefore, that during school life (8.4—3.5 = 4.9 per cent. of scholars in the good schools, have been attacked, while among the poorest class (6.5—4.3 = 2.2 per cent.) only suffered. On the other hand, at the age of entering upon school life, the records among the poorest children show a greater percentage attacked than among those in the good schools; allowance must, moreover, be made for the fact that the age of commencement of school attendance among the poorer children is early and bearing this in mind, the figure 4.3 per cent. would need to be increased and would then stand in still sharper contrast with the 3.5 per cent. obtaining in the good schools. The position, therefore, is that on entering upon school life, and for the next two or three years, the incidence upon children in the good schools is nearly double that upon the poorest children; while the percentage attacked up to this age is greater among the poorest children. It follows that the attack rate among these children must be greatly in excess of that among other children in the first few years of life; and yet when a comparison confined to school age (5-13) is instituted between the richer and the poorer boroughs the children in the former show excess over the poorer children, although when comparison is limited to the pre-school age the relation is reversed. The facts as to scarlet fever incidence may, therefore, now be set out (in a form slightly modified from that given in the 1914 report) as follows; the sign + signifying excessive incidence and the sign— abnormally low incidence. Under school age. School age. Over school age. Poorest areas + + + + + — Less poor areas + + + + — Least poor areas — + + + Upon this view of the case the children under school age are exposed to a markedly excessive extent in the poorest areas to infection by scarlet fever, and then later in virtue of acquirement of immunity they actually suffer distinctly less at school age than the children of the next higher social grade, those belonging to the less poor areas; they suffer, indeed, to no appreciably greater extent at the school age than the children in the still higher grade, those belonging to the least poor areas. The results are almost as striking if consideration be limited to children attending the elementary schools (See Diagram E. Annual Report, 1914). In the poorest boroughs elementary school children constitute the main bulk of children at school age, and they suffer notably less than the children just under school age (Diagram E(a); in the less poor areas the percentage of children in elementary schools is still quite considerable, and these children may actually suffer more than the children under school age; in the least poor-areas the percentage of children of school age is comparatively low and comparatively speaking few of these children attend public elementary schools; Diagram E (b) shows that the rates per 1,000 are throughout higher in the good schools than in the poor schools Questions of nomenclature From this analysis it will be obvious that in instituting comparisons between incidence of scarlet fever in different parts of a town or country, regard must be paid to age and to school attendance as well as to social conditions. But this is by no means all. As has been shown (Annual Report for 1916), considerable differences of fashion as regards nomenclature have existed, and to some extent still exist, so that the cases described as scarlet fever in London have not always precisely corresponded with those so described say, in Lancashire or Cornwall. The close relation and tendency to confusion between diphtheria and scarlet fever must particularly be borne in mind in this connection. Again, in some town and country districts, milk-borne scarlet fever has been more common than in others, and in prevalences of this kind adults may be even more commonly affected than children. This form of scarlet fever differs in certain respects from ordinary scarlet fever, notably as regards absence of capacity for spreading from case to case, and it has even been suggested that milk-borne "scarlet fever" is really altogether distinct from scarlet fever properly so-called. Yet another point to be recollected is the tendency which both scarlet fever and diphtheria manifest to attack the suburbs of growing towns, particularly those occupied by artisans and working people, who have recently migrated there and many of whom have young families and occupy newly built houses. This subject was carefully considered so far as diphtheria is concerned by Dr. Dowson in a paper on "Diphtheria in Older and Newer Bristol." Somewhat similar phenomena have been noted in the case of scarlet fever in London. Still another factor to be reckoned with is that manifestation of the influence of immunity which is exhibited in the tendency shown by scarlet fever, and by diphtheria also, gradually to spread from one part of a large town to another a phenomenon to be more particularly considered almost immediately. Enough has been said to explain why it has come about that frequent note has been made in the epidemiological literature of an exceptional predilection often exhibited by both scarlet fever and diphtheria for attacking well-to-do populations. The writings of Creighton and Hirsch contain many references of the kind referred to. A striking and particularly interesting allusion was incidentally made to this question last year by Dr. John Brownlee, who in a report on "Phthisis," to the Medical Research Committee cited scarlet fever as an example of a disease which may prevail in populations favourably circumstanced as regards " social condition." 47 Scarlet fever in relation to "social condition." Glasgow, 1898-1902. Dr. Brownlee took as his index of the various social conditions the number of persons per room, and he arranged the districts of Glasgow in order accordingly, beginning with a group containing .5-1 persons per room and ending with a group having 2.5-2.75 persons per room. He also gave the scarlet fever attack rates for the corresponding groups of districts and for the five year period 1898-1902; these rates ranged from 388'2 to 1384 per 10,000 children per annum. It should be especially noted that he took the total numbers of scarlet fever cases and applied these totals to the populations at ages under 10 years. The result is a very striking one, the group of least crowded districts had the highest scarlet fever incidence rate (388'2), and, passing from group to group of the districts, as the crowding increased, the scarlet fever rates steadily diminished (to 1384). Dr. Brownlee hints that this paradoxical result may be in part due to failure to notify in the more crowded districts, but he thinks it cannot thus be wholly explained away. Apart from this consideration, however, the application of the scarlet fever cases at all ages to the numbers of children under 10, materially affects the value of the rates for comparative purposes in the Glasgow districts, for some of the richer and less overcrowded districts contain quite a small proportion of children, and these are contrasted with the poorer crowded districts which have an abnormally large proportion of children. Thus the method of calculating the rates adopted goes at least a considerable part of the way in explaining the results obtained. Over and above this, moreover, it appears that two milk outbreaks occurred in Glasgow during the years 18981902, and one of these, if not both, affected the least crowded districts in question. It is recorded by Dr. Chalmers, the Medical Officer of Health, that only adults were attacked in one of these outbreaks; it was a small one and the populations upon which the rates are calculated were quite small too. The arrangement of sanitary areas in Glasgow was altered shortly after 1902, but on testing the now existing sanitary areas of Glasgow, for more recent years, results such as those yielded in 1898-1902 arc, as a rule, no longer obtainable. Despite these drawbacks Dr. Brownlee's Table illustrates in a particularly striking manner the undoubted fact that, at certain times and in certain places, the incidence of scarlet fever is more heavy upon the less poor than upon the poor; and, indeed, Dr. Robertson of Birmingham, remarks (Annual Report for 1913) that "scarlet fever is less a disease of the squalid areas than it is of the suburbs." It should be added that Dr. Brownlee observes "In some towns it is quite true, it (scarlet fever) is more common in the lower than in the upper class districts, but this is by no means the rule." The Glasgow rates in 1898-1902 have been referred to in detail not so much on account of the use made of them by Dr. Brownlee as because there is some risk that, appearing where they do, the figures may be cited as a typical instance of the natural behaviour of scarlet fever, although it is obvious that Dr. Brownlee does not so regard them. Mr. J. Netten Radcliffe many years ago (Epidem. Trans. 1864-5, p. 262) went to the root of the whole matter. He observes, "Once let it be determined that there are constant foci of scarlatinal infection and half the battle of preventive medicine is won." He then describes the 20 great "scarlatina fields" in the England of the time, and he advocates application of means of prevention " to the great foci of infection—the crowded courts of great towns." Again, referring to the cases in the poor home, he says, "These cases, which always exist more or less in great towns, are the persistent sources of infection in the Kingdom." In Mr. Radcliffe's experience scarlet fever was a terrible scourge, causing upwards of 15,000 deaths in England annually. Thanks to the preventive measures and particularly to isolation and cleansing, first advocated from 60 to 80 years ago, this mortality has been reduced to below 3,000 deaths annually; the corresponding rates being approximately 1,200 per million in 1840 and 77 per million in 1914. The epidemiologists of the middle of the last century did not live to witness the carrying into full effect of the preventive measures which they advocated. Their followers have, however, seen that practically pari passu with the carrying out of these measures, scarlet fever has declined. The course of events, indeed, justifies in large measure Mr. Radcliffe's far sighted prophecy that if cases of the disease could be" weeded out of the denser masses of population as they occur "it would be" to the incalculable gain of the people." In the light of all the facts it is clear that too great stress must not be laid upon the observation that "in the best parts of the city (Glasgow)," during a particular five years, there was " nearly three times as much scarlet fever as in the worst." Comparison of scarlet fever and diphtheria case rates in London. With the object of studying the question on a broad basis, the rates of scarlet fever and diphtheria incidence, in London boroughs during a series of 18 years, have been used for purposes of comparison in three different ways. The accompanying diagram B is divided into three sections. In the first the shaded squares above the line indicate, for any given year, a scarlet fever case rate exceeding by more than 10 per cent. the London case rate for that year; the black squares below the line indicate diphtheria case rates for any given year exceeding the London case rate of that year by 12 per cent. These percentages have been so selected as to make the total number of shaded squares and black squares equal, i.e., 147. The second section of the diagram serves to exhibit the years during which the case rate in any given borough is high as compared with the average for that borough during the 18 years shown. The shaded squares indicate a scarlet fever case rate exceeding by more than 24 per cent. the 18 year average and the black squares diphtheria case rates exceeding this average by more than 14 per cent. The shaded squares number 146 and the black 144, the numbers being thus almost the same. In the third section of the diagram the London average case rate for the 18 years is taken as the standard for each borough; the shaded squares indicate scarlet fever case rates exceeding this standard by more than 10 per cent. and the black squares diphtheria case rates more than 13 per cent. in excess, The shaded squares number 148 and the black 149. 48 On the whole study of the first section of the diagram shows that diphtheria and scarlet fever prevail abnormally in a borough during one and the same year or series of years. The diagram further shows that the west, north and central boroughs suffer on the whole relatively lightly, the east and south heavily. Again, in the eastern boroughs there is indication of an early, middle and late series of heavy years with intervening periods of comparative freedom, a phenomenon more conspicuously exhibited in the second and third sections of the diagram. Study of this first section reveals, moreover, a tendency for diphtheria and scarlet fever to spread from one borough to adjoining boroughs. Thus Poplar begins to suffer excessively from diphtheria in 1901, as compared with London as a whole, and then in 1904 Stepney and Bethnal Green become involved. Later Poplar again suffers in 1913; Stepney and Bethnal Green respond in 1914; and in 1915 Shoreditch is also affected. In the case of scarlet fever, excess prevalence apparently travels from Lewisham (1902 and 1903) affecting Woolwich in 1903 and 1904 ; or again, it proceeds from Lewisham in 1909-10 to the adjoining borough, Greenwich, in 1911 and 1912. This slow migration from borough to borough or from one part of the town to another is a phenomenon long familiar to those who have studied diphtheria and scarlet fever (and it may be added measles also) in London. Examination of the first section of the diagram further shows that in certain boroughs the incidence of diphtheria has been in excess of that in London as a whole for a long series of years. Thus, Fulham had a sequence of 11 years of excess; Woolwich, 10 years; Greenwich, 9 years; Stepney, 8 years; and Lewisham, 7 years. Similar sequences of excessive incidence are not shown to the same extent in the case of scarlet fever, although Deptford had 8 years of excess and Bethnal Green 6 years. These periods of excessive incidence of diphtheria stand in suggestive relation with devotion of special attention to bacteriological examination; there can be no doubt, for example, that the Fulham and Woolwich sequences owe some of their prominence to the fact that during the years in question, very assiduous use of laboratory methods was made. The point which the second section of the diagram more especially illustrates is the extent to which high incidence of the two diseases may occur simultaneously in the several boroughs. This phenomenon is discernible in section one, but is more marked in sections 2 and 3. It will be seen that in the case of scarlet fever (in section two) there is a conspicuous grouping of high rates in 1901-2, 1905-9 and 1913-15 throughout London, with low incidence in the intervening and succeeding years. This feature is not quite so pronounced in the case of diphtheria. The third section of the diagram brings into prominence those boroughs in which the incidence of either disease is in excess compared with London. It is noteworthy that the eastern and southeastern boroughs are those in which the greatest excess over the London average is exhibited. This fact is also clearly shown in the first section of the diagram. Movement of population may have had something to do with the contrasts here presented. In the period 1901-1910 there was a considerable influx into Fulham of poorer working class persons displaced from Chelsea by demolition of old houses, and there may be some connection between this and the continuously high diphtheria rate, although it would certainly be expected that the scarlet fever rate would also have been in excess The importance attached to bacteriological diagnosis in diphtheria during the years in question certainly, however, played some part here as already noted In Stepney for a number of years preceding 1905 there was a large influx of immigrants—mainly Russian—so much so, that the native population was actually displaced. This immigration was arrested by disturbed conditions in Russia in 1906 and also by the Immigration Act. Furthermore, in Woolwich, Lewisham and Greenwich (up to about 1912) large numbers of dwellings for the working class were erected annually, and this fact may have had bearing upon the excess shown in this part of London. On the other hand Wandsworth has added even more than these boroughs to its population, without showing corresponding excess. It is, however, very difficult to assess the type of population concerned in these movements ; undoubtedly outward migration from central areas has been mainly among growing families and thus the districts opened up would have their child population of susceptible ages augmented annually to a disproportionate extent as compared with areas not affected by such movements; in addition the possibility of such families carrying infection with them cannot be altogether excluded. High incidence of scarlet fever in new districts is not, as already remarked, confined to London, but there are practically no new districts north of the Thames within the County boundary comparable with those in the south eastern area, and to this fact is probably due the relatively small number of boroughs in the west and north of London in which excessive incidence occurs. In the main, the outward movement in this area has been over the County boundary. About 40 per cent. of "Londoners live outside the County, and this fact must be taken into account when comparisons are made between the distributions of these diseases in London, in Glasgow and in Birmingham, since the boundaries of the two last named cities have been extended as the cities have grown; high incidence of scarlet fever upon their outer districts is not infrequent, but in London north of the Thames the exact reverse of this is exhibited. (See sections I. and III. of the diagram.) Examination of the three sections, therefore, presents the facts for London, seen as it were from three different angles, and appears to justify the following conclusions. 1. There is a marked tendency for diphtheria and scarlet fever to prevail concurrently and to travel from one part of the town to neighbouring parts. 2. There is reason for thinking that the central and poorer parts serve as reservoirs of disease from which epidemic prevalence spreads to newly inhabited outlying areas. 3. Any generalisation to the effect that scarlet fever and diphtheria tend especially to affect well-to-do as contrasted with poor areas is not justified by London experience. 49 4. The facts as set out do not in any way conflict with acceptance of a flea hypothesis of spread of scarlet fever, provided it is borne in mind that there is undoubted evidence to show that in the poorer areas the disease tends to attack children at a younger age than in well-to-do areas and thus renders the poorer children at the higher ages immune from attack. Admission examinations. Defective Children. The total number of examinations conducted under the special Acts during the year was 4,264, as compared with 5,566 for 1917. Of these 993 were deemed suitable to attend elementary schools, 126 a blind school, 191 a school for myopes, 996 P.D. school, 1,386 M.D. school, 8 open air school, 59 hard of hearing school, 88 a deaf school, 32 were epileptic, 254 invalided from school attendance, 99 imbeciles, 13 feeble minded ineducable, 19 idiots. The following statement shows the nature of the conditions found among the children certified suitable for admission to physically defective schools at the admission examinations during the year:— Morbid Condition. Boys. Girls. Total. Certified. Boys. Girls. Total. Infantile paralysis 79 74 153 Heart disease 113 182 295 Cerebral paralysis 14 8 22 Congenital deformities 28 21 49 Various paralyses 12 12 24 Various deformities 37 26 63 Tuberculosis of bones and joints 169 115 284 Other diseases 58 48 106 Rotn visits 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—158 were transferred to elementary schools, 8 to deaf schools, 8 to blind and myope schools, 17 from physically defective to mentally defective schools, 6 from mentally defective to physically defective schools, 27 were excluded from mentally defective schools as imbecile, 35 were invalided on medical grounds and 2 over 14 years of age were excluded as no longer certifiable. In addition 1,555 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 shows the numbers of exceptional children recorded on 31st December, 1918:— Blind and partially blind Deaf and hard of hearing. M.D., excluding imbeciles and idiots. Physically defective. Attending public elementary schools 67 6 30 6 Attending certified special schools 826 687 6,679 3,895* Not at a school 9 20 3 29 In the age groups, out of a total of 129,202 examined, the following were found to be the mental conditions of the children: Dull or backward, age group 8-9 years, boys, 5.5 percent., and girls, 4.7 per cent.; leavers, boys, 6.7 per cent., girls, 6.8 per cent.; mentally defective, age group 8-9 years, boys and girls 0.43 per cent.; leavers, boys and girls, .015 per cent. Mental Deficiency Act Attendance at Myope Schools. During the year there were referred by the local education authority to the local authority under the Mental Deficiency Act, 205 cases, of which 77 were feeble-minded, 113 imbeciles, and 15 idiots. Attention has been drawn to the fact that there was a great difficulty in persuading parents to allow children who had been certified as suitable for a myope school to attend such school. In order to overcome this difficulty a memorandum containing advice to parents of short-sighted children who have been recommended for admission to a myope class was prepared, explaining the advantages to bo derived chiefly from a medical point of view. Residential institutions. There are 8 residential and industrial schools, 2 reformatories, 6 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 officer and a dentist, whose duties have been set out in previous reports. During the year 900 boys were admitted to Harrow Road Place of Detention, 1,495 boys to Pentonville Road Place of Detention, and 580 girls and infants to Ponton Road. Epileptics. During the past three years a register has been kept of all children reported as epileptic, and a large number of them have been specially medically examined. It is probable that this register forms a fair estimate of the numbers of the school attending population affected. It does not, however, necessarily contain the names of all children and the information is only to the date of the last examination *Of the children admitted to P.D. schools, 28.5 per ccnt. were suffering from tuberculosis of bones and joints. 50129 E 50 or report; so that the classification might require to be modified in accordance with later everts. The numbers and classification of the children of school attending age (either in institutions or on the register) are as follows:— Boys. Girls. Total. Children lor whom places are already provided 46 26 72 Already certified fit for a residential school— (а) Awaiting admission 48 38 86 (b) Parents declined residential school (1) In school attendance 5 4 9 (2) Not in attendance 8 5 13 Not statutorily examined with a view to fitness for a residential school— (а) Of elementary school standard (1) In attendance 261 249 510 (2) Not in attendance 85 96 181 (b) Mentally defective— (1) In attendance at Special school 61 51 112 (2) Not in attendance 12 10 22 (3) Under observation as to fitness for Special school at age of 7 years 5 6 11 (4) Imbecile or idiot 39 28 67 (c) Physically defective— (1) Attending a Special school 8 9 17 (2) Not in attendance 8 4 12 (d) Blind— (1) Attending a Special school — 1 1 (2) Not in attendance — 1 1 (e) Deaf— (1) Attending a Special school — 1 1 (2) Not in attendance 1 1 2 Extra-county address 1 1 2 Under care of other authorities 6 2 8 594 533 1,127 It is probable that by now a number of children registered as awaiting a vacancy at a residential school may have been admitted thereto. It is also possible that some of the parents of children registered as awaiting a vacancy may have subsequenty declined the offer on other than medical grounds, or have been rejected by the authorities of the school, and these refusals or rejections may not have come to the notice of the department, and to this extent there will be overlapping in the figures above quoted. Some of the children in elementary school attendance might do better in a residential school but the large proportion are no doubt capable of deriving benefit from the ordinary education. Of those out of school, some would be unfit for any education but it might be estimated that at least half would benefit in some measure from attendance at a residential school. Physical Exercises. A fault from which any system of physical exercises is liable to suffer is that of becoming automatic and dull. Just as food eaten without appetite does not nourish, so exercises performed without enthusiasm fail to develop physical strength and beauty. A good system, in the absence of vivacious understanding on the part of those who practise it, is less productive of results than a second best system, when the exercises are carried out with zest and delight. The syllabus of physical education in use in the schools is by no means exempt from the operation of this axiom and the announcement in the last, Annual Report of the Chief Medical Officer of the Board of Education that the forthcoming new edition of the syllabus will allow of more freedom and less formality is one that is very heartening; for the bane of the exercises as generally performed in the schools to-day is dullness, formality and absence of the sense of enjoyment. In a recent inspection of town and country children under standardised conditions, it was noted that the poise and deportment of London girls were much superior to that of the boys and that no difference in these respects was to be noted between the country boys and girls who both fall short of the London girls. The love of the London girl child for dancing is proverbial and the teaching of dancing in the schools has no doubt greatly helped, if it has not saved, the situation in regard to the physical development of London girls. Particularly noticeable is the much better arched instep of the latter in comparison with their own brothers and with the country children generally. The relative absence of fiat foot thus brought about is the foundation of that grace of carriage which the typical London girl of the elementary school class exhibits. In the country schools enquiry elicited the fact that no dancing was taught in school, nor did the children there enjoy those outside adventitious stimuli to an interest in dancing which are characteristic of London life. In 1917 the Board of Education included regulations for the organisation and supervision of Physical Training in Public Elementary Schools in the Medical Grant Regulations. The grant is to be paid in aid of expenditure upon the salaries of organisers of physical training of children in public elementary schools. In determining the rate of grant the Board will take into account, among other things, the steps taken to co-ordinate the arrangements with the work of the school medical service. (Regulation 14 (c.)) 51 In an accompanying circular (No. 976) paragraph 10 stated that, as physical training is required to stimulate the full development and healthy growth of the child, as well as to prevent various bodily deformities and defects, it is most desirable that the work of the organiser should be closely associated with the school medical service (regulation 14 (c)), and that the school medical officer should have definite functions in respect of it. Further, the school medical officer should also exercise supervision over any remedial gymnastic treatment carried out by experts in connection with the school clinic. Both he and the organiser of physical training should co-operate, not only in regard to the training of children already suffering from definite physical defects, but also in regard to the prevention of avoidable defects by means of exercises correctly taught and applied. The following observations were made upon these Regulations: "Up to the present time in London the position of the school medical service in relation to physical exercises in the schools in general has been one of friendly interest, but attention to the question has not been definitely within the school medical officer's reference and no part of the time of the staff in the school medical service has been allotted to it. During school medical inspections the effect of drill upon the individual children is noted by the school doctors and modifications or excusal from drill are advised by them in individual cases; these recommendations are invariably followed by the teachers whose attention the doctors draw specifically to each case. Occasionally broad questions such as the manner of teaching breathing exercises are brought to my notice and they then form the subject of discussion between the Education Officer and myself. In the second paragraph of the circular it is suggested that the school medical officer should also exercise supervision over all special arrangements designed for particular children. In London such special arrangements have been regarded as within the reference of the school medical officer and have been the subject of special reports to the appropriate sub-committees of the Education Committee. The closest co-operation in regard to such remedial classes has been established between the inspectors of physical exercises and the school medical staff." During the year a definite step forward has been taken by the Council in including in their Treatment Scheme provision for a remedial exercises centre in Hampstead to which children from the elementary schools are referred by the school doctor. Any departure or experiment which tends to stimulate or revive interest in physical exercises in the schools is to be encouraged as the beneficial results of special interest are so unmistakable. In every school class there will be found two or three pupils who hold themselves badly and adopt habitual postures, which tend to produce deformity and to interfere with correct growth. Such children do not require at this stage specialist treatment, or the use of apparatus. All that is necessary is that they should be drafted into a smaller class than is usual, which should meet much more frequently than is found necessary for average children, should be under an enthusiastic and capable teacher, and should receive the special notice of the school doctor at his periodical visits. In the ordinary large class, which when spaced out in drill order, fills a large hall, individual children cannot possibly be closely supervised, but the special class being relatively small, each child comes more directly under the eye of the teacher, who is able to see that the movements are correctly produced. The close association of the school doctor with the class enables modifications of the ordinary drill movements to be made in relation to special needs, enables him to measure the progress of the pupils and brings him into close co-operation with the organiser of physical exercises. Experience has abundantly shown that through the medium of such special classes the common. deformities in childhood can be prevented or corrected, if they are dealt with while the conditions are in the early stage when habitual defect of posture is alone present and before structural alteration due to faulty resultant growth has had time to appear. Since 1912 a certain number of such special exercise classes has existed in the Council's schools. In 1913 they numbered 28, but since that time, in common with all other experimental work in the schools they have been subject to considerable vicissitudes. During the year 1918 there have been 20 classes; most of these were continued throughout the year, although some were discontinued for short periods owing to difficulties in connection with the teaching staff. There is a certain amount of danger that the teachers in their anxiety to do more for the children may attempt to do too much in the way of remedial exercises and 'encroach upon the domain of the trained gymnast. For this reason the supply of special apparatus to these classes is not strongly to be recommended. The special classes, in the North Eastern Division numbering eight, are under the special observation of Dr. F. C. Lewis, the Divisional Medical Officer, who inspects the children each term. Milk is provided for each child every morning and special gymnastic dress is compulsory. The results of the classes are very gratifying as is shown by Dr. Lewis' analysis of the girls' class at Moreland-street taken as an example. Special Class of Physical Exercises at Moreland-street (G.) 1917. 1918. 1917. 1918. 5 Kypho-scoliosis with marked shoulder inequality (3 of these children were in the class from 1916) 2 cured. 7 General weakness and mouth breathing 3 cured. 3 improved. 4 greatly improved. (excluded class, June 1917, owing to rheumatism) 1 child (anasmia) 4 Kypho-lordosis, marked (2 with myopia) 4 improved greatly. 3 scoliosis only (postural curve) 2 disappeared 20 1 cured. — 50129 E 2 52 Ventilation, occupation and illumination in relation to the hygienic conditions of classrooms. Arising out of complaints of "dry throat" and other unsatisfactory physical conditions at certain mechanically ventilated schools, an inquiry has been carried out during the past four years by Mr. E. T. Swinsor, one of the Council's Inspectors, at Berner-street, Christian-street, Commercial-street and South Hackney Central Schools. Classrooms for comparison were selected as nearly alike as possible in respect to size, aspect, occupation, general circumstances and surroundings. Double control tests were frequently used, and the temperature and humidity of the external air were ascertained at the same time as the aerial state of the classrooms. The factors investigated comprised (1) heat, (2) humidity, (3) odours, and (4) air-movement The carbonic acid pollution was not taken into account, the view being accepted that none of the symptoms produced as a result of poor ventilation, are due to its presence. The observations made in regard to these factors under varying conditions of ventilation and artificial illumination are detailed below, reference being made to diagram C where necessary. Temperature results under natural lightmgwith (a) natural and (b) mechanical ventilation. Fig. 1 shows the heat increment during the day under summer conditions, in which the increase in temperature inside the classrooms, as compared with the external temperature or entering air, is solely due to body heat given off by the occupants. Under natural ventilation the maximum excess of room temperature is 7.5 deg. F., but with mechanical ventilation the maximum excess is only 3.5 deg. F. The result for the naturally ventilated classroom is more favourable than generally obtained, because the means of ventilation were fully utilised. In the case of the mechanically ventilated room, the comparison made is that between the entering air at the inlet and the room temperature itself. As the entering air was cooled by the process of washing to a point 5 deg. below the outside air, the room temperature, in spite of occupation, never exceeded that of the external air. Under winter conditions (Fig. 2), the room temperature is affected by artificial heating, as well as by heat emitted by the occupants. The naturally ventilated room shows an excess at the end of the day over the external temperature of 16 deg., but in this total the whole of the effect of the artificial heating is included; the rise of room temperature during the day is 6 deg. In the mechanically ventilated room, where the air is already heated before it arrives at the inlet, the rise of room temperature is only 1 deg., but while the room temperature is at the outset 1 deg. below the inlet temperature, it is at the end of the day 2 deg. above. The influence of gas and electric lighting upon temperature u n d e r (a) natural ventilation and (b) mechanical ventilation. Fig. 3 contrasts the conditions in two naturally ventilated classrooms one empty and the other occupied—under winter conditions, with direct heating in all cases, but with varying conditions of artificial lighting. Curve A gives the results in a room occupied and gas lighted; B gives a room unoccupied and gas lighted; while C gives a classroom occupied without gas light. The large amount of heat increment due to gas lighting is seen at a glance. Fig. 4 shows the same thing in relation to mechanically ventilated rooms. When this diagram is compared with Fig. 2, the excessive room heating produced by gas lighting is at once manifest. The room B, which was unoccupied during the afternoon, but in which the gas was lighted, had an air supply of 72,000 cubic feet an hour; yet there was an increase in temperature due to gas lighting of 6 deg. The influence of electric lighting is shown in Fig. 5. An increase of absolute humidity was found under all conditions of lighting and ventilation— an increase arising solely within the room from the occupants and illuminant. With natural ventilation the relative humidity decreased under winter conditions to the mean extent of 14 per cent. (occupation and natural lighting); 12.5 per cent. (occupation plus gas lighting); and 15 per cent. (gas lighted unoccupied rooms). In summer there was a mean increase of 6.3 per cent. under occupation with natural lighting. The winter results disclose an excessive drop in the humidity, and the summer an undesirable increment. With mechanical ventilation the conditions were reversed, for the winter conditions indicated increases up to 7.2 per cent., while in summer there was a definite mean decrease of 10.8 per cent.—conditions tending towards the maintenance of a suitable atmosphere. A large supply of air is needed to carry off the heat evolved within the room from the occupants and from gas-lighting. Moreover, the state of the initial air-supply and the condition of the room content as regards temperature and moisture markedly regulate the loss of heat and moisture by the occupants, causing sensations of comfort or discomfort. Under mechanical ventilation, with natural or electric lighting, odours were conspicuously absent below a temperature of 67 deg. F., whereas with natural ventilation they were frequently noticed with a temperature of 60 deg. F.; a result attributable to inadequate air-changes. The range of 9 a.m. temperatures, January to April, is shown in Fig. 6, In general, the enquiry leads to the following conclusions:— Proper limitation of the maximum temperature, the elimination of dust, the regulation of the humidity and freedom from odours, can only be obtained by a plentiful supply of clean and otherwise suitable air. In crowded areas it may be desirable to provide mechanical ventilation coupled with regulated warming and means for washing and cooling. Failing this the difficulties in producing and maintaining proper ventilation by artificial or natural means under town conditions should lead to the adoption of open air methods of education wherever practicable. If mechanical ventilation is employed the provision should be based upon a minimum air supply per child per hour with heating surfaces capable of warming such supply to a minimum standard. If the winter minimum supply were put at 1,750 to 2,000 cubic feet, with an initial temperature of 55 deg., the maximum could easily be kept under 62 deg. F. If gas is used for illumination, even with a minimum supply of 2,500 cubic feet of air the total temperature increment would be at least 10 deg. Heating provision should be based on warming the hourly air supply to a minimum of 55 deg. F., when the external temperature stands at 30 deg. below this, and this provision should be made both with mechanical and natural ventilation. 53 TABLE A. Table showing the results of medical inspection in London Elementary and Special Schools. Entrants. Intermediate. Leavers. Total in Age Groups. Special cases. Special schools. Boys. Girls. Boys. Girls. Boys. Girls. Boys and Girls. Boys. Girls. Children in schools for the mentally defective. Deaf. Myope. Number examined 39,088 38,648 31771 31,423 32,776 33,232 206,938 22,912 24,202 1,318 89 172 % % % % % % % % % % Skin diseases (f) 1,010 2.6 803 2.1 682 2.1 486 1.5 664 2.0 450 1.4 4,095 2.0 2,811 1,915 19 1.4 1 1.1 1 0.6 „ (x) 654 1.7 513 1.3 464 1.4 323 1.0 403 1.2 249 0.7 2,606 1.3 2,481 1,719 12 0.9 1 1.1 1 0.6 Enlarged tonsils (f) 6,591 16.9 6,517 16.9 4,232 13.3 4,470 14.2 3,033 9.3 3,740 11.3 28,583 13.8 674 876 132 10.0 4 4.5 12 7.0 Adenoid growths (f) 3,134 8.0 2,552 6.6 1,876 5.9 1,518 4.8 1,096 3.3 913 2.7 11,089 5.4 533 519 114 8.6 1 1.1 4 2.3 Tonsils or adenoids (x) 3,078 7.9 2,785 7.2 2,149 6.8 2,009 6.4 1,354 4.1 1,444 4.3 12,819 6.2 815 915 85 6.5 — 5 2.9 Other throat or nose defects (f) 1,227 3.1 840 2.2 900 2.8 599 1.9 817 2.5 543 1.6 4,926 2.4 283 329 80 6.1 3 3.4 8 4.7 „ „(x) 248 0.6 163 0.4 223 0.7 133 0.4 203 0.6 146 0.4 1,116 0.5 217 240 21 1.6 — — Enlarged glands of neck (f) 3,836 9.8 3,566 9.2 3,387 10.7 2,939 9.4 2,391 7.3 2,446 7.4 18,565 9.0 247 253 118 9.0 1 1.1 14 8.1 „ „ (x) 144 0.4 120 0.3 135 0.4 102 0.3 57 0.2 67 0.2 625 0.3 112 123 6 0.5 — — Dental defects (x) 11,030 28.2 10,922 28.3 10,135 31.9 9,853 31.4 7,863 24.0 7,979 24.0 57,782 27.9 1,198 1,382 320 24.3 8 9.0 32 18.6 External eye disease (f) 1,847 4.7 1,853 4.8 1,186 3.7 1,237 3.9 892 2.7 943 2.8 7,958 3.9 895 951 94 7.1 2 2.2 14 8.1 „ „ (x) 1,150 2.9 1,155 3.0 620 2.0 612 1.9 400 1.2 398 1.2 4,335 2.1 740 800 38 2.9 — 2 1.2 Vision (x) — — 3,116 9.8 3,387 10.8 4,524 13.8 4,913 14.8 15,940 12.6 1,667 1,955 179 14.6 — — Ear disease (f) 957 2.4 970 2.5 621 2.0 642 2.0 637 1.9 647 1.9 4,474 2.2 947 693 49 3.7 1 1.1 5 2.9 „ „ (x) 564 1.4 554 1.4 383 1.2 353 1.1 423 1.3 403 1.2 2,680 1.3 705 533 32 2.4 — — Defective hearing (f) 317 0.8 330 0.9 400 1.3 405 1.3 467 1.4 473 1.4 2,392 1.2 276 271 62 4.7 4 4.5 6 3.5 „ (x) 87 0.2 87 0.2 150 0.5 152 0.5 187 0.6 209 0.6 872 0.4 205 209 25 1.9 — 1 0.6 Stammering (f) 56 0.1 28 0.1 64 0.2 33 0.1 152 0.5 46 0.1 379 0.2 38 13 9 0.7 — 2 1.2 „ (x) 3 0.0 1 0.0 5 0.0 1 0.0 13 0.0 6 0.0 29 0.0 24 10 — — — Other speech defects (f) 219 0.6 124 0.3 178 0.6 94 0.3 109 0.3 82 0.2 806 0.4 38 24 33 2.5 3 3.4 3 1.7 „ (x) 5 0.0 3 0.0 5 0.0 2 0.0 3 0.0 5 0.0 23 0.0 11 8 — — — Heart defects (f) 1,002 2.6 982 2.5 1,066 3.4 1,101 3.5 1,109 3.4 1,535 4.6 6,795 3.3 439 670 72 5.5 3 3.4 5 2.9 „ (x) 47 0.1 51 0.1 48 0.2 71 0.2 77 0.2 102 0.3 396 0.2 124 215 4 0.3 — — Anaemia (f) 1,899 4.9 1,746 4.5 1,379 4.3 1,510 4.8 972 3.0 1,320 4.0 8,826 4.3 452 719 57 4.3 16 18.0 4 2.3 „ (x) 559 1.4 507 1.3 448 1.4 492 1.6 285 0.9 438 1.3 2,729 1.3 297 444 17 1.3 4 4.5 1 0.6 Lung complaints (f) 3,103 7.9 3,011 7.8 1,479 4.7 1,347 4.3 967 3.0 934 2.8 10,841 5.2 624 620 78 5.9 3 3.4 8 4.7 „ (x) 868 2.2 907 2.3 339 1.1 296 0.9 170 0.5 138 0.4 2,718 1.3 305 280 17 1.3 2 2.2 1 0.6 Nervous diseases (f) 429 1.1 463 1.2 425 1.3 446 1.4 326 1.0 454 1.4 2,543 1.2 552 720 46 3.5 — 4 2.3 „ (x) 73 0.2 61 0.2 73 0.2 52 0.2 52 0.2 71 0.2 382 0.2 247 302 8 0.6 — 1 0.6 Phthisis (f) 46 0.1 59 0.2 51 0.2 62 0.2 60 0.2 60 0.2 338 0.2 187 193 1 0.1 — 1 0.6 „ (x) 24 0.1 26 0.1 28 0.1 33 0.1 22 0.1 29 0.1 162 0.1 111 116 — — 1 0.6 Other tubercular disease (f) 134 0.3 88 0.2 81 0.3 70 0.2 80 0.2 69 0.2 522 0.3 225 210 3 0.2 — 2 1.2 „ (x) 55 0.1 24 0.1 26 0.1 26 0.1 24 0.1 19 0.1 174 0.1 114 115 1 0.1 — 1 0.6 Rickets (f) 1,208 3.1 604 1.6 575 1.8 306 1.0 384 1.2 250 0.8 3,327 1.6 71 63 42 3.2 — 4 2.3 „ (x) 139 0.4 82 0.2 16 0.1 10 0.0 33 0.1 7 0.0 287 0.1 42 39 3 0.2 — — Deformities (f) 486 1.2 285 0.7 471 1.5 486 1.6 580 1.8 945 2.8 3,253 1.6 190 262 50 3.8 1 1.1 10 5.8 „ (x) 159 0.4 72 0.2 102 0.3 144 0.5 145 0.4 319 1.0 941 0.4 119 144 4 0.3 1 1.1 3 1.7 Infectious disease (f) 68 0.2 60 0.2 23 0.1 17 0.1 7 0.0 12 0.0 187 0.1 69 88 1 0.1 — — „ (x) 42 0.1 39 0.1 14 0.0 8 0.0 5 0.0 5 0.0 113 0.1 44 56 1 0.1 — — Malnutrition (f) 403 1.0 378 1.0 318 1.0 324 1.0 155 0.5 171 0.5 1,749 0.8 157 169 7 0.5 1 1.1 — „ (x) 233 0.6 239 0.6 202 0.6 210 0.7 71 0.2 90 0.3 1,045 0.5 95 99 2 0.2 1 1.1 — Other defects (f) 1,291 3.3 1,186 3.1 899 2.8 922 2.9 814 2.4 1,020 3.1 6,132 3.0 973 1,247 38 2.9 3 3.4 4 2.3 „ (x) 719 1.8 635 1.6 470 1.4 464 1.5 361 1.1 408 1.2 3,057 1.5 618 709 13 1.0 1 1.1 2 1.2 Number of cases noted for treatment 16,566 42.4 15,915 41.2 15,253 48.0 15,194 48.4 13,957 42.6 14,589 43.8 91,474 44.2 8,706 9,409 646 49.0 19 21.3 59 34.3 Number of cases where parent was present 27,480 70.3 27,716 71.7 16,309 51.3 18,194 57.9 11,925 36.3 15,748 47.4 117,372 56.7 465 35.3 12 13.5 56 32.6 = Defects found. x = Defects noted for treatment. * The number of children with defective vision appears in Table B. 54 TABLE B. Number and percentage of children in each age group classified as regards clothing, nutrition, cleanliness, condition of teeth, visual acuity and mental capacity. Clothing and Footgear. a Nutrition. b Cleanliness of Head. c Cleanliness of Body. d Condition of Teeth. e Visual Acuity. f Mental Condition. g 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Entrants Boys No. 22,666 15,756 666 12,269 24,972 1,836 11 36,314 2,725 49 35,078 3,846 164 17,842 13,462 7,784 39,088 % 58.0 40.3 1.7 31.4 63.9 4.7 92.9 7.0 0.1 89.7 9.8 0.4 45.6 34.5 19.9 Girls No. 22,198 15,820 630 12,094 24,847 1,699 8 30,770 7,650 228 34,239 4,230 179 17,385 13,787 7,476 38,648 % 57.5 40.9 1.6 31.3 64.3 4.4 79.6 19.8 0.6 88.6 10.9 0.5 45.0 35.7 19.3 Intermediate Boys No. 16,290 14,488 993 6,274 23,219 2,270 8 29,111 2,618 42 27,198 4,376 197 12,211 13,423 6,137 11,745 12,938 6,072 29,974 1,752 45 31,771 % 51.3 4.5.6 3.1 19.7 73.1 7.2 91.6 8.3 0.1 85.6 13.8 0.6 38.4 42.3 19.3 38.2 42.1 19.7 94.4 5.5 0.1 Girls No. 17,140 13,728 555 6,688 22,678 2,051 6 22,410 8,741 272 26,834 4,401 188 12,520 12,992 5,911 10,616 13,339 6,655 29,918 1,467 38 31,423 % 54.5 43.7 1.8 21.3 72.2 6.5 71.3 27.8 0.9 85.4 14.0 0.6 39.9 41.3 18.8 34.7 43.5 21.8 95.2 47 0.1 Leavers Boys No. 16,783 14,803 1,190 8,246 22,792 1,731 7 30,085 2,650 41 27,523 4,994 259 15,979 14,391 2,406 17,154 8,374 7,055 30,556 2,214 6 32,776 % 51.2 45.2 3.6 25.2 65.9 5.3 91.8 8.1 0.1 84.0 15.2 0.8 48.8 43.9 7.3 52.6 25.7 21.7 93.3 6.7 0.0 Girls No. 18,137 14,514 581 8,951 22,530 1,744 7 24,220 8,757 255 28,348 4,723 161 16,537 14,406 2,289 15,573 9,705 8,019 30,961 2,267 4 33,232 % 54.6 43.7 1.7 26.9 67.8 5.3 I 72.8 26.4 0.8 85.3 14.2 0.5 49.8 43.3 6.9 46.8 29.1 24.1 93.2 6.8 0.0 Total No. 113,214 89,109 4,615 54,522 141,038 11,331 47 172,910 33,141 887 179,220 26,570 1,148 92,474 82,461 32,003 55,088 44,356 27,801 121,409 7,700 93 206,938 % 54.7 43.1 2.2 26.3 68.2 5.5 83.0 16.0 0.4 86.6 12.9 0.5 44.7 39.8 15.5 43.3 34.9 21.8 93.9 6.0 0.1 Special Schools No. Bovs and Girls 524 935 120 233 1,141 205 1,105 454 20 1,014 535 30 646 726 207 290 598 414 204 43 3 1,579 % 33.2 59.2 7.6 14.7 72.3 13.0 70.0 28.7 1.3 64.2 33.9 1.9 40.9 46.0 13.1 22.3 45.9 31.8 81.6 17.2 1.2 The classification is that set out in the Board of Education Schedule, a l=good, 2=fair, 3=bad. b l=excellent, 2=normal, 3=below normal, 4=bad. c l=clean, 2=nits only, 3=pediculi. d l=clean, 2=dirty, 3=pediculi. e l=sound, 2=less than 4 decayed, 3=4 or more decayed. f 1=6/6 in both eyes, 2=6/9 in either eye, 3=6/12 or worse in either eye. g l=normal, 2=dull or backward, 3=mentally defective. Entrants are not examined as to visual acuity or mental condition. 55 TABLE C. Result of re-inspections carried out during 1918. Percentages in italics. 1st Re-inspections. Treatment Provided. Not Treated. By doctor. Under Council's scheme. At other hospitals. Treatment no longer necessary Requiring observation only Treatment still required. Cured. Not Cured. Cured. Not Cured. Cured. Not Cured. Refraction 88 79 3,865 2,622??? 621 504 707 1,372 7,861 17,719 % 0.5 0.4 21.a 14.8??? 3.5 2.8 4.0 7.7 44.4 Nursing treatment cases 251 43 1.657 596 545 230 1,887 587 1,734 7,530 % 3.3 0.6 22.0 7.9 7.2 3.1 25.1 7.8 2310 Ear, nose and throat. 107 32 2,211 251 781 126 857 1,768 6,701 12,834 % 0.8 0.2 17.2 2.0 6.1 1.0 6.7 13.8 52.2 Teeth 1,309 607 13,097 1,084 1,280 399 2,800 1,459 26,579 48,614 % 2.7 1.2 26.9 2.2 2.6 0.8 5.8 3.0 54.7 Other ailments 391 215 16 97 1,289 1,202 2,268 2,957 2,604 11,069 % 3.5 1.9 0.4 0.9 11.6 10.9 20.5 26.7 23.5 Total 2,146 976 20,876 4,650 4,516 2,461 8,519 8,143 45,479 97,766 % 2.2 1.0 21.4 4.8 4.6 2.5 8.7 8.3 46.S 2nd Re-inspections. Treatment Provided. Not Treated. By doctor. Under Council's scheme. At other hospitals. Treatment no longer necessary Requiring observation only. Treatment still required. Cured. Not Cured. Cured. Not Cured. Cured. Not Cured. Retraction 60 55 2,678 2,270 460 454 862 1,529 6,697 15,065 % 0.4 0.4 17.8 1.51 3.1 3.0 5.7 10.1 44.4 Nursing treatment cases 61 34 585 433 185 161 832 394 1,103 3,788 % 1.6 0.9 15.4 11.4 4.9 4.3 22.0 10.4 29.1 Ear, nose and throat 50 16 1,099 126 480 87 973 1,239 4,507 8,577 % 0.6 0.2 12.8 1.5 5.6 1.0 11.3 14.5 52.5 Teeth 838 484 5,131 560 673 303 2,076 697 16,410 27,172 % 3.1 1.8 18.9 2.1 2.5 1.1 7.6 2.6 60.4 Other ailments 146 90 53 76 618 906 1.587 2,201 1,762 7,439 % 2.0 1.2 0.7 1.0 8.3 12.2 21.3 29.6 23.7 Tota 1,155 679 9,546 3,465 2,416 1,911 6,330 6,060 30,479 62,041 % 1.8 1.1 15.4 5.6 3.9 3.1 10.2 9.8 49.1 Cases noted as requiring observation. No. of cases. Discharged as cured. Still requiring observation, or treatment. 1st Reinspection 25,316 7,116 28.1 18,200 71.9 2nd Reinspection 13,991 4,151 29.7 9,840 70.3 56 TABLE D Scholars—Defects noted on medical examination. Institutions. No. examined. Defects. Teeth. Vision. Throat and nose. Bars. Heart. Lungs. Anaemia. Back. Nutrition. Various. Defective. Signs of eye-strain. Hearing. Discharge. Round. Curvature. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (i.) L.C.C. Training Colleges, Secondary and Trade Schools. Training colleges. Males 15 3 3 — — 1 — — — — 1 1 — 3 Females 1,372 185 302 23 14 16 1 14 16 62 125 34 26 146 Secondary schools. Males 701 129 95 3 35 2 2 21 7 31 11 — 4 62 Females 3,497 737 665 103 172 31 19 114 33 70 393 200 204 404 Trade Schools. Males 385 71 43 6 8 3 5 5 4 11 3 1 2 23 Females 385 86 149 9 18 4 2 17 5 10 24 25 16 53 (ii.) Secondary asd Trade Schools, aided but not maintained by the Council. Secondary schools. Males 303 55 46 1 11 1 2 4 2 4 4 — 1 9 Females 747 69 130 10 25 2 4 12 5 12 16 12 13 38 Trade schools. Males 293 72 36 — 24 4 4 6 2 — 1 — — 7 Females 255 69 ??? 9 12 — 2 9 2 7 19 6 1 47 APPENDIX. INFLUENZA. REPORT BY THE COUNTY MEDICAL OFFICER OF HEALTH. The year 1918 stands out as a great influenza year. Account has been given in annual report,s to the Council 1914-17 of the prevalences in those years of cerebrospinal fever and poliomyelitis which it was urged, must be regarded as standing in close relation with the comparatively small number of scattered cases of influenza then occurring; important observations having an intimate bearing upon this hypothesis have, moreover, been made by Lieut.-Col. Dorgan, in connection with cerebrospinal fever in army camps ; and more recently Dr. F. G. Crookshank, in his Chadwick lectures and elsewhere, has studied the close relation to influenza of the Heine-Medin disease. Reference must also be made to papers by Lieut.-Col. French and his colleagues, on epidemic influenzal "pneumonia" of highly fatal type, and its relation to "purulent bronchitis." (Lancet, Sept. 8th, 1917 and Jan. 4th, 1919.) It was thus already surmised prior to 1918 that important developments in regard to influenza might be expected, but the realisation has in many particulars differed from the anticipation; so true it is that influenza ever creates the impression of being a "new disease." Sydenham said "if any one ask how he is to fish out the species" of a particular fever, "let him choose for his field of observation some large and populous place." Clearly the observer who ventures to describe so complex an "epidemic constitution" as that of 1918, will be wise if he follow this advice. If London, however, is to be the place selected it must be realised that the honourable obligation is imposed of striving to keep in view as far as may be the behaviour there throughout the historical period of the most Protean of diseases ; more in fact has been written about influenza in London than anywhere else, and it is, therefore, especially necessary that experience gained there should not be neglected. It is recorded of one of the earliest influenzas of history, the sweat of 1485, that it killed two successive Lord Mayors and four Aldermen; again, the mortality per 1,000 of population in the sweat of 1551 is fairly accurately known, and appears to have been, if anything, somewhat higher than that of the 1918 prevalence; then there are open for study the classical descriptions by Sydenham of the influenzas and epidemic agues of the early years of the latter half of the 17th century; and so on down to the descriptions of the modern pandemic visitations of 1847 and 1890 given by such writers as Drs. Peacock and Franklin Parsons. For adequate treatment of the subject an "extensive and peculiar" knowledge, at least of the London influenzas, is to be desired; but any contribution to this will be of little value if the subject be not approached from the natural history point of view. As Creighton has said in another connection, the older or Hippocratic method must be applied. This is one which "took account of gradations, modifications, affinities, being careless of symmetry, of definitions or clear cut nosological ideas, or the dividing lines of a classification." The attempt to comply with such conditions will involve reference to the sweats, agues, spotted fevers and lethargies of the early centuries; then, throughout, to obscure pneumonias, certain outbreaks of "typhus" and various "new diseases"; and finally in the modem period to poliomyelitis, polioencephalitis and cerebrospinal meningitis. Inasmuch, however, as a large number of detailed studies from special points of view of the problem presented by the influenzal group of diseases have recently appeared, it is only proposed here to deal with the broadest aspects of the subject. The report consists of two parts:— 1. A review of recent influenzal prevalences. 2. A study of the light thrown upon these epidemics by earlier prevalences, with a summary view of the epidemiology of the influenzal group of diseases. PART I. The recent influenza prevalences. Following upon the cerebrospinal fever, poliomyelitis, etc., of 1914-17 (see Annual Reports The first for those years, and Proc. Roy. Soc. Med. Vols. VIII., X. and XII.) the first indication of the recent beginning new development was afforded by a rise in the general death rate and in the rates for respiratory diseases and influenza in the 51st week of 1917, and the maximum number of deaths from bronchitis (283) and influenza from influenza (16) was attained three weeks later (see Table p. 4). In this first wave of exceptional mortality, the deaths from bronchitis and pneumonia were notably increased, those from " influenza " 50129 H The first beginnings of the influenza of 1918-19 in London. 2 only very slightly. There were, however, numerous cases of mild influenza in London and the epidemic continued to smoulder; then a second smaller wave of exceptional mortality swelled from about the 9th to the 18th weeks of 1918, in this the maximum number of deaths from bronchitis (153), was attained in the 10th week and the maximum number from influenza in the 15th, (and during this period the "obscure disease with cerebral symptoms," first began to attract attention). Furthermore, among the deaths registered as due to pneumonia about this time there were certain grouped cases noted as being of unusual character. Then a third wave of excessive mortality rose to its height from the 24th to the 30th weeks; in this outbreak, to be referred to later as the summer prevalence of influenza, the maximum number of deaths from bronchitis (74) and from influenza (287) occurred in the 28th week. Suspicion that something new and special in the behaviour of influenza in London was in question had in the first instance, been definitely aroused in December, 1917, on the occurrence of a sudden fatal illness in a reformatory school boy. The death was attributed to "congestion of the lungs," and it took place just prior to the time when the general death rate in London showed its first distinct rise. Four further deaths occurred at intervals of some weeks, among boys from this same school; one on the 28th January, registered as due to "apical pneumonia," one on the 23rd February, due to "phthisis," one on the 12th April, attributable to cerebrospinal meningitis, and one on the 11th July, which was registered as "influenza" at Wisbech where this disease was prevalent. These deaths must be regarded with great suspicion; the signs found at the autopsies were obscure and the illnesses proved rapidly fatal; the presumption naturally arose that they might be associated one with another, despite the interval of time between the first and the last death. The above outbreak resembles a number of others which have been recorded in industrial and reformatory schools. Thus a similar prevalence was reported by Dr. A. MacLean in the Lancet (of 13th July, 1918) affecting three factories (420 cases) and an industrial school (16 cases) in Glasgow; and Dr. MacLean refers further to a like outbreak attacking some 280 persons in two industrial schools, a public school and a hosiery manufactory in the county of Lanark. "The greater number of cases in the county presented the same symptoms,and there were 8 deaths, 7 from one industrial school and one from another." These outbreaks further call to mind illnesses such as those recorded by Dr. J. B. Russell in 1888 in a Glasgow industrial school, or that described in the Scottish Office Report on an outbreak in St. Joseph's Industrial School, Tranent, in 1911. There is, moreover, an account of a similar outbreak by Drs. McNeil and McGowan in the Edinburgh Medical Journal, 1913 (p. 201). In other institutions, serious prevalences of pneumonia were recorded last year; one such instance was that referred to in a report to the London County Council upon unusual mortality during 1918 at Claybury Asylum,. It is further noteworthy that from the beginning of the year until May, Dr. Manby, of the Local Government Board, was able to trace certain obscure illnesses among gipsies in Sussex, at first looked upon as cases of pneumonia and then later regarded as typhus. (See Note on Typhus, Annual Report for 1918. Part I.) The "obscure disease with cerebral symptoms." The impression that a special epidemic influence was at work was further confirmed by the occurrence of a considerable number, some dozens, of cases presenting somewhat unusual cerebral symptoms. Side by side with the ordinarily occurring cerebrospinal meningitis, of which there had been a few examples each week throughout the early months of 1918, and of poliomyelitis of which a few were notified from April onwards, there were cases developing symptoms (ophthalmoplegia, facial palsy, etc.) indicative of polioencephalitis. Attention was pointedly called to the fact by two papers in the Lancet of the 20th April, one entitled "Acute Infective Ophthalmoplegia or Botulism" by Dr. Wilfrid Harris, the other "Toxic Ophthalmoplegia" by Dr. Arthur J. Hall. The cases could not, in spite of the most careful enquiry be connected with any particular article of food—they did not even affect persons who had partaken of any common meal. Failing positive answers to enquiries as to sausages, tinned foods, etc., the suggestion was made that potatoes might be at fault, but as to this no evidence was forthcoming. The Local Government Board in a memorandum, issued in May, stated that the earliest traceable case of the "obscure disease with cerebral symptoms," as it was agreed to call it provisionally, developed on the 26th January, and it was officially declared that "no particular food has been found to be related to the outbreak," and that there was "no bacteriological evidence of botulism. Dr. F. G. Crookshank in a paper published in the Lancet of the 18th May claimed that the prevalence was really one of the Heine-Medin disease, and in his opinion symptoms indicative of encephalitis, such as ophthalmoplegia, had already been observed during the preceding year. M. Netter in Paris had roted from early in March the frequency of cases with fever, somnolence and ophthalmoplegia, and much comment was provoked in London by the occurrence of stupor in April and May; it was even proposed that the term "epidemic stupor" should be applied to the "new disease." In conjunction with the Medical Officer of the Local Government Board a Schedule of Inquiry as to cases of the " obscure disease with cerebral symptoms" was framed and upwards of 100 forms were filled up by London medical officers of health, as a rule in consultation with one of the Council's staff; for the most part the illnesses in question commenced from the second week in March up to early in May; after that date involvemert of cranial nerve nuclei became, comparatively speaking, rare. Some 30 or 40 cases of the bulbopontine form of encephalitis were thus brought to light, over and above 20 or 30 others recorded in the medical journals. An analysis of the more typical cases, those in which stupor and palsy of one or more cranial nerves were developed, showed that persons of ages ranging from 3 to 43 were attacked, and that though the illnesses were alarming a fatal result was not very frequent. The reports were full as regards the clinical and bacteriological details, but only in a few instances were particulars as to associated illnesses recorded. Replies to an inquiry, as to how long the patient had lived in the neighbourhood where the illness developed, were obtained in 3 29 instances only out of some 100 schedules. In all such instances in which the patient had lived for a number of years in London, the diagnosis was more than doubtful; in the typical polioencephalitis cases the patients were with three exceptions either young children or recent arrivals in London. After June, the botulism theory had become generally discredited; a paper on Epidemic Encephalitis appeared in the Lancet of 6th July, by Dr. S. A. Kinnier Wilson, which indicates the trend of opinion at that date. Dr. Wilson regarded "the nervous disease now epidemic" as an encephalitis, and he specified nine features which he suggested could be relied upon for distinguishing the cases observed in the prevalence from sporadic cases of polioencephalitis. Dr. F. G. Crookshank in a letter to the Lancet of 13th July, pointed out that the epidemiological question as to the relation between the epidemic and sporadic cases is not entirely disposed of by the establishment of distinctions of the kind referred to. A like criticism seems to apply to the criteria to which importance is attached on p. 4 of Sir Arthur Newsholme's Report on the "Obscure Disease" to the Local Government Board. It is stated (p. 7 of that report) that " when the obj ect is to ascertain the nature of an illness, clinical and epidemiological similarities between it and other diseases are of less value than differences." This is, of course, a formula absolutely antithetic and polar to that of Creighton already quoted at the beginning of the present report. Dr. Wilson referred to Economo's cases of "encephalitis lethargica" in Vienna, but he said. "sleepiness, lethargy or stupor may well accompany any form of encephalitis." He added: "it is not clear we are dealing with an entirely new affection," and lie cited Chartier's monograph on a non-suppurative encephalitis in Paris in 1907. He said, moreover, "in the acute encephalitis of influenza and in numerous toxi-infective conditions it has long been recognised that symptoms may occur closely analogous to those under review." He alluded, too, to a paper by Breinl on a "mysterious disease" occurring in Queensland and New South Wales in 1917 and concluded that "what appears to be new is the occurrence in epidemic form of cases of encephalitis, not to all appearance due to the action of a known infective or toxi-infective agent, but presenting clinical symptoms, any or all of which have been noted in various kinds of encephalitis with which the neurologist has long been conversant." In this connection reference should be made to the paper "On some unusual forms of epidemic disease" by Chalmers, Picken and MacLean, which appeared in the Lancet of 13th July, 1918. Chalmers mentions Picken's suggestion that the Glasgow cases constituted an aberrant form of poliomyelitis similar to that presented in the " lethargic encephalitis " of France. So far as the presence of epidemic influenza in London was concerned, the question was finally settled about the middle of June, when certain groups of cases of acute illness occurred. The first of these was reported by Dr. A. E. Thomas on the 14th June. Dr. Pal grave ascertained that there were some 40 cases among girls in a mantle maker's establishment; severe frontal headache, pain in the eyes, back and limbs with moderate pyrexia, were observed, and the illness lasted about three days, leaving the patient depressed in mind and weakened in body. Dr. Brincker reported on the same day, on a similar outbreak occurring in Chiswick, when he found in addition to the afore-mentioned symptoms that sweating was common. On the 15th June, Dr. Hugh Dickson called and gave me full particulars of an outbreak occurring in the staff of the Medical Officer of Customs at Newington Butts. The symptoms described by Dr. Dickson were—" sudden onset with headache, feeling of extreme depression and anger, fever, sore throat, muscular pains, marked sweating on first day of illness (some of the sweats offensive), aching at the back of the eyeballs, cough, no rash, illness of two or three days' duration, followed by marked depression." The first indication o the appearance of influenza o the type familiar in pandemic prevalences, Dr. Dickson who had wide experience of the last pandemic influenza (that of 1890) diagnosed "acute influenza," and from that time forward all proffered suggestions as to the existence in London of a supposed " new disease " were discarded. Dr. Dickson pointed out that with the exception of one family, none of the patients had sought medical advice, and in the light of this and numerous subsequent similar observations, there can be no doubt that the prevalence was very widespread; it may, indeed, be further inferred that it was already widely diffused throughout London before any marked effect was produced upon the weekly death-rate, and there can, further, be no question that the deaths from respiratory diseases in January, and the mysterious pneumonias and stupors of the succeeding months, were all part and parcel of the same epidemic prevalence. The reports concerning "botulism," while obscuring the issues at the time, undoubtedly did good service in directing attention to a particular group of symptoms, and in bringing to notice the fact that the symptom complex in question is apt to occur in the development of a pandemic prevalence of influenza. It is a striking fact that even during the height of the ensuing prevalence there was still a curious disposition to attribute cases of undoubted influenza to other causes. Of this the following instance may be given. On the 5th July an outbreak of illness was reported among children who had gone on a "school journey," visiting a village a few miles out of London. In all, 9 of the 36 girls were taken ill. The first two children attacked were held to have scarlet fever, the other 7 to have influenza. Judged in the light of all the known facts no doubt can be felt as to the nature of the outbreak, but there was considerable difficulty at the time in obtaining a hearing for the contention that influenza was responsible for all nine cases. It is now necessary to refer in detail to the three main epidemic waves of declared influenza, the summer (June-July) and autumn (Oct.-Nov.) epidemics of 1918 and the epidemic of the first quarter of 1919. The weekly deaths from influenza, pneumonia and bronchitis are given in the accompanying table:— 50129 H 2 4 LONDON, Registered Weekly Deaths from Influenza, Pneumonia and Bronchitis During 1918 and 1919. No. of Week. Week ended Deaths registered. No. of Week. Week ended Deaths registered. Influenza. Pneumonia. Bronchitis. Influenza. Pneumonia. Bronchitis 1918 1918 1 5 Jan. 13 283 249 37 14 Sept. 14 38 34 2 12 „ 16 235 284 38 21 „ 9 38 40 3 19 „ 13 224 245 39 28 „ 17 55 48 4 26 „ 15 177 148 40 5 Oct. 17 82 55 5 2 Feb. 10 132 130 41 12 „ 80 132 62 6 9 „ 3 123 151 42 19 „ 371 195 96 7 16 „ 10 126 106 43 26 „ 1,256 278 143 8 23 „ 8 155 118 44 2 Nov. 2,458 522 180 9 2 Mar. 15 140 127 45 9 „ 2,433 539 240 10 9 „ 9 164 153 46 16 „ 1,665 464 236 11 16 „ 14 169 121 47 23 „ 1,178 341 251 12 23 „ 16 166 130 48 30 „ 942 266 227 13 30 „ 12 154 121 49 7 Dec. 660 176 210 14 6 April 16 156 124 50 14 „ 322 163 119 15 13 „ 20 145 99 51 21 „ 186 122 128 16 20 „ 11 124 79 52 28 „ 95 103 107 17 27 „ 11 117 117 1919 18 4 May 3 92 84 1 4 Jan. 65 115 136 19 11 „ 7 92 88 2 11 „ 68 112 136 20 18 „ 6 95 65 3 18 „ 43 96 138 21 25 „ 6 95 47 4 25 „ 33 94 147 22 1 June 5 75 47 5 1 Feb. 58 140 157 23 8 „ 5 75 36 6 8 „ 100 182 226 24 15 „ 5 58 48 7 15 „ 273 264 340 25 22 „ 10 72 48 8 22 „ 653 358 421 26 29 „ 67 84 47 9 1 Mar. 808 307 336 27 6 July 218 146 55 10 8 „ 597 218 261 28 13 „ 287 197 74 11 15 „ 435 158 214 29 20 „ 192 132 49 12 22 „ 230 124 172 30 27 „ 86 89 49 13 29 „ 125 118 172 31 3 Aug. 38 50 34 14 5 April 91 103 166 32 10 „ 21 38 31 15 12 „ 105 87 159 33 17 „ 20 42 25 16 19 „ 71 112 129 34 24 „ 12 29 27 17 26 „ 43 83 94 35 31 „ 12 35 34 18 3 May 44 82 102 36 7 Sept. 12 45 23 19 10 „ 29 70 96 Commencement and duration of the three main epidemic prevalences. With regard to the summer epidemic it should be noted that the first week in which the general death rate in London showed increase was that ended 22nd Juno. This increase was, however, small and not general throughout the county, being more noticeable in the south-eastern district than elsewhere. There was no appreciable sign of decline in the attendance of school children in the Council's schools until the following week, the decline then being rather more noticeable in South London. Returns of sickness rates among adults do not show evidence of any epidemic influence until after the middle of June. Two persons suffering from influenza were removed by the Council's ambulances from the streets in the week ended 22nd June, and a case of pneumonia had been dealt with in the previous week; cases of this kind afford a fairly reliable indication of the commencement of an extension of influenza prevalence. The epidemic appears, in the light of the sickness rates among adults, and the effect upon school attendance, to have reached a maximum about the end of the first week in July, and by the middle of August it had practically run its course. The deaths from influenza did not, however, fall to the normal for the time of year until influenza was again becoming epidemic towards the end of September. The first indications of the second or autumn epidemic, in the school attendance figures and in sickness rates, appear in the week ended 5th October. In this week also one case of influenza was dealt with by the Council's ambulance, the number of such cases thereafter increasing continuously up to the end of the month. The school attendance figures indicate that the Northern and South Eastern boroughs were affected rather earlier than other districts. This epidemic apparently dates from the last days of September. From the figures above referred to the maximum incidence appears to have been reached early in the last week of October, and consequently the time elapsing between the commencement and maximum was in London practically the same in both the summer and autumn epidemics, ramely between 3 and 4 weeks. The autumn epidemic, however, continued to affect the school attendance until the end of the autumn session, but the 5 low attendance after the first week in December probably does not represent relatively many new cases of illness. The deaths from influenza were still high at the end of the year, but practically speaking the epidemic came to an end in London about the middle of December. The third epidemic commenced in the latter part of January last; the influenza cases removed from the streets in the week ended 25th January being 6 as against 1 in the week preceding. The maximum number of removals was recorded in the week ended 22nd February, being then 32, and by the end of March the epidemic had practically subsided. Including pneumonia the total cases removed from the streets by the Council's ambulance in the three epidemics numbered 18, 451 and 174 respectively. Children of school age were far less affected during the third prevalence than in the two earlier outbreaks. While this epidemic declined more rapidly than that of the autumn, there was a slight recrudescence in April, and for several weeks the influenza death-rate remained somewhat in excess of that in the weeks immediately preceding the epidemic. The severity of the epidemics may be regarded from two points of view, firstly as to the relative number of cases and secondly as to the relative number of deaths. In regard to cases it may be observed that in the week ended 13th July, at the height of the summer epidemic, the percentage attendance in the Council's schools had fallen to 73.4 In the autumn in the week ended 2nd November, the attendance fell to 70.2, this being the lowest attendance rate recorded in the autumn session. The longer duration of the autumn incidence is well shown in the effect upon school attendance, the amount of school time lost being about twice that lost in the summer. Among adult workers, the sickness rates indicate a loss of working hours between two and three times greater in the autumn than in the summer. The relative number of cases stands, however, in no relation to the severity of the type of influenza in. the two epidemics, since in the summer the deaths in seven weeks among children aged 5-15 numbered 75, an average of about 11 per week, while in eleven weeks of the autumn epidemic there were 1,057 deaths, an average of 96 weekly. The contrast is not quite so great when deaths at all ages are compared. It, therefore, appears from the attendance rates among school children and sickness rates among adults, considered in relation to deaths in the two classes, that while clinical cases of influenza in the autumn were about twice as numerous as in the summer, the deaths, registered from or attributable to epidemic influenza were more than ten times, and the case mortality was about five times as heavy. Figures available in respect of towns where either complete or partial notification was in force, indicate that the deaths in the autumn were disproportionately in excess of the cases when compared with the figures for the summer epidemic. Thus in Copenhagen the cases notified during the autumn epidemic were about two and a half times the number in the summer, but the deaths were probably eight times as numerous. In Stockholm, where returns are made of cases treated among the poorer classes, the autumn cases were three times and the deaths about eight times those of the summer. In Gothenburg the ratios were similar to those for Stockholm. In Christiania, however, while the cases in the municipal hospital were as three to one. the deaths were only as four to one. The death-rate from all causes in Christiania during the summer epidemic rose proportionately more than in any of the principal capital towns for which figures are available. The relative severity of the epidemics. The deaths in London certified to be due to influenza from the middle of June, 1918, to the 3rd May, 1919, numbered 16,520 and of these about 989 may be allocated to the Summer, 11,898 to the Autumn and 3.633 to the Winter erridemic. Estimate of deaths caused by the three epidemics. The total deaths caused by the epidemics may be approximately ascertained from a comparison ( of the weekly deaths in 1917' and 1918 in the periods of epidemic prevalence. Taking the period 23rd June to 10th August as broadly representing the limits of the summer prevalence, it will be found that in the two weeks preceding and following this period there were about 109 deaths per week less in 1918 than in 1917. Assuming that the deaths between 23rd June and 10th August, 1918, would, in the absence of influenza, also have averaged 109 per week less than in 1917, the total in this period would have been 5,370. The actual deaths were 7,553. Hence 7,553 — 5,370 = 2,183 deaths would, as thus estimated, appear to have resulted from the epidemic. Of these about 40 per cent, were among males. The method used in estimating the total mortality due to the summer epidemic is justified by the generally stable mortality in the summer months. In the autumn, however, the rates fluctuate widely under the influence of changing weather conditions, and it happens that in December, 1917, exceptionally unfavourable conditions caused high mortality. In the autumn epidemic, therefore, comparison is limited to the 13 weeks ended 14th December, and in this period the actual excess in deaths in 1918 over 1917 amounted to 15,767 (6,755 males and 8,992 females), and this number is taken to represent the effect of the epidemic. The resulting estimated total deaths for the two epidemics would, therefore, amount to 7,756 males and 10,174 females, a total of 17,930 persons. The estimated mortality from the summer epidemic given is probably rather too high ; on the other hand, deaths resulting from the autumn epidemic occurred for some weeks after the date, 14th December, taken as marking its close, and the resulting estimate is likely to be understated. In round figures about 18,000 deaths in all resulted from the two epidemics, 43 per cent, of which were deaths of males. In the third outbreak during the first quarter of this year some 5,000 deaths may probably be referred to epidemic influenza; but in view of the wintry weather which prevailed during the early weeks of the epidemic it is difficult to arrive at a figure representing deaths attributable directly to the influenza epidemic alone. The increase during the course of the epidemic in deaths classified to other causes than influenza, chiefly pneumonia, bronchitis, diseases of the heart and phthisis, is shown in the following table, which enables comparison to bo made of tho three epidemics in this respect. The figures given, except those for influenza deaths, are the estimated excess in deaths from the causes mentioned during the weeks of marked epidemic prevalence. Increase in other causes of death during the epidemics. 6 Certified cause of death. 1918 Summer epidemic. 1918 Autumn epidemic. 1919 Winter epidemic. Deaths. per cent. Deaths. per cent. Deaths. per cent. Influenza (actual) 894 57 11,336 72 3,278 56 Pneumonia (excess) 534 22 2,181 14 1,014 18 Bronchitis (excess) 111 7 991 6 949 16 Phthisis (excess) 152 10 601 4 246 4 Heart Diseases (excess) 59 4 558 4 368 6 Total 1,750 100 15,667 100 5,855 100 The higher proportion of deaths from bronchitis and heart diseases shown in the winter epidemic does not necessarily represent any increase in complications of these diseases in influenza cases, but probably results directly from the cold weather which prevailed in the early weeks of the epidemic. A considerable number of deaths from these diseases and from pneumonia would have occurred in this period independently of the epidemic. Age incidence of death. The actual and relative incidence of death at various ages certified as due to influenza in the periods of marked epidemic mortality were as follows:— All ages. 0 1 2 5 10 15 20 25 35 45 55 65 75 Deaths registered at each age Sum mer, 1918. 966 16 12 21 27 49 83 100 212 121 122 97 72 34 Aut umn. 1918. 11,663 228 359 839 620 446 818 1,031 2,992 1,420 1,150 766 713 281 Winter. 1919 3,279 87 61 110 65 44 172 225 792 415 430 384 326 168 Deaths at each age per 1,000 at all ages Summer, 1918. 1,000 17 12 22 28 5i 86 104 219 125 126 100 75 35 Aut umn. 1918. 1,000 20 31 72 53 38 70 88 256 122 99 66 61 24 Winter. 1919. 1,000 26 19 34 20 13 52 69 242 127 131 117 99 51 A general comparison of the relative age and sex incidence in London and a group of large towns of England and Wales in the summer and autumn epidemics is shown in the following table:— Metropolitan Boroughs. * Large Towns.* London County. Age Group. Summer Epidemic. Autumn Epidemic. Summer Epidemic. Autumn Epidemic. 3rd Quarter, 1918. 4th Quarter, 1918. m. f. m. f. m. f. m. f. m. f. m. f. 0—5 6 4 16 12 7 5 19 16 6 3 14 10 5—15 5 8 11 9 8 7 11 11 9 9 10 9 15—25 18 17 11 18 13 18 12 16 15 23 12 19 25—45 26 49 31 41 33 41 33 35 28 38 34 40 45—65 27 17 21 13 29 21 18 15 28 17 20 14 65 + 18 5 10 7 10 8 7 7 14 10 10 8 All ages 100 100 100 100 100 100 100 100 100 100 100 100 * The Metropolitan Boroughs comprise Paddington, St. Pancras, Islington, Stoke Newington, Holborn, City of London, Shoreditch, Bethnal Green and Deptford. The large towns are Cardiff, Huddersfield, Leeds, Liverpool, Manchester, Middlesbrough, Newcastle-on-Tyne, Rhondda, Salford, Stoke-on-Trent and Swansea. 7 A distinguishing feature of the autumn epidemic was the relatively higher fatality among children under 5 years of age, chiefly at ages between 2-5 years. The deaths in Chicago, New York, Rome, and other cities, also show in varying degree a high incidence at these ages. There is a suggestion in the figures for the nine metropolitan boroughs for which particulars have been received that the deaths among children under five years of age are relatively highest in the poorest populations. This also appears clearly in the figures for the Dublin registration area. The maximum mortality in London in the autumn prevalence was reached somewhat earlier in the epidemic at those ages in which the total of deaths was highest than at other ages. The age-incidence of influenza mortality in 1918 offers a remarkable contrast to that usually seen in earlier epidemics. The characteristic of influenza mortality has hitherto been a high incidence in infancy and old age. There was observable in the epidemic of 1890, the first of any importance after that of 1847-8, a relatively higher incidence at ages 20-45, than in 1847-8 or in the succeeding years 1891 and 1892; indeed, there is a progressive decline in the relative mortality at these ages in 1891 and 1892 upon that of 1890, and a corresponding increase in incidence at higher ages. In 1893, however, the age-inciderce reverts to that of 1890; and from a comparison of the changes of age-incidence in the six years 1890-1895 the only definite conclusion to be drawn is that the greater the number of deaths the smaller the proportion at ages 20-45. With this rule the 1918 deaths are, however, directly at variance. Nor is it easy to frame any theory of immunity acquired in the epidemics of 1890-95 which will fully account for the abnormal age-incidence of 1918. Nevertheless the effects of immunization (and possibly also of sensitization) cannot be altogether set aside. The interval between the present pandemic and that which commenced in 1890 is shorter by 15 or 20 years than the interval between 1890 and the next preceding pandemic; hence while people aged between 20 and 40 who suffered in the "forties" of the last century would not have survived as a rule until 1890, the people between 20 and 40 who were attacked in the "nineties" of the last century would still be alive in many cases in 1918. Thus on the one hand, if it be assumed that sufferers from repeated attacks, in years about the time of a pandemic prevalence, acquire an immunity which protects them at the time of a later pandemic, this would serve to explain the comparatively light mortality at the higher ages in the recent prevalence. On the other hand, if it be assumed that sufferers in one pandemic prevalence are more liable to attack in later pandemics, the hypothesis would explain how it is that children who suffered markedly in 1890, having grown to ages 25-35 in 1918, again suffered in excess. It may be, however, that there is a difference in age-incidence of mortality in epidemic as compared with endemic and sporadic cases of influenza, analogous to that observed between epidemic cerebrospinal meningitis and sporadic cases of this disease. If that be regarded as a sufficient explanation the extent to which either form of disease is predominant might be held to determine the age-incidence of mortality in any particular year. It has been suggested that the congregation of large numbers of the population of ages between 20-45 in munition works and in camps, may account for the excessive mortality at this age period. While this factor must undoubtedly be taken into account, so far as the mortality at these ages is corcerned, it does not explain the high incidence of death upon children, especially upon those between 2 and 5 years of age. If, however, it could be assumed that a severer type of disease had been predominant among men on service, it might be urged that the civil population with which they come into most intimate association would be their wives, whose ages would average between 20 and 35, and their children of ages mainly between 2 and 15 years. Again, the ages of special incidence, 2-5 and 25-35 are perhaps more affected by restrictions of diet than other ages ; children from 2-5 because of their rapid growth, and particularly their rapid muscular development; ages 25-35 because these are the ages of hard physical labour in the civil population, and, it should be added, this labour has been largely done by the more or less unfit owing to the depletion in war time of the physically fit population ; among articles of diet the reduction of which would have lessened resistance to disease at these ages that of animal fat is probably the most important. Sir Richard Redmayne, Chief Inspector of Mines, in the course of his evidence before the Coal Mines Commission on the 11th March last, stated that so severe were the effects among miners of the epidemic of influenza that in many collieries as many as 50 per cent, of the workers were absent day after day. The mortality in many of the small towns central to mining areas is found to be altogether excessive compared with non-industrial towns of the same size in the autumn. Dr. King Brown, Medical Officer of Health of Bermondsey, in reporting upon the course of the epidemics in that borough, mentions that no cases occurred in the consumptive wards of the infirmary; should this experience prove to be general, light may be thrown on the conditions affecting the incidence of the disease. Consideration has been limited above to the age-incidence of deaths certified as due to influenza. It is, however, evident from the figures given, that many deaths during the course of the epidemic which were certified to be due to bronchitis, pneumonia, phthisis, heart disease, etc., either directly resulted from an attack of influenza or were hastened thereby. Undoubtedly a proportion of these cases would have terminated fatally, independently of the epidemic, but were the number of such instances considerable, there would have been a reaction, after the epidemic had passed, resulting in a decline in the proportion of deaths from these particular causes, since the number of persons suffering fatally from them would have become temporarily reduced below the normal. Of such a reduction there is, however, little or no evidence in the figures. The effect of the epidemic upon the age-incidence of these causes of death is considerable, but as the ages most affected are those of highest influenza mortality the figures given above, relative to the age- Anomalous age incidence of 1918. 8 Incidence upon children of elementary schools, i.) Effect on school attendance. ii.) Incilence upon children of selected schools. Mortality in metropolitan Doroughs. mortality ??? large owns of England and Wales. incidence of deaths certified to influenza, would not be materially modified by the inclusion of the estimated influenzal deaths classified to pneumonia, bronchitis, etc. The effect of the summer epidemic upon the attendance of school children was remarkable, the reduction in the percentage attending schools indicating a greater proportion of cases among children than among working adults, so far as the incidence upon the latter can be judged from the sickness rates available. The figures for the twelve school divisions of the county show that the districts most affected in the summer suffered proportionately less in the autumn, and that the total reduction in attendance for the two epidemics together was not very greatly different in the twelve divisions. This points to the conclusion that a certain definite and fairly constant proportion of the children in each division was susceptible to infection, and that those susceptible children who escaped infection in the summer succumbed in the autumn. No doubt the range of personal contact is greater at the school age than at any other period of life mainly owing to the scramble of play which, it may be remarked, is not much affected by school closure: thus it may reasonably be assumed that in the course of one or other of these two epidemics almost every child 'was exposed to infection. The resulting exhaustion of the "susceptibles" would account for the relatively small effect upon the school attendance of the winter epidemic. Much, indeed, of the reduction in school attendance occurring during the early weeks of that epidemic should rather be attributed to the severe weather than to the effect of illness. In the week of maximum influenza prevalence, the school attendance percentage for London was 85-1 as compared with 89 -4 when the schools opened at the beginning of the year, a fall of only 4-3. In the summer epidemic the maximum, reduction was 15 4 and in the autumn 19 6. The deaths at ages 5-15 in the three epidemics were 75, 1057 and 109 and as the approximate ratio of school weeks lost in the three epidemics was as 4 : 9 : 3 it appears that the case mortality in the winter was far below that of the autumn and about twice that in the summer. Enquiries were made by the school doctors into the incidence of influenza upon the pupils attending the schools under their charge. Particular trouble was taken to ascertain the percentage of children in the higher standards who were attacked, separating those suffering in the summer from those attacked in the autumn. The figures which have thus been obtained relate to about 5,000 children attending the three upper classes of 48 departments scattered over London. The percentages of boys and girls attacked are set out separately. The enquiry was limited to children attending Standards V., VI. and VII., as more reliance can be placed upon information obtained from these children than from those in lower forms and in infant departments. The freakish behaviour of influenza, in general, repeats itself in its behaviour in the schools and strange exceptions show themselves to almost every broad deduction made. It will be noticed that the percentage of boys attacked varied from 10-5 in Holland-street school to 43-5 in Bonner-street school, and the percentage of girls ranged from 14 in Bromley Hall-road to 62 in Alton-street school. The average incidence upon the school population lay between 30 and 40 per cent., in general, being higher on girls than boys. Particular enquiry was made into the previous health of children who died from influenza and schools were as a rule selected for investigation in which deaths had been reported. It appears to have been the general experience that those children who died were either debilitated beforehand or had been away from school previously for some serious ailment other than influenza. A few cases were noted in which children suffered both in the summer and the autumn but they form an infinitesimal percentage of the whole. The children, being in Standards V. to VII., are mainly of higher school age, at which the excess in incidence in the autumn as compared with the summer, was not so marked as at ages between 2 and 10 years. Nevertheless, generally speaking, the figures show that where the percentage attacked was relatively low in the summer the autumn cases were proportionately higher and vice versa. The mortality in the various metropolitan boroughs varies broadly with the general death-rate and infantile mortality, both of which depend mainly upon the social condition of the populations concerned. There are, however, certain points of contrast between the mortalities of the summer and the autumn epidemic and these are best exemplified by figures relating to representative groups of boroughs of the better class and the poorer class of population. It is found that in the summer the mortality in the poorer class attributable to the epidemic was four times that of the better class group, but in the autumn the ratio was only four to three. The conclusion is that populations suffering a relatively heavy summer mortality were proportionately spared in the autumn epidemic, and secondly that the total mortality in both epidemics was conditioned by the social class of the population. The total mortality of the summer and autumn epidemics in the large towns appears, as in London, to be broadly governed by the general death-rate and infant mortality of the town, but these rates are of course controlled by many other factors than social condition, which it is difficult to standardise when different large towns are compared. In Rhondda Urban District, Huddersfield and Middlesbrough, the summer mortality was exceptionally high, but these towns had proportionately reduced mortality in the autumn as compared with other towns. Elsewhere, as in Southampton, Swansea and Cardiff, a relatively light summer mortality was succeeded by a proportionately greater autumn death-rate. On the whole, a general consideration of the estimated total mortality caused by the summer and autumn epidemics leads to the tentative conclusion that in each locality a certain proportion of the population was liable to fatal attack, and the number of those succumbing in the autumn was in large measure determined by the number escaping the summer epidemic without attack. In judging of the severity of type of the disease in the two epidemics, much reliance cannot be placed upon conclusions based upon mortality-rates alone, since it is possible that in one locality nine- 9 tenths of the population might have been attacked in the summer with a mild type of influenza and thus have been protected; while in the autumn the remaining one-tenth may have suffered from the more severe type then prevalent, with the result that the autumn mortality might even exceed that of the summer. The important question was raised at the time of the summer epidemic as to the extent to which underground and above ground employees of the London Electric Railways were attacked, and I am indebted to Mr. Blain, Operating Manager of the London Electric Railways Company, for sickness rates in the two categories of employment. The only statistical comparison it is possible to make is between two populations partially corrected for sex only, one consisting largely of workers underground and the other of above ground workers in the company's omnibus service. The ratio of sickness in these two populations is not greatly affected by the epidemic, although there is some excess in the sickness rate among above ground employees. There are, however, certain differences as to age, length of service, and method of selection for special duties, which would have to be ascertained and allowed for before deductions based upon comparison of the sickness rates in the two services could justifiably be drawn. The sickness rates shown in the Company's figures at the height of the epidemic are much the same as those recorded in the Metropolitan Police Force and in the London Fire Brigade. Infection from person to person may fail to occur, for it is clear from the figures relating to school incidence that large sections of the population are in varying degrees naturally immune. Indeed, experiments show that persons who have escaped during an epidemic have not become infected by deliberate association with influenza patients. No doubt almost any natural immunity can be broken down by sufficiently prolonged exposure, as would appear from the high percentage of attacks recorded on transport ships, amounting, it has been stated, to as much as 80 per cent, of the troops carried. While in some households the disease has passed some members of the family and only affected the rest with a "influenzal" cold, in others the whole family has been fatally attacked in the course of a few days. In considering family incidence the possibility of there being an influenzal diathesis similar to that noted in the case of tuberculosis must, of course, not be lost sight of. In view of the great variations of case mortality at different times and in different localities, it might, perhaps, be held by some that, in the light of more complete knowledge, it may transpire that the cycle of existence of some lowly form of life, inert at one time and at another highly pathogenic, is dependent upon the presence of some substance of vital origin, and on such a theory the exhaustion of the latter would bring the epidemic to a close. Epidemic influenza was beyond a doubt already present among troops in France in April, but its movements there are not clear. It will, moreover, be remembered that during April many cases of obscure illness were reported in London which there was reason to associate with influenza, so that apparently some latent infection was already in circulation here, and indeed in many European cities, before epidemic influenza was reported prevalent. An hypothesis which may possibly account for the facts, in a measure, is that such latent infection remains more or less dormant until certain conditions arise favouring its development. Reference to abnormal weather conditions is found in almost all records of earlier epidemics. In the 10th report of the Registrar-General (p. xxvii) a description is given of the conditions which preceded and were thought to account for the epidemic of November and December, 1847. In the same report details of epidemics recorded since 1728 are given (p. xxxv.), frequent reference being made to exceptional weather conditions. Dr. Parsons reviews the meteorological records in various localities preceding and during the prevalence of influenza in 1889-90 and concludes " there is no evidence that the epidemic was associated with any particular kind of weather." (Report to Local Government Board on the Influenza epidemic of 1889-90 by Dr. Parsons. 1891. d. 821 The weather records for 1918 of England and Wales are epitomized in the following abstracts from the monthly reports of the Meteorological Office:— Monthly weather, 1918. January First part wintry, with snow and severe frost: second part spring-like. February ... ... Abnormally mild: little snow and frost: rainy in North and West. March ... ... Temperature above the normal: rainfall below it. April Temperature below normal: wet in South and East: many dull days. May ... ... Cold at first, then wann: severe thunderstorms and destructive hail. June Plentiful sunshine but nights cold: rainfall deficient. July Sunshine plentiful but rainfall excessive. August Warm, dry and moderately sunny. September ... Abnormally wet and very cold. n October ... ... Dull, damp and sunless. November... ... Damp, misty, foggy. December ... Many rainy days and abnormally mild. In January, 1919, the weather was generally dull and wet and in February an easterly type of weather was predominant. In March, cold and wet weather prevailed. No identical conditions of excess or deficiency in the principal meteorological elements appear to mark the periods of epidemic. An examination of the meteorological records and particularly of barometric readings for different localities, shows that the epidemics were preceded by a noticeable fall in pressure. The fall which preceded the autumn epidemic was far more prolonged and general than that of the summer, as also was the epidemic which followed. The winter epidemic was preceded by a depression early in January, well 50219 I Incidence in relation to exposure to infection. 10 Origin of the epidemic The course of the Epidemic. marked in the records of London and Paris—where the epidemic prevailed in February and March—but absent in the readings for Stockholm, Gothenberg, Copenhagen, Christiania and Amsterdam, in which no winter epidemic occurred. In the epidemics of the nineties, a corresponding antecedent period of low pressure, with the accompanying south-westerly winds and increased temperature, is not always conspicuous, and it is of course, possible that the association observed in 1918 is fortuitous. The time which elapsed between the low pressure period and the maximum epidemic mortality was, in London, from seven to eight weeks. The winter epidemic reached its height, as judged by mortality, in the 9th week of 1919, following a period of low pressure about 11th January. A later depression of only a few days' duration occurred about the 19th February and this may possibly have had some association with the slight recrudescence of influenza mortality shown in the records in April. In should be noted that the particular week in which the maximum mortality occurs does not necessarily stand in any fixed relation in respect of time to the inception of the epidemic. The maximum mortality may be attained within three weeks of the earliest deaths, but the interval may be twice as long or more. In Manchester, for instance, the deaths recorded from influenza do not attain a maximum until the seventh week of prevalence in the autumn, while in Sheffield the maximum was attained in the fourth week. It is difficult to trace the movements of the epidemic owing to the veil which the war has drawn over the incidence of disease in Europe. The official records available in regard to Eastern Europe and the near East are too meagre to serve as means to trace with certainty the early history of the epidemic in these localities It is stated by some to have had its origin in Germany, but the disease was described by the Germans themselves as "Spanische Seuche" and by the Swedes as "Spanska Sjukan." Indeed, so far as the civil population of Europe is concerned, public attention was first directed in the Press to the presence of epidemic influenza by the outbreak at Madrid, which was reported in May and reached its height towards the close of that month, thereafter rapidly subsiding. A Spanish origin of the epidemic is not borne out, however, on further inquiry. Influenza was prevalent among American troops in April, and a nexus seems thus to be established between the European epidemic and an abnormal prevalence of influenza and pneumonia in New York which occurred in March. The abnormal feature of this prevalence was the high fatality among young adults. I am indebted to Dr. Guilfoy, Registrar of the Health Department of New York, for the following figures illustrating this. New York—Deaths at Ages from Influenza and Pneumonia Mid-March—Mid-April 1915-17 compared with 1918. Causes of death. All Ages. 0—5 5—15 15—25 25—45 45—65 65 + Pneumonia all forms 1915-17 1,485 563 35 51 253 342 241 100 38 2 4 17 23 16 1918 2,856 876 112 329 837 466 236 100 31 4 12 29 16 8 Influenza ( 1915-17 99 14 3 4 16 28 34 100 14 3 4 16 28 35 1918 183 42 9 19 47 38 28 100 23 5 10 26 21 15 Influenza and cerebrospinal meningitis were both prevalent among troops at the front early in 1918, but the London records of deaths from influenza and pneumonia during that time do not show any alteration of age-incidence corresponding to that observed in the New York figures. It therefore seems probable that the source of "Spanish" influenza is to be found in the outbreak of a "mild grippelike disease" prevalent in New York and many other American cities in March and April. The absence of any marked increase in the death rates of New York and Chicago, between April and the advent of the autumn pandemic, certainly suggests that this spring prevalence was the American equivalent of the European summer epidemic. It may be added that the weekly bulletin of the New York^Department of Health for the week ended 16th March, 1918, refers to the weather experienced during January and February, 1918, as "two months of the most severe weather which this city has ever experienced." The progress of the summer epidemic can be broadly traced throughout Europe by its effect upon the weekly death-rates. In London the death-rate from all causes rose to a maximum in the week ended 13th July; a week earlier the rate for Bombay was at the maximum. Munich, Hamburg, Leipzig, Dresden, Cologne and Frankfort followed; thereafter in the next fortnight Christiania, Gothenberg, Madras and Calcutta. A fortnight later Copenhagen, Stockholm and Berlin show a maximum and, finally, in the week ended 17th August, Amsterdam. The early incidence in Bombay and the long interval separating the maximum there from that of Calcutta and Madras is especially worthy of note in view of the fact that the order of attack was repeated in the autumn outbreak. Elsewhere, however, there is no approximation to the order of the summer incidence. In London the height of the epidemic occurred in the week ended 9th November, instead of, as in the summer, practically contemporaneously with Bombay, where the maximum had been cached a month earlier; and during October the maximum had been attained first in Madras, Ber in, 11 Gothenberg; a week later in Chicago, the rest of the large German towns mentioned above, Stockholm and Paris; thereafter in Christiania, Copenhagen and Amsterdam, London being the last of the towns mentioned to reach the maximum of total mortality, with the exception perhaps of Calcutta. In America as much as six weeks separates the period of maximum in different towns. For 44 of the largest cities as a whole, the maximum mortality for influenza and pneumonia occurred in the two weeks ended 26th October. There is a vague indication of progression from North East to South West. Generally the mortality in the American towns exceeds that of London and other large English towns. The summer epidemic apparently terminated with the prevalence at Amsterdam in August. Influenza was reported present at the end of August in Salonica and other places in the Mediterranean, but this was probably the beginning of the autumn epidemic which, by the end of the year, had practic- ally become world wide. The autumn epidemic cannot be traced successively in point of time from one locality to another, as could that of the summer. Press reports show epidemic influenza to have been present in September in places as far apart as Canada, Honduras, Bermuda, Portugal and Korea. It is of course, possible that the Korea prevalence was actually the tail end of the summer epidemic, but the fact that influenza was reported in China in the following month, suggests rather that the autumn influenza was widespread throughout the temperate zone and was transmitted therefrom along the main line of international communication southwards and northwards In October influenza was reported from Archangel to Peru, in China, South Africa and New Zealand. It seems to have taken longer to make its way to some of the islands lying off the main routes of ocean traffic, since it was not reported in Asuncion, the Society Islands, San Domingo and Samoa until December. In January it was reported in Australia (Melbourne). Recently it has raged in Labrador, where about 20 per cent, of the population have perished. In some of the more remote localities the fatality, especially among the natives, was excessively high. In the Society Islands, Moorea with a native population of about 1,200 had 200 deaths in a few days, and Makatea and Raiatea lost 10 per cent, of their population. In Bombay the death rate reached 257 per 1,000. The occurrence of epidemic influenza in distant seaport towns has been associated with the arrival of ships in several instances. In Rio Janeiro, where 70 per cent, of the population (of about one million) are stated to have been attacked in the autumn (15.000 deaths occurring in six weeks), the arrival of the s.s. Demerara from Europe was thought to have originated the epidemic. The outbreak in Bombay in the summer was associated with the arrival from overseas of a transport on 31st May. PART II. Study of Previous Prevalences of Influenzal Diseases. The history of the recent epidemic is, as has been seen, one of gradual development over a series of five or more years of epidemic prevalence of varying types of disease, culminating at length in the appearance of successive waves of influenza which attained maximum severity at the end of 1918. It is important to learn whether light is thrown by study of earlier prevalences upon these recent experiences, and also whether any notion can be formed as to what may be expected in the future. The earliest date at which enquiry can profitably be made as to association between outbreaks of influenza and closely related types of disease (e.g., cerebrospinal fever) is at the time when the presence of, at any rate one of the two, can first be fixed, viz., at that of the occurrence of the English Sweats, 1485-1551. The five sweats were undoubtedly influenzas and they were accompanied by outbreaks of cerebritis, encephalitis, hauptkrankheit, etc., carefully described by Hecker, and a tabular statement prepared from his data, was made and published in the Milroy Lectures, 1906. Creighton, more- over, refers to the occurrence during the sweat years of "other forms of epidemic fever in the same pestilential class." Thus he describes the gaol fever at Cambridge in 1522 (and here at the outset question arises as to the diagnosis between typhus and cerebrospinal fever). A similar outbreak occurred at the Oxford Assizes in 1577, and this was followed (says Cogan), by "the same kind of agues," which "raged in a manner all over England." Anthony Wood remarks "some thought that this Oxford mortality was the same that Leonard Fuchsius styles Sudor Anglicus." Again, in 1539, "divers and many honest persons died of the hot agues and of a great laske throughout the realm"; the former Creighton d clares were "febrile influenzas," the laske he thinks was dysentery, but it may have been influenza assuming the gastro-intestinal form ? In 1558 the troops at Southampton and Portsmouth were affected and here, as in many later military outbreaks also, question again arises as between typhus and cerebrospinal fever. The widespread epidemic of 1580-82 was, once more, influenza, though all over Europe it had "so much of a sweating character that in some places they said the English sweat had come back." Creighton is not, however, quite happy as to the nature of these influenzas; thus in speaking of the gaol fever of Exeter in 1586, which he surmises was typhus, but which spread all over Devon, he distinguishes between "the Devonshire diffusion (which) was like the spreading circles in a still pool, (and) the spread of influenza (which) was like the flying ripples on a broad surface of water." And he adds, when we come to the 18th century "we shall find the same diffusiveness associated with the clear type of disease which we now call typhus. Influenza is the only sickness familiar to ourselves which shows the volatile character, and we are apt to conclude that no other type of fever ever had that character. . ." Hence, in giving the name influenza to the " hot agues" of 1540, 1557-58 and 1580-82, he does so with the qualification that he regards them as embracing the types of fever (closely resembling typhus fever) which "prevailed from time to time over wide districts of country in the centuries following." His difficulty as regards the resemblance of these sweats and agues to both influenza and typhus would be 50129 I 2 The worldwide range of the Autumn epidemic. The sweat hot agues, spotted fevers and "new diseases" o influenzal type in the 15th, 16th and early 17th centuries. 12 Willis's outbreaks of 1657-59. Sydenham's '' constitutions." met if he held the association to be one of influenza and cerebrospinal fever, rather than one of " volatile " and "non-volatile typhus." Reference must here be made to some further problems presented by the disease nomenclature of the times. There is, some difficulty in interpreting the term "ague," as used in the 16th and 17th centuries—it clearly meant originally however, merely acute fever. Dr. Jones regards his " Hot Rotten Agues" as identical with the Synochus or continued fever of the Greeks. This term and " intermittent," "tertian" and more especially "quartan," says Creighton, "can hardly be taken in their modern sense as restricted to malarial and climatic fevers." Yet another complication arises, for there were the "pestilent fevers" associated with plague, "burning fevers," "spotted fevers," some of which involved the houses of the great, while in some so many were ill that the harvest could not be gathered. Here again "we meet the old difficulty of influenza." There were years of high (non-plague) mortality in 1638-39. In "a parish in Hampshire," a malignant fever raged about harvest time and delayed the harvesting of 1638; and in the following year the "general sickness all over this country, called the 'new disease,' interfered greatly with public business." Boghurst refers to a country epidemic of "spotted fever," and Whitmore describes a corresponding prevalence in Cheshire and Shropshire. "Thus," says Creighton, "we have a remarkable epidemiological phenomenon, somewhat new to England unless, indeed,we bring all those spotted fevers and the like under the generic name of influenza. It was in country districts in 1612-13 and from 1623 to 25, it was extensively prevalent in 1638 in places as far apart as Hampshire, Monmouth and Northampton, it appeared in Berkshire and Oxfordshire in 1643 in connection with the military movements of the Royalist and Parliamentary armies, it caused a disastrous loss of life in Tiverton within a few weeks of Essex's army passing through the town in 1644, it is heard of again in Shropshire and Cumberland in 1651-52 and in the same parts in 1658, as well as in Somerset, and in London steadily from year to year." And then later he proceeds—" The universality or generality of this incidence was accounted for by assuming, on the one hand, something common in the state of the air, and on the other hand, some common predisposition in the bodies of men, which might itself have had seasonal causes. We have now only one name for such common infection of the air, namely influenza: and it is significant that the catarrhal influenzas of 1658 and 1659 were regarded by so-ne, at the time, as only the appropriate vernal form of the fever, which in the hot weather of 1657-8 had prevailed almost in the same general way as influenza, but with the symptoms of typhus." Truly much that is very suggestive of recent behaviour of influenza and cerebrospinal fever is to hand in the 16th century outbreaks—the "posting," the "new diseases," the "spotted fever," the involvement of rich as well as poor, the partiality for troops and for gaols, the prevalence "in the general way as influenza, but with the symptoms of typhus." As yet, however, there is no specific reference to the brain and spinal cord, but that will soon follow. Proceeding meanwhile with the pestilent fevers, there is Willis's war fever of 1643, "betraying its malignancy by the eruption of wheals and spots." And then there is the "war typhus" at Tiverton in 1644, which "spread far and near." This outbreak has been held to have been typhoid, but Creighton's judgment is as follows:—" If there be gradations of type, or approximations of typhus to sweating sickness (as well as to influenza) then we may perhaps take the Tiverton epidemic as coming nearer than any other to the sweating sickness, on the strength of the name in the parish register" (for, as he notes " sweating sickness " was that actually given to it). The fever and influenza of 1657-58 described by Willis are particularly interesting. First in the ^ spring and summer of 1657 comes this " new disease," spreading widely, " scarce one in a thousand died of it," but it raged throughout all England. Then second, there is noted in the spring of 1658, " a pure and unmistakable epidemic of influenza cold," which did not last longer than six weeks, and then third, in the summer and autumn of 1658, there was again a change of type to that of the original prevalence of the preceding year. '"The fever was continual in some . . . very many were ill in their brain and nervous stock. . ." (Creighton holds that this last expression of Willis's signifies spinal cord) . . "in some there were broad and red spots like the measles . . after which in some came lethargy and delirium." Creighton remarks "one notable thing in this fever was the exanthem, which reminds one more of the rash of sweating sickness or dengue (break bone fever) than of the spots of typhus." Thus once again there is d'fficulty in drawing a line of demarcation between typhus and cerebrospinal fever. Whitmore described apparently the same sequence of outbreaks ; he speaks of the whole series as "this Protean-like distemper, whose various shapes render it such a hocus pocus to the amazed and perplexed people, they being held after most strange and diverse ways with it"; and he adds it is "so prodigious in its alterations that it seems to outvie even Proteus himself." Creighton dubs these anomalous fevers "the volatile typhus of the country and the towns ... in some respects like intermittents, without the clear interval between the fits, but in respect of contagion, spots, pain and other symptoms like typhus." He says "although this epidemiological phenomenon be a strange one, th re is no reason to question the correctness of Willis's observations, corroborated as they are by those of Whitmore. But there are indeed many more experiences of the like kind in the years to follow." This group of outbreaks certainly exhibits a dovetailing of epidemics of influenza and cerebrospinal fever beyond all possibility of mistake. And now the search for association of influenza with cerebrospinal fever can be pursued with grow'ng confidence right into the very citadel of typhus, in Creighton's great chapter on "Typhus and continued fevers." He here, at the outset, uses the clue supplied by Willis in endeavouring to thread the maze of Sydenham's "constitutions." Willis has described the fever of 1661 (with which Sydenham's first constitution begins) as concisely as he did those of 1657-59, including the influenza of 1658. It corresponds says Creighton, with "the worm fever, the comatose fever, the remittent fever of children, the acute fever with dumbness, the convulsive fever," Willis himself describes it as "a certain irregular 13 and unaccustomed fever . . . chiefly infestuous to the brain and nervous stock.'' The term "acute fever with dumbness" was applied to a disease first fully described by Dr. William Butter in 1782. Willis's epidemic had, according to the summary of Creighton, " symptoms which were not quitf clearly those of enteric fever, spots like fleabites, on the neck and other parts, swelling and suppuration of the glands in the hinder part of the neck, effusion of fluid on the brain and in the lateral ventricles and the intestine free from disease." The dumbness, the modern observer will notice, finds its counterpart in the recent "epidemic lethargy"; the glandular enlargements too, have been said to be so commonly met with, in 1918, as to justify the application to the whole series of prevalences of the expression "glandu'ar fever"; but Creighton "s two last criteria are especially noteworthy, the postmortem findings being reported upon as positive qua hydrocephalus, and negative qua typhoid fever. So that Willis has helped him to the clear discernment of a group of correlated diseases prevailing epidemically in successive years, of which influenza is the central figure with cerebrospinal fever on either hand. Sydenham in his account confirms an important observation of Willis as to the incidence in 1661 upon children and young people; also the fact that the prevalence was one of a "new disease," and that there were included among its symptoms, phrensy, coma vigil and in some cases diarrhoea. Turning next to Sydenham's second constitution, the comatose fevers of 1673-76 (with influenza in 1675), there is recorded the profound stupor passing into absolute aphonia (the "acute fever with dumbness" of later writers), as in Willis's account of 1661; there is mention too, of the fact that" during convalescence the head, through weakness, could not be kept straight, but would incline to one side and then to the other." Sydenham describes the influenza of 1675 as a febris comatosa, and Creighton claims that there was a similar outbreak in 1679. This last comes of course in the group of fevers constituting the return of Sydenham!s intermittent constitution (1678-80), a constitution comparable as already said to that of 20 years before. The fever of 1679, says Creighton," produced the characteristic effect of influenza upon the London Weekly Bills and it came in the midst of epidemic agues, just as the "epidemic catarrhs of 1658 and 1659 had done." He establishes this contention more securely by a citation from a contemporary work of Dr. Christopher Morley. This group of fevers was followed by "continued depuratory" fevers, and then in 1685 by the "new fever." The depuratory fevers were apt to present purple spots, but the fevers were sporadic, says Morton, and not contagious. Creighton has dissected out Sydenham's epidemic constitutions into eight groups. Of these the first is included in (a) below ; the 2nd, 3rd and 4th are not germane to the present purpose, as they deal with plague, smallpox, dysentery, etc., respectively; the 5th becomes (b) below; the 6th becomes (c); and the 7th and 8th are included with later prevalences in (d). (a) "Intermittent" constitution of 1661-64 with a continuous fever throughout. The fevers of 1657-59 which include the influenza of 1658 had preceded these, and Wil'is's nervous fever of 1661 overlaps upon this constitution. (b) The "comatose fevers " of 1673-76, with a " new disease " (influenza) interpolated in 1675. (c) Return of the intermittent constitution (1678-80) Sydenham regards the fevers of these years as equivalent to those of 1661-64. In the midst of this constitution Creighton was able to fix the " new disease " (influenza) of 1679. (d) Depuratory fevers or dregs of the intermittents (1681-84); the new fever of 1685. Sydenham records nothing after 1686, but Harris in London and Molyneux in Dublin described a "universal short fever" (doubtless influenza) in 1688 and "spotted" and other fevers followed later. This statement may be compared with Creighton's tabular analysis of the constitutions given on p. 10 of Vol. II. of his Epidemics. The liberty has been taken of adding the last two constitutions of Creighton's table to a new constitution (d), which then comprises, as (a), (b) and (c) do, intermittents with influenza interpolated in their midst. Creighton supplies this sequence of epidemics in (a), (b) and c) and by combining constitutions in (d) that group is made into one comparable with those which precede it. It has been claimed elsewhere (Proc. Roy. Soc. Med. Vol. IX.) that the new fever of 1685 bears a very close resemblance to the 1915 outbreak (in London) of influenza plus cerebrospinal fever. It should be observed, moreover, that under heading (c) above, there is included a central influenza not referred to by Sydenham, but inserted on the strength of Creighton's discovery of a rise typical of influenza in the London mortality returns, together with his citation of corroborative evidence supplied by contemporary writings. In one of these by Dr. Morley, the prevalence is thus described." It was not so severe by half in England as in Holland, but the English made a great deal more of it, calling it the new disease, the new ague, the new ague fever and in Derbyshire sarcastically the new delight." Again, another contemporary (Dr. Simpson) describes "chills at the outset, pains in the head and back, in some with shaking, then intense burning heat, thirst, profuse immoderate sweats and great debility, a general lassitude, dulness and stupor, which in many were followed by delirium and a comatose state." The evidence supplied by the four groups (a), (b), (c) and (d) shows that epidemic agues must be joined with fevers, for the reason that, as Creighton says, "they can hardly be separated, in the earlier part of the history." He observes in a later passage: "There are periods such as 1657-59, 1678-79 and 1727-29*—when short waves of epidemic catarrhs or catarrhal fevers came in the midst of longer *It may be added here that, in 1709, Sir David Hamilton records in London a case of malignant fever in a lad who had "a great difficulty or hindrance of speech, with offensive sweats and red and purple spots ... a deadly fever with loss of speech from the beginning," which recalls the "acute fever with dumbness" and brings to mind the "epidemic lethargy" of recent notoriety. It seems to have been, says Creighton, "a common type of fever in the latter part of the 17th century and early part of the 18th." He adds, "its main features may be said to have been its incidence upon the earlier years of life, but not to the exclusion of adult ages, its remarkable ataxic symptoms which led Willis to refer it to the brain and nervous stock (spinal cord), its comatose character, its spots, occasional miliary eruption, ill-smelling sweats and other foetid evacuations, its protracted course and its hectic sequelae." Any observer of the London epidemic of 1918 can only marvel that the variously designated botulisms and lethargies of that year should have been regarded as new diseases, 14 The influenza pandemics of the nineteenth century. waves of epidemic agues, 'hot agues' or intermittents, the whole being called by the people the 'new disease' or the 'new ague,' while by physicians such as Willis and Sydenham they were taken to be distinguishable constituent parts of one and the same epidemic constitution. The last period in which epidemic agues were so recognised and named in England was from 1780 to 1785; and in the midst of that also there occurred an epidemic catarrh—the ' influenza' of the year 1782." The period now approaching is that of the great pandemics of influenza of the 19th century, those of 1803,1833,1848, 1874 and 1890. They may be taken seriatim and it will be seen how "spotted fever," " typhus," or " cerebrospinal fever " precede and follow the influenzas. (a) 1803 pandemic.—There was spotted fever in Dublin in 1801 and Creighton notes that a crop of typhus reports is forthcoming in Flintshire, 1801-3; in Meath, where "influenza superseded typhus in 1803," at St. Neots and at Clifton. Then (after the pandemic) followed the first recorded outbreak of cerebrospinal fever, that at Geneva in 1805, and outbreaks were reported in 1807-08 in America. (b) 1833 pandemic.—From 1827 to 1830 cerebrospinal fever was active in the old and new worlds. Later follow outbreaks in France (1837-42), Italy (1839-45), Germany (1834-35) and the United States in 1842. Badham's note on infantile paralysis appeared in 1835, and Heine's work in 1840. (c) 1848 pandemic.—Ureighton notes that in 184(5-47 ague and remittent lever were more in evidence than usual. Dr. Peacock writes that in 1847 "intermittent fevers were common and in March, April and May, purpura was frequently met with," he adds "that these several affections are not merely coetaneous but correlative and types and modifications of one disease with which they have a common origin." Furthermore, outbreaks of cerebrospinal fever are recorded in France (1846-48), Algiers, Denmark, Spain, Ireland and Westphalia and in the United States (1845-48). In some of these countries, outbreaks were reported during the pandemic period, and following upon it in Sweden 185458) and from 1856 onwards in the United States. (d) 1874 pandemic.—Outbreaks of cerebrospinal fever were reported in Germany from 1864 onwards, and also in Austria, Hungary, Russia and Greece. In 1866-67 the disease prevailed in Ireland and was reported near Lincoln. In Italy it appeared in 1873 and in Jerusalem in 1872. In the United States from 1866 onwards numerous epidemics were reported. Duchenne's first paper on infantile paralysis appeared in 1855; he was, however, seeing many more cases in 1872. A few years after the 1874 prevalence, the great period of cerebrospinal fever epidemics in the United States came for a time to an end. There were groups of cases in Birmingham, Bath, Plymouth and Oxford in 1876 and somewhat later in Scotland, Galicia, Germany, Poland and other parts of Europe. From that time until shortly before the next pandemic cerebrospinal fever was remarkably quiescent. (e) 1890 pandemia.—In 1887, in Vienna,Weichselbaum demonstrated the meningococcus, but from 1885 onwards there are accounts of "spotted fever," for instance among troops at Devonport and Chester, 1885-86. About this time several obscure illnesses resembling typhus were reported upon by Mr. Spear to the Local Government Board. Cerebrospinal fever occurred in Ayrshire in 1884 and in Dublin 1885-86. Also in France, 1885-86 and in Denmark from 1888 onwards. In Norway there was increased prevalence in 1887. There was a similar recrudescence in Sweden in 1887 and 1888. The researches of Dr. Medin, of Stockholm, into poliomyelitis, began about this time. In Silesia there was an outbreak of cerebro-spinal' fever in the Oppeln district in 1887. In Austria—Dalmatia, Istria and Styria suffered in 1688-89. From Russia precise information is not obtainable, but it is alleged that Silesia was from time to time infected from Russian Poland. The occurrence of cerebrospinal meningitis in the Mediterranean was the subject of a report by Sir Richard Thorne to the Local Government Board in 1888; it appeared in Sicily in 1883 and in Sardinia from 1883-88. In 1888 it was present in Syria.* In 1883 it was reported in Cape Colony and in 1884 "there was a severe outbreak, cases continuing to occur up to 1890." An epidemic occurred in the Fiji Islands in 1885. In India statistics show increase in the later eighties. In the city of New York an outbreak occurred in 1881 and deaths were registered each year throughout the period ensuing. From 1886 onwards there was increase in the registered mortality from the disease in Chicago. In reports from 1884 and onwards deaths were recorded in Montreal. A review of the period preceding the pandemic of 1889-90 thus shows that there was great diversity as regards recognition of cerebrospinal meningitis in various parts of the world. It was, for instance, comparatively commonly recorded in the State of New York and elsewhere in North America, but was practically ignored in most countries, save when a considerable outbreak forced itself upon attention. It is, however, quite clear that over the whole of the thickly populated globe, and even in places such as the Fiji Islands and South Africa, there was a notable extension of cerebrospinal meningitis prevalence from 1885 onwards. It may be added that in this country there was probably much more cerebrospinal meningitis than was recognised, and further it is of interest to refer to certain mysterious epidemic pneumonias at Middlesbrough, Scotter, etc., and to apecial prevalences of sore throat and gastro-intestinal disturbance, such as were chronicled in the spring of 1887 in the Proceedings of the Society of Medical Officers of Health. These outbreaks, as also the dengue prevalences of Southern Europe, stand in very interesting relationship with the great pandemic outbreak of influenza at the end of 1889. On tu ning now from the years preceding to those succeeding the great pandemic the records of cerebrospinal menignitis become much more complete; moreover, as Dr. Bruce Low observes, the suspicion arose that "cases regarded locally as cerebrospinal fever were really instances of epidemic poliomyelitis and vice-versa"; further, he notes that though there is no characteristic rash, as in some other specific fevers, "spots of one or another kind, purpuric, petechial, herpetic or other may be present , and, again, as M. Colin said in 1905, it began to be suspected that cerebrospinal meningitis " had a close * It is of interest to remember in connection with this outbreak—in which Gozo was affected—that Malta fever was at this time exciting some attention and, indeed, its "causal organism" was discovered in 1886. Moreover, dengue was prevailing in the Levant about the same time. 15 connection with prevalences of influenza." Dr. Boiret is reported by Dr. Low to have made a similar observation in 1909. This broadening of the point of view despite the tendency with the advance of bacteriology to limit cases to those possessing particular bacteriological features, led to great increase in the number of reported cases and the facto cannot be given in the same detail as for the years preceding 1890. On a wide survey, however, it may be said that after increase, at the time of and immediately succeeding the pandemic prevalence of influenza and after prevailing to a lessening ext nt in conjunction with tra'ling epidemics of influenza, or as at Trefail in Styria in 1898, as a "pseudo-influenza," there then supervened marked diminution; after a time increased diffusion of cerebrospinal fever again followed as in New York State in 1904, in England, France, Germany, Italy, etc., as early as 1905, in Glasgow and Belfast in 1906-07; and then later, about 1912, a ma:ked increase developed throughout the civilised world. During the first half of 1914 cerebrospinal fever was reported to be present in Moscow, for some years past, too, there has been repeated mention of poliomyelitis in various parts of Europe and America. (Brorstrom's book on the latter disease dates from 1910) In summary, taking into account, so far as may be, variations of fashion as regards nomenclature, there seems to have been round about the time of the great pandemic influenza, increased morta ity from cerebrospinal fever (and, it may be added, from poliomyelitis also) from some five or more years before to some five or more years after 1890; in the same way, for five or more years prior to the explosion of 1918 there was again a growing diffusion of both cerebrospinal fever and poliomyelitis, There has thus been an overlapping of outbreaks of cerebrospinal fever and poliomyelitis with the great preva ences of influenza. The former precede and lead up, as it were, to the pandemic prevalence; with the establishment of this, cerebrospinal fever and poliomyelitis fall into the background, but then again later come to the fore as successive "trailers" follow the great prevalence; five or more years after the pandemic they revert again to comparatively speaking insignificant proportions. There seems, therefore, to be discernible for thickly inhabited areas of the globe, a kind of law of coincidence or of overlapping between cerebrospinal fever and poliomyelitis and pandemic influenza. It was pointed out elsewhere three years ago (Proc. Roy. Soc. Med., Vol. X.) that the special years of cerebrospinal prevalence recorded by Hirsch, commenced three or four years after each pandemic influenza prevalence. A closer analysis of Hirsch's data shows, however, that the great influenza pandemics of the nineteenth century were both introduced, and followed after a few years, by cerebrospinal fever prevalences; in fact, each of Hirsch's four groups of years comprises an earlier series following a precedent influenza pandemic, and a later series leading up to the next following influenza pandemic; there is thus noticeable as a rule, a gap in the middle of each of his groups of years and this is particularly apparent in the middle of his second period. Thus, for example, in France, it is recorded in 1842 that "the succession of epidemics comes to an end." and it is not until 1846-50 that there are further references to extensive epidemics; in the United States, epidemics are only reported towards the close of Hirsch's second period. Again, as regards the middle of his third period it is notable that Sweden shows considerable decline after 1859; moreover, the south and west of Europe escape during the same series of years and until the approach of the next pandemic. Following upon the 1873-74 pandemic there was, however, a somewhat abrupt cessation of cerebrospinal fever in the United States. Moreover, as already stated, in that country there were no recorded prevalences between 1816 and 1842; thus the period round about the 1833 influenza pandemic was not productive of records of cerebrospinal fever in the western hemisphere; it is deserving of note that that hemisphere seems to have had an influenza of its own about 1815-16, and it may be that this accounts for its escaping quite lightly in the pandemic of 1833 and onwards; similarly in 1873-74 the western hemisphere again suffered disproportionately, and in correspondence with this was for a time quite clear from both influenza and cerebrospinal fever. It will be seen then, that the facts elicited on study of the relationship between influenza and cerebrospinal fever in the recent prevalences, or within the period of notification statistics, or on a wider view within that covered by Hirsch's chronologies, are strikingly confirmed, if in some measure also modified and corrected, on taking a broader sweep still and pursuing enquiry, by means of the great storehouse of facts collected by Creighton, into the history during the last five centuries of the influenzas and cerebrospinal fevers, etc., which lurk more or less disguised under such designations as sweats, agues, cerebritis, encephalitis and typhus (cerebralis or other). As Creighton has observed, influenza can be "identified as certainly in the brief phrases of mediaeval chronicles as in elaborate modem descriptions"; by his careful analysis of the facts he has, moreover, securely established the close relationship between epidemics of influenza and epidemics of ague; it is now, moreover, claimed that these remarkable related agues consisted of the fevers with gastrointestinal, pulmonary or nervous complications, which are becoming recognised as constituting the disease types the Proteus influenza is apt to assume. Attention has been more especially devoted in the present enquiry to cerebrospinal fever, because it has been possible to pick out the epidemics of this disease, like blackberries from a bush, in Creighton's great historical chapter on typhus and the continued fevers. A similar harvest has, however, been collected by Dr. Crookshank from the literature of the Heine Medin disease, and had materials relating to epidemic pneumonias or epidemic bronchitis been in like manner available, this field of enquiry could also doubtless have been exploited with profit. Two further points may be now mentioned. First—It should be realised that influenza pandemics did not in the nineteenth century affect all parts of the civilised world simultaneously, there was, indeed, a tendency to alternate between the eastern and western hemispheres (Europe suffering more in 1780-82, America more in 1798-99, Europe about 1800, America almost exclusively in 1815-16 and again in 1826-27, Europe much more about 1830, America early in the forties, Europe later in the forties, America in the fifties, and again in the late sixties and early seventies; both, however, were involved to a Summary view of an " influenzal constitution," i.e., of the development during a series of years of various types of epidemic prevalence round and about the of occurrence of pandemic influenza. 16 Contribution to a study of some of the factors governing the form of the influenza wave. tically equal extent in the early nineties, and again in 1916-18). Second—It is important to note that the constitutions extend over more years in the later centuries than in the earlier, and arising out of this it will be clearly discerned that the state of the population concerned, as regards freedom of communication with the world at large and also as regards immunisation by previous attack, has momentous influence in determining duration of the constitution and the behaviour generally of the epidemic disease. It is assumed in the following argument that influenza spreads directly from person to person, and hence, as Parsons and Clemow have shown, follows lines of communication and traffic. It is further assumed that Creighton's conclusion that there is "something more than accident in the association between epidemics of influenza and epidemics of ague'' is now accepted, on the understanding that for epidemics of "ague" the pulmonary, gastro-intestinal or cerebrospinal complications of influenza must be substituted. There is in fact change of type of the epidemic disease and the cause of the change must be sought in the degree and extent to which the particular population concerned is exposed to infection on the one hand and susceptible or immunised by previous recent attack on the other. On a review of the whole matter it would seem, therefore, that the following contributions to a theory of the surend of influenza mav lie formnlatprl from the eniHeminlnoripnl data (a) In the first place it must be recognised that the closer the aggregation of population in a particular area the more likely is the disease to maintain itself for a series of years round about a pandemic prevalence; the more sparse the population and the more removed from the great lines of communication and trarlic the area, the more likely is an epidemic when introduced to die out there quite speedily. Thus, in the years before and after 1890, London and New York presented a smouldering fire of prevalence, an epidemic constitution of ten or more years' duration; in the London of the 17th and 18th centuries the constitution only lasted from one to four or five years; and in the London of the 15th and 16th centuries there were single isolated years of epidemic prevalence. In 15th century London continental traffic was practically in abeyance in winter and all the English sweats occurred in summer time; it will hence be appreciated that in 15th century London, or again in what is fairly comparable with it, in the present day, say, some little-visited island in the high seas, or Greenland, or the Murman coast, influenza is only found to prevail when infection is newly introduced. Prevalences in such places as these are likely when they do occur to be severe ones; in contrast to the prevalences in the large and partially immunised centres of population, in which, while influenza may smoulder for years a great epidemic is only possible a long time after the last pandemic prevalence. (b) Then, secondly, certain rules as to the intervals between prevalences in thickly populated areas, the extent of these prevalences and their duration may be formulated. The prevalence of the pandemic year is, subject to some exceptions, likely to be a maximum prevalence, it extends over the shortest time, and the interval between it and its successor will be short. Succeeding "trailers "will gradually diminish in height, but will last longer and recur at longer intervals.* The form of the epidemic curve has been studied by Ross, Brownlee, Greenwood and others by aid of mathematical methods. It must suffice here to illustrate the subj ect by referring to the comparatively simple case of measles. The curve of measles in London was explained (in the Milroy Lectures of f906) as resulting in large degree from interplay between the deflecting energy due to new infections, and the restoring inertia due to resistance to spread of disease caused by acquirement of immunity and consequent increase in the amount of insusceptible material. In London, the measles wave has a 1½—2 years' length from crest to crest; about 180,000 children are attacked during that period and the number of susceptibles varies from a maximum of from 200,000 —300,000 to a minimum of about 50,000. Between the comparatively simple epidemic curve of measles and the complex curve of influenza, the disparities are great. The incubation periods in the two diseases of course differ widely; secondly, measles attacks everybody, some people appear to be immune to influenza; thirdly, measles protects, some people suffer again and again from influenza, and the period of protection afforded by a previous attack may be quite short; fourthly, there is the question of infecting power, and this, while fairly constant in measles, varies at the differing phases of influenza prevalence. It will be clear that the rate of reaping will be far more rapid in influenza, but, on the other hand, the harvest to be reaped is greater. But now comes the most noteworthy disparity. In measles, a succeeding prevalence does not occur until 180,000 recently born and comparativelv insusceptible babies have grown up to be, say, from 18 months to three years old. In influenza the babies arc of relatively small importance, for a much more appreciable effect is exerted by loss of immunity on the part of older persons. The following points will, therefore, be noted on contrasting an original (pandemic) prevalence of influenza with the next succeeding prevalence. In the former, persons who mix freely with their fellows are specially likely to be attacked ; in the latter young children and old persons will suffer in larger proportion, in the former, the prevalence will be widespread, the mortality comparatively low; in the latter, the *And here it may be parenthetically remarked that difficulty is frequently experienced in understanding how it comes about that susceptibles are not all attacked at the time of the pandemic prevalence. This difficulty presumably arises from the ingrained habit of comparing an epidemic to a conflagration. The necessary antecedent to a prairie fire is a spell of dry weather during which the grass can become like so much tinder; then by accident or design, it is set ablaze and the fire proceeds apace until the limit of the dry grass is reached, or until it is checked by interposing a bare interval which the fire cannot overleap. It should be observed, however, that the fire burns only for hours or days, the growing and drying of the grass occupies months or years. In a fire all the dry grass within reach is consumed, at any rate there is practically no replacement of it, but in an epidemic, susceptibles are continually being added to the population: moreover, spread of the epidemic only progresses slowly, for the appropriate incubation period must intervene between a person being infected and his becoming in turn infectious. Hence, provided the prairie is sufficiently extensive, i.e., provided the epidemic affects a sufficiently thickly populated area, it will never go out; and yet it will never have consumed at any one time, any thing like the whole of the grass. 17 pulmonary complications among old persons and children, and the nervous complications in children, will render the case mortality much higher. The first "trailer" will not spread so quickly as does the pandemic prevalence, partly because its predecessor skimmed off the cream, as it were, of the susceptible material (i.e., of those who mix with the world and are thus specially likely to be attacked) and partly because some of those attacked may have acquired partial immunity in the previous attack. As "trailer" succeeds "trailer" the cerebrospinal and pulmonary complications assume greater prominence, the prevalences are more prolonged and tend to recur at longer intervals, and the striking power of individual cases becomes less marked. After the lapse of six or eight years the characteristics exhibited by influenza in its pandemic phase become greatly obscured, and save for slight annual increase in the mortality from pneumonia, bronchitis, etc., the very existence of influenza in a town like London may be almost entirely lost sight of. Gradually, however, protection of the population again wanes and after a while anomalous illnesses, cerebrospinal fever, poliomyelitis, epidemic pneumonia, again begin to attract attention; then later perhaps, lethargy and other protean manifestations of influenza present themselves, and at length the moment arrives when the town suddenly realises that it is in the grip of something which it feels can only adequately be described as a " new disease." (c) Finally, the following further suggestions bearing upon the theory of influenza may be offered. When cases newly introduced, say, in London some years after a pandemic prevalence, come from a partially immunised area, they will have comparatively little infecting power, and the disease they produce will be likely to differ widely from the typical influenza of pandemic phase; it may, indeed, be even a cerebrospinal fever or poliomyelitis. Sooner or later, however, London will be exposed to infection introduced from some possibly remote part of the world where influenzal infection is in a very potent phase, and then (London being more apt to receive the infection and other conditions being favourable) widespread influenza in pandemic phase may result. Under the conditions which have obtained in the past, the United States has often been involved at a time when Europe was comparatively free and vice versa. Of late, however, with improved means of communication, the great centres of population have tended more and more to suffer together. In the big prevalences of recent years the origin of the epidemic has often, as a matter of fact, been traced to some sparsely inhabited part of the world. The phenomena may then be compared to the waves in a pond in the middle of which a stone is thrown ; the waves travel outwards to the edges of the pond and are then reflected back again. So, from the big centres of population the 'waves of influenza travel outwards to remote parts of the earth and then, later, are in due course reflected back once more. But the parallel must not be unduly pressed, for in the case of influenza the disease really remains endemic in the thickly populated areas, though with steadily waning and then again growing intensity; in the Athabascas and Kirghiz Steppes on the other hand it is not endemic; there are long intervals of complete freedom, extending perhaps over one or two generations, it may be for a century or more, but when the disease is at length introduced it almost at once gathers strength in so highly susceptible a community, and it may acquire such power of spreading that it is reflected back again over the civilised world. It is submitted that these are some of the laws or principles which can be deduced from study of influenza prevalences, and on some such lines as these the behaviour of influenza as an epidemic disease can be explained without appeal to subterranean effluvia, earthquakes, comets or other phenomenal causes. W. H. Hamer, Medical Officer of Health. 2, Savoy Hill, Victoria Embankment, London, W.C. 2. June, ,1919.