London Coming Council. ANNUAL REPORT OF THE COUNCIL, PUBLIC HEALTH. (INCLUDING THE REPORT FOR THE YEAR 1920 OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER, MAIN DRAINAGE AND HOUSING). Published by THE LONDON COUNTY COUNCIL, and may be purchased, either directly or through any Bookseller, from P. S. KINO & SON, LTD., 2 and 4, Great Smith Street, Victoria Street, Westminster, S.W. J. Agents for the sale of the Publications of the London County Council. 1921. No. 2104. Price 2s. 6d. The London Coming Council. ANNUAL REPORT OF THE COUNCIL, 1920. VOL. III. PUBLIC HEALTH. (INCLUDING THE REPORT FOR THE YEAR 1920 OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER, MAIN DRAINAGE AND HOUSING). Published by THE LONDON COUNTY COUNCIL, and may be purchased, either directly or through any Bookseller, from F. S. KING & SON, LTD., 2 and 4, Great Smith Street, Victoria Street, Westminster, S.W. 1. Agents for the sale of the Publications of the London County Council. 1921. No. 2104. Price 2s. 61. 875—(o.d. 11145—1550)—25,7.21—61004 CONTENTS. Chapter XXIII. page Public Health Reports.—Report of the County Medical Officer of Health and School Medical Officer for the year 1920—Part I. (Vital Statistics and Administration). Introductory Note 1 A—Vital Statistics.—Population—Marriages—Births—Deaths—Infectious diseases—Smallpox— Measles—Scarlet fever—Diphtheria—Typhus fever—Plague and cholera—Anthiax—Tuberculosis—Cerebro-spinal fever—Poliomyelitis and polioencephalitis—Encephalitis lethargica— Laboratory work—-Ultra-visible viruses—Typhoid—Dysentery—Venereal disease 3 B—Administration.—Tuberculous milk—Offensive trades—Common and seamen's lodging houses— Housing of transmigrants—Sanitary staffs—Housing—Building control-—National Health Insurance Acts (Treatment of tuberculosis)—Tuberculosis-—Mental Deficiency Act, 1913— Midwives Acts—Children Act, 1908—Work of the chemical branch of the Public Health Department 31 Statistical Tables.—I. Vital statistics—II. Administrative work—III. Tuberculosis dispensaries 48 Chapter XXIV. Public Health Reports (continued)—Report of the County Medical Officer of Health and School Medical Officer for the year 1920—Part II. (Education). Introductory Note.—Medical inspection and treatment—Personal hygiene—Epidemic diseases— Results of medical inspection—-Stammering children—Special investigations 52 Following-up 61 Co-operation with School Attendance Branch 63 Juvenile Employment 65 Medical Treatment 66 Nursery Schools 72 Open-Air Education 72 Physical Education 75 Personal Hygiene 77 Education (Provision of Meals) Act 79 Infectious Diseases 80 Residential, Special and Industrial Schools 93 Examination of Candidates 93 Defective Children 94 Statistical Tables.—I. Inspections—II. Defects—III. Exceptional children—IV. Treatment of minor ailments, visual defects, defects of nose and throat, dental defects:—V. Svmmary of treatment—VI. Summary—VII. Routine inspections—VIII. Summary, elementary schools —IX. Summary, secondary, etc., schools 100 Chapter XXV. Public Health—Infectious, etc., diseases—Tuberculosis—Venereal disease—Infant life protection—Lying-in homes—Midwives—Houses let in lodgings—Housing of transmigrants —Homeless persons—Soldiers' rest houses—Lodging houses—Offensive businesses—Milk—Appeal Committee—Health administration in London—Diseases of animals .. 108 Chapter XXVI. Main Drainage 120 Chapter XXVII. Housing 124 iv Chapter XXVIII. PAGE Housing Accounts and Statistics.—Memorandum by the Comptroller of the Council (Mr. C. D. Johnson)—Memorandum by the Director of Housing (Mr. J. P. Orr, C.S.I., C.B.E.) 131 Appendix. page Venereal Disease.—Report by the Medical Officer of Health and Dr. F. N. K. Menzies i. I.—Introduction ii. II.—General principles governing organisation of Venereal Disease Clinics vii. III.—Facilities for diagnosis and treatment in London viii. IV.—Stillbirths xix. V.—Poor law infirmaries xx. VI.—Publicity xx. VII.—Social aspects of problem xxii. A.—Grants in aid to hospitals, 1917-20 xxxi. B.—Attendances xxxii. C.—Report by Woman Patrol xxxiii. D.—Report by two Patrols xxxvii. E.—Information received from Commissioner of Police of the Metropolis xxxix. F.—Notifications under Mental Deficiency Act, 1913xl. G.—Insurance Act and Venereal Disease xl. Diagrams and Drawings. Marriages, Births, Deaths (1841-1920) 4 London mortality—smallpox (1841-1920)—typhus (1869-1920)—diarrhœa and enteritis (1862-1920)—infantile mortality (1858-1920)—typhoid fever (1900-20) 10 Enteric fever and dysentery 30 Seasonal incidence of measles, whooping-cough, scarlet fever and diphtheria (1891-1920) 81 Relation of summer holidays to prevalence of scarlet fever and diphtheria in London, Paris and New York 84 Seasonal prevalence of fleas and incidence of scarlet fever and diphtheria (1909-20) 87 Venereal disease clinic at St. Thomas' Hospital (Plan and sections) xii. London Coming Council. ANNUAL REPORT OF THE COUNCIL, 1920. CHAPTER XXIII. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. W. H. HAMER) FOR THE YEAR 1920. PART I.—GENERAL. Introductory Note. The Vital Statistics of London for 1920 arrest attention. The marriage rate remains, it is true, the same as last year; but the birth rate has risen from 18.2 to 26.4; the death rate has fallen to 12.6, the lowest London rate ever registered, and the infant mortality has dropped to 76, also a record, lower even than the 80 of England and Wales as a whole, and comparing favourably with the 85 of the other great aggregation of population, that of New York. These phenomenal general and infantile death rates, relating as they do to so large a population as that of the County of London, must give pause to those who advocate, at any rate on grounds of health alone, a "return to the land," and cause hope to spring in the breast of even the most gloomy and pessimistic of the 4½ millions of human beings, whose avocations compel them to live or work within a few miles of St. Paul's. A death rate of 12.6 if it were possible to maintain it at that level for a scries of years, would entail an average duration of life of the fourscore years deemed some thousands of years ago to be attainable only " by reason of strength," and far exceeding the expectation of life of the first Life Table of William Farr and of all the later Life Tables too. But the critic may object that 1920 was an exceptional year, coming as it did after five years of war, in which appalling losses were sustained ; following, moreover, upon the great influenzas of 1918 and 1919, in which such heavy toll was taken of the weak and infirm as to leave the survivors by comparison resistant to the ill-effects of disease. Again, it may be urged by the critic, the rising birth rate in itself may have tended to influence favourably the rate of infant mortality. In reply, it may be well " differentiating and drawing within an inner circle," to limit the argument, as a recent Chadwick lecturer has done, to comparison between the rates of mortality of fevers in, say, the four years 1847-50 (during which the first great Public Health Act was passed) and 1916-19. In the latter the rate of mortality in England and Wales from typhus, typhoid, cholera, small-pox, scarlet fever, diphtheria, and whooping-cough was only in the proportion of about 1 to 8 of that in the earlier period ; while the death rate in a single year, 1849, was 18 times as great as in 1919. Again a comparison of the corresponding London figures for 1920 and for 1849 shows a closely similar proportion between the earlier and the later rates. Of course 1849, as well as being a heavy cholera and fever year, was an influenza year; and while 1920 was comparatively free from influenza, two years before, in 1918, a very high death rate from influenza was registered in London. Still, even in the year 1918, the total London death rate was only rather more than half that of 1849, the earlier year of exceptionally heavy mortality. The high marriage rate of the previous year was maintained in 1920, being 22 per 1,000 of the Marriage estimated population. The Registrar-General estimates the birth rate to have been 26.4 per 1,000, as compared with Births. 18.2 in 1919. In the first quarter of the year the birth rate was 31.4, but thereafter it declined, and in the fourth quarter it had fallen to 22.9, a figure somewhat below the pre-war average for this quarter. The death rate among civilians is estimated by the Registrar-General to have been 12/6, as Deaths. compared with 13.6 in 1919. There were relatively few military deaths in the year, and the number belonging to London cannot be ascertained ; but even allowing for these deaths, and for the uncertainty as to the true population, there seems little doubt that the mortality was well below any previous record in London. The mortality among infants under one year of age per 1,000 births was 76 in 1920, which is considerably below any London rate previously recorded. Comment was made in the report for 1919 upon the fact that certain notifiable infectious diseases infections were showing increase upon the low rates of prevalence of the preceding two or three years. This upward disease. movement continued last year so far as scarlet fever, diphtheria, erysipelas and puerperal fever were concerned, and the high incidence of the two first-named diseases in 1920 is referred to in detail in the second part of this report. The case-mortality happily continued to be far lower than that of earlier experience, as has now been the case for the last forty or fifty, and very notably so during the last twenty or twenty-five, years. Smallpox did not establish itself in 1920, though several imported cases naturally gave rise to apprehension. Typhus, though widespread in some parts of the Continent, particularly Poland and Russia, obtained no footing here. The special efforts made to minimise risk of spread of typhus in London by a more systematic delousing campaign in the elementary schools, are described in the second part of this report. The urgent need for taking these steps was emphasised by the revival of the transmigrant traffic between Europe and the New World, to which reference is made on p. 33. Dysentery, which had declined in 1919 as compared with 1918, showed further decline in 1920. The behaviour of typhoid fever in the years preceding the war, during the war years and subsequently, is one of the most noteworthy epidemiological phenomena of the time. So much misapprehension exists on this subject that it was thought desirable in last year's report to review the whole position so far as the decline of typhoid fever in the last fifty, and particularly in the last twenty, years is concerned. 61004 B 2 A chart was exhibited which showed that the 50-year decline was the result in the main of the great sanitary campaign of the last half of the nineteenth century, and especially of the attention devoted to obtaining pure water services throughout the country ; while the continued and accelerated fall of the last twenty years appeared attributable partly to the cumulative effect of the advances thus made, but largely also to the cutting off of certain grossly polluted shellfish and fish supplies. The view has been consistently maintained in these reports, for the last ten years and more, that (in London at any rate) typhoid carriers, flies, milk, ice-cream, and watercress have not been responsible for the spread of typhoid fever. Furthermore, that the part played by direct case-to-case infection cannot be in any case an important one; while the influence of preventive inoculation has been altogether negligible. With these considerations in mind it was possible, in 1914, to reach the conclusion that the effect of the war was not likely to be to increase, as some supposed, the risk of spread of the disease, but to diminish it. This expectation has been realised. Moreover, as an outcome of the experience gained in the last seven years, the vogue of the carrier hypothesis has materially lessened ; the conviction having steadily gained ground that typhoid fever is for the most part water-borne and food-borne ; there remains still, however, in many minds the belief that case-to-case infection is quite commonly met with, and that important influence so far as males are concerned has been exerted in the last few years by protective inoculation. London experience does not lend support to either of these hypotheses (see p. 25). There emerges, however, from further study of the remarkable reduction in typhoid in the civilian population, right down to and persisting through the war period, and after, reason for directing attention . to the possibility that some small influence has been exerted in this connection by altered nomenclature now arising from the special reliance placed upon bacteriological as distinguished from clinical tests for purposes of diagnosis. The transference of cases, which in former years would have been classed as typhoid, to other categories, such as dysentery, diarrhoea, appendicitis, not to mention influenza, trench fever, and " pyrexia of unknown origin," is a factor to be reckoned with in considering the decline of typhoid fever. In particular as the outcome of recent experience, the question as to possible confusion between typhoid and dysentery is one to which attention may be especially directed, and on this subject some comments are made on p. 28. As regards tuberculosis, the war and the aftermath of the war have resulted in clear demonstration of the fact that lowering of resistance (resulting from poor feeding, for example) is a far more important influence for harm than increased exposure to infection. This subject was touched upon in last year's report, and is here again noticed. "The Influence of Migration upon the Phthisis Death Rate"' was first brought under notice in 1912, Two striking phenomena doubtless related to this influence have become clearly apparent since the commencement of the great war, and are referred to on pp. 13-14. Reference is made, moreover, in view more especially of its important bearing upon the influence of migration upon the death rate from phthisis, to a paper which appeared in 1920 on The Mortality of Race Stocks in America (p. 17). An important report on tuberculosis by Dr. Greenwood, which appeared in the Annual Report of the Chief Medical Officer of the Ministry of Health for 1919-20, is also commented upon, attention being especially directed (in Part I. of the present report) to the questions raised by Dr. Greenwood concerning the influence of migration and industrialisation, and (in Part II.) to the influence of immunisation in early life against subsequent attack. As for the influenzal group of diseases, so far as their prevalence in 1920 is concerned, there is fortunately but little to record. Cerebro-spinal fever, poliomyelitis and polioencephalitis and encephalitis lethargica are referred to on pp. 19-23. Epidemic hiccough, though observed in a few cases in London, has been less conspicuous than on the Continent. This affection and encephalitis lethargica are generally regarded as closely associated with influenza. As they have no bacteriology, the bacteriologist abandons them to the wolves without regret. The question of sore throat and glandular fever, which prevailed in London in the autumn, and which may have been also influenzal in origin, is referred to in Part II., p. 89. Some of the lessons to be learnt from the behaviour of influenza in the recent outbreaks are considered on p. 18. During 1919 there was a great coming and going of refugees and soldiers through London, and at the middle of that year it was calculated that there was a net addition of 400,000 to the London population. In 1920 this special traffic of 1919 came in large measure to an end, but there was beginning to spring up a new movement of emigrants proceeding westwards and ever increasingly passing on their way through London from Europe to America. These movements of population necessitated close attention being given to the question of risk of spread of epidemic disease. tions. The Council's tuberculosis scheme of May, 1914, was further extended in 1920, and there was, moreover, in contemplation during that year the addition to the Council's responsibilities of charge of the institutional treatment of insured as well as of uninsured persons. The scheme for London and the Home Counties, for the diagnosis and treatment of venereal diseases, inaugurated on 1st January, 1917, was also extended, and a comprehensive survey was made of the available provision by Brevet Lt.-Col. Harrison and Dr. F. N. K. Menzies, the results of which are fully set out by Dr. Menzies in the Appendix to this Report. Much additional work was thrown upon the Public Health Department arising both out of official representations with regard to unhealthy areas in London (see p. 33), and in connection with the Building Control Act. The framing of new by-laws (which the Council is empowered to make) under the Housing and Public Health Acts has also been under consideration. Reference will be found in the Report to work carried out under Part I. of the Children Act, 1908 (p. 45), under the Midwives Act (p. 40), and the Mental Deficiency Act (p. 39). An account of methods used in connection with examination of children under the last-named Act, by Dr. F. C. Shrubsall, is given in Part II. of this Report (p. 95). The work of the Chemical branch of the Department and the experimental work in connection with the biological treatment of sewage now inaugurated at the sewage outfalls, are referred to on pp. 46-47. 3 In last year's report reference was made to the fact that, among other problems of reconstruction, The new there had been a tendency of late to examine anew the foundations upon which the practice of preventive epidemiology. medicine is built, with the result that the whole question of nomenclature had come under critical review, and that it was now recognised that the diagnosis of an epidemic involved something more than does the diagnosis of disease in individual instances. Attention has for years past been concentrated Upon the "materies-morbi" ; it is now agreed that the "conditions of human life, both as we now say environmental and eugenic," also merit the attention of the epidemiologist. Some ways of viewing the questions at issue, as they present themselves when regarded from different angles, are exhibited, and may be studied, in recent articles and letters which have appeared in the " British Medical Journal" ("The New Epidemiology," March 19th, 1921 ; " The Science of Etiology," April 9th, 1921 ; and correspondence arising in connection therewith). There seems to be general agreement that " an exact knowledge of causes is one of the most difficult and elusive of all quests in medicine." But it is now becoming recognised that there is scope for all, for the field men as well as for the laboratory men. We have been told that, for Sydenham, " personal knowledge of the facts was the prerequisite of epidemiological theory." Just as personal knowledge of the facts must also be a prerequisite for the theory of germs, visible and ultravisible. The dispute which has arisen between the new epidemiologists and a few laboratory and clinical workers " is a very pretty quarrel as it stands ; we should only spoil it by trying to explain it." It is at least clear, however, that the champion of the new epidemiology, Dr. Greenwood, has maintained his position in the face of the criticisms " from the pen of a distinguished bacteriologist written ... in consultation with a no less distinguished clinician " ; and his success must be attributed, like that of his legendary prototype who fought with the giants of old, " to his four marvellous possessions—an invisible coat, a cap of wisdom, shoes of swiftness, and a resistless sword." There comes plainly to light, however, from this correspondence, the disconcerting discovery that-the new epidemiology stands under some suspicion of being content merely with "postulating causes " without systematically testing its hypotheses " by the stern reality of experience in its widest sense." Under such a suspicion no epidemiologist can rest undisturbed ; for epidemiology, old or new, has always been inevitably dependent upon close observation of the behaviour of epidemics. Conceptual reason has its uses, but those who study epidemics' must keep their feet on solid ground. As William James says, " Our ideas and concepts and scientific theories pass for true only so far as they harmoniously lead back to the world of sense." And yet we must not forget that a belief in human reason does not, or should not, merely mean a belief in our own reason; it means a belief in human reason as a whole. The bacteriologist and clinician are warned by the " British Medical Journal" that they certainly seem to imply that they " limit the term research to experiments in bacteriological and chemical laboratories." And the new epidemiologist must, of course, on his part, pay the closest attention to the teachings of bacteriology. All mechanisms must, in the long run, square with the facts, for, as it has been aptly said, " So long as a suggested mechanism accounts only for the phenomena which gave rise to it, it can only claim to be a possible solution of the riddle. It is when a mechanism is found also to accountfor other phenomena, widely different from those that suggested it, that it first becomes entitled to claim to be regarded as the actual solution." This clearly is the corner stone of epidemiology, and of bacteriology and clinical medicine too, upon which they must base their right to rank among the sciences. A.—Vitat. Statistics. The population of London County at the census of 3rd April, 1911, was 4,521,685, and it was Population. estimated by the Registrar-General to have fallen to 4,518,021 in the middle of 1914. Returns furnished to the Registrar-General of data obtained under food rationing schemes have enabled him to estimate the civil population for 1920 to be 4,531,971. The estimated number of men still on service is about 21,000. From these figures it would be expected that the census to be taken this year should show an increase in the population belonging to London of over 31,000 since the census of 1911. The births since 1914 exceed the deaths in this period by about 180,000; and assuming the number of Londoners who fell during the war to have been about 80,000 the increase in London population, apart from migration, would be about 100,000. Returns made in respect of rate leakages in London show that while in the financial year 1913-14 there were about 28,000 empty houses in the county, the number had fallen to 21,294 in 1918-19, and in 1919-20 more than half these houses had become occupied. Most of these houses would be in the better class districts, and the margin of empties in smaller houses must have reached an irreducible minimum. Since the conditions are the same in the rest of Greater London practically the whole of the natural increase since 1914 must now be housed within the county. Marriages. The marriages registered in London during 1920 numbered 49,185, as compared with 50,222 in 1919, the approximate marriage rate being 22 per thousand of estimated population for both years. It will be seen from the diagram facing page 5 that the marriage-rate of 1920, although not reaching the exceptional level of 1915 is nevertheless well above that of the years immediately preceding the great war. The average number of marriages annually during the six years 1909—1914 was 40,765, as compared with 47,313 in the last six years. Births. The births in London during 1920 numbered 120,529, the corresponding figure for 1919 being 82,525, and for the pre-war period 1911—1914, 110,951. The actual number of births was greater than in any year since 1908. 61004 b 2 4 5 The birth-rate is estimated to have been 26.4 per 1,000 of an estimated population, which includes Londoners on active service during the year; this compares with the corresponding rate of 18.2 per 1,000 in 1919 and 16.0 in 1918. The excess in births during last year does not suffice to make good more than about 10 per cent. of the decline during war-time. In the 13 weeks ended 2nd April, 1921, there were 26,170 births in London, this giving a birth rate of only 23.1 per 1,000; the birth rate for the whole year is generally lower than in the first quarter. Deaths. The deaths among the civil population of London during 1920 numbered 57,232, as compared with 59,114 in 1919. The Registrar-General gives the death rate as 12.6, which is the lowest rate recorded in London since the introduction of registration. In addition to the deaths among civilians there was a certain number among Londoners on active service, but this was relatively small, judging by the figures for the whole of England and Wales. The distribution of the deaths by ages during 1920 is shown in the following table together with corresponding figures for earlier years. 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 1,361 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 1919 7,039 1,430 1,846 1,472 909 1,255 1,440 3,763 4,501 6,640 8,393 20,426 59,114 1920 9,141 1,894 1,904 1,467 845 1,159 1,291 3,058 4,223 6,216 7,786 18,248 57,232 Increase(+) or ) Decrease (—) 1920 upon 1919 + 2,102 + 464 + 58 -5 -64 —96 —149 —705 —278 —424 —607 —2,178 —1,882 The death rate among infants under one year of age was 76 per 1,000 births, as compared with 85 in 1919. Climatic conditions have much to do with variations in infant mortality from year to year, and some part of the decrease in the rate of 1920 upon that of 1919 is attributable to the combination of a mild winter and a moderate summer temperature, resulting in a low winter mortality from respiratory diseases and a summer mortality from diarrhoea much below the average. The influence of favourable summer and winter weather does not however suffice to account for the marked reduction in the infant death rate of the past two years. It may be noted that the infant mortality attained the lowest recorded figure in a year of high birth rate. There is, generally speaking, a relation between the birth-rate and the infant mortality rate, both showing a tendency to vary together, so that districts with a high birth rate have a high mortality, and vice versa. Thus the low birth-rate in the betterclass districts of London is accompanied by a low mortality, while populations of the poorer class maintain a high birth rate and high mortality. During the war, the number of confinements has been greatly reduced, and this fact in itself must have affected the rate of infant mortality. Further, notwithstanding the adverse conditions, much progress was made during the war in the assistance and supervision of expectant and nursing mothers and their infants, the scope of the maternity and child welfare work being now so widened and general as to show its effect upon the vital statistics of the total population. The following table shows the influence of season upon infantile mortality. In the first quarter of 1921 the rate was 85 per 1,000 births. 1911. 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1st quarter 108 95 116 96 111 92 115 125 118 93 2nd 89 82 81 79 93 73 85 90 70 62 3rd „ 203 81 105 127 113 82 88 85 72 59 4th „ 113 103 115 109 126 103 114 117 76 79 Annual Rate 129 91 105 104 112 89 104 108 85 76 The following table has been prepared to enable comparison to be made of the exceptional figures for 1920 with other recent years. The deaths are shown per 100,000 births. Disease. 1911. 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. Measles 475 334 299 254 481 174 492 389 67 202 Whooping cough 387 394 295 377 472 354 251 702 87 289 Influenza 17 22 33 35 31 16 27 365 138 46 Phthisis 63 57 53 56 56 38 81 51 34 35 Tubercular meningitis 172 134 119 125 140 129 149 128 93 80 Other tubercular diseases 173 139 130 142 152 114 158 86 39 37 Meningitis 172 114 115 124 198 162 197 135 109 95 Bronchitis 724 618 681 550 660 529 696 702 510 565 Pneumonia 1,235 1,130 1,381 1,166 1,610 1,169 1,528 1,678 1,025 1,262 Other respiratory diseases 81 58 71 63 60 48 60 38 41 41 Diarrhœa 3,978 1,081 2,280 2,372 2,082 1,389 1,603 1,367 1,475 898 Premature birth 1,842 1,826 1,768 1,819 1,760 1,640 1,722 1,847 2,042 1,532. Congenital debility, etc., excluding premature birth 1,729 1,393 1,385 1,371 1,518 1,386 1,522 1,439 1,270 1,153 6 Infectious diseases. Smallpox During 1920, 19 cases of smallpox occurred within the Administrative County, and 51 cases were notified within the area of greater London, mainly in East Ham and West Ham. In addition, seven cases occurred on board vessels arriving in the Port of London and were removed to the Port of London Authority's Smallpox Hospital at Denton. It will be convenient to divide the London cases into groups and for the purpose of classification two Port of London cases (Group IV.) are also included in the following table:— Probable origin Initials of case, age and sex. Address. Dates of Bash. Removal to hospital. Remarks. I.—Probably abroad H.Y. (20 m.) 3rd London Gen. Hosp. Wandsworth 3rd Jan. 6th Jan. Patient was an orderly in the hospital and had assisted at a post-mortem examination on an officer who died just before Christmas. This officer left Calais on 24th Nov., 1919, and was transferred from Netley Hospital to the 3rd London General Hospital on 13 th Dec. Sgt. J.(52 m.) ,, 5th Jan. 8 th Jan. Also assisted as above. This case was seen by Dr. Wanklyn. II.—S.S.Deranha E.F. (20 f.) 248, St. Leonard'sroad, Poplar 10th Feb. 14th Feb. Patient was employed at Bell Wharf (Poplar) in sorting linen from S.S. Devanha on which smallpox had occurred. Patient died 17th Feb. A. P. (22 f.) 250, St. Leonard'sroad 23rd Feb. 24th Feb. Sister-in-law of E.F. Seen by Dr. Wanklyn. A.F. (47 f.) 200, St. Leonard'sroad 25th Feb. 20th Feb. Mother of A.P. Nursed E.F. during illness. Re-vaccinated 17th Feb. after many days in contact with E.F. H.S. (64 m.) 248, St. Leonard'sroad 28th Feb. 29th Feb. Same house as E.F. (refused re-vaccination). J.H. (45 m.) 15, Rook-street, Poplar 29th Feb. 1st Mar. Driver of borough council's disinfecting van. He removed articles from 248, St. Leonard's-road. Refused revaccination. M.A.S. (40 f.) 9, Bartlett-street, Poplar 1st Mar. 1st Mar. Patient worked at Bell Wharf where linen from S.S. Devanha was stored. III—Probably connected with Group II. F.J. (24 m.) 73, East Ferryroad, Poplar 6th Mar. 9th Mar. Patient was in Balham 14 days before rash appeared, but no origin of infection traced. Case seen by Dr. Wanklyn. D.J. (3 f.) 73, East Ferryroad, Poplar 18th-19th Mar. 19th Mar. Daughter of F.J., vaccinated primarily 11th Mar. Mrs. J. (25 f.) 73, East Ferryroad After removal to hospital 19th Mar. Wife of F.J. Re-vaccinated 11th Mar. IV.—Probably Erith A.L. (52 m.) 09, Christian-street Stepney About 13th Mar. 17th Mar. Patient was a seaman on S.S. Surf. This vessel was in the Thames off Erith (where smallpox had occurred) at the probable date of infection of patient (20th Feb.). The vessel lay at Plymouth 12th-10th Mar. Patient left ship on 10th Mar. (in an infectious condition) and travelled by train to London. He attended Seamen's Hospital on 17th Mar. and was found to have smallpox. L.L. (40 f.) 69, Christian-street, Stepnev 28th Mar. 29th Mar. Wife of A.L. L.L. (45 m.) S.S. Surf, Port of London 29th Mar. 30th Mar. (Denton Hosp., Gravesend) Probably infected by A.L. The S.S. Surf landed a case of smallpox at Barry and all the men except four were re-vaccinated before the ship left Barry for London. Patient was one of the four who refused vaccination. Case proved fatal. E.D.(34 m.) S.S. Surf, Port of London 31st Mar. 1st April (Denton Hosp., Gravesend) This man was one of the four who refused vaccination at Barry. V.—(? Erith) J.W. (45 m.) 57, Cordite-street, Woolwich 25th Mar. 27th Mar. Patient worked at Erith where there wero cases of smallpox. Patient's daughter worked in Silvertown in next office to a smallpox patient from West Ham. Patient's workmate was father of a smallpox patient in Erith. 7 Probable origin. Initials of case, age and sex. Address. Dates of Rash. Removal to hospital. Remarks. VI.—Untraced (see context below) VII.—Untraced J.G. (19 m.) J.H. (? age, m.) 0.0. (? age, m.) J.M. (40 m.) W.H.J. (23 m.) Sailor's Home, Dock-street Seamen's Hospital Greenwich Seamen's Hospital, Greenwich 46, Hyde-vale, (Seamen's Hosp.) 61, Goldhurst-terracc, Hampstead 19th April ? 3rd April ? 2nd May ? 28 th Dec. 19thApril, Seamen's Hosp., 21st April S. Wharf 21st April 21st April 2nd May 30th Dec. Patient had been an inmate of the venereal ward at Seamen's Hospital from 25th Mar. to 15th April. Returned to the hospital feeling unwell on 19th April. Rash came out that evening. This man had practically recovered when seen by Dr. Wanklyn on 21st April. He then had definite traces of smallpox on soles of feet. A.L. (Group IV. above) was removed from the hospital on the 17th Mar. suffering from smallpox (see context ). This man slept in next bed to J.H., and was infected by him. When seen by Dr. Wanklyn on 21st April he was in advanced stage of hajmorrhagic smallpox and died the following day at South Wharf. Dresser in the ward from which the three previous cases were removed Re-vaccinated 22nd April, very mild attack. Patient was on a visit for Christmas. Worked at Chelmsford for War Office. Seen by Dr. Wanklyn. This series of cases provides a striking example of the risks, which are constantly arising, of the introduction of smallpox into London through the importation of infected persons or material from abroad. As regards the groups of cases which occurred in February, March, and April, the origin of infection may be attributed directly or indirectly to association with ships or the riverside docks. The outbreak in Poplar (Group II.) which commenced in February was definitely traced to the handling of soiled linen coming from the military stores on board the S.S. Devanha on which cases of smallpox had occurred. This material was stored at Bell Wharf, Poplar, and a woman who had been engaged in sorting it contracted smallpox and died. Five secondary cases resulted, one of which was the driver of the disinfecting van ; three occurred in the same family or house as the original pat'ent; and the fifth was a workfellow of the deceased and was also employed in handling the military stores referred to. No connection could be traced between these cases and the outbreak which occurred at 73, East Ferryroad (Group III.). In this group the first patient was a marine storekeeper and his employment involved the handling of dirty sacks. Failing the discovery of any other source of infection it would be reasonable to ascribe this case to the nature of the man's employment. On the other hand, in view of the occurrence contemporaneously of the group of cases in the near neighbourhood, connected with the S.S. Devanha, it is possible that infection may have been directly or indirectly derived from this source. The East Ferry-road case gave rise to two secondary cases in the same family. The outbreak on board the S.S. Surf originated in a member of the crew (A.L., aged 52 years) who left the ship at Plymouth on 16th March. He travelled to Paddington the same day and went to his home at 69, Christian-street, Stepney, and thence to the Seamen's Hospital (V.U. Department) on 17th March, when he was found to be suffering from smallpox, the rash having appeared about four days previously. He was at once removed to South Wharf. It was ascertained that the S.S. Surf was lying off Erith on the 26th February about the time the patient must have been infected, and as a case of smallpox had occurred in Erith and further cases developed subsequently, it seems likely that the man may have come into contact when ashore with some, unrecognised case. The vessel was a tramp collier plying round the coast and no other possible source of infection could be discovered. The man infected his wife, who developed the rash on 28th March. The S.S. Surf, on leaving Plymouth, sailed to Barry, and on arrival there another case of smallpox was landed. She left Barry with a clean bill of health, all the crew except four being vaccinated, and arrived in the Port of London on 30th March, when one of the four men who refused vaccination was found to be suffering from smallpox. He was removed to Denton Hospital where he died. On 31st March another of the men who declined vaccination developed a smallpox rash and was removed the next day. This outbreak affords a good illustration of the way in which smallpox is conveyed from place to place by ships' crews and emphasises the importance of close medical supervision at the ports. To what extent (if at all) this group (IV.) of cases can be linked up with the occurrence of four cases (Group VI.) in the Seamen's Hospital during the month of April must remain a matter for speculation. The facts are as follow : On the 19th April a seaman (J.G., aged 19) living at the Sailors' Home, Dock-street, developed a rash and went to the Seamen's Hospital, where he was found to be suffering from smallpox and was at once removed to South Wharf. He had arrived in London from Seville on 25th March, and he proceeded on disembarkation to the Seamen's Hospital where he was treated as an in-patient in the V.D. ward. He was discharged dn the 15th April and he lived at the Sailors' Home until his return to the hospital on the 19th April as stated. As the man must have been in the hospital on the day he contracted the disease Dr. Wanklyn visited the hospital with a view to ascertaining the 8 possibility of the existence of an unrecognised case in the ward. His attention was directed to one of the patients (0.0.) in the ward, who was very ill and was thought to be suffering from septicaemia. Dr. Wanklyn was of the opinion, however, that he was suffering from haemorrhagic smallpox and advised immediate removal. The man died the next day. On examining a patient (J.H.) in an adjacent bed who was said to have suffered from "acne" about a fortnight previously (5th April), Dr. Wanklyn came to the conclusion that the man was recovering from a mild attack of smallpox, there being distinct evidence of that disease on the soles of the feet. This man was also removed to hospital. On the discovery of these cases the whole hospital floor was immediately placed in quarantine and arrangements were made to have all known contacts followed up and vaccinated. The seamen's and common lodging houses were kept under close observation. Only one further case resulted, viz., a ward dresser, and therp is no doubt that by the timely detection of these cases and the stringent precautions which were taken a more extensive outbreak was averted. The source from which J.H. (the convalescent case) derived his infection could not be definitely traced, as he had been an inmate of the hospital for some time, certainly on the date when he must have been infected, which from the history was some time in the middle of March. In these circumstances suspicion fell upon the case of A.L. (Group IV.) already referred to as having been removed from the Seamen's Hospital on the 17th March suffering from smallpox. It was ascertained, however, that in the ordinary course of events the two men should not have come into contact with each other, as one received treatment in the morning and the other in the evening. In view, however, of the fact that A.L. attended the hospital on the 17th March in an infectious condition and that J.H. fell ill about a fortnight later the possibility of some connection, direct or indirect, can hardly be excluded altogether. On the other hand the chances of an unrecognised case attending the out-patient's department of a hospital when seamen are daily in attendance must not be ovei looked. A report of the occurrence of smallpox in the Administrative County in 1920 would be incomplete without a brief reference being made to outbreaks which developed in greater London, namely, in East Ham and West Ham, about the same time. Want of space forbids a description of these cases in detail but theie is little doubt that the infection originated from the docks area. The following table shows the number of cases notified in greater London and the Port of London, and their distribution, monthly and geographically The ship cases which arrived in the Port of London were promptly dealt with, the contacts were followed up, and no developments arose. Locality. February. March. April. May. June. Total. West Ham 7 10 6 6 1 30 East Ham 6 1 — 13 11 Romford — — — — 3 3 Ilford 1 — — — — 1 Leyton — 1 — — — 1 Erith — 4 — — — 4 Twickenham — — 1 — — 1 (imported from Spain) Port of London. S.S. China (from Calcutta) — 2 — — — 2 S.S. City of Manchester (from Calcutta) — 1 — — — 1 S.S. Wigmore (from Alexandria) 1 — — — — 1 S.S. City of London (from Calcutta) 1 — — — — 1 S.S. Surf (coasting collier) — 1 1 — — 2 (see table page 6) Total 16 20 8 7 7 58 Dr. W. McC. Wanklyn assisted in the diagnosis of 17 suspected eases occurring in the Counties of Middlesex and Essex and the County Boroughs of East Ha m and West Ham in accordance with an arrangement previously made. Of these four proved to be smallpox. There is no doubt that the facilities afforded by the Council to medical practitioners in these contiguous areas for obtaining expert assistance in diagnosis is of great value, not only to the districts concerned, but also in preventing the spread of smallpox into London. Study of the incidence of smallpox in London shows that there has been a notable fall in the period subsequent to 1885 as compared with earlier years; indeed, since 1885, in only three years have the deaths exceeded 100, viz., in 1893 (186), in 1901 (229), and in 1902 (1,314); during the last 15 years only 24 deaths have been registered, i.e., less than 2 per annum. The question may be raised as to how long it will be possible to keep smallpox at the present low figure. The answer is that under existing conditions there is a constant risk that smallpox will strongly reassert itself, and assume a more prominent position than it does at present. A glance at a world map of smallpox makes this self evident. Smallpox is a world disease, and is very widely prevalent. In British India, for instance, during the year 1918, there were 93,000 deaths from smallpox, probably representing half a million cases ; and, as it is more or less prevalent in nearly the whole of the rest of the world, it is apparent that the total number of cases reaches a very high figure. In this country, and especially in the metropolis, with its large influx of passenger traffic from all parts, not only from the Continent, but also from the seaports of the Mediterranean and of the Eastern 9 and Western hemispheres—and foreign seaports are among the special breeding grounds of the disease— it can only be hoped to put off the evil day of the return of smallpox as long as possible; under present conditions it is not possible indefinitely to escape what is in effect a universal scourge. The case would be a very different one if general use were made of vaccination. Countries such as Holland and the Philippine Islands have rid themselves almost entirely of smallpox and any scare of it by means of vaccination ; but our population is largely unprotected and is yearly becoming more so. It is always liable to be attacked by the chance importation of a case into a neighbourhood, where infection will take hold and spread rapidly. This happened towards the end of the year 1919 in a country district where a mild unrecognised case led in a few weeks to 59 other cases, to the closing of all the elementary and secondary schools and to the closing of the Sunday schools. Similar happenings have often been reported. One such occurred in London in 1911, when 70 cases of smallpox followed a single unrecognised case, infection from which, as it chanced, lit upon a susceptible group of people. Again, in 1901, a few cases of smallpox were overlooked; with the result that while on 19th August, 1901, there were only 15 cases in hospital, eight days later there were 73. In that single week of the summer hoi'days serious damage was done; smallpox went straight ahead after that to the extent of 10,000 cases in all, and cost the Metropolitan Asylums Board alone £500,000. It is the special risk of smallpox that it cannot be foreseen, or calculated against beforehand, either as to time of attack, extent of attack, or as to expense. The late Dr. T. F. Ricketts observed that "Outbreaks of smallpox are prone to occur without warning and to reach unpleasant proportions with great rapidity." The story of each successive outbreak emphasises anew the need for being always prepared to deal with an emergency, so as to check it at the outset; the main item in such preparation being to use every available means to secure that each case of smallpox is recognised immediately it occurs. The deaths from measles in London during 1920 numbered 1,016, as compared with 353 in Measles. 1919. The mortality was 0 22 per 1,000 living, and this is much below the average of the past 20 years. The monthly deaths from measles in London since 1890 are shown in the diagram facing page 80 in Part II. of this Report. The mortality from measles is greatest in the second year of life ; the low birth rate of 1917-18 has therefore to be taken into account in contrasting the 1920 figure with that of earlier years. There were 22,705 cases of scarlet fever in London in 1920 (52 weeks), as against 12,935 in 1919 Scarlet fever. (53 weeks). The deaths numbered 207 (366 days), giving a death rate of 045, the corresponding figure for 1919 being .033. The monthly incidence of scarlet fever cases in London since 1890 is shown in the diagram facing page 80 of this Report, and some notes upon the seasonal fluctuations of prevalence will also be found there. It will be seen from the diagram referred to that the autumnal incidence of scarlet fever in London in 1920 was greater than in any year since 1892. The number of cases of diphtheria notified in 1920 (52 weeks) was 13,780, as compared with 9,459 Diphtheria, in 1919 (53 weeks). The deaths in the calendar year were 1,023, the corresponding figure for 1919 being 775. The number of cases of diphtheria in London in the year 1920 exceeded that in any calendar year since the disease became notifiable, although, as will be seen from the diagram facing page 80, the autumnal incidence in 1893 was slightly higher than that of 1920. The Ministry of Health's annual returns of the incidence of infectious disease show that the excess in incidence of diphtheria in London over that in the rest of England and Wales has steadily increased since 1911, the date when the returns' were first prepared. Only two cases of typhus fever were notified during 1920, and in both cases the diagnosis was Typhus revised after admission to an M.A.B. fever hospital. In one of these cases the medical practitioner fever. called in one of the Council's consulting medical staff to assist in the diagnosis. Dr. J. G. Forbes examined the patient and advised removal to hospital for observation on suspicion of typhus fever. The possibility was, however, negatived after a period of supervision of the patient at the South Eastern M.A.B. Hospital. No cases of plague or cholera were notified during 1920. It will be of interest, however, to refer Plaaue and briefly to a case in which suspicion of plague was raised. The patient was a man under treatment at a cholera. nursing home and was suffering from lumps in the axillae and enlarged glands in the groin. One of the Council's consulting medical staff (Dr. W. McC. Wanklyn) was called in and he advised that a specimen of glandular fluid should be taken for bacteriological examination. This course was adopted and as a result, staphylococcus aureus was isolated from the specimen. It subsequently transpired that the patient's condition was due to the bite of an Asiatic bug, and that all the members of the family had suffered in a similar way. The patient and his family had not long previously arrived in this country from China, and it was ascertained that on board the vessel in which they sailed there was a number of Chinese coolies travelling en route for Russia. During 1920, 15 cases of anthrax occurred in London, of which four proved fatal. The origin Anthrax, of infection was traced in 11 instances to the handling of imported hides, hair or wool, during the course of the patient's occupation. With regard to the remaining four cases the use of an infected shaving brush was definitely traced as being the cause of the disease in three cases, and strongly suspected in the fourth; in the last mentioned case it was ascertained that the patient had used a new shaving brush immediately before the appearance of the disease, but the brush, which had been bought from an unknown man off an unknown U.S.A. ship, could not be obtained. It was pointed out in last year's annual report that certain cases of anthrax had occurred as a result of using Japanese shaving brushes, and that following upon prompt administrative action an Order in Council was issued under the Anthrax Prevention Act, 1919, prohibiting the further importation of these brushes. In spite of this Order, however, it was found that large numbers of Japanese brushes were still on the market, owing mainly to the difficulty in tracing all the brushes in circulation before 61004 c 10 11 prohibition took place. The occurrence of further cases of anthrax from infected shaving brushes induced the Ministry of Health to issue a circular (No. 172) in January, 1921, to medical officers of health, drawing attention to the risks of the spread of anthrax from this source and suggesting that retailers should be prevailed upon either to destroy any Japanese brushes in their possession or to return them to the wholesalers with an appropriate explanation. In this connection Dr. James Fenton, Medical Officer of Health of Kensington, reported that there was nothing to prevent brushes, so returned to the wholesalers, from being put on to the market again, and stated that a number of brushes seized had been retained by him. The Ministry pointed out that the only obstacle to wholesalers re-selling the brushes was a possible claim for compensation in the event of a purchaser contracting anthrax; further, that the borough council must pay compensation for any brushes retained. Dr. Fenton, thereupon, advised that the appropriated brushes should be destroyed and compensation paid as the only safe means of preventing spread of the disease. The borough council agreed to his recommendation and their decision was circulated to the councils of other metropolitan boroughs in the hope that similar action might be taken. The death rate from pulmonary tuberculosis in the civil population of London during 1920 was Tuberculosis. 1.05 per 1000 lis ing, the deaths numbering 4,791, as compared with 5,332 in 1919 and 7,048 in 1918. Tuberculosis other than phthisis caused 954 deaths, as against 992 in 1919 and 1,398 in 1918. The total number of deaths from phthisis given above does not properly represent the movement of the phthisis mortality in the past three years for the disease is largely incident upon males of military age. In some cases active service may actually have inhibited incipient phthisis, while in others the hardships of war undoubtedly lowered resistance to attack. The figures given above relate to civilian deaths only, except in cases of deaths occurring after discharge from the army. Further, in order to arrive at a true picture of the changing incidence of tuberculosis, it is necessary to know the agedistribution of the population concerned. The latest available data on this point are for the year 1911, and cannot, owing to changes brought about by the war, any longer be relied upon. When the results of the forthcoming census are to hand, and figures are published relating to the strength of the army at various periods of the war, the movement of the phthisis mortality can be more accurately appreciated. The number of "primary" cases of tuberculosis notified in London during 1920 (52 weeks) was 13,163 as against 15,587 in 1919 (53 weeks) and 19,178 in 1918 (52 weeks). These figures do not relate exclusively to the civil population. Of the total "primary" cases notified in 1920 there were 10,670 cases of pulmonary tuberculosis, and 2,493 of other forms of tuberculosis. The following is an analysis of the cases notified in London in 1920 (52 weeks):— Form of tuberculosis notified. Sex. Notifications on Fonn A. (Total of primary notifications received in London boroughs, other than elementary school cases, injra.) 0— 1— 5— 10— 15— 20— 25— 35— 45— 55— 65 + Age not stated. Total. Pulmonary tuberculosis M. 18 76 274 225 463 638 1,344 1,292 989 465 149 5,933 F. 18 72 204 247 584 651 1,139 866 509 199 93 — 4,582 Other tuberculosis M. 39 189 367 186 118 67 89 67 29 20 13 — 1.184 F. 32 138 311 181 108 82 108 50 36 23 13 — 1,082 All forms of tuberculosis M. 57 265 641 411 581 705 1,433 1,359 1,018 485 162 7,117 F. 50 210 515 428 692 733 1,247 916 545 222 106 5,664 Form of tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools.) Notification on Form .C. (Secondary notifications from institutions receiving cases.) 0— 5— 10— 15 + Total. Poor Law. Other. Pulmonary tuberculosis M. 2 43 31 1 77 824 2,762 F. 4 37 35 2 78 971 921 Other tuberculosis0 M. 8 73 40 1 122 197 129 F. 5 51 49 105 164 151 All forms of tuberculosis M. 10 116 71 2 199 1,021 2,891 F. 9 88 84 2 183 1,135 1,072 The corresponding figures for 1919 (53 weeks) were as follows:— Form of tuberculosis notified. Sex. Notifications on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, injra.) 0— 1— 5— 10— 15— 20— 25— 35— 45— 55— 65 + Age not stated. Total. Pulmonary tuberculosis M. 8 83 346 269 492 697 1,639 1,443 1,124 512 154 9 6,776 F. 5 80 300 330 577 723 1,282 1,027 566 228 110 — 5,228 Other tuberculosis M. 32 246 493 254 114 76 96 46 40 18 12 — 1,427 F. 22 183 415 278 111 94 99 51 37 18 21 — 1,329 All forms of tuberculosis M. 40 329 839 523 606 773 1,735 1,489 1,164 530 166 9 8,203 F. 27 263 715 608 688 817 1,381 1,078 603 246 131 6,557 61004 c 2 12 Form of tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools). Notifications on Form C. (Secondary notifications from institutions receiving cases.) 0— 5— 10— 15 + Total. Poor law. Other. Pulmonary tuberculosis M. 4 115 53 2 174 877 2,627 F. 11 93 71 3 178 1,078 994 Other tuberculosis M. 11 154 72 1 238 198 60 F. 21 131 84 1 237 147 88 All forms of tuberculosis M. 15 269 125 3 412 1,075 2,687 F. 32 224 155 4 415 1,225 1,082 The increase in the number of cases notified in the earliest years of life is explained by the increased number of births since the latter part of 1919; some part too of the decrease at ages between five and ten years is due to the reduction in the population at this age resulting from the lowered birth rate of war-time; otherwise the decrease in the notifications is much the same for the different agegroups except of course in those mostly effected by demobilisation. The figures of "primary" notifications were incorrectly given in the report for last year (page 21) and the above figures should be substituted. Some axperfs of the Epidemiology of Pulmonary Tuberculosis as exemplified by the statistics of London Boroughs. Dr. Greenwood's statistical analysis of these figures in the Annual Report for 1919-20 of the Chief Medical Officer of the Ministry of Health, and the same writer's Chapter VI. in the Health of the Industrial Worker by Collis and Greenwood, 1921, raise questions of great practical moment with regard to Pulmonary Tuberculosis. The main points considered are :— (a) Migration. (b) A possible differential effect of adverse home conditions on males and females respectively, and a possible sensitising influence of industry in promoting this effect in the case of males. (c) The three hypothetical types, young adult, middle age and old age phthisis. Dr. Greenwood's two contributions to the examination of these three problems are models of lucidity and conciseness; they are if anything too concise; the reader asks for more. In particular, additional Tables for the younger and older ages (corresponding to that for age 25—45 given in Table 13 on p. 339 of the first-named paper), and more details with regard to the occupations studied, would be highly valued, indeed, it is to be hoped they will be given by Dr. Greenwood some day. in extenso. But, here and now, the reader cannot fail to realise that, in Dr. Greenwood's presentment of his case, the dry bones of Miss Hilda Woods' Industrial Statistics, and of Miss C. M. Thompson's correlation coefficients relating to the 28 London boroughs, are made to live. The treatment of the last named material, in particular, appeals irresistibly to the London reader, who sees, or thinks he sees, in his mind's eye, how the men tend to toil in the central crowded areas, in regions that is of mixed social character, while the women work presumably in part there also, but mainly in such surroundings as those of the jam and other factories of Bermondsey and Hackney Wick, the match and other factories of Poplar, and the laundries, &c., of Hammersmith and Fulham, more outlying localities these and withal more homogeneous from a social point of view. Again, boroughs with many common lodging houses, shelters and furnished rooms, Stepney, Southwark, Westminster and Kensington, clearly play their part in moulding and finishing off Dr. Greenwood's partial correlations. Further, it is apparent that old time influences extending from former village populations constituting the nuclei upon which London was deposited, hamlets like the SomersTown of an earlier day, the heart of Merrie Islington, then, much later, the Kensington Potteries and the Italian and Russian Pole settlements in various parts of the modern town, all these and their like have contributed informative touches to a picture, which to the undiscerning, or untutored eye, may merely present a crude cubist or forbidding " partial correlationist " appearance. What a unity of opposites London is ! As we study these correlation coefficients and try to probe their meaning we are reminded of the witches' cauldron, the ingredients of which Shakespeare haled from such diverse sources. In London there is an analogous medley of races, if not " nose of Turk, and Tartar's lips," at least specimens of mankind from the wide world over ; such coming and going, and all transmuted and confused, from what seems in comparison the Arcadian simplicity of Shakespeare's London of the 16th and 17th centuries, by the bewildering complications introduced in the 18th, 19th and 20th. II we think only of the changes of the last 80 years, there are the advent of statistics, vaccine therapeutics, anaesthetics, eugenics and civics, the numbering of the people, the naming of their diseases, modern medicine and surgery and midwifery (for the drab of Shakespeare's "ditch delivered " babe is now replaced by the possessor of a Central Midwives Board certificate) to say nothing of the as yet puny efforts, productive however of such remarkable consequences, of preventive medicine. In particular as regards phthisis death returns there are the effects produced by the discovery of the tubercle bacillus and the changes which have resulted from institutional treatment and from immigration and emigration of fit and unfit. For the influence thus exerted it is true the Registrai General now attempts in part to supply the necessary " correction," so far as certain migrations within the country are concerned, but this takes no account of influences associated during life with all the travel to and fro—the 13 Crowded bridges at 8 a.m. and 6 p.m., the thronged termini, the tram queues, the strap hangers in 'bus and tube ; note should be made, moreover, of the size of the vast army of toilers in Dr. Greenwood's 28 boroughs, who work every day in a 29th area, the centrally lying City, not included with the 28, owing to the difficulties arising out of trying to grapple with its quite phenomenal figures. It is herein, in fact, that the great difficulty resides: if only some of these human units could be traced from the cradle to the grave as Dr. Greenwood tells us they will be in the years to come. Now, it is for all the world like counting a flock of sheep, everything is on the move, even the discerning eye of partial correlation is at a loss. One thing we may be sure of. The movement is there, a factor to be reckoned with. Bulstrode declared, arguing on now unfashionable a priori principles, that as soon as the " segregation in sanatoria conception " came to be fairly floated the death rate from phthisis in this country must, for a time, rise. It seems so obvious. The outflow is checked, the cistern must thereupon tend to fill. The same contention proved capable of being demonstrated, a posteriori, at the hands of Prof. Pearson, by the most refined mathematical methods, a few years later. The slackening of the fall in the phthisis curve, indeed, its decided manifestation of a tendency even to rise, was in fact already plainly in evidence at the close of the first decade of the present century. The protests from America, South Africa, Australia against the despatch to them of phthisics from Europe, first voiced 40 or 50 years ago, greatly accumulated in force and volume during the nineties and in the years following. Legislative action and organised effort to prevent such transfer, moreover, assumed practical shape from the early nineties onwards. It is true that in the period of more precise statistics, specially considered by Dr. Greenwood, the removal of tuberculous persons to a better climate had been reduced to comparatively small proportions, but the fact remains that in the 60 yeffrs from 1851-1911 the number of persons emigrating from these islands was equal to 25 per cent, of the total number of deaths occurring in the United Kingdom during those years, and very many of the said emigrants left the country on account of suspected or declared phthisis. It is, on the other hand, urged by objectors.: "Show us the mortality returns of the countries in which it is suggested these consumptives have died." Here is, indeed, a difficulty, as I found, in 1912, in exploring the data, forthcoming say from Graubiinden, the canton of Swiss Sanatoria, or from South Africa, or the Western States of America. No one can expect health resorts to make unnecessary parade of their phthisis death rates. Again, objectors say the effect of the exclusion by America and the Colonies of phthisics should have produced an even more marked rise than that actually observed in the England and Wales death rate, but it must be remembered that the strictness exercised with regards to exclusion has more or less gradually come into operation. Dr. Greenwood suggests that the recent considerable rise in the rate for young women, noted as early as 1916, may have been due to factory employment. This is, however, very soon for the presumed cause to show so marked an effect on the death rate. Moreover, as Dr. Greenwood and Dr. Brownlee both note, the rise has been appreciable at the age 10—15. The Influence of Migration. Dr. Greenwood endorses the views urged by me nine or ten years ago (Proc. Roy. Soc. Med. 1912), so far as young women are concerned, and concludes that movement of population between rural villages and cities has exerted considerable influence in modifying phthisis death rates. He asks, " Have we to do with a consequence of the migration from country to town of healthy and ambitious young women ?" He supplies (Table 8, page 331) corrected phthisis rates for females, which give " some measure but only a very rough measure " of the effect produced by the Registrar General's attempt to correct for deaths of non-residents. It is very interesting to find that the officially recognised transfer of deaths of nonresidents, which as Dr. Greenwood says does not of course account " for the whole force of migration, oidy correcting for quite temporary change of residence," does as a matter of fact reduce the considerably excessive death-rate in rural districts for females at the four ages given in the Table ; and at the ages 15—20 the corrected rate for all rural districts now falls below that for all urban districts. If it be borne in mind that the migration is not all one way, the results obtained by correcting for transference are seen to be " significant of much," and the fact that the effect of the correction is most marked at the youngest age (15—20) is particularly noteworthy. For, it should be observed, that while the "healthy and ambitious " girls, to quote Dr. Greenwood's phrase, move from the country to the town, it is clear that oftentimes when they develop phthisis they return home to die; and they especially tend to do this when they are still in close relation with home, i.e., at the age 15—20. This, however, is only the beginning of the migration story. The facts as to the adolescent girls were emphasised, in 1912, because in this case the phenomenon is gross as a mountain, open, palpable, but they were meant to be applied not only to one age and sex, but generally and not exclusively to rural parishes within 50 or 100 miles of London but to the world at large. It should be added here, to prevent any possible misconception, that there can be no question as to the fact that the great decline of phthisis in England and Wales in the last 60 or 70 years is in considerable part accounted for by the general improvement in the condition of the masses of population. There are two points of special interest arising out of the statistics of the years since the outbreak of war. (i.) It was pointed out, in 1912, that the decline exhibited for half a century in the phthisis death-rate would, with discontinuance of resort of invalids to foreign countries for health reasons, be likelyjto continue to diminish and perhaps be transformed into a rise. The outbreak of war practically stopped migration, and correspondingly there followed, as had been anticipated, decided augmentation of the phthisis rates of this country. (See Table L1V., p. LXX., Ann. Rep. of Reg.-Genl., 1918.) 14 (ii.) It was urged, in 1912, that one of the reasons for concluding that migration had played an important role in connection with declension of phthisis, was the shifting of age incidence of phthisis mortality during the last 50 years from young adult to middle age, and, then in males, more particularly, to older ages. The phenomenon in question was first noted by Dr. Tatham in 1907. Its bearing upon the migration theory was pointed out in 1912. Since 1914 there has been a backward movement, the maximum rate of mortality reverting again towards the younger ages (see p. LXXI., Ann. Rep. of Reg.-Genl. for 1918). Following upon removal of the presumed cause (migration) there has thus supervened diminution of the effect (altered age-incidence). It would appear that while the facts concerning interchange of population as between country and country are now widely appreciated (witness the legislative enactments already referred to and the rigour of the tests applied in America and in the Colonies on landing) sufficient significance is still not being attached to those relating to migration between urban and rural areas in one and the same country. Dr. Greenwood, in his discussion of the statistics of England and Wales relating to young women, shows quite conclusively how the recent figures, those subsequent to 1911, the year for which the Registrar General first instituted partial correction, confirm the view that the young women who go to work in the towns are apt to return to their country homes to die. But he does not say much about the young men—they too migrate from country to town, though it is true they do not seem to return home to die in quite the same proportions; and, yet the evidence as to the extent to which certain urban death rates benefit at the expense of those of surrounding areas is unmistakable in the case of these young men, though not quite so conspicuously so as in that of the young women. In the second part of this report a question affecting the young lads and girls raised by Dr. Greenwood is considered in some detail. Dr. Greenwood found the correlation coefficients for ages 15—25 between crowding and tuberculosis were decidedly negative and he examined a suggestion as to the beneficial influence of blind alley employments in this connection. A more far-reaching hypothesis, it would appear, is, however, one of combined selection and partial immunisation of survivors. This hypothesis is fully considered in Part II. p. 70. If the force of the reasoning thus applied, in the case of the ages 15—'25, be admitted, the argument cannot rest here ; indeed, it now remains to show that the immunising influence of town life upon those who become acclimatised to it, explains more than it might at first be held to do—it may in fact apparently be applied throughout life and not merely to adolescents. But, first a word as to the ages of town immigrants. London it is now agreed, draws in, as it were like a vortex, the enterprising and ambitious girls and boys from miles around. But, perhaps, even more important from the phthisis point of view is the fact that the lure of London continues to be exerted in later years. At the higher ages there are, however, marked distinctions and differences qui sex and qua quality. The female immigration apparently reaches its maximum at an earlier age than the male, and the male curve continues at a higher level long after the female curve has noticeably declined. Moreover, as the age of the immigrants is increased their quality becomes poorer and this is particularly the case in the males. Young single women and single men coming to London are, it is agreed, as a rule, enterprising and ambitious; after a time the young men fetch up their sweethearts from the country and start house-keeping in London, and a considerable number of young married people, perhaps with small families, come too. Friends join friends, and so on. But there is a noteworthy falling off in immigration of women after 30 or 35; but few country women come to London to stay there after 40; and very few after 50 years of age. Mr. Thomas A. Welton, F.S.S., F.C.A., in his great work on "England's Recent Progress," published in 1911, gives "Migration-graphs" for numbers of localities. In speaking of London he notes that the remarkable manner in which (p. 39), "The gain of women from outside seems to diminish at age 30—35, and to become a loss on balance at 35—40, is likewise in accordance with probability. Mr. Welton's curves relating to 10 large towns (given on pp. IX. and X.) show how the ages of male immigrants (1891-1901) differ markedly from those of females. At first, in early years, the numbers may be presumed to be practically identical, then at 15—20 the girls have forged ahead, later (25—30) the young men begin to gain on them. Between 30 and 35 the men immigrants are the more numerous, their immigration having reached a high level does not fall away so rapidly as in the case of women, and the males maintain this higher level throughout the remaining ages. Even at 40—50 the temptation to make a fortune seems to draw men to London. Some no doubt bring wife and family with them, but often single men come and even when 50—60 is reached there are apparently still optimists (men, not women), who aspire to the Lord Mayoralty. But not so many Dick Whittingtons realise their ambitions among these older men as among the young apprentices. It may be added here, in connection with female migration, that Sir A. Newsholme, ("The Prevention of Tuberculosis"), supplies an instructive chart contrasting female death-rates in 1861-70 with those in 1891-1900. In the later decade the rates are notably higher in adolescents and lower in women over 25. This result corresponds well with increase in migration into the towns in the case of adolescents, and out of the towns in the case of other women (loc. cit., p. 170). The attempt has been made at various census enumerations (undertaken by the London County Council), of homeless persons in the London streets, or temporarily lodged in night shelters, to gauge the extent to which the older homeless men are Londoners. In the sense of being London born very few of course comply,but if a limit of duration of stay in London be applied, say, of one month, or two months, it is remarkable how considerable a percentage fail to pass the test. Twelve years ago, on a February night when the Embankment was frequented by some hundreds of homeless persons, enquiries made at the King's Tents, then open to men without any home to go to, showed that from 25 to 30 per cent, of the inmates had tramped up to town in search of work within a period of less than six weeks. Such men constitute a large source of supply of phthisis cases to common lodging-houses and infirmaries. 15 Dr. Niven has commented upon cases from common lodging-houses, and presumed that in many of these instances the phthisis was contracted in the common lodging-house itself. This is not the general experience in London. Record has been kept for many years past of the history in fatal cases of phthisis removed from common lodging- houses. In most of them it is clear that phthisis was already declared before the man became a common lodging-house inmate (i.e., the common lodging-house was not responsible for the phthisis). Many of the men had come up from the country; in a few instances the man dated his illness from the time, pathetically enough in some cases, "when his home was broken up "or" when he lost his wife." The precise magnitude of the volume of uncared-for old men who drift up to London is very difficult to gauge. Dr. Niven, as already said, was much impressed by this phenomenon of old-age male phthisis in Manchester; indeed, it was his observations which led twelve or fifteen years ago to the undertaking of our London enquiries. In later years, as the annual censuses of homeless persons each February in London show, the evil so far as this test can be relied upon has lessened, but taking account of all the mean streets of London housing surveys, there must be oftentimes more than 100,000 men over 35, in London, in the ranks of casual labour, a considerable percentage of whom are not Londoners born; and from this army of poverty-stricken humanity the poorest tenement houses, many of the furnished rooms, and the common lodging-houses and shelters, draw their clientele year by year. The mortality upon the later aTches of this Bridge of Mirza (and particularly in the common lodging-houses) is appallingly high. The results of enquiry concerning 1,138 cases, notified from common lodging-houses from 1907-1914, was given in the annual report for the year 1914, p. 54. Of the total, 1,069 were men and 69 women. Of the men, 908 were over 35 years of age. In nearly half the total number, the symptoms of the disease, it transpired, actually developed subsequent to the man's first entering upon common lodging-house life. The place of birth in 297 of the cases was stated to be outside London. Judging by these figures, it may be hazarded at a rough guess (no exact figures can be given) that nearly a sixth of the recorded phthisis mortality of London is a mortality of men and women (mostly men) who have only come to London after early middle life. Side by side with this must be remembered the fact that much of the earlier mortality in born Londoners is not credited to London at all. These conclusions it may be objected are based largely on mere a priori reasoning. This is not, however, the case. They are the outcome of much close observation of life in London's mean streets, in the nineties, and the first ten or twelve years of this century, supplemented by the February census results, by examination of many phthisis histories, and by study of London phthisis statistics generally. But it should be noted that the conclusions seem to derive some support from the higher mathematics. At any rate, as it appears to me, Miss Thompson's coefficients give them a helping hand. Dr. Greenwood says (p. 340), after considering very carefully the rival hypothesis of the.influence of employment, "I am far indeed from supposing that this explanation is demonstrated to be true; the statistical basis is slender, and it would be easy to imagine many other ways in which the particular statistical results of Miss Thompson might be explained." Here, then, for what it is worth, is an "imagined" other way, as to the merits of which note will be made immediately. But first a word as to further help forthcoming from Dr. Brownlee's work on the three types of phthisis. From this hypothesis some minds probably continue to experience an a priori revulsion. But to Dr. Brownlee the migration theory is at any rate indebted for a piece of a posteriori evidence which may be diverted from its original purpose and made to tell in the migration theory's favour. Dr. Greenwood (Collis and Greenwood, p. 140) alludes to this "extremely important point"; he refers to Dr. Brownlee's conclusion that "the middle-age type is more susceptible to environment than the others, and the fact that this is the predominant type in London, Lancashire and the great industrial districts explains why in these the phthisis rate becomes excessive in the later adult ages; in these districts that type most responsive to environment prevails." Now it is to be carefully observed that in footnotes, on this page and on page 141, Dr. Greenwood sounds a warning as to the possible unreliability of Dr. Brownlee's coefficients, nay even as regards the entire reliability of Miss Thompson's coefficients. This, too, just when they seemed to promise us help; it is only possible, therefore, to hope for the best. Still one cannot help noting how much more remarkably Dr. Brownlee's coefficients chime in with the migration hypothesis than they do with the three-type hypothesis which they are held to confirm. We have seen how the enterprising and ambitious young people have come up to London, and then in the event of their contracting phthisis have been prone to leave London, and in many instances to die elsewhere; and how marked is the drift of older but still ambitious, though necessarily less enterprising, men to London, where they are too apt to contribute to the mortality from late middle-age or old-age phthisis. Clearly a priori, on this showing, we should expect Dr. Brownlee's middle-age type of phthisis, in London at any rate, to seem to respond to environment, for it is just at these middle ages par excellence that the death . from phthisis is registered in the actual environment in which the disease is developed. Thus it may be argued we need to invoke no hypothetical types of phthisis to explain the statistics; their explanation is ready to hand if we are prepared to accept the established facts with regard to migration. The young people are conspicuous by their absence from the phthisis death returns, partly because they represent in large measure healthy stock from outside, partly because if they do succumb to the influence of the London environment they often leave and die outside London. The old people, on the other hand (men for the most part), who die in London, have in many instances drifted there after contracting phthisis. Finally the middle-aged phthisics do succumb in considerable numbers in London itself, to the London environment, mainly for the reason that when they fail they are more likely than the young folk and the elderly women to remain in London to die, partly also for the reason that at the later middle ages (among men) the figures, as has been seen, are swelled by immigrants from the country districts for miles around. 16 The influence of industry. Two, then, of the three problems mentioned at the outset, (a) and (c), Migration and the Three Types, have been examined. But there remains to be considered (b), Influence of Industry as illustrated by the study of Miss Thompson's coefficients. Dr. Greenwood's Table 11 presents us with two striking paradoxes. First, the partial correlations for males and females between tuberculosis and overcrowding, at 15-25, are distinctly negative. This question is considered elsewhere, Part II. (p. 70). Then, second, Table 11 shows a striking negative partial correlation between tuberculosis and factory employment in females at 45-65. This point is dealt with by Dr. Greenwood on p. 341. The conspicuous drift away from the towns of the older women may also have some influence in this connection. Coming now to the ages 25-45, those mainly affected by industry, the fuller Table 13 shows three high partial correlations, set out by Dr. Greenwood on p. 339, the first of them easy to interpret; but there remain two rather, at any rate at first sight, paradoxical correlations. , (i.) "The female death-rate from tuberculosis is highly correlated with the death-rate from all other causes in women ; there is no such substantial correlation in men. (ii.) The male death-rate from tuberculosis is highly correlated with the index of overcrowding ; the female death-rate is not so correlated." Now it should be noted that the high partial correlations which are associated with one or the other sex are already ab initio observed in the total correlations ; the sex then showing the lower correlation, in each instance, loses ground in one or both the corresponding first partial correlations, and emerges with a very low coefficient in the second partial correlation. As to the original total correlations, no difficulty arises. The coefficient for women for tuberculosis and other causes might be expected to be higher than for men; for with the former the child-bearing diseases and the higher birth-rate fit well with more poverty and more tuberculosis; with the latter the results of accident and strain and of syphilis and alcoholism figure more largely in the " other causes," and these are less closely associated with poverty and tuberculosis than the special diseases of childbirth are. Again, the fact that the total correlation between tuberculosis and overcrowding is higher in men than in women need cause no surprise, having regard to the evidence already adduced as to the social, or rather unsocial, habits of the immigrant males at these higher ages in London, leading to their resort to lodging-houses and shelters, while the older women generally have a friend or friends and may be perhaps presumed to live under conditions of less crowding as estimated by a " more than two to a room " standard. Coming now to the First Partials," the more severe exhaustion of the total correlation for tuberculosis and other causes in the case of males than of females, when overcrowding is made constant, needs no comment after what has already been said. The exhaustion of the total correlation for tuberculosis and overcrowding is much more severe when either other causes or employment are made constant in the case of women. Here, again, no further comment seems to be needed. In the light of these facts, perhaps, the " Second Partials " are not so paradoxical after all. While, therefore there may be some force in Dr. Greenwood's suggested solution of problem (6)— viz., that industrial employment may act indirectly, sensitising the male to deleterious influence of bad home conditions, a subject discussed by him very judicially on p. 142 of the paper on Tuberculosis and Industry (Collis and Greenwood, Chapter VI.)—it is to be noticed that he concludes (p. 143) that the inference as to this differential effect of home conditions (in men and women) cannot be accepted as proven. At the same time he delivers a like verdict concerning the theory of the three types. On the other hand he refers to the importance of migration, for, he says: "We find that with advancing age the disadvantage of the town dwellers increases, and that the apparent advantage of young female city inhabitants can be accounted for more or less completely by immigration from the country of healthy females." He adds that at ages above 35 the excessive death-rates among town dwellers are " far greater amongst males than amongst females." The influence of employment has been more particularly considered in the case of young women (15-25) and of the older men. As regards the former, see Annual Report Med. Off. Ministry of Health, 1919-20, pp. 143 to 145, and a report by Dr. Rosenfeld on Tuberculosis in Austria, where from 1917 onwards food shortage was very severely felt in certain urban communities. Dr. Rosenfeld finds that industry was commonly accompanied by high mortality, but where the industry was not associated with food shortage this influence was far less apparent. In the case of the older males the high phthisis rates may be due not so much to factory-produced infection, direct or indirect, as to urban influences of a more general character operating especially on immigrant males who are already on the down grade. These phthisical men no doubt to some extent swell the number of deaths among shoemakers, tailors, printers and bookbinders, as Dr. Greenwood justly claims they do ; but the large majority of them have not seen the inside of a factory for many years, they are made up from general labourers, casual labourers, and some of the porters and messengers of Dr. Greenwood's Table 12, and include even more definitely characterisable " blind alley employments," such as sandwichmen, street newspaper vendors, and the like. It may be observed that open-air blind alley employments after middle age may not be so conducive to length of life as Dr. Greenwood hints they possibly may be in adolescence. It is clear, too, that important influences in aggravating an already acquired phthisis at these higher ages are alcoholism and exposure to cold and wet weather. A word may perhaps be interpolated here concerning Dr. Greenwood's Table I., p. 129 (Collis and Greenwood), apropos of the much greater decline since 1851-60 in the death rate of women than of men. Here it is probable altered nomenclature is in considerable part responsible, chlorosis in young girls, and cancer in older women often figured as " phthisis " 60 or 70 years ago. Again as regards the comparatively light incidence at the higher ages upon women two factors must not be lost sight of. First, as already hinted, alcoholism is less destructive in women than in men; and second, the harmful effect 17 of puberty (qua tuberculosis) in girls may have as some compensation an added resistance to tubercle in women at the grand climacteric. Moreover, the evidence already adduced as to outward movement of older women from the towns to the country no doubt plays some part here. It would seem there has been a marked tendency of late years for women to revert to a country life at an age when the stress of urban conditions might especially be expected to be manifested. Chapter VI. (Collis and Greenwood, p. 143) contains an admirable summary of practical measures to be taken with a view to mitigating the ravages of tuberculosis. "What is the matter with the poor is largely poverty. Not through any special intensive measures of campaigning against the tubercle bacillus, not even by the segregation of the actively tuberculous, does there seem any real hope of salvation. We have to improve the homes of the working classes in the first place—it is a sound popular instinct that inspires the popular outcry against urban and even rural housing conditions; in the second place we have to secure better factory conditions; here it is not so much sanitation in the popular sense as hygiene in the wider apprehension of the term." So far I follow the argument, but I do not feel happy about the concluding sentence which harks back to the danger of a man reaching home " in a condition of definitely lowered resistance to an infection which must still be regarded as ubiquitous." On this I hope to be able to read, mark, learn and inwardly digest Dr. Greenwood's forthcoming Milroy Lectures. My own suspicion has all along been that the real primary cause, as distinguished from the secondary associated organisms, should not be regarded as ubiquitous. Tuberculosis mortality and racial susceptibility. A paper entitled The Mortality of Race Stocks in Pennsylvania and New York, 1910, by L. I. Dublin and C. W. Baker (American Statistical Association, March, 1920), throws further light from a newpoint of view upon some of the questions reviewed in the preceding discussion. Mr. Dublin had already published (Amer. Economic Review, Sept., 1916) a similar enquiry with regard to New York State, and this is extended in the present enquiry to Pennsylvania. Great diversity was found among the immigrant peoples in the earlier enquiry. The Russians (mainly Jews) and the Italians showed low death rates ; Irish and Germans very high rates, " especially from the tuberculous and the so-called degenerative diseases." The later enquiry confirms and amplifies the conclusions of the former. In the first instance the death rates are composed of (A) the native-born of native parentage ; (B) the native-born of foreign or mixed parentage; and (C) the foreign-born. At the youngest ages there are but few foreign-born, and the figures are unreliable. " But beginning with age 20 and continuing throughout the rest of life the rates for the native-born of native parentage are decidedly the lowest of the three groups, the only exception being among the foreign-born females in New York ages 20-24 ; the advantage, moreover, of the native stock becomes greater with advancing age. A comparison of the two branches of the foreign slock shows a remarkable similarity in the death rates from age 10 onward. The one striking exception is at the ages 25-44, during which period the foreign-born males have very much lower death rates than the native-born of foreign parentage." Thus from 20-44 the foreign-born of both sexes show to much less disadvantage than at higher ages; at 25-44 the immigrant men show lower rates than the native-born of foreign parentage, and at 20-24 the immigrant women actually show lower rates than the native-born. In general, Pennsylvania compares favourably with New York, but foreignborn males 15—44 constitute an exception to this rule, there being exceptional "hazards in mines and mills which are more serious in Pennsylvania than in New York." There is thus clear indication that the young adults and those of early middle-age belonging to the newly arriving foreign stocks have considerable resisting powers to disease, but a like deduction cannot be drawn for those at higher ages; this suggests further enquiry. Before referring to this question, however, the figures for immigrants from the six main contributing countries may be examined. In the following table an analysis is made of the facts as to these six countries :— Date at which extent of immigration became marked. Whether rates better (†) or worse (—) than those of Country of origin. New York. Pennsylvania. Comparison with phthisis rates in America. Austro-Hungary About 1890 + 0 — Rates low for phthisis in both sexes at 20—44. Groups in which foreign- Russian mn Do. ? + — Do. Do. ers compare on the Italian Do. O + — Rates low for men up to 60, whole favourably with for high in young women, the natives males 25-44 German From 1850onwards — — — Pulmonary and degenerative but a falling off of diseases largely responsible late years for high rates (German women not so as regards Groups in which foreign- phthisis.) ers compare unfavour- British From 1850, falling —† —† —† Special stress is laid upon pneuably with the natives. of of late years monia, cancer and Bright's disease ; but the phthisis rates are also high. Irish From 1850, falling — — — Pulmonary tuberculosis very off of late years high. Statement made that "It is difficult to understand thi9 condition of unfavourtble mortality in view of the fact that the rates for the British in their own country are among the most favourable in Europe." 61004 D 18 The report, in the light of the statistics for these six countries, reverts to the problem presented by the somewhat paradoxical rates in the three groups A, B and C at lower and higher ages. The figures are as follows in the case of males ; those for females, speaking generally, follow on the same lines :— Sex and age. Pennsylvania. New York. A. B. C. A. B. C. Males— 25—44 6.2 12.3 9.1* 6.9 14.3 8.7* 45—64 16.8 25.7 25.7 18.8 28.2 28.0 65—84 75.2 91.4 91.5 77.3 89.9 90.4 From this table it will be seen that the rates marked with an asterisk in column C are distinctly lower (in both Pennsylvania and New York) than those in column B ; while at the two higher age periods the rates in columns B and C are in fairly close correspondence. Thus the "first generation Americans" of column B compare unfavourably with the foreign-born at ages 25—4, but not at the two higher age periods. The Report explains this by pointing out that—"In the age period 25-44 the predominating stocks which make up the native-born of foreign parentage are the Germans, British and Irish whose death rates we have found are high. The foreign-born group at the same age period, on the other hand, has large proportions of Italians, Russian Jews and Hungarians. It is the low mortality of these races which at ages 25-44 offsets the very unfavourable conditions among the Germans, British and Irish elements of the foreign-born, and gives a net rate lower than that for the native-born of foreign or mixed parentage, which contains no such reducing factor. But here this influence stops. The foreign-born at 45-64 and 65-84 are predominantly Germans, British and Irish ; we see that their rates are almost identical with those for the native-born of foreign or mixed parentage composed at these ages of similar stock." This explanation doubtless contains a certain element of truth, but the following facts must not be lost sight of— (a) The age distribution of the Austrians, Russians and Italians in the 25-44 age group must differ considerably from that of the Germans, British and Irish in that age group ; partly because of the differing dates at which emigration commenced and partly because the former nations at the present time emigrate more largely by families than do the latter. (b) Strict requirements as to medical inspection on landing have only been in force for 15 or 20 years, and this fact must have made a difference in the quality of the more recent arrivals as compared with earlier entrants to the U.S.A. (c) It does not seem safe to assume that the quality of the emigrants of British, Irish and German origin respectively in years gone by and at the present time can be looked upon as absolutely invariable ; indeed, there are good reasons for thinking that changes have occurred. The conclusions of the pamphlet are deserving of close study, as they throw fresh light upon the problem of migration in its influence upon phthisis death-rates. Influenza, cerebrospinal fever, acule poliomyelitis and polioencephalitis, encephalitis lethargica, epidemic hiccough. Influenzal group of diseases.—Advances in knowledge find most unexpected application in actual practice. Thus, the discovery of the telephone has had notable influence upon the prevention of diffusion of smallpox by facilitating prompt dealing with suspects. Similarly improved facilities for the spread of news, the world over, have worked quite a revolution in the science of epidemiology in connection with the diseases of the influenzal group. It is possible now, within the course of a day or two, to come across news of a dengue prevalence in Australia, of trench fever investigations on the Western front and of a poliomyelitis outbreak in New York ; and then in a like short space of time to learn from Dr. Bassoe how the Epidemic Encephalitis of Chicago appears to be connected with influenza, and how Dr. Crookshank has made a like observation in London ; just as the "nona" of 1889-90 followed the pandemic of influenza of the time ; and as similar phenomena were noted by Camerarius of Tubingen in 1718 ; by Lepecq de la Cloture in 1768 ; and by Ozanamas occurring in Germany in 1745, in Lyons in 1800 and in Milan in 1802. The " little endians," of course, discountenance any such attempted surveying of mankind from China to Peru, and complain that the " new epidemiologists renounce the laborious accumulation of facts." But the " big endian " retort is, of course, that there is room for everybody, for there are so many facts to explain. The big-endian facts are not quite the same as the little-endian facts, but both may prove to be facts, for what they are worth. While we must all bear one another's burdens, even to the extent of trying to make out the meaning, for example, of the American Red Cross Trench Fever experimental work, or that of the results of the inoculation experiments with dengue blood in Australia, yet it is incumbent upon epidemiology also to bear its own load, and to note, for example, the correspondence in time of both these last-named sets of inquiries with the development of the world epidemic of influenza, and the absence of any display of ability on the part of either this particular dengue virus or the trench fever virus to accomplish anything appreciable—away from Australia or from the trenches—i.e., when regarded from an epidemiological point of view. Moreover, the fact cannot be overlooked that the Australian dengue was speedily engulfed by the great pandemic influenza, and trench fever, though sedulously hunted for on this side of the Channel, failed altogether to put in any appearance—unless, of course, we are expected to run it to earth among some of the mysterious P.U.O.'s which have recently been ticketed as " encephalitis lethar- 19 gica without lethargy," or the " sore throat with glandular feveV described in Part II. of this report, and the like. An important Report on the Pandemic of Influenza, 1918-19, was issued at the close of last year by the Ministry of Health. Sir George Newman thus summarises the growing experience of the "setting" of an influenza epidemic. He says the epidemiological records go far to establish— "(a) That the epidemiological features of the cycle of years within which influenza explodes are different from those of the influenza-free cycles." "(b) That preceding epidemic influenza there is often a rise in general morbidity of the population, an 'epidemic constitution' develops favourable to influenza, there are early though often mild and typical forerunners of the disease, and parallel or allied clinical maladies are seen." "(c) That there are occurrences, similarities and inter-relationships between outbreaks of cerebro-spinal fever, poliomyelitis and outbreaks of influenza, bronchitis and pneumonia." Sir George refers, inter alia, to the evidence set out in the special report on London Influenza made to the Council in June, 1919. In Part I. of the Ministry Report an interesting analysis by Dr. Greenwood of the observations of Jno. Huxham of Plymouth is made, which establishes the proposition that " the epidemiological features of the cycle of years within which influenza exploded once or more were, apart from stick explosion, different from the characteristics of the influenza-free epochs." This analysis materially adds to the evidence already collated by " such profound epidemiologists as Creighton Hirsch, and Haeser," to the effect that " influenza does always cast a shadow before or behind." We are led, moreover, irresistibly to entertain the suspicion that " Even in a world-wide pandemic the problem of epidemic influenza may be largely an internal problem of each nation, a problem of social relationship, of social factors of domestic habits and life. The materials of the conflagration come from within. As the compilers warn us, the wolf is in the fold all the time. " His ravages depend as much upon the disposition of the sheep within the fold as upon his appetite." With the conviction that this view of the matter embodies the most important practical lesson to be learnt from the epidemiology up to date, attention has been concentrated in London upon safeguarding, wherever possible, the disposition of the sheep within the fold. It is quite clear that, whatever may be done in the future, there is no sign up to the present time that prophylactic vaccination is of any value whatever. The one plain indication is just to reduce as far as may be the danger to be apprehended from badly ventilated and overcrowded places of assembly. Thus every effort should be made to secure satisfactory mechanical means of ventilating rooms and passage-ways which are apt to be thronged by large numbers of people. Every effort, too, should be made to resist curtailment of the very modest requirements laid down in statutes and bylaws with regard to cubic and floor space and the height of rooms. It was ascertained, on the instruction of the Public Health Committee, that so far as the Tube Railways were concerned careful consideration was already being given to the problems involved. Under instructions from the Theatres and Music Halls Committee renewed examination was made of the atmosphere of theatres, etc., in which necessary works had been postponed during the war years. A deputation from the Council attended upon the Minister of Health to deprecate any weakening of the requirement in the Building Act as to the minimum height of rooms. In the existing state of knowledge it is in directions such as these that the evil consequences of influenza prevalences can best be countered. There can be no doubt that influenza has been far more widely spread than is generally realised in London since the third considerable outbreak of the present series (that of Feb.-March, 1919), but the epidemic influence has been in many instances cloaked in the guise of the gastro-intestinal, and nervous forms which influenza is apt to assume. There is reason for thinking that some of the cases, at any rate, of glandular fever and of anomalous scarlatinal sore throat, as well as much of the so-called epidemic hiccough, epidemic lethargy, poliomyelitis and cerebro-spinal fever of 1920 were in fact of influenzal origin. Fortunately the case mortality has remained quite low. Cerebro-spinal fever itself has, as is its wont, been comparatively unobtrusive during the swell of the great influenzal wave which culminated in 1918 and in the years immediately following. The number of cases of cerebro-spinal fever notified during 1920 was 164, as compared with Cerebro199, 265, 430, 432 and 674 in 1919, 1918, 1917, 1916 and 1915 respectively. The disease has, therefore, spinal fever been steadily declining in prevalence during the last five years, following upon increased prevalence manifested in 1915. This behaviour follows that of earlier prevalences of cerebro-spinal fever, which, as noted in the London Influenza Report of 1919, tend to fall into the background during a period of some eight or ten years, of which the centre point is a year of pandemic prevalence of influenza. The abnormal crowding of population, both civil and military, during the war undoubtedly, however, contributed towards aggravating mortality from the disease. Of the 164 cases notified during 1920, 28 were not confirmed as cases of cerebro-spinal fever, whilst in 8 cases, in which the diagnosis was arrived at post-mortem, no official notifications under the Act were received. The actual number of cases which occurred during the year was, therefore, 144. Of these, 108 (75 per cent.) proved fatal. The monthly distribution of these cases is set out in the following table :— Month. Jan. Feb Mar. April. May. June. July. Aug. .Sept. Oct. Nov. Dec. Total. Total number notified 20 9 26 22 10 11 13 9 15 8 7 14 164 Cases notified but not confirmed 4 2 3 2 1 4 2 — 4 2 2 2 28 Cases not notified 2 1 — 1 — — — — 1 — — 3 8 Total number of actual cases 18 8 23 21 9 7 11 9 12 6 515 144 Number of deaths 14 5 17 15 7 7 9 6 8 5 3 12 108 61001 D 2 20 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. Total. Number of cases 65 14 25 23 7 4 3 2 1 144 Particulars were obtained in 144 of the 164 cases. In 28 the diagnosis was finally definitely rejected, and in 51 others there remains a more or less decided element of uncertainty, arising, generally speaking, on bacteriological grounds. In 65 instances the diagnosis was finally confirmed, though only in about a quarter of these does a rigorous bacteriological diagnosis appear to have been made, and in only 7 instances is there any reference to demonstration of the presence of a particular type (I., II., III., or IV.) of meningococcus. It is noteworthy that the 65 cases in which the diagnosis was finally confirmed include a larger proportion of children under one year and under ten years than do the cases as a whole. These 65 cases, moreover, include 8 in which there is reference to concurrent "influenza" in the affected family, and four others where there is mention of "colds." In the remaining 79 cases there is only mention of suspected "influenza" in the family in one instance, and in another instance "pneumonia" occurred in a brother a few davs previous to the patient's sickening. The number of cases of noliomvelitis and nolioencenhalitis notified during 1920 was 55. Poliomyelitis and Polioencephalitis. The following table shows how this figure compares with previous years dating back to the Notification Order of 1911:— Year. 1911, from 1st Sept 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. Number of cases 66 132 145 93 97 197 53 53 96 55 The subjoined table shows the age incidence of actual cases:— Age. Under 3. 3—5. 5—10. 10—20. 20—30. 30—40. 40—50. 50—60. Over 60. Total. Number of cases 15 10 13 4 4 2 1 — — 49 Particulars were obtained in 52 of the 55 cases. In six the diagnosis was not finally confirmed, and in nine others there was an element of doubt. Of the remaining 37 it may be said that all were examples of infantile paralysis affecting an arm or leg or more than one limb. They include two pairs of cases in children of the same families. One of the 37 cases was at first notified as cerebro-spinal fever. Three cases in which there was considerable doubt as to the diagnosis are deserving of special mention. In case No. 2 the diagnosis was said to lie between influenza with meningeal symptoms, polioencephalitis or poliomyelitis or encephalitis lethargica. On the whole it was held that the history, the evidence of meningitis found on post-mortem examination and the character of the cerebro-spinal fluid, seemed to point to polioencephalitis. In the two remaining cases, Nos. 26 and 28, there was great difficulty in deciding definitely as to the diagnosis ; drowsiness was marked in both these instances. In three of the 37 poliomyelitis cases there was concurrent illness possibly of an influenzal nature in other members of the affected families. Thus the mother of one of the three children (a boy aged 11) "had bronchitis of influenzal type just previously." In the case of a woman aged 26 her "husband had influenzal sore throat a week earlier." And in the case of a child of 4 months, a brother (aged 11) and a sister (aged 2) simultaneously suffered with gastro-enteritis. In six cases of encephalitis lethargica a history of influenza in the patient was observed, and of colds or sore throat in six cases, whilst in other members of the same family there were said to have been attacks of influenza in six cases and of colds in four cases. No detailed study of cases of epidemic hiccough in London has been made; indeed, a few instances only of this affection have been reported. The following summary may be given of the replies on the forms (relating to cerebro-spinal fever, polioencephalitis and poliomyelitis, and encephalitis lethargica) filled in, at the instance in each case of the borough medical officer of health concerned, returned by him to 2, Savoy Hill and then circulated to the medical officers of health of all the London boroughs. The general impression left on the mind is as follows— The particulars recorded are, as a rule, fairly complete with regard to clinical symptoms; but the laboratory examinations of cerebro-spinal fluid, etc., are only fully detailed and precise in a few instances ; and questions relating to the environment of the patient and to other illnesses in members of the patient's family are only quite occasionally answered. In London, polioencephalitis was from the outset made notifiable with poliomyelitis, and thus some overlapping results now that encephalitis lethargica has been made a separately notifiable disease. This circumstance and the designation encephalitis lethargica given to the supposed "new disease" have no doubt led to special emphasis being placed upon drowsiness in weighing in the balance as to whether a case shall be notified as encephalitis lethargica or as one of acute polioencephalitis. Broadly speaking, the cases notified under all three categories (cerebro-spinal fever, poliomyelitis and encephalitis lethargica) manifest a certain family resemblance, particularly as regards their initial symptoms. They appear to be, generally speaking, allocated to one or other of the three groups, on two main underlying principles of differentiation. (a) The age of the patient. The youngest ages especially tend to be brought under the category cerebro-spinal meningitis; those rather older as a rule go to poliomyelitis; and the average age is considerably higher still in encephalitis lethargica. 21 (b) The anatomical location of the mischief. If the stress of the attack falls upon the cells in the grey matter of the anterior horns of the spinal cord, the case is one of poliomyelitis ; if the nuclei of the cranial nerves are involved it is polioencephalitis or encephalitis lethargica; if the meninges of the brain and cord are affected it is cerebro-spinal meningitis. Upon this general scheme there are superimposed the following further qualifications. Drowsiness is held to imply encephalitis lethargica; retraction of the head, cerebro-spinal meningitis; and when lumbar puncture is practised the physical characters and bacteriological findings in the fluid are held to differentiate between cerebro-spinal meningitis and the other two categories of the disease. The strict bacteriological tests for identification of the meningococcus are so rarely complied with that this criterion alone does not often determine the diagnosis. As a result of reviewing some hundreds of the cases assigned to the three categories of disease the suspicion already entertained has been strengthened, that in most of the cases one common influence was at work, operating here upon one and there upon another portion of the central nervous system; here in an infant, there in a young child, or again in a young adult or older person. It may therefore be suggested that had the point of attack of the mischief been, say, the respiratory mucous membrane instead of the cerebro-spinal system, a parallel state of things would have resulted if some hundreds of "common colds" had been notified in part as affections of the anterior fauces, in part as affections of the pharynx, tonsils and eustachian tubes, etc., and finally in part as affections of the larynx or lungs. The following report on encephalitis lethargica in London during 1920 has been prepared by Dr. J. G. Forbes:— Dr. J. G. Forbes' Heport on Encephalitis Ltthargica. During 1920, 149 cases of encephalitis lethargica were notified as occurring within the Administrative County of London; in 19 of these cases the diagnosis was not confirmed. The actual number of cases of the disease was, therefore, 130, of which 48 proved fatal, or close on 37 per cent. Seasonal incidence showed distinct waves of greatest prevalence during the summer and winter months, the crest of each wave being attained in June and December with 22 and 27 cases respectively, and the trough in April and October with 4 and 3 cases. This incidence may be compared with that of the three previous years which provide the following figures :— Year. No. of cases. Mortality per cent. Seasonal prevalence. 1919* London 85 48.3 Dec.-Feb. England and Wales (including London) 538 54.6 Dec.-Feb. 1920 London 130 36.9 Dec.-Jan. June-July England and Wales (including London) 914 —Dec.-March May-July * Encephalitis lethargica was made notifiable as from 1st January, 1919. The monthly incidence, of cases, together with the number of deaths (in brackets) was as follows:— January 19 (7); February, 6 (3); March, 8 (4); April, 4 (2); May, 10 (4); June, 22 (7); July, 15 (6); August, 4 (1); September, 6 (2); October, 3 (0); November, 6 (3); December, 27 (9). The maximum and minimum incidence of each wave, therefore, occurred at intervals of exactly six months. The number of cases and mortality rate of the disease for each month do not appear in direct ratio to each other, the months of lowest case incidence providing the highest mortality rate, as is indicated by the bracketed figures of fatal cases in the above list for each month, The distribution between the two sexes falls about equally—viz., males, 69 (24 fatal); females, 61 (24 fatal). The age incidence is shown in the following table. The number of cases proving fatal is noted in brackets :— No. of cases. No. of cases. Under 5 years 5 (3) 30-40 years 24 (6) 5-10 years 12 (4) 40-50 „ 13 (7) 10-20 „ 38(10) 50-60 „ 10(5) 20-30 „ 19 (6) Over 60 years 9 (7) The disease therefore appeared most prevalent among those in the second decade of life, whilst the mortality was highest in the later decades, particularly over the age of 60. The duration of illness from the onset of first symptoms was noted in 44 fatal cases as follows:— 24 hours 1 case (fulminating) 3-4 weeks 4 cases 1 week and under 6 cases 1-2 months 7 „ 1-2 weeks 18 „ 3 „ 1 case 2-3 6 „ 4-5 „ 2 cases Examination of the cerebro-spinal fluid is often of much value as an aid to the diagnosis of encephalitis lethargica, and without this necessary investigation it may be impossible to distinguish the meningitic type of the disease from tuberculous meningitis, cerebro-spinal and other forms of meningitis, particularly in children, if reliance is placed solely on clinical evidence. The fluid obtained by lumbar puncture in encephalitis lethargica is occasionally under pressure and increased in amount, is usually clear and colourless and showing but little change from the normal; it may be blood-tinged and exceptionally yields any visible cell deposit on centrifugation apart from traces of blood. Very rarely is there evidence of fibrinous coagulum, in fine particles, but not in the delicate pellicle of clot so familiar in the slightly turbid fluid from tuberculous meningitis. The definite trace of protein generally present in amounts which may not be capable of measurement, and from .005 to .01 per cent, of albumen, serve to distinguish from the normal faint trace of globulin, and from the larger amounts of albumin present 22 in tuberculous fluid, which may range from .01 to .2 per cent., and the still larger quantities in other forms of meningitis. Evidence cf the presence of dextrose in slight trace is invariable; it also exists in normal cerebrospinal fluid ; usually, too, in the fluid of tuberculous meningitis, but is absent in other forms of meningitis. The number of cells (lymphocytes) per c.mm. may show but little increase above the number,. 1-5, normally present, but it is by no means uncommon to find 10 or 20 per c.mm.—i.e., in excess of the normal limits; occasionally the cell increase may reach 40 or 50, it is rarely as high as 150-200 per c.mm., in contrast to the well-marked cell increase existing in fluid from tuberculous meningitis, and ranging from 250 to 1,000 or more per c.mm. with still larger numbers in other forms of meningitis. The type of cell obtained by centrifugation apart from red corpuscles possibly present is invariably the small lymphocyte, which may in film preparations from the centrifugalised deposit appear to be in considerable numbers, occasionally suggesting the possibility of tuberculous meningitis. The absence of clot formation however, and the failure to find tubercle bacilli by appropriate staining of the cell film will in the great majority of cases serve to exclude the latter, and the bacteriological culture of the fluid in encephalitis lethargica proving sterile will exclude also other types of meningeal infection. It must be said that a report on the cerebro-spinal fluid for purposes of diagnosis should always be regarded and weighed in conjunction with the clinical features, and that the slight changes usually found as above described will not serve to distinguish encephalitis lethargica from such conditions as polioencephalitis, poliomyelitis, neurosyphilis of the brain or spinal cord (in the absence of the Wassermann test), arterio-sclerosis of cerebral vessels, cerebral softening, cerebral tumour, uraemia, meningitis, and other conditions associated with cerebral symptoms—e.g., in particular, influenza. With regard to the diagnosis of encephalitis lethargica and the classification of its various types, a disease so protean in its clinical aspects and presenting as it does so much diversity in its symptomatology may necessarily offer very considerable difficulty in diagnosis, the possibilities of which in a doubtful case are indicated by the variety of the foregoing list of diseases, depending for diagnosis perhaps solely on elimination by process of exclusion. Attempts at satisfactory classification of a number of cases are likely to prove both baffling and incomprehensible, unless resting on a scientific basis. The symptomatology is so varied that, if relied on alone, the grouping becomes intensely complicated with the numerous permutations and combinations which arise, and it is possible that in ten cases of the disease no single symptom will be common to all. Any and every part of the nervous system may be involved, and there is no combination of symptoms that may not be encountered. In consequence, many cases cannot be placed in any type unless types are to be multiplied until they cease to have either value or significance. (Walshe. Brain, Vol. XLlll., Part 3,. Nov., 1920., p. 213). It is, therefore, certain that a clear grasp of the anatomical distribution of the lesions of encephalitis lethargica is essential both for diagnostic purposes and for providing the only dependable system of classification. MacNalty has suggested the recognition of a number of clinical types (vide also Bramwell's contribution in Lancet, 29th May, 1920, p. 1154) under some of which the 130 cases notified during 1920 are capable of being grouped as follows :— I. The most common type in which the lesions are situated in the mid-brain—characterised by fever, lethargy of varying degree in association with weakness of the eye or face muscles—55 cases (16 fatal). II. Lesions situated in the upper or cortical region of the brain. Lethargy combined with symptoms of meningeal infection—difficult to distinguish from tuberculous and other forms of meningitis more particularly the former, influenza, typhoid fever, uraemia,.and cerebral arterio-sclerosis—20 cases (11 fatal). III. Type in which fever and lethargy are transitory or inconspicuous, but with pronounced focal symptoms referable to lesions of the mid-brain, such as paralysis of the ocular and facial muscles —13 cases (2 fatal). IV. Ah abortive type in which the symptoms of lethargy, fever and diplopia (double vision) never well marked, pass off after two or three weeks—6 cases. V. Type resembling paralysis agitans, with slow defective utterance, mask-like expression, marked tremors and muscular twitchings (myoclonus), and occasionally choreiform movements, with onset of fever, lethargy, and diplopia, due to lesion in the pons varolii or lower part of the brain—26 cases (14 fatal), one case of violent choreiform movements (like St. Vitus' dance) in a girl of 16, who recovered. VI. Ataxic type—cerebellar in origin—marked by giddiness, staggering and headache, in addition to lethargy and fever—13 cases (1 fatal). VII. Type presenting evidence of lesions of the cerebral cortex or part of the motor tract in the mid-brain, giving rise to hemiplegia or paralysis or Weakness of both arm and leg on one side, or loss of power in one limb only, with history of fever, lethargy and ocular palsy at the outset—17 (2 fatal). Walshe has also dwelt on the importance of adopting classification on an anatomical basis, directing attention to the symptoms which may be ascribed to lesions affect ing the neurones of the three physiological levels—the upper or cortical, the middle, involving the mid-brain and basal ganglia, the lower affecting the medulla and spinal ganglia. In describing cases of myoclonic encephalitis, he attributes the prevailing symptoms of muscular contraction, which occur in varying degree and distribution, to an irritative or exciting action of the virus upon the nerve cells of one or other of the three levels. This action of the virus may affect any or every part of the nervous system from cerebral cortex to spinal roots and thus give rise to the polymorphic character of the disease in cases showing what may be called irritative symptoms. On the other hand, in cases showing negative or paralytic symptoms, there is evidence that the virus has shown a definite and selective action on cells of the basal ganglia and of certain motor nerves of the brain stem, producing the familiar mid-brain types of the disease with associated lethargy. 23 An attempt has been made from the clinical particulars provided of the 130 cases to group them into one or more of the three levels in which the lesions would appear to be located— I. The upper level—Cortical, 12 cases. II. The middle and lower levels—Mid-brain and cranial nuclei, 112 cases ; cerebellum, 5 cases; lower levels and spinal ganglia, 37 cases. Grouping of the symptomatology of the 130 cases from the clinical features supplied showed the following particulars:— Lethargy was present in 126 cases; fever in 80 cases; paralysis or weakness of ocular muscles (squint or diplopia) in 68 cases. These symptoms were manifested in combination as follows :— Fever, lethargy and ocular palsies—65 cases. Lethargy and ocular palsies—27 cases. Fever and lethargy—16 cases. In addition, other ocular manifestations were noted—viz,, ptosis in 29 cases; nystagmus in 27 cases ; paralysis or inequality of pupils in 6 cases ; blindness or dimness of vision in 2 cases. Weakness or paralysis of facial muscles on one or both sides was noted in 30 cases, and of the tongue in 5 cases; deafness supervened in 3 cases; difficulty in swallowing (3 cases); mask-like expression (9 cases); speech—slow or scanning (48 cases); aphonia (6 cases). Other conditions were hemiplegia (8 cases); monoplegia (9 cases); paraplegia (9 cases); foot drop (2 cases); tremors, muscular twitchings, involuntary and choreiform movements (myoclonus and paralysis agitans type) affecting muscles of one or both limbs, face or abdomen, in 31 cases;; catatonia of limbs (5 cases); chorea (2 cases); paralysis agitans (2 cases); muscular rigidity—(i) of neck or with head retraction (5 cases), (ii.) of limbs (13 cases). Reflexes recorded: Knee jerks normal in 4 cases, absent in 3, diminished in 5, and exaggerated in 5 cases ; plantar extensor response absent in 4 cases and present (flexor) in 2 cases; Babinski's sign present in 2 cases ; Kernig's sign present in 5 cases. Skin eruptions in the form of general erythema, macules, petechias, were noted at the onset of illness in 3 cases. Incontinence of urine or faeces, or both (25 cases). The distribution of pain an early symptom, and usually severe, was recorded as follows :—Head (66 cases); neck and back (14 cases); chest and abdomen (5 cases); joints (7 cases); arms (9 cases); legs (3 cases). Other conditions noted at onset or during the course of illness were vomiting (24 cases) ; delirium (35 cases ; 2 maniacal); giddiness (12 cases); staggering (1 case); convulsions (4 cases, one being violent and epileptiform)— one case was definitely associated with epilepsy ; anaesthesia is also recorded as occurring in three cases, affecting the whole of the right half of the body in one case, and one or both legs in two cases. Laboratory work and assistance in diagnosis The Council has continued to place at the disposal of medical officers of health and medical practitioners the services of its consulting medical staff for the purpose of assisting them in the diagnosis of doubtful cases of illness associated with cerebral symptoms or morbid conditions of a cognate character. The facilities afforded for pathological investigation into such cases in the Council's laboratory have proved of great value in indicating the probable cause of illness and in establishing correct diagnoses. During 1920, either Dr. J. A. H. Brincker, or Dr. J. G. Forbes, was called upon to assist in the diagnosis of 106 such cases, clinically, or pathologically, or both. An analysis of these exammations and the conditions found either at, or subsequent to, the consultation is shown in the following table:— Visits to patients'' homes. Classified diagnoses. Diagnosis on clinieal grounds. Diagnosis after pathological investigation following lumbar puncture. Cerebro-spinal fluids received from infirmaries, etc. I. Affections of the meninges. (a) Cerebro-spinal meningitis (including post-basic meningitis 1 5 6 (b) Tuberculous meningitis — 7 16 (c) Other forms of meningitis due to pneumococcus, streptococcus, etc. — 2 5 II. Syphilitic lesions of the central nervous system, e.g.,hemiplegia, general paralysis, tabes dorsalis, myelitis, gumma 2 — 10 III. Other cerebral or spinal conditions, e.g., cerebral degeneration or thrombosis, mastoid disease and cerebral abscess, meningeal haemorrhage, epilepsy, paraplegia 1 — 9 IV. Encephalitis lethargica — 2 10 V. Polio-encephalitis — 1 2 VI. Meningismus, i.e., meningeal symptoms occurring in gastro-intestinal disorder, bronchitis and pneumonia, influenza and other acute febrile conditions 6 2 11 VII. Intoxications, e.g., ursemia, infective endocarditis, veronal poisoning, etc. 1 1 6 Total 11 20 75 24 In addition to the cases mentioned in the above table the following specimens were examined in the laboratory :— (i) Blood examinations. 17 specimens were examined by serum agglutination tests in connection with the occurrence of para-typhoid fever at Bedford College, Regent's Park. Also blood cell counts were made in three cases of influenza and neurosis. (ii) Examination of faeces. 14 specimens of stools were examined in connection with the occurrence of dysentery at an Industrial School. (iii) 90 eye specimens submitted by the Council's inspectors of midwives were examined in suspected ophthalmia neonatorum cases, of which 21 showed the presence of gonococcus. (iv) 9 specimens of sputum were examined, three of which showed the presence of tubercle bacilli. (v) 5,811 swabs were examined for Diphtheria bacilli and 3,239 hair specimens were tested for the presence of Ringworm ( see report of the School Medical Officer). In one instance the assistance of one of the consulting staff (Dr. Forbes) was requested in a suspected case of leprosy. The case, however, proved to be one of leucoderma. In last year's report reference was made to Mr. F. W. Twort's demonstration of " watery looking areas " on agar, by the cultivation upon it of glycerinated calf lymph ; these areas he thought, " might represent a condition, or disease of a micrococcus," or be due to an enzyme secreted by the micrococci, and leading to their destruction. This ultra-microscopic virus, he said, may be " an enzyme with power of growth." So, in 1891-2, when at work " On the conditions determining insusceptibility," I obtained a glycerinated pancreatic extract capable of producing watery looking areas upon a gelatine medium, with " no development of scum, of turbidity, or of flocculent material, such as is usually associated with the growth of bacteria." (Supplement to 21st Ann. Rep. of Loc. Gov. Board). The whirligig of time has brought the ultra-visible virus, almost undreamt of 30 years ago, into the common light of day, and phenomena such as those just noticed are now being regarded as worthy of further study. F. d'Herelle as stated in last year's report, has succeeded in growing an invisible organism (it seems at first sight a contradiction in terms), a " bacteriophage," as he calls it, which attacks Shiga's dysentery bacillus. He claims that, inasmuch as the power of " lysing " cultures of Shiga bacilli can be transmitted, by inoculation with very minute quantities of infecting material, from tube to tube, such transmission generation after generation must be due to a living agent endowed with powers of reproduction. Thereupon, M. Kabeshima objects that the bacteriophage is not a living virus but a " ferment " (See Medical Science, Vol. II., No. 2). The further discussion of this question is referred to in Medical Science , Vol. IV., No. 1, where abstracts from papers from ComptesRendusdes Seances de la Societe de Biologie(Tome LXXXIII, 1920, No. 29, etc.) appear. F. d'Herelle (Seance du 23 Octobre) deals with M. Kabeshima's criticisms, adducing strong evidence in favour of the view that his " principe bacteriophage " multiplies in vitro and, hence, that it is " necessairement un etre autonome " : he adds, " le principe bacteriophage ne peut etre qu'un etre qui jouit de la propriete de se reproduire aux depens de la substance des Bacteries qu'il dissout." D'Herelle refers to J. Bablet's demonstration of the facts that the bacteriophage does not develop in sterile bouillon, nor in the presence of certain antiseptics, and that it loses its activity after long exposure to glycerine : Bablet concludes that it is " un etre vivant." Meantime, J. Dumas finds the bacteriophage not only in material from the intestines of dysenteric convalescents, but in the healthy intestine of guinea pigs, in water and in air; Salimbeni points out that phenomena like those described by d'Herelle are known in connection with the myxomycetes, and he considers some stage in the history of a pleomorphic organism is in question; J. Bordet and M. Ciuca claim that a transmissible bacterial autolysin is the agency concerned, and that here is to be found the explanation of variations being transmitted to descendants ; Wollman points out that Bordet's views recall Darwin's doctrine of pangenesis ; Wollman, moreover, has carried out experiments to determine whether the bacteriophage will pass through a collodium membrane. These observations clearly possess an importance far greater than any concern they may have with the life history of Shiga's bacillus. They open up a path through the as yet unexplored country of the ultravisible viruses. Study of ultra-viaible viruses. Typhoid Fever. During 1920 there were 387 cases of typhoid and paratyphoid fever notified in London, as compared with 342 in 1919 and 357 in 1918. The deaths numbered 48, as against 63 in 1919. The cases in 1920 included 48 of paratyphoid fever, and among these a group of 20 cases affecting students and others at a ladies college is included. The cases notified among males between the ages of 20 and 45 increased by 17 (from 55 in 1919 to 72 in 1920); while among females there was an inciease at these ages, from 97 in 1919 to 122 in 1920. There was, therefore, for both sexes, at ages 20—45, an increase of 42 ; at all ether ages there was an increase of 3 cases. Nearly half the increase at ages 20—45 is attributable to the paratyphoid outbreak above referred to. In addition to this considerable group of cases, there were three sets of three cases in households in Wandsworth, Lambeth and Deptford, and ten double cases in various parts of London. In 209 cases particulars were obtained by borough medical officers of health as to the possible sources of infection. Fish, shell-fish, are mentioned in 74 instances ; in 39 cases the disease is said to have been contracted outside London ; eight nurses were attacked ; one illness was ascribed to river bathing, one to "drainage," and 5 to drinking water Twenty-two of tue cases, concerning which information was supplied proved not to be cases of typhoid fever. In 1918 two groups, one of 8 and one of 7 cases notified as paratyphoid fever, occurred just about the time of commencement of the summer influenza prevalence. In 1919 no considerable group of cases of paratyphoid was notified ; and in 1920 the only 25 considerable paratyphoid group of cases was that above referred to; when this last named outbreak occurred there was some influenza in London but the disease was not nearly so prevalent as was the case, in 1918. Reference has been made (p. 2 ) to the facts, that in London (at any rate) the great decline of typhoid fever in the latter half of the last century was due in the main to improvement of water and food supplies, and that the continued and accelerated fall of the last 20 years was mainly attributable (the water being for the most part beyond suspicion) to improvement effected as regards supplies of shellfish and fish from certain sources. On the other hand, no clear evidence has been adduced during the last 25 years to show that carriers, flies, milk, ice-cream or watercress have spread typhoid fever in London. There remain to be considered two further possibilities ; first the view, which still finds some favour, that considerable importance must be attached to direct case to case infection ; and, second, the opinion now beginning to find expression that preventive inoculation has caused a lowered incidence upon young men since the war. In support of the former view appeal is sometimes made to nurse infections and to infections of laboratory workers. The number of cases notified in nurses has been carefully recorded in London for many years past. In 1919 there were four, last year there were eight such cases. The whole question was considered in a paper on " Typhoid Carriers and Contact Infection " (Proc. Roy. Soc. Med. Epidem. Sect. 1910, p. 128-130), the data relating to the preceding 20 years being analysed. It transpired that the incidence of typhoid fever upon nurses "does not very much exceed that upon other women of those ages in London in those years." Moreover, as typhoid fever has especially affected in the past certain sections of the London population, question arose as to whether nurses had circumstances in common with the sections of the population which have escaped, or with those more especially attacked. Again, the likelihood of detection of atypical and obscure cases of typhoid fever in nurses in institutions is, of course, distinctly greater than in persons outside institutions. Furthermore, the cases in nurses were found as a rule to present themselves in groups, and in several instances the circumstances were suggestive of food causation. When nurse infection is thus considered as a mass phenomenon, the ordinary opinion as to risk run by nurses, in the particular respect in question, does not find confirmation. Reference was made in the Annual Report for 1912 to the fact that the available data relat ing to laboratory workers, supposed to have been directly infected with typhoid cultures, stands in very similar case. It has been pointed out from year to year, in recent annual reports, that any conclusions drawn from statistics relating to inoculation in the armies engaged in the late war need to be considered in the light of the corresponding statistics for the civilian communities of the nations concerned. It has, however, been only too commonly the practice of writers on the subject, in discussing attack rates and death rates of the armies in the recent war, to contrast them with attack rates and death rates in previous wars. Such comparisons are of course beside the mark. For, while it is quite true that the recent military rates are only one tenth or one twentieth of those in previous wars, the same statement holds good as a ride with respect to the corresponding civilian rates also. In last year's report, page 12, reference was made to the American and German military experiences, which indicated that the case for the general adoption of inoculation is by no means clearly made out. But, perhaps, an even more important point is the teaching of the figures for the years immediately succeeding the war. If anything more than a transient and partial protection is claimed, then as demobilisation was effected it should have been clearly evident that there was a very material reduction in the male rates as compared with the female rates among civilians, in view of the fact that the demobilised men had as a rule been inoculated. Such a claim has in fact been recently made (see Journal of the American Medical Association, 27th November, 1920, p, 1501), it being urged that in 1919 there is evidence to show that in the experience of a particular metropolitan life insurance company the male rate had declined 64 per cent, as compared with a corresponding decline of only 47 per cent, in the female rate, when comparison was made between 1919 and the years 1911-16. Appeal is also made to the low rate in the male white population of the United States between 20 and 35 years of age, which is given as 8 0, and is only slightly in excess of the corresponding female rate (7"9 per 100,000). There are possible fallacies here ; we are assured that the population figures must not be too implicitly relied on, and in the case of the insurance company the figures under review cannot be very large. Since this point was raised in America, a study of the available military statistics for this and other countries has appeared in the International Journal of Public Health, (Vol. 2 No. 2, March-April, 1921). An opinion on the whole favourable to the influence of inoculation is given in this review, but there is not anything approaching unanimity of testimony on this head, and there is apparent as before the tendency to compare present day case rates and death rates with those of twenty or more years ago. Thus, the writers referred to in this review argue from the data of the Great War, back to those of the Boer War, or, in the case of the American Army figures back to the figures of the Spanish American War. At the time of sending the present report to press, No. 3 of the Journal above referred to, containing a review of the " Anti-typhoid Inoculation of Civil Populations," has just come to hand. References are given to 60 papers dealing with the subject; again opinion is divided but by some writers the wholesale inoculation of civilian populations is advocated. There is apparent, however, on the part of these writers a disposition to infer that compulsory inoculation during an epidemic, followed by decline, or cessation of the prevalence, proves the case for inoculation. (See, for example, the Kansas Hospital case on p. 285, and the Paris Boarding School experience, p. 286). But, in the same way the inauguration of mere bacteriological examinations pn Drigalski-Conradi lines, without any inoculation, in a London institution sbme years ago, was immediately followed by cessation of a severe typhoid prevalence. As the bacteriologist entered the door of the institution the typhoid bacillus, metaphorically speaking abandoned the unequal contest. In contrast with these experiences were those of the milk 61004 E Causation of typhoid fever in London Anti-typhoid inoculation. 26 borne outbreak referred to on p. 285, and a somewhat similar recent instance in a London institution noted on p, 31 of the present Report, in both of which the inoculations preceded the prevalences and the attacks were almost, or entirely, limited to inoculated persons. In dealing with inoculation carried out during a prevalence of typhoid fever the fallacy of unequal exposure of inoculated and uninoculated persons to risk, so carefully examined some years ago (Proc. Roy. Soc. Med. Epidem. Sect. 1914) by Greenwood and Yule, needs to be borne in mind. This caution would apply to many cases referred to in the review now under consideration. Furthermore, in several of the outbreaks mentioned the criticism is inevitable that, perhaps, too much is proved. For example, Peset's description of the epidemic at Tomares, p. 287, and the account of the influence exerted by inoculation, stage by stage, atVoeuxles-mines, p. 288, may be mentioned. Some of the American experiences were decidedly unfavourable ; that of Sawyer, for instance, p. 289; while that of Mackid is inconclusive as no notice is taken of the time factor, or of dangers lurking in the fallacy above referred to. Descroix (p. 292) points out that, if inoculation repeated every three years were adopted in France, it would mean a loss of 40,000,000 working days a year, or 600,000,000 francs in salaries. Finally, Rathery and Mathieu (p. 293) are reported to be frankly antagonistic. As the subject is being seriously considered in some quarters, it appears desirable to make a few comments on it from the bacteriological, epidemiological and statistical points of view. In the first place a sentence from a paper by Lt. Col. Harper maybe quoted ("Lancet," 11th December, 1920, p. 1,190). He holds that inoculation has been "an important item" in the prevention of typhoid fever on the Western front; but he very fairly adds, "At the same time it must be admitted that there were other very important factors at work, viz., the exceptionally capable sanitary administration, the great care taken in the feeding and comfort of the men, the elaborate arrangements for bacteriological investigation, the prompt recognition by the regimental officers of the cases of suspect enteric, and the wisdom of the course adopted early in the War of selecting special hospitals for the investigation and treatment of this disease ; all these factors had their share in producing such an excellent result." This comprehensive statement shows a determination to take account of all the pertinent facts, but if so much be admitted an appeal to inoculation as an important factor is almost rendered unnecessary. The difficulties are not lessened by the fact that opinion is much divided among bacteriologists with regard to the bearing of recent enquiries upon the general question. Thus, Lt. Col. Harper belongs to the school of bacteriologists who hold that the diagnosis of enteric fever has become much complicated since protective inoculation was established, although he says of typhoid in the inoculated: " There are times when the symptoms are so characteristically toxic that they resemble the enteric so often seen in the uninoculated." The official figures for the total incidence of enteric infections in the British Armies in France he gives as 7,423 cases. This must err considerably on the side of defect, if, as he holds, the disease is to be regarded as being much modified in the inoculated; indeed, Dr. Topley (" Lancet," 25th December, 1920) considers that " between 5 and 7 per cent, of those cases which were invalided to this country from the western front, suffering, or convalescent from undiagnosed febrile conditions, were in reality examplesof a typical enteric infection." Thus, the military case-rate for the Western front is on this showing, at least three or four times as high as that in the London civilian population for corresponding years. Dr. Garrow, on the other hand (" Lancet," 30th October, 1920), writing concerning "The myth of atypical enteric fever," declares that "The influence of anti-enteric inoculation is not to modify enteric fever, but to prevent it." Dr. Topley criticises this view (loc. cit. and "Lancet," 30th November, 1920). Dr. Ryle, in the issue of the Lancet last cited supports Dr. Garrow, pointing out "that there occur from time to time cases of clinically indisputable typhoid fever in which all laboratory efforts fail to achieve a diagnosis," and contending that "the clinicians rather than the laboratory workers have been at fault in their too casual acceptance of (laboratory) tests, an insufficient study of their significance, and also in the needless loss of confidence in their own clinical ability, which the discovery of more minute scientific methods seems to have engendered." Dr. Ledingham (" Lancet," 8th January, 1921), while expressing sympathy with Dr. Garrow's main argument, questions his statement that there is difficulty in recovering enteric bacilli from the blood of inoculated soldiers (Dr. Garrow subsequently agrees with Dr. Ledingham on this point). Dr. Ledingham thinks the "fostering of such views gave the impetus to that concentration on agglutination tests which formed such a feature of enteric diagnosis in France." He quotes Major Vaughan (The Amer. Med. Assoc., 1920, pp., 1,074, 1,145) to the effect that, "The most striking feature of the disease in the inoculated is its almost classical resemblance to the old typhoid as we knew it in the unvaccinated." He gives some very striking "Blood culture results from Mesopotamia."—" Of 139 cases diagnosed by blood culture, 78 were inoculated men, 28 were returned as not inoculated and 33 were set down as ' no paybook entry.'" Thus, of the total at least 56.1 per cent, yielding positive blood cultures were definitely inoculated men; 35 had received T. A. B. vaccine in 1918, the year of the attack, 24 had received their last dose in 1917, 17 their last dose in 1916, and 2 in 1915, (probably typhoid vaccine only) Dr. Ledingham appears, moreover, to attach considerable importance to "Besredka's recently promulgated views on immunity in enteric infections." These "Lancet" letters and articles vividly illumine the obscurity of the situation from the laboratory point of view, but exigencies of space require that a veil should now be drawn over this troubled scene. From the preventive medicine point of view interest mainly turns on the practical question as to the value of typhoid inoculation. Here, of course, it is necessary to speak with caution for as yet full information is not obtainable. Attention may, however, profitably be directed to the meagre character of the statistical records to which much significance has recently been attached. For example, there is Professor Chauffard's communication (alluded to in the British Medical Journal of 30th April, 1921), comparing the ages of 11 men attacked in 1912-13, and those of 10 men attacked in 1918-20; and again somewhat similar figures relating to "a number of localities" in America have been referred to 27 (Journal of the American Medical Association, 26th March, 1921, p. 863). It has been thought well, therefore, to examine the data furnished by the population of London as a whole (p, 24). The figures are given in the annexed Table. Notified civilian cases of typhoid fever in London at ages 20—45 and 45 and upwards. Ages 20—45. Year 1911. 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. Males 253 177 169 225 159 94 55 57 55 72 Females 227 168 195 174 172 125 122 116 97 122 Ages 45 and upwards. Year 1911. 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. Males 53 33 44 44 41 26 34 22 20 32 Females 43 42 34 29 36 30 29 19 17 18 At the ages 45 and upwards, in which inoculation scarcely complicates the question at all, it will be seen that in both sexes there is from 1911 to 1920 a general downward trend, to about half as many cases in the last three years (1918-20) as in the first three (1911-13). In women 20—45 (again practically an uninoculated population) a closely similar movement of the figures is discernible. In the civilian men 20—45, there is observed a greater reduction, first shown in 1915, marked in 1916 and more marked still in 1917; the proportion of civilian men attacked closely corresponds, however, with that of women, if regard be paid to the fact that by 1917 approximately half the men were away on military service. In 1918 the position was not materially altered; in 1919 and 1920 most of the men who had not been killed or badly injured returned to ordinary civilian life. In 1920 the cases at ages 20—45 in both men and women rise, those in women are 122 as against 72 in men. It should be noted that some 20 of the former cases belong to a group of cases of "paratyphoid fever," occurring in a women's college in the spring of the year; if this group of cases be excluded from consideration, the figure 72 for males is approximately the number that might have been expected, having regard (a) to the general trend of the figures in the other three groups, viz., women 20—45 and men and women over 45; (b) to the greater number of women at risk at ages 20—45. The excess of women at 20—45 cannot be precisely given, but it was about 16 per cent, above that of men just before the war, and, if account be taken only of the men "killed in action," the excess must have been about 24 per Cent. above that of the men in 1920. The 72 cases in men are, it should be understood, civilian cases and do not include a small number of cases still in military hospitals in 1920. The figures for the London civilian male population do not, therefore, when comparison is made with uninoculated women of like ages, or with uninoculated persons of higher ages lend support to the view that inoculation has afforded any appreciable lasting protection to the men at risk. The American article already referred to especially emphasises the great importance to be attributed to improvement of water supplies. The typhoid death rate it is pointed out has fallen to something like one-tenth of its former rate during the last 15 years. In view of this fact and of the consideration that inoculation of course can in any case only come into question subsequent to 1916, it seems strange that, having swallowed the camel of admitting a reduction in the typhoid death rate of 57 cities from 19 59 per 100,000 in 1910 to 7.61 in 1916, the American article should strain at the gnat of assuming that a continued reduction from 6.65 in 1917 to 3.52 in 1920 may be regarded as resulting from the maintained influence of the causes previously at work. (See Table loc. cit., p. 863.) It is of course admitted that the theoretical interest as to the possibility of inoculation being also in question is great, but the figures up to date will scarcely bear the burden of sustaining the argument. As Dr. Greenwood says, "If any bacteriologist thinks that the elimination of, say, epidemic disease of the typhoid group, can be secured by immunising the population first against B. typhosus, then against paratyphoid A, paratyphoid B, paratyphoid C, and so on, to the end of the alphabet, all other things remaining constant, he must be rather naif." Some further addition can now be made to Dr. Greenwood's alphabetical list of typhoid bacilli, inasmuch as Rosher and Wilson ("Lancet," 1st January, 1921) suggest in the light of their case of typhoid "due to Gartner's bacillus, the advisability of testing the sera of patients suffering from enteric-like infections against a more extended series of antigens than are common'y employed." Further evidence bearing upon the point at issue is furnished by the Registrar-General in his annual reports for 1918 and 1919. In the former (p. lvi.), after stating that the mortality in the civilian population ot England and Wales, 26 per million living, was the lowest ever recorded, he adds, "to some extent this fall is due to absence on foreign service of a large number of males of the ages at which mortality from this cause is highest; but (after allowing) for this change in the population the standardised deatli rate of males remains considerably below previous records." And then, following upon this statement, there comes, in the report for 1919, the announcement of a further decline of mortality from enteric fever to 16 per million living, and the annexed table is given showing the crude rates and standardised rates, for males and females, 1901-19. The excess of the standardised rates for males over the crude rates, which arose in the years before 1919 from absence on foreign service of a large number of males of the ages at which mortality from this cause is highest, has now almost disappeared. 61004 e 2 28 Enteric fever—Mortality per million living, 1901—1919. Crude rates. Standardised rates. Males. Females. Persons. Males. Females. Persons. 1901-10 (total population) 109 74 91 109 74 91 1911-14 „ 60 39 49 60 39 49 1915 (civil population) 43 29 35 46 29 38 1916 „ 37 25 30 41 25 32 1917 „ 33 34 28 44 23 33 1918 „ 29 25 26 35 25 30 1919 (total population) 18 13 16 19 13 16 The crude rates and the standardised rates also indicate that some influence or influences have been at work fairly steadily throughout the twenty years, reducing in like proportions male and fen ale mortality. They lend no support to a hypothesis that the fact, that between 1914 and 1918 some four millions of men were inoculated against typhoid fever, has been a prime factor in reducing mortality. Dysentery. To those who accept the view that typhoid fever and dysentery are largely spread by healthy bacillus carriers, the behaviour of dysentery during and after the war has been even more surprising perhaps, than that of typhoid fever. True, as the Registrar General states, "the dysentery mortality in England and Wales was four times as high in 1918 as it was before the war, but 81 per cent, of this mortality was in lunatic asylums." The rise commenced in 1919, and had reached its height already in 1917. "It appears, therefore," the report continues, "that although a large amount of infection was introduced into this country in 1915 and succeeding years, it has shown no tendency whatever, so far as can be inferred from the death returns, to spread among the general population. The asylum mortality stands by itself and does not appear from the death returns to have any relation to the health of the general public." This phenomenon seems to call for careful consideration on the part of those who hold the belief above referred to. Dysentery and fever have again and again been associated with war. At the time of the South African War both dysentery and enteric fever were very prevalent and fatal and a Royal Commission was appointed to inquire into the "Nature, pathology, causation and prevention of dysentery and its relationship to enteric fever." The Commissioners, in the introduction to their report of 1903, state that they visited Johannesburg and Pretoria to ascertain "which would be the most suitable for the estab lishment of a laboratory, to study the bacteriological and pathological character of dysentery and their relationship, if any, to enteric fever." The last part of this study is dealt with in Part I. (the bactericlogical part) of their report, and is not referred to at all in Part II., which relates to field inquiries The conclusion arrived at is "there is no connection between dysentery and enteric fever. Eteith's bacillus is not found in the organs or intestines of dysentery." So from first to last the Commissioners make no reference to the question of any possible epidemiological relationship between dysentery and enteiic fever; they have, in fact, quite ingenuously limited the scope of their reference, so as to exclude epidemiological relationship altogether. To such an extent were the minds of medical etiologists obsessed by bacteriological considerations in 1903. It is scarcely to be wondered at then that they failed in this part of their quest. Under the strict limitations they imposed upon themselves, Part I. of their report contains, nevertheless, points of great interest, for acting under the "instructions given for the guidance of the Dysentery Commission .. . that the connection between dysentery and enteric, if any such existed, was to be investigated .. .every favourable opportunity was taken of making post-mortem examination of cases of enteric and subjecting them to the same procedure as in cases of dysentery ..." and 18 cases of dysentery and 7 of enteric fever thus came under observation. It is deserving of note that two of the last named were cases of enteric fever followed by dysenteric symptoms. As regards one of them (case 24) it is said that the case was hard to interpret—it might be "enteric fever from beginning to end"—"it might be dysentery throughout"—"it might be a case of dysentery following on enteric fever." On the whole the scale turns in favour of "enteric fever throughout." The other case (25) is also difficult of interpretation, but again the same conclusion is reached. The final outcome of the bacteriological inquiry, so far as dysentery is concerned, is that, "if there is a special micro-organism in dysentery it must be sought for in the large intestine, where, we imagine, the task of finding it will prove an arduous one." It is stated at the outset in Part I. that there is "something rather fascinating" in the theory that "the common colon bacillus may assume a pathogenic role in dysentery," as it was long ago said to do by French bacteriologists in enteric fever. Whatever prcspect there may be of clearing this question up, so far as the small intestine is concerned, the above-quoted statement would make it appear that such a task is likely to "prove an arduous one" when the large intestine comes to be considered. It will be very interesting to see how in the light of present knowledge these laboratory difficulties aie dealt with in the enteric fever and dysentery reports, of the Western Front, of Gallipoli and of Mesopotamia. Meantime, reference may be made to some of the epidemiological aspects of the problems in question, as revealed in Mott and Durham's report of 1900 on Asylum Dysentery. They, too (p. 27), considered that it was "advisable to obtain further information about the occurrence of typhoid fever in the asylums, not only because of the chance of comparison of a better-known specific infective disease, 29 with very slight power of spread from person to person, but also because of the occasional confusion in diagnosis between dysentery and this fever, as was met with for instance by Turner." They sought to obtain returns, and note that "it is strange that in five large asylums, each with roughly similar numbers of patients, no single case of enteric fever should have occurred in the space of three years, whilst at the other three, where the conditions and class of persons are to all intents similar, so many cases should have occurred." Their attention was turned, as has been that of other observers before and since, to cases in laundry workers (p. 29), and in workers amongst sewage-polluted soil on irrigated areas (p. 32), to the involvement of particular wards (p. 36), to the implication also of attendants and officers (p. 38); and they note (p. 40), that all the attendants attacked "lived in," and that bedridden patients, as well as those who ar£ up and about, suffer. Close study of ail these points has been made by Drs. Brincker and Wanklyn, in consultation with the mental hospital superintendents, in connection with the London prevalences of the last few years; recommendations have been drawn up with a view to preventing spread of infection through laundry operations, and the subject of food, including fish supplies (shell-fish can be practically excluded) has been explored. In each of these directions no final results, one way or another have, however, baen reached. On the one hand it must be agreed that the facts elicited from the institution inquiries relating to "dysentery," if not to "typhoid" also, accord more easily and naturally with case-to-case infection than do those elicited from study of extra-institution typhoid. But, on the other hand, food cannot be absolutely ruled out. True it is difficult to explain, on a food hypothesis, how it comes about that one institution is taken, or one side of an institution is taken, and another left. But at this point the facts elicited with regard to typhoid may be recalled—the limitation of outbreaks in London in the last 20 years to persons consuming certain kinds of fish and shellfif-h. Its excessive incidence in particular years—for example, in 1911 (see diagram, p. 17, Ann. Rep. for 1919) upon populations supplied with East Coast fish. In this connection, too, it may be noted that while typhoid moitality is highest in Ihe Northern Counties, "the Midlands" (to quote the Reg. Gen'. Rep. for 1918) "and not, as is usually found, the South, hold the best position." The comparative freedom from attack of inland populations (Bir ningham, for example) during the war years, moreover, has been specially noteworthy. Another fact noted by the Registrar General is the "great advantage of county boroughs over the smaller towns and rural districts, a feature of recent development." The county-boroughs may, perhaps, be thought of as being, prior to the war, owing to smaller freight charges, exposed to n ore risk of receiving polluted fish supplies than sma'ler towns and rural districts; just as London wrs undoubtedly more exposed to such risks than, say, Birmingham. These risks were, however, as has been elsewhere explained, materially reduced on the outbreak of hostilities. Again, the behaviour ot typhoid in large American cities during the last 15 years is very interesting in a somewhat similar connection. The improvement of water supplies in America came nearly 20 years later than the improvement here; our improvement was fairly continuous down to 1885, after which date there was almost complete arrest until 1900 (Rep. of Reg. Genl. 1919). It is not until within the last 15 years that the death rates in large American cities have come to rival our rates of 15 or 20 years ago. As the water peril has diminished, at first here and later in America, it has become clear that a residual peril (certainly from shellfish, possibly from fish also) still remains, and it is interesting to obseive that some of the inland cities in the New World (Chicago, Milwaukee, Minneapolis, St. Louis, St. Paul, for example) take pride of place now, corresponding to that of the Midlands in this country as noted bv the Registrar General. It appears from figures given in a table on p. 862 (Journal of the American Medical Association, 25th March, 1921) that there are 24 large American cities with a death rate from typhoid not exceeding 3 par 100,000 in 1920, and of these only two (Boston and New York) are on the Eastern seaboard On theother hand there are 41 cities with a higher death rate, of which 11 are actually on the Eastern seaboard, and some 12 others ar3 within a few hundred miles thereof. It must, of course, be remembered that there is a noteworthy concentration of population in the north-eastern section of the United States area ; but despite this fact it must be regarded as a striking feature of the tab'e that so many cities with high rates should be located east. The review in the American Journal makes mention, apart from water, to which special significance is, of course, attached, of milk, flies, carriers, and protective inoculation, but does not allude to shellfish. This is remarkable since a good deal of work upon shellfish typhoid comes from the U.S.A. New Haven, Connecticut (a city which it is observed has still a rate of 6.1 per 100,000) was associated with one of the earliest outbreaks of typhoid traced (by Professor Conn) to the consumption of oysters. The outstanding impression left on the mind after examination of the behaviour of enteric fever and dysentery in the London mental hospitals is that it would be well in the future if further attention were devoted to study of "the relationship, if any" between the two diseases. As a beginning, the accompanying chart has been prepared to illustrate the way in which they have prevailed in association with one another, in the institutions concerned, throughout the war years—not that they have always affected an institution, or even the two sides allotted to male and female patients, and certainly not the same wards in any of the institutions, simultaneously; but that, viewing the institutions as a whole, there is a suggestion that some as yet not clearly envisaged influence may have been operative producing the epidemiological phenomena in question. The annexed diagram shows the mortality ascribed to enteric fever and dysentery respectively in London as a whole during the last seven years, and the cases among inmates of seven institutions (mental hospitals, each accommodating some 2,000 patients) during the same period. The cases of dysentery represent a substantial proportion of the total number of cases belonging to London. It will be noted that enteric fever (shown above the line) was lower in London as a whole in 1918-20 than in the earlier years Institution A was almost entirely free from cases. In B and E women only were 30 31 attacked. Institution C suffered the most severely of the seven institutions, being especially involved in the latter part of 1917, the whole of 1918 and the early months of 1919. 4s regards dysentery (shown below the line), the deaths increased in 1917 and 1918, but this increase was largely attributable to the deaths in institutions. Among the latter B, D, E and F had already suffered markedly in 1915; F showed a considerable prevalence in 1916 ; and five of the institutions suffered heavily in 1917 and 1918. Particularly noteworthy is the incidence of dysentery with almost complete absence of entericfever in A, the limitation of enteric fever to females in two of the institutions,and the fact that D, E, F and G, which suffered markedly from dysentery, escaped comparatively lightly as regards enteric fever; while C, which suffered most acutely from enteric fever, had but little dysentery, this being notably the case during the special prevalence of enteric fever. The facts as regards inoculation may be briefly summarised as follows:—In B and D a few members of the female staff were inoculated in 1918 and 1919; in E nearly 100 of the staff were inoculated during the same years, and in G some 160 of the staff were inoculated in addition to 14 patients, Inoculation was systematically carried out in institution C from the middle of 1919 onwards, It is noteworthy that all the 18 cases occurring in this institution (C), during the lattei part of 1919, and in 1920 (four of which were fatal), were in inoculated persons. The intervals betweer completion of inoculation and onset of illness varied from 10 days to 17 months ; in six of the 18 cases the interval was less than 6 months. B.—Administration. It may be noted at the outset that certain statistical information available is summarised ir Table II., see page 49 Tuberculous Milk—L.C.C. (General Powers) Acts, 1904, Part V. and 1907, Part IV. The Council's inspectors obtained 1,483 samples from churns of milk consigned from the country to the various London railway termini, and these were submitted to the Lister Institute for bacteiiological examination. The milk was sent to London from 36 counties. Of the 1,294 completed examinations, 76 or 5 9 per cent, yielded tubercle bacilli, as against 6 5 per cent, in 1919, 7 4 per cent, in 1918, and 10 3 per cent, in 1917. In connection with these samples the veterinary inspector visited 67 farms and examined 2,737 cows. It was found that 63 cows—i.e., 2'3 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 revisited 326 farms and inspected 14,352 cows ; all the animals examined at these revisits were found to be in a satisfactory condition with the exception of 145, which appeared to be tuberculous. In each instance the owner undertook to have the animal removed. During the year 1920 there were four inspections of the cows in the 108 London cowsheds.- In all 7,120 examinations were made. No cases of tuberculosis of the udder were detected, but in 144 cases other unhealthy conditions of the udder were found. One cow was found presenting symptoms of general tuberculosis. Offensive Trades. Section 19 of the Public Health (London) Act, 1891, requires the sanction of the Council to the establishment anew of noxious trades or the enlargement of the premises on which they are conducted. During the year under review sanction has been given to the establishment of the businesses of a gutscraper, a catgut-maker or catgut manufacturer, and a tripe-dresser. In three instances also the establishment anew of the business of a slaughterer of cattle has been sanctioned. An application for permission to establish anew the business of a soap-boiler was not granted. Under the provisions of the same section, orders were made by the Council declaring the businesses of a dresser of fur-skins and a slaughterer of poultry to be offensive trades These orders were in due course confirmed by the Minister of Health. Common and Seamen's Lodging Houses. The administration of the Common Lodging-houses Acts devolved upon the Council in 1894. By the passing of the London County Council (General Powers) Act, 1902, the Council obtained powers to license common lodging-houses annually. New bylaws for the regulation of such houses came into force on the 1st October, 1903. Common lodging houses. 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 dunng 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 — 1919 197 19,684 14,656 370 1 1 8 0 0 1 1920 186 18,763 12,811 343 1 1 3 0 0 2 In 1901 the London County Council made bylaws 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 bylaws were amended in certain particulars and a new series came into force on 1st January, Seamen's lodging houses. 32 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 bylaws were further amended to permit of a wider interpretation of the definition of a "seaman," as the then existing bylaws 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 eea service within this period, and the four-week limit was therefore eliminated in the new bylaws. 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 houses licensed. Authorised number of lodgers. No. of day visits. No. of night visits. No. of prosecutions. No. of convictions. Penalties and costs. f cases of infectious disease. £ 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 — 1919 57 1,381 1,542 76 17 17 118 0 0 — 1920 53 1,298 1,496 109 10 6 91 10 0 — Census of Homeless Persons. In accordance with the practice which has obtained for several years, a census of homeless persons in thecounty of London was taken on the night of 13th February, 1920. The area covered extended over the whole of the county except the outlying portions which are not usually the resort of such persons. The night was fine and fairly mild. Only ten persons (3 males and 7 females) were found sheltering under arches or on staircases. In the streets, 28 men and 13 women were found, as compared with 1 man and 5 women in 1919, and 296 men and 76 women in the early part of 1914 before the war. In the common lodging-houses, 14,333 persons were accommodated as compared with 12,336 in 1919, and 20,173 in 1914. In the free shelters and labour homes not licensed as common lodging-houses there were 86 men, 61 women and 2 children, as compared with 31 men, 59 women and 1 child in 1919. The number of persons in London casual wards on the night in question was 86 males and 2 females, and there were 308 vacant beds. The number of inmates at the date of the last census was 50, and the vacant beds numbered 346. At Rowton House 5,054 men were accommodated as against 4,984 in 1919, and there were no vacant beds as against 80 in 1919. Scheme for the Diagnosis and Treatment of Venereal Disease. As the outcome of the findings of the Royal Commission, the Local Government Board issued, in July, 1916, the Public Health (Venereal Disease) Regulations, which placed on County Councils, etc.. the duty of making arrangements for the diagnosis and treatment of venereal diseases within their areas. The Council thereupon entered into negotiations with the governing bodies of the principal London hospitals, and as a result 22 of these institutions intimated their willingness to undertake the requisite services. A Scheme, in which the authorities of certain areas adjacent to the County of London were desirous of co-operating, was prepared and came into force on the 1st January, 1917. Since that date the arrangements have been renewed annually, and where considered desirable increased facilities for treatment have been provided and existing arrangements made more efficient. During the year 1920 special provision was made for the treatment of infected pregnant women and for the residential treatment of children, especially female children, suffering from gonorrhoea. Further it was found possible to include in the Scheme provision for hospital treatment of ophthalmic conditions associated with venereal disease. Additional hostel accommodation was also secured and a further extension of this valuable adjunct to hospital treatment is contemplated. Towards the end of the year a complete survey of the whole of the existing arrangements was made and a comprehensive report was prepared by Brevet-Colonel L. W. Harrison, D.S.O., M.B., of the Ministry of Health and Dr. F. N. Kay Menzies of the Council's public health department. Recommendations for extending and increasing the efficiency of the clinics and for dealing more adequately with the problems of rescue and preventive work were submitted and are now being considered by the Public Health Committee of the Council. The following table shows the extent to which the facilities have been utilised by London patients during the four years the Scheme has been in operation. The number of beds available for the use of in-patients is 230. Year. 1917. 1918. 1919. 1920. Number of hospitals 225 26 28 New patients 12,211 12,538 20,908 23,612 Attendances 96,398 131,869 232,659 365,478 In-patients days of treatment 48,860 49,590 54,431 54,529 Pathological examinations for practitioners 2,992 5,122 8,258 11,234 Practitioners on the approved list 108 178 240 297 33 Housing of Transmigrants. Prior to the war the question of the accommodation of transmigrants arriving in this country from Eastern Europe en route for America, was frequently under consideration by the Public Health Committee, owing to the fact that these persons were found to be housed under very unsatisfactory conditions during their stay in the metropolis. During the period of hostilities the traffic ceased, but was again resumed in the early part of 1920. Previously two blocks of tenements in the East-End of London had been used for the housing of these people, but on the resumption of the traffic these tenements were reported to be no longer available. Overcrowding and insanitary conditions again beingfound, the Council brought the facts to the notice of the Home Office and the Ministry of Health. Conferences were arranged between representatives of these departments, and the shipping companies engaged in this traffic, a representative of the public health department of the Council being invited to be present, these conferences culminated in two of the large shipping companies making satisfactory provision for the housing, cleansing and disinfection of transmigrants. At the time of writing this report the adequacy of the arrangements made was still being inquired into. Sanitary Staffs. The subjoined table shows the number of sanitary officers and health visitors employed by the sanitary authorities in the Administrative County of London:— Sanitary area. Sanitary inspectors. Male. Female. Health visitors. Whole time. Part time. Whole time. Part time. City of London 8 1 — — — Battersea 12 — 2 — 2 Bermondsey 11 — — 8 — Bethnal Green 12 — 1 10 1 Camberwell 12 3 — 1 — Chelsea 3 1 — 1 — Deptford 8 — 1 5 1 Finsbury 8 1 — 5 — Fulham 9 1 — 5 — Greenwich 6 1 — 6 — Hackney 18 2 — 9 — Hammersmith 9 1 — 3 — Hampstead 7 1 — 3 — Holbom 3 — 1 1 1 Islington 20 2 — 7 — Kensington 10 2 — 4 — Lambeth 14 2 — 4 — Lewisham 9 — 2 7 2 Paddington 8 2 — 2 — Poplar 10 1 — 6 — St. Marylebone 11 — 3 3 3 St. Pancras 14 4 2 4 2 Shoreditch 13 — — 5 — Southwark 13 2 — 9 — Stepney 23 — — 12 — Stoke Newington 2 — — 3 — Wandsworth 12 1 2 4 2 Westminster, City of 10 1 — 5 — Woolwich 10 1 2 5 2 London County 305 30 16 137 16 Housing Acts. In the Annual Report for the year 1919 particulars were given of a scheme for the provision of dwellings for the working classes which had been submitted by the Council to the Ministry of Health for approval. In January, 1920, the Minister of Health accepted the scheme as ranking for state financial assistance subject to approval of details, in so far as it may be completed within the period of five years from the passing of the Housing, Town Planning, etc., Act, 1919, or such further period as the Minister may allow, in view of difficulties arising in connection with labour or material, or from other circumstances beyond the Council's control. The approval was given on the understanding that there would be a review of the adequacy of the proposals within the next two years, and that the Council would submit a definite annual building programme and would make satisfactory provision for dealing with slum areas. At the present time the Council has under consideration 26 representations of insanitary areas by borough medical officers of health. Of these four—Ware-street, Shoreditch, Bell-lane, and Ellenstreet, Stepney, and Hickman's Folly, Bermondsey—have formed the subject of improvement schemes under Part I. of the Housing Act of 1890 and the Acts amending the same, with the following result A representation having been made to the Council by the borough medical officer of health of Shoreditch, the Council decided to make an improvement scheme under Part I. of the Housing of the 61004 f Ware-street area, Shoreditch. 34 Working Classes Act, 1890, and the Acts amending the same, in respect of an area in Hoxton known as the Ware-street area, about 9 acres in extent, and comprising 386 dwelling houses, and to apply to the Minister of Health for an order confirming the scheme. The Minister caused a local inquiry to be held on 18th November at the Town Hall, Old-street. Bell-lane and Ellen-street area*. Official representations under Part I. of the Housing Act of 1890 were made by the borough medical officer of health of Stepney with reference to two insanitary areas in the borough, known respectively as the Bell-lane area and the Ellen-street area. The first-mentioned area is about 4½ acres in extent, containing some 248 houses with an estimated working-class population of 1,284 persons; while the Ellen-street area is about 1½ acres in extent with 112 houses and a working-class population estimated at 568 persons. On 18th May the Council authorised the making of a scheme for the improvement of these areas, providing for the rehousing of not less than 1,230 persons and decided to apply tothe Ministry of Health for an order confirming the scheme. In October the ministry held a local inquiry at the Town Hall, Cable-street, E. In addition to these schemes under Part I. of the Housing Act of 1890, the Council has in progress a scheme for the amelioration of the Tabard-street and Grotto-place area, Southwark, and Crosby-row, Bermondsey. This area is some 17 acres in extent, and the scheme involves the displacement of 4,552 persons with rehousing accommodation for 2,580. At the end of December 90 tenements were in course of erection. Hickman's Foilj area, Bermondsey. On 20th July, 1921, the Council had under consideration a scheme for the improvement of an area known as Hickman's Folly, Bermondsey. The area involved was some 3£ acres in extent, comprising 163 dwelling-houses in addition to a number of manufacturing premises, workshops and buildings used for storage purposes. The displacement of 891 persons of the working class was contemplated for about 650 of whom accommodation was proposed in five-storey block tenements. This scheme was eventually referred back to the Housing Committee in order that a conference thereon might be held with the borough council. Stepney. Brady-street area, Bethnal Green. As regards action taken under Part II. of the Housing Act, 1890, the Council in 1919 made a scheme for dealing with the first section of the Brady-street area, and in due course a local inquiry was held by an inspector of the Ministry of Health. In September the Ministry intimated to the Council that the Minister wras not prepared to agree to the proposed exchange of land, but considered that practically the whole of the area should be used for re-housing; that a wider area should be adopted than that included in the Council's scheme; and that with the exception of two blocks of premises of five storeys, the proposed tenement buildings in the area should be rest -icted to a height of three storeys. Having regard to this decision the Council in February, 1920, made an amended scheme embracing nearly all the additional property referred to by the Minister, and involving a displacement of about 1,875 persons of the working classes, accommodation for some 1,800 persons being provided. This scheme was forwarded to the Minister for sanction and a public local inquiry held in due course. Action taken under Part III. of the Housing Act, 1890 during the year was a6 follows :— The Bermondsey and Deptford Metropolitan Borough Courcils put forward for the approval of the Minister of Health a proposal to undertake a joint housing scheme at Grove-park in the metropolitan borough of Lewisham and containing a small portion in the adjoining borough of Bermondsey. The Minister took up the position that the provisions of section 41 of the Housing Act of 1919 should be applied to the proposal. This section provides that in the case of London the Council shall be the local authority for the county for the purposes of Part III. of the Housing Act of 1890, to the exclusion of any other authority so far as regards the provision of any houses outside the county, and that the metropolitan borough council shall be the authority for the provision of houses within its own borough. With the approval of the Minister, the Council may, however, develop land in a metropolitan borough to meet the needs of the district outside the area of such borough. In these circumstances the Minister urged upon the Council the desirableness of acquiring a site at Grove-park for housing purposes, and on 13th March the Council made and submitted to the Minister of Health for confirmation an order for the compulsory acquisition of some 573 acres in the neighbourhood of Grove-park. This order was on 12th May confirmed by the Minister. In November the Council sought from the Minister permission to purchase about 14 additional acres of land adjoining the site originally proposed. The Minister of Health, in January 1920,approved, subject to a satisfactory price being arranged, of the acquisition by the Council of about 250J acres of land situated in Bellingham in the Metropolitan Borough of Lewi"ham, on which it is proposed to erect about 2,355 houses for persons of the working classes. In December, 1920, 250 houses were in course of erection. In order to meet the suggestion of the Ministry that provision for additional dwellings in the southwestern district should be made, the Council decided, subject to the approval of the Minister, to acquire a site at Castelenau, Barnes, of some 50 acres in extent. This approval was subsequently given subject to a satisfactory price being arranged. In last year's annual report it was stated that the Council had applied for powers to acquire an area of approximately 3,000 acres capable of mixed development situated in the urban districts of Barking Town and Ilford and in the Parish of Dagenham in the rural district of Romford. In October, 1920, application was made to the Minister of Health for the confirmation of an order for the compulsory acquisition of certain additional land at Dagenham some 87½ acres in extent required for the purposes of development, including the formation of a road to afford access to the site from the river Thames. On 2nd November the Council decided to name the whole of this area "Becontree," and at the end of the year 260 houses were in course of erection thereon. In addition to these estates the Council decided in 1919 to purchase, in the exercise of its powers under Part III. of the Housing Act, 1890, a site of about 143 acres at Roehampton, known as the Dover House Estate. At the end of the year 1920, 211 houses were in course of erection. Other schemes in Grove-park estate, Lewisham. Bellingham estate, Lewisham. Castlenau estate, Barnes. Dagenham or Becontree estate. Roehamptor estate. 35 progress under Part III, are White Hart Lane estate, Tottenham, of about 164 acres providing for the housing of 3,638 persons, the Norbury estate where 60 houses were completed and 150 in course of erection at the end of the year, and old Oak Estate, Hammersmith, with an area of 46½ acres and providing for the housing of 2,231 persons. At this estate 183 houses were completed and 257 in course of erection at the end of December, 1920. Section 26 of the Housing, Town Planning, etc., Act, 1919, requires the Council to make by-laws for regulating houses let in lodgings, such by-laws to be enforced by the councils of the several metropolitan boroughs, with the exception of those by-laws in the series which deal with securing stability and prevention of and safety from fire, which will be made and enforced by the Council. Draft by-laws were in due course prepared by the Council and submitted to the borough councils for their observations, and the Council is at the present time in correspondence with the Minister of Health on the subject From the date on which the Housing (Additional Powers) Act, 1919, came into operation until 31st December, 1920, 537 applications under Section 6 (Prohibition of demolition or change of use of dwelling nouses) have been received. Of these 330 were found not to be affected by the section, the properties being either unsuitable without reconstruction for being renderea fit for human habitation, or, being in use on 3rd December otherwise than as dwelling houses. In 110 cases permission to demolish, or to use the premises for purposes other than as dwellings was refused. In 94 cases demolition, or change of use. was authorised. By-laws as to houses let in lodgings. Building oontrol. Tuble showing the number of houses in each borough in 1920; the number repaired under Section 28 of the Act of 1919; certain other particulars as to conditions in 1920 ; and 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 —the figures for the years 1914, 1915 to 1918, inclusive, and 1919, are included for comparison. Metropolitan borough. No. of houses. No. of houses for the working classes. No. of representations. No. of closing orders. No. of houses demolished. In borough. Inhabited by working classes. Repaired by local authority. Erected In course of erection. 1920. 1920. 1920. 1920. 1920. 1914. 191518. 1919. 1920. 1914. 191518. 1919. 1920. 1914. 191518. 1919. 1920. Battersea 26,118 23,246 17 9 — 185 — 1 11 38 — — 11 Bermondsey 19,140 18,850 77 — 30 — — 13 — — — 46 — 36 — — — Bethnal Green 14,709 — — — 1 31 34 — 5 25 19 — — — 2 — — Camberwell — — — — — — — — 3 — — — — — — — 3 Chelsea — — 2 — — 3 — — — — — — — — 8 — — Deptford — — — — — 5 7 1 — 5 7 — — 6 2 — — Finsbury 17,480 tenements 16,700 — — — — 17 — — — 17 — Fulham 26,142 80% — — — — 1 — — — 1 — — — — — — Greenwich 16,302 — — 2 192 193 — — — — — — — — — — — Hackney 34,676 13,000 — — 80 — 29 — — — 34 — — — — — — Hammersmith 21,621 — — 296 150 37 26 — — 6 38 — 1 — 25 — — Hampstead 12,091 1,833 — — — 9 11 6 16 9 11 6 14 5 — — 10 Holborn 9,416 9,021 — — — 2 3 1 1 2 1 1 1 — — — — Islington — 2 3rd — 47 325 21 8 2 1 1 8 — 1 6 1 — — Kensington 23,900 5,690 1 — 62 13 9 — — 3 9 — — — — — — Lambeth 44,123 33,093 — — 230 7 — 38 17 7 — — 17 7 — — 6 Lewisham 33,500 — — — 93 — 9 — — 3 19 — — 6 3 — — Paddington 17,610 9,443 4 — — 5 5 12 15 5 4 6 15 — — — — Poplar 22,472 All 1 15 96 cotts., 10 29 10 — 10 29 4 — 2 1 — — 39 flats St. Marylebone 21,400 7,266 — — — 1 16 4 — — 15 4 — 6 — 3 — St. Pancras 23,345 20,000 — — 76 flats 37 37 16 — — 44 12 — — — — — Shoreditch 13,000 12,400 4 — 65 flats, — 3 6 — — 3 — — — 7 — — 14 cotts. Southwark 18,310 11,956 — — 90 — — 4 37 — — — 17 — 32 — 15 Stepney 36,000 — 50 12 15 6 23 4 2 6 59 — — — 2 4 — Stoke Newington — — — — 18 flats — — — — — — — — — — — — Wandsworth 56,539 41,598 1 108 522 — — 1 — — — — — 6 1 — Westminster, City of — — — — 70 — 7 — — — 6 — — 11 39 — — Woolwich 26,223 22,084 — 12 252 18 33 7 5 9 29 3 4 7 5 2 National Health Insurance Acts—Treatment of Tuberculosis. The annual report last ye£tr contained a brief resume of the history of the development of organised provision for the treatment of tuberculosis in London, and, in an appendix, the results of the working of the Council's Tuberculosis Scheme during the years 1914-9 were reviewed in considerable detail by Dr. F. N. Kay Menzies, following a survey of the whole field which included the inspection of each of the tuberculosis dispensaries. The report indicated that a considerable amount of effective work had been done in spite of the adverse conditions due to the war, but that there was a considerable number of defects which called for remedy. It is only necessary here to revert to such matters in the report as led to action on the part of the Council. 61004 f 2 36 Taking first the dispensary service, the Council on 13th July, 1920, and 9th November, 1920, passed a series of resolutions modifying the Tuberculosis Scheme approved in May, 1914, with a view to improvement in the dispensary service in the following directions:— (1) Provision for the appointment of tuberculosis officers as assistants to the borough medical officers of health in order to secure a fuller measure of co-operation between the tuberculosis officer and the officers of the borough public health department for the following purposes:— (i.) To enable the tuberculosis officer to become aware of all cases "notified" under the Tuberculosis Regulations, 1912, and to arrange for the examination of contacts so as to secure that "notification" of definite cases is made at an earlier stage of the development of the disease than the results of the investigation indicated had been the practice. (ii.) In order that there may be an exchange of information between the dispensary staff and the staff of the public health department as to environmental and sanitary conditions of the homes of dispensary patients. In this connection it is laid down that the tuberculosis officer shall visit, at least once, the home of all dispensary patients both for the purpose of acquiring first hand information as to environmental conditions and for supervising adequately the work of the dispensary nurse, unless he considers that, in the interests of the patient, such a visit is undesirable. (2) Prevention of congestion at the dispensaries by the retention of doubtful cases under observation for long periods and prolonged treatment of patients by means of drugs. With these objects (a) the existing arrangements, under which each dispensary is linked with a hospital to which are referred difficult cases needing the services of physicians of special experience, or the use of expensive medical appliances to aid diagnosis, are to be supplemented by the establishment of "consulting centres" which in addition to these facilities, will be equipped with "observation" beds; (b) the dispensaries are to be used as centres for diagnosis and consultation rather than as treatment centres, treatment being limited as a rule to cases requiring special knowledge, or technical skill, and to those unable to obtain other adequate medical treatment; and (c) the fullest possible co-operation is to be developed between the dispensary, and the school medical service so that all doubtful cases are kept under observation at school instead of at the dispensary, the school medical staff, on the other hand, referring cases to the dispensary whenever necessary. (3) Staffing of Dispensaries. In order to secure adequate time for the efficient discharge of the duties of the dispensary staff it is now laid down that the working week shall be thirty-six hours, and that medical staff shall be allowed on the basis of one doctor for every 160 deaths from tuberculosis in the area served by the dispensary, part time officers being employed proportionately for lower number of deaths. Nurses are to be correspondingly employed and each dispensary is to have clerical assistance. (4) " Following up." Experience has indicated the need for more adequate arrangements for following up patients for whose failure to continue in attendance at the dispensary no satisfactory reason has been ascertained, and, during the ensuing year attention will be given to the improvement of this feature of the dispensary service. (5) Regulations of numbers in attendance. It has also been shown that congestion at the dispensaries and long periods of waiting on the part of the patients can be avoided by a system regulating the attendance by means of definite appointments made with regard to the convenience of the patients in relation to working hours and that provision for evening sessions is likely to reduce the number of lapses from medical supervision. These matters also will come under special observation during 1921. At the end of the year (December, 1920), the Ministry of Health issued a Circular (No. 149) to borough councils directing the attention of the borough councils to these matters, and to the need for other modifications in the dispensary service when "sanatorium benefit" is withdrawn under the National Insurance Act, 1920, from the benefits provided under the National Insurance Acts. This Act is expected to come into operation in May, 1921. The number of dispensaries at the end of 1919 was 33, of which 9 were municipal dispensaries, 13 voluntary dispensaries and 11 dispensaries at hospitals. During the year the Wandsworth Borough provided a new branch municipal dispensary which is of considerable convenience on account of the size of the borough. Proposals were under consideration at the end of the year for the provision of a branch dispensary for part of the Borough of Poplar, and it seems to be desirable that a branch dispensary should be provided for the Rotherhithe district of Bermondsey. On the basis of staffing of dispensaries in proportion to the number of deaths from tuberculosis in the borough dealt with above, it v. ill be necessary to increase the total number of tuberculosis officers from 32 whole time officers, and 9 part time officers in 1919 to the equivalent of 50 full time officers. In one or two instances assistant tuberculosis officers have already been appointed, and it is expected that during the year 1921 the revised standard will be in operation throughout London. The work of the dispensaries has brought into prominence the lack of facilities for dental treatment. The dental defects of many of the dispensary patients have been so bad as seriously to retard their prospects of benefit from the treatment provided at the dispensaries, and, in sanatoria ; but the patients, when willing to undergo dental treatment, have frequently experienced difficulty in obtaining it. The Council in June, 1919, in view of the importance of this matter decided to regard the provision of facilities for dental treatment as an essential part of the tuberculosis dispensary service, and, further, that the grant payable by the Council in respect of approved dispensary schemes shall include expenditure on the dental treatment of patients. Including the City of London, eight boroughs have made provision for this treatment, and schemes of four other boroughs were under consideration at the end of the year. Various methods have been adopted. In some cases the dispensaries have been specially equipped for dental service and contracts have been made with the British Dentists' Hospital to provide the dentist and necessary material; in 37 others special services for tuberculous persons have been arranged at dental clinics established in connection with other branches of public medical work, (e.g , maternity and child welfare), and, in the case of tuberculosis dispensaries at hospitals, the facilities available in the dental departments have been used. In one case a firm of private dentists have undertaken the work in the tuberculosis dispensary which has been equipped for the purpose. Generally stoppings and fillings are provided without charge to the patients, but payments are expected for dentures according to the financial circumstances of the patients. Two methods of payment to the authorities undertaking the work are in operation, (1) payment on the capitation basis and, (2) by means of a block grant. There are objections to the capitation payment system, but the experience gained will be of assistance in fixing a reasonable block payment rate. This work is regarded as being in the experimental stage, and is under special observation. The whole position will be reviewed in 1921, and it is hoped that it will then be possible to draw up a uniform scheme for the whole of London. In an appendix III. a statistical statement is given indicating the work done at the dispensaries in London during 1920. An important feature of the dispensary service has been the linking up the charitable, and other agencies for social service with the dispensary so as to secure extra assistance, such as additional food, clothing, improved home conditions, and, in some cases changes of occupation, which are frequently necessary if the patients are to benefit from the treatment provided for them. It was contemplated that borough committees would be appointed which would include in their membership representatives of all such agencies in the borough. Six borough committees have been appointed, one of them being a joint committee serving two boroughs; and twenty of the remaining boroughs are served by twenty-two interim tuberculosis care committees appointed by the Council to do the work until borough committees can be appointed. In the borough of Lambeth the work is done partly by a social worker in the public health department of the borough council, and partly by the Lady Almoner of St. Thomas's Hospital, in co-operation with the social welfare agencies of the borough. The City of London has a dispensary service of its own. The existing committees are frequently able to persuade parents, who hesitate to part with their children, of the advantages of institutional treatment, and to remove difficulties in the case of women patients by arranging for the care of children during absence of the mothers. It is a very common thing for reports to be received in the public health department that the care committees have been able to arrange for separate beds for patients who have hitherto shared a bed with others, and to effect other improvements in hygienic conditions. The reasonableness of the assessments recommended by the care committees, for giving effect to the provision in the Council's tuberculosis scheme that a charge should be made roughly equivalent to the cost of keeping the child at home, is demonstrated by the fact that, apart from revision due to change of financial circumstances, the amount which has had finally to be written off as irrecoverable has been comparatively small. In December, 1918, the Council decided to supplement the tuberculosis scheme by the provision of open air schools for children who have been "notified" under the Tuberculosis Regulations, 1912, as definitely tuberculous. These schools, on the one hand, obviate the necessity of sending to sanatoria children who are unfit for an ordinary public elementary school, but who do not need sanatorium treatment—and on the other hand, reduce the risk of breakdown in children after treatment in sanatoria resulting from too sudden change from the open air conditions of the sanatorium to those of ordinary life. The types considered suitable for the schools are early lung cases more or less quiescent and gland cases in which there are no discharging sinuses. One such school, Kensal House, having accommodation for 90 children, was opened in 1910 as a voluntary institution, but was later transferred to the Council. Two similar schools, Stormont House, Hackney, and Springwell House, Clapham Common, were opened by the Council in September, and October, 1919, respectively, the former having accommodation for 75 children, and the latter for 125 children. In addition to these, as a temporary expedient, two Central Fund Dispensaries—Camberwell and Fulham—have provided classes for 25 each, the first at a house in Grange Hill-road, Denmark Hill, and the second in the garden of the dispensary in New King's-road, Fulham. The Council in each case has provided the teacher and educational equipment. The Fulham School is shortly to be replaced by a school for 50 children to be established by the Council at the Elizabethan Schools, Broomhouse-lane, Fulham. The Council's Open Air Schools have been established under the provisions of the Elementary Education (Epileptic and Defective Children), Act, 1899, and the work will accordingly be referred to in the section of this report dealing with the school medical service. With regard to residential treatment much has been written during the year on the question whether or not " sanatorium " treatment is an effective means of treating pulmonary tuberculosis. In the report already referred to, dealing with the survey of the arrangements in operation in London for the control and treatment of this disease, results were given of enquiries made by Dr. Bardswell, then medical adviser of the London Insurance Committee, supplemented by particulars relating to uninsured persons, as to the condition of a limited number of patients at the end of four years after their discharge from residential institutions. These results indicated a very high percentage of deaths. Similar enquiries in other parts of the country gave practically the same results and the conclusion was thereupon drawn that sanatorium treatment was a failure. The examination of the figures in detail shows clearly that there has been considerable misconception of the meaning of the term "sanatorium treatment," not only by the lay public, but also by medical men, and, further, that in more than 50 per cent, of the cases sent to sanatoria the disease was too advanced for sanatorium treatment, properly understood, to be of permanent benefit to the patients. These experiences have indicated the need for improvement in the direction of (i.) providing machinery of detecting the disease in the early stage at which sanatorium treatment has been Tuberculosis care committees Open air schools for tuberculous children Residential treatment for tuberculosis 38 strated to be successful and (ii.) improved facilities for diagnosis. The first defect, it is hoped, will be overcome by the provision, to be made in connection with the dispensary service for searching out and examining contacts, and, the second, partly by greater use of the out-patient facilities available at hospitals to be used as consulting centres, and partly by the provision in these institutions of a number of observation beds to which patients will be sent for short periods and thence drafted to institutions suitable to their condition. Negotiations with regard to the latter proposal were in progress at the end of the year. Dealing now with the accommodation in residential institutions provided, and the results obtained during 1920, the Council continued its policy of utilising accommodation available through the Metropolitan Asylums Board supplemented according to necessity by beds in voluntary institutions. The Council completed its agreement with the London Insurance Committee under which the Council had assumed responsibility for seeing that adequate accommodation was provided for insured and uninsured persons, including special provision for ex-service patients, and for meeting any deficiency in the cost involved in treating insured persons after the London Insurance Committee had exhausted the whole of the money available for the purpose under the National Insurance Acts. At the beginning of the year it was estimated that accommodation would be required as follows (a) Insured persons 750 (6) Ex-service patients 500 (c) Uninsured adults 375 (d) Children 625 At the end of 1919, the accommodation amounted to 105 beds for uninsured adults, and 258 beds for children in institutions belonging to the Metropolitan Asylums Board, and 94 beds for uninsured adults and 306 for children, in voluntary institutions. Diving the year 1920 there were further extensions of accommodation provided by the Metropolitan Asylums Board, particularly beds for advanced cases in men, and for children. This increase was, however, in some degree counter-balanced by the reversion to their normal purpose of certain fever hospitals which were used for ex-service advanced cases, with the result that the accommodation for civilian men in the advanced stage has been seriously reduced. The accommodation available through the Metropolitan Asylums Board on 31st December, 1920, was 197 beds for uninsured adults and 426 beds for children. In the case of adults, practically the same accommodation has been required in voluntary institutions owing to increased numbers dealt with. There has been a slight reduction in the number of beds necessary in voluntary institutions for children, although this reduction has been less than the additional Metropolitan Asylums Board accommodation owing to the increased number of children requiring treatment, attributable in part to the increasing difficulty experienced by charitable agencies of the type of the Invalid Children's Aid Association in meeting the increased charges due to the present high cost of maintenance. The total number of beds in use on 31st December, 1920, was as follows:— Adults. Children. Total. Insured. Ex-service. Uninsured. Metropolitan Asylums Board institutions 212 272 197 426 1,107 Voluntary 499 345 109 278 1,231 Total 711 617 306 704 2,338 The Council continued the scheme of co-operation with the Invalid Children's Aid Association under which, in return for a grant, the Association provided convalescent treatment for children, and also assisted in the provision of surgical appliances for children who had received treatment in residential institutions under the tuberculosis scheme. The sum allowed during the year for this service was £1,350. The following extract from the annual report of the Invalid Children's Aid Association indicates the work accomplished with this financial assistance:— "The scheme of co-operation between the L.C.C. and the I.C.A.A. for the treatment of tuberculous children, which has been in operation for the last five years, has again been carried on through another year with, we venture to hope, successful results. Owing to the greatly increased cost of Homes the council agreed in July last to raise their grant on each case to two-thirds of the balance of cost, after deducting parents' payments, with a maximum of 7s. 6d. This has been a great help to the I.C.A.A. As,"heretofore, the Council has in most instances provided treatment for the more serious cases of tuberculosis, and all cases of pulmonary tuberculosis—referring them on in many cases to the I.C.A.A. for convalescence when discharged from sanatoria. The Tuberculosis Sub-committee has met every month, and 368 children were sanctioned for convalescent treatment with help from the Council's grant, and 26 surgical appliances were provided—116 of these children are still away in 1921. This Committee also considered 23 cases which were found to be ineligible for the Grant-in-Aid, but whose requirements were subsequently supplied by the I C.A.A. In addition to the above, many tuberculous children were sent away, the cost being met by the parents' payments so that no help was required from the Grant-in-Aid." Co-operation with Invalid Children's Association for convalescent treatment 39 By arrangement with the Invalid Children's Aid Association,158 children attending the Open Air Schools for tuberculous children, whose parents were unable to take them away for a holiday, were each sent for a fortnight's holiday, the Council making a grant amounting to £316 for their maintenance. The Council also paid the railway fares amounting to £28 18s. Id. The children were distributed as follows:— 88 boys were sent to a private house belonging to Miss Sanderson, who generously lent the house for the occasion. 47 girls were sent to St. Mary's Home, Broadstairs. 23 girls were sent to St. John's Home, Kemp Town. Mental Deficiency Act, 1913. On the 31st December, 1920, of the 2,051 cases being dealt with at the expense of the Council there were—In institutions, 900; under guardianship, 14; under supervision, 1,079; in places of safety waiting other action, 58. There remained 1,936 out of the total number 3,987 of cases of alleged mental defect, of which notice has been received since the Act came into operation. These cases include 248 in which no action could be taken; 621 ascertained not defective, or not to be London cases; 373 dealt with through the Poor Law; 354 removed from the register (died, discharged, or removed, to lunatic asylums), and 340 still under consideration. During the year 698 cases were examined with the following results:— Type. Male. Female. Total. Type- Male. Female. Total. Idiot 15 15 30 Not defective 22 18 40 Imbecile 121 71 192 Insufficient evidence 4 13 21 Feeble-minded 198 220 418 Moral imbecile — 1 1 Total 360 338 698 In continuation of the analysis of the records made last year, the aetiological factors in a random sample of cases under the Mental Deficiency Act have been extracted.0 Percentage of frequency. Percentage of frequency. Condition— Consanguinity in parents 1.8 Family history of— Acquired insanity 21.6 Influence associated with birth— Feeblemindedness (all grades) 16.0 Premature birth 9.8 Moral imbecility — Prolonged parturition— Epilepsy 14.4 Protracted pressure 9.0 Hysteria, neurasthenia, spasmodic asthma, chorea 17.0 Instrumental delivery 5.8 Asphyxia 2.8 Deaf mutism — Accident at birth 1.0 Habitual criminality 2 Twin birth 2.8 Intemperance 30.6 Drug habit 14 Conditions occurring or noted subsequent to Syphilis 20 birth— Tuberculosis 48.6 Infantile convulsions 12.4 Epilepsy 18.4 Conditions associated with abnormal state, of Infantile paralysis 5.4 mother during gestation— Meningitis 4.2 Mental stress arising from tidings of failure, 30.8 Chorea 2.8 trouble or death Injury to head from fall, blow, etc. 12.0 Physical disturbances—general bad health 7.4 Febrile illness, e.g. from any cause, privation, etc. Scarlet fever 1.6 Falls or injuries 9.2 Diphtheria Influence of deleterious occupation—exhausted vitality from extreme mental or physical exertion 1.8 Whooping cough Measles Enteric fever Specific fevers or other general infections — Small pox, etc. Syphilis 4 Malnutrition in early life (signs of rickets, etc.) 100 Manifestation of syphilis 6 The family history is of importance as indicating a predisposition to mental defect, or instability which may be of great weight in a doubtful case, but it is important not to overweight this factor should it conflict with actual observation. Dr. Shrubsall has analysed the returns with a view to ascertaining the extent to which the mental status of defectives is affected by the physical characters of their defects. For the purpose of making this comparison he has used as an index, the quotient obtained by dividing the assessed mental age as ascertained by mental tests, by the chronological age, or by 16, whichever be the lesser number. It has been suggested by American observers that those with a quotient below .25 should be regarded as idiot, those with a quotient between 25 and 5 as imbecile, and those with a quotient between 5 and .75 as feebleminded, while a subject with a quotient between .75 and .9 might be regarded as dull, and this, coupled with evidence of vicious, or criminal tendencies undeterred by punishment would be sufficient to bring him within the definition of moral imbecile. The quotients shown in the following tables have been calculated since action was taken, and show the degree of correspondence between the older and newer methods. 40 Intelligence quotient. Primary amentia. Mongol. Cretin. Microcephalic. Hydro cephalic. Epileptic. Cereb. paral. and Epilepsy. Cereb. paral. Miscellaneous. Total. Feebleminded. 000—019 — — — — — — — — 0.2 —0.39 58 1 1 1 1 9 1 2 5 79 0.4 —0.59 935 2 10 4 7 86 12 25 38 1,119 0.6 —0.79 330 1 1 2 1 37 7 8 8 395 0.8 —0.99 17 — — — — 2 — — 1 20 Total 1,340 4 12 7 9 1 4 20 35 52 1,613 Imbeciles. 0.00—0.19 25 5 2 1 1 5 8 9 6 62 0.2 —0.39 449 111 24 25 17 128 35 56 28 873 0.4 —0.59 279 57 15 12 11 80 16 34 20 524 0.6 —0.79 30 7 1 1 — 6 1 4 2 52 0.8 —0.99 - - - - - 1 - 1 — 2 Total 783 180 42 39 29 220 60 104 56 1,513 Idiots. 0.00—0.19 42 5 2 11 4 44 35 28 7 178 0.2 —0.39 29 8 — 5 5 23 18 12 1 101 0.4 —0.59 2 1 — 2 — 4 — 2 — 11 0.6 —0.79 — — — — — — — — — 0.8 —0.99 — — — — — — — — — — Total 73 14 2 18 9 71 53 42 8 290 The tables reveal the tendency to give a chance of special education, or training, to those defectives who show such definite physical disabilities as paralysis, or epilepsy, often when their mental status was slightly below the level on which the line was drawn in the case of those defectives not showing such defects. The point is of interest since it is commonly stated that the tendency is to under-assess the abilities in paralytic, or epileptic cases. Midwives Acts, 1902 and 1918, and Lying-in Homes. The number of midwives with London addresses whose names appear on the Roll of Midwives exceeds 5,000. Of this number 734 notified their intention to practise during the whole year or for shorter periods. This is an increase of 86 on the previous year. In addition, notice was received from 20 midwives that they had acted in their professional capacity on specific occasions within the Administrative County of London. The 734 midwives who gave notice of intention to practise cannot be taken as the number of midwives practising at any given time in the county. In some institutions it is the custom for a midwife to act as assistant for three months or less after she is qualified, and her place is then filled by another newly-qualified assistant, who in her turn gives notice of intention to practise. At any given time it is probable that some 500 midwives, or about 10 per cent, of those on the roll, are in actual practice in London. The remaining 90 per cent, act for the most part as monthly or general nurses under medical supervision. All practising midwives, except those working in hospitals under medical supervision, are subject to inspection by the Council's officers, to ascertain whether they are complying with the rules of the Central Midwives Board as to cleanliness, the possession of antiseptics and appliances, the keeping of registers and case books and the sending of the required notices to the local supervising authority. The work of inspection is carried out by four women medical inspectors. In addition to the ordinary routine inspection, special visits are paid to the midwife when any case of a septic nature or a persistent high temperature occurs in her practice, and in all cases of inflammation of infants' eyes. The inspectors also advise midwives on any points of difficulty which may arise in the course of their duties, and in some instances instruct them as to methods of work. On occasion the midwife is accompanied by the inspector either to a confinement or on a subsequent visit to a patient to ascertain whether her methods of work are efficient. This is done more particularly when there is reason to believe that the midwife's work is not up to standard, and also in cases where she has applied to the Central Midwives Board for approval to supervise the training of pupils for the Board's examination. The inspectors paid 1,935 visits during the year to midwives or institutions employing midwives. In 62 cases there were infringements of the rules of the Central Midwives Board. 15 of these were slight, and a verbal caution was deemed sufficient. 38 cases were of a more serious nature, and were dealt with by a written caution. Of the remaining 9 cases, 2 midwives were interviewed by the committee, and personally cautioned, one being advised to give up practice, and 7 cases were reported to the Central Midwives Board, who investigated them with the following results :— (а) one midwife, charges not proved. (b) two midwives, judgment was postponed for further reports at intervals of three and six months. (c) four midwives, struck off the roll. Three midwives were suspended from practice in order to prevent spread of infection, and payment in compensation was authorised in each case. Two applications for restoration to the roll were received : one was granted and the other refused. 41 The fee a midwife receives, for attending a confinement and the subsequent visiting for 10 days, varies in different localities from 15s. per case upwards, but usually a fee of 20s. to 30s. is expected. The charities employing midwives pay from 15s. 6d. to 21s. a case, and provide the midwife with registers, forms, antiseptics, etc. Certain midwives with a fairly large practice are approved by the Central Midwives Board to give practical instruction to pupils preparing for the Board's examination. The pupil resides with the midwife and goes with her to cases. From information received under the Notification of Births Act the following figures have been obtained showing the number of births notified by midwives:— 5 midwives reported over 500 cases in the year. 9 „ „ between 400 and 500 cases in the year. 17 „ „ „ 300 and 400 „ „ 14 „ „ „ 250 and 300 „ „ 25 „ „ „ 200 and 250 „ „ 35 „ „ „ 150 and 200 „ „ 79 „ „ „ 100 and 150 „ „ It is computed that about 59,794, or 495 per cent, of the total births in London were attended by midwives, excluding the cases attended by midwives in infirmaries. This is an increase of 16,000 on the 1919 figures. By section 1 (2) of the Act it has been illegal since March, 1910, for any woman, unless she be certified under the Act, habitually and for gain to attend women in childbirth except under the direction of a registered medical practitioner. During the year enquiries were made into all cases in which it was brought to the knowledge of the Council that a delivery had been conducted by an uncertified woman. In one of these cases it was decided to take no further action; 9 others were dealt with by a verbal or written caution, and proceedings were taken against two uncertified women who conducted a large number of confinements partly inside or partly outside the county. Convictions were obtained. The rules of the Central Midwives Board provide that, in certain emergencies which are specifically enumerated, a midwife must advise in writing and obtain medical help. The form on which this written advice is given is sent to a medical practitioner, and a copy is forwarded to the local supervising authority. During the year 7,458 of these notices were received, as against 5,347 the previous year. The figures for the previous years were 1916, 3,540; 1917, 3,159; 1918, 2,738. The rise in the figure during the past two years is no doubt due to the general increase in the births attended by midwives, and to the fact that midwives realise more fully the importance of complying with the rule of the Board, and also to the fact that since January 1st, 1919, the Council became responsible for payment of the fees of the medical practitioners called in. These notices were received from 508 midwives. Midwives acting under the direction of a qualified medical practitioner within infirmaries and hospitals are not required to comply with this rule. The number of instances of advising medical help in the practice of midwives during the year may be summarised as follows:— 2 midwives reported advising medical help between 120 and 140 times during the year. 1 midwife „ „ „ „ „ 100 „ 120 „ „ 1 midwife „ „ „ „ „ 80 „ 100 „ „ 12 midwives „ „ „ „ „ 60 „ 80 „ „ 26 „ ,, ,, „ ,, ,, 40 „ 60 ,, ,, 86 ,, „ „ „ ,, ,, 20 ,, 40 ,, ,, 120 „ „ „ „ „ ,, 10 „ 20 ,, „ 260 „ „ „ „ „ less than 10 times during the year. Assuming that 59,794 births were attended during the year by midwives, it is estimated that medical assistance was required in 12.6 per cent, of the cases; in 8.2 per cent, on behalf of the mother, and in 4 4 per cent, on account of the child. Midwives are required by the rules of the Central Midwives Board to notify the local supervising authority whenever a dead body is laid out by them, and 23 such notices were received during the year. There is a similar requirement in cases where there is a possibility of the midwife becoming a source of infection, and 35 such notices were also received. 159 notices of cases in which it was proposed to substitute artificial feeding for breast feeding were also received and transmitted to the sanitary authorities concerned, in order that the cases might be followed up by the health visitors. During the year 316 midwives reported the occurrence of stillbirths in their practice, the number stillbirths of stillborn children being 896. This represents 1.5 per cent, of the births attended by midwives— approximately the same percentage as in 1919. The form for notifying stillbirths provides for information as to (a) sex of child; (6) period of gestation; (c) whether macerated or not; (d) presentation. The information obtained under (a) showed that 484 stillborn infants were males, 396 females, and in 16 cases the sex was not stated. Of the total 896 stillborn children 465 were reported macerated, 400 not macerated, and there was no statement with regard to the remaining 31. The presentations of these stillborn children were as follows:— Vertex 566 Face or brow 9 Complicated vertex 4 Funis 6 Breech 148 Placenta prsevia 1 Complicated breech 4 Born before arrival and presentation not known 112 Footling 38 - Transverse 8 Total 896 61004 g 42 Some additional information was obtained as to stillborn infants not macerated, of eight or more months' gestation, as follows:— Concerning the child— One of triplets 2 White asphyxia 3 One of twins 11 Cord round neck 4 Hydrocephalic head 2 Anencephalic head 9 Malformed child 7 Spina bifida 2 The rules of the Central Midwives Board require the midwife to notify to the local supervising authority all cases in which the mother or child dies before the attendance of a registered medical practitioner. In 47 cases midwives notified the deaths of infants, and in 6 cases notices of deaths of mothers were received. By the courtesy of the London coroners notices are sent of inquests in which midwives are concerned and one of the Council's inspectors attends the Court to hear the evidence and learn whether the midwife has complied with the rules of the Board. Ninety-seven inquests were thus reported upon. In the following table particulars are given with respect to these cases:— Confinement conducted by Total number of inquests. Death of mothers. Deaths of Infants. Midwives 97 17 80 During the year 445 cases of puerperal fever were notified in the county, and the Registrar General records 201 deaths from puerperal septic disease in the same period, not including one case in which the death was not recorded by the Registrar General. The term puerperal septic disease used by the Registrar General includes puerperal septicaemia, pyaemia and sapraemia, as well as peritonitis and metritis occuring in connection with parturition. A list of deaths is received weekly from the Registrar-General, and the deaths are compared with the notified cases, so that it is possible to ascertain whether the latter terminate fatally. Of the 445 notified cases, 160 proved fatal, a case mortality of 36 per cent. The 42 other deaths related to cases which were not notified. Early information of notified cases of puerperal fever is received from the Metropolitan Asylums Board or from the borough medical officers, and I am indebted to the latter for information as to the person by whom the patient was delivered. The following table gives the results of these inquiries which relate to the 445 notified cases. Delivery conducted by Cases. Deaths. (a) Medical practitioners (including cases attended by medical students and also cases in which a medical practitioner was in charge of the case, but the birth took place before his arrival) 204 81 (b) Certified midwives (including cases in which birth took place before the arrival of the midwife) 152 44 (c) Medical practitioner and certified midwife, i.e., cases in which a midwife was unable to deliver and called in a medical practitioner 5 3 (d) Hospitals and poor law institutions 68 26 (e) Cases of miscarriage or abortion where no attendant was engaged 11 3 (f) Uncertified woman 2 2 (g) Unascertained 3 1 Total 445 160 The cause of death as stated in the death certificates in the 202 fatal cases occurring in London is shown in the following table:— Cause of death. Notified cases. Unnotified Cases. Total. Puerperal septicaemia, post partum septicaemia, and streptococcal septicaemia 139 21 160 Puerperal sapraemia — 2 2 Salpingitis 1 1 2 Puerperal pyaemia 4 3 7 „ peritonitis 11 11 22 „ mania 1 — 1 Septic abortion 1 1 2 „ pneumonia 1 1 2 „ endometritis 1 — 1 Pelvic cellulitis 1 2 3 Total 160 42 202 Ophthalmia neonatorum It is the duty of a midwife to advise that medical help is required when inflammation of the eyes, however slight, occurs in infants. Great stress has been laid by the Council on the importance of strictly observing this rule. When a notice is received from a midwife that medical assistance has been sought on this account, the Council's medical inspector at once visits the infant to ascertain that it is receiving the medical assistance which the midwife has advised, and the medical officer of health of the borough in 43 which the patient resides is immediately informed of the condition of the case and whether the infant is being removed to a hospital for treatment. The midwife is also visited to learn particulars as to the case, the antiseptic precautions taken beforehand, and the disinfection adopted by her after each of her attendances. It was found in the past in some cases that when medical assistance was obtained, the medical practitioner, after examining the infant's eyes, gave directions to the parents as to the course of treatment, and left instructions for them to seek medical help again if the inflammation did not yield to treatment, and if there was no improvement in the condition of the child's.eyes. So long as the midwife remained in attendance, the treatment was for the most part carried out, at all events once a day ; but many of these cases had not recovered by the tenth day, the time the midwife usually ceases her attendance. It was also found impossible for the midwife personally to attend to the infant's eyes as often as was requisite—i.e., in some cases four or five times daily, and this duty was then left to the friends of the patient, who were utterly ignorant of the need for using clean rags and sterile water. It is in cases of this description that the voluntary nursing associations have rendered most valuable assistance. Practically every street in the county is now covered by the activities of one or another of these, and arrangements exist between the boroughs and various agencies by means of which a nurse can always be obtained when wanted for the home treatment of a case of ophthalmia neonatorum. In two districts (Bermondsey and Southwark) the boroughs have their own nurse available for such cases, instead of contracting out for such services. During the year 1,079 notices were received from midwives, stating that medical assistance had been advised on account of inflammation of the eyes of infants, and, in addition to these, 39 other cases came to light in which medical help was not called by the midwife. Of these 1,118 cases 684 proved to be ophthalmia neonatorum; in addition 480 cases of ophthalmia neonatorum not occurring in the practice of midwives were notified, making a total for the year of 1,164 cases of ophthalmia neonatorum. The percentage occurring in the practice of midwives was thus 59% for the year. The Council's inspectors investigated the 681 cases of ophthalmia—642 cases were reported to be completely cured. In 15 cases there was damage to the cornea; 16 died while still suffering from the disease, and in 11 instances the result could not be ascertained owing to the removal of the patients, who could not be traced. The following facts are noted relating to the cases in which impairment of vision, or any other injury to the eyes supervened:— No. 232.—Mother had severe leucorrhoea during pregnancy. Boracic lotion used for eyes at birth. Onset of symptoms on tenth day, according to mother, but midwife thought eye normal. Outpatient hospital treatment about fourteenth day. Later admitted to St. Margaret's Hospital. Result— Corneal opacity of right eye. No. 258.—Boracic lotion used for eyes at birth. Onset of symptoms on fourth day, and outpatient hospital treatment the next day. Result—right eye excised. No. 454.—Boracic lotion used for eyes at birth. Onset of symptoms and medical assistance on seventh day. Admitted to St. Margaret's Hospital on nineteenth day. Result—sight of right eye impaired, the other clear. No. 495.—Mother a single woman. Boracic lotion used for eyes a few minutes after birth. Onset of symptoms and medical assistance on tenth day. Admitted to St. Margaret's Hospital on twelfth day. Result—Slightly impaired sight left eye, right clear. No. 647.—History of leucorrhoea in mother. Silver nitrate 1 per cent, used for eyes at birth. Onset of symptoms (oedema) at birth; pus the next day and medical assistance the same day. Admitted to St. Margaret's Hospital on fifth day.—Result—Right eye removed, other eye clear. No. 683.—No history of vaginal discharge in mother. Collosal argentum 1 in 2,000 drops used for eyes at birth. Onset of symptoms on seventh day and medical assistance the next day. Result— Sight slightly injured. No. 705.—History of gonorrhoea. Weak solution (less than 1 per cent.) silver nitrate used for eyes ten minutes after birth. Onset of symptoms on sixth day and outpatient hospital treatment the next day. Admitted to St. Margaret's Hospital on eighth day. Result—ulceration on both corneae. No. 756.—No history of vaginal discharge in mother. Lids swabbed with Hg Cls 1-8,000 and a solution of protargol dropped into eyes at birth. Onset of symptoms eight hours after birth, and medical assistance the same day. Result—slight opacity on cornea of one eye. No. 946.—History of slight yellow leucorrhoea in mother. Boracic lotion used for eyes at birth. Onset of symptoms on sixth day. Outpatient hospital treatment on ninth day. Admitted to St. Margaret's Hospital on tenth day. Result—sight impaired by scars and ulcers of both corneae. No. 1019.—Mother unmarried. No signs of disease to account for ophthalmia. Ag NO3 1 per cent, used for eyes at birth. Onset of symptoms on fourteenth day and medical assistance on fifteenth day. Admitted to St. Margaret's Hospital later. Result—blindness of left eye. (This baby has since died.) No. 1,082.—No history of vaginal discharge in mother. Boracic lotion used for eyes about twenty minutes after birth; delay owing to difficult delivery. Onset of symptoms and outpatient hospital treatment on fifth day. Admitted to St. Margaret's Hospital on same day. Impaired sight. Right eye blind, left eye scars and old ulcers. No. 1,158.—Boracic lotion used for eyes at birth. Onset of symptoms on eighth day; outpatient hospital treatment obtained by mother on sixteenth day. Midwife cautioned for failure to advise medical aid. She said the discharge on eighth day cleared up, and eyes were all right when she left the case on tenth day. Result—right eye sight impaired by scar, left eye sight good. No. 741.—History of gonorrhoea. Protargol 10 per cent, used for eyes at birth. Onset of symptoms and medical assistance on ninth day. When baby was two weeks old, mother and baby went to 61004 G 2 44 infirmary for five weeks, then baby was transferred to St. Margaret's Hospital. Result—left eye appears quite destroyed; has dense central opacity (leucoma) with bulging of cornea (staphyloma). Right eye dense central opacity (leucoma). This eye has been needled, and appears sensitive to light. No. 867—Mother has had severe leucorrhoea since the birth of this child. Boracic lotion used for eyes at birth. Onset of symptoms on seventh day, and medical assistance on ninth day. When three weeks old was taken to Royal Eye Hospital, and from there sent into St. Margaret's Hospital. Result—slight opacity, covering all but a small portion of the upper external part of left pupil. At eight months of age this opacity appears to be less dense than before admission to hospital, and it is hoped the condition may further improve. No. 968.—History of vaginal discharge of mother. Hg Cl2 1-4,000 used for eyes at birth. Onset of symptoms and medical assistance on fifth day. Admitted to St. Margaret's Hospital on seventh day; in hospital for three months. Result—(seven months of age)awaiting operation for ulcer on eye. The 684 notified cases of ophthalmia neonatorum occurred in the practice of 274 midwives: Two midwives had 21 cases each during the year, and 28 others had from 5 to 15 cases each; 244 had from 1 to 4 cases each. Considerable use, especially in the northern areas of the county, has been made of St. Margaret's —the hospital provided by the Metropolitan Asylums Board, for the reception of cases of ophthalmia neonatorum. This provides accommodation for 30 infants and 18 mothers which, up to the present, has proved adequate to meet the calls made upon it. Possibly the provision of a similar institution on the south side of the Thames might lead to more cases from that part of the county seeking admission. The erection of such an hospital has been under consideration. The classes arranged by the Council for the further instruction of midwives have met with much success. It was found that the short, intensive series of lectures, etc., presented considerable difficulties in the matter of the attendance of midwives, and consequently it has been arranged that the course should be spread over a period of nine months, with one lecture weekly at various institutions both north and south of the Thames. This plan has enabled midwives to attend in increased numbers. The Midwives Act, 1918, came into force on January 1st, 1919. Section 14 provides for the payment by local supervising authorities of a fee to a medical practitioner in all cases where he is called in by a midwife to her assistance in a case of emergency, and the local supervising authority may recover the fee from the patient's husband or other person liable to maintain the patient, unless they are satisfied that the patient or husband, or such other person, is unable by reason of poverty to pay such fee. A scale of fees was laid down by the Ministry of Health in which, generally speaking, the doctor was entitled to a fee of two guineas in cases of difficult labour, etc., where an operation is involved ; one guinea where no operation was necessary, and 3s. 6d. for an ordinary day and 7s. 6d. for a night visit. This scale has since been revised, but the new scale did not come into force until 1st January, 1921. During the year 3,646 approved claims were received from 466 medical practitioners, amounting in all to £5,334 2s.—i.e., an average of 29s. per case, and a total increase of fees of 75 per cent, over the previous year. This increase is to be accounted for chiefly by the higher birthrate, and also by the provisions of the new Act becoming more widely known amongst medical practitioners and midwives. In accordance with the provisions of the Act the Council appointed two inquiry officers to investigate the financial circumstances of each patient in respect of whom a fee became payable, and in due course each case was considered by a committee of the Council, and assessments varying from 3s. 6d. to £2 2s. were made according to the merits of the case. Up to the present about £400 has been recovered representing 7½ per cent, of the fees paid. Towards the end of the year an experiment was commenced on a small scale whereby the services of the inquiry officers might be dispensed with and assessments made direct by correspondence. It is anticipated that in the future this system will be adopted for the entire county. In 1915 the Council obtained powers from Parliament for the registration and inspection of premises for the reception of lying-in patients. In accordance with the provisions of the Act, which came into force on February 1st, 1916 hospitals, infirmaries, and similar institutions are exempted from registration, and in cases where a lying-in home is carried on by a registered medical practitioner the Act also provides for exemption, which must, however, be renewed annually. Six premises were the subject cf certificates during 1920. At the beginning of the year 258 premises were on the register, 75 were added duringthe year, 1 registration was cancelled, and 74 premises ceased to be used for lying-in purposes, leaving 258 premises on the register at the end of the year. All lying-in homes on the register are inspected at regular intervals by the Council's medical inspectors to ensure that a proper standard of cleanliness and general efficiency is maintained. During the year 567 inspections were thus made. In the early part of 1920 the Ministry of Health issued a memorandum (15/M. & C.W.) which indicated the standards of measurement suitable for the accommodation of maternity cases. The space suggested is 960 cubic feet for mother and child, 800 cubic feet when the baby is removed at night, and 600 cubic feet for waiting patients. The last-named patients, in the great majority of cases, may be reasonably expected to be up for most of the day, and able, therefore, to move into other rooms. Taking the above measurements as a guide, a survey was made of the private lying-in homes in the county, and it was satisfactory to find that the instances in which the space available fell markedly below the standard were very few in number. Furthermore, it was found possible, by various methods of re-arrangement, to ameliorate these conditions without the loss, except in one case, of any of the available beds. The number of beds available for maternity cases in registered homes may be estimated approximately at between 700 and 800. A certain number of these, however, belong to high-class premises. Classes for midwives. Midwivea Act, 1918— Payment of fees. Lying-in homes 45 and only a very limited number are used for confinement cases ; the remainder of the homes are devoted almost exclusively to maternity work, and are capable of accommodating about 10,000 cases annually. During the year the registration of one lying-in home was, as already stated, cancelled on account of the owner's bad character, and the unfitness of the premises and equipment for the purpose to which they were put, An appeal was made by the owner against this decision, but, after the hearing of the case, which lasted several days, the magistrate dismissed the appeal, with costs, against the appellant, and the order of the Council was confirmed on both the above grounds. This is the first occasion on which an appeal of this description has been heard in Court since the Act came into force in 1916. It may be mentioned that the Council has applied to Parliament for additional powers (including the making of by-laws) for the regulation of lying-in homes. Children Act, 1908.—Part I. The work imposed upon the Council by this part of the Act relates to the supervision of infants under the age of seven years, the nursing and maintenance of whom, apart from their parents, have been undertaken for reward. The Act requires that any person undertaking the charge of such infants shall give notice of their reception to the local authority (in London, the Council) within 48 hours of the said reception. A similar requirement is imposed upon the foster-mother in the case of her change of address, or the removal of an infant from her care. The death of any such infant must also be notified to the coroner of the district within 24 hours, and to the local authority (the Council) within 48 hours. The following table indicates the number of foster-mothers and nurse infants from 1914 to 1920 inclusive:— 1914. 1915. 1916. 1917. 1918, 1919. 1920. Foster mothers, 31st December 3,125 3,162 3,110 2,995 2,654 2,481 2,296 Nurse infants, 31st December 3,983 4,028 4,109 3,900 3,461 3,114 2,952 An examination of this table will indicate that since 1916 the number of nurse infants and fostermothers has notably decreased, this probably being due to economic conditions. On the other hand the cost of the keep of such infants has risen owing to the extra cost of living ; and the average weekly charge now made is from 12s. 6d. upwards, as compared with 5s. prior to the war. It may be noted, however, that in special circumstances, lower charges than those above mentioned have been accepted, but this is generally due to friendship between the parties concerned. The difficulty of finding suitable foster-mothers for young infants still continues. Numerous applications are received, but unfortunately it is impossible to suit them all. The same difficulty occurs with institutions established for the care and maintenance of infants. Two societies whose work is entirely confined to bringing about the adoption of infants are now in full activity, and they have dealt with a large number of such cases. Fourteen female visitors and two male inspectors carry out the executive work under this part of the Act. The visitors call upon foster-mothers periodically and see that proper care and attention are bestowed upon the infants, and they also advise foster-mothers as to methods of feeding, etc., the infants in their care. With regard to the two male inspectors, their work differs materially from that of the visitors, and may be classed as more or less of a detective nature. Advertisements appearing in the press are carefully watched by them and followed up, with a view to tracing unregistered fostermothers. The inspectors also verify the removal of infants from foster-mothers outside the county to parents or other relatives within the county ; and follow up cases where notice of removal of the fostermother has not been given, with a view to tracing such foster-mothers, and they also help the visitors in difficult cases. It must be borne in mind that some foster-mothers may be, or may become, unfit to have the care of nurse infants entrusted to them, and the Act accordingly gives power to the Council to remove to a place of safety—that is, a workhouse—any infant in charge of a foster-mother who is unfit by negligence ignorance, inebriety, immorality, criminal conduct, or other similar cause, to have charge of an infant. Where the premises are overcrowded, dangerous, or insanitary, or the infant is kept by a person or in any premises in contravention of the Act, similar action may be taken. During the year 14 infants were removed under this section as compared with 33 in the previous year. The Council, as the local authority under the Act, is also empowered to exempt, either partially or wholly, any premises which, in the opinion of the Council, are so conducted as to render ordinary inspections unnecessary. No total exemptions were granted, but partial exemptions limited to one or two visits a year were allowed in 7 cases, as compared with 11 in the previous year. The sanitary condition of the homes is made the subject of particular attention. All new fostermothers' premises, or premises to which any foster-mother may remove after registration, are inspected by the sanitary staff, and similar steps are taken if doubt arises in the mind of the visitors as to the suitability of the premises, or if a complaint is made by the foster-mother as to any serious defect or nuisance. The number of such reports made during the last year was 966 as compared with 1,124 during the previous year. The premises were reported to be satisfactory in 573 cases, as compared with 592 in the previous year. Sanitary defects were discovered in 186 cases, as compared with 278 in the previous year. Overcrowding was reported in 138 cases as compared with 134 cases in the previous year ; while both overcrowding and sanitary defects were discovered in 22 cases, as compared with 34 cases in the previous year. In 47 cases an inspection could not be made owing to the removal of the infant before the visit of the inspector. In each case in which a serious sanitary defect was discovered, 46 the attention of the borough council was drawn to the matter. In many of the premises in which overcrowding was reported, it was possible, by a slight re-arrangement of the accommodation, to bring about an improvement in the conditions, but, in other cases, the foster-mother was requested to obtain other and more suitable premises or give up the nurse infant. It was found to be particularly difficult to enforce the former requirement, owing to shortage of housing accommodation, and, as a consequence, the infant was, in most cases, given up. In the case of the illness of a nurse infant, the assistance of the local Infant Welfare Centre is obtained ; foster-mothers being urged and encouraged to take ailing infants there, and to obtain and follow up the advice given. It is the duty of the visitors to see that any treatment that may be advised is duly carried out. There is no doubt that the help afforded by the Local Infant Welfare Centres has produced very beneficial results. It may be noted also that on reaching the age of five years the nurse infant is generally sent to school, in which case, it comes within the purview of the school medical service, and thus continues to receive any necessary medical supervision. The deaths of nurse infants during the year continued to fall in number, as there were only 26 as compared with 51 in 1919, and 103 in 1918. This is exceedingly satisfactory, and gives hope that the number of deaths may continue to fall. Inquests were held in 5 cases, as compared with 16 of the previous year ; the verdicts were 3 deaths from natural causes, as compared with 12 of the previous year, one from misadventure (swallowing spirits of salts) and one child was run over by a motor-bus. The irregularities discovered reached a total of 318 in respect of which 302 written cautions were sent. The number of cases of legal proceedings was 16, and 16 convictions were obtained. The sentences and costs amounted to £35 8s. Two persons convicted received terms of imprisonment. In last year's report reference was made to the fact that the Council had been approached by the London War Pensions Committee with a view to the inspection by the Council's officers of homes in which the neglected children of deceased or serving soldiers and sailors had been placed by that committee. Since the arrangement has been in force no less than 266 homes have been inspected, of which 205 were found to be suitable, both as regards the foster-parents and the accommodation at their disposal; while in 47 cases it was advised that the children of the committee should not be placed there, and in 14 cases the application was withdrawn before an inspection could be made. During the year the question of the amendment of this part of the Act has been again under consideration ; but no action has been so far taken with a view to the promotion of an amending Bill in the House. Work of the Chemical Branch. A reorganisation of the staff of this branch has provided more suitable arrangements for carrying out the work of the central laboratory at Savoy-hill, of the two laboratories at the Northern and Southern Outfalls, and of the newly-established laboratory at the Greenwich Power Station. Central Laboratory. The general work of the central laboratory has included the examination of a great variety of materials required by the Council for their undertakings, including milk and other meals supplied to necessitous children; materials examined as to general suitability or compliance with specification such as paints, oils, metals, cements, and other building materials; fuel, soaps and other cleansing materials; fertilisers and feeding-stuffs (for cattle or poultry); and oils and petroleums examined under Acts of Parliament regulating their storage. The Chemist and Staff at the Central Laboratory have carried out various investigations on matters of outstanding importance. The Council has for many years co-operated in the work of the Advisory Committee on atmospheric pollution, which is now connected with the Meteorological Office; but in addition the air of underground London, both in the Tube railways and in some of the Council's tunnels under the Thames, has been the subject of careful investigation. The chemical and bacteriological condition of the air of the underground railway was examined with the help of officers of the railway, who have afforded every possible assistance in connection with this work. The great use which is made of the tunnels under the Thames has, by congestion at certain hours, given rise to problems of ventilation. Examinations, made under varied conditions of the air of these tunnels have included determinations of humidity, carbon-dioxide, acidity, and the collection, estimation, and microscopical and chemical examination of dust. In addition, use has been made of an automatic filter which gives a continuous visible record of the dirt in the atmosphere. Examinations have also been made in the open air and in a shallow tramway tunnel. The peculiar condition of fog observed in deep tunnels appears to be very largely due to the changed nature of the traffic. The introduction of power-driven vehicles has caused a new kind of atmospheric pollution. The air in various theatres and picture-theatres has been examined. In several cases the results indicated the need for improved ventilation. The examination of the atmosphere in degreasing and dry-cleaning machines of the closed type used at certain works in the county continued to show that, probably under stress of work, the requirements as to a definitely non-explosive atmosphere, obtained by means of an inert gas are not always complied with. Some of the firms in question have obtained apparatus for testing the gas, in their machines, and have been advised as to its use. It is hoped that the effect of the quality of cleaning spirit now in use on the safe limits of composition of the gas may be investigated in the near future. A very serious explosion in a degreasing plant several years ago directed attention to this matter. Various cases of failure of materials under conditions of use have been investigated. River Lee The condition of the River Lee, in consequence of the pollution arising from the effluent of the Enfield Sewage Works passing into an intercepting drain and thence into the Lee below Tottenham Lock has continued to give anxiety. The chemist has at intervals made a careful examination of the conditions arising from this pollution. Above the lock the Lee is a clean stream with a clean bed. Below 47 the lock it is a foul stream with a fermenting bed. The river is much used for pleasure purposes, and the state of affairs is much to be deplored. The litigation on the matter between the Lee Conservancy and the Enfield District Council has resulted in the latter body being admonished by the County Court Judge to do all they can to push forward improvements at their works; but it does not appear that a permanent improvement in the effluent may be expected for three or four years. The condition of the River Wandle has also called for some attention. At the Outfall Laboratories in addition to the systematic daily examination of sewage treated thereat and the resulting effluent and sludge, the river water lying off each outfall is examined daily at high and at low water. The examination of the tideway of the Thames and of the estuary, as far as the sludge-depositing area, has been continued. The opportunity afforded by the return to more normal staff conditions at the Central Laboratory and offices has allowed of a more complete examination of the results obtained in past years than was possible during the war, and, on the basis of this statistical work and of special experiments, it has been possible to suggest a means of temporary relief by carrying out an examination on a reduced scale which will afford useful results of a fair order of accuracy. It does not appear that any other public body makes a systematic examination of the tidal river, the condition of which, apart from this work, is a matter of surmise only. The Main Drainage Committee, as a result of their visit to various provincial cities have decided to experiment on various modifications of biological treatment of sewage. Some work on one of these modifications has been going on for some time and the requisite structural work for the other experimental plant is being proceeded with. An investigation has been made on the gases dissolved in the feedwater. Examinations have been made of the gaseous contents cf the water throughout the whole circulating system from hotwell, through the economisers, boilers, turbine condenser and again to the hotwell. The presence of dissolved oxygen in the water or of free oxygen in the steam is a potent cause of corrosion both of the steam raising plant and of the blades of the turbine itself. This has led to proposals for degassing the water, and experiments with a small plant designed by the electrical engineer are now in progress. The efficiency of the water softening plant has been greatly increased as shown by systematic tests, which enable the supply of chemicals to be controlled. The routine examination of waters, etc., has been extended to include samples of the coal burnt each day at the station, deliveries supplied to the station still being examined at the Central Laboratory. Other necessary investigations are being made. River Wandle Outfalls Biological treatment of sewage Greenwich power Etation 48 TABLE I. COUNTY OF LONDON. Vital statistics for the several metropolitan boroughs and the County of London in the year 1920. (Rates per 1,000 of civil population). Metropolitan borough. (In topographical order). Estimated civil population. 1920. Births. Deaths. Infant mortality per 1,000 births). Measles. Scarlet fever. Diphtheria. Whooping cough. Typhold fever. Diarrhœa and Enteritis age 0-2 (per 1,000 births). Phthisis. Cancer. Cases of notifiable infectious disease. Smallpox. Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Puerperal fever (per 1,000 births). Cerebrospinal fever. Western Paddington 149,673 22.7 11.4 78 .16 .02 .17 .10 — 12.3 .86 1.29 — 3.37 3.12 .13 .54 4.4 .01 Kensington 164,177 24.2 13.4 83 .13 .03 .13 .14 .01 17.7 .86 1.49 — 3.92 2.13 .15 .43 2.5 .03 Hammersmith 136,200 24.4 11.5 67 .12 .04 .26 .09 .01 6.9 1.00 1.15 — 5.35 2.83 .06 .42 6.3 .03 Fulham 158,621 27.1 11.4 74 .14 .06 .28 .11 .03 7.9 .91 1.16 — 5.89 3.96 .16 .66 7.4 .03 Chelsea 62,987 22.2 12.1 53 .14 .03 .13 — .02 7.1 1.08 1.35 .02 2.95 2.28 .11 .41 5.7 .02 Westminster, City of 132,615 16.2 11.9 73 .09 .04 .07 .03 .02 10.3 1.08 1.63 — 2.95 1.79 .12 .51 4.5 .02 Northern St. Marylebone 101,856 21.6 12.8 67 .08 .09 .08 .13 — 10.4 .99 1.52 — 4.27 1.20 .31 .65 2.7 .02 Hampstead 91,519 17.1 9.4 48 .09 .04 .05 .07 .02 3.2 .45 1.31 .01 2.89 1.80 .25 .43 0.6 .02 St. Pancras 228,178 25.3 12.5 74 .28 .05 .14 .27 .00 7.8 1.08 1.32 — 3.67 3.25 .07 .53 2.9 .03 Islington 335,907 28.1 13.4 72 .28 .04 .40 .22 .00 7.8 1.07 1.23 — 3.90 3.97 .07 .49 3.1 .04 Stoke Newington 52,984 23.0 12.9 80 .09 .08 .38 .19 — 10.6 .66 1.32 — 4.22 3.14 .04 .45 1.6 .02 Hackney 225,372 26.6 12.7 81 .38 .03 .31 .30 .00 10.6 .94 1.15 — 4.86 3.44 .06 .55 3.8 .03 Central Holborn 39,676 20.8 15.2 67 18 .05 .13 .05 — 13.3 1.13 1.43 — 3.08 3.72 .15 .56 1.2 .03 Finsbury 78,291 31.8 14.8 77 .15 .05 .34 .17 — 6.8 1.40 1.07 — 6.53 2.89 .08 1.45 20 .05 London, City of 14,447 12.6 14.0 71 .07 — .07 .07 .07 110 1.66 1.86 — 2.57 2.29 .07 .35 — .07 Eastern Shoreditch 102,044 36.5 15.5 91 .49 .06 .27 .12 .01 17.1 1.45 1.03 — 5.12 3.91 .11 .60 30 .03 Bethnal Green 114,471 33.6 14.8 95 .54 .10 .33 .50 .02 13.2 1.39 1.04 .01 9.22 5.09 .04 1.17 3.4 .06 Stepney 241,770 31.1 14.4 87 .20 .06 .16 .30 .01 11.4 1.26 101 .01 10.18 2.84 .06 .64 3.1 .06 Poplar 159,766 34.1 14.7 82 .22 .09 .36 .35 .02 8.4 1.34 1.18 .07 8.80 4.38 .11 .53 4.4 .07 Southern Southwark 187,142 31.7 14.6 87 .34 .03 .20 .15 .03 8.9 1.34 1.30 — 4.78 2.45 .04 .95 2.9 .04 Bermondsey 129,189 31.8 13.1 85 .44 .05 .21 .30 .01 8.3 1.08 113 — 7.77 2.16 .05 .42 5.1 .05 Lambeth 293,572 27.7 13.2 69 .27 .05 .26 .12 .00 9.5 1.14 1.42 — 4.22 2.42 .05 .48 3.9 .02 Battersea 165,664 28.0 12.5 83 .27 .04 .22 .20 .01 11.6 1.02 1.18 — 4.20 3.41 .08 .54 6.7 .05 Wandsworth 346,990 20.8 10.3 64 .14 .03 .19 .06 .01 6.8 .78 1.17 — 4.25 3.15 .07 .51 4.9 .04 Camberwell 284,712 26.4 11.7 71 .21 .05 .22 .13 .02 11.0 1.06 114 — 4.60 3.21 .06 .52 2.7 .02 Deptford 115,636 28.2 12.1 79 .17 .02 .18 .14 .02 12.8 1.11 1.03 — 6.22 2.77 .10 .72 5.5 — Greenwich 102,408 25.8 12.1 72 .25 .03 .13 .19 .02 5.9 1.25 1.22 .01 5.73 2.95 .15 .52 1.9 .02 Lewisham 174,438 23.0 10.9 67 .05 .05 .26 .07 .01 5.7 .76 1.28 — 4.12 2.67 .03 .41 2.2 .03 Woolwich 141,666 24.7 10.5 61 .15 .03 .18 .10 .01 5.5 1.13 1.09 .01 3.76 2.98 .04 .56 3.3 .04 London 4,531,971 26.4 12.6 76 .22 .05 .23 .17 .01 9.6 1.05 1.23 .00 5.02 3.05 .09 .57 3.8 .03 49 TABLE II. COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1920. 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. Milk. shops. Ice cream premises. Other food places No. licensed. No. of inspections. No. licensed. No. of inspections. No. licensed. No. of inspections. Observations. Complaints. Notices. No. illegally occupied. No. closed or otherwise remedied. Instances found. No. remedied. 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 * — — 166 11 — — — 3 3 153 459 — 1 455 21 504 153 — 121 484 — — 937 1,177 Battersea 1 2 3 472 2 4 159 53 22 6 6 12 12 89 267 — 2 147 419 4,213 3,610 51 134 465 66 366 226 1,329 Bermondsey — — 1 — 12 73 16 — 8 — — — — 223 446 — 3 1,153 31 — 2,728 — 292 437 92 305 325 3,535 Bethnal Green 12 59 3 14 1 3 74 10 4 — — — — 243 630 3 7 395 21 — — — 194 690 107 205 249 1,244 Camberwell 1 13 6 41 1 1 9 114 4 — — — 55 317 87 — 5 460 52 4,991 2,548 — 434 779 270 272 293 480 Chelsea — — 3 40 — — 2 2 2 — — — — — — — 3 207 52 30 1,061 66 150 17 17 70 70 Deptford — — 2 55 2 16 — — — — — — — 289 578 — 5 1,116 — 2,655 — — 189 293 129 114 117 282 F1nsbury — — 2 78 2 20 46 44 3 — — 13 13 954 3,445 — 1 98 — — 87 6 112 117 59 66 196 258 Fulham — — 2 12 — — — — — — — — — — — — 2 94 — 295 1,230 — 122 290 40 103 — 1,100 Greenwich 3 112 5 32 — — 25 9 3 1 1 6 6 — — — 2 90 10 1,508 — — — — 54 62 170 256 Hackney 10 128 19 284 1 4 179 21 19 — — 23 7 470 63 — 5 416 190 2,410 558 1 240 1,366 160 141 89 58 Hammersmith — — 7 268 — — 220 22 19 3 3 23 5 2,718 550 — 1 292 — — 164 10 74 2,000 166 449 ? 3,142 Hampstead — — 4 24 — — 29 3 — 34 34 13 13 405 663 — — — 26 1,525 42 86 85 260 72 118 515 1,545 Holborn — — 1 5 — — 54 11 5 4 4 2 2 603 841 31 16 1,155 194 — 89 7 156 181 31 73 442 2,493 Islington 1 25 18 810 7 48 64 63 2 3 3 7 7 1,058 8,167 3 23 752 27 5,323 5,678 68 608 577 242 44 486 9,948 Kensington 1 — 6 391 — — 282 7 — 4 4 21 21 2,067 4,921 4 9 467 56 2,140 1,021 2 178 937 195 42 762 1,097 Lambeth 4 10 12 168 3 36 68 12 12 — — 18 18 372 4,464 — 5 469 — — 262 18 259 1,554 — — — — Lewisham 8 66 9 140 — — 23 4 5 — — 9 *9 2 48 — — — — — 40 — 137 254 — — — — Paddington 1 4 5 320 — — 116 7 4 15 15 5 5 1,404 2,720 35 3 165 — — 141 2 100 250 75 109 400 1,412 Poplar 10 23 9 78 5 18 6 69 24 — — 14 14 1,448 — — 6 1,032 174 4,305 707 — 194 209 83 44 311 926 St. Marylebone 4 58 3 159 2 70 18 7 2 6 6 1 1 1,152 6,621 — 5 763 3,562 3,113 610 35 186 405 90 106 353 1,252 St. Pancras 2 13 9 144 2 39 477 30 4 2 2 42 30 2,364 7,574 — 3 119 864 7,404 1,932 14 211 604 125 208 — 4,612 Shoreditch 2 6 3 12 — — 1 16 1 — — 31 31 283 366 — 5 324 — — 702 84 194 1,512 ? 63 248 451 Southwark 1 13 5 39 2 12 17 6 10 1 1 103 103 1,349 1,324 2 23 2,920 139 2,202 1,811 70 518 1,548 51 49 381 1,199 Stepney 25 81 4 9 7 30 257 62 38 12 12 62 62 2,512 5,857 3 28 3,968 345 6 4,456 5 420 1,616 119 224 411 1,296 Stoke Newington 1 4 4 12 — — 21 6 1 — — — — 259 — — — — 2 383 65 1 68 86 6 18 ? 597 Wandsworth 2 26 12 112 4 71 23 17 17 — — 42 42 292 681 5 6 173 94 — 384 — 441 442 313 232 242 590 Westminster 1 15 — — — — 2,123 29 28 4 3 20 15 1,164 3,241 1 5 1,586 88 1,183 196 69 479 606 155 300 6,000 1,066 Woolwich 14 43 8 34 — — 18 7 — 7 4 390 118 449 697 — 13 402 29 3,633 229 3 72 165 91 195 187 129 61004 Note.—In the columns above a dash signifies a nil return. Common lodging houses, licensed number, 187; lodgers, 19,218; visits—day, 12,811, night, 343 ; prosecutions, 1; penalties and costs, £3, Seamen's lodging houses, licensed number: 53; Bermondsey, 7; Deptford, 1; Poplar, 14; Stepney, 31; lodgers, 1,298. Visits—day, 1,496; night, 109; convictions, 6; penalties, £91 10s. Prosecutions—Smoke Nuisances: Greenwich, 2; Hackney, 3; Poplar, 4. Water Supply: St. Pancras, 1; Shoreditch, 2; Bethnal Green, 3; St. Marylebone, 1. Overcrowding: Chelsea, 1. Milkshops: Wandsworth, 1; Poplar, 3; Chelsea, 2 ; Stepney, 3; Bermondsey, 5; Bethnal Green, 1. * Continuous supervision during slaughtering. H 50 51 TABLE III. COUNTY OF LONDON. Tuberculosis Dispensaries—Analysis of Returns, Jan.—Dec., 1920. 1 Borough. 2 Examined for the first time. 3 No. included under (2). Suffering from Pulmonary Tuberculosis. 4 No. Included under (2). Suffering from Non. Pulmonary Tuberculosis. 5 No. Included under (2). Found to be NonTuberculous. 6 No. Included under 2 in which the Diagnosis Doubtful. 7 Total Attendances at Dispensary, Including those in column 2. 8 Attendances included In column 7 at which systematic examinations and records were made. 9 Visits to homes made by Dispensary Medical Officers. 10 Visita to homes made by Dispensary Nurses. 11 Referred to hospitals to which Dispensary is affiliated. 12 Specimens of sputum examined. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Uninsured. Insured. Unin sured Insured Unin sured. Insured. Unin sured. Insured. Unin sured. Insured Unin sured. Insured. Unin. sured.[/####] M. F. M. F. Chldn. M. | F. M.| F. Chldn. M. f. M. F. Chldn. M. F. M. F. Chldn. M. F. M. F. Chldn. City of London 50 43 34 56 61 25 17 16 24 8 3 3 1 5 18 17 16 28 41 4 6 1 4 7 1394 1194 255 308 1 3 218 482 11 23 74 74 Battersea 270 134 26 160 424 83 36 9 38 24 2 2 — 1 8 51 36 3 54 161 134 60 14 67 231 1796 3950 963 1245 120 171 765 2117 180 93 307 159 Bermondsey 177 84 3 118 576 98 39 — 34 36 6 1 — 1 20 32 24 2 52 321 41 20 1 31 199 1496 6966 827 2076 26 279 1093 2010 15 9 405 274 Bethnal Green 209 96 14 101 333 92 30 5 23 20 8 1 1 — 19 80 56 6 70 274 29 9 2 8 20 2809 2247 873 797 37 14 462 346 70 23 348 128 Camberwell 367 156 40 275 756 141 52 18 55 27 7 3 2 9 60 108 43 12 146 527 111 58 8 65 142 5638 9747 3413 4728 334 560 4827 10515 132 289 886 353 Chelsea 90 45 15 134 307 24 14 3 15 5 2 — 1 2 5 29 17 8 79 214 36 14 3 38 83 1452 2389 434 865 12 11 834 2199 — — 301 260 Deptford 129 51 43 113 353 76 23 9 26 65 6 1 — 4 27 32 15 22 52 204 15 12 12 31 57 2985 3630 748 984 54 30 913 994 16 39 378 200 Finsbury 135 63 26 108 228 68 18 6 27 8 — 3 — — 10 49 32 16 62 186 18 10 4 19 24 2585 2142 618 619 94 92 1248 1084 — — 102 65 Fulham 189 96 18 157 523 51 25 2 19 11 6 3 — 1 27 47 48 9 100 360 55 20 7 37 125 1870 6916 1108 2411 606 1398 1927 3062 5 — 322 189 Greenwich 145 78 15 128 553 31 23 — 19 21 3 1 1 2 120 84 41 13 80 311 27 13 1 27 101 2233 651s 526 1336 19 26 1898 3064 — — 142 66 Hackney— (1) Victoria-park Hospital 224 124 28 136 373 77 33 12 42 12 10 6 — 4 45 114 78 14 82 298 23 7 2 8 18 4147 4169 1070 1154 44 29 1655 1940 81 40 482 199 (2) Metropolitan Hospital 108 58 20 88 170 64 21 11 29 8 6 3 1 1 20 22 24 8 48 120 16 10 — 10 22 1935 2021 489 702 8 5 1506 1321 53 91 170 96 Hammersmith 189 111 8 141 393 108 42 5 48 32 11 3 — 7 35 64 55 3 80 289 6 11 — 6 37 1600 2565 726 1064 67 130 1785 1631 — — 231 176 Hampstead 64 47 12 88 173 19 17 6 14 4 8 5 — 2 11 9 7 2 22 60 28 18 4 50 98 650 1975 412 728 8 3 35 58 2 14 al07 136 Holborn 35 22 7 18 56 24 8 5 5 6 1 — — — 4 7 9 1 11 43 3 5 1 2 3 537 406 232 199 11 — 738 559 6 8 37 14 Islington— (1) Gt. Northern Hospital 200 74 17 95 268 116 34 10 32 7 13 2 1 1 11 64 36 6 57 237 7 2 — 5 13 2299 1622 761 752 170 56 759 918 4 5 203 84 (2) Royal Chest Hospital 271 108 38 131 212 133 44 15 32 14 8 3 — — 8 96 47 18 81 170 34 14 5 18 20 3865 3069 987 734 112 102 1304 504 — — 220 97 Kensington— (1) Ladbroke-gr. 122 50 15 123 296 60 18 8 15 18 10 2 2 1 30 19 17 4 70 169 33 13 1 37 79 1425 3231 508 986 47 187 887 2482 — — 249 114 (2) Brompton Hospital 27 27 2 32 64 10 10 1 3 — 3 1 — — 5 4 8 — 18 43 10 8 1 11 16 503 969 121 215 2 — 146 261 — — 43 17 Lambeth— (1) Central Dispensary 237 108 13 111 214 114 37 5 42 24 3 2 1 2 10 20 18 1 9 51 100 51 6 58 129 2937 5065 653 634 27 21 885 1050 416 459 177 103 (2) St. Thomas's Hospital 508 188 57 326 517 214 58 22 99 42 20 10 — 11 44 224 104 27 167 363 50 16 8 49 68 3262 3802 1518 1485 — — 570 572 485 664 202 101 Lewisham 148 59 18 92 175 101 29 13 46 16 6 3 1 2 20 32 23 4 38 113 9 4 — 6 26 1123 1534 476 527 14 6 1076 1191 2 3 43 21 Paddington— (1) Talbot-road 131 87 28 130 264 30 20 5 21 4 6 3 1 4 25 79 57 19 86 185 16 7 3 19 50 1971 3931 231 407 294 283 993 1657 3 7 41 25 (2) St. Mary's Hospital 69 38 7 46 91 37 16 4 5 3 9 8 1 6 32 11 9 2 24 40 12 5 — 11 16 1422 2437 602 704 166 182 234 528 40 76 36 43 Poplar 185 70 25 432 1305 66 21 6 69 35 2 — — 7 60 21 14 5 246 883 96 35 14 110 327 1182 7187 839 2487 31 6 1782b b1956 — — 313 242 St. Marylebone— (1) Marylebone-rd 108 49 10 69 182 50 12 2 13 14 — 1 — — 15 34 20 4 31 61 24 16 4 25 92 1422 4334 178 328 195 417 665 1354 4 4 121 69 (2) Middlesex Hospital 11 4 3 10 8 7 3 1 1 1 — — — — 2 2 1 — 5 3 2 — 2 4 2 101 95 67 44 — — — — — — 10 4 (3) Margaret-st. Hospital 14 12 11 21 9 4 3 5 4 1 — — 1 — — 5 3 3 12 5 5 6 2 5 3 205 337 123 208 — — — — — — 3 4 St. Pancras— (1) Oakley-sq 187 53 7 68 133 102 28 3 22 12 5 2 1 4 20 56 13 1 33 75 24 10 2 9 26 1518 1802 788 940 114 44 62 47 78 72 532 266 (2) Malden-rd 8 5 — 17 64 4 4 — 4 5 — — — 1 6 4 1 — 11 26 — — — 1 27 45 681 42 324 c— c— c— 10 2 16 c— c— (3) UniversityCollege Hospital 74 20 11 21 48 55 15 7 7 5 2 2 — — 5 13 1 3 9 35 4 2 1 5 3 765 517 299 221 4 1 486 375 14 8 51 15 Shoreditch 252 101 39 155 320 96 23 15 25 16 9 — — — 10 120 60 17 99 269 27 18 7 31 25 4742 4279 1125 1022 101 96 1712 1081 — — 213 96 Southwark 356 203 19 177 634 140 59 12 44 36 5 3 1 4 55 120 114 4 106 463 91 27 2 23 80 3815 3203 1126 1262 29 32 1099 970 3 4 217 45 Stepney— (1) Stepney-green 139 89 37 175 733 66 13 13 25 46 3 2 — — 29 29 39 10 89 375 41 35 14 61 283 1376 10729 426 1304 151 152 356 2985 — — 63 110 (2) St. George'sin-the-East 91 40 27 136 320 39 11 6 30 11 5 2 — 2 7 26 18 16 75 242 21 9 5 29 60 1254 3752 520 1453 112 405 277 1082 6 8 91 142 (3) Whitechapel 73 29 57 157 395 41 4 15 16 10 — — — — — 18 10 35 108 295 14 4 7 33 90 698 4207 166 1186 31 428 193 2581 — — 82 179 Stoke Newington 51 20 9 24 56 35 13 3 9 8 3 1 1 1 3 6 3 3 11 27 7 3 2 3 18 772 1011 195 176 2 3 366 396 29 35 88 179 Wandsworth 404 198 44 322 724 237 75 27 79 24 13 7 1 7 23 132 94 13 199 650 22 22 3 37 27 5342 6421 1192 1987 69 36 1683 1845 34 33 316 354 Westminster 149 68 20 76 275 78 30 9 21 14 6 3 1 2 19 17 21 6 35 202 48 14 4 18 40 1818 3449 750 993 72 93 1954 2969 13 32 180 59 Woolwich 301 125 47 220 596 113 35 11 33 28 9 1 2 4 13 68 47 12 102 326 111 42 22 81 229 4313 5180 1335 2042 469 85 2189 3554 3 — 490 253 61004 (a) An additional 31 specimens of sputum were examined but no distinction is made between insured and uninsured. (b) These numbers include visits by the health visitor. (c) The numbers for these columns are included in the Oakley-square numbers. 52 REPORT OF THE SCHOOL MEDICAL OFFICER (Dr. W. H. HAMER) FOR THE YEAR 1920. PART IT. (EDUCATION). Introductory Note. In a New Year's address entitled "Continuity in Change" there appeared in the Literary Supplement of the Times, the statement that " At this New Year (1921) the whole world seems to have reached a great moment of transition. It seems to have got near the top of the narrow pass which will look over into a new era. Some climb with high hope confident that the unseen country on the other side of the mountains will prove to be a land flowing with milk and honey. Others accustomed to the sights and sounds of the valley in which they have always lived, and to its familiar way of life, shrink from the crossing over." So far as school medical work is concerned the results obtained during 1920 justify confidence for they have been favourable beyond all expectation. To begin with, in London, the general death rate and the infant mortality per 1,000 births are lower than they have ever been before, and the recently available reinspection results, obtained by the school doctors, show that here, too, a record level was obtained in regard to the percentage of school children found defective who had been treated during the year, or who were at the end of the year still under treatment (see p. 62). In commenting four years ago upon the marked decline in infant mortality, "which actually dates from 1900, and potentially of course, from long before that year" (Ann. Rep. 1916, p. 5), it was pointed out that the influence of schools for mothers and infant welfare centres was then only just beginning to be felt and that it was to be hoped that this influence would steadily grow, " but that it should be recognised that so far as schools can be said to have had any effect in producing the decline of infant mortality of the last 16 or 17 (now 20 or 21) years, it is the schools established under the Education Act of 1870, and not the schools for mothers which date from 3 or 4 (now 7 or 8) years ago, that are in question." It was noted that just as the boys had, according to high military authority, made good soldiers, "in spite of the Board Schools," so it might apparently be assumed the girls had made better mothers "in spite of their having enjoyed the advantages of an elementary education." It seems reasonable to conclude in fact that the main cause of the improved health of the children during the last 30 years has been the advance in public health generally, materially aided and supplemented, however, by the increased realisation by the modern parent of a sense of personal responsibility. Confirmation of this view is to be found in the notable decline of the general death rate since 1870, and in infant mortality since 1900; the delayed response of the latter death rate may be attributed partly to the fact that, speaking generally, the enhanced force of parental influence followed only after an interval upon that exercised by health authorities. The latter, moreover, had some years start of the education authorities, and it was not until the Education Act of 1870 had been operative for a generation that its full indirect effect exerted through the parents upon the youngest children could become clearly manifest. Furthermore, improvement as regards infant mortality, though anxiously looked for in "the nineties," was masked in large measure by exceptional epidemic manifestations (diphtheria, scarlet fever, influenza, diarrhoea) in those years; but the fall at length unmistakably commenced with the new century, steady improvement followed from 1900 to 1914, and the position gained was practically maintained during the years of war, while during the last two years still further advance is recorded. Thus it would seem that a new factor has begun in the last 10 or 12 years, to assert itself, and the direct work done in the schools, and for children under school age in the maternity and welfare centres, seems to be now finding manifest expression. A great deal of this work, it must be remembered, has been voluntary work, carried out just for the work's sake, and the fact that so much has been accomplished is clear proof of the ever widening interest taken in child welfare. Indeed, accompanying the limitation of the amount of danger, to be apprehended from disease producing infective agencies, there has been notable manifestation of the "infectiousness of good things," resulting in a fostering of the interest, taken by many thousands of workers, in the promotion of the healthiness of the bodies as well as of the minds of the rising generation. The attempt to measure the good results accruing from all these efforts in terms that can be appreciated by mere lookers-on is hedged about with difficulty. The school doctor must perforce fall back upon school records, and the tests mentioned last year may be again appealed to. Dirt, overcrowding and hunger are the three main physical evils which, it has been said, have affected humankind from the time of the cavemen onward. Applying these tests there was marked improvement so far as London children were concerned, even during the difficult years of war and the first succeeding year of peace. The year 1920, too, has not been without its difficulties. Someone is reported to have said in the early years of the war that the seventh year might be expected to be the most difficult; this prophecy as applied to the war happily failed, but a pessimist of to-day suggests that it might prove true if applied to the years of peace. So far as London is concerned, however, the year 1920 showed distinct further improvement as regards the first test and a new departure (see p. 78) in the special campaign against vermin was inaugurated; as to overcrowding some progress is undoubtedly being made, but the effect of this upon the statistics could not as yet in the nature of things be apparent: referring to hunger, the conditions of 1920 have been favourable, the number of necessitous children fed having been less that a quarter of that of the pre-war period, but in the closing months of the year there was an upward tendency, inasmuch as there has been some slight falling off in the "nutrition" of entrant infants (see p. 56) and forebodings have not been wanting as to the possibilities of 1921 in this regard. 53 It was pointed out twelve months ago that the time was an hypercritical one and that weeping philosophers flourished; in 1920 there were at first indications of improvement, and fanned by a gentle breeze of optimism steady advance was made ; thus the Council's scheme under the Act of 1918 was approved and the task of putting it into operation undertaken. Then with the approach of winter there came a frost, the effects of which were felt in the country generally; but London's forwardness in the matter of preparation stood it in good stead, so far, inter alia, as school medical work was concerned, and at the close of the year the "Council's Scheme" was still manifesting vitality. In respect of physical conditions the great gains secured during 1920, are those accruing (a) from medical oversight of continuation school young persons, and of children coming within the scope of the new by-laws as to employment, (b) from the extended medical treatment scheme, affecting elementary school children, secondary school children, and any "young persons" unable to obtain treatment save under the Council's scheme, and (c) from the materially improved methods of cleansing now being put into operation throughout London. These gains are all substantial ones; from the purely medical and epidemiological aspects, (b) is perhaps as great a gain as (a); and on the long view (c) an even greater gain than (b). The fixed resolve to clear up the question of verminous infestation has only slowly grown into being, but the hope may now be entertained that it is steadily gaining strength year by year and, once it really starts upon its feet and goes forward, the delousing process should be as easy of accomplishment, when determinedly undertaken in London, as has been found possible under military rule in Serbia or Poland. This subject (c) is further considered on p. 78; and the extension of the medical treatment scheme (6) on p. 67. It may be here noted, however, that a question of special and immediate interest arises with regard to (a) continuation schools. These schools are now in being within London and in three or four other education areas. Details as to medical supervision are given on p. 59; but an à priori consideration, further referred to later, may here with advantage be cursorily mentioned. This is the possible relation of blind alley employment to lowered phthisis mortality in adolescents. The point has been raised by Dr. M. Greenwood (p. 70) in connection with an analysis of the tuberculosis statistics of the 28 metropolitan boroughs. From these data the covariation of the tuberculosis death rate with each of three other variables ("overcrowding," "other diseases" and "factory employment") taken in isolation, has been evaluated. There emerge certain remarkable contrasts between the correlation co-efficients for the two sexes at ages 25-45, of which more will be said elsewhere; but the point specially deserving of note here is the negative partial correlation in the group of young adolescents, between the index of overcrowding and the death rate from tuberculosis. Dr. Greenwood reminds us that he is dealing with "partial correlations," which represent "residual values" only; moreover, the index of overcrowding available is but "a rough measure of domestic conditions"; still, he says, "it is a measure, and the arithmetical results lead to the paradox that the worse the home conditions (so measured) the lower the death-rate from phthisis in adolescents." This is not the first time correlation co-efficients, total or partial, have brought us up against a stone wall of paradox. Dr. Greenwood tries to circumvent the difficulty by tentatively examining the possibility that this, at first sight startling, negative correlation may not mean "that bad housing is good for adolescents, but that it is correlated with something else which is good for them." And this brings him to the question of blind alley employments. He says, "spending one's boyhood on the tail of a van, driving a milkcart or carrying telegrams may be a very bad preparation for the economic future; but it may be a good thing for one's health as a boy or girl." This hypothesis, by the irony of fate, emerges from study of the statistics of an area in which blind alley employment has for many years past been a by-word and in which continuation schools have this year been established. Dr. Greenwood it should be remarked, is far from being satisfied with the suggestion made, indeed he tells us that he is "alive to the insecureness of the argument "; but he says the question must not be allowed to rest, "because if the explanation proved to be correct, it follows that the lengthening of the period during which an adolescent is not of full earning capacity and the closing of blind alleys, reforms which are about to become effective may, unless other suitable measures are taken, bring as a by-product some increase of juvenile phthisis." Dr. Greenwood's investigation greatly stimulates curiosity with regard to this and other topics considered in his paper, and in this report (loc. cit.) an attempt is made to follow up the line of enquiry opened up for study. Here it must suffice to remark that observations made in previous annual reports, concerning the behaviour of measles and scarlet fever in schoolchildren in London, suggest a means of escape from the difficulty. Here, as in the former cases, it seems possible that there may be discerned the effect of immunisation against later attack, of children and young persons in the poorer boroughs, owing to their having already undergone previous attack, in the case of tuberculosis by non-pulmonary forms of the disease. During the year 208,924 children in the age groups were examined by the school doctors in elementary schools, and of this number 82,740 were found to require treatment for one or more defects. 13,372 children at the age of 14 were examined prior to their admission to day continuation schools (see p. 8). A further 1,923 children in the age groups were inspected in the special schools and 83,516 elementary school children not in the age groups were specially examined, giving a total of 307,735. In addition the school medical staff inspected 5,460 children for scholarship awards, and 16,315 children in connection with their specific defect in special schools. A detailed analysis of the result of the examination of elementary school children has been made by Dr. C. J. Thomas and is given on pp. 55-63. The results of the examination of 12,408 students in secondary schools, trade schools and training colleges are set out in the appendix Table IX. The chief feature of the year has been the opening of a centre in Woolwich at which children operated upon for enlarged tonsils and adenoids are kept for two days after the operation. The Medical inspection Secondary Schools, etc. Medical treatment 54 building was presented to the Council by Lady Henry and has been named the "Cyril Henry" treatment centre in memory of her son who was killed in the war. 894 children have been operated upon at the centre since its opening in June and the results have been most satisfactory. At a centre in Stepney, a new method of treating discharging ears by ionisation has been carried out by Dr. Friel and an analysis of the results is given on p. 68. The provision made for mastoid operations at Cleveland-street has been continued and is referred to on p. 68. A considerable increase in the provision for medical and dental treatment has been made. The number of children who obtained treatment during the year at the hospitals and centres included in the Council's arrangements was 197,700, as compared with 169,200 during the year 1919. Re-inspections The number of re-inspections carried out was 158,641, of which 93,985 were first re-inspections and 64,656 were second re-inspections. The combined result of the first and second re-inspection gives a figure 76.9 per cent. of cases satisfactorily dealt with after the lapse of fifteen months from the primary inspections. This is the best result that has so far been obtained. Personal hygiene Much attention has been devoted to the question of Personal Hygiene during the year. Hitherto one of the main difficulties in connection with the Scheme has been the opposition of the parents of those children, whose heads contained "nits only," to the cleansing being carried out at stations where badly infested cases were also dealt with. In order to meet this objection the Council has decided that differentiation should, where possible, be made by arranging that the slight cases shall be treated at minor ailments centres thus removing them from the ordinary cleansing stations. Ten new stations are to be established for this purpose, and incidentally they will provide much-needed facilities for dealing with some 35,000 extra cases annually. Another objection on the part of the parents has been the necessity for cutting the hair in some cases. The Council has, however, had brought to its notice a special comb which, used in conjunction with a newly devised shampoo soap, has proved very efficacious in removing nits without resorting to hair cutting. With the ten new centres and the improvements in method now introduced, it is anticipated that the most serious objection on the part of the parents will be removed and that it will be possible to secure their full sympathy and co-operation in this very important work. In February, 1921, a conference was held with representatives of the City and Metropolitan Borough Councils with a view to discussing whether more effective co-ordination could not be established between the Central and Local Authorities. It is anticipated that valuable results will be obtained from this conference. At the end of the year there were 24 cleansing stations in operation. In all, 822,337 examinations of children were made; in 43,764 cases the children were found to be verminous, 16,355 children were cleansed by the parents, 27,409 children were cleansed at the cleansing stations, and 9,675 children suffering from scabies were also given baths. The total number of cleansings at the stations was 123,975. The experiments in Camberwell and Kensington of bathing children with the co-operation of the Borough Councils at the Public Baths have been continued with most satisfactory results. Under this scheme 6,978 baths were given in Camberwell and 6.434 in Kensington. Epidemic diseases Those who ventured to make prophecies concerning the behaviour of influenza in 1920, shared the common fate of all who thus attempt to look into the future in this regard. Time cannot wither nor custom stale the infinite variety of this epidemic disease. According to the precedents of the "nineties" the two prevalences of 1918 and the February-March prevalence of 1919, should have been succeeded after an interval of at any rate not more than 18 months, by a further outbreak in 1920. Dr. Brownlee applying the method of harmonic analysis, has deduced a 33 weeks periodicity for influenza, but he says that when the appointed day falls between the end of June and December the epidemic is apt to miss fire. It is true there was a notable recent exception to this rule, for the most serious known prevalence of influenza, that of October-December, 1918, occurred well within the prohibited period; Dr. Brownlee's close time for influenza was, however, duly observed in 1919. He anticipated a further prevalence in February-March, 1920, and there were at that time "many colds about," and some increase in encephalitis lethargica also occurred, but the effect of these prevalences upon "influenza" mortality and upon the general death-rate was little marked. Towards the end of the year 1920, "colds" and "gastro-intestinal influenza" again became widespread; in December "epidemic hiccough," a form of disease which had made its appearance in Vienna in the preceding winter, prevailed on a small scale in London and it was accompanied or quickly followed by the appearance of encephalitis lethargica, which increased in prevalence in the early months of 1921. This sequence of events might conceivably be hailed, both by those who rely upon the method of harmonic analysis, and those who think there is something in the doctrines expounded by Hippocrates and Sydenham concerning epidemic constitutions, as representing a development "according to plan." Fortunately the net result for 1920 as a whole, was that there was no considerable addition to the death-rate from the influenzal group of diseases among school children. A special report by Dr. Armstrong on catarrhal sore throat or glandular fever will be found on p. 89. The main epidemic visitations of the year were those of measles in March-April and of scarlet fever and diphtheria in the autumn. Account is given of the former outbreak and of the special preventive measures undertaken in connection with it on p. 90. With regard to scarlet fever a major wave of the disease was due to appear. Fortunately the hospital provision available proved fairly adequate to meet the demands made upon it. On p. 86 some notes are made concerning the behaviour of the curve of flea prevalence during the year. The facts are first, that the maximum week of the curve of seasonal flea prevalence antedates by a few weeks, as is its wont, the maximum week of scarlet fever seasonal prevalence; and, second, that the statistics for 1920 render manifest for a wellnigh completed cycle the rough correspondence between the decline and swell of the major multi-annual 55 waves of flea and of scarlet fever prevalence which has for five or six years past been noted as being in course of development. In 1920, the flea curve did not, however, rise so markedly as did that of scarlet fever. Moreover, the rise in scarlet fever was especially abrupt in London as compared with the country generally. The bearing of these facts upon the flea-scarlet-fever hypothesis is considered on p. 86. On p. 88 there will be found some notes with regard to the influence of the main holiday period of the year upon the prevalence of scarlet fever and diphtheria, in London, Paris and New York. In all 6,301 examinations were conducted with a view to admission to special schools. Of these 3,323 (1,733 boys and 1,590 girls) were certified as suitable for admission, and the remainder were either returned to elementary schools or found to be unsuitable for any of the Council's institutions. The results of the periodical examinations in the schools for the mentally and physically defective are shown on p. 94, and special reports are submitted dealing with causes of blindness and deafness, mental deficiency and mental tests of deaf children. The results of medical inspection. Routine inspections were carried out of all children in the three age-groups prescribed by the Board of Education, viz., entrants, children aged eight and children aged twelve. The numbers comprised 41,975 entrant boys, 40,667 entrant girls, 29,477 eight-year old boys, 29,282 eight-year old girls, 33,728 twelve-year old boys and 33,795 twelve-year old girls, making 208,924 children examined in public elementary schools at the prescribed ages. At these ages also a physical examination was made of 1,923 children in the special schools. In addition all children whose fourteenth birthday occurred on or after the appointed day, on which children leaving elementary schools became liable to attend compulsory day schools, were examined : these comprised 6,956 boys and 6,416 girls. Over and above the 224,219 children thus examined in age groups there were seen by the school doctors 83,516 children specially examined, owing to some indication of ill-health noticed by teachers, school nurses or members of care committees, at the instance of attendance officers on account of absence from school, as to fitness for special courses of study such as attendance at Central schools, or for other reasons. The total number of children inspected during 1920, exclusive of scholarship children, was therefore 307,735, compared with 265,230 in 1920, and 255,631 in 1918. These figures denote a considerable extension of the medical work in the schools, an extension due largely to the examination of children nominated for attendance at Central schools, and to the leaving children examined as entrants to continuation day schools. In addition 144,876 children were re-examined who had previously been found ailing, and 13,765 of these were twice re-examined. The proportion of children at routine inspections during the year found to require treatment for defects shows a marked decline. Including the fourteen-year old group the number referred for treatment was 87,632, being 39.4 per cent. of those examined. Of the three official age-groups 82,740 children were referred for treatment, or 39.6 per cent. as compared with 42.6 per cent. in 1919, and 44 per cent. in 1918. This continued improvement in health is a matter for congratulation. The general state of the children's clothing, nutrition and cleanliness has been proved to afford a valuable index to the care bestowed upon the children and has reflected the great improvement in this respect which has taken place in recent years. It is in these figures that we may expect first to find any indications of a set-back in health and well-being in childhood due to alterations in economic conditions. Special schools Number of children inspected Number of ailing children General conditions ENTRANT INFANTS. Clothings And Footware. Nutrition. Cleanliness (Head). Cleanliness (Body). Year. Good Fair. Poor. Excellent. Normal. Subnormal. Clean. Nits. minous. Clean. Dirty. Verminous. Boys 1913 53.9 42.5 3.6 30.7 58.5 10.8 86.6 12.8 0.6 77.7 20.6 1.7 1914 56.3 40.4 3.3 31.2 60.7 8.1 88.0 11.6 0.4 81.7 17.3 1.0 1915 57.8 39.9 2.3 32.1 62.4 5.4 90.0 9.7 0.3 82.0 17.2 0.8 *1917 55.7 42.2 2.1 31.1 64.1 4.8 90.0 9.8 0.2 82.9 16.3 0.8 1918 58.0 40.3 1.7 31.4 63.9 4.7 92.9 70 01 89.7 9.8 0.4 1919 59.6 38.3 2.1 29.3 64.6 6.1 93.4 6.4 0.2 91.5 8.2 0.3 1920 60.3 37.9 1.8 26.1 67.5 6.4 93.8 5.9 0.3 90.9 8.7 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 1919 59.6 38.9 1.5 29.2 65.1 5.7 80.5 18.3 1.2 90.9 8.8 0.3 1920 60.7 380 1.3 26.6 67.5 5.9 82.2 16.5 1.3 90.6 9.0 0.4 INTERMEDIATE AGE GROUP (aged 8). 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 70.1 100 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 0.6 1919 53.9 42.8 3. 3 20.3 71.8 7.9 93.1 6.7 0.2 89.2 10.4 0.4 1920 55.8 4.06 3.6 16.8 74.2 9.0 93.4 6.4 0.2 88.5 11.1 0.4 * The figures for infants for 1917 are for the third term only, when inspection of entrants in detail was resumed after its discontinuance in 1916. 56 [$###] Clothing And Footware. Nutrition. Cleanliness (Head). Cleanliness (Body). Year. Good. Fair. Poor. Excellent. Normal. Subnor mal. Clean. Nits. Verminous. Clean. Dirty. Verminous. INTERMEDIATE AGE GROUP (aged 8)— continued. Girls 1913 51.4 43.9 4.7 251 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 1919 56.1 42.0 1.9 22.4 70.6 7.0 74.2 240 1.8 89.5 10.2 0.3 1920 58.2 39.8 2.0 18.2 74.0 7.8 76.5 21.9 1.6 88.6 10.9 0.5 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 1919 50.6 45.1 4.3 26.1 68.7 5.2 93.4 6.5 0.1 88.4 11.2 0.4 1920 53.5 43.0 3.5 23.5 70.2 6.3 94.2 5.7 0.1 87.1 12.5 0.4 Girl.s 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 0.8 85.3 14.2 0.5 1919 56.0 42.2 1.8 27.7 67.3 5.0 740 24.7 1.3 89.0 10.7 0.3 1920 58.1 40.5 1.4 25.4 69.0 5.6 75.8 22.8 1.4 88.4 11.2 0.4 Sufficiency of clothing There is little alteration in the condition of the children as regards clothing and what alteration there is has been in the right direction. Attention is, of course, chiefly paid to the sufficiency, warmth and suitability of underclothing and the general slight improvement suggests that it has become more easy to supply the children with proper under garments than it was during the war years in spite of any deterioration of economic conditions. Nutrition of the children It is to the nutrition figures that greatest attention will be paid. During the war years there was a notable improvement in the general physical condition of the children as shown by the state of their nutrition. In 1919, however, it was remarked that there was a perceptible deterioration of the nutritional state and that this was especially marked in the case of the infants entering upon school life, in whom it might be expected that the earliest reaction to adverse circumstances would be seen. Unfortunately this deterioration has continued and is now shown in boys and girls at all three ages, but especially in the case of the eight-year old group in which the greatest amount of under-nourishment is apt to be found. Although the deterioration is not as yet alarming it is significant and reflects the effects of combined high prices and unemployment. The significance of the figures is underlined by their close correspondence with the numbers of children requiring to be fed at school. There is serious cause for concern at the fact for instance, that nine per cent of the boys at the age of eight are marked as under-nourished, and that the number so marked has increased during the last two years. Cleanliness Dirt remains the greatest enemy with which we have to contend and it is gratifying that progress continues to be made in the cleanliness of the children attending the schools in spite of all difficulties. Though steady, this progress is slow but it is only maintained at all through the very strenuous efforts made by the school nurses backed up by the authority and interest of the teachers. As in the case of clothing the condition of the children in regard to cleanliness as revealed by medical inspection shows the best that can be attained rather than the state which normally obtains. Parents are warned of the medical inspection and naturally trick the children out in their best clothing and send them especially well washed and brightened up for the occasion. It is beyond the powers, however, of a careless mother to remove from the long hair of the girls the manifestations of long neglect shown by the presence of nits. More than twenty per cent. of the girls show these traces of verminous infestation at medical inspections. This percentage, however, is a marked improvement on the state of affairs which existed only a few years ago. Of eight-year old girls in London, in 1913, 30.3 per cent. had nits in the hair and in 2.4 per cent. even at medical inspections, live vermin were found; in 1920, 21.9 per cent. had nits and 1.6 were afflicted with live vermin. In 1913, 30.4 per cent. of twelve-year old girls had nits and 2.4 per cent. had lice; in 1920, 22.8 per cent. had nits and 1.4 per cent. lice. Medical inspections, therefore, show that there has been a 3.0 per cent. improvement in seven years in verminous conditions and this improvement has been accelerated during the last three years during which a great forward campaign against infestation by vermin has been going on, since the Council made addition for the purpose to the personnel of the school nursing staff. Dental conditions Although little alteration from year to year is noted in the condition of the teeth of children on their entrance to school there is evidence of slight ground being gained each year in the condition of the teeth of the older children. This must be due entirely to the results of dental inspection and medical inspection of the children coupled with the increase of facilities for dental treatment. 57 CONDITION OF THE TEETH. 1913. 1914. 1915. 1916. 1 2 3 1 2 3 1 2 3 1 2 3 Entrant boys 62.2 27.7 10.1 51.6 33.9 14.5 47.6 38.2 14.2 28.6 40.0 31.4 ,, girls 63.0 27.2 9.8 52.0 34.3 13.7 47.2 39.1 13.7 27.1 41.0 31.9 Eight year old boys 51.4 36.6 12.0 48.9 39.1 12.0 45.9 43.2 10.9 47.6 41.8 10.6 ,, girls 51.6 36.3 12.1 49.1 39.0 11.9 46.6 42.8 10.6 47.7 41.7 10.6 Twelve year old boys 50.0 40.0 10.0 51.9 38.9 9.2 53.1 39.7 7.2 53.1 40.4 6.5 „ „ girls 52.4 39.0 8.6 54.1 38.2 7.6 55.5 37.8 6.7 55.0 39.2 5.8 1917. 1918. 1919. 1920. 1 2 3 1 2 3 1 2 3 1 2 3 Entrant boys 40.5 35.7 23.8 48.6 34.5 19.9 49.3 34.3 16.4 53.2 32.7 14.1 ,, girls 39.2 37.5 23.3 45.0 35.7 19.3 48.1 35.5 16.4 52.7 33.6 13.7 Eight year old boys 46.2 39.8 14.0 38.4 42.3 19.3 43.1 40.6 16.3 48.2 38.7 13.1 ,, girls 46.9 40.0 13.1 39.9 41.3 18.8 44.1 41.4 14.5 48.4 38.8 12.8 Twelve year old boys 55.2 38.6 6.2 48.8 43.9 7.3 55.1 39.7 5.2 58.0 37.6 4.4 ,, girls 56.4 38.1 5.5 49.8 43.3 6.9 56.5 39.1 4.4 59.7 36.7 3.6 The percentages shown in the above table are (1) children with sound teeth, (2) children with slight dental caries, (3) children with severe dental caries. The one almost consistent manifestation observed in the table is the steady improvement, with exception for 1918, in the number of children at twelve years of age who have teeth free from caries and the diminution in the proportion of children at that age who exhibit severe dental decay. It is significant that the greatest advance in this respect has occurred during the past two years. Although the worst cases of dental caries are not now met with so frequently as formerly among the older children, owing to the fact that special pressure is put upon bad cases to attend the treatment centres, the immense problem that remains to be solved requires our courage to be braced up to the highest pitch. Forty-six dental centres have been provided and are working at full pressure, and although the numbers of children at the older ages with serious dental caries have been halved since provision for treatment began to be made, yet forty per cent. of the children leaving school still have obvious dental caries. Now dental decay is held by all to be a preventable disease, and it is clear that in order to cope with this great mass of trouble, all the aid that can be given by education and the practice of hygiene must be pressed into the service. Not by treatment of the worst cases but by prevention at the outset will success finally be achieved. The interesting suggestion was made by Dr. Wheatley, the county medical officer of Shropshire, that the compulsory change in diet during the war might have caused an alteration in the condition of the teeth of children entering school in that county. It appears that from 1910 to 1914, 95 per cent. of the Shropshire entrants were returned as presenting dental decay and that in 1919-20 only 56 per cent. were found to have carious teeth. If this great alteration were due, as Dr. Wheatley suggests, to a cause which was universally operative in the country, it would be expected that the medical officers of other authorities would find the same result; but the London figures certainly lend no support to the theory. It is suggestive that while the pre-war figures in Shropshire bore no resemblance at all to the London figures, those of 1919 approached most nearly, and could be considered comparable, to the London figures. In this connection attention might be drawn to the London report for 1916, where the figures setting out the condition of the teeth of the entrant infants bear no relationship to the figures of any year before or since. The condition of the teeth of the entrant children in this year appears in the table to be extraordinarily bad, and the result would be inexplicable to anyone who was not aware of the fact that throughout this year alone, in all the series of years set out, was the practice of inspecting ailing children only, and not all children, carried out. A revolutionary transformation in a statistical figure like this suggests an alteration of method, rather than a change in the facts themselves, and one cannot be too careful in applying to the whole of a population, figures which are derived from a specially selected group. Such an error was committed by those who argued that, because in hospital patients suffering from other complaints ten per cent. were found to give the Wassermann reaction for syphilis, therefore, 10 per cent. of the whole population was tainted with this disease. 11,447 children in the age-groups were referred for treatment for "adenoids and tonsils" either separate or combined. This number was 5.5 per cent. of all those examined and is an improvement on the corresponding figures of the two previous years, as 6.1 per cent. were referred for treatment in 1919, and 6.2 per cent. in 1920. It is thought that there were fewer catarrhal conditions during 1920, affecting the children and that this accounts for the improvement. The numbers of boys and girls suffering from these conditions are practically identical, with the exception that older girls seem to be more prone to enlarged tonsils alone than boys, but entrant infants suffer more from both these conditions than older children and there is a steady diminution of the incidence throughout school life. Adenoids and tonsils 61004 i 58 Ear disease and deafness Closely associated with the prevalence of enlarged tonsils and adenoid growths are discharging ears and hardness of hearing. In these conditions, too, there is no difference between the incidence upon boys and girls, but while that of ear disease, which is curable, diminishes during school life, being highest amongst entrant infants, the effects of ear disease, hardness of hearing, being often permanent accumulate during school life and deafness is found more often amongst the oldest scholars than amongst the youngest. Two per cent. of the children in the age-groups were found to be suffering from ear disease and 0.9 per cent. from hardness of hearing, both figures being fractionally less than those of last year (2.2 per cent. and 1.0 per cent. respectively). An analysis of the cases of ear disease shows that over 80 per cent. are suffering from otitis media and otorrhoea. Visual acuity A total number of 14,617 children were referred for treatment for visual defect or 11.0 per cent. of those inspected at the eight and twelve-year old groups. This was again a fractional improvement upon the previous year. Eight-year Old. Twelve-year Old. Boys. Girls. Boys. Girls. Normal. Poor. Bad. Normal. Poor. Bad. Normal. Poor. Bad. Normal. Poor. Bad. 1918 38.2 42.0 19.7 34.7 43.5 21.8 52.6 25.7 21.7 46.8 29.1 24.1 1919 39.7 40.2 20.1 35.6 42.8 21.6 51.6 26.9 21.6 47.8 29.5 22.7 1920 42.4 36.7 20.9 38.9 38.5 22.6 55.0 24.3 20.7 52.2 25.7 22.1 The table of visual acuity given above shows continuing improvement. Not only is the number of boys and girls who possess normal vision increasing each year, but a very satisfactory improvement is noted in 1920 over all previous years and the disparity between the vision of boys and girls at the older age continues to diminish, although it still exists. The sight.saving campaign in the schools is, therefore, bearing fruit. In this connection it should be pointed out that ophthalmic surgeons at the hospitals and treatment centres now very frequently forward recommendations with regard to modification in the studies of children with weak eyes at school, and that these recommendations for "oral teaching only" and "easy treatment" are being adopted largely by the teachers in these special cases. Formerly it was constantly noted that the proportion of children at the older age with bad vision was greatly in excess of that at the earlier age and this was taken as a condemnation of the methods pursued in the schools; in 1920, for the first time since medical inspection was introduced, the proportion of children at twelve years of age with serious defect of vision uncorrected is less than that of the children at eight years of age. This is a very notable achievement and shows that the measures taken by the Council are conceived on right lines. Squint 2,564 cases of squint were noted at routine inspections, rather more than one per cent, of the whole number examined. Heart defects and anaemia 7,086 children in the age-groups were returned as suffering from heart defects (or 3.4 per cent.), which is identical with the proportion found in the previous year, and 8,566 (or 4.1 per cent.) with anaemia, an increase of 0.6 per cent. The preponderance of the incidence of heart defect upon the older girls is still very marked. Older boys suffer less than any other group from anaemia, presumably because they spend more time in the open air than the others. In 12 per cent. of the cases of heart defect organic disease is definitely diagnosed. Lung complaints 9,845 children were recorded as presenting some lung trouble ; this represents 4'8 per cent., which is practically identical with the proportion found last year. There is little difference in the incidence upon the sexes, but there is a great disparity in the age incidence. Infants provide by far the greatest number of sufferers from bronchial catarrh and this condition is no doubt associated with the prevalence of rickets in younger children. Phthisis and other tuberculous diseases 460 cases of phthisis (0.2 per cent.) were recorded at routine inspections and 543 cases (0.3 per cent.) of other tuberculous lesions. The proportion of other tuberculous lesions was the same as in 1919, but the proportion of cases of phthisis showed a fractional decline. Not more than one in five hundred children attending regularly at school are therefore found to have phthisis and of these more than half are already known at the date of inspection and are under observation. These, of course, are not " open " cases or they would not be in attendance. Rickets and other deformities Rickety manifestations were noted in 2,815 children (13 per cent.) compared with 17 per cent. in 1919. The chief incidence is upon infants, of course, and more largely upon infant boys than infant girls. 3,342 cases of deformity other than rickets were found (1.6 per cent.), a proportion identical with that found in 1919. Again, the preponderance of incidence upon the older girls is marked, consisting practically entirely of minor degrees of spinal curvature. Diseases of the skin and external eye disease 3,860 children were found suffering from skin diseases (1.8 per cent. compared with 1.9 per cent. in 1919), and 6,705 with external eye disease (3.2 per cent. identical in proportion with that of the previous year). These diseases are largely due to dirt and unhygienic home surroundings. The undue prevalence of scabies of late years has been referred to, and in a later section of the report it will be shown that the prevalence of scabies still remains serious. About one quarter of the cases of skin disease were found to consist of scabies and another quarter of impetigo. Albuminuria It is impossible to examine the urine of children in elementary schools as a routine practice, nor in the light of what is known of the occurrences of albuminuria in children does it appear desirable 59 Arrangements are made whereby an analysis can be carried out in particular cases. Dr. Frewen Moore asked permission to carry out an investigation in December, 1920, on boys in a London elementary school. 397 boys were in attendance and in every case a specimen of urine was obtained and tested by the salicyl sulphonic acid method. 91 boys were found who had albuminuria in varying degrees, i.e., no less than 23½ per cent. Similar high percentages have been found by other investigators. Bugge, in 1913, found albuminuria present in the urine of 14.9 per cent. of boys and girls in the elementary schools of Christiania. Clement Dukes, in 1907, noted albuminuria in 16.4 per cent. of the entrants at Rugby. Nicholson, in 1914, found 28 per cent. of the boys in Framlingham College had albuminuria. Practically all these cases of albuminuria must be looked upon as physiological, but from investigations made by Dr. Boome at the elementary school above mentioned, it would appear that the better boys are "trained" for sports the less likely they are to have albuminuria. This raises the interesting question, which has not previously been taken into consideration in such investigations, whether physiological albuminuria is not associated with the presence in the blood of fatigue products. Reviewing the literature of the subject in the light of this idea there appears to be much to be said for this view, as many investigators find the number of individuals presenting albuminuria increases with strenuous exertion of a sporadic nature. It is but rarely that children suffering from congenital syphilis are found in elementary schools. The action of the syphilitic virus upon the progeny of those suffering from the disease is of the "all or nothing" type. Usually what is found is a series of miscarriages which may be followed by the birth of normal children, but intermediately a child may be born showing signs of congenital syphilis. Generally such children, if they survive, develop serious defect and are to be found in special schools for the mentally defective, for the blind, or for the deaf. Not so many as one hundred children in ordinary elementary schools out of 200,000 examined are found with the least trace of congenital syphilis. In one year when the reports were carefully scrutinised, out of 224,264 children examined, including both routine and special cases, there were only 58 cases where Hutchinsonian teeth were noted, 13 cases of interstitial keratitis and 15 cases where other signs were present of congenital specific disease. These figures include doubtful cases. It is clear therefore that the percentage of children attending elementary schools in whom some taint of congenital syphilis can be found by the ordinary methods of medical inspection is very small. Hitherto the last age-group inspected has been that of twelve-year old children. There has therefore been two years left of school life during which ameliorative efforts have been effective, but the complete results of those efforts have, in the absence of a final inspection, not been fully recorded. During the Autumn term of 1920, 6,956 boys and 6,416 girls at the age of 14 were inspected in detail as entrants to continuation school. Thus we have for the first time material from which to judge the final result of care during elementary school life. The records of the inspection of these children fully confirm the deductions made from the results of the three earlier age-group examinations and show that those tendencies already described are continued and confirmed. The nutrition of these fourteen year old children was found to be distinctly better than in the twelve year old children, only 4.7 per cent. of boys and 4.4 per cent. of girls being recorded as under-nourished, compared with 6.3 per cent. and 5.6 per cent. respectively at age 12. The fourteen year old girls were appreciably superior in personal hygiene, fewer being found with nits in the hair. The condition of the teeth was slightly better than that of the twelve year old children as was the acuity of vision, although the boys still preserved their superiority over girls in this latter respect. There is a continued fall, in the proportion of children with unhealthy conditions of the throat, in " dirt" diseases of the skin and eyes, in anaemia and in lung defects. The preponderance of girls with heart defects and deformities is still marked over boys, but there appears to be no very significant increase in the numbers so affected. In short it may be stated that the last two years of school life are good years so far as health is concerned ; no new disturbing factor is apparent at work, and all the effects of amelioration noted through the earlier years are continued to the end. Particularly gratifying is the improvement in vision, as the proportion of children with more serious uncorrected defect continues to fall. As might be expected the children in the special schools show a much higher degree of defect. than those in the ordinary schools, even in the case of conditions which have no relation to their special, defect. They are far worse clad; they are very much less well nourished (13.9 per cent. undernourished as against 6.6 per cent.); their cleanliness is far inferior. The acuity of vision is very much lower than that of the normal children, defects of hearing, ear diseases and defects of speech are increased by the hundredfold. There is in fact no ill to which the flesh is heir in which an excess is not shown by the children in the special schools over those in the ordinary elementary schools. It would appear that the degeneration which produces the special defect which prevents them from profiting by instruction in the ordinary school is part of a general degeneration involving all tissues and organs alike, although it must always be borne in mind that for a variety of reasons remedial measures are harder to carry out in the case of defective children than in the case of normal children. The inspection of special cases is a most valuable section of the work, and the numbers seen approximate to those of an age group. The bulk of the cases of skin disease coming under notice is derived from this group and greater numbers of cases of conjunctivitis, of epilepsy and of chorea were found amongst the 56,571 children brought forward for examination because they appeared to be ailing than were found amongst the 222,296 children in the age groups. All the above conditions are such as cannot fail to strike the attention of lay observers. On the other hand the bulk of those conditions that can only be revealed by skilled clinical examination continues naturally to be found only at set inspections, and without routine medical inspections of all children nearly all the cases of defective vision, of enlarged tonsils and of chest complaints, including serious defect of heart and lung, Congenital syphilis I Children at 14 years of agd leaving for continuation schools The routine inspection of special school children Special casts 61001 I 2 60 would be entirely missed during school lite. Of the 56,571 special cases 33,637 were referred for treatment or placed under continued observation for defects. Secondary school children 8,878 children in secondary schools (exclusive of trade schools and training colleges) were inspected during the year, including 5,672 girls and 3,206 boys; 1,808 were found to require treatment for dental defect, or 20 per cent., which corresponds very closely with the percentage of leaver children in the elementary schools so found. 1,442 pupils required treatment for visual defect, or 15.1 per cent., as compared with 12.8 per cent. of leaver children in the elementary schools. 979, or 17.3 per cent. of the girls suffered from defective vision, the excess of girls over boys being as marked here as in the elementary schools. 369 pupils suffered from defects of the nose and throat, or 41 per cent., which is in close approximation to the proportion referred for treatment in leavers from the elementary schools. 86, or rather less than 1 per cent., had defective hearing, as compared with 1.5 per cent. of leavers in elementary schools and 32, or 0.37 per cent., suffered from ear discharge as compared with 2.9 per cent. of elementary school leavers. 263, or 2.9 per cent., were found with anaemia compared with 4 per cent. of elementary school leavers. As the examinations in secondary schools have hitherto not been standardised as carefully as those in elementary schools, and more variation is apparent in the results obtained by different school doctors, it is impossible to feel the fullest confidence these figures. From the beginning of 1921 a schedule based upon that issued by the Board of Education will be in use and a more reliable comparison will be possible in future year3. The figures given, however, show how necessary medical supervision of the health of pupils is in every type of school, and specially noticeable is the strain which modern education throws upon the eyes of all students. Stammering children. It was computed from the medical inspection returns that there would be about 1,200 stammering children in the London schools, and that the boy stammerers would outnumber the girl stammerers in at least the proportion of three to one. In preparation for the establishment of special classes the teachers of all the schools were asked to forward the names of all the stammering children under their care. They were also asked to estimate the degree of the infirmity under the headings acute, moderate, and slight. The total number of notifications received was 914, 682 of boys and 232 of girls. It was arranged that five classes should be formed of twenty children each. All were kept under observation by the school medical officer. A considerable measure of success attended the work at the classes. Out of 76 children, 34 were discharged cured at the end of the first term, and 32 others who had shown improvement were recommended for further attendance. Considering that the first term's work was experimental, and that many disturbing influences necessarily obtained at the beginning, these results must be regarded as highly satisfactory. The case of each child was carefully investigated from the medical point of view. There were found to be two distinct sets of cases. In the first the stammering came on together with the development of speech; these cases were the more difficult to cure. In the second, the stammering came on later after a period during which the child spoke normally. Frights of various kinds were frequent causes, and amongst these air raids during the war played a part. Night terrors and nightmare were associated with many of these. The majority of the children were found at the outset to possess very poor chest development with marked rigidity and spasmodic breathing. Part of the training was accordingly directed towards the improvement of the condition of the chest, particularly with the object of inducing relaxation. In the case of a class held at Santley-street (Brixton), out of twelve children in whom the stammering was first noticed at or before the sixth year of age, only three were cured by the end of the course, whereas out of seven children in whom the stammering developed after the age of six, six were cured. Of these seven children it is interesting to note that stammering in two was ascribed to the effects of fright (one by air raid, the other by a dog), two were imitative cases, and in two the condition was ascribed to rheumatic fever. The common association of rheumatic fever with another disease of co-ordination in childhood (namely, chorea) is, of course, well established. The most noticeable feature about the aspect of a class of stammerers at the beginning was the strained and anxious look they collectively presented. It was amazing how this improved during the course, as the children found more confidence in themselves and entertained solid hopes of cure. It was considered by the medical officers that it was a disadvantage to have older boys and girls together in the same class, as the children appeared to be more self-conscious in the presence of those of the other sex, and an exaggerated self-consciousness is, of course, a special feature of the mental state of the stammering child. The classes were reorganised recently ; the elder boys and girls are instructed separately, and each class consists of 12 children only. The total accommodation is now 144, and, if all the children in attendance during each of the three terms could be cured, the output of the classes would be 432 a year. Assuming, however, that each term 72 children (50 per cent.) will be receiving further treatment, about 300 individual children will be dealt with annually. In a few years time therefore the arrears will be overtaken. Younger children will be admitted in an increasing proportion, and the attendance at the classes will slowly fall, owing to the difficulty of such children travelling alone. The centres at which the classes are held will then tends to move outwards, towards the county boundaries. This will afford the Council an opportunity, if desired, of co-operating with extrametropolitan authorities in accordance with section 6 (1) of the Education Act, 1918, since the density of population of stammering children in the areas of these authorities may be too small for local classes. 61 The Board of Education have agreed to provide, under section 44 (2) of the Education Act, 1918, for onehalf of the expenditure incurred by the Council in connection with these classes, and have requested the school medical officer to give some account of them in his annual report. The reports for the whole of the year 1920 show that 275 children were treated, 106 were cured, 61 left before care or were withdrawn for various reasons and 108 were still in attendance at the end of the year. Of the children discharged as cured 10 boys and 3 girls (12 per cent.) relapsed after a little time. Stammering commenced at an early age, that is in infancy, in the greater proportion of cases; while a greater percentage of cure was shown amongst those in whom stammering had more recently developed. Amongst tie causes to which the habit of stammering was attributed were imitation 10 cases, shock 56 cases, heredity 36 cases, neuropathic tendencies 47 cases, physical causes 43 cases. Left handedness was found in 13 cases, a number which does not greatly support those who consider that this condition is largely responsible for stammering. In 56 cases stammering was noticed from the early beginnings of speech, so that quite a large proportion of the children never spoke normally. The work of the classes is proceeding steadily and satisfactorily, and there is evidence that they are appreciated by head teachers, parents and children. Special Investigations. The year 1920 was one of sheer hard work for the medical staff and the various sections of the report testify to the exceedingly great amount carried through. The calls upon the time of the school doctor are innumerable and have increased more rapidly than has the increase in personnel. During 1920, the demands were augmented in a high degree by the necessity for medical investigation in the schools in consequence of the almost unprecedented prevalence of scarlet fever combined with a high incidence of diphtheria. There was, therefore, practically no opportunity for special investigations. Attention may be drawn, however, to Dr. E. J. Boome's observations upon the condition of children as affected by physical training which will be found in. the section dealing with the latter, to Dr. Richard Armstrong's investigation upon the occurrence of epidemic sore throat appended to the section on Infectious Diseases and to the researches into the cause and cure of stammering conducted by Drs. Margaret Hogarth and.E. J. Boome, upon whose reports the section on the subject of stammering has been based. In the section on Personal Hygiene, the results of a special enquiry by Dr. Elwin Nash into the prevalence of scabies are given. Following-up. The work of following-up children suffering from minor defects, writes Dr. C. J. Thomas, is essentially one of education. It is tedious and prolonged or never-ending. However it may be attempted to tabulate the results in figures—and figures in abundance will be found in the appendices to the report— the very nature of the work eludes statistical representation. It is impossible to eliminate the human element. Poetry cannot be weighed with scales nor can the emotions of the heart be measured in grammes and centimetres. The system of following-up adopted in London differs essentially from that adopted in many other places; it is a special manifestation of the British spirit, so different in its essential qualities from that of the Teuton or the Latin, and it is particularly insusceptible to mathematical treatment. There are those who would deal with the parents of children suffering from minor defects on a stern bureaucratic basis, they would have each child officially catalogued and enumerated and would in a very short and prescribed time present a table in which should be shown each child accounted for either by the certificate of the school doctor that his edict has been complied with, or by the appearance of the parent as a unit in a statistically represented number of prosecution cases, some of which had undergone fines and some imprisonment. Such a system as this in London would inevitably defeat its aim ; the London parent can be taught and, given time, can be persuaded, he cannot be driven. The fact that medical inspection in school is not compulsory of itself forbids such a system in dealing with those who voluntarily permit the examination of their children. Any manifestation of official overbearance would result in wholesale withdrawal of children from the medical oversight in the schools which they are now enjoying. The choice for the watch-dog, therefore, appears to lie between creeping into the freedom of Paradise with the Asses of Francis Jammes or bursting into Limbo with the tin-can of bureaucratic efficiency attached to his tail. The London Education Authority in its care for children has consistently chosen the former course. The duty of following-up has been delegated to the school care committees consisting of voluntary workers attached to every school. Each school care committee is given direct responsibility and the whole of the school organisation, including teachers, attendance officers, organisers and officials is enjoined to give every aid to the voluntary workers in their devoted endeavours. No body of officials could probably vie with the voluntary workers in their conception of duty or their tenacity in clinging to well-nigh hopeless causes, but no one has yet been found who can induce voluntary workers to take the credit due to them and to prepare reports giving the numbers, results and present position of the cases entrusted to their care; they know no "office hours," they will not submit to official domination and they will not "waste their time "over preparing statistics or writing reports. Yet who shall say that any other system could produce better results than the figures which are derived from indirect and independent sources reveal ? Much of the success of the work depends upon the personality of the worker. Some voluntary workers are more persuasive than others. A great deal depends upon the doctor. Some school doctors are able to impress upon parents the importance of attending to minor defects in a way that others who may possess greater professional 02 skill are unable to emulate. Very much depends upon the influence of the head teacher of the school. The vast majority of the teachers appreciate the impartance of the work and leave no stone unturned which can aid in its success, and it is impossible to over-estimate the share of the credit for ultimate success which is due to the enthusiasm of the teachers. A few head teachers remain, however, still indifferent or even hostile and in schools, fortunately very rare, where these conditions exist, the results are poor in the extreme. Especially do the numbers of parents who attend the inspections appear to be affected by the sympathies of the head teachers and the presence of the parent at the inspection is found to be a most important element in obtaining speedy treatment for the child. The process of bringing the necessity of treatment home to the parent is often a very slow one. The school doctor at the inspection finds a chi'd has one unsound tooth. This is recorded as a defect and failure to get it remedied brings discredit. The parent is busy or apathetic and does not attend the inspection. The school nurse visits the home and gives the mother, if she can find her, an advice card telling her what is wrong and advising her to get treatment The voluntary visitor follows her after a little time and endeavours to persuade the mother to take the child for treatment. There may be no difficulty and an appointment is made forthwith at a treatment centre. On the other hand several visits may be made before the mother can be found. She is harassed possibly by domestic worries, makes difficulties, the father must be consulted and he does not hold with tampering with the teeth, there is money to be paid for having it done, she will lose a day's work over it, which she cannot afford, it has never given the child any pain so why should she bother and so forth. The date of the first re-inspection comes round. The care committee representative is present when the doctor sees the child again, nothing has been done, the tooth has now gone too far to be saved. Is it any use bothering any more ? No, the case is given up. It has been a failure. Or perhaps the doctor says there are signs of decay now in the adjoining teeth. It is decided to persevere with the case. A strongly worded advice card is sent. The visitor resumes her visits of persuasion. She may now be successful or on the other hand the parent may have become more like adamant. The doctor down the street has seen the child and says it is only a first tooth and will drop out. The second re-inspection comes round. Nothing has been done ! Some conclusion must be come to. Further persuasion seems to be useless. Can the case be sent to the N.S.P.C.C. for prosecution ? No, it is not of sufficient importance, a prosecution would probably be unsuccessful, especially as the mother has taken the child to a doctor. Or else, now there is an abscess and the case is rather serious. The special officer is asked to visit and as the child is now complaining of pain the mother may consent; if she does not the N.S.P.C.C. must intervene. Many of the cases run such a course as the above ; there is nothing for it but to keep these cases under observation until they pass from the early beginnings of disease into a more serious condition when, as a rule, treatment can be insisted upon and indeed the obstinate opposition dies down of itself. The very nature of the work is thus essentially educative and ultimate success will depend on bringing home to the people the importance of attendance to the beginnings of disease and the truth of the adage " a stitch in time saves nine." Re inspections As will be gathered re-inspection of children found with defects is an important part of followingup. It is no use pulling plants up to see how they are growing, and to serve any useful result the re-inspection should not follow too close upon the original discovery of a defect. A clear term is, therefore, allowed to elapse between the primary inspection and the re-inspection and another clear term between the first re-inspection and the second re-inspection, if the latter is found necessary. The total number of re-inspections carried out in 1920 was 158,641. 93,985 of these were first re-inspections and 64,656 were second re-inspections. The tables in the appendix show that a larger number of children are now treated in the year than are referred for treatment in the year. During the war many causes combined to reduce the efficiency of following-up and it is now clear that not many cases are final y unaccounted for. Reinspection, however, shows that the process, though in the iong run nearly complete, is a very slow one. At first re-inspection it was found that 38.9 per cent. of the children referred for treatment had not received it and still required it. Including these with the children who were undergoing treatment which was still however, incomplete, 56.1 per cent. were referred lor second re-inspections. At second re-inspections the percentage of children not under treatment and still requiring treatment was 41.1. The children seen at second re-inspections are not all identical with those seen at first re-inspections in the year, some of them having been referred for further re-inspection from the previous year, but, if it is assumed that a similar proportion will obtain for the cases that have not yet undergone second re-inspection, the combined result gives a figure of 76.9 per cent. of chi dren satisfactorily dealt with after the lapse of fifteen months from primary inspection, as compared with a similar figure of 73.5 per cent. in 1919. The figure of 76.9 per cent. of children found satisfactorily dealt with by the time the second re-inspection was carried out is the highest yet obtained since the Council undertook the provision of treatment for ailirui children. Dental cases Were it not for the inclusion of figures of dental cases referred by the school doctors for treatment the results would be still better. As is well known the scheme of the Board of Education for dental treatment aims at beginning with the younger children and, as yet, full fac lities do not exist in any case for the treatment of the mass of dental defect. There is also more reluctance on the part of patients to face the dentist's chair than to undergo any other form of treatment. It is not surprising therefore that the "leakage" in the case o. children referred for dental treatment by the school doctors is higher than in the case of any other class of defect. The percentage of children suffering from dental defect found still requiring treatment at first re-inspections is 49.8 and at second re-inspections is 53.6. 63 It will be seen from Table IV. in the Appendix that while during 1920, 16,883 children were referred for treatment for defects of nose and throat, no fewer than 17,383 received treatment during the year; it is clear, therefore, that arrears are being now overtaken; 9,976 children were operated upon for tonsils and adenoids under the Council's scheme alone. At first re-inspections during the year 41.7 per cent. of the children needing it were found to be untreated and at second re-inspections 40.7 per cent. of the remainder were still untreated. Of the children treated 27 per cent. were treated at hospitals (institutions not included in the Council's scheme) as compared with 25 per cent. in 1919. Rather more than one-fourth of the work of performing operations upon the throats of school children still falls therefore upon the general hospitals. The "leakage" in the case of visual defect is much less than in the conditions already discussed. At first re-inspections only 39.3 per cent. of children were found to be still untreated and in need of treatment and at second re-inspections 39.8 percent. The vast number of 32,013 children was treated during the year, of whom 29,887 were submitted for refraction under the Council's scheme. The numbers treated were greatly in excess of those referred during the year, showing that arrears are rapidly being overhauled. Spectacles were prescribed at the Council's centres for 22,827 children and obtained in 19,882 cases. Only 14 per cent. of children obtain spectacles apart from the Council's scheme. The general hospitals show considerable reluctance to undertake much refraction work and children are thrown back by them to a large and increasing extent upon the Council's scheme. No part of the cost of providing spectacles falls upon the rates; in the majority of cases the parents find no difficulty in buying them at the wholesale prices charged at the centres. Provision is made by the care committee visitors for payment by instalments, in some cases this has in the past delayed the supply of the spectacles a little. In cases of necessity help is forthcoming from voluntary funds managed by the local associations of care committees. Re-inspection shows that "other complaints" are attended to with less difficulty by the care committees than in the case of the defects for which provision has been made by the authority. At first re-inspections 17.9 per cent. only of these conditions remain in statu quo ante, and at second re-inspections 17 6 per cent. In other parts of the report glimpses will be seen of the agencies at work. The general hospitals and infirmaries make little trouble in providing for serious conditions of heart and lung. Stammering classes have been established. Tuberculosis dispensaries are now within reach of all children for diagnosis, observation and treatment of all tuberculous conditions, and sanatorium treatment for children can be obtained without difficulty by the Council. The ever-widening provision of open-air treatment for the anaemic and debilitated is also described and the good offices of such bodies as the Invalid Children's Aid Association are much drawn upon. The Children's Country Holiday Fund, too, now concentrates upon the anaemic and debilitated child and makes up for loss of numbers by more discriminating incidence of benefit. In view of the great importance of the condition of discharging ears both as regards the peril to the individual, and the offensiveness of the condition to others, special methods of following-up have been adopted. Dr. Chaikin reports as follows:—I would like to point out the great importance of the school nurses' supervision in the schools. They have brought to my notice many cases of otorrhœa. Some were under no treatment at all. Others were not attending treatment centres regularly. The notification to me was followed by a communication to the Care Organisation and, in the term following notification, the children were seen by the school doctor. In cases of otorrhoea there is need for constant supervision. Children fail to continue regular attendance at centres because parents think they are better ; then there comes an exacerbation ; the discharge becomes profuse or there is pain and the child reappears. The work of the nurses in discovering quiet cases constitutes a great preventive service. There were 333 cases of otorrhoea notified by school nurses and 5 by head teachers, in the Eastern Division, in 1920. More boys than girls were affected. My own view is that it is easier to notice ear discharge in a boy than a girl owing to the latter's hair. During the past year the total number of examinations made by Dr. Wells of chronic cases, which do not clear up after treatment at a centre was 2,476. This number represented 939 cases, of which 502 were new cases during the year. Of the cases under observation, the number discharged as " cured " was 230, representing a percentage for the whole of London of 28.2 per cent. during the year. The total number of purely deaf cases was 114 and the number discharged as " cured " was 53, giving a percentage of 46 per cent. The work of the School Attendance Branch in connection with Medical Supervision of Children. The points of contact of the School Attendance branch with the school medical service are innumerable and extend along the whole line of operations. So much is this the case that very substantial allocations are made to the school medical vote in the estimates on account of services of the school attendance officers. Not only are the local officers of the two services in constant touch regarding children absent from school on account of alleged ill-health, but important services are rendered by the attendance officers in connection with the following-up of difficult cases where treatment has been recommended, in connection with the service upon neglectful parents of statutory notices under the Children Act and with the recovery of charges for medical treatment. The departments are in close touch upon questions involving juvenile employment particularly, at present, in regard to children employed in entertainments. In addition to the constant interchange of information and assistance in regard to children absent from school, a special register is compiled from information supplied by the attendance branch, of children who have been absent from school for a period of three months and upwards. The names Nose and throat cases Visual defect Other complaints The follow ing up of cases of discharging ears 64 of the children are transferred to a card index in the Public Health Department each month and the lists are returned to the Divisional Superintendents, who remove from them any children who have returned to school and add the children who fall into the category of absent for three months in the interval before the lists are again sent in. The average numbers of children's names received monthly during 1920, from each division are as follows:— Southwark 520 St. Pancras 210 Total 3,390 Camberwell 500 Lambeth 200 City and Stepney 430 Wandsworth 170 Islington 430 Chelsea 160 Greenwich 380 Hackney 80 Poplar 250 Paddington 60 In the month of November each year, an analysis is made of the cases and this analysis is given in the following table for the years 1919 and 1920. It will be observed that the percentage of children suffering from rheumatism, heart disease and chorea in November, 1920, forms a larger proportion of the whole than in November, 1919, having increased from 14.43 per cent. to 21.12 per cent., but the proportion of children suffering from skin complaints (mainly scabies) has been reduced from 5.63 per cent. to 3.83 per cent. As regards the increase in rheumatism, etc., it is noteworthy that such increase seems to occur, as a rule, coincidently with increase in scarlet fever and diphtheria. The total number of children reported as absent for long periods in November, 1920, is less than in November, 1919. CHILDREN ABSENT FROM SCHOOL THREE MONTHS OWING TO ILLNESS IN THE MONTHS OF NOVEMBER, 1919 AND 1920. Complaint. Children. Percentage of total. 1919. 1920. 1919. 1920. Rheumatism, heart dis?ass and chorea 412 537 14.43 21.12 Nervous disorders 211 219 7.38 8.21 Tuberculosis (pulmonary and other) 586 595 20.51 22.33 Anaemia and debility 226 155 7.91 5.82 Ringworm 129 125 4.51 4.69 Skin (other than ringworm) 161 102 5.63 3.83 Eve complaints 180 167 6.30 6.27 Other diseases 951 765 33.29 28.70 All diseases 2,856 2,665 — — The age distribution of children absent is as follows in percentages of the total:— Age. Percentage. Ape. Percentage. Age. Percentage. 5 7.8 9 9.8 13 11.8 6 14.1 10 9.8 14 3.7 7 12.2 11 9.6 15 1.0 8 10.3 12 10.8 The greatest amount of absence is at the ages 6 and 7 years. Between the ages 9 and 11 the percentage remains steady but rises during the years 12 to 13. This rise is entirely due to the excessive number or girls absent at the ages 12 and 13, for while the attendance of boys improves at these ages the number of girls upon the lists at ages 12 and 13 is very high, forming at age 12 years 11'8 per cent, of all girls absent and at age 13, 14" 1 per cent., whereas the boys at age 12 form only 9'3 per per cent, and those at age 13, 8'4 per cent, of the tota boys listed. It is difficult to avoid the conclusion that the help the older girls are able to give in domestic work in the homes is a factor in prolonging absence in many cases. The consequence is that the number of girls absent exceeds the number of boys by about 40 per cent. The small numbers of children at ages 14 and 15 refer to children who are still on the roll of special schools. All the cases reported are industriously followed up. An assistant medical officer every month considers each case with the particulars afforded. Further information is obtained from the divisional officers or district organisers where advisable; and in a large number of cases an endeavour is made to have the children brought up to a special medical examination. As a result many children are found fit either for ordinary or special school. Every case of tuberculosis is referred to the tuberculosis department and is followed up locally; these cases form over 20 per cent. of the whole number. Special reports from the school nurses are required in ringworm cases (4.5 per cent. of the whole), and chronic skin conditions (4 per cent. of the whole). A number of the children with chronic eye complaints (6.27 per cent.) are brought up to the weekly examination by the Council's ophthalmologist and of these some are found fit lor blind institutions or myope schools. All epileptic children are notified to the special schools section and are seen with a view to deciding upon admission to a colony. 65 Although a considerable proportion of the children are seen at special examinations there is a residue that defies all efforts at following-up, the parents not infrequently being supported in their attitude by private or hospital doctors. Except by putting the Defective and Epileptic Act into force there are no powers of dealing with such cases and it is only when very flagrant neglect is suspected that it is possible to take further action. It should be noted, however, that the number of cases of this sort is infinitesimal compared with the total number of children liable to attend school in London. Juvenile Employment. Amended by-laws have been drawn up under the Employment of Children Act, 1903, as altered by the Education Act, 1918. The draft by-laws after an enquiry held by the Home Office have, with the necessary alterations, now been approved and will come into force at an early date. The general effect of these by-laws is as follows:— (a) To prohibit the employment of children in certain occupations unless (1) notice has first been given by the employer to the head teacher of the school at which the child attends, and (2) a certificate has been obtained from the school medical officer and has been produced to and endorsed by the employer. (By-laws 1 and 2.) (b) To regulate the hours during which children may be employed on week days and to prohibit early morning and employment on school days except in the delivery of newspapers and in light household work, in which occupations children may be employed from 7 a.m. to 8 a.m. (By-laws 3, 4 and 5.) (c) To regulate the hours of employment on Sunday and to prohibit employment on that day in the occupations specified in by-law 1. (By-law 6.) (d) To prohibit the employment of children in certain specified occupations. (By-law 8.) (e) To provide that children, employed out of doors in the occupations specified in by-law 1, shall be suitably clad and in inclement weather supplied with a waterproof coat or similar garment. (By-law 9.) (f) To prohibit the employment in street trading of persons under the age of 16 years with the exception of the sons of costermongers, over 14 years of age and exempt from school attendance, when such boys are employed to assist their parents in their business at a fixed pitch and subject to certain conditions. (By-laws 10 and 11.) The occupations referred to in paragraph (a) comprise:—the delivery of milk, the delivery of newpapers, carrying or delivering goods or parcels; occupation in, or in connection with, any shop, in any coal yard, in industrial work at home, in housework away from home, or as a messenger. It will be seen that all children employed in such occupations will be required to obtain a certificate from the school medical officer. It is anticipated that a great deal of additional work will be thrown upon the medical staff in connection with these examinations. A new duty placed upon the school medical officer by the passing of the Education Act, 1918, is the medical examination of all children of school age applying for licences for employment in entertainments. The rules made by the Board of Education in regard to such licences came into operation on the 1st April, 1920. Every application for a licence must be accompanied by a certificate of the school medical officer of the local education authority of the area in which the child resides that he (she) may be so employed without prejudice to his (her) health or physical development and that the employment will not render the child unfit to obtain the proper benefit from his (her) education. Further, the child shall be submitted to examination by the school medical officer at intervals of not more than three calendar months. A local education authority may also direct that the child shall be examined by their school medical officer on such other occasions as they think proper and any such directions shall be complied with. For the purposes of this article the examination shall be by the school medical officer of the area in which the licence is granted or by the school medical officer of any area in which the licence is to take effect. Thus, the school medical officer is required to issue a certificate in the case of every child residing in the area of the local education authority for whom an application for a licence is made. He is further required to re-examine every child licensed at intervals not exceeding three months. He may also be required to re-examine children at more frequent intervals or upon special occasions and he may be required to examine children licensed under another local education authority but performing in the area of his own local education authority. The education authority may attach to the licence any reasonable restrictions tending generally to promote the health, comfort and moral protection of the children. The rules are expressly drawn up with a view to securing that each case is judged on its individual merits, and the school medical officer by judicious suggestions in his report to the authority can do much to safeguard the child's health from injury and may even secure the improvement of the child's physical condition by the insertion of reasonable restrictions. For instance, he may in the first case recommend that the licence be not granted until defects are remedied. Thus the condition of cleanliness of the children and their physical condition may be remedied if defective at the outset. He may also give suggestions as to holidays or rest periods (especially at re-examinations); he may advise that in particular cases an extension of the time for leaving the theatre beyond 10 p.m. is inadvisable, or he may even recommend that the time should be earlier than this. He may also recommend special attention to diet or continuance of medical treatment. No hard and fast standards can be laid down for the examination of the children. Each case must be considered on its merits. A child who would not be injured by a small walking-on part at a Notes by Dr. C. J. Thomas on the medical examination of school children employed in entertainments 61004 K 66 London theatre might be quite unfit to travel with a touring company in a strenuous turn. The nature of the entertainment and the length of time spent upon the stage must be considered in relation to the age and physique of the particular child. For the most part beautiful, symmetrcal and healthy children are chosen for engagement, but, in order to fit certain parts children are sometimes selected for opposite reasons. Children who are dwarfed and deformed may be selected for parts where intelligence combined with small size is required. Thus a set of children aged 12 to 13 may be brought for examination who, ow'ng to rickety dwarfing, are no taller and heavier than average children of 6. The number of foreign born and coloured children is also noticeable, the number of negroes and mulattos examined being surprising. Often doubts will arise as to the propriety of issuing a certificate of fitness, but all these must be resolved with the consideration of the best interest of the child paramount in the examiner's mind. For instance, here is a small, fragile child quite unfit, on first impressions, for training. She is accompanied by her parents, both delicate persons, who get their living by giving entertainments at provincial and suburban music halls. They wish their child to appear with them on the stage for a few minutes every evening ; the alternative is leaving the child to be looked after by strangers. In this case the best interests of the child appeared to be served by granting a certificate. The very individual character of the work of examining these children makes it especially interesting. A preponderant number of the children seen under the rules in London can be divided into two main groups. First those living at home and appearing at high class theatres; secondly those employed by touring companies. A committee of experts appointed by the President of the Board of Education to advise as to the Rules which should be made reported in 1919 generally upon the problems involved. In regard to the touring children their report points out the very great disabilities under which such children suffer. Evidence was adduced that they were frequently tired, took little interest in school work, and were backward in education. The facts as to hours and conditions, said the committee, are undisputed and speak for themselves. The committee also found itself unable to obtain any reliable figures as to the number of children employed upon the stage. The contrast found at medical examination between the two sets of children is most striking and experience emphasises the special difficulties under which the touring child labours. As a general rule the child employed at a West End theatre is of superior type, of good physique and soignee to a degree. On the other hand the touring child springs for the most part from poorer homes where lack of consideration for physical health and personal hygiene may be the rule. In the conditions under which the children travel and lodge while on tour there is also manifest difficulty in maintaining the personal hygiene at a reasonably high standard. It was suggested to the advisory committee above mentioned that the conditions were so good in regard to the employment of children on the stage that benefit rather than harm was likely to accrue to the individual child from the employment. Experience shows that for the touring child in general this is emphatically not the case. When re-examined such children are often in a state of fatigue and the condition of the skin and hair leaves much to be desired. On the other hand, in children who are engaged for high class productions at the London theatres there is often a marked improvement found on re-examination owing to the care and assistance provided by the theatre authorities. The number of children presented for examination in connection with licences in London from 1st April to 31st December, 1920, was 276, of whom only 19 were boys. There were three cases in which certificates were refused or withdrawn for health reasons. The first was a child of 10 with mitral disease of the heart, the second a child of 11 with congenital heart disease, the third a child of 11 who was on tour taking a heavy part in a play ; this child broke down in health four months after the original licence had been granted and her breakdown was no doubt contributed to by endeavouring to sustain her part and travel from town to town while suffering from an attack of gastritis. In a fourth case a certificate was not granted in the first instance because of the child's anaemic and fatigued condition and she was consequently not considered in a fit state of health to go on tour. After a holiday at the seaside, however, she was again presented and a certificate was issued. In nine further cases a certificate was withheld temporarily while defects were remedied ; in most of these cases the trouble was "verminous heads." The defects noted need not be discussed in detail but on the whole they were less in number than, but not different in character from, the defects found in an equal number of unselected elementary school children. A special occupational deformity is to be met with in corns and bunions developed upon the dorsum of the middle phalanges of the toes in dancing children. It is, therefore, necessary in all cases where toe dancing is chiefly the occupation of the child to make a careful examination of the condition of the feet. Treatment for obvious defects was in all cases secured as a condition of granting the licence. In 32 instances special restrictions or conditions based on medical grounds were recommended. In addition to the 276 primary examinations 101 special or continuation examinations were made. There is no doubt that the institution of the new procedure has already had its effect in improving the care bestowed upon stage children but the school medical officer cannot rest satisfied while such a great disparity is displayed in the health and personal hygiene of children employed on tour in comparison with the condition of the children employed at the best theatres. Medical Treatment The year 1920 has been one of progress both as regards facilities for treatment provided and as regards methods of treatment carried out. 67 Much discussion has taken place both in medical and lay circles upon the question of after treatment of children operated upon for enlarged tonsils and adenoid growths. The practice of performing operations in out-patient departments and handing over the child directly after the recovery from the effects of the anaesthetic, to the mother, to find her way home by crowded public conveyances has been felt to be unsatisfactory. The presentation to the Council by Lady Henry of a building in Woolwich which had been erected during the war for the purpose of a day nursery, has provided a most suitable hospital wherein operations upon the throat can be carried out In addition to residential staff quarters, operating theatre and other accessory rooms, two wards each receiving twelve children have been provided. The establishment was opened in June, 1920 under the name of the "Cyril Henry" treatment centre, so called in memory of the son of the donatrix. Twelve boys and twelve girls are operated upon each alternate day and each child is detained in the hospital for two nights after the operation. It has thus been found possible to deal with all the children formerly treated at the Woolwich, Greenwich, Deptford and Peckham centres. The children are seen by the surgeons at their local centres in the first place and those referred for operation are dealt with at the Cyril Henry centre, each surgeon visiting the centre in turn to carry out the operations upon his own cases. After discharge from the Cyril Henry centre each child returns to the local centre for breathing exercises under the supervision of his own surgeon until finally discharged as cured. The arrangement has proved highly successful and less difficulty is now being experienced in the South-Eastern division in persuading parents to have the necessary attention to nose and throat defects as they are relieved from the ordeal of the care and transport of the chil d immediately after the operation. The question of providing an ambulance for the conveyance of children from other centres to their homes after operation has been discussed but no decision on this point has yet been arrived at. The arrangements for medical treatment generally have continued to be developed according to the scheme outlined in the annual report of the school medical officer for the year, 1912. At the end of the year 1920, the scheme included 14 hospitals, and 46 treatment centres, the latter managed by voluntary local committees of medical practitioners, nursing associations, and dispensary and other committees. The agreements with these 60 centres provided for the treatment of 194,100 children, the numbers of the particular ailments treated being as follows:—eyes (refraction, 30,490; eye diseases, 2,050); ear, nose and throat, 15,800; ringworm, 2,100; minor ailments, 44,440; teeth, 99,220. The facilities thus provided for treatment are available for elementary school children and scholarship holders in secondary schools at a nominal charge of Is. for each ailment treated except that in the case of minor ailments the charge of 3d. has been made. Fee paying pupils at secondary schools are also treated, in default of available private means, subject to the actual average cost of treatment being refunded to the Council. The average cost for the year 1920, was fixed at 6s. 6d. per case. The question of revising the charges made for medical and dental treatment is at the present time (March, 1921), under consideration. Under the Council's arrangements for treatment for the year 1921-22, it has been necessary to ncrease the allowances to treatment centres in several respects. For instance, to meet the high cost of adaptation of new centres a grant of £100 is now made. The allowances for equipment are, moreover, higher than in former years, and now stand at £75 in respect of eye or aural treatment; £100 for dental work ; and £150 for X-ray treatment of ringworm. The salaries of treating doctors have been raised from £70 to £80 per annum for work on one session a week; dentists as from 1st April, 1921, will receive £65 per annum instead of £50 or £55; and £175 per annum will be paid for the whole time services of a nurse. The capitation payments hitherto made have proved insufficient to meet the current expenditure on maintenance of the hospitals and centres, and a separate grant is now paid, based on the total number of cases for which agreement is made for treatment, in order to meet the difficulties encountered at the present time. The number of children actually treated shows a further increase on the comparison of successive years, the total for the year 1920 being 197,700, as against 169,200 for the year 1919. More detailed particulars of the treatment of the separate ailments are here summarised. (a) Minor ailments.—The year has been one of acute pressure upon all the minor ailment departments. Simultaneously with the increase in epidemic prevalence of scarlet fever, there appears to have been a corresponding increase in septic conditions of the skin, and the Consequence has been that children have required treatment in larger numbers than usual. During the year four new minor ailment centres were established, and the accommodation at existing centres was increased so that the total provision at the end of the year was for 44,440 cases. Notwithstanding this provision, larger by more than 10,000 than the figure for 1919, many centres were still overcrowded. Altogether 61,771 cases were treated —a number greatly in excess of the accommodation nominally provided—and the number of attendances made reached 1,121,026, a number which has never been approached in former years, and representing a 32.4 per cent. increase on the numbers for 1919. In considering the provision for minor ailments in London, and in comparing the work done with that in other areas, it must be remembered that the Council deals with a large number of children at the cleansing stations for parasitic conditions which in other areas are dealt with at minor ailments centres. In addition to cases of infestation by lice, all cases of scabies are treated at the cleansing stations, and on account of scabies alone 9,675 cases must be added to the 61,771 cases referred to, making a total of 71,446. (b) Aural defects (including enlarged tonsils and adenoid growths).—Under this heading, 18,615 appointments were made for treatment under the Council's scheme. 14,746 children attended for examination, and 9,976 underwent operative treatment. 10,351 children were discharged as " treatment completed." 61004 K 2 68 Ionisation treatment for otorrhœa. Treatment by ionisation of cases of suppurating ears was commenced at the Almeric Paget centre at the beginning of the winter term, 1920, under the direction of Dr. Friel. One ionisation apparatus was installed in the first place, but subsequently towards the end of the term a second apparatus was added. Cases of suppurating ears which resisted the usual conservative treatment, were referred from the various centres in the Eastern Division, but an arrangement has recently been made whereby one centre is being dealt with at a time. The object of this plan is to find out which cases at the particular centre are suitable for ionisation, and to treat these, referring those which are not suitable to Dr. Wells in order that he may advise as to other methods, such as mastoid operation, etc., as opportunity permits. In this way, the cases attending a particular centre are separated into two groups, viz., those suitable for ionisation and those not suitable, and thus a more comprehensive way of dealing with the cases is assured. During the winter term the total number of cases seen at the Almeric Paget centre was 61, of which 52 received ionisation treatment, and 9 were considered unsuitable. In 25 cases the discharge ceased as the result of treatment. There were 11 failures for the following reasons—mastoid disease, 3; granulations, 3; attic disease, 1; polypi, 3; cause unascertained, 1. One case gave up treatment and 15 cases still remain under treatment. There is no doubt that ionisation is an excellent method of treatment in certain cases of suppurating ears, and the above results fully justify this opinion. Since the beginning of the winter term of 1920 an ionisation apparatus has also been installed at the Children's Infirmary, Cleveland-street. The cases dealt with here were of two kinds, viz., (a) cases upon which a mastoid operation had been performed, (b) cases on which no operation had been performed. The object of ionising cases of class (a) was to endeavour to cut short the after-treatment of mastoid operation cases, and the details below will show the results obtained. Dr. Wells reports that ionisation expedites the healing process, but it is not yet determined how soon after the operation ionisation can be performed with best advantage. Cases in class (b) were similar to those dealt with by Dr. Friel at Cable-street. Of 17 cases ionised in which no operation was performed, in 9 the discharge ceased, clearing up within two weeks in 7 cases, and within four weeks in the other 2 cases. In the 8 unsuccessful cases, failure to clear up was due to mastoid disease, as was afterwards proved. Of 118 cases ionised in class (a) in which mastoid operation had been previously performed, 80 were successful, and 38 were apparent failures. Of the successful cases, 64 cleared up with one ionisation, 15 with two, and 1 with four ionisations. Mastoid operations. During the past year 125 mastoid operations have been performed at the Cleveland-street institution, under the arrangement made with the Metropolitan Asylums Board, with the consent of the Ministry of Health. Of these, 16 cases were lost sight of after the operation, owing to the children having left school or for other reasons, before their treatment was completed. Of the remainder 76 per cent, of the cases healed and were discharged as " cured." This is a very excellent percentage of successes, but particularly is it so when one realises the material which has been dealt with. The cases that have been operated on have been almost entirely of the very worst type possible. If it had been possible to pick out cases with a view only to obtaining the best results, no doubt the percentage of successes would have been even higher than 76 per cent. But, owing to the fact that only a limited number of operations can be done, those that have appeared to be the most urgent and the most diseased have been selected. The result of this work is proof of what can be done for some of the bad cases of chronic mastoid disease, which have in most instances existed for many years, and for which conservative treatment has been of no avail. (c) Ringworm.—Of the 1,840 children referred under the Council's arrangements for treatment of ringworm of the scalp, 1,758 received X-ray treatment, and 1,593 were discharged as cured. Only 44 children were treated with ointment. (d) and (e) Vision.-—The number of children attending the Council's centres for defective vision was 29,887, an ncrease of 1,876 on the figures for the year 1,919. Spectacles were prescribed in 22,827 cases, and in 19,882 cases they were obtained. (f) Dental defects.—Mr. C. Edward Wallis reports that the great difficulty in obtaining suitable premises for dental centres has to some extent been met by increasing the number of sessions devoted to dental treatment, and facilities are now available for nearly 100,000 cases. The total number of dentists engaged is 70, of whom four are whole time and 66 are on a part-time basis. The only new centres have been the Battersea (" Gonville ") centre and that at Bushy Park Camp School, for which the dental equipment was presented by the Canadian Government. The cost of dental equipment has risen greatly, for example, a clinic operating chair, which formerly cost £17, now costs as much as £50. In the latter part of 1920, the opportunity was taken of obtaining six surplus army dental chairs and other apparatus at a greatly reduced cost for the use of prospective centres. It has now been decided that in connection with all centres children below the age of six shall be dealt with. For some years past the age of children inspected has been extended fiom the age 6-8 upwards by one year at each succeeding re-inspection, so that in course of time the scheme will deal with the whole of the school population. In order to co-ord nate the work of the various inspecting and treat ng dentists two series of rules have been drawn up and supplied to all concerned. Bushy Park Camp School. The need for opening a dental centre at Bushy Park is proved by the statistics obtained by the dentist in charge, Mr. W. D. McDonald, who lound that 78 per cent. of the admissions required dental treatment, and that 27 per cent. were suffering from septic inflammation of the gums associated almost invariably with enlarged lymphatic glands. The fact of the children being actually resident enabled Mr. McDonald to institute a special scheme of gum treatment and massage, to be supervised by the 69 sister in charge, whereby each child was led to take a personal interest in the healthiness of his gums and teeth. It is obvious that so long as a child's mouth is foul and septic, whether from the teeth or gums, it cannot possibly derive the maximum benefit obtainable from the fresh air and good dietary at the camp school. During the year 18,000 tooth brushes and 6,250 tubes of tooth soap were sold at the centres and at the dental inspections held at the schools. This appreciation by the parents of the importance of dental hygiene must be largely attributed to the influence of the dental inspectors, and shows the value of the short addresses which are given at the inspections. The number of anaesthetic sessions at each centre varies with the needs of the locality, but the general rule is that the session weekly is sufficient for a half-time centre, and two sessions for a whole time centre. There is, however, a "credit" of extra anaesthetic sessions which can be drawn upon as necessity arises. The number of administrations of nitrous oxide was 20,245 and the number of ethyl chloride administrations 13,438 during the year. Not a single fatality occurred in spite of the very large number of anaesthetics administered. The use of a local anaesthetic is customary in cases in which it is required. (g) Tuberculosis.—At the commencement of the year 1920 the Council had in use 564 beds for children, of which 306 were in Voluntary Institutions and the remainder in Metropolitan Asylums Board Institutions. Later in the year additional accommodation was obtained in the latter institutions. The number of children under treatment on the 31st December, 1920, was 696. On the 1st January, 1920, 282 boys and 282 girls were under treatment and 506 boys and 452 girls were sent away during the year. The total treated during the year 1920, was, therefore, 1,522 as compared with 1,225 in 1919. In addition, 500 children had the advantage of convalescence through the Invalid Children's Aid Association, with financial assistance from the Council. The Council has provided three open-air day schools for children notified under the Tuberculosis Regulations, 1912, as definitely suffering from tuberculosis of the lungs or from tubercular glands without discharging sinuses, viz., Kensal House (Paddington), Stormont House (Hackney), and Springwell House (Clapham Common). The accommodation is for 90, 75 and 125 respectively. In addition, the Council has provided teachers and educational equipment for a class of 25 children held in the garden attached to the Fulham Tuberculosis Dispensary, and also for a class of 25 held in connection with the Camberwell Tuberculosis Dispensary at 6, Grove Hill-road, Denmark-hill. The Fulham class is to be closed early in 1921, on the opening of an additional open-air school for 50 tuberculosis children provided by the Council, to be known as the Elizabethan School. Broomhouse-lane, Fulham. d Supply of tooth brushes and tooth soap. Anaesthetics. School. No. on Roll Reasons for Discharge. Gain or Loss in Weight. 31.12.19. 31.12.20. Admitted 1920. Discharged 1920. Fit for E.S. Work. Transferred to Hosp. or Sanat. Removed from district. Transferred to Sp. School. Other reasons. No. Gained. Average gain in kilos. No. lost or stationary. Average loss it. kilos. Kensal House 94 91 31 42 14 6 7 10 1 3 57 3-27 — — Springwell House 81 130 103 54 24 9 12 2 1 6 111 2.38† 7 — Stormont House 35 83 64 13 1 4 3 1 — — 54* 3.5‡ 1 .6§ * Children at school for more than 6 months. Accommodation of school increased from 50 to 75 in August, 1920. † Refers to 61 children who were in the school for 12 months. ‡ Refers to 29 children who were in the school for 12 months. § Children in school less than 6 months. The following are the occupations taken up by children who have left Kensal House School during the year:— Cabinet-making. Secretarial training. Making lamp-shades. Domestic service. Clerk. . Working at home. The tuberculosis officer attached to the tuberculosis dispensary in the borough in which cach school is situated has been appointed on the staff of the school medical officer for the purpose of supervising the health of the child en, and he visits the school on at least one half-day a week. The dispensary nurse spends part of each day at the school. In the selection of the children preference is given to children who have had sanatorium treatment, and regard is paid specially to the condition of the homes. Children are not admitted if the home conditions are likely to nullify the advantages of the open-air school. The medical officer of Stormont House, in his report for the year, concludes as follows:—"Taking everything into consideration, I am convinced that the result of treatment at the school has been a marked success. Whether the direct supervision of the rest and exercise of each child, or the fact that the children are practically always in the open air, or the excellent midday meal and milk, is responsible, it is difficult to tell, but probably the success is due to a combination of these. It is most encouraging to see the progress of each case, as illustrated by the fall of the temperature, the improvement in signs and symptoms, the increase in weight, and the happy mental outlook of the children." During the summer of 1920 the Invalid Children's Aid Association, with financial assistance from the Council, sent 170 of the children attending these schools to convalescent homes at the seaside. 70 Blind alley employment of adolescents in relation to phthisis death-rates. In a paper by Dr. M. Greenwood, entitled " The Epidemiology of Pulmonary Tuberculosis," which appears in the 1919-20 report of the Chief Medical Officer of the Ministry of Health, a question is raised concerning blind alley employment of adolescents in relation to phthisis death rates, which opens up some far-reaching considerations. We have been reminded elsewhere by Dr. Greenwood that " the epidemiologist is concerned with disease as a mass phenomenon ; his business is not with individuals but with aggregates." This view has of late years certainly received increasingly wide acceptance. We are beginning to appreciate, too, the fact that the mass consists of living beings, and is, in fact, an organism whose constituent units are here to-day and gone to-morrow, now susceptible and anon immunised. Before approaching the particular case of phthisis in young persons a word may be said concerning some other scjiool diseases. Thus, as a case in point, the extent to which, in London elementary schools, the " under fives " are mainly important when measles and whooping cough are in question, while, on the other hand, older children are also largely implicated when scarlet fever and diphtheria are concerned, and so on, has for some years past been increasingly realised. But beyond this there is now seen to be urgent need for study of the varying resistances encountered by epidemics at one and another point of time, or in one or another part of London, according to the degree of immunity (natural or acquired) of the population at risk. In the annual report for 1914, a first attempt was made to grapple with the problem, in so far as the behaviour of scarlet fever in London is concerned. Study was made of the paradoxical phenomenon that the good elementary schools suffer more from scarlet fever than the poor schools, and in the annual report for 1918 (p. 46) further examination was made of scarlet fever prevalence in the poorest, the less poor, and the least poor areas of London. The conclusion was reached that 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 living in the " least poor areas." In the same report (p. 47) comment was made upon Dr. John Brownlee's study of scarlet fever incidence in Glasgow in relation to "social conditions." Dr. Brownlee was confronted with a somewhat similar paradoxical result to that above mentioned, and the bearing of his observations upon the London problem was accordingly illustrated (loc. cit.). Again, in the annual report for 1918 problems involving similar considerations relating to tuberculosis, scarlet fever, and influenza were considered. In last year's report the same theme was again touched upon in regard to measles. Dr. Brownlee had treated measles as he had before treated scarlet fever and tuberculosis, in the mass, concerning himself not with individuals but with aggregates ; but he had not attempted in one and the same enterprise to secure the aid and assistance to be derived from field methods in combination with his statistical method, and thus it would seem had not fully recognised that "epidemiology is not a mere branch of mathematics." The song is, as we have been told, of the man as well as of the arms, "the conditions of human life—both as we now say environmental and eugenic—(are) quite as important to the epidemiologist as the materies morbi." To lay undue emphasis upon the germ is to miss the full significance of interplay between germ and environment; and, indeed, to obscure the factors which operate in producing actual variations in the germ itself. We are in danger of being led away from the straight path by being induced to step aside to explore the potentialities of strains of measles paramcecia or to chase will o' the wisp varieties (young adult, middle age, and old age) of tubercle bacilli; and this despite the fact that the track, narrow and rugged though it be, stretches right ahead, past the landmarks set up by numbers of epidemiologists who have explored this difficult tract of country. But, now, to come to the point raised by Dr. M. Greenwood with reference to blind alley employment. In an analysis of the London borough statistics, which is contained in section X. of his paper, he has dealt with figures relating to three different age periods (15-25, 25-45, 45-65) in the two sexes. The attempt to interpret the meaning of the partial correlation coefficients, which are obtained between Tuberculosis and Overcrowding, Tuberculosis and Other Diseases, and Tuberculosis and Factory Employment—in males and females belonging to these three age groups—compels him to take arms against a sea of troubles; inter alia, the paradoxical result emerges that, taking the percentage of population in a borough living more than two to a room as a rough measure of domestic conditions, "there is a negative correlation between the index of overcrowding and the death rate from tuberculosis. ' in both males and females at ages 15-25; in other words "the worse the home conditions (so measured) the lower the death-rate from phthisis in adolescents." Dr. Greenwood, however, hastens to reassure us by pointing out that correlation does not necessarily mean "completely isolated covariation, unless we are certain that the two variables are not correlated with a tertium quid not included in our system of measurements." And then he goes on to suggest that this unknown correlated factor may possibly be ready to hand in "blind alley employment." "If," he says, "it were at all generally true that the adolescents of the worst-housed families—in general these are the families dependent upon casual and unskilled labour for subsistence—have for a few years more money to spend than their coevals in skilled industry, then we have introduced a positive correlation between bad housing and certain advantages of adolescents (more money to spend, less confinement in factories, more out-of-doors life), and these advantages will in turn be negatively correlated with the death rate from tuberculosis. And this leads Dr. Greenwood to the hypothesis outlined in the sentence quoted on p. 53 of the present report. " Spending one's boyhood on the tail of a van, driving a milk cart, or carrying telegrams may be a very bad preparation for the economic future; but it may be a good thing for one's health as a boy or girl." Dr. Greenwood, however, continues—" I am alive to the insecureness of this argument, which will be proved or disproved by further statistical analysis." 71 Those of us who, frankly, do not like the look of this tertium quid will naturally try to explore other possibilities of escape. And, first of all, the question may be raised as to the extent to which reliance can be placed, in such a connection as this, upon "partial correlation." When a scientific method is newly introduced, it is apt to carry all before it; and yet every student of preventive medicine who studied Professor Pearson's early papers was perplexed on learning that while coefficients of correlation encourage a belief that a child may resemble one or other or both its parents, they give but little added support to many of the hard-won truths of epidemiology; and further, it may be urged, that while from the ultimate judicial point of view the size of the samples and the range of the enquiries made are very important, from the point of view of the field enquirer, who is working on new ground, perhaps even more depends on quality than quantity in the matter of observations. The bearing of these considerations may be better appreciated by considering, on the one hand, Professor Pearson's somewhat ambiguous correlation coefficient for vaccination and immunity from smallpox, and, on the other hand, the quite definite evidence of the value of recent and efficient vaccination in the case of doctors and nu ses who have been freely exposed to smallpox infection. Moreover, on turning from total to "partial correlation," there can be no doubt about the fact that the plot thickens. Thus (i.) the strain upon the reliability of the data is now far greater than before; (ii.) and perhaps the most important of all, in the case of partial correlation, the very fact of having allowed for possible disturbing influences exerted by other variable factors may have introduced a new source of error, for these other factors may stand in such close relationship with one of the factors primarily concerned, that in eliminating the influence of the other variables, we may have exhausted from our first and second partial correlation coefficients almost all trace of a correlation which really does spell causation; (iii.) finally, even when correlation is somewhat close, the fact may merely mean, as Dr. Greenwood says, that some unrecognised tertium quid is deluding us into supporting a false theory of causation. In the present instance all three difficulties in interpreting the partial correlation co-efficients are probably in question. First as to unreliability of data. The measure of overcrowding (more than 2 per room) is admittedly untrustworthy; the details concerning the industrial employments are not given, but clearly, in making comparison between the sexes, the considerations referred to on p. 340 of Dr. Greenwood's paper render appraisement of the precise influence of industry in a place like London particularly difficult; then over it all there is the feeling that the items of information scrutinised are, so to speak, every one of them, on the move—thus, the young persons employed in an overcrowded borough, for example, do not in many instances live in the borough, and deaths of those who do live or work there, when in the fulness of time they occur, may possibly (it may perhaps be said, probably), not be registered in or transferred to the borough. The second difficulty is that already referred to of the exhaustion of the apparent effect of an influence when allowance is made for other influences closely associated with it. "Other diseases," "overcrowding," and "employment" are all bound up with poverty, and the task of allotting to each its special share in the total result qua tuberculosis is a well nigh impossible one. Thus in table 13 on p. 339 the total correlation of overcrowding and employment in females, 25-45, is high 8472; the first partials "Tuberculosis and Overcrowding" (employment constant), and "Tuberculosis and Overcrowding" (other causes constant), are only 2707 and 2311; the second partial "Tuberculosis and Overcrowding" (the other two variables constant) is 0519, i.e., practically zero. But does not this merely mean that when allowance is made for the overcrowding bound up with employment of these women, and for the overcrowding bound up with other diseases affecting them, we have entirely exhausted the effect of overcrowding? And, if so, it clearly does not mean that overcrowding and tuberculosis are not closely correlated in the case of women at these ages. Now as to the third or "tertium quid" difficulty at the ages at 15-25. If this were "blind alley employment" one would expect the males to be much more affected than the females; the actual difference is not, however, great, both partial coefficients being decisively negative. Again the statistics of Table XII. do not give much support even to the case for males; for the factor of selection must operate in the earlier ages—a lad of 15-20 in the group "Carmen, carriers, etc.," might be expected to be better grown and of superior physique to the average young person, and thus less likely to die from tuberculosis—furthermore, alcohol plays great havoc in some of the employments here in question, and its influence would, of course, not be apparent in favouring tuberculosis until the later ages; and yet again the mobility of these young persons, the shortness of time taken up by the employments in question and the number of years likely to elapse in fatal cases before death supervenes, all these considerations are likely to vitiate the conclusions tentatively suggested. But in connection with this question of the tertium quid at the earlier ages (15-25), there is a special claim to be made I submit for immunisation. In these reports, as pointed out at the commencement of the present discussion (p. 70), the close correlations between measles and scarlet fever, on the one hand and poverty and overcrowding, on the other, have during the past seven years, been frequently emphasised. Hence the earlier attack, in the case of these diseases of children, in the poorer boroughs. The same phenomenon certainly plays a part in tuberculosis; measles and scarlet fever afford life-long protection; but the position in tuberculosis is not, of course, so clear as this. It is known, however, that those who manifest in early life tuberculosis of glands, joints, or spine, the ordinary non-pulmonary tubercle of the children's hospitals and sanatoria, are not prone to develop pulmonary phthisis in early manhood and womanhood. There is, in fact, a growing conviction at the present time that slight forms of tuberculosis in early life protect against later manifestation of the disease. Furthermore, the heavy death toll from abdominal and cerebral tuberculosis in young children must act as a severe selective influence. 72 It may here be noted that Sir Shirley Murphy, as long ago as 1898, called attention to a question of importance with regard to comparative death rates at certain age periods, in groups of London sanitary districts arranged with respect to their condition as to overcrowding. (See Ann. Rep. M.O.H., County of London, 1898, Diagram xix. opposite p. 46.) The point raised is really very much the same as that disclosed by Dr. Greenwood's partial correlation co-efficients—for, as reference to Sir Shirley's diagram shows, at age 5-20 all save the two extreme groups of boroughs with most overcrowding stand in a better position qua phthisis than does the group with least crowding. Dr. Brownlee, moreover (Medical Research Committee's Report on Epidemiology of Phthisis, Part III., pp. 50-54), has surmised "that in some way tuberculosis in childhood protects against tuberculosis in early adult life," and again "that some degree of immunity may be developed during childhood which persists into the early adult ages." Dr. Brownlee has worked out in this connection the correlations between percentages of infected milk and the amounts of his so-called "young adult" and "middle age" types of phthisis— these are—76 and + .50 respectively. The bearing of such results upon some of the questions at issue was considered in my annual report for 1919, p. 22. It seems at least clear that immunity, however brought about, may supply a partial explanation of the apparent paradox that young adults (15-25) in the poorer boroughs are less liable to pulmonary phthisis than persons of like age in less poor boroughs; just as, in the same way, the schools in the poorer boroughs yield less scarlet fever, and the infants departments in the poorer boroughs less measles, than the corresponding schools and departments of other boroughs. Here, it seems, is a tertium quid the credentials of which are deserving of examination; one which may throw light on the correlation between overcrowding (measured by more than two to a room) and comparatively low phthisis death rates in adolescents; one, moreover, which will obviate the need either for further defence of the policy of closing blind alleys, or for entering upon a studied justification of continuation schools. Nursery Schools. There are in London nine recognised nursery schools accommodating 330 children. Of these two are attached to the Goldsmith and the Gypsy Hill Training Colleges, and one, the Rachel McMillan Nursery School in Deptford, is recognised as a training centre for nursery school teachers. The Nursery School at Christ Church L.C.C. School, Hampstead, is the only school for which the Council is entirely responsible. In all these schools provision has been made for frequent medical inspections of the children in attendance, and arrangements are in force in all cases for treatment of major and minor defects. For the most part treatment is obtained at the ordinary school treatment centres. Six schools are visited daily by one of the Council's nurses, whose duty it is to inspect the children, paying special attention to children who have been absent. Children returning to school after sore throat or infectious disease are kept apart from the other children until after the nurse's visit. In this way the possibility of infectious disease being introduced into the school is considerably reduced. The nurse also deals with minor ailments, and is responsible for the cleanliness of the children. The standard of cleanliness in these schools is exceptionally high. Open-Air Education. Definite progress has been made during the year in the provision for open-air education. A residential convalescent camp school for 64 girls has been opened at Wanstead House, Margate, an additional open-air day school for 200 ailing children has been established at Stowey House, Clapham Common, 94 open air classes in playgrounds and parks were held as against 87 in 1919, and children were examined in connection with 283 school journeys as against 124 in the previous year. The provision of these extra facilities represents a notable step in resuming the progress which was arrested during the war, but it is to be feared that straitened financial circumstances will now intervene and restrict the normal growth of facilities, however desirable they are. This establishment was placed by the King at the disposal of the Council in the summer of 1919; it was actually opened for the reception of the first draft of boys on August 8th, 1919. The total number of boys admitted during the year 1920, was 2,700. The admissions to the school are drawn from the ranks of those boys, who by reason of existing anaemia, debilitated conditions or malnutrition, appear likely to benefit by a stay in the country. No child under the age of ten is admitted; actively tuberculous cases, mentally defective boys, and those suffering from persistent enuresis are ineligible. Enuresis did occur at the school, although the greatest care was taken to exclude such cases. In several there had been a history of it some time previously, but apparently they relapsed under the different conditions prevailing at the school. Although since the opening of the school (September, 1919), 3,500 boys have passed through it, there have been only two cases of diphtheria, two cases of scarlatina and one case of measles. Much attention during the year has been given to the question of vermin amongst the children. The boys for admission are inspected at various centres on Monday of each week and sent down to the school (if apparently clean) on the following Tuesday. Boys who are found on the Monday to have nits are re-examined by the nurse at the school on the Tuesday before starting for Bushy, and if still found to have nits are not allowed to proceed. Children definitely verminous are rejected. The children are examined as carefully as is possible on these occasions, but it is impracticable without a strong lens to detect nits in the scalp or to find body vermin in the seams of the clothing. As an instance of the difficulty in detecting nits with the naked eye, an experiment was made at Addison Gardens School on a batch of these candidates for the Camp School. The boys were carefully inspected both by the doctor and the nurse, and those considered clean (twenty in number) were again seen by a The King's Canadian Camp School Bushy Park. 73 superintendent of nurses in another room and examined closely with a powerful lens. Out of twenty of these apparently clean children, six were found to have nits for the most part sheltered under the scurf in the scalp, and of these six, two shewed the actual louse emerging from the nit! Again, it is possible that boys' seen on the Monday and passed clean on that day, may be reinfected that evening in their homes. It is, moreover, the practice in some districts for the parents to purchase second-hand clothing to complete the required kits for Bushy, and this is frequently verminous. The only certain way of avoiding the introduction of vermin into a camp school of this kind, especially where the children are drawn from the poorest neighbourhoods, is the provision of a disinfector on the premises. With the provision of a new form of disinfector there should be no danger of any further spread of verminous infestation. The following figures relate to 1,200 boys (the records of 400 being taken from three periods of the year):—Average gain in weight, January to May, 1.78 lb.; June to September, 3.26 lb.; October to December, 2.69 lb.; average gain throughout year, 2.69 lb. per boy for the month. It will be seen that there is a greater gain in weight in the last seven months of the year as compared with the first five months. Throughout the year the boys whose stay was extended to six weeks showed a fairly equal gain of about one pound for the extra two weeks. These boys, however, were specially chosen on account of their debilitated condition. Here again there was a greater gain in the latter seven months of the year than that of the first five months of the year. Wanstead House Camp School for the reception of 64 girls was opened in August. The house occupies an elevated site on the front at Margate, and is ideally situated for its purpose. Thirty-two girls selected by the school doctors are sent from each district in London in rotation, and the normal stay of each girl is six weeks. Every three weeks a new batch of 32 girls arrives. Much benefit is derived by the children from their stay, and the school has already become very popular. As at the Bushy Camp School, the normal charge to the parents is ten shillings a week, but no suitable child is refused admission on the score of lack of means. Here also some difficulty has been found in combatting the spread of verminous conditions, but by the introduction of suitable measures the trouble has been overcome. Dr. McCombe reports:—"The children are medically examined, weighed and measured on arrival, and a note made of their condition. As a general rule, a tonic consisting of iron and cod liver oil is prescribed for the first fortnight, and continued afterwards if considered advisable. It is also one of the rules that every child has an hour's rest lying down every day. The children are again weighed each succeeding fortnight, and medically examined before returning to their homes. "Education is not neglected, as under the care of two able teachers they are taken out for walks and nature studies, and in inclement weather are taught in a practically open-air school recently erected in the garden at the rear of the house. It is wonderful to see the improvement in the children in such a short time; some have been known to gain from 9 to 14 lb. in the six weeks, and none less than a steady pound per week. I have often wondered if their parents would know them with their rosy faces and bright appearance, so different from the pale and weary look on arrival. "The children vary in ages from 9 to 14, and we notice that the older girls, between 13 and 14, derive the most benefit from their stay. We have been most fortunate in the way of illness, only a few cases of sore throat, two of mumps, and one or two gastric attacks requiring medical attention." It is estimated that 2,000 places in open-air day schools are required in London for non-tuberculous children and 2,000 places for tuberculous children. The position in regard to this provision at the end of 1920 was as follows :— I.—Open-air schools for ailing children— (a) In being. (i.) Birley House Open-air School, (iii.) Stowey House Open-air School, Forest-hill places 110 Clapham-common places 200 (ii.) Shooter's-hill Open-air School, Plumstead 100 (b) Proposed. (i.) Bow-road Open-air School, E... places 100 (iii.) Aspen House Open-air School (ii.) Putney-park House Open-air Brixton-hill places 200 School, Roehampton ,, 200 (iv.) Castlewood, Shooter's-hill „ 200 (Alternative site for (a) (ii.).) Accommodation already provided, 410; proposed, 600. II.—Open-air schools for tuberculous children— (a) In being. (i.) Springwell House, Clapham-com- (ii.) Stormont House, Hackney places 75 mon places 125 (iii.) Kensal House, N. Kensington „ 90 (b) Proposed. (i.) Elizabethan Schools, Fulham places 50 (ii.) Grove-hill-road, Camberwell places 50 Accommodation provided, 290 ; proposed, 100. Unfortunately it has been necessary, in view of the financial stringency, to postpone for the present proceeding with a part of the proposed accommodation. The new open-air school for ailing children at Stowey House, Clapham-common, was opened in June, 1920, but owing to incomplete accommodation and later to the approach of winter and the 61004 L Wanstead House Convalescent Camp School. Open-air schools 74 necessity of children being acclimatised to open-air conditions, before undergoing the rigours of winter it has not yet been filled to its full capacity. The school is in an admirable situation and the very large garden attached to the house gives ample scope for the open-air operations required. Birley House and Shooter's-hill Schools have been continued with the success which has always attended them in past years. The question came up for consideration during the year as to closure of day open-air schools for the educational holidays. From the outset these schools remained open all the year round and the making of a change whereby the staff and children should be given school holidays was much debated. In 1919 an experiment was carried out, whereby it appeared that in the case of the Birley House children no serious results attended a holiday period in the summer, but at Shooter's-hill the children appeared to lose ground. In December, 1919, the Council decided that as an experiment, and during the educational year 1920-21, the Birley House Open-air School should be closed for a period of six weeks, four of which should form a continuous period during the "summer. The headmaster prepared figures of weights showing that in the summer holiday there was a slight increase, but in the winter holiday a slight decrease. The managing committee considered that the holidays, generally speaking, had little effect either way on the health of the children and pointed out that a large number of the children went either to the seaside or the country for a period. They thought the experiment increased the children's freshness and zest in their school life. Further, it was considered advantageous that the school should be closed from an administrative point of view. From the medical point of view it is very doubtful whether the open-air schools should be closed in the summer just at the time when the maximum benefit is being received by the children, and, at all events, it would appear that if the schools are closed care should be taken in the case of each child that some alternative measure is adopted which will obviate the break of continuity of treatment. At Shooter's-hill it has been decided that the school shall remain open continuously, but at Stowey House and Bow-road it is proposed that the ordinary elementary schools' holidays shall apply. During the summer of 1920, 94 open-air classes were, with the approval of the Board of Education, held in connection with elementary schools. The classes were of the same types as those described in preceding years, and included 8 classes of type A, 22 of type B, 40 of type C, and 24 of type D. As it has long been recognised that classes in parks and open spaces are much more beneficial to the children than those held in playgrounds, it is satisfactory to find their numbers steadily increasing, 45 having been held last year, as compared with 37 in 1919 and 22 in 1914. It has been clear from the beginning, and is becoming more and more so, that it is as a part of the provision for ailing children that open-air classes justify their position in the Council's system. Educationally, they have both advantages and disadvantages, and it is sometimes difficult to decide which are the more weighty. The point upon which most of the inspectors lay stress is the increased alertness and brightness of the children after working for a time in the open air, and their improvement in general intelligence, especially in the case of those who had previously been dull or backward. This no doubt, is chiefly the result of improved health; it is also due, in some measure, to the freer curriculum which is possible, and which, in fact, is generally adopted in the case of open-air classes. Indeed, the improvement in health itself probably arises not only from the actual fact of being out of doors instead of indoors, but also from the facilities for physical exercises and games, and, in general, the greater freedom of movement made possible by the fact that the class has more space at its disposal. Special mention should be made of the girls' department of Kilburn-lane school (Paddington, N.), where, for the past three years, practically the whole department has been enabled, through the kindness of the Corporation of the City of London, to do the greater part of the work during the summer months in Queen's-park. Another piece of pioneer work has now been begun at Sirdar-road School (Kensington, N.). The Education Committee decided to establish, on a piece of ground adjoining the school, two open-air classes for delicate girls from schools in the neighbourhood. A shed has been erected for their shelter and certain other work carried out on the site; special furniture has been provided, and the classes, which are to continue throughout the year, began on the 27th October. At first some difficulties were experienced in securing the attendance of the children who were selected, and also in finding suitable teachers; these, however, have been overcome. The general impression produced by a survey of the open-air classes is that attention should be increasingly concentrated on those types of class which are specially established with a view to improving the health of delicate children, namely, type A and type B. As regards these two types, classes of type B, where the pupils are all taken from one school, should be as advantageous from the point of view of health as those of type A. They are certainly easier to arrange administratively, and have a far greater appeal for the majority of head teachers. It seems desirable, therefore, that such classes should be encouraged and extended as much as possible, that the children should be selected by the school medical officer (as is now done in the case of the type A classes), and that, as a rule, preference should be given to classes of the B type, rather than to those of the C and D types, in the matter of sites, equipment, "supply" teachers, and so on. Detailed reports have been received from the school doctors in the case of 36 playground or open-air classes held during 1920. The reports, without exception, state that special benefit was obtained by the large majority of children attending the classes in the direction of improved health. Continuous charts of improvement in height and weight were kept in most cases. The improvement noted in Open-air classes 75 physique varied from class to class according to the circumstances of the case. In general, greater improvement was found in those classes where children had been chosen on medical grounds than in classes containing normal children only; no doubt because in the former category there was greater room for improvement. Thus, in the Lucas-street boys' class (type B) (Deptford) everyone increased in height and weight, the average increase in height being 1.4 inches and in weight 4 pounds, whereas in "Latchmere" boys' class (type C) the pupils increased on an average 0.6 inches in height and only put on an average of 5 ounces in weight during the same time. Several of the school doctors independently report upon the marked absence of catarrhal conditions in the children educated in the open-air compared with those remaining in the school buildings— Wood-street (B) (held in Maryon-park)—"Eight cases of bronchial catarrh considerably improved; nine cases of enlarged glands much reduced in size" Farncombe-street (B) (held in Southwark-park)—"Children with inflammations, e.g., bronchial catarrh, nasal catarrh, etc., cleared up." Monteith-road (G)—"Cervical glands improved, 3; tonsils improved, 1; catarrh of lung improved, 1; otorrhoea arrested, 1." Virginia-road (I)—"Of seven children who had bronchial catarrh in May only two so affected in October." Cork-street (B)—"The final examination is also characterised by the absence of catarrh." At the "Chaucer" (I), special daily exercises in breathing and the use of the handkerchief resulted in six mouth-breathers being cured of their habit. No doubt the personality of the teacher has a very great effect, and where the class has the advantage of the backing of an enthusiastic head teacher in close touch, better results may be obtained. On the other hand, type A classes are very useful, as urgent appeals from hospitals and tuberculosis dispensaries for open-air education for specific children can only be met, in the absence of open-air schools in many districts, by including the children in question in the nearest playground class. Owing to the largely increased numbers of children taking part in school journeys during the summer of 1920 it was found impracticable to examine all the children after their return, but in every case a medical examination of the children was arranged before departure to ensure that all were fit to participate and especially to make certain that none were suffering from contagious, infectious, or verminous conditions. In all, 283 school journeys were notified and 9,286 children were inspected before their departure. To carry out this work the services of an additional full-time temporary school doctor were necessary throughout the summer term. In the case of 29 school journeys a medical examination was carried out of the children after their return. These were nearly all in the South- Western Division where the total number of school journeys was comparatively small. While the immediate result on the health of the children is uniformly good there is no doubt also a lasting effect due to improvement in manners and personal habits arising out of the influence of the teachers extending over the whole of the activities of the children for the period. The following extracts of reports of the school doctors are typical:— St. Saviour's (G) School, Red Cross-street.—A party of 20 girls spent 14 days at Seaford. Before their departure the school doctor noted several suffering from anaemia and enlarged glands. The school doctor reports: "The improvement in the anaemic and glandular children was most marked and in itself was sufficient to justify any expenditure incurred." Franciscan-road (G) School.—Twenty-five girls from this school spent the fortnight ending 19th May at Boxhill. The school doctor reported: "It is not too much to say that the change in appearance, the general look of well-being, and the bright vivacity of the girls was most remarkable. They had lost the tired, listless looks so noticeable at the first examination. The result of this journey to the children is eminently satisfactory and it may be hoped that it will be possible to extend the privilege on a much wider basis." Lavender-hill (G) School.—Thirty girls from this school were selected for the journey. The school doctor reports: "Several girls appear to have markedly benefited; those noted as anaemic now look better; they are brighter and have lost their languid air." "John Ruskin" (G) School.— Twenty-nine children who had been taken to Littlehampton were examined after their return. It is reported: "Without exception they all were improved in general condition and were more full of vigour and life." Physical education. At the commencement of the year 1920 the question of the future of physical training in the Council's schools came under careful consideration by the Education Committee. It was reported by the organiser that the greatest obstacle to the fullest success of the arrangements in London was the fact that many of the teachers had not enjoyed the advantages of thorough training. Following upon a report by Major Gem, the Council's organiser of physical education, it was decided to form a College of Physical Education for London Teachers, at which all teachers untrained in physical exercises might have the opportunity of attending, and at which courses in the nature of "post-graduate" work might be held for those already trained. The establishment of this college is the outstanding feature of the year in relation to physical training. Facilities for half-time attendance at the college were offered to teachers in the service and were accepted by a large number. All candidates for the course have been examined as to physical fitness by the Council's medical staff, a precaution which has proved very necessary as many elderly teachers whose health is precarious, were desirous of taking advantage of the facilities offered. Major Gem has reported that the work of the college has naturally monopolised 61004 L 2 School ourneys, 1920 Establishment of a College of Physical Education 76 the greater part of the time of the organisers of physical education since its inception. It was considered advisable to give a series of demonstrations for head masters prior to commencing the practical courses for the assistants, and over 400 headmasters attended. The commencement of the first course for assistant teachers took place on the 27th October, but prior to this the College staff gave demonstration lessons to teachers (at 25 very small non-provided schools) who are not at present eligible for attendance at practical courses. Since the opening of the practical courses this work has been continued and about 60 other schools have been visited. 151 teachers have attended the practical course, which has included (a) the Board of Education (1919) syllabus, (b) organised games, (c) swimming, (d) dancing, (e) theory of physical education, and (f) boxing—a voluntary subject. In the course of medical inspection in the schools a large number of children are found by the medical officer to be suffering from incipient deformities which can be corrected by special attention to physical exercises. It is impossible for them to receive attention at hospitals because of their large numbers, the frequency with which they should attend, the long period over which the exercises must extend, and the necessity for reserving hospital accommodation for more serious cases. Indeed, the problem, being merely that of giving special daily attention to particular children in the way of carrying out the ordinary physical exercises used in the schools, is not one which could be coped with at hospitals, nor should the children be sent to hospitals for the purpose. Faced with numbers of children on their hands for whom special provision for physical exercises had been advised, many school care committees became distressed because it seemed impossible to get the advice acted upon, and the incipient deformities in many cases developed and became fixed. In consequence of this, the Elementary Education SubCommittee, in November, 1911, decided to arrange, as an experiment, for a period of six months, for special classes in physical exercises for weakly children to be held for 20 minutes daily at eight L.C.C. schools. The experiment was placed under the joint supervision of the organisers of physical training and the school doctors. The experiment proved that, by daily exercises of 20 minutes arranged in small classes and carried out by assistant teachers who are competent to teach physical exercises, the incipient deformities above referred to are entirely corrected and the physique of the particular children wonderfully improved. The Elementary Education Sub-Committee, in November, 1912, agreed to the extension of the scheme, and from time to time have considered reports upon the classes being held. .The Elementary Education Sub-Committee, in May, 1914, decided that special classes should be formed only in schools where it is possible to arrange for a teacher already on the staff to undertake the instruction, that no special appratus should be supplied, and that the teacher should work in close co-operation with the school medical officer and the organising teacher of physical exercises. During the war, owing to shortage of staff, little extension of the scheme took place, but subsequently notices were issued in the Council's Gazette drawing the attention of the head teachers to the scheme, and, as a consequence, there are now about 25 special classes of the kind described being carried on. Meanwhile, in certain districts where no such classes were available, the school care committees pressed for some arrangement which would meet the case, and the Education Committee, in November, 1919, included in the arrangements for medical treatment the provision of three remedial exercise treatment centres. These centres should properly receive more advanced cases, such as are unsuitable for daily classes in the schools, but owing to the lack of revision of the latter classes in the neighbourhood, the majority of children attending these cent es are found to be of the early incipient type. The Board of Education suggested, in a letter in October, 1920, that no further provision of such centres should be made at present, but that the authority should extend the system of daily classes in the schools. The education officer and the school medical officer thought that an endeavour should be made during the coming financial year to increase the number of daily classes to at least 100. It was not suggested that any increase in teaching staff would be required, and until the number of classes has increased to above 100 it is thought that they can be supervised by the present staff of organisers of physical exercises. The provision of apparatus to the classes is generally to be deprecated, but it has been found of great advantage in the experimental classes to have available a set of simple Swedish forms which have undoubtedly contributed to the success of the classes. It was suggested that apparatus should be Limited to the provision of four Swedish forms for each class. The children in the classes need to be carefully examined at least once a term by the school doctor ; each class, therefore, requires three visits of a school doctor per annum. It will be necessary to ask for additional medical staff for the purpose, and it is suggested that authority should be obtained for a parttime school doctor giving three sessions a week during the coming financial year. The proposal is at present before the committees of the Council. Special classes in elementary schools Very many most interesting experunents and schemes for furthering health and physical culture have been introduced by the head teachers of various schools. One such experiment which has been closely watched by Dr. E. J. Boome has been that at the Vauxhall-street School, where the head teacher, Mr. J. J. Thompson, has endeavoured to found all the educational activities of the school upon a basis of physical training. Mr. Thompson defines the aims and results of his experiment in the following words:— Aims: To raise the physical, moral and mental standard of the boys in a school situated in a poor neighbourhood. Physically—By means of health development as the dominating factor of life and labour; by inculcating the love of cleanliness and clean living; and the abhorrence of dirt. A school whose "bias" is that of physical training 77 Morally—By means of the spirit of "playing the game"; by discipline; personal control and responsibility. Mentally—By producing alertness of mind by physical fitness. Results : Attendance—Consistent regularity with steady improvement during the year, and in some classes very considerable improvement, 87 5 to 923 per cent. Exceptionally small number of absences through minor ailments and unwarranted absences. Evidently a desire to be present at school has been engendered. Boys realise that they have something to gain by coming to school. Physical—A marked improvement in deportment, cleanliness, general agility denoting definition of purpose. The regulation requiring all physical training to be undertaken with no unnecessary clothes has led to a higher standard of cleanliness (person and clothing), especially in bare-foot dancing, eurhythmies and swimming. This aspect affects the home and parents. Accelerated growth of physique and activity is noticeable. Game-shy boys and previously considered delicate boys participate now in robust games. The records of height, weight, girth, vital capacity and well balanced muscular development are most encouraging. Moral—A spirit of sportsmanship is gradually evolving as intelligent games are learnt. Team work telling ; less quarrelling, and vicious tendencies, e.g., bullying, petty theft, destruction of property, etc., are manifest. Honour and trustworthiness are slowly becoming respected. An excellent spirit and understanding between boys and teachers is being reached. Mental—Response, industry, retentive powers, awakened interests, mental effort following physical exercise, questions asked are the improvements observable. In certain cases physical training seems to have proved to be the direct way of approach to intelligence. Permission was given by the Council to Dr. F. G. Hobson of the Oxford Physiological Laboratory to carry on investigations into physical measurements in certain London schools as part of a larger research by Professor Georges Dreyer. Vauxhall-street School was selected as one of these schools in virtue of the physical bias which there existed. Measurements of the "vital capacity" of the boys taken by Dr. Hobson have been continued by Dr. Boome, and remarkable increases have been noted in a large proportion of the boys in relation to this function. The measurements were taken as in the Oxford researches by means of a Verdin's spirometer. The investigations are being continued, but Dr. Boome has made some interesting observations which are here summarised: Previous illness and res angusta domi, both are influences which markedly reduce the vital capacity which should be attained in comparison with other standard measurements. One boy, aged nine years, who w as the son of a widow and who had himself been in the infirmary a year previously, attained a vital capacity of 0.7, whereas according to his physical measurements it should have been 1.6. Mr. Haley, one of the masters, has carefully investigated the home conditions, and in several instances boys who proved to be below their expected figures for vital capacity were found to live in overcrowded tenements. There appears to be a correlation between the occupation of the fathers and the measurements of the vital capacity of the pupils. At Lollard-street School, which was taken as a "control" to Vauxhall-street, there were 11 boys in the 200 examined who were boy scouts, and these presented a vital capacity relatively higher than the others. One boy, approaching 14, at Vauxhall-street, who in June, 1920, gave an index figure for vital capacity 26 higher than that estimated for his other measurements, was found in October to have a vital capacity slightly below his true index, and it was considered that this deterioration in physique was due to his having in the interval fallen a victim to the habit of smoking. The work being done at Vauxhall-street School is thus of great interest, and where they can be carried out Professor Dreyer's measurements prove of much value in comparing the physique of individuals. It is to be noted that in those classes which were given the maximum opportunity for physical training and games the incidence of albuminuria found by Dr. Frewen Moore at Vauxhall-street School was least. Personal hygiene. The late London School Board more than 20 years ago gave permission for voluntary nurses to visit the schools, where they examined children with cuts, sores, etc., and in 1903 the Board itself appointed three nurses whose duties were specifically extended to the supervision of personal hygiene. The Council, in its General Powers Act of 1904, inserted clauses empowering sanitary authorities to cleanse, purify or destroy articles which the medical officer of health certifies are filthy, dangerous or unwholesome; and powers were also obtained to compel owners to strip and cleanse any house or part of a house certified by the medical officer of health to be infested with vermin. This Act was followed in 1907 by another General Powers Act and in 1908 by the Children Act, in both of which Acts powers were obtained to examine school children and, if necessary, after due warning, compulsorily convey and detain for cleansing such children as were found to be verminous. In 1910, after some experimental work had been carried out at Westminster, Bermondsey and Whitechapel the Council decided that the powers obtained in the Acts above referred to should be used throughout London as a whole and accordingly agreements were entered into with several borough councils for the use of their cleansing stations, generally at a flat-rate remuneration of 2s. payable by the L.C.C. in respect of each child cleansed. In those districts where there were no stations already in existence the Council proposed to establish its own stations for dealing with school children only. In 1913, 22 stations were available for this cleansing work. The figures as to the number of cleansings carried out were: Council stations, 11,636; other stations, 29,822 ; a total of 41,458. Factors causing alteration in "vital capacity " 78 The results of the work for the several years 1912-1920 of the cleansing station nurses arising out of inquiries and examinations of the district school nurses are shown in the following table :— Year. No. of Examinations Made. No. of Children Verminous. No. Cleansed by Parents. No. of Verminous Children Cleansed at Stations. No. of Scabies Cases Bathed at Stations. No. of Cleansings for Vermin and Scabies. 1912 630,359 23,573 10,179 10,340 - 26,913 1913 858,691 29,903 15,241 14,662 - 41,458 1914 917,582 28,361 14,392 13,969 589 42,557 1915 1,006,546 28,063 14,677 13,386 1,059 43,884 1916 988,288 24,705 11,314 13,391 3,213 54,945 1917 798,643 19,506 8,506 11,000 6,940 80,755 1918 516,566 13,237 4,912 8,325 9,624 95,033 1919 566,178 33,222 15,929 17,292 8,371 105,639 1920 822,337 43,764 16,355 27,409 9,675 123,975 It should be noted, however, that the total number of examinations made during 1920 by district school nurses at rota visits amounted to 1,944,105; the number of children found verminous was 368,732, or 18'96 per cent., as compared with 22.6 per cent. in 1919. For the first four years the numbers dealt with under the scheme increased, but owing to the additional work arising, mainly out of dealing with children suffering from scabies, the time given by the nurses to the work of following up was somewhat restricted, hence the reduction in the number of examinations made in the next succeeding years. The conditions arising out of the war no doubt gave rise to the spread of scabies as well as of ordinary verminous conditions; several cases did, in fact, come under notice of scabies having been communicated to the children by soldiers. To deal with these new developments 10 additional nurses were appointed in 1918 by the Council. At the same time additional baths were provided at the stations in order to cope with the increased demand for cleansings. Cases of scabies seen by school doctors and nurses, or at hospitals and treatment centres, were advised to attend the stations for medicinal baths and arrangements were made for certain stations to be kept open during the school holidays in order that immediate steps could be taken for dealing with the condition. In 1919 the scheme was further improved, more particularly in the direction of providing for children who were only slightly infested. These children had been gradually eliminated from the scheme for the reasons already stated, but it was now decided to include again all such cases within the operations of the cleansing scheme. More facilities were given for voluntary attendances at stations for cleansing, in order that cases might be dealt with at the first sign of infestation, and more stringent action was taken in those cases where the parents persistently sent their children to school in an unsatisfactory condition. The temporary additional nursing staff granted in connection with this further extension was 18. The working of the revised scheme took effect in the latter part of 1919, as will be seen from the increased number of verminous children examined in the years 1919 and 1920 and from the increased numbers relating to the children cleansed at the stations (as set out in the table). In the case of children reported by the school nurses as verminous (whether in head or body) provision was made for a notification to the medical officer of health at three stages of the scheme, and the medical officer of health was asked to state on a slip attached to the notification the action, if any, which was taken regarding the disinfection of clothing, bedding, etc., in the homes. The outbreak of war interfered considerably with the activities of the boroughs in this direction largely owing to depletion of staffs, and ultimately it was decided to limit notifications to cases of body infestation only, on service of the statutory notice, it being understood that action would be taken wherever possible thereon. With a view to securing as great a measure of co-operation as possible several of the borough medical officers were recently visited by the superintendent of school nurses, when the question was discussed and arrangements have been made for consultative meetings to be held between the local sanitary and school nursing staffs. During November and December, 1920, the Council had under consideration the question of providing additional facilities for slight head cases. Hitherto, one of the main difficulties in connection with the Council's cleansing scheme has been the opposition of parents, of those children whose heads contained nits only, to the necessary cleansing being carried out at the stations where bad cases were dealt with. In order to meet this objection the Council has now decided that differentiation should, where possible, be made in dealing with these two classes by arranging that slight cases shall be treated at minor ai ment treatment centres or at special "shampoo centres," thus removing these cases from the ordinary cleansing stations. The Council has stipulated that ten new centres are to be established for this purpose in boroughs where adequate provision is made by the borough council for the proper cleansing of the other inmates of the child's home, as well as of the home itself and of the bedding, etc. This will necessitate the appointment by the Council of five additional nurses. Hitherto, in the case of a badly infested head it has been almost impossible to remove the nits without cutting the hair, but the Council has had brought to its notice a special comb which, used in conjunction with a shampoo soap, has proved very efficacious in removing nits without resorting to hair cutting. Thus, a further objection on the part of the parents has been removed. The soap is prepared by taking 1 lb. soft soap, 10 ozs. paraffin and 6 drams turpentine, the whole being thoroughly 79 mixed while warm and stirred well until completely emulsified. The hair is thoroughly washed with this preparation and after an interval of about 10 minutes, the comb is used. It is estimated that the proposed new centres will provide facilities for dealing with some 35,000 extra cases annually and it is anticipated that a considerable improvement in the standard of cleanliness among school children will be effected. The number of cleansings given during the year was 123,975 as compared with 105,639 in the previous year. During 1920, an additional cleansing station was opened by the Council in the Old Ford district, but the station established by Miss McMillan at Wellington-street, Deptford, was closed in August, and the Kensington Borough station was only at work for 7 months, the borough council having decided on its demolition in connection with their housing scheme and the erection of a new station on a different site. Agreements are now in force with 16 of the 29 local authorities (an agreement is, moreover, pending with Stepney) and with one voluntary committee. The 12 boroughs councils with which there is no agreement are Bermondsey, Bethnal Green, Chelsea, Finsbury, Fulham, Hammersmith, Holborn, Lambeth, Lewisham, Paddington, Shoreditch and Wandsworth; the majority of these boroughs have made no provision under the Cleansing of Persons Act, 1897. The total number of examinations made of children who were followed up under the cleansing scheme was 822,337; verminous conditions were found in 43,764 of these andsecond warnings given. In 14,745 of these latter cases advantage was taken voluntarily and without further warning of the facilities offered for cleansing at the stations, but in 16,384 instances it was necessary to serve, after a further examination, statutory notices ; following upon these statutory notices 4,572 children attended the stations voluntarily, but of the remainder 8,092 were found verminous after a still further examination and were compulsorily taken by the nurses for cleansing. Among the children who were compulsorily cleansed, 628 were subsequently found to have relapsed and prosecutions under the Act were instituted in 528 cases. The practice was continued throughout the school holiday of arranging for the cleansing stations to be kept open, where possible, in order that there might be no interruption in the treatment of scabies cases. The number of children treated at the stations during the year was 9,675, showing an increase of 1,304 over 1919, whereas in the latter year there was a decrease as compared with the figures for 1918. On the other hand it is satisfactory to note that the measures taken resulted in quicker cure, and although there was an increase in the number of cases there was a decrease in the number of baths per child. Much attention has been given latterly to the question of scabies by Dr. Nash, and arrangements have been made to carry out certain suggestions made by him for enabling a stricter control to be maintained during the current year. In the course of his investigations Dr. Nash found that often the difficulty in securing effective control is the interval that elapses between the notification of the case to the local sanitary authority in order that infected bedding may be dealt with, and the actual date of disinfection. In some boroughs as many as 14 days, while in others only 3 days, elapsed. The method of treatment also varied considerably, but that carried out at the Southwark station (Izal baths and sulphur ointment) appeared to Dr. Nash to be the most effective in shortening the period of treatment. Towards the end of the year attention was drawn by Dr. Parkes, M.O.H. of Chelsea, to a method adopted in Denmark for curing scabies. Experiments were tried at the Council's stations with the preparation used in Denmark and, although it is early as yet to form definite conclusions, there appears to be no doubt as to the value of the method so far as rapid curing of the condition is concerned. The question of re-infection (after being completely cured) by unsatisfactory home conditions, however, still remains as an outstanding difficulty. The experiment of bathing certain children of the 6-8 age group referred to in last year's annual report, has been continued successfully in Camberwell and Kensington. The question of extending the scope of the scheme and including the borough of Shoreditch is now under consideration, but in the meantime the Board of Education has been asked whether the extension of the scheme would rank for grant in payment of 50 per cent. of the cost. The following report by Miss Marion Moore, the head teacher of Sirdar-road girls' school, shows how the teachers are entering into the scheme:—"A group of girls from this school has attended Lancaster-road baths, in order to have hot baths, for some months. The homes of the children are very overcrowded, and there is no bathing accommodation in them. When the matter was put before the girls they were eager to go and the parents were willing for them to do so. The baths are much appreciated by the children, who benefit by them. Plenty of hot water, a properly constructed bath, a warm private room, are comforts they cannot have in their own homes, and strongly appeal to girls of thirteen and fourteen years of age. Attendance at the baths does take the girls out of school for a time, but by judicious arrangement of the time-table, they lose as little time as possible, and the nurses have been at a great deal of trouble to arrange for the baths to take place at a time suitable to the school. I consider the baths of great value as a means of training in citizenship in this particular district, and I should be glad if more children could be allowed to attend." The number of baths arranged for under this scheme during 1920, was 6,978 in Camberwell and 6,434 in Kensington, a total of 13,412. Education (Provision of Meals) Act. In the section on the results of medical inspection, it was pointed out that there has occurred a slight deterioration in the general nutrition of the children during 1920. This deterioration is closely followed by the increase in the number of necessitous children fed, which has grown with each succeeding Scabies, Use of public washing baths by classes of children during school hours. 80 month. month. The following table gives comparative figures for the final twelve weeks of school attendance in the years 1919 and 1920 :— Final twelve weeks. No. of necessitous children fed in public elementary schools. Number of meals to necessitous children. Dinners. Breakfasts. Milk. Oil. Total. 1919 113,747 240,981 11,907 307,801 28,337 589,026 1920 191,514 551,618 38,875 383,545 40,298 1,014,336 Supervision of dietaries. The close association of the school medical work with the administration of the provision of Meals Act is shown by the large proportion milk or cod liver oil "meals" bear to the total, as the choice of these methods of feeding follows almost entirely upon the advice of the school doctor. In connection with the scheme for the supervision of dietaries served to necessitous and other children, the systematic examination of milk meals has been continued during the year. The total number of samples dealt with was 1,087. The improvement noted in 1919 in the general quality of the supplies has been continued, only 4.9 per cent. of those examined being reported to be unsatisfactory, whereas the corresponding figure for 1919 was 8.6 per cent., and that for 1918, 31 per cent. The maximum addition of water found in any one sample during the year was 38 per cent. As much as 53 per cent. was found in one sample examined during the previous year ; the largest percentage of fat abstracted was 33, as compared with 40 per cent. reported in 1919. It is to be noted that during the months of October and November last, all the samples examined were reported to be satisfactory. The continuance of the improvement in quality is probably attributable to the knowledge that an analytical control is kept upon all deliveries. Periodical examinations of samples of meals other than milk meals have been made as in former years. In a number of cases the result has shown the meal to be below the recognised standard in nourishing or heating constituents, and steps have been taken to remedy the deficiency. Scarlet fever. Infectious diseases. During 1920, 11,860 cases of scarlet fever occurred among children attending the Council's public elementary and secondary schools, as compared with 22,717 (uncorrected) cases among persons of all ages (see Diagram, p. 81). On the whole, the type of illness was mild, and a large number of ambulant cases remained undiscovered until the desquamation stage appeared, and there is no doubt that a very large number of similar cases were never detected. During the height of the epidemic it became necessary to augment the staff temporarily by the appointment of two medical assistants on infectious disease work. The numbers of special enquiries into scarlet fever necessitating school visits during the year was 681. A noteworthy feature of the epidemic was the manner in which the disease persisted in certain districts, whilst other areas were comparatively slightly affected. The districts mainly attacked were in the East End (Stepney, Poplar, Bethnal Green), the area contiguous to these boroughs across the water (Bermondsey), and, to a less extent, the extreme western border of the county (Fulham and Hammersmith), and the extreme north-eastern districts (Stoke Newington and Hackney). There were evidences, however, during the last few weeks of the year that the disease was becoming more prevalent in the south-eastern districts (Greenwich and Deptford). Only one school was closed, viz., Hotham-road school, Putney (Borough of Wandsworth), during the last two weeks in November, and in this case the closure was ordered by the local sanitary authority under article 57 of the Board of Education Code. The adoption of such a drastic measure, entailing as it does dislocation of school work and loss of education, should not be lightly undertaken. During epidemic periods there is often least justification for school closure, owing to the ubiquity of agencies of infection. It usually happens, moreover, that closure of a school on account of infectious illness is carried out when the outbreak has passed its meridian of intensity, or, in fact, has spent itself. Diphtheria. Diphtheria.—During 1920, 5,841 cases of diphtheria were reported as occurring among school children as compared with 13,804 (uncorrected) among persons of all ages. These figures are the highest recorded since the establishment of the school medical service, in fact for nearly thirty years. The number of visits by the Council's medical staff to schools specially involved during the course of the year was 311. During these investigations large numbers of children in the affected classes were swabbed with a view to discovering carriers of diphtheria germs. During the year, 5,811 swabs were taken, and of these 721 showed positive results. In the majority of instances these "carriers" clear up and are able to return to school within a month. A small proportion of cases, however, become persistent, and are very resistant to treatment. The following analysis of 493 cases discovered during 1920, or outstanding at the end of 1919, shows the periods elapsing between the dates on which children were found to be carrying diphtheria germs and the dates on which they were free from bacilli, and in a fit condition to return to school. Period. Number of cases. Up to 4 weeks 324 4 to 8 weeks 111 8 to 12 weeks 27 12 to 16 weeks 12 16 to 20 weeks 9 Period. Number of cases. 20 to 26 weeks 3 6 to 9 months 5 9 to 12 months 1 18 months 1 81 82 With the object of securing greater control over carrier cases, the medical officers of health in seven of the metropolitan boroughs (Lambeth, Wandsworth, Paddington, Battersea, Hackney, Greenwich and Kensington) require them to be officially notified, and in this connection 99 notifications of cases of bacteriological diphtheria discovered among school children were forwarded during the year. This method is open to objection, however, inasmuch as, if widely adopted, it creates artificial epidemics: there is also the further point that, in view of the length of time some of these unfortunate carriers are harbouring germs, it would be impracticable, even if desirable, to insist on strict isolation, nor would it be desirable to treat them in an isolation hospital intended for the accommodation and care of acute cases. In fact, the medical superintendents of Metropolitan Asylums Board institutions, as a rule object to receiving carrier cases into their hospitals, and most of the general hospitals are also reluctant to receive them in their out-patient departments. In one hospital, however, limited numbers of carriers are being dealt with each week as out-patients, and a special form of vaccine treatment is being under taken. Special methods of treatment are also being carried out under the supervision of Dr. Wells, one of the Council's divisional medical officers, and his report is appended. Report on " Diphtheria Carriers;'' by Dr. A. G. Wells. "During the year 1920, thirteen cases of "diphtheria carriers" were submitted to me to be investigated and supervised. The plan adopted was to make a careful clinical examination of the nose, throat and ears, as well as a bacteriological test. In cases which showed unhealthy tonsils and nasopharyngeal growths an attempt was made, as a first step, to get this condition dealt with by operation. This was not an easy matter. If the attempt was made at a hospital, the case was refused when it was known to he a "diphtheria carrier," though in point of fact many undiscovered cases of this kind must be operated on daily. Some were, however, operated on more or less satisfactorily, and others, again, did not require such an operation. If ear discharge was present, that, of course, was treated concomitantly. "The next step was the treatment of the nose and throat with a solution containing potassium chlorate and other salts, which has a solvent action on diphtheritic material. The practice was to douche the nose and throat, but the treatment could only be carried out at home in most of the cases. Weekly swabs were taken, and if a negative result was not recorded after a short time, the treatment was varied. "Altogether nine cases (having cleared up during the treatment) were returned to school after three negative results. Six cases responded with a negative result within a week, but one of these relapsed. One responded after two weeks, and one after three weeks. The other cases have been intermittently positive and negative, and, with one exception, have not yet cleared up. One of the unsuccessful cases, however, was found not to have had any treatment at all for the nose (which was constantly positive), while the throat, which had treatment, varied in result. "Of the above thirteen cases, eleven had various degrees of nasal catarrh and rhinitis, six had definite pharyngeal catarrh, three had enlarged tonsils, five had palpable adenoids, and three of the cases were operated on. Other conditions found, which probably have a definite relation to the persistence of the organisms, are ulcers in the nasal mucosa, hypertrophy of the turbinals, deflected septum, in fact most pathological conditions of the nose. "There did not appear to be any very marked differences in the cases, with the exception that in two of those that cleared up the defects were very slight, and consequently there were no indications to go upon before treatment was administered, as to which cases would be likely to clear up and which would not. In view of the fact that about 8 per cent. of all throats show organisms resembling B. Diphtheriæ, which are non-pathogenic when inoculated into guinea pigs, it would seem hardly justifiable that cases should be kept away from school for an indefinite period. In the absence of any clinical symptoms in the patient or of actual clinical cases of diphtheria at the school, it may be advisable in the future to allow such children to attend school." Local persistence of Diphtheria. Instances of the persistent prevalence of diphtheria in certain schools or localities over a period of two or three years have frequently been observed (see annual report for 1912, p. 154), and in this connection it will be of interest briefly to record a series of outbreaks which occurred in North-East London during the period 1918-20. The area affected may be described as a rectangle measuring, roughly speaking, 3 miles long and 2 miles wide, and comprising the southern part of the borough of Hackney, which included the Dalston and Homerton groups shown in the following table ; the whole south-eastern border of the borough of Islington with a small part of Stoke Newington, represented by the Stoke Newington and Islington groups ; and the northern half of the borough of Shoreditcli, comprising the Hoxton and Haggerston groups. TABLE showing a Series of Outbreaks or Diphtheria in N.E. London during the Three Years, 1918, 1919 and 1920. Essex-road. STOKE NEWINGTON GROUP. Kingsland-road. DALSTON GROUP. Mark-street HOMERTON GROUP. School. 1918. 1919. 1920. School. 1918. 1919. 1920 School. 1918. 1919. 1920 Newington-green 11 37 14 Gayhurst-road 4 22 15 Morning-lane 51 6 2 St. Jude's 3 3 8 Eleanor-road 6 4 6 Berger-road 8 20 3 St. Paul's 1 2 6 London-fields 5 10 10 Homerton-row 9 14 9 Princess May road, 8 4 36 Enfield-road 2 1 22 Orchard-street 1 17 9 Wordsworth-road 5 5 10 Bay-street 1 2 10 St. Matthias 8 3 5 83 Essex-road. ISLINGTON GROUP. Kingsland-road. HOXTON AND HAGGERSTON GROUP. mark-street. Queen's Head-street 1 11 85 Hasgerston-road 4 22 19 Ecclesbourne-road 6 7 26 Canal-road 6 2 4 Popham-road - 13 34 Laburnum-street 1 4 6 Rotherfield-street 4 5 22 Gopsall-street 6 4 20 Shepperton-road 1 2 14 Hamond-square 6 7 10 St. John's - - 2 Shap-street 2 - 12 Hanover-street 5 7 33 Napier-street 13 8 15 St. Matthew's 2 2 12 Trinity-place 3 - - Wenlock-road 1 - 12 Note.— In the above table the schools are arranged roughly in order of their proximity to each other and are grouped within defined areas demarcated or traversed by the three main thoroughfares indicated viz., Mare-street (Hackney); Kingsland-road (Hackney and Haggerston); Essex-road (Islington). It will be seen from the above table that in each group there are one or two schools which are predominantly affected. These are shown in bold type. The original outbreak made its appearance at Morning-lane school, Homerton, in the autumn of 1918, and was short, sharp and severe. There were 12 cases in September and 33 in October, confined, with the exception of three cases, to the infants' and girls' departments. The type of illness was severe. The school was repeatedly visited by assistant medical officers, and large numbers of children were swabbed, with the result that many carriers of diphtheria bacilli were discovered and excluded from school. The outbreak ceased as suddenly as it appeared. On the other hand, in the schools in the immediate neighbourhood, Berger-road, Homertonrow, and Orchard-street, which were also affected in 1918, though to a less extent, the disease persisted endemically throughout 1919 and 1920. The next outbreak occurred at Newington Green school in the borough of Islington. There was no apparent direct connection with the Homerton prevalence, as the two groups of schools are two or three miles apart. The outbreak at Newington-green was confined to the infants' department, and commenced in February, 1919, when four deaths occurred among children attending the same classroom. In two of these cases the cause of death was not reported as being due to diphtheria but to a "septic throat" and "chicken-pox which went to the throat "respectively. They were, however, undoubtedly unrecognised cases of diphtheria. During the period February to July, 1919, 29 cases occurred, and repeated visits of enquiry were made by the Council's medical officers. All the children attending the infants' department, numbering 534, were swabbed, and of these 43 were found to be "carriers" of diphtheria bacilli. No cases of diphtheria were reported in August or September, but cases commenced to reappear in October, and continued to occur until March, 1920. There was a fresh introduction of infection in September, 1920, which continued to the end of the year, when the outbreak subsided. The outbreak at Princess May-road school in the same group and within a mile of Newington Green school did not occur until the end of 1920. As in the case of Morning-lane school, the period of invasion was short (2 months) and the type of illness severe. The prevalences in the Dalston group and Hoxton and Haggerston group followed hard upon the heels of the Homerton epidemic, whilst the Islington outbreak, the most severe of the series, prevailed in the latter half of 1920, and the early part of 1921. A review of this local prevalence over the whole period of three years appears to indicate that there were originally two separate epidemic centres, viz., at Homerton and at Stoke Newington. From the Homerton focus the disease apparently spread southwards through Dalston, Haggerston, and Hoxton, and similarly from the Stoke Newington centre of infection the epidemic followed a south westerly direction towards the Islington group, the southernmost schools of which link up with the schools in the, Hoxton area. The effect of holidays, especially the prolonged midsummer holidays, upon the prevalence of scarlet fever and diphtheria has frequently been discussed in these reports. The marked decrease in the number of notifications received during August results from diminished exposure to infection on the one hand, and decreased supervision of ailing children on the other. Regarding the latter factor, non-attendance at school interrupts the supervision of teachers and school nurses, and undoubtedly leads to mild cases of disease—more especially of diphtheria—escaping detection and notification; but there are no means of determining the number of cases thus missed. They may be few in number, but they are a potential source of infection when schools reassemble, a circumstance which has to be borne in mind in interpreting what follows. The decrease arising from diminished exposure of the children to infection during holidays is accounted for first by limitation of contacts and secondly by absence of children from London. Some time ago endeavour was made to determine the relative value of these two factors. Information was obtained from a number of children as to the length of time they were away from London during the summer holidays ; and from the resulting figures it was deduced that the average period of absence was for all children of school age less than one week, and that the reduction in the child population of London could be taken to be about 12 per cent. This percentage, therefore, of the total decrease can be regarded as approximately due to holiday exodus. 61004 M 2 School Holidays in relation to the spread of Scarlet Fever and Diphtheria. 84 85 The calculation of the total reduction in the number of cases resulting from holidays is a matter of some difficulty. It is necessary to determine approximately the contour of prevalence as it would be if there were no holidays, and the simplest method is, of course, to assume that the cases would increase from week to week during August at the same rate as in July, that the curve of incidence from July to, say October, is, in fact, a straight line. The error involved in such an assumption is not determinable from consideration of the London figures alone, and in order to form some idea of its magnitude it was necessary to examine the records of seasonal prevalence of other towns in order to find a case where the maximum seasonal prevalence fell at some time of the year when school holidays could not affect the seasonal contour. New York furnishes the best contour for the purpose, and the figures relating to that city which were kindly supplied by Dr. Bolduan to Mr. Spear are exhibited in the diagram on p. 84—where corresponding figures for Paris supplied by Dr. Bertillon are similarly reproduced. It will be noticed that the New York curve is decidedly asymmetric, reaching a maximum in the course of eight months and falling to a minimum in four months, and the London contour, if allowance be made for the effect of holidays, is also evidently asymmetric. An experimental curve was obtained by combining the figures for New York and Paris and calculating from the resulting contour the effect of midsummer holidays in London, and close examination showed that an assumption of linear progression during this period does not give results which differ seriously from the more accurate method of calculation in the series of years in question. ' The total number of cases represented by the difference between the cases actually recorded in August and the calculated number were holidays not in operation involves, for ages 5-13, an addition to the actual figures of about 22 per cent. Similar contours are shown for diphtheria, but there is in this case nothing like the pronounced seasonal recurrence found in scarlet fever, even in New York; nor do the contours show anything like the same degree of asymmetry. The irregularity of the diphtheria contour appears to be to some extent due to a tendency for the notifications of the two diseases to fluctuate in harmony, a point to which reference has elsewhere been made; it may, however, be remarked here that the high proportion of cases of diphtheria in New York and in Paris during the period February-June, absent in the London curve, is probably a reflex of the high scarlet fever incidence in those cities at this period, not found n London. In the case of diphtheria the calculated addition to the actual cases in the midsummer holiday period required to allow for the effect of the holidays was found to be about 26 per cent. ; this compares with the corresponding figure for scarlet fever given above of 22 per cent. The difference in the two percentages might suggest that school attendance plays a greater part in the case of diphtheria than in scar et fever ; here, however, the loss of supervision during the holidays, to which reference has been previously made, comes into account; for the bacteriological testing of the children's throats on the scale adopted in any affected school or class room during term time is absent, and this circumstance probably suffices to explain the difference between the percentages found. The high incidence of scarlet fever in 1920 simultaneously with the relatively even higher incidence of diphtheria put a severe strain upon the resources of the Metropolitan Asylums Board especially during October. Uncertainty as to when the climax of the combined epidemics would be reached added to the difficulty of allocating the available accommodation. The value of some means of forecasting the course of the epidemics thus became apparent, and possibly gave rise to a note upon this point by Dr. Brownlee in the Lancet for 27th November (p. 1093). The method adopted was that of fitting a normal curve of error to the observed case-sequence in the nine large London epidemics since 1890, and from the sequence of the weekly cases for the seven weeks known at the time of writing his note Dr. Brownlee deduced by means of the auxiliary curve, the probable case-sequence of the epidemic in the following eight weeks, with a fair amount of accuracy. It has, however, been shown above that the autumnal curve for London is asymmetric, when the effect of school holidays is allowed for; that is to say that theoretically the curve of case-sequence cannot except for short periods and more or less accidentally follow a normal curve of error. The forecasting of the course of an epidemic must under any circumstances be somewhat unsatisfactory from the point of view of the authorities upon whom falls the duty of providing the requisite hospital accommodation, for while a few hundred cases more or less than the estimate does not disturb the equanimity of the prophet, an unexpected demand for two or three hundred beds is a different matter. It may well be asked, with the present high incidence of scarlet fever in view, what are the prospects for this year ? Already, during January and February, the cases notified number over 4,000 whilst in the corresponding period of last year less than 2,500 cases occurred. In past years the total of the cases for any given year has not depended upon the prevalence in the opening months; the correlation has been found to be greater between the cases recorded in July or June and the year's total than with earlier months, so that a forecast of the probable incidence for 1921, would be mere guess-work until about July. It will be noticed from the diagram (p. 81) that in London scarlet fever has tended to recur at intervals of about six years with epidemic force. The epidemic of 1907-8, was followed by that of 1913-4 and this again by that of 1920-1. Upon these major "waves" the annual seasonal fluctuations are super-imposed. At times these seasonal curves are imposed upon a rising major "wave"; at others the major "wave" is falling or level; and it is obvious that the contour of case-sequence for a given year is to some extent influenced by the phase of the major "wave" in that year. On an ascending major "wave" the seasonal maximum is attained later than on a descending "wave." The changes are shown in Sec. I of the diagram on page 87: in the epidemic year, 1913, the maximum prevalence occurred in the middle of the last quarter, but in 1915 it appears 86 earlier—in the first month of the quarter—and in 1916 slightly earlier again. Similarly in 1919 the maximum is shown in the middle of the quarter, but it is earlier in 1920. The major " wave " appears therefore already to have atta'ned its maximum in this epidemic. An exceptionally wet summer would speed the parting guest, but an exceptionally dry summer might make him linger. Scarlet fever and diphtheria in relation to flea prevalence. In the annual report for 1917 a summary was given of the evidence collected during the preceding nine years bearing upon the hypothesis that scarlet. fever is commonly transmitted by the flea (Pulex irritans). This evidence was considered under ten heads. As regards heads (iv.) to (x.) (with an exception to be referred to later concerning the relation of flea prevalence to rheumatic fever—a maladv belonging to Dr. Longstaff's scarlatinal group of diseases—and the bearing of this upon geographical distribution) there are no fresh facts to adduce, the case stands where it did; a word may, however, be said concerning the latest experience gained under heads (i.) to (iii.). (i.) It was noted in 1917 that there was a close correspondence in form between the last nine seasonal curves of scarlet fever and of flea prevalence, and that the autumnal maximum of the latter had invariably antedated that of the former, the antedating being by periods of from one to eight or more weeks. The years 1918, 1919 and 1920 conform with this rule ; the antedating in question last year was by a period of two weeks. The occurrence of this antedating in each year, over a succession of 12 years, is a notable phenomenon. (ii.) and (iii.) relate to the correspondence between the contour of the major wave of scarlet fever, The corresponding curve depicting annual flea prevalence, and the cycles of dry and wet years. Points of some interest are to be observed with regard to the most recent developments in this connection. The crests of the major waves of prevalence were encountered in 1863,1870,1875,1880,1887,1893,1901, 1907 and 1914—the interval between crest and crest being from 5 to 8 years. The wave of scarlet fever swelled from the trough of 1916-17 during 1919-20. As regards the flea curve a maximum was attained in 1914, corresponding with the scarlet fever maximum; thereupon followed a decline; while, however, 1920 showed a distinct rise, the level attained by the flea curve was not equal to that of 1914. The following comments may be made on this : (a) The special attention directed to flea bites since 1909, i.e., during the last 12 years may be credited, perhaps, with producing some good effect. (b) But, on the other hand, the rise to the maximum in scarlet fever may not be completely accomplished until next autumn, and by that time the flea curve may rise to a higher level than that already reached. It may be noted that the evidence of flea prevalence, forthcoming from common lodging house inspections, shows a rise continued from last spring through autumn and winter and still maintaining a comparatively high level even during the first three months of this year (1921). (c) There is some reason for thinking that the rapid rise in " notified scarlet fever " to its seasonal maximum last October, may have been somewhat steepened by concurrent development of " influenza " prevalence. As scarlet fever ran up, a mild epidemic of influenza was steadily gaining ground in London. In some cases of influenza, especially in children, a rash not very unlike that of scarlet fever may be developed ; moreover, during November and December, 1920, and January, 1921, " glandular fever " was reported as occurring in various parts of London (see p. 89) ; and here, again, disturbance of the figures relating to scarlet fever and influenza was likely to be brought about. The behaviour of the statistics of scarlet fever and of influenza also will, therefore, be watched with much interest during the next ensuing months. It has been urged, by an interested observer of the recent behaviour of scarlet fever, that were the flea hypothesis true a greater rise in the flea curve should have accompanied tha of scarlet fever last October. (See Section I of diagram p. 87 ) It needs to be remembered, however, that the flea hypothesis does not necessitate a precise correspondence between the fluctuations of the flea and scarlet fever curves. An important influence affecting scarlet fever prevalence, which does not necessarily involve flea prevalence, is the extent to which a new generation of susceptible young children, as yet unattacked ty scarlet fever, has grown up since the last considerable prevalence. Here the low birth rate following upon the date of the last wave crest (in 1914), and the recovery of the birth rate in 1919 and 1920, must have had some influence. Again, dry and wet cycles do not manifest their effects upon the fleas and the scarlet fever at precisely the same points of time. In this connection the long, dry spell of weather in the spring of the present year may have first favoured flea development and then somewhat later been in part accountable for the delayed fall of the weekly notifications of scarlet "fever, which was a striking phenomenon during February and March, 1921. A rise in the flea curve should, however, as a rule, always ante-date a rise in scarlet fever, and this requirement has hitherto invariably been complied with. It is a matter of some interest to note that following upon the exceptionally high scarlet fever prevalence of 1893, the notifications of scarlet fever remained just about the average in the first three quarters of 1894, but no autumnal rise above the average was observed in the 4th quarter. (See diagram p. 81). It remains to add a note with regard to the geographical distribution of the human flea, and of a men.ber of the scarlatina: group of diseases, to wit, rheumatic fever. In heading (ix). of the ten heads of discussion in the report for 1917, it was stated that Pulex irritans and scarlet fever both appear to have spread, with increase in facilities of communication from Europe to other parts of the globe. In a paper contributed last year by Mr. J. Tertius Clarke of Perak to the Society of Tropical Medicine and Hygiene (Trans. 1919-20, p. 83), entitled " The Etiology of Rheumatic Fever from a Tropical point of view," it is pointed out that rheumatic fever, and scarlet fever also, are practically unknown in the tropics. " In the State of Perak during the years 1912-17 inclusive, there have been 97,914 deaths recorded in a mean population of 548,606, and not one of these deaths has been ascribed to rheumatic fever." It is further noted that Sir James Cantlie in the year 1899, in the Journal of Tropical Medicine, was the first to publish the observation that scarlet fever is not encountered 87 88 in the tropics save as an imported infection and never spreads. It is added that " The number of fleas in the tropics is small compared with the numbers in Europe "and that "The human flea (Pulex irritans) and the European rat flea (C. fasciatus) have not been found in the Federated Malay States." Mr. Clarke referred in his communication to the observations on the flea and scarlet fever which have been made in London, and at the request of the Secretary of the Society of Tropical Medicine and Hygiene I contributed a note, which appears (p. 89) as an appendix to Mr. Clarke's paper. Comparison between the curves of seasonal prevalence of scarlet fever in New York, Paris and London. High autumnal prevalence of scarlet fever is the rule in London year after year and it seems strange, therefore, to find the contours of seasonal incidence shown for New York and Paris strikingly different from those of this country. In German and Scandinavian towns, however, the English autumnal periodicity appears to be the rule, at least in those the records of which have so far been examined. The amplitude of the yearly wave in New York is far in excess of that for London, and this suggests the possibility that the density of the populations concerned may have an influence in this connection. In order to determine this point, the London periodicity has been examined in relation to " social condition," which is, of course, much the same thing as the density of population. It will be seen from section 4 of diagram p. 84 that in the denser populations of group 3 the amplitude is much greater than in group I, It has further been found that there is also a considerable degree of relationship between the amplitude of the " major waves," or recurrent epidemic periods, and the density of the population; the relatively severer incidence in epidemic years upon the crowded populations being followed by years of relatively decreased incidence. The density of the population has, then, much to do with the amplitude of the "seasonal" wave; and the conclusion seems to be warranted that the explanation lies in the fact that in the denser populations the disease runs more quickly through the population and consequently more thoroughly picks out the susceptible persons, leaving a population of resistant or insusceptible persons, and as a result a relatively lower incidence of the disease. On the other hand in the less dense population the infection threads its way more slowly, and a corresponding degree of exhaustion is in this case not reached. This explanation does not, however, account for the maximum incidence occurring at different times of the year in different towns ; but it is possible that here also the density of the population comes into account, though in a different manner. If the direct operation of climatic conditions be disregarded, the cause of seasonal periodicity must be one that recurs annually and at about the same time of the year in any given town. In the diagram (p. 84) showing "seasonal" incidence in London, Paris and New York, the range of the midsummer holidays is shown. In New York the holidays cover annually a period of some ten weeks, in Paris eight and in London four and a half weeks. During these periods, as has been shown earlier, the population is reduced in density ; probably the proportion of reduction is greater in the more densely populated parts of New York than in those of London. At this time of the year then the course of the infection through the population is largely interrupted in New York ; and when the schools reassemble, many of the " threads " of infection have been broken. In London on the other hand, the interruption is nothing like as great and may not suffice to disestablish what is perhaps to be regarded as the "natural" periodicity. The London holiday period of four and a half weeks applies, however, only to children of the Council's schools ; in the case of private schools the midsummer holidays are considerably longer, and average perhaps seven or eight weeks. Not only, therefore, would children attending private schools, as a whole, live in less densely populated areas, but their density would be more largely reduced in holiday time, and for longer, than in the case of the " Council children." With these facts in mind, the contrasts shown in section 4 of diagram p. 34 may be in some measure accounted for. In group I. of metropolitan boroughs in which the proportion of "Council children" of ages between 5 and 13 is least, the incidence of scarlet fever increases from the beginning of the year ; in group 3, the poorest districts, however, there is a decline to a decided minimum at about Easter time. The proportion of " Council children " in the least poor districts varies between 60 and 80 per cent., while in the poorest group the percentage is about 100. Assuming that the " Council children " form 70 per cent. of the total school children in the first-named districts, and that the seasonal contour relating to them roughly follows that of the children of the poorest districts (a considerable assumption this) attempt may be made to arrive at an approximate seasonal contour for the 30 per cent. of private-school children in the first-named districts. A contour obtained in this manner shows some resemblance to those of Paris and New York, inasmuch as it now exhibits a period of seasonal maximum about May in addition to the autumnal maximum. The question as to possible influence of decreased density in association with longer school holidays in connection with seasonal incidence seems deserving of further study. There remains to be considered the question as to whether the reduction in the number of cases of scarlet fever occurring as the result of the midsummer holidays means an actual escape of a corresponding number of children from attack, or whether the children who escape in the holidays succumb to infection when the schools reassemble. It is found that there is very little difference in the total number of cases per thousand children in populations of different social class, and this points to the probability that those who escape during holidays enjoy only a temporary respite. Susceptibility to infection appears to be the determining factor, rather than exposure to infection, for the range of exposure in the densely populated poorest areas must be far greater than in the better-class populations, yet the total incidence upon the two classes differs but little. The possibility that a large proportion of cases escape detection and notification in the poorer class populations has, of course, to be taken into account, but the circumstance to which reference has been made above, that the distinction between the densest and the less crowded populations lies particularly in the amplitude 89 of the seasonal wave, as well as that of the major "waves" of epidemic periods, is consistent witl the hypothesis that the susceptible stock becomes more rapidly exhausted in the denser areas. Report by Dr. R. Armstrong on catarrhal sore throat or glandular fever in Fulham and Hammersmith. Intercurrent with the outbreak of scarlet fever there was a heavy incidence of epidemic sore throat which greatly complicated matters and added to the difficulties of prevention in school. Dr. Richard Armstrong made a special investigation into certain outbreaks of catarrhal sore-throat in the North-Western division, and reported as follows :— "As assistant school medical officer, I carried out, during the months of November and December last, a number of routine enquiries into the occurrence of cases of scarlet fever and diphtheria in schools in the Fulham and Hammersmith districts. Whereas the cases of scarlet fever and diphtheria were apparently sporadic and infected from external sources, there have been a very large number of cases of catarrhal sore-throat in the schools, particularly in the Infants' Departments and there seems reason to believe that this disease, from whatever source primarily derived, has spread from child to child and class to class within the schools. The Infants' Department of Flora-gardens school has suffered very heavily in respect of absence due to sore-throat, " colds," etc.—approaching 50 per cent. of children in attendance—and in addition cases accepted as scarlet fever have also arisen. The occurrence in all scarlet fever epidemics of mild or abortive cases suggested that there might be some relationship between the large number of cases of sore throat and the cases notified as scarlet fever. The observation that haemolytic streptococci constitute a characteristic infection of the throat during scarlet fever suggested that these micro-organisms afford a means of detecting the possible presence of scarlet fever virus in cases otherwise clinically atypical. Having sought and obtained permission to investigate the epidemic at Flora-gardens school from this standpoint I have undertaken the following experiments. (1). Bacteriological examination of material from the tonsils of three selected groups of children at Flora-gardens school, namely, (a) children acutely ill, about to be excluded by the head teacher; (b) children returned after exclusion, having suffered from sore throat; (c) children regularly in attendance during the outbreak. (2) As a control test, similar examination of children from (a) a school which has been quite free from throat illness ; (b) a school slightly affected in which no further cases had recently occurred. (3) As a further control, the results are recorded of the examination of material from the fauces of ten typical cases of scarlet fever at the South Western Metropolitan Asylums Board hospital, during the first week of the disease, carried out by Dr. M. H. Gordon, C.M.G., C.B.E., at the same time as the above, in the laboratory of St. Bartholomew's Hospital. As a result of the investigation it has been found:— (1) That the fauces of infants examined at Flora-gardens school are almost all heavily infected with micrococcus catarrhalis, haemolytic streptococci being absent. This holds not only for infants who developed symptoms but also in others of the same school who escaped illness. (2) That infants from the control unaffected school are free from M. catarrhalis, the flora of the fauces consisting mainly of streptococci, pneumococci, diphtheroids, etc., the streptococci present being non-heemolytic. By far the greater number of organisms found in the throat in health and disease normally belong to the above mentioned non-hsemolytic groups. (3) That children from the school in which the epidemic has run its course fall into two groups ; (x) Those showing persistent signs of illness e.g., enlargement of tonsils, etc. (about 60 per cent). Such have yielded cultures in which M. catarrhalis predominates. ; (y) those in all respects in good health (about 40 per cent.) Such yield cultures from the fauces of streptococci, diphtheroids, etc. (4) That the scarlet fever cases at an early stage of the disease uniformly show heavy infection with hemolytic streptococci. So far as these observations go they suggest— (1) That the outbreak of catarrhal sore throat which has prevailed recently at Flora-gardens school and to a greater or less extent in other schools in the Fulham area, has no relationship with scarlet fever. (2) That the cases of catarrhal sore throat, etc., are apparently the result of infection with Micrococcus catarrhalis. (3) That the carrier rate of catarrhalis corresponds with the incidence of this disorder, since the micro-organism was present in over 90 per cent, of the children affected with the disease or in contact with it, while the same micro-organism was absent in approximately 90 per cent, of the children examined at the control school where no such outbreak of illness had taken place. (4) That the outbreak has the characters of a true epidemic in that it presents a recognisable disease symptom-complex constantly associated with a definite infecting agent, the distribution of which corresponded with that of the disease. A summary of the clinical features of the epidemic, the experimental observations on which the above conclusions are based, a reference to literature and certain observations with regard to treatment, follow. Owing to the limited facilities for studying cases presented by the brief examination which is all that school conditions permit, a complete survey cannot be given. The following are salient symptoms and signs. (1) Onset usually sudden, with (2) lassitude ; (3) malaise ; (4) thickly furred tongue ; (5) dysphagia. (6) Marked and persistent tonsillar enlargement. Injection of the fauces is seldom marked— dilated venules are conspicuous over the tonsils which are swollen, hard and often (as commonly described) of " gristly" appearance, no exudate on surface nor in crypts. I suggest the name 61004 n 90 " Parenchymatous lonsilitis " for the condition in contradistinction from Membranous or Follicular tonsilitis. (7) Marked and persistent enlargement of glands at the angles of the jaw. Particular stress is laid on the persistence of the enlargement of tonsils and lymphatic glands. The enlargement seems to remain much longer than is the case in ordinary acute tonsilitis. The cases are often designated mumps by the teachers in schools owing to the marked enlargement of glands at the angles of the jaws. I have seen no case of parotid enlargement and none in any way resembling sub-maxillary mumps. The practice of using this description should, if possible, be discouraged. (8) Raised temperature. (9) Running at the eyes—conjunctival congestion is common. (10) Cough (frequent). (11) Coryza (frequent). (12) Vomiting (occasional). I have had no opportunity of testing for albuminuria and I have not in any case detected a rash. Generalisations, concerning the Flora-gardens outbreak, based for the most part on information supplied me by the head teacher, are alone possible. I understand that the earliest cases occurred in October, amongst the youngest children in Class A. This class became bodily converted at the time of the school remove in October into Class B, which is at once the youngest and largest class in the infant school. It is not, therefore, surprising that the incidence of illness has been heaviest there. The head teacher inclined to the opinion that infection had spread upwards through the infant school, Class E being the penultimate class affected and Class D the ultimate. Opportunities for free admixture of all the children in the department exist and, save that there seemed little doubt that infection had spread from class to class at the remove and from child to child, the exact path could not be traced, seating arrangements having undergone much alteration as the attendances diminished from illness. Adult teachers, male and female, and older children in the boys' and girls' departments have succumbed to sore throat with symptoms similar to those described amongst the infants and, therefore, inferentially, to the same infection. Neither in numbers nor severity were senior departments in any of the schools I have visited, attacked as were the youngest children. (Here there follows a detailed description of the Bacteriological methods of Investigation employed). A considerable literature is in existence on the part played by Micrococcus catarrhalis in Epidemic disease, particularly in association with outbreaks resembling influenza, and writings on the subject tend to confirm the view that the epidemic under investigation is of the nature suggested. Particular reference is here made to a paper by R. A. Dunn and M. H. Gordon on " The Clinical and Bacteriological aspects of an Epidemic simulating Influenza in the East Herts. district "(B.M.J., August 26th, 1905), wherein a very complete account of clinical features and bacteriological findings is recorded. In discussing the symptomatology of the outbreak, the authors make the significant observation that " taken individually, many of the younger patients bore a striking resemblance to scarlet fever, and the rash, sore throat, circumoral pallor, vomiting, strawberry tongue and desquamation, were extremely suggestive." I have stated above that I did not observe any child with a rash among those I examined. It is of further importance to note that in the East Herts. epidemic severe cerebral symptoms followed closely on tonsillotomy in two cases. The marked and persistent tonsillar enlargement combined with relatively little evidence of acute inflammation which forms an outstanding feature of the present outbreak, so far as I have observed (and this observation has, I know, been confirmed by others of my colleagues in the school medical service), is likely to induce those who are unaware of the cause, freely to advocate the operation of tonsillotomy. In conducting this enquiry I have been very greatly indebted to the advice and experience of Dr. Mervyn Gordon, Bacteriologist at St. Bartholomew's Hospital, and in particular have to acknowledge my thanks for his permission to make use of the essential link in my chain of evidence afforded by the results of his examination of cultures from the throats of acute cases of scarlet fever." Measles. After a period of very low prevalence in 1919, measles became epidemic in the spring of 1920. During the year 28,888 cases of measles and German measles were reported from the schools, the highest number recorded since 1915. The scheme providing for the better control of measles in the schools through the co-operation of the school nursing service, school attendance officers, and the staffs of the local sanitary authorities (described in the annual report for 1919), was put into operation for a period of 6 weeks during April and May with very satisfactory results as will be seen in following statement. (1) No. of schools visited by nurses 233 (2) No. of sessions devoted to work 673 (3) No. of cases of definite measles discovered to be in attendance at school, excluded and reported direct to the borough medical officer 59 (4) No. of suspicious cases of measles discovered in school and excluded by nurse 541 (5) No. of these suspicious cases referred to in (4) which subsequently proved to be measles 139 (6) No. of doubtful absentees reported to school attendance authorities for immediate visitation 4,296 (7) No. of these absentees referred to under (6) subsequently proved to be measles 776 Unprotected children were temporarily excluded from 465 class-rooms and all children under 5 years of age were excluded from 72 schools as precautionary measures. Under regulations of the 91 Ministry of Health measles and German measles were made compulsorily notifiable in the following metropolitan boroughs as from the dates mentioned in brackets—Lambeth, St. Pancras, Paddington and Fulham (1-4-20), Greenwich (1-7-20). In St. Pancras and Lambeth notification by the medical practitioner is limited to the first case in the household. On the instructions of the Public Health Committee the County Medical Officer presented in December, 1920, reports as to measles in London, with recommendations as to measures which in his opinion would be of advantage for the better control of the disease, and as to the compulsory notification of measles. In these reports I described the methods which had been employed by the Council during many years past for obtaining information of cases and securing control of the disease through the medium of the school organisation. It was explained that special methods are adopted where there are indications of rising prevalence, with a view to speeding up the machinery of " notification." The scheme of co-operation between the nurses, attendance officers, and the staffs of the local sanitary authorities was also referred to. As was pointed out in the annual report for 1919, this last-named scheme was devised, as the outcome of the rescission by the Ministry of Health of the Compulsory Notification Order of 1915, with a view to securing more efficient co-operation of the various services concerned in efforts to combat measles. It was suggested further, that it should be incumbent upon the parents to notify the head teacher within 48 hours when a child is kept at home on account of illness, stating the apparent nature of the indisposition from which the child is suffering. With regard to the question of compulsory notification, it was pointed out that this was in force throughout the country during the years 1916-1919, inclusive, and that the original Order of the late Local Government Board had been revoked by the Ministry of Health on the ground that compulsory notification as a general measure was not the best method of dealing with the problem of measles. Compulsory notification had thus been given a trial extending over a period of four years. The following reasons were, moreover, given in the report showing that the balance of advantages as between the compulsory and voluntary systems could not be said to be in favour of the former. (1) In a large proportion of the cases a medical man is not called in at any stage of the disease, and in another large proportion only when serious complications have set in and death is imminent is medical advice sought. It is principally in the class of home in which a medical man is not called in that early information is most desirable. (2) Compulsory notification is costly to the community, and on that ground should not be adopted unless there is very strong evidence that it is necessary or will be instrumental in reducing mortality. It is estimated that on an average it would cost the community between £6,000 and £7,000 annually, even if the notification were limited to the first case in the household. If every case were notified, the expenditure would be correspondingly increased (probably nearly threefold). It is claimed that an expenditure thus entailed could be utilised more beneficially in extending and rendering more efficient schemes of home nursing. (3) Compulsory notification has often been tried in various towns and localities, and has been as often abandoned because the advantages gained were by no means commensurate with the expenditure involved. (4) Experience shows that more complete information may be obtained through the school organisation, especially if the machinery is speeded up and rendered more efficient. An analysis of the results accruing from compulsory as compared with voluntary notification in one of the London boroughs, where compulsory notification was in force was made for a period of three months in 1914. It was found that during the period in question 95 houses were invaded by measles. Of these, 87 per cent. contained school children, and 78 per cent. were reported through the school organisation. The comparatively small leakage of 9 per cent. could no doubt be further reduced. Of the 13 per cent. of houses in which knowledge could not have been received from the schools, 6 per cent. were houses in which there were no children of school age, 4 per cent. were above the elementary school class, and in 3 per cent. no information could be obtained. Of the whole 95 houses invaded, only 66 per cent. were made known through compulsory notification as against 78 per cent. through the schools. It has been urged that the information received through the school organisation is not sufficiently expeditious, but the means exist, and in fact are being utilised, for accelerating the machinery of voluntary notification. Every borough council, moreover, has power, with the sanction, and under the regulations, of the Ministry of Health, to introduce an order for compulsory notification, and a certain number of such orders have already been made by borough councils, as has been previously stated. Thus local option is preserved. It is now recognised that the main desideratum in dealing with measles is an efficient scheme of home nursing, and it is in this direction that the efforts of public health authorities should be mainly directed. Arising out of these reports the Public Health Committee invited representatives of the Metropolitan Borough councils to confer with the Council's representatives on the recommendations submitted by the County Medical Officer. At the conference held at the County Hall, Spring Gardens, S.W., on 25th February, 1921, the above-mentioned recommendations were carried by the delegates present and in addition a resolution was passed with regard to compulsory notification. These resolutions are at present sub-judice and a pronouncement of the Council's policy will in due course be made. Whooping cough. The number of cases of whooping cough occurring among school children during 1920, was 8,779, as compared with 3,397, 11,671, 7,117, 8,595, 10,959, 9,977 and 9,762 in the years 1919, 1918, 1917, 1916, 1915, 1914 and 1913 respectively. Whooping cough is notifiable in the boroughs of Holborn, Wandsworth and Greenwich. 61004 N 2 92 Ringworm and favus. For several years prior to 1919, the number of cases of ringworm discovered in the schools had been steadily diminishing. During the past two years, however, there has been some retrogression, for in 1919, there was an increase of 800 cases over the previous year, followed by a further rise in 1920. The actual number of fresh cases reported during the year under review was 3,983, as compared with 3,447 in 1919, and 2,639 in 1918. It is satisfactory to record, however, that the number of cases cured maintains a satisfactorily high level, 3,856 cases laving been cured during 1920, thus keeping pace almost with the increase in the number of cases reported. At the end of the year there were 1,332 children known to be suffering from ringworm. The appended Table shows the number of fresh cases reported annually during the past decade, together with the cured cases and the number known to be suffering at the end of each year. Fresh cases. Cured cases. Cases outstanding at the end of the year. Fresh cases Cured cases. Cases outstanding at the end of the year. 1911 6,214 5,872 2,458 1916 3,115 3,0811 1,232 1912 5,311 5,131 2,204 1917 2,814 2,9641 992 1913 5,573 5,257 2,277 1918 2,639 2,555 979 1914 4,449 5,902 1,638 1919 3,447 3,103 1,259 1915 3,747 3,928 1,334 1920 3,983 3,856 1,332 Dr. Chaikin, the divisional medical officer for the eastern division, states that from 1914 onwards the incidence of the disease in the East End, steadily diminished until the summer of 1919, a period which " coincided with the absence of the permanent nurses on war service, as a result of which much of the diagnostic skill for ringworm exhibited by this branch of the service was not available." Dr. Chaikin points out that the causes favouring the spread of ringworm still exist. In this connection the importance of suitable cloakroom accommodation in the schools is emphasised. With regard to treatment, the objection of parents to X-rays is being overcome, but the unsatisfactory method of treatment by ointments is still favoured by many medical practitioners ; under this form of treatment years may elapse before a child is cured. The persistence of doctors, both in private practice and in hospitals, in giving certificates of freedom from ringworm, even after the parents have been informed that the fungus has been demonstrated in the Council's laboratory, militates to some extent against the efficient control of ringworm. From time to time cases in which the diagnosis is disputed by a private doctor or by hospital medical officers are referred to Dr. Brincker, one of the Council's principal assistant medical officers, and almost invariably the diagnosis is confirmed microscopically and the parent is persuaded to continue treatment or preferably to place the child under X-ray treatment. There was a slight increase in the number of cases of favus reported during the year, viz., 10 as compared with 7 in 1919, of these 5 cases occurred in the East End. During 1920, 3,239 specimens of hair stumps were examined in the Council's laboratory, of which 1,662 proved to contain ringworm fungus, whilst 11 showed the presence of favus. Dr. Chaikin's report on favus in the East End. Dr. Chaikin refers to cases of favus dealt with in the eastern division from the year 1911 to the end of 1919. As systematic supervision by nurses was undertaken, more and more cases came under notice. The numbers increased steadily up to 1915, when there was a very marked decline of new cases. No doubt the fact that migration from eastern Europe was suspended accounts for this. Boys seem to be almost equally affected with girls, though the latter are fewer by 10 in the cases found. In distribution the heaviest incidence was in that group of Whitechapel schools round Aldgate. Other parts of Whitechapel were also affected. Patches were found in Bethnal Green, Mile End, and even Poplar and Wapping. 96 per cent. of children affected were of foreign origin. The records do not show every case in its beginning, but the evidence as far as it goes shows contact with someone from abroad. 4 per cent. were English children. Very close contact would seem necessary for favus. Hence its ethnographical limitations. In only 4 families the disease affected two members of the same family and in 1 case three members of the same family. The slow infectivity of favus is very remarkable, and contrasts in this respect with ringworm. contrasts in this respect with ringworm. I he following table shows the number ot cases reported in the last ten years in the East End of London. Year No. of cases. Year No. of cases. 1911 1 1916 7 1912 4 1917 5 1913 24 1918 4 1914 30 1919 3 1915 21 1920 5 Dr. Sequeira,. of the London Hospital, drew attention during 1920, to the number of cases of favus coming under treatment there and attributed the increase to the influx of aliens. In this connection the attention of the Council was directed to difficulties which were being experienced in regard to the accommodation of transmigrants passing through London from Poland and other provinces of Eastern Europe en route for Canada and the United States. Many of these aliens were found to be suffering from diseases such as favus, trachoma, and other infectious conditions. On this account they were debarred from entry into Canada or America, and thus the anomalous position was created that transmigrant aliens suffering from infectious diseases constituting a danger to the public health could remain in London and become a charge upon the public health resources of the Metropolis as well as a menace to health, until they could be pronounced cured and fit for admission to another country. Appropriate representations were accordingly made to the Minister of Health, who was 93 asked to receive a deputation from the Council for the purpose of demonstrating the urgent need for the provision of accommodation for transmigrants and for preventing transmigrants suffering from infectious diseases from becoming a source of infection to the population of London. The question is still under consideration. Residential special and industrial schools. There are 8 residential and day industrial schools, 1 reformatory, 6 residential special schools (2 for blind, 3 for deaf and 1 for mentally defective children). In these schools, the health of the children, as far as infectious diseases are concerned, was on the whole satisfactory. Two outbreaks, however, one of diphtheria at Portslade Industrial School, and one of ringworm at Highbury Industrial School, call for brief comment. The outbreak of diphtheria at Portslade School originated with 2 boys who complained of sore throat on 3rd August, 1920. They were swabbed with positive result and sent to the Hove Sanatorium. All the boys at the school, and also the staff and workmen, were swabbed, and during the following two weeks four additional mild cases were discovered, and removed to the Sanatorium. The outbreak of ringworm at Highbury Industrial School commenced in September, 1919, when 12 cases were reported from the school. A visit of inspection was made by the school nurse, who found that some of the cases were tinea circinata (ringworm of the body) and others tinea tonsurans (scalp ringworm). Cases continued to occur sporadically up to the end of the year. Early in 1920, the outbreak assumed larger dimensions, 30 cases having been discovered in the first three months. A considerable proportion of these were, however, cases of tinea circinata, which quickly cleared up under treatment. On 24th March, Dr. Culverwell, one of H.M. Inspectors of Reformatory and Industrial Schools, visited the school and made a number of recommendations, which were carried out. Dr. Lewis, the Council's divisional medical officer, also investigated the outbreak, and arranged for inspections by the assistant superintendent of nurses from time to time. The boys who were found to be suffering from tinea tonsurans were referred for X-ray treatment under the Council's scheme. Examination of candidates. The number of candidates submitting themselves for first examination during the year was 7,159, as compared with 6,493 in 1919, an increase of 666 or 9.7 per cent. The candidates may be classified as (a) candidates for entrance to the permanent service, (6) candidates for the award of scholarships. Candidates for permanent service The total number of candidates examined was 1,851 (544 males and 1,307 females), but of these 58 attended for their first examination in the previous year. There were, however, 2,101 examinations (605 males and 1,496 females), the excess being due to the fact that in 282 cases (59 males and 223 females) a second or third examination was necessary. Of the number thus referred, remedial treatment was satisfactorily obtained in 264 cases ; 17 were rejected ; 7 withdrew their applications ; and 52 were still under consideration at the end of the year. The total number of rejections was 45. Candidates for the award of scholarships The scholarships and awards granted by the Council fall into three divisions, each of which requires different treatment in so far as the medical examination of candidates is concerned. (a) County scholarships enabling candidates to proceed to institutions of university rank ; (6) Technical scholarships enabling candidates to receive instruction in trades, and special scholarships; (c) Awards enabling candidates to prepare for the teaching profession. During the year the Council has been authorised by the Air Ministry to nominate boys for training as mechanics in the Royal Air Force. The candidates selected have been medically examined before nomination and the figures showing the results of the examinations have been included with those for the technical scholarships described under (b). The total number of candidates examined was 5,460; these include 94 who attended for their first examination in the previous year. There were, however, 6,968 examinations, the excess being due to the fact that in 1,432 cases a second or third examination was necessary. 1,317 (or 92 per cent.) obtained satisfactory treatment and were on re-examination certified as fit. 134 candidates were found to be unfit; of these 7 were rejected for two defects each and 4 for three defects each ; 100 were rejected as the result of their first examination and 34 as the result of subsequent examinations. The reasons for rejections were:—defective vision 63 ; unsatisfactory personal hygiene 10 ; defective teeth 12 ; unsatisfactory general health 23 ; tuberculosis 3 ; unsatisfactory condition of heart 5 ; miscellaneous 33. Cases specially referred. There are also referred to the Public Health Department cases in relation to employees in the Education Service absent owing to personal illness ; questions in regard to students in institutions for higher education whose health is considered such as to render exceptional attention advisable ; cases of teachers returning to duty after extended leave of absence (a) owing to personal illness ; (b) for educational purposes ; (c) to married women under No. 31 of the Regulations in regard to the Education Service; cases of teachers about to be superannuated; applications for special consideration owing to wounds, etc., of teachers demobilised from the Forces ; and claims received from teachers and others in the permanent service for exceptional treatment as regards sick pay and re-imbursement of medical and other expenses in respect of illnesses alleged to be due to the conditions under which they may have been required to carry out their duties. The number of cases thus specially referred was 1,806, as compared with 1,565 in 1919, an increase of 241 or 15'4 per cent. To carry out the provision of the Education Act, 1918, in regard to the physical instruction of school children, the Council during the year instituted courses of training for its teachers, and decided that applicants before commencing their course should be subject to examination by the School Medical Officer. 745 teachers were examined and 650 found to be fit to undergo the prescribed training. 94 Admission examinations. Defective children. The total number of examinations conducted under the special Acts during the year was 6,301 as compared with 5,494 for 1919. Of these 1,459 (780 boys and 679 girls) were deemed suitable to attend elementary schools, 98 (47 boys and 51 girls) a blind school, 367 (171 boys and 196 girls) a school for myopes, 1,216 (608 boys and 608 girls) P.D. School, 1,399 (772 boys and 627 girls) M.D. School, 25 (16 boys and 9 girls) open air school, 88 (44 boys and 44 girls) hard of hearing school, 130 (75 boys and 55 girls) a deaf school, 40 (20 boys and 20 girls) were epileptic, 559 (277 boys and 282 girls) invalided from school attendance, 106 (62 boys and 44 girls) imbeciles, 25 (12 boys and 13 girls) idiots, 4 (3 boys and 1 girl) blind and deaf, 10 (3 boys and 7 girls) deaf and mentally defective. 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. Infantile paralysis 106 90 196 Cerebral paralysis 10 16 26 Various paralyses 14 14 28 Tuberculosis of bones and joints 178 138 316 Congenital deformities 32 37 69 Other deformities 104 92 196 Heart disease— Congenital 19 34 53 Acquired valvular 107 163 270 Acquired non-valvular 7 10 17 Other diseases 31 14 45 Rota 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; 278 were transferred to elementary schools, 1 to deaf school, 1 to blind school, 18 from physically defective to mentally defective schools, 33 were excluded as imbecile, 25 were invalided on medical grounds and 362, over 14 years of age, were excluded as no longer certifiable. In addition, 684 special examinations were made of children already on the rolls of special schools in connection with applications for nonenforcement of attendance at special schools, committals to industrial schools, reformatories, etc. The statistical returns of after-care work had been quite impossible to obtain during the war. During the last year, the Associations concerned with the after-care of the children have resumed work on more extensive lines and the following tables have been submitted:— After careers of children formerly attending special mentally defective schools lor the year ended December 31st 1920. (Data furnished by the London Association for the Care of the Mentally Defective.) 1. Number of children born in or subsequent to 1900, and have left special mentally defective schools 2,269 1,726 3,995 2. Number who— (a) have since died 15 13 28 (b) who are known to be incapable by reason of mental or physical defect of undertaking employment 83 40 123 (c) are in attendance at an institution for further education not known. (d) are in any other institutions 19 27 46 *3. Number employed in— (a) Industrial or Manual occupations (i.e., factory work, any trade or part of a trade) 490 372 862 (b) Agricultural or rural occupations 8 1 & (c) Domestic occupations (i.e., servants sleeping in or out, lift boys and approximately 10 per cent. " Helping at home ") 29 131 160 (d) Commercial (i.e., shop assistants or selling behind a counter), Professional (or Army and Navy) Clerical (office boys or girls) 91 24 115 (e) Blind Alley or other precarious occupations (i.e., van-boys, newsboys, errand boys or girls, selling from a barrow) .. 196 77 273 4. Number whose after careers have not been traced or who have left the neighbourhood 1,338 1,041 2,379 Totals 2,269 1,726 3,995 In employment during the last year and mostly during last quarter. Under £1. Between £1 and £2. Between £2 and £3. Over £3. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. (a) Industrial or Manual 132 160 243 133 17 2 4 — (b) Agricultural or rural 1 1 — — • — — — — (c) Domestic 10 47 18 19 — — — — (d) Commercial, professional, clerical 7 7 17 3 — — — — (e) Blind alley 81 32 26 13 — — — — Note.—Information as to wage earning is only available for the young persons recently visited. The After Care Association for blind, deaf and crippled children has furnished the foregoing information, which, however, deals only with about 40 per cent of the total number attending the schools, these cases having been referred to the Association by the school managers. 95 After careers of children formerly attending schools for the physically defective. Total 1916-1920. Placed as apprentices 59 Application withdrawn 56 Placed as learners 905 Returned to school 16 Placed themselves 90 Lost sight of 3 Referred to other societies 22 Refused places found 144 Too delicate to place 54 Character unsatisfactory 21 Died 2 1,372 Diagnosis of mental defects. Dr. Shrubsall and Dr. Williams have been considering the question of diagnosis of mental defect, both under the Education Acts and under the Mental Deficiency Act. The legal administrative concept is of a social character dependent upon the power of the individual to care for himself or his affairs, or to be educated so to do. The pathological basis is defective neuronic development, either from primary or inherited sub-normality or as a result of trauma or pathological change during the life of the individual. The diagnosis of this, however, is inferential, depending on observation of behaviour coupled, it may be, with evidences of such physical defects or stigmata as are commonly associated with mental defect. The task of the certifying officer is, therefore, to determine whether the individual is fitted for his normal environment, whether that be the nursery, the school or the world, and if he is not, whether this is due to mental deficiency from an early age. The data available consist of the history (personal and family) of the subject, the results of a physical examination and of a special mental examination. The factors concerned in diagnosis are expressed in brief in the certificate which has to be given when a petition is presented. This distinguishes between the facts observed by the medical officer in the course of his physical and psychological examination and the information he received from others as to the personal and family history of the subject. The fact of deficiency must be established by interpretation of the facts observed in the light of the history ; it may be established without such history, but can never be firmly sustained on the evidence of the latter alone. A large part of the process of diagnosis consists in a critical estimate of the value of the subsidiary evidence put forward. The family history is of importance as indicating a predisposition to mental defect or instability which may be of great weight in a doubtful case, but it is important not to overweight this factor should it conflict with actual observation. The child of a psychotic parent might be merely backward from ill-health, malnutrition, or lack of school attendance even though he have undoubtedly defective brothers and sisters. Personal history, including any natal and prenatal influences, is of greater importance for diagnosis ; incidents at birth, a history of previous illnesses and accidents are essential. Of these meningitis, hemiplegia, epilepsy and a history of syphilis are the most important. The antecedent history is somewhat more definite in the case of those defectives who have required to be dealt with under the Mental Deficiency Act than in those sent to special schools. Order of birth has little significance, save that a mongol is usually the last living child in a family. An important piece of evidence is the age at which the subject began to walk, to talk, and to become clean in his habits, delay beyond the third year is suggestive of mental defect in the absence of physical explanations. This serves for purposes of diagnosis in the case of young children and as evidence of defect from an early age in the case of those of maturer years. Extrinsic factors such as loss of schooling, change of school, out of school conditions, foreign origin with bilingual conditions at home, previous illness or crippling which might in part account for educational retardation, have to be noted and assessed, as have the possible factors of social inefficiency in those beyond school age. When a child has been in attendance at a school, it is customary to receive a full account from the head teacher setting out the child's attainments and conduct. Formerly, this only described the attainments in the terms of grades and standards, and in the forms now being issued, the teacher is asked to state definite performances. The following examples have been prepared for the guidance of the teachers :— Reading.—The child attempted the following (or any selected) passage. Words (or letters) not recognised are cut out thus, [dog]. Words (or letters) recognised with difficulty are underlined Writing.—The child copied the following words or, the child attempted the following letters or words or piece from dictation (with errors indicated). Memory.—Give two or three examples of success or failure. Example.—A [dog] ran into the [road] to look for a bone, but a cart came by and hit his [tail.] Example was — dog — he — went, and failed to copy rightly :— say — joy — kick. Example.—Th dg ren in th wu. The child knew his teacher's name, knew his dog's or cat's name or baby's name. But did not remember if it was raining hard when he came to school, and did not remember if he brought any lunch. Calculation.—The child cannot count beyond (say) 7, and does not recognise (say) figure 7 or 9. He cannot add (say) 5 and 3, cannot subtract 2 from 5; he could add 5 and 4 but not 7 and 8 ; could subtract 2 from 5 but not 7 from 13. Knows twice times table to 2 by 4 equals 8. Medical examination falls into two parts :—(i) Physical—In the course of the physical examination are noted any conditions such as definite illness, malnutrition, fatigue, defects of the special senses, adenoids and the like which might give rise to a condition of temporary retardation or spurious defi- 96 ciency, or any impairment of the motor mechanisms such as paralysis which might act as a handicap. Stigmata of degeneration are noted, but the importance of these has been somewhat exaggerated save so far as they tend to indicate one or other of the types of infantilism. A few definite clinical types may be recognised, but the bulk of the cases are examples of simple primary amentia. The general attitude of the subject at the time of examination may be very significant, but too much reliance must not be placed on superficial appearances, as many, for example, past sufferers from meningitis may appear bright though their ultimate performances shew considerable defect. Speech defects, lalling, echolalia, idioglossia, or even mere babyishness, are all very significant. Special indications may lead to a complete neurological examination. Instability of the nervous system may be indicated by physical manifestations such as nystagmus, head-nodding, choreiform movements, tics, habit spasms, dysphagia, enuresis or even epileptic forms of convulsions. With these there is often a ready onset of fatigue and irritability under stimuli insufficient to affect the normal individual. Such instability is inherited and is in some measure an indication of physiological failure, but is in itself insufficient to bring the individual within the purview of the Mental Deficiency Act. (ii.) Psychological—It is now the practice to endeavour to assess the general intelligence by the use of one or other of the graduated series of tests which have been proposed for developmental diagnosis. Of these the De Sanctis tests, the Binet Simon tests and their various modifications, the Healy tests, the Porteous tests, and the Word Association tests, have been most used in London. As a result of these various tests which have been standardised for age it is possible to express the resulting evidence as to intelligence in the form of a mental age corresponding to the number of tests passed successfully. Temperamental features are more difficult to assess since the information must always come mainly from others, and no satisfactory series of tests have as yet been devised, though some confirmation may be made from general observation during the course of the examination. The children may be classified as being either unemotional or as belonging either to a restrained or an unrestrained emotional type. So far as the specific instincts are concerned there is considerable variation, the defective is usually lacking in some with perhaps an unbalanced exaggeration of others. Information on these points may be derived from the parents or others. The former, unless the subject has recently been very troublesome, are apt to minimise all the evidence and should the case need to come before a judicial authority may go back on their previous statements owing to their desire to keep the subject at home. Teachers on the other hand are sometimes apt to over-emphasise the detrimental aspects of a child's conduct and to claim that a child is defective when in reality it is only troublesome. Social workers, especially if engaged in rescue work, are often inclined to place a sexual significance on every act, and to refer to suspicions rather than to directly observed facts on which evidence could be given. Others are more dispassionate but are usually less skilled observers. Complaints may be grouped along the lines of three main types of instinct, self, sex and social, though there is naturally a considerable degree of overlapping. In general the instinctive manifestations in the defective remain fixed in the form of conduct which resembles that of a child of less mature years. In this way a rough age classification may be made. Dirty habits and lack of care of personal appearance are common sources of complaint, they vary from extremes like coprophagia or defæcating into the clothes, to mere lack of care in washing. This is a persistence of infantile traits, but the defective may continue for years to bite coal, stones, or dirt of all kinds, a condition, which is a fruitful source of complaints against those who have them in charge. Whereas the normal child is usually dry and of clean habits by the early part of the third year defectives may remain wet or dirty to five or six or even longer, enuresis is often cited as evidence of defect, but may be due to other factors. Transient ungovernable rage is a normal infantile feature, but its persistence in later life together with a longer duration, is suggestive of feeble mental control. Many of these manifestations, however, are due to insufficient or irregular home control; great improvement is repeatedly noted when the subject can be placed in a residential school, hence cases in which the defect is mainly temperamental are better observed in a place of safety, if this be possible, before a final diagnosis is made. The tendency to bite those who have offended them is almost normal in young children as a passing phase, but it often remains in the defective, and the charge of biting other children is frequently made the ground of a suggestion that the presence of a given child is detrimental to others. Inefficiency in handwork is a common trouble. The instinct of construction remains as a rule rudimental in the defective, who is usually handicapped by deficient psycho-motor control. Boys always seem to like promotion to the manual rooms in the school for the elder defectives, and in some cases this leads to an improvement in self respect. The first improvement often results from a child acquiring some useful accomplishment, such as mending boots, which his fellows in the ordinary school have not learnt. Petty pilfering is often due to unrestrained action of the instinct of acquisition. Even low grade defectives collect and treasure some articles. This instinct early conflicts with social requirements and therefore brings many of the subjects to notice. This is not by itself of great diagnostic significance. The sex instinct proper is a source of great difficulty. In many defectives the initial strength of this instinct is sufficiently strong to over-ride social sanction, particularly as their intellectual status prevents them from appreciating the full consequences or significance of the act. In normal individuals the sex impulse is sublimated into all forms of artistic effort, but in the less intellectual this process is more difficult owing to the limited channels available for diversion so that the impulse is more strongly directed along the original lines or into the crudest forms of pornography. In school cases much stress is laid by the teachers on precocious sex interests, perversions or exhibitionism. The latter is a common feature in imbeciles, but in children has often little direct 97 sexual significance, but rather is of the nature of self display or intentional insult, and sex precocity although morbid is often unassociated with congenital defect. Immorality brings many older girls to the notice of the Mental Deficiency Act Committee, and the following table shows the relation between their mental and chronological ages. Actual age. Mental age. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 12 — 1 — — — — — — — — 13 — — — — — — — — — — 14 — — 1 — 1 — — — — — 15 — — 1 1 1 1 — — — — 16 and over 8 41 39 62 42 18 19 8 — 5 8 — 5 The psychological examination of the subject shows the existence of mental retardation or of temperamental defect and enables the degree of retardation to be broadly expressed in terms of years. When this is considerable the subject deviates so far from the average of his fellows that he may be provisionally regarded as defective. If this is accompanied by a history of school or social inefficiency the social postulates of the law are in large measure fulfilled. If, in addition, he shows some signs of imperfect physical development in the form of stigmata and there is a history of deficiency in other members of the family, or some evidence of personal causal factors, such as meningitis, birth injuries or a neuropathic family history, the diagnosis of mental deficiency is simple. All such, however, are not often present, mental retardation and social inefficiency are essential, but slight accessory evidence suffices in the absence of other explanations of the retardation or inefficiency. Mere backwardness may be an explanation should there be a history of frequent absence or of change of schools, more particularly if this has been accompanied by ill health. In this event, however, the educational deficiency is likely to be much more marked than the failure at mental tests. The backward child shows no retardation in tests involving little verbal imagery or dealing with home as apart from school experience. At older ages they do well at the manual tests and mazes. In the event of doubt it is the practice to return a child of school age for a period (or further period) at an ordinary school, and then to re-examine him, when it should be found that if he is merely backward he has made considerable progress at a rate corresponding to more than half that of a normal child. The true defective under such conditions although making perhaps some advance does so at less than half the rate of the normal. Physical defects such as partial blindness or deafness or the condition known as aprosexia associated with adenoids may lead to retardation, so that if such conditions are present the subject must be placed under treatment and re-examined after this has been effected. If these are present the tests involving the affected senses are notably inferior. Malnutrition and debility or fatigue may lead to poor responses at examination. They can in a measure be excluded by the history and by deferring report until the condition has been remedied. They may, however, accompany real defect in which case the mental retardation shown will be considerable. Neuroses and psychoses can be distinguished by the history, the presence of special symptoms, by the scattering of the response in the graduated series of tests and by the nature of the responses to word association tests. Epilepsy may be difficult to decide upon but a common sign is the marked variability of the subject's response from time to time. When the history shows that fits have occurred from early life, and mental retardation is present, it is usually safe to regard the subject as so far defective as to require special education. In all cases irregularity of development is characteristic; slight progress in some one line with failure in many others being the usual history. Delay in talking and walking, in sitting up or in becoming clean is valuable evidence which may be given full weight in a doubtful case. Physical appearances may reveal the presence of some particular variety of deficiency such as infantilism, microcephaly or paralysis. Where there are coincident physical disabilities, the resulting influence on mental output has to be assessed and allowed for. This is more evidenced in the following table which contrasts the frequency of types as returned from admission examinations for special schools and from examinations under the Mental Deficiency Act. Type of defect. Suitable for special school. Unfit for special school. Mental Deficiency Act. Primary amentia 90.77 44.87 60.6 Mongolism .97 11.54 5.5 Cretinism .39 2.46 2.05 Microcephaly .52 3.25 2.3 Hydrocephaly .33 2.03 1.09 Epilepsy 2.12 17.00 14.1 Cerebral paralysis .27 8.66 5.7 Paralysis and epilepsy — 6.38 4.0 Various secondary amentia 4.63 3.81 3.9 61004 0 98 All factors have to be weighed, it is not practicable to say that because an individual is 3, 4 or more years retarded in psychological or educational tests he is ipso facto defective, on the other hand a subject may in many tests pass up to the average of his age and yet in other ways indicate that he lacks the wisdom to care for himself. The law recognises four grades of mental deficiency, which, however, to some extent overlap. Interpreting these definitions in the terms of mental age as ascertained by tests of various kinds, it has been the practice to regard those of later school age and over who show a mental age of less than 3 as being idiots, those with a mental age between 3 and 7 as imbeciles, and those who show a retardation of 3 years or more but with a mental age of above 7 as feebleminded. It was, however, at once clear that the latter definition was of limited application to those of mature years. Experience under the Mental Deficiency Act, in London, seems to show that no young person with a mental age under 8 is able to fend for herself, some with a mental age of 8 are able to carry on provided they can secure a sympathetic employer and are carefully supervised, while those with a mental age of 9-10 are often able to fend for themselves with a reasonable degree of supervision. It has been found that failure in the Healy tests or in the Porteous tests is more significant in this respect than failure in the Binet Simon series. With a mental age above 10 evidence of defective conduct or social maladaption is essential. There is some difficulty in expressing the degree of defect in terms of years of retardation owing to the greater import of a year's deficiency at the younger ages. To avoid this the quotient obtained by dividing the assessed mental age by the chronological age or by 16 whichever be the lesser number may be employed. The intelligence quotients calculated from the records of the examination of detectives for school purposes in recent years are shown in the following table. Intelligence quotient. Suitable for further trial in elementary school. Capable of deriving benefit in special school. Incapable of deriving benefit in special school. Total. 0.00—0.19 - - 180 180 0.2—0.39 — 33 681 714 0.4—0.59 9 705 459 1,173 0.6—0.79 347 2,778 36 3,161 0.8—0.99 838 606 4 1,448 1— 487 53 — 540 Total 1,681 4,175 1,360 7,216 There is a certain degree of overlapping between the groups due to the fact that the decision rests not only on estimates of mental age from actual examination but on attainments in reading, writing and the like. So long as ability to read school books is a postulate for education in ordinary elementary schools some provision for special or intermediate schools is needed for those who are unable to learn to read or write, even though otherwise their general mental processes are but little retarded. Over the age of 14 it has been the practice, in London, to regard a child who showed a mental age of 10 or upwards combined with attainments equal to standard II. and some evidence of fitness for employment or of ability for self protection in the world as being no longer certifiable. When the time comes for leaving a special school cases are re-assessed. Stress is no longer laid on the specialised educational abilities, but rather on the question of employability and self protection, so that although a child might be regarded as defective in the sense of the Education Acts, in that he needed a special variety of education, he would not be regarded as defective at 16 in the sense of the Mental Deficiency Act, unless there was definite evidence that he was in need of care, supervision and control for his own protection. Dr. Boome has inquired into the use of simple tests of recognition of absurdities in the detection of backward children in Cork-street (S.) School. He contrasted 25 children aged 2-14 years in a special backward class with 38 normal children aged 11. The absurdity, viz., A soldier wrote home to his mother as follows:—"Dear mother,—I am writing these few lines to you with a pistol in one hand and a sword in the other," was read out to the children by the teacher and the number of readings required before the point was detected noted. Normal class. Special backward class. Detected absurdity at first reading 17 10 Detected absurdity at second reading 14 5 Detected absurdity at third reading — 2 Detected absurdity at fourth reading — 1 Failed altogether to detect absurdity 7 7 Mr. Bishop Harman gave evidence before the Committee enquiring into the causes of blindness in children and a complete report of the evidence will be found in the official documents issued by the Government. The following data are taken from the evidence. Tests for backward children. Causes of blindness. 99 Investigating the condition of 3,300 blind and partially sighted school children seen by him between 1904 and 1920 he found the following to be the causes of their condition:— (1) Injury or destruction (surface)— Blind. Partially sighted. (a) Ophthalmia neonatorum 299 68 (b) Purulent conjunctivitis of 69 21 later years (c) Phlyctenular keratitis 66 176 (2) Inflammation within the eyeball or optic nerve— (а) Interstitial keratitis and iritis 284 129 (b) Disseminated choroiditis and 294 55 optic atrophy (c) Injuries 29 14 Buphthalmia or congenital 17 3 glaucoma Blind. Partially sighted. Macular defects 32 5 Congenital nystagmus 17 41 Double detachment of retina 2 - Retinitis pigmentosa 34 5 (3) Congenital defects— (a) Albinism 33 36 (b) Defects of the crystalline 170 78 lenses (c) Varied defects of the globes 66 25 (4) High myopia 54 1,181 Mr. Harman finds that the percentage of cases of blindness certainly due to Venereal disease is 53.2 and that an additional 2.7 per cent are probably due to this cause. The relative frequency of the condition has varied during the period of investigation but owing to the different constitution of the blind school population at the beginning and at the end of the period it is impossible to set the facts out in a comparable manner. Year of investigation. Total seen to date. Cases of ophthalmia neonatorum. Cases of congenital syphilis. 1904 255 94 48 1906 363 132 64 1913 1,100 268 343 1920 1,869 369 618 Between the earlier and later periods the proportion of cases of ophthalmia neonatorum fell and those of congenital syphilis rose. This may be due to three factors:— (1) The altered conditions of medical inspection. In the earlier period the arrangements for medical inspection were less comprehensive. The children who then got most certainly to the blind school were those who on being brought to an elementary school for admission were rejected by the head teacher on account of bad sight, and thereon reported with a view to their admission to a school for the blind. These children would be those blinded by congenital defects or by ophthalmia neonatorum. Congenital syphilis does not begin to act in the majority of cases until school age so that these cases would be on the school list marked "absent ill," and until there were close arrangements between the attendance department and the medical officer little was known of their conditions. Improved school and medical arrangements probably account for the greater part of the increase of cases of this kind as between 1906 and 1913. (2) There may have been an apparent increase due to better means of diagnosis. A real diminution of cases of ophthalmia neonatorum may be responsible for some of the change. (3) The difference between the returns of 1913 and 1920, is smaller, they have not been subject to the influence of a revolution in school and medical arrangements. In considering this report it may be taken that the war had little or no influence, for few of the children born in 1915 appear in the list, while only one was born in 1916. Mr. Harman presents no figures which might suggest the numbers brought to notice in each year. If, however, the comparison be made of the difference in numbers seen in 1904 and 1906, with the numbers admitted in the years 1916-1920, it appears as if the respective annual crops were, as to ophthalmia 19 in 1904-1906, and 10 in 1916 1920, and as to congenital syphilis 8 in 1904-1906, and 22 in 1916-1920. Mr. Yearsley has made an analysis of causes of deafness in 198 cases seen for the first time in 1920. These may be divided thus:— Boys. Girls. Total. Congenital 24 18 42 Acquired 66 69 135 Doubtful 12 9 21 102 96 198 The congenital cases were either instances of true hereditary deafness, or sporadic deaf-birth; two were instances of congenital aphasia. The acquired cases were due to the following causes:— Boys. Girls. Totals. Meningitis— Epidemic cerebro-spinal 6 3 9 Measles 1 1 2 Scarlet fever 1 1 2 Pneumonia 0 1 1 Causes not ascertained 3 4 7 -11 -10 -21 Infectious diseases— Scarlet fever (suppuration) 1 4 5 Measles (suppuration) 3 1 4 Measles (internal ear affection) 1 0 1 Pertussis (suppuration) 1 0 1 Influenza 0 1 1 - 6 - 6 -12 Boys. Girls. Totals. Tubercle (suppuration) 0 1 1 Pneumonia (suppuration) 0 1 1 Congenital syphilis 6 6 12 -6-8 -14 Primary ear diseases— Middle ear catarrh 23 15 38 Middle ear suppuration 19 24 43 Middle ear suppuration (results of) 1 1 2 Otosclerosis 0 2 2 -43 -42 -85 Injuries 0 3 3 -0 -3 -3 Totals 66 69 135 61004 0 2 Causes of deafness. 100 Mental tests of deaf children. The marked feature is the increase in the proportion of cases due to epidemic meningitis following the prevalence of this condition in past years. With a view to obtaining some criteria for estimating the mental level of a young deaf child, Dr. A. C. Williams applied some mental tests to children at the Hugh Myddelton school for the deaf, and also at the Homerton school for the defective deaf. Fourteen tests were chosen which did not call for any speech in response and could be applied without the subject having any power of lip-reading, knowledge of the finger alphabet, or ability to read written questions. The following table shows the number tested and the proportion at each age who passed. The unit figure indicates that all succeeded, the decimals, the fraction of successes. Test. No. tested. Ages. 5 6 7 8 9 10 11 12 Repetition of 2 digits 56 1 .6 1 1 1 1 1 1 Repetition of 3 digits 55 0 .25 .75 .8 1 1 1 1 Repetition of 4 digits 50 0 0 0 .6 1 .5 1 1 Copying a square 63 .8 1 1 1 1 1 1 1 Copying a diamond 55 .4 .6 .8 1 1 1 1 1 Counting 4 objects 42 .8 .75 1 1 1 1 1 1 Counting 13 objects 54 .3 .67 .75 .9 1 1 1 1 Use of adaptation board (1/2) 57 .3 .5 .75 .66 1 1 1 1 Use of adaptation board (complete) 47 0 .2 0 .35 .86 .66 1 1 Fitting triangles (patience) 50 .6 .6 .5 .7 .86 1 1 1 Reproduction of design (A) 44 - - .5 .84 .86 1 1 1 Reproduction of design (B) 44 - - .5 .38 .64 .5 .8 1 Tying bow knot 50 0 .5 1 .85 1 1 1 1 In visual memory span the deaf were markedly inferior, e.g., the deaf child of 7 could only reproduce 3 digits while a hearing child of that age succeeds with 5. This is of interest as an illustration of how greatly the hearing subject re-inforces his visual memory by slight articulatory movements. With the rest of the series in the table the results showed no consistent difference from those obtained with hearing children. In the test with the Norsworthy form board the essential feature is the speed of performance; the deaf gave records which were slower than those quoted for American children who are not deaf. This may be due to a failure on the part of the deaf to appreciate that speed was desired. The average times in seconds were:— Age 5. 6. 7. 8. 9. 10. 11 Deaf 50.3 46.4 37.5 32.5 29.3 23.7 21.6 Hearing 30.3 27.5 25.4 20.7 19.2 16.6 15.9 From these tests as a whole there seems little difference between deaf and hearing children whereas it has been suggested that the deaf show a considerable retardation on the Binet scale as a whole. This appears to affect more particularly those tests which involve verbal imagery and may be due partly to lack of ability readily to comprehend the wishes and thoughts of others, or to express themselves with facility and, partly, to a paucity of experience and associations. TABLE I. Number of Children inspected 1st January, 1920, to 31st December, 1920. (a) ROUTINE MEDICAL INSPECTION, 1920. Age. Entrants. Intermediate! group. Leavers. Total at routine medical inspection. 3. 4. 5. 6. Other ages. Total. 8 12. 13. 14. Continuation school group. Total. Elementary schools. Special schools. Boys 3,387 10,835 20,319 5,950 1,484 41,975 29,477 27,529 5,558 641 6,956 40,684 112,136 1,069 Girls 2,725 9,224 21,202 5,947 1,569 40,667 29,282 27,095 6,092 608 6,416 40,211 110,160 854 Total 6,112 20,059 41,521 11,897 3,053 82,642 58,759 54,624 11,650 1,249 13,372 80,895 222,296 1,923 (6) SPECIAL INSPECTIONS. (c) TOTAL NUMBER INSPECTED. Special cases. General* examinations. Re-examinations. Number of individual children examined. Boys 27,726 13,826 140,789 Girls 28,845 13,119 139,694 Total 56,571 (26,945) 144,876† 280,483 * These cases are children seen as infectious disease contacts examined en masse, individual records being kept only when some defect is noted for treatment or observation. These cases are not included in the total number of children examined. † Excluding 13,765 children see??? at both first and second reinspections. 101 TABLE II. Return of Defects found in the Course of Medical Inspection in 1920. Defect or disease. Routine inspection. Specials. Defect or disease. Routine inspection. Specials. Number referred for treatment. Number noted for observation. Number referred for treatment. Number noted for observation. Number referred for treatment. Number noted for observation. Number referred for treatment. Number noted for observation. (1) (2) (3) (4) (5) (1) (2) (3) (4) (5) Malnutrition 988 1,437 376 182 Heart Disease— Uncleanliness See report on clea nliness. Organic 141 562 262 172 Ringworm Head 63 9 294 52 Functional 84 1,046 96 297 Body 86 2 104 3 Not Stated 187 3,803 287 676 Scabies 517 8 2,347 37 Anaemia 2,670 1,795 1,542 388 Impetigo 606 17 1,021 18 Other akin—non-tubercular 1,359 289 1,221 144 Bronchitis 2,579 1,819 579 193 Other Non-Tubercular lung diseases 300 398 221 348 Blepharitis 1,310 141 538 38 Conjunctivitis 450 41 576 22 Pulmonary Tuberculosis— Keratitis 19 7 56 15 Corneal Ulcer 46 16 120 31 Definite 203 84 265 99 Corneal Opacities 34 36 44 11 Suspected 1,720 194 278 Defective Vision 16,310 6,324 5,456 436 Tuberculous— Squint 2,019 545 562 38 Glands 101 48 122 55 Other Eye Defects 212 76 178 16 Spine 2 1 17 12 Hip 4 10 34 15 Defective Hearing 947 406 569 87 Other bones & joints 21 20 57 14 Otitis and Otorrhœa 2,359 652 1,830 212 Skin 13 9 26 4 Other ear Defects 554 154 235 43 Other forms & general 65 44 79 23 Enlarged Tonsils 5,837 5,747 1,362 239 Epilepsy 73 133 279 140 Adenoids 2,250 1,117 754 63 Chorea 87 101 344 152 Enlarged Tonsils and Adenoids 3,846 963 601 35 Other Nervous conconditions 150 395 266 162 Other Nose and Throat Defects 1,445 611 788 277 Rickets 198 145 124 38 Spinal Curvature 814 550 214 58 Enlarged Cervical Glands 694 1,587 261 127 Other Deformities 353 259 248 75 Defective Speech 149 295 168 62 Other Defects and Diseases 3,908 2,377 4,143 1,130 Dental Disease 52,489 1,346 3,743 71 Number of children referred for treatment or observation j Routine 109,133 Total 142,770. Special 33,637 TABLE III. Numerical Return of all Exceptional Children in the Area in 1920. Boys. Girls. Total. Blind (including partially blind) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893. Attending Public elementary schools (a) 42 72 114 Attending certified schools for the blind 402 508 910 Not at school (b) 18 22 40 Deaf and Dumb (including partially deaf) within the meaning of the Elementary Education (Blind and Deaf Children) Act. 1893. Attending public elementary schools (a) 3 8 11 Attending certified schools for the deaf 411 377 788 Not at school (b) 7 16 23 Menially deficient— Feebleminded. Attending public elementary schools 41 32 73 Attending certified schools for mentally defective children 4,071 3,244 7,315 Number notified to Local Control Authority by Local Education Authority during the year 44 69 113 Not at school (c) 276 280 556 Imbeciles. Number notified to Local Control Authority by Local Education Authority during the year 101 62 163 Not at school (b) (c) 750 625 1,375 Idiots (c) Number notified to Local Control Authority by Local Education Authority during the year 6 12 18 Not at school (c) 133 121 254 102 Epileptics— Boys. Girls. Total. Attending public elementary schools 379 398 777 Attending special M.D. schools 66 53 119 Attending special P.D. schools 12 9 21 Attending blind schools - 1 1 Attending deaf schools 1 2 3 Attending certified schools for epileptics 56 36 92 Not at school (b) 279 251 530 Imbeciles or idiots (c) 246 224 470 Physically defective— Pulmonary Tuberculosis. *Attending public elementary schools (d). 300 306 606 Attending certified day schools for physically defective children (day open air schools for tuberculous children) 210 130 340 Attending certified residential schools for physically defective children 75 81 156 In institutions other than certified schools 308 311 619 Not at school (b) 156 199 355 Crippling due to tuberculosis. Attending public elementary schools (d) 645 552 1,197 Attending certified day schools for physically defective children 573 475 1,048 Attending certified residential schools for physically defective children 55 46 101 In institutions other than certified schools 391 361 752 Not at school (b) 126 114 240 Crippling due to causes other than tuberculosis i.e., paralysis, rickets, traumatism. Attending public elementary schools (d) 1,818 2,388 4,206 Attending certified day schools for physically defective children 1,001 801 1,802 Attending certified residential schools for physically defective children 11 4 15 In institutions other than certified schools 150 112 262 Not at school (b) 94 98 192 Crippling due to heart disease— Attending public elementary schools (d) 591 630 1,221 Attending certified day schools for physicallv defective children 390 508 898 Attending certified residential schools for physically defective children - - - In institutions other than certified schools 11 . 14 25 Not at school (b) 79 152 231 Other physical defectives, e.g., delicate and other children suitable for admission to open-air schools Attending public elementary schools (d) 8,469 7,977 16,446 Attending certified day schools for physically defective children 78 68 146 Attending certified residential schools for physically defective children 12 - 12 In institutions other than certified schools 15 15 30 Attending open air schools 195 125 320 Attending playground classes 1,200 1,900 3,100 Attending certified holiday camps (e) Bushy 2,700 - 2,700 Margate - 192 192 Not at school (b) 633 916 1,549 Dull or Backward— Retarded 2 years 10,071 9,135 19,206 Retarded 3 years 762 798 1,560 * Suspected pulmonary tuberculosis. (а) These figures refer to cases of partial blindness and partial deafness. (b) The number "not at school" includes children permanently disabled, certified as unfit to attend school for various periods, in the country, etc. Many are in attendance at other institutions, such as hospitals, or in the care of the Metropolitan Asylums Board. (c) Feebleminded children, imbeciles and idiots. This includes certain children who have been transferred to institutions outside the County and also some under school age. There are 1,021 boys and 770 girls in the institutions of the Metropolitan Asylums Board who are mentally defective and under 16 years of age. These numbers to some extent but not entirely overlap the figures quoted under the heading "not at school." A certain number have been dealt with under the Mental Deficiency Act; others are under the care of the Metropolitan Asylums Board as the Poor Law Authority. (d) The figures of the physically defectives in the ordinary schools are made up from the returns of three years routine inspection and may include certain cases which also come under other categories. The greater number of these cases would not be in any way certifiable as defective in the terms of the Elementary Education (Defective and Epileptic Children) Acts, 1899 and 1914, the crippling not being of such an extent as to interfere with ordinary education. At the last scheduling of the number of children who had been certified as suitable for admission to P.D. schools only 34 cases were in attendance at ordinary schools. (e) The figures refer to the number of children passed through the camps during the year (accommodation 31.12.20, Bushy 300, Margate 64.) 103 TABLE IV. Treatment of Defects of Children during 1920. A.—Treatment of Minor Ailments. Disease or defect. Number of children. Referred for treatment by school doctor. Treated. Under scheme. Otherwise. Total. Scabies 2,864 9,675 - 9,675 Ringworm—Head 3,983 1,840 2,016 3,856 Ringworm—Body 190 61,771 2,402 64,173 Impetigo 1,627 Other Skin Diseases 2,580 Ear Disease 4,978 Eye Disease 6,164 Miscellaneous 1,516 Total *23,902 73,286 4,418 77,704 * Note.—The numbers treated greatly exceed the numbers referred for treatment by the school doctors. Cases of minor ailments are referred directly to the centres without ceremony by teachers, care-committee representatives, school attendance officers, etc. B.—Treatment of Visual Defect. Number of children during 1920. Referred for refraction by school doctors. Submitted to refraction under scheme. Treated by private agencies. *Total number treated. No. refracted. No. of spectacles prescribed. No. of spectacles obtained. Other forms of treatment. 21,766 29,887 22,827 19,882 7,069 2,126 32,013 * Note.—The number treated is greater than the number referred during the year; this is partly due to catching up arrears, and partly due to cases being referred directly to the centres from hospitals, etc. C.—Treatment of Defects of Nose and Throat. Number of children during 1920. Referred for treatment. Received treatment. Under scheme. Otherwise. Total. Operation cases. Other cases. 16,883 9,976 4,770 2,437 *17,183 * See Note to IV. B. D.—Treatment of Dental Defect. I. Inspected by dentist. Number of children dealt with in 1920. Referred for treatment. Treated under scheme. Re-treated under scheme. Otherwise treated. By dentist. By school doctor. 154,347 115,619 56,232 89,456 10,663 5,185 II. Particulars of time given and of operations undertaken. No. of half-days dentist to inspection. No. of half-days dentist to treatment. No. of attendances made by children. No. of teeth extracted. No. of fillings. No. of other operations. No. of general anaesthetics. Temporary. Permanent. Temporary. Permanent. 1,859 13,727 141,905 272,054 36,582 21,926 46,806 17,143 34,913 104 TABLE V. Summary of Treatment of Defects as shown in Table IV. Disease or defect. Number of children. Referred for treatment. Treated. Under scheme. Otherwise. Total. Minor ailments 23,902 73,286 4,418 77,704 Visual defects 21,766 29,887 2,126 32,013 Nose and throat defects 16,883 14,746 2,437 17,183 Dental defect 171,851 89,456 5,185 94,641 Other defects 23,988 1,022 20,137 21,159 Total 258,390 208,397 34,303 242,700 TABLE VI. Summary relating to Children Medically Inspected at the Routine Inspections during the year 1920. (1) Total number of children examined at routine examinations 224,219 (2) Number of children suffering from— Malnutrition 2,497 Heart disease, organic 880 Skin disease 3,959 Heart disease, functional 2,093 Defective vision and squint 75,726 Heart disease, not defined 4,717 Eye disease 3,469 Lung disease (not stated to be tubercular) 10,192‡ Defective hearing 2,281 Pulmonary tuberculosis, definite 203 Ear disease 4,566 Pulmonary tuberculosis, suspected 279 Nose and throat defects 36,761 Non-pulmonary tuberculosis 576 Enlarged cervical glands 13,826 Nervous diseases 2,502 Defective speech 1,408 Deformities and rickets 6,706 Dental disease 103,285 Other defects and diseases 7,150 Anaemia 9,094 (3) Number of children in (1) suffering from defects (other than uncleanliness or defective clothing) who require to be kept under observation (but not referred for treatment) 20,667 (4) Number of children in (1) referrel for treatment (excluding uncleanliness and defective clothing) 88,466 (5) The number of children referred for treatment during 1920 who were reported at re-inspection to have received treatment for one or more defects 8,536† ‡ Many of these cases are probably suspected tuberculosis though not definitely stated to be so. † Very incomplete. Only the children referred for treatment during the first term of the year are re-inspected during the same year. 105 TABLE VII. Routine Inspections, 1920. Clothing and footgear. Nutrition. Cleanliness. Condition of teeth. Acuity of vision. Mental condition. Head. Body. 1. 2. 3. 1. 2. 3. 4. 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. Entrants— 41,975 Boys 25,329 15,907 739 10,960 28,319 2,688 8 39,364 2,493 118 38,142 3,666 167 22,336 13,729 5,910 — — — — — — % 60.3 37.9 1.8 26.1 67.5 6.4 93.8 5.9 0.3 90.9 8.7 0.4 53.2 32.7 14.1 — — — — — — 40,667 Girls 24,712 15,440 515 10,820 27,429 2,411 7 33,408 6,717 542 36,833 3,678 156 21,428 13,682 5,557 — — — — — — Age 8— % 60.7 38.0 1.3 26.6 67.5 5.9 82.2 16.5 1.3 90.6 9.0 0.4 52.7 33.6 13.7 — — — — — — 29,477 Boys 16,442 11,981 1,054 4,966 21,862 2,645 4 27,530 1,885 62 26,088 3,277 112 14,209 11,404 3,864 12,187 10,551 6,025 27,968 1,480 29 % 55.8 40.6 3.6 16.8 74.2 9.0 93.4 6.4 0.2 88.5 11.1 0.4 48.2 38.7 13.1 42.4 36.7 20.9 94.9 5.0 0.1 29,282 Girls 17,043 11,658 581 5,333 21,654 2,292 3 22,398 6,419 465 25,934 3,194 154 14,176 11,360 3,746 11,195 11 ,085 6,491 28,088 1,170 24 Age 12— % 58.2 39.8 2.0 18.2 74.0 7.8 76.5 21.9 1.6 88.6 10.9 0.5 48.4 38.8 12.8 38.9 38.5 22.6 95.9 4.0 0.1 33,728 Boys 18,054 14,482 1,192 7,920 23,692 2,112 4 31,775 1,912 41 29,362 4,218 148 19,565 12,677 1,486 18,501 8,160 6,949 31,975 1,745 8 % 53.5 43.0 3.5 23.5 70.2 6.3 94.2 5.7 0.1 87.1 12.5 0.4 58.0 37.6 4.4 55.0 24.3 20.7 94.8 5.2 0.0 33,795 Girls 19,619 13,705 471 8,572 23,341 1,878 4 25,623 7,701 471 29,867 3,793 135 20,177 12,387 1,231 17,565 8,656 7,446 31,987 1,803 5 % 58.1 40.5 1.4 25.4 69.0 5.6 75.8 22.8 1.4 88.4 11.2 0.4 59.7 36.7 3.6 52.2 25.7 22.1 94.7 5.3 0.0 Leavers for continuation school— 6,956 Boys 3,995 2,764 197 1,997 4,633 326 — 6,576 364 16 6,128 797 31 4,190 2,517 249 4,109 1,428 1,374 6,607 349 0 % 57.5 39.7 2.8 28.7 66.6 4.7 — 94.5 5.3 0.2 88.1 11.5 0.4 60.2 36.2 3.6 59.4 20.7 19.9 95.0 5.0 0.0 6,416 Girls 3,985 2,374 57 2,215 3,921 280 — 4,993 1,334 89 5,697 694 25 3,872 2,352 192 3,545 1,478 1,369 6,107 309 0 % 62.1 37.0 0.9 34.5 61.1 4.4 — 77.8 20.8 1.4 88.8 10.8 0.4 60.4 36.6 3.0 55.5 23.1 21.4 95.2 4.8 0.0 Total— Elementary schools 222,296 129,179 88,311 4,806 52,783 154,851 14,632 30 191,667 28,825 1,804 198,051 23,317 928 119,953 80,108 22,235 67,102 41,358 29,654 132,732 6,856 66 Special schools 1,923 % 58.1 39.7 2.2 23.7 69.7 6.6 86.2 13.0 0.8 89.1 10.5 0.4 54.0 36.0 10.0 48.6 29.9 21.5 95.1 4.9 — ... 677 1,094 152 353 1,303 263 4 1,437 439 47 1,378 514 31 981 758 184 472 612 498 — — — % 35.2 56.9 7.9 18.3 67.8 13.9 1 74.8 22.8 2.4 71.7 26.7 1.6 51.0 39.4 9.6 29.8 38.7 31.5 — — — 31004 1 = good, 2 = normal, 3 = poor in clothing and nutrition. In cleanliness 1 = clean, 2 = dirty (nits present), 3 = pediculi. Vision: 1 = 6/6 in both eyes, 2 = 6/9 in either or both eyes, 3 = 6/12 or worse in either eye. Teeth: 1 = sound, 2 = less than 4 decayed, 3=4 or more decayed. Mental condition: 1 = bright or normal, 2 = dull or backward, 3 = mentally defective. 106 TABLE VIII. Summary of Medical Inspection, 1920. Elementary Schools. Entrants. Age 8. Age 12. Age 14.* Total. Special schools. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Number examined 41,975 40,667 29,477 29,282 33,728 33,795 6,956 6.416 222.296 1.923 % % % % % % % % % % Skin disease (f) 1,023 2.4 730 1.8 581 2.0 452 1.5 526 1.6 448 1.3 73 1.0 83 1.3 3,916 1.8 43 2.2 „ (x) 728 1.7 443 1.1 403 1.4 289 1.0 346 1.0 292 0.9 50 0.7 56 0.9 2,607† 1.2 24 1.2 Teeth (x) 10,015 23.9 9,823 24.2 7,733 26.3 7,827 26.7 6,830 20.2 7,005 20.7 1,418 20.4 1,448 22.6 52,099 23.4 390 20.3 Enlarged tonsils (f) 4,663 11.1 5,000 12.3 2,786 9.5 3,280 11.2 2,328 6.9 2,970 8.8 419 6.0 454 7.1 21,900 9.9 136 7.1 „ (x) 1.202 2.9 1,259 3.1 731 2.5 876 3.0 623 1.8 866 2.6 121 1.7 125 1.9 5,803 2.6 34 1.8 Adenoids (f) 1,358 3.2 1,096 2.7 669 2.3 502 1.7 384 1.1 284 0.8 48 0.7 50 0.8 4,391 2.0 74 3.8 „ (x) 647 1.5 524 1.3 370 1.3 226 0.8 214 0.6 173 0.5 33 0.5 28 0.4 2,215 1.0 35 1.8 Tonsils and adenoids (f) 1,894 4.5 1,587 3.9 714 2.4 752 2.6 385 1.1 387 1.1 39 0.5 52 0.8 5,810 2.6 60 3.1 ,, ,, (z) 1,186 2.8 997 2.5 490 1.7 493 1.7 289 0.9 281 0.8 25 0.4 44 0.7 3,805 1.7 41 2.1 Other nose and throat (f) 1,117 2.7 806 2.0 640 2.2 435 1.5 626 1.9 500 1.5 90 1.3 97 1.5 4,311 1.9 79 4.1 ,, ,, (x) 317 0.8 221 0.5 221 0.7 143 0.5 237 0.7 207 0.6 . 37 0.5 42 0.7 1,425 0.6 20 1.0 Glands of neck (f) 3,526 8.4 3,129 7.7 2,137 7.3 1,929 6.6 1,395 4.1 1,186 3.5 204 2.9 178 2.8 13,684 6.2 142 7.4 „ (x) 232 0.6 138 0.3 100 0.3 93 0.3 60 0.2 46 0.1 6 0.1 6 0.1 681 0.3 13 0.7 Vision (x) — — 2,938 10.2 3,084 10.7 4,258 12.7 4,337 12.9 754 10.9 745 11.7 16,116 11.7 194 12.3 External eye disease (f) 1,694 4.0 1,667 4.1 933 3.2 898 3.1 760 2.3 753 2.2 132 1.9 105 1.6 6,942† 3.1 131 6.8 ,, ,, (x) 1,141 2.7 1,051 2.6 495 1.7 474 1.6 392 1.2 358 1.1 62 0.9 57 0.9 4,030† 1.8 60 3.1 Ear disease or defect (f) 960 2.3 1,016 2.5 527 1.8 622 2.1 596 1.8 537 1.6 122 1.8 88 1.4 4,468† 2.0 98 5.1 ,, ,, (x) 599 1.4 624 1.5 371 1.3 363 1.2 403 1.2 346 1.0 88 1.3 61 0.9 2,855† 1.3 58 3.0 Hearing defect (f) 320 0.8 373 0.9 302 1.0 313 1.1 411 1.2 339 1.0 82 1.2 72 1.1 2,212 1.0 69 3.6 „ (x) 126 0.3 126 0.3 128 0.4 122 0.4 181 0.5 156 0.5 44 0.6 32 0.5 915 0.4 32 1.7 Stammering and other speech defects (f) 331 0.8 175 0.5 213 0.7 103 0.3 287 0.9 115 0.3 64 1.0 20 0.3 1,308 0.6 100 5.2 „ „ „ (x) 6 0.0 5 0.0 21 0.1 11 0.0 74 0.2 9 0.0 21 0.3 - 147 0.1 2 0.1 Heart defects (f) 1,105 2.6 975 2.4 1,039 3.5 1,085 3.7 1,295 3.8 1,587 4.7 258 3.7 278 4.3 7,622† 3.4 68 3.5 „(x) 42 0.1 42 0.1 49 0.2 64 0.2 86 0.2 93 0.3 20 0.3 11 0.2 407† 0.2 5 0.3 Anaemia (f) 1,708 4.1 1,479 3.6 1,336 4.5 1,354 4.6 1,194 3.5 1,495 4.4 198 2.8 243 3.8 9,007 4.1 87 4.5 „ (x) 514 1.2 411 1.0 430 1.5 423 1.4 311 0.9 426 1.3 49 0.7 73 1.1 2,637 1.2 33 1.7 Lung defects (f) 3,067 7.3 2,751 6.8 1,240 4.2 1,103 3.8 883 2.5 801 2.4 122 1.8 121 1.9 10,088 4.5 104 5.4 „ (x) 1,007 2.4 875 2.2 338 1.1 271 0.9 155 0.5 162 0.5 19 0.3 18 0.3 2,845 1.3 34 1.8 Nervous disease (f) 471 1.1 462 1.1 360 1.2 386 1.3 282 0.8 381 1.1 41 0.6 67 1.0 2,450 1.1 52 2.7 „ (x) 66 0.2 47 0.1 42 0.1 53 0.2 43 0.1 42 0.1 5 0.1 7 0.1 305 0.1 5 0.3 Phthisis (f) 85 0.2 78 0.2 85 0.3 69 0.2 65 0.2 78 0.2 11 0.2 7 0.1 478 0.2 4 0.2 „ (x) 34 0.1 39 0.1 36 0.1 31 0.1 24 0.1 31 0.1 6 0.1 1 0.0 202 0.1 1 0.1 Other tubercular disease (f) 127 0.3 91 0.2 84 0.3 64 0.2 90 0.3 77 0.2 15 0.2 13 0.2 561† 0.3 15 0.8 „ „ (x) 48 0.1 33 0.1 36 0.1 19 0.1 25 0.1 29 0.1 6 0.1 1 0.0 197† 0.1 9 0.5 Rickets (f) 1,099 2.4 569 1.4 471 1.6 233 0.8 288 0.9 155 0.5 47 0.7 25 0.4 2,887 1.3 32 1.7 „ (z) 95 0.2 58 0.1 22 0.1 14 0.0 3 0.0 3 0.0 1 0.0 1 0.0 197 0.1 1 0.1 Deformities „ (f) 410 1.0 292 0.7 459 1.6 460 1.6 702 2.1 1,019 3.0 163 2.3 215 3.4 3,720† 1.7 67 3.5 „ (x) 96 0.2 81 0.2 127 0.4 147 0.5 191 0.6 382 1.1 46 0.7 82 1.3 1,152† 0.5 15 0.8 Infectious diseases „ (f) 63 0.2 62 0.2 20 0.1 24 0.1 15 0.0 10 0.0 - 1 0.0 195 0.1 4 0.2 „ (x) 43 0.1 42 0.1 16 0.1 12 0.0 11 0.0 8 0.0 - - 132 0.1 2 0.1 Malnutrition (f) 532 1.3 488 1.2 432 1.5 420 1.4 268 0.8 249 0.7 34 0.5 35 0.5 2,458 1.1 39 2.0 „ (x) 225 0.5 178 0.4 181 0.6 170 0.6 108 0.3 75 0.2 16 0.2 16 0.2 969 0.4 19 1.0 Other defects „ (f) 1,540 3.7 1,375 3.4 880 3.0 913 3.1 819 2.4 1,055 3.2 140 2.0 171 2.7 6,893 3.1 58 3.0 „ (x) 894 2.1 802 2.0 509 1.7 535 1.8 395 1.2 462 1.3 72 1.0 79 1.2 3,748 1.7 26 1.3 Number of children noted for treatment 16,128 38.4 15,223 37.4 12,621 42.8 12,800 43.7 12,731 37.7 13,237 39.2 2,432 35.0 2,460 38.3 87,632 39.4 834 43.4 * Children leaving elementary schools to attend continuation schools. † These cases are sub-divided in Table II. (f) Defects found. (x) Defects noted tor treatment. 107 TABLE IX. Medical Inspection of Students in Secondary Schools, Training Colleges and Trade Schools. Institutions. No. examined. DEFECTS. Teeth. Vision. Nose and throat. Hearing. Ear discharge. Heart. Lungs. Anaemia. Back. Nutrition. Various. Defective. Eye strain. Round. Curvature. L.C.C. schools. Training colleges— Males 176 22 62 2 — — — 4 — — 2 1 — 14 Females 1,206 158 207 10 25 10 6 15 7 49 123 47 65 99 Secondary schools— Males 2,284 371 348 5 72 11 13 56 14 70 32 11 13 126 Females 5,103 1,135 894 113 262 40 15 112 40 169 485 251 240 542 Trade schools— Males 615 108 52 — 3 1 1 8 2 5 17 1 1 19 Females 617 74 110 27 28 7 3 21 6 30 91 23 34 82 Aided by L.C.C. Secondary schools — Males 647 171 80 5 12 1 3 28 5 6 11 1 4 13 Females 460 99 75 7 20 — — 8 2 12 15 19 6 36 Trade schools— Males 353 77 32 3 1 5 2 3 — 3 6 2 — 16 Females 563 141 86 14 21 10 6 6 1 17 29 8 — 80 L.C.C. scholars at unaided institutions. Males 275 15 35 — 1 5 — 1 — 2 l — 1 9 Females 109 17 10 — 2 — 1 1 — 4 1 2 1 15 12,408 2,388 1,991 186 447 90 50 263 77 367 813 366 365 1,051 61004 p 2 108 CHAPTER XXV. PUBLIC HEALTH. Infectious and epidemic diseases. The Council, as the central authority, maintains special arrangements for dealing with infectious and epidemic diseases. With regard to these diseases generally, the Council provides expert assistance in diagnosis and bacteriological examination. Returns of notifications of infectious diseases are forwarded weekly to the Council and are examined by the county medical officer, and, when necessary, inquiries are instituted and special reports are published by the Council. Special steps are taken with regard to cases of infectious disease arriving in this country from abroad. The Council retains the use of certain premises for the purpose of temporarily accommodating contacts of plague, cholera or other epidemic disease. Treatment of tuberculosis. The following table shows the development of the provision for residential treatment under the Council's scheme (excluding insured persons and ex-Service men):— Year. New cases admitted during year. Beds occupied at end of year. Adults. Children. Total. Adults. Children. Total. 1914 47 121 168 33 90 123 1915 322 374 696 126 241 367 1916 492 551 1,043 133 320 453 1917 594 573 1,167 162 375 537 1918 667 738 1,405 133 376 509 1919 690 833 1,523 170 557 727 1920 932 1,167 2,099 306 704 1,010 The responsibility for the public provision of treatment for tuberculosis rests in the county of London on the Council, which has made a comprehensive scheme under which the Council provides or arranges for the provision of residential accommodation, and the metropolitan borough councils provide or arrange for the provision of dispensary treatment. With regard to residential treatment it has been the policy of the Council to take advantage of all suitable accommodation available in hospitals and sanatoria, and to look to the Metropolitan Asylums Board, the authority for the provision of residential treatment for infectious diseases in London, to provide the further accommodation required. The treatment for tuberculosis of persons insured under the National Health Insurance Acts was the responsibility of the insurance committees, and the London Insurance Committee made their own arrangements for the residential treatment required, and entered into agreements with the various metropolitan borough councils for the dispensary treatment of insured persons. During 1920 the Council, after prolonged negotiations with the Insurance Committee, concluded an agreement under which the Council became responsible to provide or arrange for the provision of residential treatment for insured persons. Under this agreement the Council became responsible for the cost of such treatment so far as insurance funds proved insufficient for the purpose; any additional expense so incurred by the Council being reimbursed, as to one-half, from Government grant. The National Health Insurance Act, 1920, provided for the discontinuance, as from a date to be determined, of sanatorium benefit, which included the benefit of institutional treatment for tuberculosis ; but Parliament had not determined, before the close of the year, the arrangements to be made for the treatment of insured persons after the discontinuance of sanatorium benefit. During the war the London Insurance Committee undertook, at the request and at the cost of the Ministry of Pensions, the arrangements necessary for the residential (and preferential) treatment of discharged sailors and soldiers suffering from tuberculosis; and concurrently with the agreement referre d to in the preceding paragraph the Council concluded an agreement with the Insurance Committee under which the Council became responsible for the arrangements for the residential treatment of discharged sailors and soldiers. As a result of the transfer to the Council, under the two agreements referred to, of responsibility as regards residential treatment of insured persons and ex-Service men, the arrangements for the provision of all residential accommodation required through public authorities for the treatment of tuberculosis in London were centred in the hands of the Council. The advantage of bringing into the hands of one authoritv the arrangements for all residential treatment will be appreciated from the undermentioned considerations. During the war, owing to pressure on hospital accommodation in connection with the treatment of the wounded and sick from the various theatres of war, the accommodation available for tuberculosis cases was inadequate, and as arrangements for residential treatment of London cases were in different hands, it was not possible to secure that the best use should be made of available accommodation. During the interval which has elapsed since the termination of the war, the available accommodation for tuberculosis cases has gradually increased, so that, with the arrangements for all cases in the hands of the Council, the most suitable accommodation for the individual patient is more readily obtained and the number of cases waiting for beds has been substantially reduced. Reference has been made to the shortage of bed accommodation, during and after the period of the war, for the treatment of tuberculosis. During the war the greatest possible effort was exerted to obtain accommodation for cases for which the Council was responsible, and these efforts were continued after the war without relaxation. Owing largely to the assistance given by the Metropolitan Asylums Board to meet the Council's needs, the position with regard to the available accommodation was much improved during the vear. 109 The figures above exclude cases of children referred by the Council to the Invalid Children's Aid Association for residential treatment under an agreement between the Council and the Association. The number of children so referred during 1920 was 368. At the end of 1920 there were 155 cases (95 adults and 60 children) on the Council's waiting list for residential treatment. On the basis of restoration of the normal provision in poor-law infirmaries, the number of beds available for London cases is approximately as follows:— Authorities providing beds. Beds provided. Numbers (included in column (2)) of beds provided for the Council. the Insurance Committee. (1) (2) (3) (4) Authorities of General and Special Hospitals and various homes (not exclusively for London cases) 1,532 400 685 Authorities of London Poor-law Infirmaries 2,000 - - Metropolitan Asylums Board 1,868 350 522 5,400 750 1,207 In 1913 the Departmental Committee on Tuberculosis suggested tentatively, as a working standard for residential accommodation, one sanatorium bed and one hospital bed for every five thousand population. Applied to London, with a population of 41/2 millions, this standard, known as the "Astor" standard, would give 900 sanatorium beds and 900 hospital beds. Recent evidence before the Departmental Committee (1919) shows that this standard has proved inadequate in certain large cities, e.g., Glasgow and Liverpool. After history of patients. During the year particulars were obtained of the after-history of the Council s patients who received residential treatment during part of 1914, and during 1915, and of insured persons recommended for sanatorium benefit in 1914. Of 306 uninsured adults treated, 122 (39'9 per cent.) were not traced, and of 288 children treated, 89 had passed out of supervision. Of 3,224 insured adults recommended for sanatorium benefit, 636 (19.9 per cent.) were not traced. The ascertained mortality in each clinical group, excluding untraced cases, was as follows— Number of cases. Number known after four years to be Alive. Dead. 1. Council's patients (а) Adults (uninsured):— For diagnosis 5 3 (60 %) 2 (40 %) Early cases 59 27 (45.8 %) 32 ( 54.2 %) Moderately advanced cases 97 33 (34 %). 64 (66 %) Far advanced cases 23 4 (17.4 %) 19 (82.6 %) (b) Children (pulmonary):— Diagnosis doubtful 24 20 (83.3 %) 4 (16.7 %) Early cases 81 78 (96.2 %) 3 (3.8 %) Moderately advanced cases 48 36 (75 %) 12 (25 %) Far advanced cases 10 4 (40 %) 6 (60 %) (c) Children (non-pulmonary) Hip 16 12 (75 %) 4 (25 %) Spine 2 1 (50 %) 1 (50 %) Other bones 4 3 (75 %) 1 (25 %) Glands 14 12 (857 %) 2 (14.3%) 2. Insurance Committee patients:— Adults (insured)— Early cases 552 386 (70 %) 166 (30 %) Moderately advanced cases 1,417 361 (25.4 %) 1,066 (74.6%) Far advanced cases 619 20 (3.2 %) 599 (96.8 %) The figures for insured and uninsured adults are not comparable, as insured persons, of both sexes, work under the stress of industrial conditions, whilst uninsured persons, principally women, are not engaged in ordinary industrial life. Moreover, of the 3,244 insured persons recommended for sanatorium benefit only 1,515 received residential treatment. The results shown above are broadly similar to those ascertained in other parts of the country. Contributions. In accordance with the Council's scheme, when an adult patient, or the person legally responsible for an adult patient, has an income of £160 a year or more, and the circumstances of the case appear to justify the demand, a charge is made for treatment. In the case of children, the Council approved the principle of a small contribution, roughly equivalent to the cost of maintenance of a child at home, being collected from the parents or guardians of children sent away under the Council's scheme. The voluntary care committees, who are referred to later, assist the Council in deciding the assessment by reporting on the financial and social circumstances of the family and advising as to the charge which they consider reasonable. From the amounts contributed towards the treatment of children grants were made, as in previous years, to the Invalid Children's Aid Association, a voluntary organisation, for the purpose of providing for the convalescent treatment of children suffering from tuberbulosis, and also for providing surgical instruments and other accessories to treatment. 110 Tuberculosis dispensaries —survey of their work. The working of the tuberculosis dispensary service in London was the subject of a special survey during the year.* The tuberculosis dispensary is—in the words of the Departmental Committee on Tuberculosis—"not a building but an organism." The scheme which they recommended in 1912, for preventing, detecting and treating the disease was based on the establishment and equipment of two units related to the general public health and medical work carried on by medical officers of health and working in harmony with the general practitioner. This scheme was intended to complete existing public health administration in respect of tuberculosis. Of the two units referred to, the first consisted of the tuberculosis dispensary or an equivalent staff, the second unit consisting of sanatoria, hospital, etc., in which residential treatment is given. The opinion was expressed that the tuberculosis dispensary should be the common centre for the diagnosis and for the organisation of treatment of tuberculosis in each area, at which the various bodies and persons connected with the campaign against tuberculosis would be brought together. The Departmental Committee expressed the view that the aim should be that no single case of tuberculosis should remain uncared for in the community, and that whatever services the scheme provided should be available for all cases of the disease ; that next to the tuberculosis dispensary should stand the second unit, consisting of a system of sanatoria, hospitals, farm colonies, open-air schools, etc., and that the tuberculosis dispensary should be linked up to these institutions, for which it would act as a clearing house. The Departmental Committee stated that, in a general way, the function of the tuberculosis dispensary should be to serve as (i) receiving house and centre of diagnosis; (ii) clearing house and centre for observation; (iii) centre for curative treatment; (iv) centre for the examination of "contacts"; (v) centre for "after-care"; (vi) information bureau and educational centre. Some of these functions are complementary to the preventive work, under the Public Health (Tuberculosis) Regulations, 1912, and the general powers, in relation to sanitary matters, of the municipal health departments. The functions of dispensaries in connection with early detection of cases of tuberculosis are of great importance, and early detection of the disease and preventive work are activities likely to yield the most fruitful results in the general effort to reduce the prevalence of the disease. The disappointing results of treatment of tuberculosis, as disclosed in recent statistical information to which reference has been made earlier in this report, emphasise the importance of this side of the work. Development of the dispensary system. The Central lund for the Promotion of the Dispensary System for the Prevention of Consumption in London was established in 1911, and in that year eleven dispensaries under the scheme of the Central Fund were established. In the following year two other voluntary dispensaries were established. In the same year (1912) the Departmental Committee suggested that dispensaries should be provided by metropolitan borough councils, which were then invited by the late Local Government Board to provide dispensaries. In 1913, municipal dispensaries were established in 6 metropolitan boroughs. In 1914, 12 schemes of borough councils, relating to 13 separate dispensaries, were approved by the Council under its comprehensive scheme made in that year. The number of approved dispensary schemes increased each year until, in 1919, there were 29 approved schemes relating to 33 separate dispensaries and two branch dispensaries. The various voluntary dispensaries were included as part of the borough dispensary provision, and have continued on a voluntary basis subject to compliance with the requirements of public authorities. Of the total number of dispensaries, 13 are voluntary and 9 municipal, the remainder being established at hospitals. During 1920, the Central Fund intimated that it was no longer able to continue its grants to the eleven dispensaries which it had established and supported, and it accordingly became necessary for the metropolitan borough councils in whose areas the dispensaries were situated, to consider as to the future arrangements to be made for the maintenance of adequate dispensary service. The medical officers of dispensaries are designated tuberculosis officers, and are selected owing to their possessing, in addition to ordinary medical knowledge and experience, special qualifications in respect of tuberculosis likely to command the confidence of the general practitioners in their areas. There are in London 41 tuberculosis officers, of whom 9 have part-time appointments. In order to coordinate the work of the public health departments and the dispensaries, borough medical officers have been appointed "administrative tuberculosis officers," the position of the tuberculosis officer being assimilated with some limitations to that of an assistant to the borough medical officer, except in clinical matters, in which the tuberculosis officer is independent of control. One-half of the cost of approved arrangements for the dispensary service for uninsured persons is met by Exchequer grant. One-half of the balance of the cost of such arrangements, approved by the Council in accordance with its scheme, is borne by the Council. Views of Council on present working of dispensaries. In normal circumstances it would have been possible to follow closely the development of the work of the dispensaries from July, 1914, or the later date of their establishment, as the case might have been, but it was not possible during the period of the war to make the close investigation necessary for the purpose of revealing the deficiencies discovered in the course of the survey undertaken during this year. The deficiencies are largely attributable to understaffing and other conditions due to the war. As a result of the survey, the Council, with the approval of the Ministry of Health, approved the undermentioned proposals as part of its scheme for the treatment of tuberculosis in London, and decided that such proposals should be severally brought into effective operation at the earliest practicable date or dates after 31st December, 1920. (i) Consulting centres with physicians with special experience in tuberculosis and equipped with observation beds should be provided, if possible, at a number of London hospitals ; tuberculosis officers should have access to these beds, and consultations upon the occupants of these beds and other patients brought by tuberculosis officers should take place at regular intervals ; * Tuberculosis in London. Report of the Public Health Committee. 1st July, 1920. No. 2035. Price 6d. 1ll and in the selection of hospitals to be consulting centres there should be a variation of existing arrangements with hospitals, each dispensary being, under the modified arrangements, linked to a hospital which is also a recognised consulting centre. (ii) The fullest possible measure of co-operation should be developed between the dispensary service and the school medical service. (iii) In each dispensary area in the County of London the normal basis of staffing should provide for one tuberculosis officer for each 160 deaths a year in that area from tuberculosis; part-time (preferably half-time) tuberculosis officers should assist in dispensary areas requiring on the above-mentioned basis, the services of more than one whole-time tuberculosis officer; and there should be one dispensary nurse (whole or part-time) for each tuberculosis officer (whole or part-time) in each dispensary area. (iv) The working week of each tuberculosis officer should normally be equivalent to twelve sessions of three hours each. (v) At each dispensary at least one evening session in each week should ordinarily be held for the convenience of working men and women, and, where practicable, a session should be held each week on Saturday morning, or at some other suitable time outside school hours, for children in attendance at school. (vi) Treatment as distinct from diagnosis and consultation at the dispensary should as a rule be limited to patients whose continued treatment requires special knowledge or technical skill, and to those who are unable to obtain other adequate medical attendance. (vii) The practice of treating patients at the dispensaries on a large scale and over prolonged periods with bottles of medicines, etc., and of giving medicines to ensure the attendance of patients, should be discouraged. (viii) In order to arrive at the earliest possible date at a definite diagnosis in doubtful cases, there should be shorter periods of observation combined with more intensive study of each case, full use being made of the facilities and aids to diagnosis afforded by the consulting centre. (ix) In connection with each dispensary there should be adequate arrangements for following up patients for whose failure to continue in attendance at the dispensary no satisfactory reason has been ascertained. (x) The local arrangements should be such as will enable the tuberculosis officer to visit the homes of dispensary patients, in order to become familiar with the environmental conditions of the patients in his district and to enable him to supervise adequately the work of the dispensary nurses; and he should actually visit, at least once, the home of each patient unless he considers that, in the interests of the patient, such a visit would be undesirable. (xi) Adequate arrangements should be made for the examination by the tuberculosis officer of the home contacts of newly notified cases. (xii) The tuberculosis officer should become personally acquainted, as far as possible, with all medical practitioners practising in the area served by his dispensary, in order that the fullest degree of co-operation may be secured. (xiii) Adequate clerical assistance should be afforded to the dispensary staff, and all communications between the tuberculosis officer and the Council relating to the treatment or clinical supervision of individual patients should, in future, be made direct. (xiv) Efforts should be made to introduce at the dispensaries a system by which patients would be seen, if practicable, by individual appointment, or other means should be adopted to reduce to a minimum the time during which patients are kept waiting at the dispensary. The numbers of new cases examined at the dispensaries were:—9,219 adults (insured), 5,957 adults (uninsured) and 13,182 children. Dental treatment. Proposals for the provision of dental treatment in connection with dispensary treatment were subm'tted by eleven metropolitan borough councils, the Council having in 1919, decided to regard dental treatment as an essential part of the tuberculosis dispensary service. Seven of these proposals were approved and the remainder were still being considered at the end of 1920. Care committees. The late Local Government Board, in 1915, suggested that metropolitan borough councils should form tuberculosis care committees in connection with local dispensaries mainly for the purpose of coordinating the activities of public health officers, concerned with the medical side of the work, and voluntary agencies, concerned with the social side and with the function of providing auxiliary aids to treatment, such as additional food, change of air, clothing, better home conditions, etc. The Council formulated a model scheme for the establishment of such committees, prescribing their constitution and duties. In 1919, six borough councils appointed care committees (two of these borough councils combining for this purpose to form one committee) in place of the interim committees, leaving interim committees to be appointed by the Council in the remaining 22 boroughs. As the Ministry of Health was considering the future constitution and functions of cafe committees, no progress was made during 1920 towards forming nermanent care committees in the 22 boroughs referred to. Venereal ditease. The Council on 15th March, 1920, decided to continue the scheme, in force since 1st January, 1917, for the diagnosis and treatment of venereal diseases. Under this scheme the Council has joined with the councils of the counties of Buckingham, Essex, Hertford, Kent, Middlesex and Surrey, and the county boroughs of Croydon, East Ham and West Ham to utilise the facilities afforded by certain London hospitals, for diagnosis and treatment, and (except as regards the county of Kent) to provide laboratory facilities for aid in diagnosis and treatment. Arrangements have been made for free 112 ment and diagnosis for in-patients and out-patients at 28 hospitals and for the reception of patients for treatment at 7 hostels. During 1920 special provision was made for the treatment of pregnant women and very young children suffering from venereal diseases. Practitioners secure, at the cost of the Council, scientific reports on materials from patients suspected to be suffering from venereal disease and the supply, free of cost, of salvarsan or its substitutes. The cost of treatment and diagnosis at hospitals is met by the local authorities affected in proportion to the number of attendances of new patients in the respective areas. The Council makes direct payments to hospitals for salvarsan or its substitutes supplied to medical practitioners in London. These facilities have been fully advertised. By arrangement, as in previous years, the National Council for Combating Venereal Diseases (a voluntary organisation which co-operates in the carrying out of the propaganda campaign under the supervision of the Ministry of Health) gave lectures and addresses to selected audiences, and published information relating to venereal diseases and their treatment, and grants were made by the Council to the National Council for these purposes. During 1920, 23,612 persons residing in London were dealt with for the first time at the hospitals or 2,704 more than in 1919. The number of attendances made by out-patients was 365,478, or an increase of 132,819 over the number during 1919. Three-fourths of the Council's expenditure in respect of venereal diseases is recoverable from the Government. Prophylaxis. Careful consideration was given to the conclusions of the Inter-Departmental Committee on Infectious Diseases in connection with Demobilisation, particularly their note-submitted to the Minister of Health in August, 1919, on prophylaxis in relation to venereal diseases. The note was concerned mainly with the advisability, or otherwise, of officially making available for the civil community methods of prophylaxis (commonly spoken of as the "packet" system) publicly commended as successful among members of the Forces during the war, and stated that the evidence put before the Committee did not justify them in recommending the official encouragement of these methods among the civilian population. The Council studied the evidence on which the Committee based their conclusions and discussed with experts various aspects of the questions involved. The information obtained did not warrant any different conclusion, and the very careful investigations made confirmed the Council's view that, apart from moral considerations and the question whether an effective packet system could be organised for the civil community, the disadvantages incident to official encouragement outweighed any advantages. The Inter-Departmental Committee expressed the opinion that energy should not be dissipated on measures of doubtful value, but concentrated rather on wise propaganda and the provision of early, prompt and skilled treatment. These are objects of constant attention in the carrying out of the Council's scheme. Infant life protection. Part I. of the Children Act, 1908, provides that a person who undertakes tor lure or reward the nursing and maintenance of an infant under the age of seven years apart from its parents shall, within 48 hours, give due notice of such reception to the local authority, in London the Council. If an infant dies the foster-mother must notify the coroner within 24 hours, and the Council within 48 hours. The following table shows the number of foster-mothers and nurse-infants notified on 31st December in each of the years 1915-1920:— 1915. 1916. 1917. 1918. 1919. 1920. Foster-mothers 3,162 3,110 2,995 2,654 2,481 2,296 Nurse-infants 4,028 4,109 3,990 3,461 3,114 2,952 Power is given under the Act to remove to a place of safety, i.e., a workhouse, an infant in the charge of a foster-mother who is unfit to have the care of it owing to negligence, ignorance, inebriety, immorality, criminal conduct or other similar cause. Similar action may be taken where the premises are overcrowded, dangerous or insanitary, or if the infant is being kept by a person or in any premises in contravention of the Act. The Act also empowers a local authority to exempt either partially or wholly premises which in the opinion of the authority are so conducted as to render ordinary inspection unnecessary. Towards the end of 1919, the London War Pensions Committee asked the Council to make arrangements for the inspection of homes in which the Committee proposed to place the neglected children of deceased or serving soldiers and sailors, and the Council agreed, as a temporary arrangement, to carry out the work as part of the routine inspection undertaken by its visitors under the Children Act. Details of the Council s work are given in the following table. Year. Infants removed from foster mothers. Exemptions. Deaths. Infringements discovered. Cautions. Prosecutions. Convictions. 1918 48 5 103 446 420 25 *24 1919 33 11 51 432 416 16 16 1920 14 7 26 318 302 16 16 * 1 case was adjourned sine die on a point of law. 113 The need for the amendment of Part I. (Infant Life Protection) of the Children Act, 1908, has long been felt, and after careful examination of the proposals and suggestions of public authorities and voluntary agencies concerned or interested in the administration of the law relating to infant life protection, and as the result of wide experience in the working of the Act, the Council on 18th May, 1920, expressed the opinion that Part I. of the Children Act, 1908, required amendment, so that— (i.) Persons receiving infants to which Part I. of the Act applies, and such infants, shall be registered with the local authority, which shall be empowered to refuse or cancel registration if satisfied that such persons are unsuitable to have the care of young children or that the environment is unsatisfactory. (ii.) All persons who shall enter into any agreement, whether oral or in writing, or who shall conduct negotiations whereby a person shall undertake for reward the nursing or maintenance of one or more infants under the age of seven years apart from their parents or having no parents shall, within 48 hours from the making of such agreement or the completion ol such negotiations, give notice in writing thereof to the local authority. (iii.) The adoption or maintenance of an infant in consideration of a lump-sum payment shall be illegal, unless the arrangement be on conditions approved by the local authority. (iv.) The onus of proof that a child has been received or adopted without reward shal be on the person by whom the child has been so received or adopted. (v.) The transfer of an infant adopted or maintained in consideration of a lump-sum paymenl shall require the consent of the local authority ; and any person knowingly accepting the transfer without such consent shall be liable to a penalty. (vi.) The removal of an infant to a place of safety from unsuitable premises, or from a person incapable owing to physical or mental infirmities, of devoting to it proper care, shall be authorised. (vii.) It shall be an offence for any person (instead of the foster-parent only) to refuse tc allow an infant protection visitor to visit or examine infants, to which Part I. of the Act applies, on the premises on which they are kept; and it shall be an offence for any person to obstruct an infant protection visitor or other person in the course of examining the infants or the premises on which they are kept. (viii.) Proceedings for any offence under Part I. of the Act may be instituted within six calendar months after the offence shall have been first discovered and made known to the local authority, provided that no proceedings shall be commenced after expiration of twelve calendar months from the date of the offence. These proposals of the Council were communicated to the Minister of Health with a request that he would endeavour to secure the amendment of the Act on the lines indicated. Lying-in homes. Part IV. (Lying-in homes) ot the London County Council (General rowers) Act, 1915, prohibits any person from carrying on a lying-in home unless the name of such person and the premises used are registered by the Council. The Act empowers the Council to inspect premises believed to be used for the purpose of a lying-in home, and to refuse to register or to cancel registration on the grounds of the character of the responsible person, the unsuitability of the premises or their equipment, or the use of the premises or premises in connection therewith for immoral purposes. Recognised hospitals and similar establishments, homes approved for the training of midwives and lying-in homes in which relatives alone are received, are exempt from the Act. Homes carried on by duly qualified medical practitioners are also exempt from the Act, provided that the necessary approved certificate is submitted to the Council annually. Six premises of this kind were exempted during 1920. At the beginning of 1920, 258 premises were on the register, 75 were added during the year, one registration was cancelled, while 74 entries on the register were removed (owing to discontinuance of user, removal, etc.), leaving a total of 258 premises on the register at the end of the year. In the course of over four years' experience of the working of the Act practical proof was obtained of the inadequacy of the existing law, and after careful consideration of all the facts the Council decided on 27th July, 1920, to apply to Parliament in the session of 1921 for the amendment of Part IV. of the Act of 1915 in order to provide that— (i) An application for registration shall state the full name, address, age, nationality and qualifications (if any) of the applicant and such further information as may reasonably be required, as regards the applicants or the premises or their equipment, in connection with the consideration of the application. (ii) The power to refuse or cancel registration shall be exercisable against a person who is "unsuitable" instead of "of bad character." (iii) An additional ground for refusal or cancellation of registration shall be that the applicant is under the age of 21 years. (iv) The Council shall be empowered to make by-laws—(a) Prescribing the records to be kept; (b) prescribing the number of patients that may be accommodated; (c) prescribing the equipment; (d) providing that all deaths of patients shall be notified to the Council. During the year 1920 the Ministry of Health issued a memorandum (15/M & C.W.) which indicated the standards of measurements suitable for the accommodation of maternity cases. The space suggested is 960 cubic feet per bed for wards to contain patients with infants, 800 cubic feet per bed for wards to contain only the mother at night, and 600 cubic feet per bed for wards to contain antenatal cases. Midwives. Under the Midwives Act, 1902, the duties of the Council, as the Local Supervising Authority for London were chiefly disciplinary in connection with the conduct, professional or otherwise, of mid61004 Q 114 wives or persons practising as midwives within the county. To enable it to carry out these and allied duties the Council appointed four qualified women medical practitioners, to inspect midwives and to investigate special cases. The Midwives Act, 1918, passed to amend the Act of 1902 enlarged the Council's responsibilities, the chief alteration dealing with the provision of medical assistance for midwives. By section 14 midwives are required to summon medical aid in any case of emergency as defined by the rules of the Central Midwives Board. The fees of the medical man so called in are payable by the Council (in accordance with a scale fixed by the Local Government Board and amended by the Ministry of Health), which has power to recover them from the patient, her husband, or other person liable to maintain her, unless it can be shown that such person is unable to pay the fees. From 1st April, 1920, to 31st March, 1921, the Council's expenditure under this head was about £5,050, of which about £560 was recoverable. Under Section 5 of the Act of 1902, as amended by section 2 of the Act of 1918, any adverse balance in the accounts of the Central Midwives Board is apportioned between the councils of the several counties and county boroughs in proportion to population at the last census, and the Council's proportion for the year 1920 was £615. The following are brief statistics of the Council's work during the year:— Notifications by midwives:— (i.) Of intention to practise during the year 709 (ii.) Of intention to practise for specific periods less than a year 25 (iii.) Of having acted in specific cases 20 Births attended by midwives 59,655 Percentage of total number of births 49.5% Cases of puerperal fever 445 Cases of ophthalmia neonatorum 684 Inquests:— (i.) Women 17 (ii.) Children 80 97 Legal proceedings against uncertified persons 3 Prima facie cases of negligence or misconduct reported to the Central Midwives Board 7 Prima facie cases in which the Central Midwives Board found that charges had been established and removed the name of the midwife from the roll 4 Prima facie cases in which the Central Midwives Board suspended judgment pending the receipt of further reports after intervals of three and six months 2 Under the provisions of section 11 of the Midwives Act, 1918, the Council, as a local supervising authority, may aid in the training of midwives, whether within or without its area, and may make grants for the purpose. In addition, grants to assist in the training of midwives may be secured under the Board of Education (Midwives' Training) Regulations, 1919. With a view to ascertaining the need for the training of midwives for work within the County, representatives of various hospitals and institutions which are training centres for this purpose, and other persons interested in this matter were consulted. It was admitted that there was no real shortage of practising midwives in London, but suggestions were made for improving their status and qualifications. As a result the Council, in addition to continuing its courses of post-graduate instruction for practising midwives, represented to the Board of Education that it was desirable that a standard of general education and health should be established for pupil midwives who desire to avail themselves of the provisions of the Board of Education (Training of Midwives) Regulations, 1919. The Board replied that it was prepared to support any training institution which took steps to secure candidates of good general education; that, with regard to the elimination of candidates who were physically unfit for the work, it thought that for the time being, it would be preferable to leave the matter to the discretion of the managers of training institutions; that it would impress upon such managers the need for careful selection of candidates; and would refuse grants in cases where, in its opinion, unsuitable candidates were being admitted. In connection with the reconstitution of the Central Midwives Board under section 1 of the Act of 1918, the Council represented to the Ministry of Health that representation on the Board should be allocated to the Council. The Ministry, however, intimated that it did not think that it would be justified in taking action with a view to securing special representation of the Council upon the Board. The attention of the Council was drawn to an offer made to the Central Midwives Board by the Ministry of Health to arrange for the women medical officers and nurse inspectors on the staff of the Ministry to inspect and advise the Board upon midwives or institutions desirous of obtaining the Board's sanction to undertake the training of pupil midwives. As it was the practice, instituted at the request of the Board, for reports in this respect to be made to the Board by the Council's inspectors under the Midwives Act, it appeared to the Council that the action of the Ministry was unnecessary and would lead to confusion and involve wasteful expenditure and the Ministry was informed of the Council's views upon the matter. Jouses let in lodgings, etc. The Housing, Town Planning, etc. Act, 1919, requires the Council, in lieu of the metropolitan borough councils, to make for the county by-laws respecting houses divided into separate tenements. Section 26 provides that such by-laws shall deal with (a) the number of persons who may occupy a house or part of a house which is let in lodgings and for separation of the sexes therein; (b) the registration and inspection of such houses; (c) the enforcing of drainage and the promotion of cleanliness and ventilation; (d) the provision, adequate for the use of and readily accessible to each family of 115 (i.) closet accommodation; (ii.) water supply and washing accommodation; (iii.) accommodation for the storage, preparation and cooking of food; and, where necessary, for securing separate accommodation for every part of such ho ise which is occupied as a separate dwelling; (e) the repair and adequate lighting of any common staircase; (/) stability, and the prevention of and safety from fire; (g) the cleansing and redecoration of the premises at stated times, and the paving of the courts and courtyards; (h) the provision of handrails, where necessary, for all staircases of such houses; and (i) the adequate lighting of every room. There are various additional provisions as to the execution of works, the position of persons holding premises under lease or agreement, and the power of the Minister of Health to make by-laws in default of local authorities. The section applies to London with the following modifications—(a) as regards the County of London, the by-laws shall be made by the Council, but shall be observed and enforced by the council of each metropolitan borough except as regards by-laws for the purposes specified in clause (f) above, which shall be enforced by the Council; (b) as regards the City of London such by-laws shall be made and enforced by the common council except as regards by-laws for the purposes specified in clause (f) above. Early in 1920 model by-laws were issued by the Minister of Health, and on 27th July, 1920, the Council made by-laws based on the model by-laws, and applied to the Minister of Health for confirmation of the same. The by-laws are under consideration by the Minister of Health. Housing of transmigrants. Prior to the war accommodation provided tor transmigrants arriving in this country from Eastern Europe on their way to America was in many instances very unsatisfactory. During the war the traffic ceased, but since then numbers of transmigrants are constantly arriving in London. Many come from countries where typhus, typhoid fever, small-pox, and other dangerous infectious diseases are prevalent, and the Council on 13th July, 1920, decided to urge the Home Secretary to ensure that transmigrants during their stay in London should be released only to persons known to have suitable accommodation for them. As a result it was arranged that the shipping companies engaged in this traffic should make every endeavour to acquire premises in London to accommodate about 1,000 persons, but at the end of 1920 nothing definite appeared to have been done. Census of homeless pei sons. Censuses were taken by the medical officer, in continuation of those in previous years, of homeless persons in order to ascertain the use made of common lodging-houses, and the provision existing for the accommodation of persons of the poorest class. The censuses were taken on a winter night, and the total numbers of homeless persons found in streets, on staircases and under arches were : February, 1915, 178; 1916, 44; 1917, 28; 1918, 9; 1919, 8 and 1920, 51. Soldiers' rest houses. In February, 1916, the Council agreed to assist tne Army council in connection with the supervision of the sanitary arrangements and other kindred matters affecting shelters provided for troops in London. Since that date 300 houses were measured up and apportioned, and nearly 10,000 visits were made. The standard of equipment and maintenance was most satisfactory. In March, 1920, the General Officer Commanding, London District, intimated that these shelters had been discontinued and expressed his thanks for the Council's assistance. Common lodging houses. Particulars with regard to common lodging-houses licensed by the Council are as follows:— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious disease 1018 211 20,818 3 3 £43 - 1919 198 20,139 1 1 £8 1 1920 186 18,763 1 1 £3 2 Seamen's lodging houses. Particulars of seamen's lodging-houses licensed by the Council are as follows:— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious diseases 1918 59 1,486 15 12 £139 2s. - 1919 57 1,381 17 17 £118 - 1920 53 1,298 9 6 £91 10s. - In the latter part of 1914, it was decided, owing to the war, not to grant licences to enemy aliensIn the event of licences being held by aliens (other than enemy aliens) arrangements were made for the Commissioner of Police of the Metropolis to be informed of any non-compliance with the Aliens' Registration Order. On 17th February, 1920, it was decided that, as seafaring men are able to avail themselves, more readily than other persons, of simple means of escape in case of fire from upper floors of buildings of moderate height, the requirements of the Council in connection with the grant of licences for the use of such buildings as seamen's lodging-houses, more particularly those accommodating fewer than 40 persons, or as houses in which lodgings are let to seamen, be limited, as regards structural works for securing means of escape in case of fire, to works of the simplest character consistent with adequate protection from fire risk, provided, in respect of each building, that the requirements be determined on merits, with full regard to any special statutory provisions affecting the case, and that requirements limited in accordance with this order be applicable only so long as the house is occupied and used solely for the accommodation of seamen. 61004 Q 2 116 Offensive businesses. The following table gives particulars of licensed slaughterhouses, knackers' yards and registered offensive businesses for 1918-20. Year. Slaughterhouses. Knackers' yards. Offensive businesses. 1918 174 4 63 1919 174 4 53 1920 165 4 53 The Council for some time past has considered the conditions under which the businesses of a fur-skin dresser and a slaughterer of poultry have been conducted, and after careful investigation decided that in many instances such businesses constituted nuisance and a danger to health. Accordingly early in 1920 it made orders declaring these businesses to be offensive businesses within the meaning of section 19 (1) (6) of the Public Health (London) Act, 1891. The Minister of Health has confirmed the Orders and bv-laws for regulating the conduct of the businesses are now being pre pared. Keeping of pigs. Section 17 (4) of the Public Health (London) Act, 1891. prescribes 40 yards as the distance from any street or public place within which premises may not be used for the keeping of swine, but this was amended by No. 2.0. of the Code of Regulations under D.O.R.A. so as to provide that, irrespective of the distance from the street, but subject to the consent of the local authority, pigs might be kept in any premises or place where they did not cause a nuisance or injury to health. Any permission granted under the regulation is valid for at least five vears. Cowhouses. The numbers of cowhouses licensed by the Council are as follows:—1915, 154; 1916, 145; 1917, 141; 1918, 132; 1919, 116; 1920, 107. Tuberculous milk. Under the powers conferred upon the Council by Part IV. of the London County Council (General Powers) Act, 1907, samples of milk forwarded to London from places outside the county are examined. In 1920, 1,483 samples from milk consigned to London railway termini from 36 counties were submitted for bacteriological examination. Of the 1,294 completed examinations 76, or 5.9 per cent., yielded tubercle bacilli, as against 6.5 per cent. in 1919, 7.4 per cent. in 1918, 10.3 per cent. in 1917, and 8.7 per cent, in. 1916. In connection with these samples the veterinary inspector visited 67 farms and examined 2,737 cows. It was found that 63 cows, i.e., 23 per cent., showed signs of tuberculosis or were otherwise unhealthy. In each case the farmer undertook to have the animal slaughtered and meanwhile not again to use the milk. In addition the inspector re-visited 326 farms and inspected 14,352 cows; all the animals examined at these re-visits were found to be in a satisfactory condition with the exception of 145 which appeared to be tuberculous. In each instance the owner undertook to have the animal removed. During 1920 four inspections were made of the cows in 108 London cowsheds, and the total number of examinations made was 7,120. No tuberculosis of the udder was detected, but in 44 cases other unhealthy conditions were found. One cow was found with symptoms of general tuberculosis. Milk supply and storage. The Milk and Dames Act, 1914, was repealed in 1915 by the Milk and Dairies (Consolidation) Act, which consolidated the law set out in the Act of 1914, with certain provisions of the Contagious Diseases (Animals) Acts, 1878, and 1886, and the Food and Drugs Act, 1899. It was provided that the Act of 1915 should come into operation on such date, not later than one year after the war, as the Minister of Health might appoint. In the autumn of 1920 a Bill to amend the consolidating Act of 1915 was introduced into the House of Commons by the Minister of Health, but was dropped before second reading. Appeal Committee. The Appeal Committee are the statutory appeal committee under the Metropolis Management Act, 1855, section 212. The Committee also hear and decide all appeals made to the Council under any other Act of Parliament (except appeals under section 20 (5) of the Public Health (London) Act, 1891, against decisions of the Public Health Committee). During 1920 the Committee decided five appeals under the Act of 1855. Health administration iu London. The Council on 25th March, 1919, appointed a Special Committee to consider and report what alterations and extensions were desirable in the powers and duties of the different local authorities and other bodies, both official and voluntary, responsible for performing health duties in London. The Special Committee on 19th December, 1919, submitted a report dealing fully with the development of, and the serious defects in, the present organisation of health services, with proposals for reconstruction.* The Council received the report and agreed to the Committee's,recommendations, which were as follows:— That, in the opinion of the Council, a scheme for the better organisation of health services in London should provide that— (i.) The health functions of London Poor Law authorities should be divided between the Council, the City Corporation and the metropolitan borough councils substantially on the basis proposed in the report of the Local Government Committee appointed by the Minister of Reconstruction on the subject of the transfer of functions of Poor Law authorities in England and Wales. (ii) The administration in London of such additional health services as may by future legislation be required to be administered by public authorities should be entrusted to the Council, the City Corporation and the metropolitan borough councils, in addition to the duties already placed upon them by statute. * Report of the Special Committee on Health Administration in London. No. 2000. Price 3d. 117 (iii) The Council should be the central organising authority for the services referred to under (i) and (ii), and should be responsible for preparing such surveys of health services in London as may from time to time be required. (iv) Any exercise of powers by the Council as central organising authority should be governed by scheme to be prepared by the Council after consultation with the City Corporation and the metropolitan borough councils, and submitted by the Council to the Minister of Health for approval. (v) The Council should have power, by scheme, to appoint a health committee, of whom a majority should be members of the Council and a minority persons of experience in health matters who are not members of the Council, and to refer to such Committee such duties as are set out in the scheme, including (should the Council hereafter consider such inclusion desirable) any or all duties regarding the medical inspection and treatment of school children at present standing referred by statute to the Education Committee. (vi) The cost of the public health services of environmental or entirely local character should be borne by local funds. (vii) The cost of prevention of the spread of infectious diseases should be borne as to not less than one-half by national funds and as to the balance by local funds. (viii) In the case of the medical treatment of school children a charge should continue to be made by the authority responsible for the provision of such treatment. (ix) In connection with medical treatment provided by public authorities in cases other than those under (vi.) to (viii.) inclusive above, the general principle should be recognised that the cost (excluding expenses of administration) of such treatment should be borne, to the extent of his ability to pay, by the person treated or by a fund, such as the insurance fund, made up mainly by contributions of employers and employed. (x) A Central Council of London Hospitals should be formed. On the same date, the Special Committee were authorised to confer with other authorities and bodies exercising health functions in London, with a view to the formulation of detailed proposals based on these principles. Copies of the Special Committee's report and of the Council's resolutions were sent to the Minister of Health, with a request that he would receive a deputation from the Council, and also to the City Corporation, to each of the metropolitan borough councils, to the Council of King Edward's Hospital Fund for London and to the metropolitan hospitals. The deputation was received by the Minister of Health (The Rt. Hon. Christopher Addison, M.D., M.P.) on 23rd April, 1920, when he commented favourably on the general lines on which, in the Council's considered opinion, the development of health administration in London should proceed, and suggested that a conference between the Council and the metropolitan borough councils should be convened to discuss the whole question.* Diseases of animals. The Diseases of Animals Acts, 1894 to 1911, the object ot which is the suppression ot contagious diseases in animals, naturally do not affect London so much as the country. In London, apart from swine fever, attention is now principally directed to glanders, anthrax, rabies, and parasitic mange, diseases which are communicable to man. The Acts are supplemented by Orders issued by the Ministry of Agriculture and Fisheries. The following table shows tor the year 1920 the incidence ot the principal animal diseases so far as London is concerned:— Disease. Number of outbreaks. Number of animals attacked by disease. Glanders, including farcy 3 11 Swine fever 6 - Anthrax 1 1 Parasitic mange 469 1,201 * The number of swine involved in these outbreaks was 157. Glanders or Farcy Glanders is the disease in animals which has caused most trouble and expense to the Council. The London (Notification of Glanders) Order, 1906, required veterinary surgeons on becoming aware that any horse, ass, or mule was, when it died, affected with glanders, to notify the local authority. The Animals (Notification of Disease) Order, 1919, extended notification to all diseases of animals, and applies to the whole country. The Glanders or Farcy Order of 1907 provided for the payment of one-half value as compensation for animals slaughtered solely as a result of reaction to mallein. Full value was to be paid when disease was not detected by the post-mortem examination, and the maximum value for the purposes of the Order was £50 for a horse and £12 for an ass or mule. During 1916 only £197 10s. was so paid, and it was hoped that the disease had been brought under control, but in 1918 and 1919 there was a disquieting recrudescence of the disease involving the slaughter of 76 and 39 horses respectively, and the payment of £1,026 and £648. A conference was convened in March, 1920, by the Ministry of Agriculture and Fisheries to discuss the adequacy of the compensation payable under the Order of 1907, having regard to present economic conditions. As a result, the Ministry issued a new Order entitled the Glanders or Farcy Order of 1920, which came into operation on 15th November, 1920. This provides for the payment of increased compensation in respect of the slaughter of diseased animals, both for animals showing clinical symptoms of glanders and for those slaughtered solely upon reaction to the mallein test. The increase, which depends to some extent upon the adoption by the owner of precautionary measures, is accompaniec by other extended powers to local authorities for dealing more effectively with the disease. The Ministry pointed out that, in view of the progressive reduction in the prevalence of glanders since the Order of 1907, the number of outbreaks having been reduced from 854 in 1907 to25 in 1919, "the present appears to be an opportune time in which to make a final effort to * Report of the Special Committee on Health Administration in London. No. 2029. Price 2d. 118 secure the complete eradication of the disease." The necessary steps were therefore taken to secure wide publicity to the provisions of the new Order in the hope that the adoption of the more liberal scale of compensation now payable will encourage horseowners to co-operate with the Council. The powers of the Council under the Glanders or Farcy (Metropolitan Police District) Order of 1911 to destroy nose-bags and other stable material not capable of disinfection, continue to be fully utilised, and, after each outbreak, all infected material of this kind is burnt at one of the knackers' depots at the expense of the Council. The cases of glanders dealt with, and the compensation paid, during 1920 are shown in the following table:— Horses slaughtered.* Comensation paid. Clinical 3 £6 †Re-actors 8 185 11 £191 * Ewluli.15 Army horses. † Average value of re-actors, £46 5s. Swine fever. Swine fever has been very prevalent throughout Great Britain during the past tew years, 44 outbreaks being reported in London during the four years ended 31st December, 1919. The work carried out during 1920, under the Swine Fever (Regulation of Movement) Order, 1908 was as follows:— Store pies brought into London, 2939; swine examined at feeder's premises, 28,000; infringements, 17. Anthrax. Occasional cases of anthrax occur in London, and so long as fodder is imported from abroad it is probable that sporadic cases will arise. Most stringent precautions in the way of cleansing and disinfection are taken by the Council's inspectors who personally supervise the destruction of the entire carcase of an infected animal as well as any article with which it may have come into immediate contact During 1920 there were 15 cases of anthrax among men, of which four proved fatal. In 11 of these infection was traced to the handling of imported hides, hair, etc., in the course of the patients' employment, and in the remaining four to the use of infected shaving-brushes. One case of animal anthrax in London was confirmed during 1920. Rabies. Although deaths from hydrophobia are now very rare, thirty years ago they were fairly frequent. The most efficacious measures for stamping out the disease are muzzling, the seizure of all stray dogs, and the regulation of the importation of dogs. Under the Dogs Order, 1906, which revoked all then existing muzzling regulations, the Council made new regulations requiring the wearing of collars by dogs while on a highway. Under these regulations, 11,611 dogs were seized by the police during 1920 and 7,244 destroyed. In April, 1919, rabies was proved at Byfleet, Surrey, in a dog which had strayed from Ealing, and, following thereon, the London, Middlesex and District (Muzzling and Control of Dogs) Order, 1919, was promulgated, restricting the movement of dogs in the whole of London and Middlesex and parts of adjoining counties, and requiring a dog in the prescribed area at all times, (a) whilst in any public place, to be properly muzzled with a wire muzzle, and (6) whilst in any other place to be kept under control. The existence of rabies at Shepherd's Bush led to the issue of the London, Middlesex and District (Muzzling and Control of Dogs) Order of 1919 (No. 4), which, as regards Hammersmith, made the provisions of the earlier order more stringent. Five subsequent Orders merely extended or reduced the area of muzzling or leading control. In consequence of the decrease in the number of cases the Minister of Agriculture and Fisheries issued the London, Middlesex and District (Muzzling and Control of Dogs) Order of 1920, which came into operation on 2nd February, 1920. This Order withdrew the muzzling and movement restrictions on dogs in London and certain parts of the counties of Middlesex, Hertford, Bucks, Southampton and Surrey, but muzzling restrictions remained in force in parts of the counties of Middlesex, Bucks, Berkshire, Southampton and Surrey. A further Order revoked, as from 26th July, 1920, the whole of the various London, Middlesex and District (Muzzling and Control of Dogs) Orders. In consequence, however, of the confirmation of a case of rabies at Acton, the Ministry made the Middlesex (Acton and District) (Control of Dogs) Order, 1920, requiring the muzzling at all times and the leading in a public place of all dogs in an inner controlled area comprising Ealing, Hammersmith, Willesden Acton, Chiswick, Old Brentford, Isleworth, Twickenham, Heston, Norwood (adjoining Hanwell), Hanwell, Greenford, Perivale, Wembley and West Twyford. The Order provided that dogs must not be moved out of this area. The movement of dogs was also prohibited from a district surrounding the inner area and including the whole of the County of London, the greater part of Middlesex, and small parts of Surrey, Berkshire and Buckinghamshire. The Council has brought the Order to the notice of persons concerned and, as in the case of previous Orders, the Commissioner of Police of the Metropolis has been asked to enforce the provisions of the new Order so far as the County of London is concerned, and to institute legal proceedings. Thirty-nine cases of suspected rabies in dogs in London were notified during 1920. In 5 cases the animals were allowed to live, the suspicious conditions being attributable to other causes than rabies. In the remaining 34 cases the animals were killed and post-mortem examinations made, all the results being negative. A few persons have been bitten by suspected animals, but the Council's inspectors have been able to reassure the persons that the animals were not suffering from rabies. Altogether the Council's veterinary inspectors have dealt with 163 cases of suspected rabies, their diagnosis being, in every case, confirmed by the Ministry of Agriculture and Fisheries. A corollary to the Rabies Orders was the issue of Importation of Dogs Orders, under which dogs can come into Great Britain from abroad only under licence from the Ministry. The Council is responsible for seeing that the terms of the licences are complied with, the principal condition being the detention of the imported dog on special premises under observation for a considerable period after landing. Several prosecutions for breaches of the regulations have been found necessary. 119 Parasitic mange. Parasitic mange in equines is still very prevalent in London, but for a few years before the war the number of cases reported much decreased. Unfortunately, on the outbreak of the war, it was necessary to suspend temporarily the Order dealing with the disease with the result that it increased very largely. The conditions under which trade horses are fed and worked in London, particularly during busy seasons, tend to encourage the spread of the disease. The following figures relate to 1920:— Outbreaks, 469; Horses affected, 1,201; infringements, 102; written cautions sent, 59; convictions, 43; penalties and costs. £322 7s. Sheep scab. Two new Orders, the Sheep Scab Order of 1920 and the Sheep (Double Dipping) Order of 1920, have been made by the Ministry of Agriculture and Fisheries with a view to the eradication of sheep scab, a disease which has increased during the past few years in Great Britain. The first-named Order contains new provisions for improving the administrative arrangements for dealing with the disease on premises on which sheep scab has appeared. The County of London has not been made a " double dipping " area, but the Order has been applied to several districts, including one close to London. Sheep farming is carried on only in the south-eastern portion of the county, and that to a very limited extent, but large numbers of sheep are brought to London for slaughter at the Metropolitan Cattle Market at Islington. A copy of the Sheep Scab Order of 1920 was served on every sheep owner in London. Arrangements have also been made for enforcing the requirements of the Orders and for the issue of licences by inspectors of other local authorities regarding the movement of undipped sheep from a "double dipping" area to the Metropolitan Cattle Market. The Ministry subsequently issued an Order revoking as from 1st December, 1920, the Orders requiring the compulsory general dipping of sheep in this country involving a single dipping and, in forwarding the Order, directed attention to the power given to local authorities, under Article 12 of the Sheep Scab Order of 1920, to make regulations to continue the general compulsory dipping of sheep in their districts as a safeguard against the risk of the introduction of sheep scab. The Ministry was informed that the County was affected to only a slight extent, as practically all the sheep which come into London are sent there from the districts of other local authorities for the purpose of immediate slaughter. No case of sheep scab has been reported in London since 1901. Epizootic abortion. The Gloucestershire County Council asked the Council to support representations to the Mimstry of Agriculture and Fisheries for an amendment in certain directions of the Epizootic Abortion Order of 1920. In \iew of the fact that there are comparatively few dairy cows kept in the County, the greater number that come into London being brought there for the purposes of slaughter, it appeared to be undesirable for the Council to be associated as suggested in any such representations to the Ministry. Animals in transit. In order to ensure that the requirements of the Ammals (Transit and General) Order, 1912, and the Horses (Importation and Transit) Order, 1913, are being observed, and that the animals are free from signs of disease, the Council's inspectors pay numerous visits to railway wharves, depots, etc., where animals in transit are collected. The visits during 1920 numbered 3,174, the animals examined being— horses 30,477, cattle 45,435, sheep 42,136, swine 3,798, making a total of 121,846. There were 39 infringements, 32 written cautions, and 7 convictions, with penalties and costs amounting to £54 5s. 6d. In accordance with a request of the Ministry of Agriculture and Fisheries in connection with the veterinary examination of horses before shipment to the Continent under the Diseases of Animals Act, 1910, and the Exportation of Horses Act, 1914, the Council has arranged for the inspection of horses at the London railway termini previous to entraining for Folkestone and othe r ports. 120 CHAPTER XXVI. MAIN DRAINAGE. Drainage area and statistics. The district drained by the Council's main drainage system has an area of nearly 149 square miles with a population (in 1911) of 5,334,731. This includes an area of nearly 32 square miles, with a population of 813.046. outside the countv. The following statement shows the quantities of sewage, etc., dealt with during 1920:— Sewage treated— Million gallons. Northern outfall 59,634.5 „ „ (daily average) 162.9 Southern outfall 38,392.9 „ „ (daily average) 104.9 Sludge sent to sea— Tons. Northern outfall 1,274,000 „ „ (daily average) 3,481 Southern outfall 809,000 „ „ (daily average) 2,210 The sludge vessels made 2,083 trips, and travelled altogether 229,560 miles. Sewers under the Council's control. Generally speaking, the sewers under the control of the Council comprise: (1) outfall and intercepting sewers which flow roughly parallel to the Thames, and convey the sewage to the outfalls; (2) main sewers, many of which are on the lines of streams formerly discharging into the Thames but which now connect with the intercepting sewers; and (3) storm relief sewers which discharge rainwater into the Thames by the shortest practicable route. Many main sewers have storm-water outlets to the river. Northern outfall. Further repairs to the pier at the Northern outfall, which have proceeded continuously since 1913, were authorised during the year at a cost not exceeding £1,600. Southern outfall. After the opening in 1916 of the new engine-house at the southern outfall, it became possible to lay off for overhaul the main beam-engines and pumps. The work is proceeding continuously. The expenditure authorised during the year amounted to £1,000 for work to be executed by direct employment of labour and, in addition, the tender of the Lilleshall Company, Ltd., for the supply and delivery for £1,043 of valve-seats, valves, etc., was accepted. The erection of a new economiser-house, with a new fuel economiser to take the place of No. 1 fuel economiser which was worn out, has been completed at a cost of £5,124. Abbey Mills pumping- station. In 1913, the Council authorised work preliminary to the alterations to the Worthington enginehouse at Abbey Mills pumping station, including the erection of an annexe to which it was proposed to remove the hydraulic machinery for the whole station. A contract for the supply of new hydraulic machinery had been entered into before the war and it was necessary therefore to proceed without delay with the erection of the annexe. This work was completed at a cost of about £4,620. Further work in connection with the proposed alterations to this engine-house was however postponed owing to the war. On 13th July, 1920, the Council approved an estimate of £95,000 for the continuation of the work. The pumps in the Worthington engine-house raise the sewage from the Isle of Dogs sewer and a portion of that from the low level sewers. There are two engines which are badly worn and it is proposed to instal five vertical engines and centrifugal pumps which will nearly double the present pumping power. Two additional boilers will be required and these will be installed in the main boiler house. The tender of Clayton, Son and Company, Limited, amounting to £5,446 was accepted for the supply, delivery and erection of the boilers, subject to adjustment in respect of any variation in rates of wages or cost of material or transport. Tenders were also invited for the supply of engines and pumps, Only one tender amounting to £39,411, was received for the engines and three for the pumps. The pumps offered were all unsuitable and invitations to other firms brought in one tender amounting to £20,900. It was therefore decided to wait until market conditions were more favourable and there was a better chance of obtaining competitive tenders. In the meantime it became necessary to repair the present engines and this was authorised at a cost not exceeding £400. The repair of the river wall of the station has been undertaken at an estimated cost of £300. North Woolwich pumping station and rising main. Owing to the increase in the quantity of sewage to be dealt with at North Woolwich pumpingstation, principally due to the development of West Ham south of the Victoria and Albert Docks, the Council on 17th December, 1912, decided to enlarge North Woolwich pumping station and to lay an additional line of sewer between that station and the Northern outfall. The enlargement of the station was completed in 1918, and advantage was taken of the opportunity afforded by the construction by the Port of London Authority of the new dock in the vicinity to lay that part of the new sewer which would be within the works of the Port Authority. Until the fine of the new rising main between the pumpingstation and the outfall was completed no benefit could be derived from those works, and the Council on 16th March, 1920, approved an estimate of £30,000 for the purpose. For pipe founding four tenders were received, all of equal amount, namely £27,072 10s. for pipes of ordinary section and £29,152 10s. for pipes of special section thickened in the parts subject to heaviest wear. The coincidence that all tenders were the same was discussed by the Council, and in Parliament, and the President of the Board of Trade undertook to bring the matter before the Central Committee which was investigating the 121 question relating to building materials. The work of pipe founding was entrusted to the Stanton Ironworks Company, Limited, Notts., and to the Staveley Coal and Iron Company, Limited, Chesterfield, in approximately equal proportions. For laying and fixing the pipes the tender of Mr. Whittaker Ellis, amounting to £15,169, was accepted. All the tenders referred to are subject to adjustment in respect of any variations in the cost of labour and materials. The Northern outfall sewers are above the ground level from Old Ford to the outfall at Barking, and they run in an embankment. During 1920, repairs were authorised to the road on the embankment between the outfall and High Street South, West Ham, at a cost not exceeding £1,000. Barbed wire fencing has been erected in place of broken fencing along the foot of the embankment at a cost of about £1,000. £3,000 has been authorised for repairs to the bridges supporting the Northern outfall sewer. Outfall and intercepting sewer. To mitigate floodings on low ground in Greenwich and Woolwich, alterations were authorised to the Southern outfall sewers and a local sewer in Greenwich-road at an estimated cost of £1,450. The Southern high-level sewer No. 1(Clapham to Putney extension) is carried over the Wandle by means of the Wandsworth aqueduct, which consists of a series of brick piers and arches. For many years a lateral movement has been taking place, the greatest deviation from the perpendicular being 23½ inches. It is essential that support should be given to the structure and brick buttresses are being placed against certain of the piers, the estimated cost of the work being £2,000. To alleviate flooding near Queen's-road, Battersea, a local sewer in Lavender-hill has been connected with the southern low level sewer No. 2 at a cost of approximately £718. Repairs to old main sewers have been authorised during the year as follows—(i.) £4,000 for Eelbrook sewer, (ii.) £3,000 for Fleet sewer, (iii.) £2,000 for Hackney-brook sewer, (iv.) £3,000 for Londonbridge sewer, (v.) £5,000 for Ratcliff-highway sewer, (vi.) £2,000 for Ranelagh sewer, (vii.) £2,000 for Regent-street sewer. Main sewers. The upper end of the Counter's Creek sewer ceased to be used as a main sewer, and, as it interfered with the development of the St. Quintin housing-estate belonging to the Kensington Royal Borough Council, its retention as a main sewer was formally terminated and the Borough Council accepted future liability therefor. The Council on 22nd July, 1919, had before it a scheme as follows of works to mitigate floodings in various parts of London during times of heavy rainfall:— Flood relief works. North Side. Pumping-station at Hammersmith and new relief sewer from Hammersmith-road (Hammersmith storm-relief sewer) Enlargement of Lots-road pumping-station and new relief sewer from Walham-green. (Walham-green relief sewer) Storm-relief sewer from Kilburn and Shepherd's Bush to Hammersmith (North-western stormrelief sewer). Alterations to King's Scholars' Pond sewer and pumping-station. North-eastern storm-relief sewer. Storm-relief to Fleet sewer. Alterations and new engines at Abbey Mills pumping-station. Isle of Dogs pumping-station enlargement. Supplementary works. South Side. Beverley Brook relief culvert Wandle-valley sewer—1st portion. Wandle-valley sewer—2nd portion. Improvement of the River Graveney. Storm-relief sewer from Norwood, Streatham and Dulwich to Vauxhall (South-western stormrelief sewer). Shad Thames pumping-station—Additional engines. Storm-relief sewer and storm water pumping-station at Deptford. Storm-relief sewer from high-level sewer No. 2 to River Thames at Charlton (Charlton stormrelief sewer). Storm-relief sewers in Lewisham and Woolwich. Supplementary works. The construction of the north-eastern storm-relief sewer had been decided upon before the war, and the plans were practically complete, but the Government restrictions on expenditure during the war prevented the work from being undertaken. The proposed sewer will run from Kelvin-road, Highbury to the Thames at Shad well, a distance of about 4 miles. The initial diameter will be 8 feet; this will be increased at points of connection with other sewers and its ultimate diameter will be 11 feet 4 inches. From Highbury to Bethnal Green-road the sewer will be of brick, and from the latter point to the river in cast-iron tunnel. By relieving the pressure on existing sewers, the new sewer should mitigate floodings over a widely spread area including parts of Islington, Stoke Newington, Hackney and Shoreditch. The differences in construction lend themselves to a division of the work, and the sewer has been made the subject of two contracts. For the section from Highbury to Bethnal Green-road, seven tenders ranging from £342,928 to £610,548 were received, and for the remaining 61001 R 122 section, nine tenders ranging from £576,608 to £705,932. All tenders were subject to movements in the cost of labour and materials, and other conditions were inserted by various tenderers. In order to reduce the cost, negotiations took place with the tenderers for contracts upon a cost plus profit basis. Ultimately the Council on 2nd November, 1920, decided to entrust contract No. 1 to the Metropolitan Tunnel and Public Works Company, Limited, and contract No. 2 to Scott and Middleton, Limited, and to pay, in each case, a sum to cover remuneration, establishment charges, etc., upon the understanding that any saving in the actual cost of the work below the companies' estimates, after adjustment for quantity and for variation in the rates of wages and materials, shall be shared equally between the companies and the Council, and that the companies shall lose 20 per cent, of any excess in cost over their respective estimates. The improvement of the river Graveney is comparatively simple, and is a work for which a fair amount of unskilled labour will be required. In view of the great amount of unemployment the Council on 23rd November, 1920, decided to invite tenders with a view to the work being expedited. Tenders will be upon a cost plus profit basis with a provision for comparing cost with estimate and sharing any difference between the Council and the contractor. A site has been acquired for £6,520 for the pumping station for the proposed relief works in Hammersmith. The position of the outlet of the sewer necessitated negotiations with the Port of London Authority and the Authority's certificate under section 28 of the Metropolis Management (Amendment) Act, 185S, has been obtained to the plans. Dwelling houses on low lying lands. Part III. of the London County Council (General Powers) Act, 1920, takes the place of Part XI. of the London Building Act, 1894, and provides that, except with the Council's consent and subject to such conditions as the Council may require, no building for use wholly or in part as a dwelling house may be erected or re-erected on land, below the level of Trinity high-water mark, which cannot be efficiently drained at all times by gravitation into an existing sewer of the Council, Two such cases were dealt with between the passing of the Act on 4th August, 1920, and the end of that year. Buildings', etc., over sewers. Under section 204 of the Metropolis Management Act, 1855, and section 68 of the Metropolis Management (Amendment) Act, 1862, no building or any other encroachment may be erected in, over or under any sewer vested in the Council except with the Council's consent. During 1920 the Council gave its consent in twelve such cases. Discharge into sewers. Part IV. of the London County Council (General Powers) Act, 1894, prohibits the discharge into any sewer under the control of the Council, or into any drain or sewer communicating therewith, of solid matter or refuse, except such as is contained in ordinary house sewage, or offensive liquid refuse, or steam or hot water of a higher temperature than 110° Fahr. Legal proceedings were taken in two cases of discharge of heated water. In one case the defendants were fined £20 and ordered to pay £5 7s. costs, and in the other the summons was dismissed, but an application for costs against the Council was refused. Local sewers. Section 69 of the Metropolis Management Act, 1855, provides that no local sewer shall be made without the approval of the Council. During 1920 the construction or reconstruction of 7,0334 feet of sewers of various sizes has been sanctioned. When plans of local sewers proposed to be constructed at various housing estates were submitted for the Council's approval, the use of concrete under or around such sewers was not specified, but it was proposed to lay the pipes directly upon the bed of the trenches. This omission, except in special circumstances, was the result of instructions issued by the Ministry of Health. In the Council's opinion the value of this use of concrete had been abundantly proved ; sewers laid without this safeguard would be extremely liable to become disconnected, and sewage would soak into the soil with serious results. The Council declined to associate itself with the adoption of such proposals or to approve plans of sewers in which concrete was not used. Subsequently the Minister of Health decided that sewers in London should be encased in concrete except when officials of the Council and the Ministry agreed that this was not necessary. Sludge vessels. The Council has six sludge vessels which were launched at different dates between 1887 and 1895. The oldest vessel is the s.s. Bazalgelte, and if she were to be retained in commission new machinery was required and also extensive structural repairs to her hull. The question of spending a large sum upon so old a vessel was carefully considered, but the conditions in the shipbuilding trades made the cost of a new vessel prohibitive. It was estimated that, if repaired, she would have a further life of 15 years and tenders were invited, for the work. Only one was received and that was not considered to be satisfactory. The Council on 18th May, 192) decided to arrange with Vickers, Limited, the builders of the vessel, to undertake the work upon a basis of cost. Sewage treatment. The overhaul and quadrennial survey by Lloyds of the s.s. Bmme, Barrow and Belvedere became due during the year, and the total estimated cost of work required to these vessels amounted to £17,000. Much pioneer work in the biological treatment of sewage was done by the Council's officers, and before the war important questions arising out of their experiments were being considered. A new process was then being developed which, by prolonged aeration of sewage, produced an inoffensive sludge, quite different from ordinary sewage sludge, and an effluent of excellent quality. This treatment, generally known as the "activated sludge" process, alters the physical and bio-chemical features of the suspended matters, and they become purifying agents. Successful resufts on a small scale were obtained in the Council's laboratories, but the outbreak of war suspended the work. Early in 1920 the work was resumed and the Main Drainage Committee visited Sheffield, Manchester and Worcester, where further experiments in this treatment were being worked upon a practical scale. At all these plaeas the general principles were the same, but at Sheffield different mechanical means were adopted. 123 The Council on 6th July, 1920, approved an estimate of £7,000 for the purposes of experiment upon a larger scale, and it was decided to equip the tanks at the Southern outfall in which lime water used to be prepared, but which are at present out of use. Out-county drainage. During 1920 the Council considered the contribution paid by the West Ham Corporation in respect of the drainage of the borough into the Council's system. Under the award, given in 1904, of the late Sir Hugh Owen, the annual contribution was fixed at 2¼. in the £. on the assessable value of the borough (excluding government property). In 1904-5, £11,930 was paid by the Corporation, equivalent to 10.47d. a head of population. In 1920-1 the estimated contribution was £12,850, but the sum paid for each inhabitant remained stationary at 10.47d. The corresponding figures in London showed during the same period a large increase, the amount of the main drainage charge having risen from £510,734 in 1904-5 to £926.898, the amount of rate from 2.98d. to 4.87d. in the £, and the cost a head from 2s. 3.05d. to 4s. 2.21d. The Corporation drew a large sum in rates upon the Council's main drainage works, the amount levied in 1920-1 being £34,999 as compared with £10,207 in 1904-5. The borough is divided for drainage purposes by the Victoria and Albert Docks. The sewage is pumped from the northern area by the Corporation into the Northern outfall sewer, and from the southern by the Council at its North Woolwich pumping station. Owing to the development of property, principally in West Ham, it has been necessary, at a heavy cost, to enlarge North Woolwich pumping station and to lay a new sewer from that station to the Council's Northern outfall. In view of the additional burdens thrown upon the ratepayers in the area, outside West Ham, served by its system, the Council decided on 9th November, 1920, to apply to Parliament in the session of 1921 with a view to the revision of the contribution payable by the Corporation. Applications for permission to drain parts of their respective districts into the Council's system were made bv the Wemblev and the Bexlev Urban District, Councils hut were refused. Floodings in the River Lee Watershed. The River Lee Watershed (Flood Prevention) Act, 1920, empowers the Lee Conservancy Board to prepare a scheme for mitigating the flooding of lands within the watershed of the river and its tributaries. The cost of preparing a scheme is limited, except with the consent of the Ministry of Health and of the contributing authorities, to £6,000, and is to be divided equally between the County Councils of London, Hertford, Essex and Middlesex, and the Corporations of West Ham and the City of London. An engineering advisory committee has been appointed consisting of the engineers to the contributing authorities with the engineers to the Metropolitan Water Board, the Lee Conservancy Board, and the Lee Valley Drainage Commission and the consulting engineer to the Tottenham Urban District Council. 124 CHAPTER XXVII. HOUSING. The powers of the Council with respect to the housing of the working classes are derived from the Housing Acts, 1890 to 1919, and questions relating thereto are considered by the Housing Committee. Apart from administrative duties the main divisions of the Council's housing work consist of (a) the provision of new dwellings to meet the need for additional accommodation, and (b) the improvement or reconstruction of unhealthy areas, including the provision of dwellings for rehousing the persons displaced. Powers and duties of the Council. Rent restrictions. In view of the special conditions brought about by the war affecting the provision and letting of housing accommodation Parliament, in order to obviate undue hardships to tenants, passed legislation in 1915 and 1919, temporarily suspending the rights of landlords to resume possession of low rented dwelling houses and tenements and to raise the rents thereof, except to cover the amount of increase in rates. Under the Increase of Rent, etc. (Restrictions) Act, 1920, tenants of dwellings of a rental value (in the metropolitan police district) not exceeding £105 a year, are secured in their tenancies, except in certain circumstances, until March, 1923, and increases of rent are restricted to 40 per cent, of the net rent in August, 1914, of which 30 per cent, could be levied one month after the passing of the Act in July, 1920, and the remaining 10 per cent, after one year. The Act does not apply to houses erected after 2nd April, 1919. Outline housing scheme. In conformity with Section 1 (1) of the Housing, Town Planning, etc., Act, 1919, the Council submitted for the approval of the Minister of Health a scheme for the provision of dwellings for the County and for the improvement of the housing conditions therein. The heads of the scheme as finally approved are as follows :— (a) The Council shall provide within a period of five years not fewer than 29,000 new dwellings, with accommodation for approximately 145,000 persons, by the development of lands under Part III. of the Act of 1890. Not fewer, if possible, than 10,000 of these dwellings, with accommodation for about 50,000 persons, shall be completed within two years. (b) The undermentioned estates shall be developed for the purposes of the scheme, viz. :— (i.) The remainder of the Old Oak estate, Hammersmith, about 32 acres in extent, by the erection of about 680 houses. (ii) The remainder of the Norbury estate, Croydon, about 11 acres in extent, by the erection of about 220 houses. (iii) A section of the White Hart Lane estate, Tottenham and Wood Green, about 57 acres in extent, by the erection of about 680 houses. (iv) 97 acres or thereabouts out of the 147 acres of land on the Roehampton estate, for the erection of about 1,200 houses. (v.) 176 acres or thereabouts of a site of about 250 acres at Bellingham in the metropolitan borough of Lewisham, for the erection of about 2.000 houses. (vi) The whole or part of a site about 2,000 acres in extent at Becontree near Dagenham, Essex, for the erection of over 20,000 houses. (vii) A site or sites at Grove Park, Lewisham and Bromley, with an area of 500 to 600 acres, for the erection of about 5,000 houses. (viii) A site at Castelnau, Barnes, with an area of 50 to 70 acres, for the erection of about 700 to 1,000 houses. (c) Dwellings shall be provided to accommodate not fewer than 1,960 persons in fulfilment of the rehousing obligation under the London (Tabard-street, Grotto-place and Crosby-row) Improvement Scheme, 1910, under Part I. of the Housing Act of 1890. (d) A scheme under Part II. of the Housing Act of 1890, for the clearance of the Brady-street area, Bethnal Green, including the provision of dwellings for rehousing persons displaced shall be carried out. (e) Immediate action shall be taken under Parts I. and II. of the Housing Act of 1890 to facilitate the clearance of the worst of the insanitary areas in the county, with an estimated population of 40,000, provision being made for new accommodation in lieu of that destroyed. The scheme was accepted by the Minister on 17th January, 1920, as ranking for State financial assistance in so far as it might be carried out within five years from the passing of the Housing, Town Planning, etc., Act, 1919, or within such further period as the Minister might allow in view of difficulties arising in connection with labour or materials or from other circumstances beyond the Council's control. The Minister's approval was further subject to a review within two years of the adequacy of the proposals. Good progress was made during 1920, with the development operations outlined in the scheme. A great deal of preliminary work had to be carried out before building operations could be proceeded with on a large scale, but at the end of the year 270 houses had been completed and 1,500 others were in various stages of construction. The number of men engaged was about 3,500 in December, 1920, and was rapidly being increased as the work of organisation developed. Delay occurred owing to shortage of skilled workmen, especially bricklayers, and at the end of 1920, a considerable number of additional bricklayers could have been employed on the contracts had they been available. The difficulty is being overcome to a large extent by the adoption of forms of concrete construction in lieu of brick. Particulars are given later of the new works in hand. Old Oak estate. Roads and sewers were constructed before the war on the remainder (32 acres) of the Old Oak estate, Hammersmith, and at the beginning of 1920, two contracts for the erection of 221 houses and two 125 shops were being executed. On 14th January, 1920, the Council accepted the tender of Messrs. Allen Fairhead and Son, who were already engaged on one of these contracts, for the erection of 418 additional houses. The contract price for the first 166 houses was £132,000 and the remaining 252 houses were to be priced pro rata with the prices quoted in the tender. During the year 190 houses, in addition to the 2 shops, were completed and occupied. On 10th March, 1920, the Council authorised expenditure of £300 for repairs to Ducane-road, along the southern boundary of the estate, the work being carried out by the local authority. The initial net rents of the houses,which are of similar design to those erected on the estate before the war with some additional amenities, have been based, with the approval of the Minister of Health, on the rents of the existing comparable houses, with the addition of 1s. 6d. a week and amounts sufficient to cover the extra cost of maintenance and management as compared with the cost immediately before the war. The houses to which this decision applies may be grouped into four main classes and particulars thereof and of the net rents charged are given in the following table— Type of house. Accommodation. Net rent. Class A Class B Class C Class D Living room, 2 bedrooms, scullery, and bath Living-room, 3 bedrooms, scullery, and bathroom Parlour, living room, 2 bedrooms, scullery, and bathroom Parlour, living room, 3 bedrooms, scullery, and bathroom s. d. 10 - 11 - 12 6 14 - The gross rents are liable to fluctuation in accordance with variations in the amount of the rates payable and the net rents are subject to increases in conformity with any general rise in rents which may take place. On 2nd March, 1920, the Council decided to retain for housing purposes a plot of land, 1¼ acres in extent, which had been reserved, but was no longer required, for the erection of a church by the Ecclesiastical Commissioners from whom the estate was purchased. Good progress was made during the year with the development of the remainder (11 acres) of the Norbury estate. A tender had been accepted for the erection of 140 houses on similar lines to those erected on the estate before the war but with some improvements, and it was proposed to extend the contract so as to complete the development of the estate by the erection of 116 houses of similar design and two shops. Objection to the planning was, however, raised by the local authority and, having regard to the need, which became apparent, for more bedroom accommodation than was originally contemplated, a revised scheme was prepared for the provision of 74 houses of an improved type in substitution for the 116 houses and 2 shops. On 13th October, 1920, the Council accepted an offer by Messrs. Rowley Bros., who were already building on the estate, to erect the 74 houses for £85,759. During the year 80 houses were completed. The initial rents of the first 140 houses have been fixed on a similar basis to that approved for the rents of the new houses referred to above on the Old Oak estate. A scheme has been approved by the Minister of Health for the development of about 112½ acres of the White Hart Lane estate, Tottenham and Wood Green, on the lines of a garden suburb for the accommodation of persons of the working classes and others. During the year the Council decided to sell about 30 acres of the garden suburb area to the Wood Green Urban District Council for housing purposes and to purchase from the district council about 3½ acres of land in the south-west corner of the estate for the development of the estate. Some 21 acres are reserved for leasing for the erection of larger houses than those usually provided by the Council. On 28th April, 1920, the Council accepted the tender of John Mowlem and Co., Limited, for the construction of roads and sewers on the portion (56 acres) of the estate to be developed for working class houses. The contract price for the first section of about 28 acres is £39,016, and the remainder of the work is to be executed at prices fro rata with the prices quoted. The scheme of development provides for the erection of about 720 working-class houses and the laying out of about 7 acres as allotments for the tenants. Some 3½ acres have been allocated for open spaces and about 6½ acres as sites for public buildings and schools. Tenders for the building work were invited from a number of selected firms on a cost plus participating profit basis. The tenderers were invited to state a lump sum per house which they would require to cover profit, head office charges, and the use of plant, etc., and they were also required for the purpose of determining the estimated net cost to submit with their tender schedules of prices for four typical houses. On 14th July, 1920, the Council decided to entrust the work to Messrs. Fred and T. Thorne, whose tender, taking all the factors into consideration, was the most favourable. The price given by them for four houses amounted to £4,458 12s. 3d., and the sum quoted as the " fee " per house was £55. Any saving of actual cost below estimated cost is to be shared in stated proportions between the Council and the contractors, and in the case of an excess of actual cost over estimated cost a deduction is to be made from the contractors' fee. At the end of 1920, work had been commenced on some 50 houses. A scheme has been approved by the Council for the training and partial culverting at an estimated cost of £7,990 of the Lesser Moselle stream, along the northern boundary of the estate. The proposed works will form a channel for the existing watercourse, and, as it will also take surface water from the adjoining housing estates of the Wood Green and Tottenham Urban District Councils, the cost will be apportioned amongst the three authorities on the basis of the number of houses to be erected on the three estates. An adjustment of the boundary between the estates of the Council and the Tottenham Urban District Council was agreed to during the year. Norbury estate. White Hart Lane estate. Roehampton estate. 126 The Roehampton estate, acquired in October, 1919, for £120,000, payable in instalments of £20,000 a year, free of interest, comprises about 147 acres lying between the Upper Richmond-road and Putneyheath. Nearly 100 acres on the northern part of the site are being developed for working-class houses. On 3rd March, 1920, the Council accepted the tender of Messrs. Henry Woodham and Sons, for the construction of roads and sewers over the whole estate. The contract price for the first portion of about 50 acres is £66,671, and the remainder will be priced pro rata with the prices quoted in the tender. In considering the arrangements to be made for the erection of the houses, the Council had regard to the difficulties involved in obtaining lump sum tenders under the conditions prevailing and it was decided that in this instance contracts should be entered into on the basis of certain arrangements agreed between the Minister of Health and the Joint Industrial Council of Building Trades for agreed price contracts. The principal feature of this arrangement is that representatives of the local authority and the local federated builders together with the housing commissioner (or the Minister of Health in the case of the Council's work) confer and arrive, where possible, at an agreed price at which houses shall be erected, and the number of houses to be built under the arrangement is then distributed by the local association of the federation to builders in proportion to their resources. For the purpose of arriving at an agreed price bills of quantities are supplied for each type of house and priced out by representatives of the federated builders, and the price or lump sum is determined by agreement between the three parties concerned. The number of houses of each type to be erected is then determined by the local authority with the approval of the housing commissioner. In accordance with this arrangement prices were obtained from the Building Trades Federation based on bills of quantities for four representative types of houses on the Roehampton estate and these showed an average net cost per house of £1,150. After allowing for certain variations at the suggestion of the Minister of Health a price of £4,349 17s. 1d. was submitted for four typical houses. On 12th May, 1920, the Council decided to arrange for contracts to be entered into with Mr. F. G. Minter and with Leslie and Co., Ltd., for the erection, respectively, of 636 and 546 houses and flats, or 1,182 in all, on the basis of the price quoted for the four typical houses. By the end of 1920, progress had been made with the formation of 15 roads, and some 200 houses had been commenced. Arrangements have been made with the London and South Western Railway Company for the construction of an additional siding at Barnes station in connection with the transport of materials to the estate at an estimated cost, to be borne by the Council, of £1,700. The Brentford Gas Company has agreed to instal a gas supply, subject to the Council contributing £10 in respect of each installation. An agreement has also been entered into with the Metropolitan Water Board for the supply of water to the estate, the Council undertaking to pay to the Board an amount up to 10 per cent, a year on the cost of the pipe-laying where the domestic water rentals received are less than 10 per cent, of the cost of laying the pipes. The Roehampton estate is the first of the new estates acquired since the war in which the scale of rents has had to be determined. There are no working-class houses in Roehampton or in the immediate neighbourhood properly comparable with those in course of erection on the estate, and in coming to a decision, therefore, as to the rents which should be charged the Council has had regard to the net rents approved for the new houses erected since the war on the Old Oak estate, Hammersmith. The houses on the estate are larger than those provided on the Old Oak estate, and are of a much improved design, intended to meet the post-war demand for a superior class of accommodation. For the purpose of calculating the rents a sum corresponding to the further increase of 10 per cent, permitted in July, 1921, in the case of houses governed by the provisions of the Increase of Rent, etc. (Restrictions) Act, 1920, was added with amounts varying from 2s. to 3s. a week in respect of the larger rooms and 6d. to 1s. 1d. for improved amenities, such as larger cupboard space, lavatory basin, lobbies, larder, etc. On 14th December, 1920, the Council fixed initial weekly net rents on this basis for each type of house and flat on the first section of the estate as follows :— Type of house. Accommodation. | Xet rent. Class A Class B Class D Two room flat Three room flat Living room and two bedrooms, with scullery and bath Living room and three bedrooms, with scullery and bath Living room, parlour and three bedrooms, with scullery and bathroom Living room and one bedroom, with scullery and bathroom Living room and two bedrooms, with scullery and bathroom s. d. 14 6 15 6 18 6 *9 - *12 - j Becontree These rents are subject to reasonable variation in anv case by reason of position or other special amenities. The Council is acquiring under a compulsory order approved by the Minister of Health a large estate, the main portion of which is in the parish of Dagenham, Essex. The total area of the land to be purchased for development is 2,787 acres, but operations have so far been mainly confined to what is known as the Ilford (No. 1) section comprising about 440 acres of which nearly 104 acres lie within the rural district of Romford. The total number of houses proposed to be erected on this section is 2,876. The estate, which has been named Becontree, is situated in two urban districts (Barking Town and Ilford) and in one rural district (Romford), and the question of the local government of the area has engaged the attention of the authorities concerned. After careful consideration of various alternatives the Council decided to support an application by the Barking Town Urban District Council to the Essex County Council for an Order which would have the effect of including the whole estate within the Barking * The rents for the two and three roam flits were subsequently increased to 11s. and 12s. 6d. respectively. 127 Town Urban District. The application was unsuccessful, and, in the circumstances, the Council felt that it had no alternative but to proceed with its development plans on the basis of the estate remaining under the divided control of three local government authorities. Having regard to the magnitude of the undertaking which was contemplated, involving the building of a new township with an ultimate population of some 120,000 persons, the Council came to the conclusion that the whole work of organisation and the development of the site should be entrusted to one large firm of master contractors with wide experience and substantial resources at their command, and that the work should be paid for on a cost plus participating profit basis. The tenderers were invited to state the amount of the fee (to include head office expenses) they would require, such fee to be given as a lump sum on stated amounts of expenditure or " actual cost " ranging from £1,000,000 to £30,000,000,so that in the event of the work being suspended for any reason the amount of the fee payable at any stage would be a definite sum fixed beforehand. In response to an advertisement 20 tenders were received and, after very careful consideration of the many factors involved, the Council decided to accept the offer of C. J. Wills and Sons, Ltd., who asked for a fee of £450,000, or 1½ per cent., on an actual cost of £30,000,000. The form of contract was the subject of negotiation with the contractors and the Ministry of Health and work was commenced on 1st September, 1920. Good progress was made during the year with the construction of roads and sewers and by the end of December work on some 500 houses had been commenced. In view of the difficulties as regards both materials and skilled labour and the great cost involved in brick construction, the Council decided to take advantage of the local conditions by building a large number of the houses in concrete. The aggregate required is available on the site and, in addition to a saving in transport, it is anticipated that the use of concrete will ensure greater rapidity of construction. The supply of water presented considerable difficulty and, in view of proposals for the speedy development of the site, it was important that all necessary steps should be taken with despatch to place the matter on a satisfactory basis. The whole site is within the area of the South Essex Waterworks Company, but the company requires additional sources of supply before it can provide an adequate supply for the whole estate and it is necessary, therefore, for the company to apply to Parliament for powers. So far as the estate lies within the Barking Town and Ilford Urban Districts there is no obstacle to the Metropolitan Water Board extending its mains in competition with the company, subject to satisfactory terms being arranged, but under section 36 of the Metropolis Water Act, 1902, the Board is prohibited from supplying the parish of Dagenham so long as the company is able and willing to supply. In case the company should not be immediately successful in obtaining the additional powers the Council thought it most desirable, in order to provide an alternative, that the restrictions imposed on the Board should be removed, and it was decided to promote legislation with this object in the session of Parliament of 1921. The question of lighting had also to be considered, and inquiries were made as to the practicability of using gas or electricity or a combination of both. The cost of installing electric light is heavy and higher prices would be charged for gas for cooking and heating purposes if electric light were employed. For these reasons it will probably be necessary to dispense with the use of electricity for the working-class houses, but the final decision is being deferred, pending negotiations with the gas company which were in progress at the end of the year. The Council gave early consideration to the forming of main and arterial roads and providing facilities for the transport of building materials. The proximity of the site to the Thames naturally suggested the employment of water transport, and arrangements are being made with a view to the construction of a jetty in the river and a railway to connect the wharf with the building site. For this it was necessary to acquire about 87½ acres of additional land to afford access from the river and an order for the compulsory acquisition of this land was made by the Council and confirmed by the Minister of Health on 16th October, 1920. A proposal was provisionally agreed to during the vear for the diversion and construction of Ripple-road as an arterial road through the southern portion of the estate and for the allocation of the cost between the Council, the Ministry of Transport and the Essex County Council. The Council has agreed to bear the additional expense which may be incurred by the Essex County Council upon the maintenance of certain main roads on or in the vicinity of the housing site by reason of extraordinary traffic induced by the development operations. The Council has given preliminary consideration to the question of controlling the sale of intoxicating liquors on the estate. Among the properties over which the Council has obtained compulsory powers are three beerhouses. Within the area there is a fourth licensed house which was omitted from the original compulsory order, and application has been made to the Minister of Health for confirmation of a further order made by the Council on 9th November, 1920, for the compulsory acquisition of the premises. On 13th July, 1920, the Council decided that the existing licences should not be abandoned for the present and that the supply of refreshments on the licensed premises should be controlled by the Council. On 26th October it decided that the system of control should be based on management by a company or association whose servants would not have a pecuniary interest in encouraging the sale of intoxicating liquors and that such system should provide for the general entertainment and refreshment of the population. The terms and conditions upon which any such system of control and management can be established are being considered. The Council has acquired an estate of 252 acres at Bellingham between the Mid-Kent branch of the South-Eastern Railway and the Bromley branch of the London, Chatham and Dover Railway. The purchase price, part of which has been fixed by arbitration, has amounted to £50,339. The scheme Bellingham. 128 of development provides for the allocation of 176½ acres for the erection of working-class houses and 52 acres for the erection of other houses, an area of 23½ acres unsuitable for building being allocated for market gardens or allotments. Provision is made for the erection of about 2,056 working-class houses together with 18 shops and covered and open markets, the division of the land being approximately as follows:— Sites for dwelling-houses, including gardens, etc., 102 56 acres ; playing fields, 10.25 acres; tenants' allotments, 23.5 acres; sites for two schools and half adjoining roads, 5 acres; sites for public buildings, 2.63 acres ; site for shops and market, 2 acres ; central open space, 225 acres; roads, 28.31 acres. As it was impossible, owing to the necessity for expediting the work, to supply contractors with the requisite data to enable them to submit lump-sum tenders, the Council decided to entrust the development of the estate to one firm on a cost plus participating profit basis. Tenders were accordingly invited from a number of selected firms for the construction of the roads, sewers and bridges, as well as the erection of the houses to be provided on the estate. The tenderers were invited to state what lump sum they would require as fee, profit, commission or reward, to include head office expenses, on stated amounts of expenditure or " actual cost," ranging from £100,000 to £2,500,000. Six tenders were received and after careful consideration the Council decided on 22nd June, 1920, subject to any modification that might be required, to accept the offer of Sir Robert McAlpine and Sons, who quoted a "fee" of £125,000 on the basis of an expenditure of £2,500,000. Tenderers were required to deliver with their tenders schedules of prices for roads, sewers and houses, to form a basis of arriving at an "estimated net cost" for comparison with the "actual cost." Any saving of actual cost below estimated cost corrected to suit actual conditions experienced is to be shared in stated proportions between the Council and the contractors, and in the case of an excess of actual over estimated cost a deduction is to be made from the contractors' fee. Messrs. McAlpine's estimate of the cost of four typical cottages, which was the lowest received, amounted to £4,148 12s. 10d. Their price for a section of roads and sewers comprising onefourth to one-fifth of the total was £58,867. The order to commence was given on 23rd October, 1920, and by the end of the year the construction of seven roads had been commenced, some of the sewers had been laid, and work had been started on some 250 houses, of which 50 were up to first floor level. It has been decided to light the houses by gas, and terms have been agreed with the South Suburban Gas Companv for installations, free of cost to the Council. Grove Park site. The Bermondsey and Deptford Metropolitan Eorough Councils put forward to the Minister of Health a proposal for a joint housing scheme at Grove Park, Lewisham, but at the desire of the Minister the Council agreed to undertake the scheme, and on 30th March, 1920, made the necessary order for the compulsory purchase of the site, comprising upwards of 500 acres. The order was confirmed by the Minister on 12th May, 1920, and about 441 acres have been purchased for £56,000. The plan of development is under consideration. On 23rd November, 1920, the Council made an order for the compulsory acquisition of an additional field of about 14 acres immediately adjoining the south-west corner of the site. This field contains a considerable deposit of gravel which will be utilised in the development of Bellingham as well as of the Grove Park site. Castelnau site. On 30th March, 1920, the Council decided, at the suggestion of the Minister of Health, to acquire an additional site for housing purposes at Castelnau, Barnes, and on 9th November, 1920, it determined at 50 acres the actual area of the land which, after investigation, it was thought desirable to develop. The owners of the property have expressed their willingness to sell upon terms to be settled by an arbitrator. Tabard Street, etc. scheme. The scheme under Part I. of the Housing Act of 1890, for the clearance of the Tabard-street and Grotto-place areas, Southwark. and the Crosby-row area, Bermondsey, was confirmed by the Local Government Board on 13th March, 1912. The areas contained about 17 acres and comprised 875 houses with a population of 4,593. The confirming order requires the provision on the Tabard-street area of rehousing accommodation for not fewer than 2,580 persons, the accommodation to include not less than 25 cottages. One block of dwellings, named Chaucer House, with accommodation for 620 persons, has been completed. Becket House, a five storey building to contain 90 tenements with accommodation for 500 persons, was commenced in 1919, and by the end of 1920 was approaching completion. On 30th November, 1920, the Council accepted the tender of Walter Lawrence and Son, Ltd., amounting to £55,678 for the erection of the third section of dwellings, comprising 54 tenements with accommodation for 300 persons. An electric passenger lift is to be installed as an experiment with the approval of the Minister of Health. Work on the foundations for this block had been commenced before the end of 1920. Plans for the remaining blocks of dwellings are being prepared and the Minister of Health has given the Council authority to demolish the old buildings as required, when the new accommodation which is being provided becomes available for the persons to be displaced. An agreement has been entered into with the South Metropolitan Gas Company for the supply of gas to the new buildings, the fittings, gas cooking stoves and water circulating heaters being provided free of cost to the Council. In view of the arrangements for heating water by gas it is proposed to omit boilers from the kitchen ranges in all the dwellings yet to be completed on the area. An open space of about 5 acres is to be laid out on the Tabard-street area. This will be called Tabard-garden, and the estate as a whole will be known as the Tabard-garden estate. The scale of rents to be charged for accommodation in Becket House was fixed by the Council on 14th December, 1920. The properties in the immediate neighbourhood formed no guide and the rents of typical tenements in Chaucer House were therefore taken as a basis. To these rents 10 per cent, was added to correspond with the increase to be permitted in July,'1921, in the case of houses governed by the provisions of the Increase of Rent, etc. (Restrictions) Act, 1920, and also an amount varying from 129 l0d. to 2s. l0d. a week for larger rooms, with 1s. for additional amenities, such as bath, hot-water supply, larger larder, and a coal store. These additions resulted in net weekly rents, exclusive of rates, as follows : for each type of tenement, viz.:- Two rooms (living room and one bedroom), 1ls.; three rooms (living room and two bedrooms), 13s. 6d.; four rooms (living room and three bedrooms), 15s. 6d.; five rooms (living room and four bedrooms). 17s. These typical rents are subject to variation in such cases as may be determined on account of position or other special amenities. The Council decided on 28th July, 1920, that, as the properties acquired under the scheme and held temporarily pending demolition were included in areas condemned under the Housing Acts as insanitary, it would not, under the Increase of Rent, etc. (Restrictions) Act, 1920, increase the standard rents of such properties. On 4th April, 1912, the medical officer of health of Bethnal Green made an official representation to the Council under Part I. of the Act of 1890, with respect to the Brady-street area of about seven acres. On 29th July, 1913, the Council decided that it was not then prepared to undertake the scheme. Subsequently, on 24th October, 1913, a local inquiry was held by the Local Government Board, and, after considerable correspondence, the Board, on 22nd September, 1914, made an Order requiring the Council to deal with portions of the area under Part II. of the Act. The Council decided on 23rd February. 1915, to carry out the Order by two successive schemes, but the restrictions imposed by the Government on expenditure during the war prevented any action being taken. The matter was reconsidered in 1919, and proposals were submitted to the Board for carrying out a scheme to deal with the area included in the Order of 1914, in co-operation with Mann, Grossman and Paulin, Ltd., as owners of a substantial part of the area. These proposals were strongly opposed by the local authority, and the Minister of Health, who had, in the meantime, succeeded the Local Government Board, was of opinion that under the conditions then prevailing a more comprehensive scheme was necessary. He was, moreover, not prepared to agree to the proposed arrangement with the company. Having regard to the views expressed by the Minister the Council on 10th February, 1920, decided to make a revised scheme to include additional property indicated by the Minister, all the property thus proposed to be dealt with being included in the original representation made in 1912. The revised scheme involved the displacement of about 1,875 persons of the working-classes, and the Council had in view the rehousing on the cleared area, or in the vicinity, of a number of persons approximating to the number to be displaced. In view of the necessity for providing in the first place a substantial measure of rehousing accommodation to enable the work of demolition to be commenced, provision was included in the scheme to enable the Council to acquire a site belonging to the Great Eastern Railway Company on the west side of Brady-street upon which it would be possible to erect dwellings three storeys in height capable of accommodating about 200 persons. The Council also decided to appropriate for rehousing purposes in connection with the scheme a plot of land in Goldsmith's-row, about a mile distant, for the crection of a five-storey building to accommodate about 100 persons. Accommodation in three-storey dwellings can be provided on the cleared area for 1,500 persons which, with the accommodation on the land to be acquired from the railway company and on the Goldsmith's-row site, makes a total provision for rehousing not less than 1,800 persons as compared with an estimated displacement of 1,875 persons. The cost of carrying the revised scheme into effect, including the acquisition of property on the area and the two rehousing sites outside the area, and the laying out of streets, etc., but excluding the erection of dwellings, is estimated at £101,000. Bradystreet area Ware-street area. A local inquiry on the scheme as amended was held on 1st June, 1920, and the decision of the Minister of Health is now awaited. An official representation under Part I. of the Housing Act of 1890, was made to the Council on 6th August, 1919, by the medical officer of health of Shoreditch, with regard to an area known as the Ware-street area, Hoxton. The area, as represented, comprised 580 houses, but the Council thought that certain of these should be omitted. On 4th May, 1920, the Council decided to make a scheme for the clearance of part of the represented area about 9¼ acres in extent, comprising 386 dwelling houses, including 3 fully licensed public [houses and one beer-house and a few premises used for commercial purposes. The displacement of 2,648 persons of the working classes is involved, and it is proposed to provide rehousing accommodation on the cleared area for a minimum of 2,550 persons. The cost of acquiring the property is estimated at £70,000 and of constructing roads and other works at £23,500, making a total estimated expenditure of £93,500, exclusive of the cost of erecting new dwellings on the area, The scheme was duly submitted to the Minister of Health for confirmation and a local inquiry with regard thereto was held on 18th and 19th November. 1920. Bell-lane and Ellenstreet areas. Official representations under Part I. of the Housing Act of 1890, were made to the Council by the medical officer of health of Stepney, on 2nd December and 6th August, 1919, respectively, with reference to two insanitary areas known as the Bell-lane area, Spitalfields, and the Ellen-street area, St. George-inthe-East. The Bell-lane area, lying between Commercial-street, Wentworth-street, Bell-lane and Butlerstreet, is about 4¼ acres in extent and comprises 248 houses in addition to a few stables and commercial premises ; the number of persons of the working classes in occupation is estimated at 1,284. The Ellen-street area comprises about 1¼ acres, within the quadrilateral formed by Ellen-street, Boydstreet, Berner-street and Backchurch-lane, and contains 112 dwelling houses (including one beer house) with an estimated working class population of 568. On 18th May, 1920, the Council decided to make one scheme for dealing with the two areas as represented, the combined scheme to provide for the erection of dwellings to accommodate not less than 1,230 persons of the working classes, or approximately two-thirds of the number to be displaced. It is not possible to make a larger provision for rehousing on the cleared areas, and there is no other building land available in the vicinity. The deficiency in accommodation thus created will be made good by the provision of houses in other districts in connection with the various schemes undertaken by the Council under Part III. of the Housing Act 61004 s 130 of 1890. The estimate of the total gross cost of the scheme, exclusive of the cost of any new dwellings to be erected, amounts to £106,000, made up as follows—Bell-lane area, gross cost of acquisition of property, £75.000 ; cost of roads, etc., £15,000 ; total, £90,000 ; Ellen-street area, gross cost of acquisition of property, £16,000. The scheme having been submitted to the Minister of Health for confirmation, a local inquiry in regard thereto was held on 29th October and 1st, 4th, 5th and 8th November, 1920. Hickman's Folly area. An official representation under Part I. of the Housing Act of 1890, with reference to an area known as the Hickman's Folly area having been made to the Council on 6th Januarv, 1920, by the medical officer of health of Bermondsey, the Council on 20th July, 1920, considered certain propsals for dealing with a part (3½ acres) of the area by means of an improvement scheme. The Council was not satisfied that the scheme proposed was sufficiently comprehensive for dealing adequately with the evils existing in the area and the whole question is being reconsidered in consultation with the local authority. Eents. In view of the provisions of the Increase of Rent, etc. (Restrictions), Act, 1920, the Council considered the question of the desirability of increasing the rents charged in respect of its dwellings, and, after consideration of all the circumstances, decided on 27th July, 1920, that the rents should be increased by the full amounts allowed by the Act. The Council had already on 3rd February, 1920, decided that the rents of shops and workshops on its housing estates should be fixed and revised from time to time on the basis of current conditions of letting in the respective localities. On 15th May, 1920, the charges for accommodation at the Council's lodging houses were revised and fixed as follows:— (i) Bruce-house—Ordinary cubicle, 1s. a night, or 6s. a week for not more than 400 a week; special cubicle, 1s. 3d. a night, or 7s. 6d. a week; special bedroom, 1s. 6d. a night, or 9s. a week. (ii) Carrington-house—Ordinary cubicle, 1s. a night, or 6s. a week ; special cubicle, 1s. 3d. a night, or 7s. 6d. a week. (iii) Parker-street-house—Ordinary cubicle, lOd. a night, or 5s. a week. Oarrington House. In view of the large number of unoccupied cubicles at Carrington House, the Council considered whether the vacant accommodation could be put to some useful and profitable purpose. Several proposals for utilising the accommodation had been found unsatisfactory on account of the heavy cost of the work of adaptation. The only suggestion that would bear the financial test was one for the conversion of a number of ordinary cubicles into a smaller number of special cubicles or bedrooms provided with additional furniture and let to a different class of lodger who could afford to pay for better accommodation. On 21st December, 1920, the Council voted £1,550 for the conversion of 80 cubicles on the second floor and for the cost of the necessary furniture. It is proposed to proceed with the scheme by instalments as and when experience may demonstrate the extent of the demand for the better accommodation. Selection of tenants. Before the war it was the general practice for the Council, upon the receipt of satisfactory references, to accept tenants in the order in which their applications were received. Preference' was given (a) to persons displaced through the acquisition by the Council of property for clearance or improvement schemes or other public purposes and (6) to persons already residing in the county. This preference still holds good. Owing to the shortage of housing accommodation since the war the Council has from time to time, given temporarily further preferences as follows—(i) To persons who gave up their homes in order to join H.M. Forces or to undertake other work of national importance, including a small number of instructors of the Territorial Force Association ; (ii) to ex-firemen who are required to vacate quarters at fire stations ; (iii) to members of the staff, to the extent of 5 per cent, of the houses provided ; (iv) on the Grove Park site and at Bellingham, to families from the metropolitan boroughs of Bermondsey and Deptford in the proportion of one out of every ten houses provided, up to a maximum of 1,400 houses on the two estates. The last-mentioned preference is granted in view of the accessibility of the sites to persons residing in the boroughs named and of the fact that the Grove Park scheme was originally promoted by the local authorities. On the Old Oak estate special consideration is given to the claims of persons living in overcrowded conditions in some neighbouring boroughs upon representations by the local medical officer. With a view to facilitating the work of development a limited number of houses on certain of the new estates are placed temporarily at the disposal of the contractors, subject to the payment of the approved rents, for the accommodation of skilled workmen engaged in the execution of contracts. In order at the same time to make full use of all available accommodation the Council has adopted the following general principles :—(i) Applicants are to be allotted houses and tenements not larger than are deemed to be sufficient to meet the reasonable needs of the families, taking into consideration the sex and ages of the children and the bedroom accommodation required ; (ii) no person residing alone is to be accepted as a tenant; and (iii) not more than two rooms are to be allotted to a married couple without children or to two single women living together. Subject to these conditions applications for tenancies are entertained strictlv in the order in which they are re eived. Cost of building. The increase in the cost of building which has taken place in recent years has caused the Council great anxiety, in view of the magnitude of the operations undertaken to meet the housing needs of the county. The increase is necessarily reflected not only in the higher rents which have to be charged to meet maintenance as well as debt charges but also in the much larger deficiency to be met out of public funds. The cost of building towards the end of 1920 approached three and a half times as much as it was before the war, the increase' being due to the extra cost of both labour and materials. The rates of pay of a mechanic and a labourer were on an average 178 per cent, above those current in 1914. The cost of labour was also greatly influenced by diminution in output, due partly to the loss to the building industry of many of the higher grade workmen owing to the war. 131 Materials generally cost from three to four times what they did in 1914, and in some cases, particularly metal goods, the increase is substantially greater. A comparison of tenders received in November, 1919, and November, 1920, showed an increase in cost, due to the increase in the cost of labour and materials amounting to £86 per habitable room, or approximately 331/3 per cent. The rates of pay of a mechanic and a labourer together advanced during the year by 39 per cent., i.e., from 3s. 2d. to 4s. 5d. an hour. Shortage of labour and inefficient deliveries of materials have extended the time required for the completion of contracts, and overhead charges have consequently had to be borne over an extended period. The Council has published a fully illustrated account of housing in London up to 1912* and also a detailed account, with seven illustrations, of its present proposals.† The Council has for many years past given continuous attention to "the question of workmen's trains, and has endeavoured to secure better facilities for workmen travelling to and from their work. The question has been considerably affected by the war. Several railway stations were closed on account of war requirements, although many of these have now been re-opened for passenger traffic. Several, however, still remain closed notwithstanding representations made by the Council in the early part of 1920 to the Ministry of Transport and the railway companies concerned. Ordinary passenger fares on the railways have been increased by 75 per cent, and season ticket rates have also been raised. On 7th July, 1920, the Minister of Transport referred to the Rates Advisory Committee the question of the revision of workmen's fares, and other fares lower than the ordinary. Evidence on behalf of the Council was given before the Advisory Committee indicating in general terms the effect which an increase in workmen's fares would have in accentuating the difficulties of the housing problem by inducing people to remain in the central and more congested areas near the industrial centres. The Advisory Committee recommended the following revised scale of charges for workmen's trains which they suggested should be called Cheap Early Trains:.— Workmen's trains, etc. For any distance not exceeding 2 miles 3d. for return journey, do. between 2 and 21/3 miles 3½d. do. do. 21/3 and 2⅔ miles 4d. do. do. 2⅔ and 3 miles 4½d. do. do. 3 and 31/3 miles 5d. do. do. 31/3 and 3⅔ miles 5½d. do. do. 3⅔ and 4 miles 6d. do. The recommendations of the Advisory Committee received the general approval of H.M. Government and came into force on 1st September, 1920, except that with a view to the prevention of any hardship, the advance on any particular section was limited to a sum not exceeding 2s. a week. CHAPTER XXVIII. ACCOUNTS AND STATISTICS. Memorandum by the Comptroller of the Council (Mr. C. D. Johnson) relating to the Housing Accounts for the Year 1920-21. The housing accounts as now prepared furnish a comprehensive statement of the financial results of the Council's operations under the Housing of the Working Classes Acts, 1890 to 1919 (Clearance of unhealthy areas and rehousing under Parts I. and II., and housing under Part III. of the Act of 1890), and various Street Improvement, etc., Acts (rehousing), and include the income and expenditure relating to Clearance Schemes, as distinct from, and in addition to, the accounts of the actual dwellings erected for rehousing persons displaced. The figures are subject to audit, and in certain particulars are provisional only, and are subject to revision. The " Clearance Schemes " sections of the accounts cover the acquisition and clearance of unhealthy areas. The "Working-class dwellings" sections deal with the dwellings. In the case of dwellings erected in pursuance of an obligation to rehouse persons displaced, the capital account includes for land the " housing value " of the site used, the balance of the cost of acquiring and clearing the land being regarded as part of the cost of the Clearance or Improvement Scheme. As regards estates under Part III. of the Act (schemes to provide accommodation for persons of the working classes, apart from displacements), the capital account of the dwellings includes the whole cost of the site. The difference in treatment is explained by the desire to set out clearly the financial results of the Council's management of the dwellings themselves and by the fact that dwellings under Parts I. and II. and Improvement Acts represent compulsory provision for rehousing on sites which for the purpose of working-class dwellings are nearly always unsuitable from a financial point of view, whereas the Council's action under Part III. (until the passing of the 1919 Act) was voluntary. The accounts show also the broad division between the " Assisted Scheme " under the Housing * Housing of the Working Classes in London, 1855-1912 (No. 1555); price Is. † Housing (No. 2032); price 1s. 61001 s 2 132 Town Planning, etc., Act, 1919, and the earlier " Non-Assisted Schemes." The accounts .ore arranged as follows— A.—Non-Assisted Schemes— 1. Clearance Schemes. 2. Working-class dwellings. B.—Assisted Scheme— 1. Clearance Schemes. 2. Working-class dwellings. 3. Housing Schemes of Metropolitan Borough Councils. 4. Local Bonds (for housing). C.—Coal supply to tenants. D.—Well Hall Estate (Government estate managed by the Council. It will he convenient to deal with each of these sections separately. A.—Non-Assisted Schemes. This section comprises the accounts of schemes carried out by the Council prior to the Housing, Town Planning, etc., Act, 1919. Clearance Schemes.—The net capital expenditure to 31st March, 1921, amounted to £2,718,591 6s. TOd. The net debt outstanding on the same date was £1,059,972 18s. The revenue account shows a deficiency of £63,517 14s. 1d., attributable to the debt charges on the cost of acquisition and clearance works. Working-class dwellings.—The net capital expenditure to 31st March, 1921, amounted to £2,983,168 18s. 2d. (Housing Act, £2,239,630 13s. 4d.; Improvement Acts, £743,538 4s. lOd.); the net debt outstanding on the same date after taking into account the accumulated sinking fund was £2,599,6:6 18s. 5d. The results of the year's working compared with those of the previous year are as follows :— Dwellings— 1920-21. 1919-20. Housing of the Working Classes Act, 1890- £ s. d. £ s. d. Part I. Surplus 1,479 - 8 Deficiency 61 17 11 Part II. Deficiency 51 13 6 Deficiency 218 5 11 Part III.—-Dwellings Deficiency 5,782 4 4 Deficiency 6,120 11 6 Total—Housing Act Deficiency 4,354 17 2 Deficiency 6,400 15 4 Improvement Acts Deficiency 2,390 9 8 Deficiency 2,305 11 4 Total—Dwellings Deficiency 6,745 6 10 Deficiency 8,706 6 8 Estates in course of development—- Housing Act, 1890—Part III Deficiency 1,143 16 - Deficiency 1,887 8 7 Total—Non-assisted Schemes Deficiency 7,889 2 10 Deficiency 10,593 15 3 The above results have been arrived at after charging interest and sinking fund, and after transferring to the Repairs and Renewals Fund sums designed to cover the average cost of repairs and renewals during the whole of the loan period. In view of the higher cost of repairs compared with pre-war prices, the amounts of these transfers have already been substantially increased. During 1920-21 the actual expenditure out of the Fund exceeded the amount credited thereto by £21,123 0s. 11d. (Housing Act, £13,762 7s. 2d. ; Improvement Acts. £7,360 13s. 9d.) The gross rental amounted to £314,665 10s. 5d. in 1920-21, as compared with £255,462 19s. 11d. in 1919-20, an increase of £59,202 10s. 6d. This increase is the result of the rise in rents permitted by the Increase of Rents, etc., Act. The total financial result on all "non-assisted" dwellings and estates taken as a whole from April, 1894 (the date of the opening of the first block) to 31st March, 1921, amounts to a surplus of £814 5s. 5d. £2,086 6s. 5d. has been transferred to the rates and £1.272 1s. has been contributed from Tramways Account in respect of certain rehousing obligations in connection with the Greenwich Generating Station. B.—Housing (Assisted Scheme). This section comprises the whole of the Council's operations in fulfilment of its statutory obligations under the Housing, Town Planning, Etc., Act, 1919, with the losses incurred by the metropolitan borough councils as the result of their operations under the Aet. It also includes the transactions relating to the issue by the Council of local bonds for housing under the Housing (Additional Powers) Act, 1919. The form of the account is generally governed by regulations issued by the Minister of Health, under the Housing, Town Planning, Etc., Act, 1919. Any deficiency (approved by the Minister of Health) on the Housing (Assisted Scheme) Account in excess of the produce of 1d. rate will be met out of moneys voted by Parliament. The "deficiencies" at present arise principally from debt charges in respect of expenditure which, during the period of development is not revenue-producing. The results for the vear 1920-21 are as follows :— £ s. d. 1. Clearance schemes Surplus 13 2 8 2. Working-class dwellings Deficiency 62,852 15 11 3. Housing schemes of Metropolitan Borough Councils (partly estimated) Deficiency 63,455 18 7 4. Local Bonds (for housing) Deficiency 19,011 1 3 Total deficiency £145,306 13 1 133 This deficiency (£145,306 13s. 1d.) being less than the produce of a 1d. rate, will fall to be met entirely out of the Special County rate. As regards 1 and 2, these accounts are kept generally on the same lines as similar accounts in the section relating to Non-Assisted Schemes. Clearance Schemes.—The Capital expenditure to 31st March, 1921, amounts to £2,173 3s. 7d. representing preliminary expenditure in respect of the Bell-lane and Ellen-street, Ware-street and Brady-street areas. The Revenue Account shows a credit balance of £13 2s. 8d., due to an adjustment in respect of establishment charges debited to Revenue Account instead of Capital Account in 1919-20. Working-class dwellings.—lhe results for 1920-21 are as follows :— Dwellings— In occupation—- £ s. d. Part I. Deficiency 48 10 5 Part III. Deficiency 2,006 9 4 £2,054 19 9 In course of erection— £ 8. d. Part I Deficiency 1.925 13 8 Part II Deficiency 84 1 3 2,009 14 11 Total—Dwellings ... ... 4,064 14 8 Estates in course of Development—Part III. ... ... Deficiency 58,788 1 3 Total—Dwellings and estates ... ... ... Deficiency 62,852 15 11 The transactions for 1919-20 were very small, and no useful purpose would be served by comparing the results with the above. It will be seen that the bulk of the deficiency appears under the head of " estates in course of development," the interest and sinking fund charges in respect of which, less receipts in aid, are shown in a separate account. This course follows the Council's past practice, and is adopted in order to permit a clear view of the results of managing completed dwellings. As the work on each estate proceeds, the . proper proportion of capital expenditure and debt charges is allocated to the account of the dwellings available for letting, until the total capital expenditure on land and development is entirely absorbed in the cost of the dwellings. The gross rental of the completed dwellings for 1920-21 is £7,322 3s. 3d., as compared with £12 7s. 9d. in 1919-20. The capital expenditure to 31st March, 1921, amounted to £1,903,033 15s., and the net debt; including stock, etc., issue expenses, to £2,026,707 15s. Housing Schemes of Metropolitan Borough Councils.—-Under the Act of 1919, the Council has to refund to the borough councils the losses, approved by the Minister of Health, arising in connection with schemes carried out by them under that Act. The Council's Housing Accounts thus show the financial result of the assisted scheme for London as a whole. The amount payable to borough councils in respect of 1920-21 (including estimated losses where actual figures are not available) is £63,241. Adding expenditure of £214 18s. 7d. for establishment charges, the charge for the year under this head is £63,455 18s. 7d. This figure is subject to revision. Corrected figures which cannot be determined until the accounts of the borough councils have been audited will appear in the Council's annual volume of accounts. Local Bonds (for housing).—The amount raised by this means to 31st March, 1921, was £3,561,940. Deducting £103,856 13s. 11d. for expenses of issue, the net amount raised is £3,458,083 6s. 1d. £1,202,742 of this sum has been advanced on loan to the borough councils for housing purposes, leaving a balance in hand of £2,255,341 6s. 1d., available for future use. In addition, there is a balance of £1,625 4s. 3d. on the redemption account, some of the money advanced to borough councils having already been repaid. Up to the present no part of the proceeds of the bonds has been used for the Council's own capital purposes. The Minister of Health has agreed to the expenses of issue being spread over a period of 5 years, and charged to the assisted scheme. The first instalment will fall due in 1921-22, and provision has been made in the 1921-22 estimates accordingly. The rate of interest charged on the loans to the borough councils is the same as that payable by the Council on the face value of the bonds, viz., 6 per cent., so that the instalments in repayment of the expenses of issue and 'the annual cost of management (£1,398 0s. lid. in 1920-21) fall wholly on the Council's assisted scheme account. C.—Coal Supply to Tenants. To meet war conditions accommodation was provided for the storage of coal in bulk, the price of issue to the tenants being fixed to cover the cost of labour and other expenses incurred in carrying out the scheme. The scheme has now been discontinued and the accounts will be completed in the year 1921-22. D.—Well Hall Estate. By arrangement with the Commissioners of H.M. Works, etc., the Council undertook the maintenance and management of this estate on certain agreed conditions. The Commissioners have given notice to terminate the arrangement on 30th September, 1921. Housing Statistics—Memorandum by the Director of Housing (Mr. J. P. Orr, C.S.I., C.B.E.) The Council's housing programme under the Housing and Town Planning Act, 1919, provided for the erection of 29,000 working class houses, in addition to dwellings for 40,000 persons, the estimated Housing progress. Accommodation provided. 134 population of certain slum areas proposed to.be cleared. The year 1920-21, was marked by the completion under this scheme, of 44 block dwellings and 326 cottages on the Norbury (106 cottages), Old Oak (215 cottages) Roehampton (5 cottages) and Tabard-garden (44 block dwellings) estates. Towards the end of 1919-20, six cottages on the Old Oak estate had been completed under this programme, so the total number of post-war dwellings had by the end of 1920-21, reached 376. The pre-war dwellings comprised 6,543 tenements in block dwellings, 3,148 cottages, and 294 cottage flats. The total of all dwellings was at the end of 1920-21, 10,361 dwellings, containing 30,043 rooms, besides 1,874 cubicles in lodging houses affording, all told, accommodation, on the basis of two persons a room, for 61,431 persons. The actual population at the end of the year was 41,544 persons, including 1,723 at the lodging-houses, as compared with 39,985 persons on 31st March, 1920. Financial results. In the Housing Accounts for the year 1920-21, prepared by the Comptroller of the Council, full details are given of the financial results of the Council's housing schemes up to 31st March, 1921, but it may be apposite to repeat here some of the more important figures. In this connection it is necessary to preserve a clear distinction between the Non-Assisted schemes promoted before the Housing, Town Planning, Etc., Act, 1919, and the Assisted schemes promoted under that Act, the assistance taking the form of an annual subsidy from Government sufficient to ensure that the annual deficiency on all Council and metropolitan borough council schemes shall not exceed the produce of a penny rate. Dealing first with the Non-Assisted schemes, the aggregate capital expenditure on dwellings provided to 31st March, 1921, was £2,983,169. The financial result of the year's working of all dwellings provided under the Non-Assisted schemes, after providing for interest and sinking fund charges on the capital charges, was a deficiency of £6,745, or 2 14 per cent, of the gross rental of £321,988, as compared with a deficiency for the preceding year of £8,707, or 3.41 per cent, of the gross rental of £255,463. This deficiency is mainly to be accounted for by the general increase under all heads of working expenses arising out of post-war conditions and by the fact that, owing to the Rent Restriction Acts, the rents could not be raised to meet these expenses until a considerable part of the year had elapsed. The interest and sinking fund charges amounted to £118,238, or 37.6 per cent, of the gross rental. Management and maintenance cost £198,926, or 63.2 per cent, of the gross rental, including £86,310 (27.4 per cent, of the gross rental) for rates and taxes. As regards the 376 dwellings in Assisted schemes occupied during the year, the financial result, after providing for interest and sinkingfund charges, was a deficiency of £2,055 or 28*1 per cent of the gross rental of £7,322, this deficiency being attributable to the necessity of charging rents within the reach of the working classes. The interest and sinking fund charges amounted to £5,871, or 80.2 per cent, of the gross rental, and the expenditure on management and maintenance was £3,478, or 47.5 per cent, of the gross rental, including £1,273 (17 .4 per cent, of the gross rental) for rates and taxes. Bent Restrictions Acts. Under the Increase of Rent and Mortgage Interest (War Restrictions) Act, 1915, the additional rates which the Council had to pay in respect of the dwellings were added to the rents payable by the tenants, while, in accordance with the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920, the rents have, as from September, 1920, been further increased by 30 per cent, of the net rents of 1914. The amount paid in respect of rates on the dwellings was about £52,457 in 1919-20 and about £80,203 in 1920-21. The amount produced by the 30 per cent, increase in 1920-21 was about £27,020, the increases amounting to about £962 a week or about £50,030 for a full year. No difficulty has been experienced in the collection of the increased amounts. The rent paid in respect of the new dwellings brought into occupation in 1920-21, amounted to £7,322. These factors account for the increase in the gross rental for 1920-21, which was about £321,988 as compared with about £255,463 in 1919-20. Removals, empties, transfers, rents irrecoverable, etc. During the year 1920-21, 326 tenants left the dwellings. This is equivalent to 3.14 per cent, of the number of tenements, as compared with 3 63 in 1919-20. Of the 326 tenants, 7 were given notice to quit, either for non-payment of rent, disorderly conduct or some other cause. The remaining 319 gave notice and left to suit their own convenience. The loss by empties during 1920-21, was 0.57 per cent, of the gross rental, as compared with 0.45 per cent, in 1919-20. The empties occurred as usual mainlv in Carrington House; elsewhere the percentage of loss was only 0 02. Applications for accommodation. In 1920-21, 10,151 applications for accommodation on the estates (excluding lodging houses) were received, and 300 transfers were effected. These transfers are sometimes to a different estate, owing to the tenant having changed his place of work, and sometimes to a larger or smaller tenement on the same estate, owing to the increase or decrease of the tenant's family. Out of the applications, it was possible to suit only 722. During the year it was found necessary, in view of the abnormal conditions, to close the waiting lists of applicants for accommodation on the Council's completed estates, except as regards cases of applicants entitled to preferential treatment. Preference given to oertain applicants. The basis on which preference is given to certain classes of applicants and the general principles adopted by the Council in order that full use may be made of all available accommodation have already been described (see p. 130). Subject to these conditions applications for tenancies are entertained strictly in the order in which thev are received. Rent irrecoverable. Some tenants of dwellings and shops left without paying arrears of rent. Every effort was made to recover these arrears on vacation, but the amount of £13 1s. 10d., or .004 per cent, (less than 1d. per £100 of the gross rental) has been included in the accounts as irrecoverable, as compared with £385 8s. 7d., or 0.16 per cent. (3s. 2¼d. per £100) in 1914-15, and £13 7s. 4d. or .005 per cent (1d. per £100) in 1919-20. Rehousing. Owing to war conditions the Council did not during the years 1915-20, rehouse any persons who had been displaced by its street improvement, clearance and education schemes, although a clearance was made on the Tabard-street area. During 1920-21, however, the Council rehoused 106 persons, all of whom had been displaced in consequence of the Tabard-street clearance. The total number rehoused up to 31st March, 1921, was 1,862 out of a total of 34,734 displaced. 135 The enumeration of tenants of the Council's dwellings was taken in March, 1921, and showed that the rooms (excluding lodging houses) available for lettings were actually occupied by 39,846 or an average of 1.33 persons a room. As in previous years, the enumeration returns were carefully examined in order to detect overcrowding. The maximum number of persons to be allowed in any tenement in the dwellings has been fixed by the Housing Committee at two adults a room, children up to the age of five being for this purpose reckoned as nil, and each child between the ages of five and ten as half an adult. This year the number of cases not complying with this standard was 216 or 2.08 per cent, of the total number of tenements, as compared with 2.56 per cent in 1919-20. Of these 216 cases, 79 were carried over from the previous year. The increased amount of overcrowding is due to the continuance of the general shortage of accommodation, and the consequent difficulty of obtaining larger tenements. All the cases, however, although not complying with the Council's regulations, fall short of contravening the by-laws made under the Public Health Act, 1875. The overcrowding will be remedied as opportunities occur bv transfers to larger tenements. Enumeration of tenants, overcrowding. £68,572 9s. 7d. (21.3 per cent, of the gross rental) was spent in repairs to the pre-war buildings during the year, as compared with £23,934 4s. 8d. (105 per cent, of the gross rental) in 1913-14, and £51,195 11s. 8d. (20 per cent.) in 1919-20. The increase is due to increases in wages in the building trades and the heavy rise in the price of materials, and also to the necessity of overtaking the arrears of painting and other work suspended during the war. The repairs executed (all by direct labour) include external painting at 71 blocks of tenements and 1,069 cottages, comb-graining and varnishing the woodwork of 2,294 tenements and 299 cottages, and the cleansing and distempering of 5,551 tenements and cottages. Repairs. During 1920-21, twenty-eight small fires occurred. The total cost of re-instatement, amounting to £64 9s. 1d., was covered by the Council's insurance fund. Fires. Vital statistics. Well Hall Estate. During the year 274 deaths of residents in the dwellings took place, representing a death-rate of 6.60 per 1,000, as compared with a rate of 12.59 per 1,000 for the county of London. The number of cases of infectious diseases was 331, of which 228 were cases of small-pox, 78 cases of diphtheria, and 14 cases of measles. In 1915, the Council undertook the administration on behalf of H.M. Government, of the Well Hall estate, Woolwich. The Commissioners of H.M. Works, etc., have given notice to terminate this arrangement on 30th September, 1921. For the work involved the Council receives a commission based on the gross rental. The estate comprises 212 three-room dwellings, 613 four-room dwellings, 358 five-room dwellings, and 112 six-room dwellings, or 1,295 dwellings in all, with accommodation for 11,100 persons. In October, 1920, difficulties arose in connection with charging the increases in rent permitted under the Increase of Rent and Mortgage Interest (Restriction) Act, 1920. In accordance with instructions received from H.M. Office of Works, notices enforcing the increases permissible under the Act were prepared and issued to the tenants on this estate. The increases on account of rates became due on 20th September, 1920, and were paid without demur. An increase of 30 per cent, on standard net rent became due on 11th October, 1920, but the majority of the tenants refused to pay it, and representations were made by the tenants to the Commissioners, protesting against this increase on the ground that the rents originally fixed were in excess of those charged for similar accommodation in the locality. The Commissioners did not accept this contention, and, as a result of negotiations, the tenants, through their Association, accepted the offer of the Commissioners to submit the question of rents to arbitration on certain conditions, the collection of the 30 per cent, increase being meanwhile left in abeyance. The decision of the arbitrators had not been issued at the end of 1920. In July, 1917, the Council undertook, at the request of the Coal Controller, the sale of coal to tenants in block dwellings. The coal was delivered in bulk to a store provided in the yard, and issued by the caretaker at fixed times. The selling price was fixed by the Coal Controller, and was calculated to cover expenses. It was decided to discontinue this arrangement on 31st March, 1921. Up to that date, 17,357 tons, priced at about £43,045, had been distributed. Distribution of coal. APPENDIX. VENEREAL DISEASES. / REPORT BY THE MEDICAL OFFICER OF HEALTH ON THE VENEREAL DISEASES SCHEME. The joint venereal diseases scheme for London and the Home Counties having been in operation for four years, it was considered both by the Ministry of Health and the participating authorities concerned that it was desirable to make careful enquiries into the existing arrangements with a view to considering any modifications which experience had shown to be necessary. After consultation with Sir George Newman, the Chief Medical Officer of the Ministry of Health, it was agreed that a representative of the Ministry (Brevet-Colonel L. W. Harrison, D.S.O., M.B.) and Dr. F. N. K. Menzies, representing the Council, should carry out a joint inspection of the clinics. With this object in view, they visited all the hospital clinics and hostels at which the work is being carried on, and their observations are embodied in the following statement which corresponds with one on similar lines which is being submitted to the Ministry of Health. Reference is made in the statement to questions such as "stillbirths," "publicity" and the " social aspects " of the venereal diseases problem, which will no doubt be read with considerable interest by those who are taking part in the campaign against these diseases. The report which, for presentation to the Council, is signed only by Dr. Menzies, a principal assistant medical officer in the Public Health Department, has been prepared jointly by him and Colonel Harrison. As the Committee are aware, Colonel Harrison's position in relation to the question of venereal disease is one of world-wide eminence and the value of the report both to the Council and to the general public is greatly enhanced by the fact of his collaboration. W. H. HAMER, Medical Officer of Health. 61004 T ii VENEREAL DISEASES. REPORT ON THE VENEREAL DISEASES SCHEME. I. Introduction. The Public Health (Venereal Diseases) Regulations, 1916, made by the Local Government Board, required that the councils of the counties and county boroughs in England and Wales and the Common Council of the City of London should (1), subject to the approval of the Board, make arrangements for enabling any medical practitioners practising in the area of each council to obtain, at the cost of the council, scientific reports on material from persons suspected to be suffering from venereal disease ; and (2) prepare and submit to the Board a scheme (a) for the treatment at and in hospitals or institutions of persons suffering from venereal disease, and (b) for supplying medical practitioners with Salvarsan or its substitutes for the treatment and prevention of venereal disease. The regulations were the outcome of the first report of the Royal Commission on Venereal Diseases (Cd. 8189), which was issued in March, 1916. The Royal Commission found that the effects of venereal disease upon the individual and upon the race were grave and far reaching, involving a heavy loss to the community in actual and potential population, as well as in money. They reported that the medical evidence given before them established the fact that, by early and efficient treatment, venereal diseases could be brought under control and reduced within narrow limits, but that treatment was in most cases unduly deferred and the best modern methods of diagnosis and treatment were not within reach of the population generally. They recommended that arrangements should be made for providing free for the whole community adequate laboratory facilities for diagnosis, combined with the provision of adequate and skilled free treatment for all persons affected with venereal disease. They further recommended that the organisation of these arrangements should be entrusted to the councils of counties and county boroughs, and that 75 per cent, of the cost of carrying out approved schemes should be met from Imperial Funds. The Government adopted these recommendations. The principles underlying the scheme of the Local Government Board were to prevent the spread of these diseases (a) by rendering non-infectious the greatest possible number of infection carriers and (b) discouraging, by education and general propaganda, practices which lead to exposure to infection. They sought to accomplish the first of these principles by the establishment of free treatment centres, and the institution of various measures by which those centres and their auxiliaries are fed. The second was placed largely in the hands of the National Council for Combating Venereal Diseases as recommended by the Royal Commission. For the purpose of carrying them out with the least possible delay, the Local Government Board being of the opinion that the conditions at the time constituted a case of emergency within the meaning of Section 2 of the Public Health (Prevention and Treatment of Disease) Act, 1913, made regulations under the Public Health Acts which empowered the Board to require county councils to execute and enforce regulations made under Section 130 of the Public Health Act, 1875, without the consent of those authorities. The expenses of the county council under these regulations were to be defrayed as expenses for general county purposes, the Government, as already stated above, repaying 75 per cent, of the expenditure incurred and approved by the Local Government Board. The regulations were accompanied by circulars, dated July 13th, 1916, from the Local Government Board to the authorities concerned, indicating the nature of the arrangements which, in the opinion of the Board, should be made for the purpose of combating venereal disease. As regards diagnosis, the facilities provided by the council were to be made available for the whole population of the area, without cost to the patient or to the medical practitioner, for the pathological examination of specimens sent by any doctor practising in the area. As regards treatment, special attention was drawn to the findings of the Royal Commission that the existing facilities were extremely deficient, that adequate institutional treatment should be available for the whole community, and should be so organised that persons affected by these diseases should not be deterred from taking full advantage of the facilities provided, and that this result would be best secured by the use of the existing general hospitals rather than by setting up special institutions for the purpose. It was also pointed out that both in-patient and out-patient treatment would be required, and that the arrangements for the latter would form the most important part of the scheme. Moreover, it was indicated that, in all cases, the arrangements with the hospitals should be such that the clinics for venereal cases should not be specially designated and that nothing should be done to distinguish the patients who attended for the treatment of those diseases. Furthermore, treatment at hospitals must be available for all comers, irrespective of place of residence and means of the patient. The high proportion of the Government grant was fixed in order that the facilities provided under the schemes should be available for the whole population. It was also suggested that where the same hospital would conveniently serve more than one area, the councils concerned should confer as to the iii ments which should be made, and as to the method by which the expenditure should be shared between them. Stress was also laid on the necessity for securing in any scheme the co-operation of general practitioners, and for affording facilities to enable practitioners to participate in the work of the hospitals. The Local Government Board thought that, though there should be no refusal of treatment to any patients at the hospitals, medical officers of such institutions might properly suggest to patients who could obtain satisfactory treatment from their own doctors, and could afford to pay, that they should do so. Lastly, conditions were laid down under which Salvarsan, or its substitutes, should be -supplied to medical practitioners, including district medical officers and medical officers of Poor Law institutions. It should be carefully noted that at this date (June, 1916) the measures required to be undertaken were limited to those necessary for securing adequate facilities for diagnosis and treatment. At an early stage in the deliberations upon the steps to be taken in London, it became evident that great advantage would accrue if the local authorities adjoining the County of London would co-operate with the Council in the utilisation of the facilities afforded by the great general and special hospitals of London. Conferences on the subject were accordingly arranged between representatives of the counties of London, Bucks, Essex, Hertford, Kent, Middlesex, and Surrey, and the county boroughs of Croydon, and East and West Ham. The final conferences which were held at the Local Government Board had the additional advantages of the advice and assistance of the officers of the Board, and, ultimately, the following decisions, among others, were arrived at:— (1) That any scheme provided for London would be utilised by many patients from the surrounding areas, and that it would be equitable for the councils of these areas to contribute towards the cost of the scheme. (2) That it was desirable to leave the preliminary negotiations with hospitals in London to the London County Council and that it should be made clear to the authorities of these hospitals that the facilities provided would be required for patients not only from London, but also from the surrounding areas. (3) That the payments made to hospitals for the first year's working of the scheme should be divided into three parts for the following services:—(i.) the work of the treatment centre, including the supply of Salvarsan or approved substitutes for patients treated at the centre and any pathological examinations of specimens from these patients; (ii.) the pathological examination of specimens sent to the hospitals by medical practitioners in the areas included in the scheme ; and (iii.) the supply of Salvarsan or approved substitutes to such practitioners. (4) That for the purpose of framing estimates and making advance payments to the hospitals, the sum required for the advance payments should be apportioned between the councils on some agreed basis, but that at the end of the year the total payments to the hospital should be apportioned between the councils according to user. (5) That the Local Government Board should undertake to settle the payments to be made by the councils according to user. These principles were approved by all the participating authorities, and negotiations were opened with the governing bodies of the principal London hospitals on behalf of the local authorities concerned. All the hospital authorities which were approached expressed their willingness to undertake the work, and to enter into agreements with the local authorities in the scheme. The services which it was proposed should be undertaken by the hospitals were :— (1) The appointment of a committee of the staff to draft a scheme for carrying out the special work at the hospital for the diagnosis and treatment of venereal disease, and to organise and superintend these arrangements within the hospital. (2) The appointment of a competent staff. (3) The provision of necessary beds for patients. (4) The treatment of out-patients at evening sessions and other suitable times. (5) The supply of Salvarsan or its authorised substitutes to medical practitioners on an approved list to be supplied by the local authorities concerned. (6) The supply to practitioners of any apparatus necessary for taking samples of blood, etc., and the furnishing of the necessary reports on such specimens to such practitioners. (7) The supply of statistical information of work done in the treatment centre and laboratory. (8) The provision of free instruction for practitioners and medical students. (9) Opportunity for practitioners to act as clinical assistants at approved rates of remuneration. (10) The employment where possible of women doctors in clinics for women patients. (11) The issue of printed instructions for the guidance of patients and practitioners. It should be noted that, while no limitation was placed upon the right of the hospital to treat cases of venereal disease at any stage, the local authorities concerned definitely limited their financial liability to cases in the early and at all communicable stages. The financial arrangements made with the hospitals undertaking the work were very simple. It was generally recognised by all parties to the agreement that, for the first year or two, it would be impossible to forecast with even approximate accuracy the probable number of patients who would take advantage of the facilities provided, more especially in those hospitals where no special provision of any kind had hitherto been made for the diagnosis and treatment of these diseases. Furthermore the Great War was bound tc have all kinds of disturbing 61004 2 iv effects upon any known data for purposes of calculation even in those hospitals where treatment had been available for some years before 1916. It was, therefore, decided to pay a lump sum to each hospital undertaking the work as a grant in aid, and it was hoped that, after several years' experience, sufficient data would be forthcoming to enable a more accurate system of payment to be drawn up. With regard to the division of the cost amongst the local authorities participating in the scheme with the London hospitals, it was agreed that the amount payable by each participating authority should be based upon two factors, viz., (a) the estimated population of the area of the authority to be served by the hospitals, and (b) the actual user as ascertained at the end of each year from the returns of addresses of patients. In this connection, it may be noted that the population to be served was estimated at 7,659,000. Other features of interest and importance in connection with the arrangements were that the grants in aid to the hospitals were divided into payments in respect of (a) the work of the treatment centre, including the supply of Salvarsan or its approved substitutes for patients treated at the hospital clinic, and the pathological examination of specimens sent to the laboratory from those patients, and (b) the pathological examination of specimens sent to the hospital laboratory by medical practitioners in the areas of the local authorities participating in the scheme. This division of payment was made necessary by the fact that certain of the participating authorities, notably Kent, had already made provision for the examination of samples sent by medical practitioners in the County of Kent, and it would have been difficult, if not indeed impracticable, to devise any other method of payment for laboratory work undertaken at the hospitals except the one above described. Finally, it should be noted that the Local Government Board undertook at the request of all the participating authorities the duty of assessing and collecting the contributions due from each authority, and distributing the grant in aid to each hospital included in the scheme on the following lines :— (a) An instalment of 50 per cent, of the amount payable by each participating authority shall be paid to the Local Government Board before 31st March, 1917. (b) The amount payable under (a) by each participating authority shall bear the same proportion to the total amount payable by all the participating authorities as the estimated population of the area of the authority to be served by the hospitals bears to the total estimated population to be served in the areas of all the authorities. (c) The Local Government Board shall distribute the amounts payable to the hospitals, and at the end of the year, shall determine the actual amount to be paid by each of the participating authorities on the basis of user. The amounts payable by the several local authorities for the year 1917 on the basis above referred to are indicated in the following table :— Authority. Treatment at hospitals. Pathological examination of materials. Population to be served. Contribution. Population to be served. Contribution. London County Council ... 4,500,000 £ 4,500,000 £ 15,864 3,686 Buckingham County Council 200,000 705 200,000 164 Essex County Council 500,000 1,763 750,000 614 Hertford County Council 250,000 881 311,000 255 Kent County Council 200,000 705 Kent County Cou ncil will make its own arranements. Middlesex County Council 900,000 3,173 900,000 737 Surrey County Council 540,000 1,904 676,000 554 Croydon Corporation 140,000 493 170,000 139 East Ham Corporation 140,000 493 140,000 114 West Ham Corporation 289,000 1,019 289,000 237 7,659,000 £27,000 7,936,000 £6,500 In addition to the grants in aid made to the hospitals under their agreements for the diagnosis and treatment of venereal diseases, etc., etc., the Council became responsible for the payment for Salvarsan substitutes supplied to approved medical practitioners for private patients residing in the County of London, and for patients in Poor Law institutions. Payments were made by separate accounts to the hospitals for the supply of these drugs, including postage, the hospitals acting in fact as distributing agencies on behalf of the Council for this purpose, and being, of course, recouped for the whole of their expenses in this connection. The Council also made provision for the giving of instructional lectures and for the preparation and publication of reliable information on questions relating to venereal disease. For this purpose arrangements were entered into with the National Council for Combating Venereal Disease. The general principle underlying this agreement was that the Council would undertake the dissemination of information and instruction in the cases of bodies of an official character, e.g., the Metropolitan Police, etc., whereas the National Council for Combating Venereal Disease would by means of a grant in aid from the Council concentrate its energies upon bodies of an unofficial character, e.g., factories, workshops, etc. These in broad outline were the features of the venereal diseases scheme which received the approval of the Council and the Local Government Board as well as the councils of the participating authorities, and which came into operation on January 1st, 1917. They may be shortly summarised thus:— (1) Restriction of scheme to voluntary hospitals. V (2) Concentration of all medical and pathological work ; distribution of drugs ; teaching, etc., under one roof. (3) Limitation of Council's financial aid to cases in the early and communicable stages, i.e., exclusion of such cases as locomotor ataxia and general paralysis of the insane. (4) Payment by block grant to the hospitals and by each participating authority according to user. (5) Propaganda work distributed between councils of participating authorities and the National Council for Combating Venereal Disease, according to whether the bodies concerned are official in character or not. The hospitals included in the scheme for the year 1917 were the following:— Charing Cross Hospital. « The Hospital for Sick Children, Gt. Ormond-street. The Great Northern Central Hospital. Guy's Hospital. King's College Hospital. The Lock Hospital (male and female). The London Hospital. The Middlesex Hospital. The Miller General Hospital. The New Hospital for Women (Elizabeth Garrett Anderson. The Royal Free Hospital. St. John's Hospital, Leicester-square. St. George's Hospital. St. Paul's Hospital, Red Lion-square. St. Mary s Hospital. The Seamen's Hospital, Greenwich. St. Thomas's Hospital. The University College Hospital. The South London Hospital for Women. The Westminster Hospital. The West London Hospital. During the year 1917 the scheme was carried out under very great difficulties. These were mainly due to the ever-increasing demands made upon the personnel of the medical profession by the Great War. Notwithstanding, these immense difficulties, however, every hospital carried out its schedule of advertised clinics; in the course of the twelve months, no fewer than 15,000 new patients attended, (see Appendix A), and many practitioners availed themselves of the facilities provided in the laboratories for the free examination of pathological specimens from patients suffering, or suspected to be suffering, from venereal disease. During the fyear quite a large number of other hospitals and laboratories expressed their willingness to provide facilities for the diagnosis and treatment of venereal disease, but after most careful enquiry it was decided to include only three more institutions in the scheme, viz.: the Metropolitan Hospital; the Hospital for Diseases of the Skin, Blackfriars ; and St. John's Hospital, Lewisham. These hospitals were included in the scheme for the year 1918, on the same conditions in all respects as those which had been at work throughout 1917. Considerable efforts were also made to provide some special hospital in-patient, as well as out-patient, treatment for pregnant women suffering from venereal disease, but owing to the acute shortage of both medical and nursing staff at the lying-in hospitals, the proposal had to be abandoned. On the other hand, the importance of endeavouring to link up certain sociological factors with the diagnosis and treatment at venereal disease clinics was recognised for the first time. From time to time attention had been drawn to the fact that many patients were in attendance, more or less irregularly, at the clinics, who were living under conditions which either made efficient treatment impossible or rendered the patient liable to convey infection to another person. Common examples of these were domestic servants, shop girls, waitresses, cooks, and scullery maids in public restaurants, etc. It was also ascertained that in many instances women patients, whilst under treatment, were still walking the streets as prostitutes. In some of these cases there is no doubt that the girls were devoid of any other adequate means of subsistence, and would gladly have taken advantage of any offer of board and lodging which would have saved them from the necessity of adopting or continuing a life of prostitution. Numerous other examples could be cited of women and girls in attendance at venereal disease clinics for whom, for a great variety of reasons, it was very desirable to make hostel provision for at least part of the time whilst they were under treatment. It might be asked why they were not taken into the hospitals as in-patients. Such a course could easily have been adopted under the scheme, but there were many obvious objections. In the first place, the demand upon hospital beds is always of such an acute character that only cases which could not otherwise be satisfactorily treated should occupy such beds. Secondly, the occupation of a hospital bed for several weeks or months by such a patient would be a very unnecessarily expensive method of dealing with the case. Thirdly, a properly constituted hostel, conducted more or less on the lines of a residential club for girls, under the control of a wise, sympathetic, and understanding matron, who would be a mother in the best sense of the word to the girls while under her care, was much more likely to prove to be a satisfactory method of dealing with the varied types of girls seen at the venereal disease clinics. Moreover, it was considered that, whilst the girls were in residence in such hostels, they could undergo a certain amount of necessary treatment daily, their regular attendance at the venereal diseases clinic could be ensured, and they could usefully be employed in housework, needlework, etc.; taken out for healthy exercise; and last, but by no means least, moral and spiritual help could be extended in such a manner as to be of great assistance to them in many ways which need not be entered into in detail at this juncture. It may be added that, for obvious reasons, the daily cost of a bed at such a hostel is less than half that of a hospital bed, and experience has shown that the girls after leaving it as residents, frequently make such a friend and confidant of the matron that they often visit her afterwards for advice and help, and come to regard the hostel as a kind of club. Reference should also be made to the fact that in many instances it has been possible to place a girl when she leaves the hostel, in a good situation with a respectable and trustworthy environment, and thus to give her another chance of making good. vi With all these considerations in mind, the Council, therefore, with the consent of the Local Government Board decided to make grants in aid to three hostels, on the understanding that the patients for whom board and residence were provided were women and girls in attendance at the venereal disease clinics included in the Joint scheme. The three hostels were (1) the Women's After-care Hostel, Highbury-quadrant; (2) the Hostel, Burton-street (attached-to the Royal Free Hospital); (3) the Hostel at St. Mary's-street, Woolwich, under the auspices of the Southwark Diocesan Association,, subsequently transferred to 80, Stockwell Park-road. The arrangements in the case of each hostel were in the hands of a committee of voluntary workers to which representatives of the medical staff and almoners of certain of the venereal disease clinics were elected, so as to ensure close co-operation and consultation where necessary. The grant in aid was distributed in exactly the same manner as in the case of the hospitals, and the Local Government Board repaid 75 per cent, of the amount. The only other development of importance during the year 1917 was the provision of a special hospital for the in-patient treatment of cases of ophthalmia neonatorum by the Metropolitan Asylums Board. In this connection it may be noted that on the 5th July, 1917, a deputation, consisting of certain well-known ophthalmologists, waited upon the Public Health Committee of the Council and drew attention to the urgent need for special arrangements being made for the treatment of this disease. It was intended to make such arrangements in the Council's scheme for 1918, but in the meantime, after consultation with the Local Government Board, it was found possible to make such provision immediately by means of an institution in the possession of the Metropolitan Asylums Board, now known as St. Margaret's Hospital, Kentish Town, which contained accommodation for 18 mothers and 30 children, and was opened on the 16th September, 1918. Under the circumstances, the Council decided to take no further action in this direction until an opportunity should occur at a later date to report upon the results of the provision made at St. Margaret's Hospital. 1918.—During this year the venereal diseases scheme was continued on substantially the same lines as in 1917. Increased grants in aid were made to most of the hospitals owing to the greater number of patients in attendance at the clinics, and the larger demand upon the laboratory facilities of the hospitals for the examination of specimens sent by medical practitioners. (Appendix A.) Great difficulties continued to be encountered in connection with the provision of medical and nursing staff, owing to the very pressing demands for both arising out of the Great War, and also to the growth of the work of the clinics themselves. Two additional hospitals were included in the list of institutions approved for the work, viz., the Royal Albert Dock Hospital and the City of London Lying-in Hospital, City-road, but the latter hospital was unable to carry out its undertaking, and had to be withdrawn from the list. Increased grants were also made to the three hostels included in the arrangements for the year and it is very satisfactory to note that the best anticipations of the useful work likely to be done by these institutions were fulfilled. Special enquiries and reports were made into the following matters :— (a) The large number of patients who ceased to attend before completing treatment. (b) The need for agreement upon the standard of cure in both syphilis and gonorrhoea. (c) The great difficulty of providing satisfactory treatment for children suffering from gonorrhoea. (d) The urgent need for a carefully considered system of recording the statistics of the venereal disease clinics. During the year 1918 it was decided that the grants in aid to hospitals and hostels would be made in future years for the period of the financial year of the Council, i.e., from April 1st to 31st March, instead of as heretofore for the calendar year. This alteration, though accompanied at the moment by some inconvenience to all parties concerned, was agreed to because of its advantages in other directions :— (1) On financial grounds it was convenient for all the local authorities participating in the London scheme. (2) The hospitals and hostels, having expressed a desire to continue the system of grants in aid by lump sum, were enabled in the early portion of each year to submit statistics of the work of the venereal disease clinics for a full calendar year, and from these data it became possible to calculate more accurately the amount of the grant in aid for the year commencing 1st April, immediately following the receipt of such statistics. For these reasons the grants made by the councils concerned at the end of 1918 were for a period of fifteen months, terminating on 31st March, 1920, and the next complete report on the work of the venereal disease clinics was submitted to the Council in February, 1920. lst January, 1919, to 1st April, 1920.—Certain recommendations were made (a) in regard to increased grants in aid to hospitals and hostels owing to a further large increase in the work of these institutions in all sections of the venereal disease work, and (b) four additional institutions were added to the list included in the scheme, viz. :— The Bolingbroke Hospital, Wandsworth. The Royal London Ophthalmic Hospital, Moorfields. The City of London Lying-in Hospital (included in 1918 list but afterwards withdrawn). Nos. 82-84, Stockwell Park-road (for the treatment of children suffering from gonorrhoea). The City of London Lying-in Hospital was again compelled to withdraw its application owing to financial difficulties in connection with the alteration and adaptation of existing premises and the provision of certain additional premises which were necessary for satisfactorily carrying out the work vii of a venereal disease clinic. In these circumstanees it was fortunate that the Royal Free Hospital was able to make some special provision for the treatment of pregnant women suffering from venereal disease by means of its new Maternity Hospital at 21, Endsleigh-street, and the Hostel at 13, Burton-street, for which provision a considerable addition was made to the grant in aid to this hospital for the year 1920-21. The premises at 82 and 84, Stockwell Park-road, which the Federation of Children's Rescue Committees proposed to adapt and utilise for the treatment of gonorrhoea in children, were ultimately abandoned owing to difficulties in connection with the lease of the premises, but in this instance it is a matter for congratulation that much more suitable premises were found at Coldharbour, Waddon, (near Croydon) Surrey, with accommodation for 25 children, and these are now in occupation. One of the special features in connection with the treatment of these cases is the immense importance of the provision of education for the children whilst still under treatment, not only because of the fact that this is generally prolonged in such cases (often many weeks and even months), but also in order to. divert the naturally active, precocious minds of such children from dwelling upon " treatment " as the dominant factor in their lives. During the year 1919, two more hostels were opened, one at 168, Lambeth-road, and the other at 24, Gloucester-road, Regent's Park. The former is directly associated with the work of the venereal -disease clinic at St. Thomas's Hospital, and the latter with the venereal disease clinic at the Royal Free Hospital, though in both institutions cases may be accepted from any of the venereal disease clinics in the scheme. At the time of writing this report, it may be noted that arrangements have recently bean completed for the opening of a hostel at 93", Grove-lane, Camberwell, for pregnant women suffering from venereal disease, and negotiations are in progress for linking up another hostel in Sinclairroad, Hammersmith, with the work of the venereal disease clinic at the West London Hospital. It is also worthy of note that each year's additional experience serves to confirm the value of hostels in increasing the efficiency of treatment of certain types of patients and in preventing to some extent the spread of these diseases in the manner indicated in an earlier portion of this report. Two other matters of considerable practical importance may conveniently be referred to at this juncture in connection with the development of the London scheme. One is the fact that at St. Thomas's Hospital during the year 1920 the whole of the venereal disease clinic has undergone a complete reconstruction in every sense of the word. New premises, especially designed for the needs of a venereal disease clinic, have been provided, and concurrently with the opening of these premises, there has been appointed a specially selected medical, nursing, and male orderly staff sufficient to permit of the facilities for diagnosis and treatment being available from 8 a.m. until 10 p.m. daily. A description of these arrangements will be found in page 11, but attention is drawn to them here as they constitute the most important development in the direction of the facilities provided for diagnosis and treatment in the scheme for the year 1920. The other matter to which attention should be drawn is the opening of a venereal disease clinic at the Royal London Ophthalmic Hospital, Moorfields. To some minds it may doubtless appear to be somewhat difficult to justify such a step, but to those who know the immense amount of blindness, partial and complete, which is directly traceable to venereal disease and is avoidable by appropriate treatment at the right moment, there will be no difficulty in appreciating the great possibilities for good work arising from the establishment of facilities for the treatment of these diseases at the Royal London Ophthalmic Hospital and their possible extension later to other ophthalmic hospitals. During the year 1920 the number of sessions at most of the venereal disease clinics throughout London has been increased in order to cope with the constant and continuous increase of the work. To meet these demands, the councils participating in the scheme have also made considerable additions to their grants in aid to the hospitals carrying out the work, as will be seen from Appendix A. By the end of the year 1920, the scheme will have been in operation for four years, and in view of the fact that the difficulties of staff, which were so pronounced during the first three years are now much less marked, the present moment seemed a convenient one for a careful survey of the work of the venereal diseases clinics, and for a review of the direction in which future developments of the campaign against venereal disease should aim. Accordingly, as opportunities have offered, special visits have been made from time to time to each of the venereal disease clinics included in the scheme, and in addition numerous enquiries have been made and stimulated in many directions as to the various activities which may reasonably be considered as directly or indirectly concerned with the campaign against venereal disease. Whilst the immensity and complexity of this task is fully recognised, as well as the important issues involved and the vast amount of time which would be necessary for a complete study and appreciation of all the activities concerned, an effort has been made to include in this report some comments, criticisms and suggestions based upon the results of these enquiries, which it is hoped may be of service to those who are charged with the responsibility of providing both for the diagnosis and treatment of these diseases and for their prevention. II. General Principles Governing the Organisation of Venereal Disease Clinics. Before commenting on the conditions which were found to exist in the clinics operating under the scheme it would be well to set out briefly the general principles which should govern the organisation and conduct of such clinica. viii A treatment centre which properly fulfils the purpose of the venereal disease scheme should (a) attract for treatment the maximum number of infected persons within its sphere of influence. Obviously it would be useless to set up a clinic, however well equipped with treatment appliances, and however distinguished its staff, if, for some reason, such as the length of time spent in waiting for treatment, undesirable exposure of the person to which patients were subjected, inconvenience of hours at which sessions were held, and so forth, the clinic was not popular. (6) The premises should be so arranged that, conformably with (a) the staff can work with a minimum waste of time and energy. Thus, if a medical officer has to wait whilst a patient prepares himself for examination, or has frequently to walk comparatively long distances to carry out his different functions, it is impossible for him to see as many patients efficiently in a given time as if the premises were arranged to preclude the necessity of his time and energy being wasted over these manoeuvres. The arrangements should include provision for intermediate treatment of gonorrhoea in both sexes by nurses and orderlies. This should be available all hours of the day, in order that patients may not be deterred from daily attendance by loss of work. (c) The medical and surgical equipment should be the most convenient possible, and be at once available where required. This implies that equipment should be grouped in sections (1) for taking of specimens, (2) for special examination and treatment of gonorrhoea, and (3) for special treatment of syphilis. A useful plan is to equip separate instrument tables on castors so that they can be moved quickly from one place to the other as required. The alternative plan of requiring the patient to go to some special room or cubicle where the equipment is stationed is not so convenient if adhered to alone, and, in practice, it is better to duplicate the equipment for some purposes, such as the special examination of gonorrhoea, keeping one set fixed and the other movable. (d) The staff should be co-ordinated under one head, who should be responsible for the ideal of treatment carried out by those under him and for the conduct of the clinic generally. He should be responsible also for assigning to members of the staff their due proportion of work and should see that this work is of a proper nature. Thus, in a well-organised clinic a medical officer does not perform duties which can equally well be carried out by a clerk or an orderly, though this does not imply that a medical officer should never touch a pen, or that he should never irrigate a patient himself. On the other hand, it does imply that an orderly, however skilled, should not pass urethral instruments. (e) The hours at which sessions are held should be determined by the convenience of the patients, since venereal diseases do not necessarily incapacitate from work, and the financial loss incurred by attendance during work hours is a powerful incentive to discontinuance. Some patients can attend in the evenings only, and some during the day, so that, during the week, some sessions should ordinarily be held in the evening and some during the day. The number of hours during which medical officers attend for the examination and treatment of patients, or the number of medical officers appointed, should be sufficient to permit of each patient receiving the attention which is adequate to render him non-infectious in the shortest space of time. It is a self-evident fact, which is, however, frequently forgotten, that a medical officer could see many hundreds of patients in a comparatively few hours and thus register a huge total of attendances, but the value of such work to the public health would be nil. Merely to glance at a large array of patients week after week, with the mere injunction to most of them to " carry on," is not applying that skill for which the medical officer was appointed. Indeed payment for such work is a waste of public money. As mentioned under (b), the clinic should be open for intermediate treatment all day, and until late in the evening. (/) The conduct of the venereal disease clinic should be governed by the principle that it was established to render venereal patients permanently non-infectious, and that in every instance where it fails to accomplish this object, it fails entirely to achieve the purpose for which it was established. To alleviate symptoms, leaving the patient a carrier of infection, is, indeed, worse than useless to the general public, since the patient is the sooner enabled to follow those practices which lead to conveyance of his infection to others. III. Facilities for Diagnosis and Treatment in the London Clinics in 1920. Premises.—With only a very few exceptions, the venereal disease clinics operating under the London scheme are located in the out-patient departments of the various hospitals. This arrangement frequently interferes with the efficiency of the clinic for various reasons, the chief of which are that (a) the premises are available only at certain hours on certain days during the week, and it is impossible to arrange for intermediate treatment of both sexes to be carried out at all hours. This is an important defect, since patients frequently cannot attend every day at the hours when the clinic is open, and the success of treatment depends very largely on its daily application. Further the restriction of the hours during which the rooms are available leads to congestion of patients during those hours, and not only is it impossible for the staff to give them the individual attention which is necessary, but patients have to suffer the discomfort and inconvenience of waiting long periods for treatment. If the rooms were available all of every day, it would be possible for the staff to arrange for patients requiring lengthy examination to attend at some time when the clinic was not crowded. Experience in those clinics where the rooms are available at any hour has shown that, since this detailed examination is not required very frequently, many patients can be persuaded to attend specially for it. The importance of a detailed examination of each case of gonorrhoea at regular intervals, with the formulation of a definite plan of treatment to be carried out for some weeks to come, cannot be over-estimated ; clearly it is ix far superior to the cursory examination, with haphazardly chosen treatment, which the staff is compelled to adopt when the clinic is open during restricted hours, and is " crowded out" with patients who must be " got through somehow." (6) The rooms of the average out-patient department are not arranged conveniently for the work of a venereal disease clinic. The nature of venereal disease makes it necessary to examine in privacy, otherwise the patient is discouraged from attending. The preparation for the private examination takes time, and must be done in private, so that the patient must be put into a separate room or cubicle. Sometimes the examination is only a short one, but must still be made privately and the disrobing and robing which precede and follow it take practically as long as for the complete examination. To work quickly it is necessary that the medical officer should have at his disposal a number of rooms or cubicles into which he can put patients, who can then prepare for the examination in their own time. If sufficient of these rooms or cubicles in which patients can be examined and treated are not available, the medical officer has, perforce, either to wait whilst some of the patients prepare, or has to let the examination of a number go by whilst one patient, or perhaps two, are getting ready. Usually, the result is a compromise, and, whilst one patient prepares in a special room, a dozen are put off with a repeated prescription until some future date. It may be asked why patients receiving free treatment should be humoured in regard to privacy of examination. Why should they not subordinate their ideas of modesty to the convenience of the clinic and expose themselves regardless of the presence of a number of other patients looking over a screen ? The answer is that they may submit to this exposure so long as their discomfort or fear of consequences impels them, but as soon as their symptoms have disappeared (and that is long before they have become non-infective) they begin to weigh up the discomfort of attendance against what is to them the slight need of attendance, and the result is that they discontinue long before they have been rendered non-infective. The case is totally different from that of the ordinary out-patient, since, in the latter, if the physician or surgeon has achieved some measure of relief he has accomplished some good, and it is the patient's look-out if he does not choose to attend again. In the case of the venereal out-patient, no good whatever has been attained until the patient has been rendered non-infective, and it is not merely a matter of individual, but of national importance if the patient chooses to cease attendance, consequently reasonable privacy must be secured and this, owing to the large number of patients, in such a manner as will not waste one moment of the medical officer's time. In most of the clinics inspected there are one, or perhaps two, private rooms for special examination, and the general interviewing takes place in a larger, common room. Usually one medical officer interviews and a second conducts special examinations. If there is only one medical officer, he interrupts his routine " running through " the patients from time to time to conduct a special examination. In this case, either one of the attendant staff is kept waiting about doing nothing in particular, or the attendant in the common room has to " switch off " to a different train of duties. If there is another medical officer, he and his attendant are kept waiting whilst the patient prepares for examination. In either case considerable time is wasted. If privacy is sacrificed, something approaching the state of affairs discovered in one hospital results. Here, in a single room, some patients were waiting, others were having instruments passed, others undergoing prostatic massage, and still others were irrigating, all within view of one another. Truly efficient from the point of view of time-saving, but truly discouraging to any but the most callous patient. In some hospitals the medical officer has to walk a considerable distance to another room in which to conduct any special examination he wishes to make; not a great matter, perhaps, if the patients were few in number, but they are usually more than the staff could efficiently attend under the best circumstances. In connection with the arrangements resulting from the sharing of the ordinary out-patient department by the venereal disease clinic mention must be made of the indifferent irrigation arrangements which usually result. These are of a temporary nature, since all traces of the apparatus must be removed after each session. Time is wasted in setting up and dismantling the apparatus, and they are never arranged in such a manner that the orderly can serve them quickly and efficiently. In other cases the apparatus is hidden away in an isolated room or a basement, far from the view of the medical officer, and not only is there no skilled supervision, but either an attendant has to be employed whole-time in the supervision of one or two irrigators, a great waste of man-power, or he has to attend to the irrigation when his other duties will allow him, with the result that patients have to wait long periods before being attended to. It is unlikely that patients will continue attendance for long under such conditions. Most of the adverse circumstances which have been commented upon above are undoubtedly associated with the difficulties arising out of the considerable capital expenditure which would be involved in the provision of properly designed premises. In these circumstances, it is unfortunate that no arrangements have been made for the provision of capital grants in the case of venereal disease schemes. In consequence of these difficulties the internal arrangements of most of the London clinics make for inefficiency or waste of man-power or both. Assuming that maximum efficiency is the goal, and there may be no other under the public health venereal disease scheme, more men are required for the conduct of the average London clinic than would be necessary if the premises were designed for the special needs of venereal disease work. It is hardly necessary to remark that the capitalised value of the salary of a single male attendant would go far towards the provision of entirely new and up-to-date premises. In a number of hospitals it is not possible to provide new premises because no space is available, but in others this does not hold, and it would probably be a more economical plan to erect new premises specially designed for venereal disease work wherever possible, encouraging the growth of venereal disease clinics here, and even to close down some which, conformably with the ideal of efficient treatment, cannot be run economically. In the case of one clinic—St. Thomas's Hospital—completely new premises have been 61004 D X allotted, with internal arrangements specially adapted for the purposes of a venereal disease clinic. It may not be out of place in this report to describe this clinic and the principles on which it was designed. The St. Thomas's Hospital venereal disease clinic consists of two separate sections, male and female. The former is located in a hut, and the latter in the basement of block 8, adjoining the male clinic. In the same block are 20 beds for venereal disease in-patients. The hut devoted to the male clinic is 90 ft. by 40 ft., and at the end furthest from the entrance are two annexes, one for the laboratory, the other for W.C.s and lavatory. The main portion of the hut is arranged as shown on the plan, page 13, which may be explained by giving an account of the manner in which it is worked. On arrival each patient reports at the enquiry window of the clerk's office. He may be:— (a) A new patient. (b) An old patient attending for anti-syphilitic treatment. (c) An old patient suffering from gonorrhœa, and attending for examination by a medical officer. (d) A gonorrhœal case attending for irrigation. In the case of (a), the particulars are entered in the confidential register, the patient receives a ticket showing his identification number, a treatment card is made out for him, and he is directed to one of the examination cubicles shown on the left of the plan. The clerk knows to which cubicle to direct the patient, as there is an electric light indicator behind him which is operated by the bolts on the cubicle doors, and shows a number when a cubicle is occupied. The examination cubicle is reached by the patient via the corridor on the left of the plan, and no patient is permitted within the central space between the two rows of cubicles. On reaching the cubicle, the patient undresses sufficiently for a complete examination to be made, and is then examined by a medical officer. Each examination cubicle is closed by 7 ft. high partitions on three sides, and is open on the fourth side. On this side, as shown on the plan, is a counter 2 ft. 8 in. high and 1 ft. 4 in. broad, which is upholstered so as to serve as an examination couch if required. Access by the medical officer to the cubicle is obtained by lifting a flap in the counter. The fourth side can be closed by a curtain if desired. The furniture of each cubicle consists of— (i.) A small writing table on which are all stationery requirements. (ii.) An instrument table on which are all the instruments for taking specimens and for making an ordinary examination. (iii.) A double basin, portable wash hand stand with perchloride lotion above, in which to sterilise hands, and carbolic or lysol below for used instruments. (iv.) A rack holding four urine glasses. The cubicle equipment is supplemented by that for special examinations, and treatment, which is carried on trolleys standing in the central space of the clinic. This supplementary equipment is grouped according to its purpose. Thus there are:— (i.) A minor operation and dressings trolley, holding all the instruments, etc., required for dealing with a case of, e.g., bubo. (ii.) A gonorrhœa trolley containing all the instruments required for special examination of a case of gonorrhœa, including urethroscope and rheostat, the latter working from an electric wall-socket in a partition of each cubicle. (iii.) Mercurial injection, arsenobenzol and urine-testing trolleys. If a medical officer requires special instruments other than those which form the normal equipment of an examination cubicle, he calls up the appropriate trolley, which stands whilst in use outside the cubicle alongside the counter or examination couch. The result of these arrangements is that neither patient nor medical officer need leave the cubicle from beginning to end of the examination, except when the medical officer wishes to examine a microscopical specimen. This is done at the bench running down the centre of the clinic. Incidentally, it may be mentioned here that a partition, the top of which is 7 ft. above the floor, divides this work bench longitudinally and serves both to carry shelves and cupboards and as a screen preventing patients from seeing others in opposite cubicles. (b) In the case of patients attending for anti-syphilitic treatment, the routine is as follows:— (i.) Anti-syphilitic injections are given at set hours, though new cases are injected at once, (ii.) Each patient is first interviewed and examined in the doctor's room and receives a slip on which is written the dose to be injected. He is then sent to one of the examination cubicles, these being filled at the rate of five to each cubicle, (iii.) Each patient passes his urine. (iv.) All urines are tested by an orderly passing from cubicle to cubicle with a trolley carrying urine-testing apparatus. (v.) A medical officer follows with a trolley holding the arsenobenzol injection syringes and gives the injections. For this purpose the patient sits in a chair within the cubicle and lays his arm out over the counter conveniently for the medical officer standing outside the cubicle. (vi.) Another medical officer follows with the mercurial trolley. (vii.) The cubicles empty in turn as the trolleys proceed along the line of cubicles, so that by the time the last cubicle is finished the first has filled with a fresh batch of patients, and so on until all have been treated. (c) Patients attending for treatment for gonorrhœa by the medical officer may require only a minor examination, in which case they are sent into the room behind the doctor's room; or a more detailed examination, which is carried out in the room behind the office. (d) Patients attending for irrigation receive a pink ticket on which are written the details of the irrigation required. The patient takes his pink ticket to one of the irrigation cubicles shown on the xi right of the plan, and the orderly working at the bench in the centre of the clinic supplies solution, nozzle and, if required, assistance for the irrigation ordered. Each cubicle is fitted with hot and cold water, so that, for most types of irrigation, the orderly need bring to the cubicle only the concentrated solution and the nozzle. It will be seen that the main principles of the clinic are that:— (i.) The staff works on internal lines and has ready access to every part of the clinic. Thus anyone standing at the end of the central bench can see the greater part of the clinic, and the staff is almost entirely within view. Also the distance to be walked by any member of the staff is comparatively small, and his passage is unimpeded by any door. (ii.) The patients are examined and treated in reasonable privacy without thereby interfering with the working of the clinic. This and other advantages are secured by making the patients use the corridors on the outside and never permitting them to enter the central, working space. It is easy, also, with this arrangement to give demonstrations to students, since the patient lies on the counter and most of the class stand in the central space. It may be added that, although the average male attendances per day are now over 200, the small waiting room is never more than half full and only approaches that state when patients are congregating for anti-syphilitic injections. This is because the clinic is open all day, and it is possible to relieve the normal evening congestion by getting many patients to attend for special examinations during slack hours. The female clinic is worked on much the same principles as the male. New patients interview a lady almoner, who obtains social particulars which are often of great value. Thus girls in distress may be provided for in the hostel or elsewhere, and often also the lady almoner is able to get the patient to send husband and children for treatment, so that one case becomes the means of securing for treatment a number of infected members of the community who might otherwise escape notice. In the main part of the clinic are five examination cubicles, each fitted with an examination chair and other appliances on the complete equipment principle observed in the case of the male cubicles. At the back of each cubicle is a small dressing space screened off by a curtain. The patients enter the cubicles from the corridor, as in the case of the male clinic, and the cubicles all open on to a working space which is sacred to the staff on the same principle as in the male clinic. In addition to the rooms mentioned, are a doctor's room, nurses' room, sterilising room, lavatories and W.C.s. Experience of the clinic arranged as described above has proved that the principle is correct. The work proceeds without rush, and patients are not kept waiting unduly long, while time is given for the individual examination and treatment which are essential to the efficient management of venereal diseases. The laboratory attached to the male department makes the clinic a complete unit. It would be difficult to over-estimate the advantages derived from the proximity of the laboratory, which it must be remembered, however, is not employed for routine microscopical examinations. These are carried out in the clinic itself. Days and hours of clinics.—The total number of clinics in London is 28, and the total number of sessions (morning, afternoon, and evening) provided at 27 of these clinics is well over 200 per week, of which more than one-half begin at or after 5 p.m. The remaining clinic, viz., St. Thomas's Hospital, is open for treatment from 8 a.m. to 10 p.m. daily (except Sundays). If credit be taken for the work done at this clinic at the rate of say, four sessions daily, the total number of sessions in all the hospitals included in the London scheme would closely approximate to 250 per week. It is noteworthy that only 17 of the 27 clinics are open on Saturdays, and only one of the 17 provides an evening session on this day. There are no clinics available for any form of treatment on Sundays. The question as to whether the days and hours of the clinics are conveniently arranged for the various classes of patients, and sufficiently numerous for the demands made upon them at present, naturally required very careful consideration, and many enquiries were made in a variety of directions upon this subject. With regard to the provision made for diagnosis and treatment, it would appear that the facilities available on Saturdays for these purposes are inadequate and that considerable extra provision should be made on this day as soon as possible. The provision of clinics on Sundays for diagnosis and treatment of new cases is not advocated at present, but a recommendation is made later as to the use of the clinics on Sundays, which it is believed will be found to be of great practical value. There is unquestionably definite evidence that certain of the clinics suffer from overcrowding, and that the large number of patients in attendance per session must tend to inefficient treatment. The medical officer of a venereal clinic is in just the same position as any other medical officer of the staff of a hospital, in that, however competent he or she may be, a high standard of efficiency of work can be attained, and, above all other things, maintained, only if his time, thought and skill, are concentrated upon a limited number of patients. The moment he succumbs to the temptation of working beyond his capacity is the moment when the efficiency of the work of the clinic begins steadily to deteriorate. It is impossible to over-estimate the importance of a high standard of efficiency in connection with the treatment of venereal disease. Too much stress cannot be laid upon the extent to which the efficiency of the work of the clinic is dependent, not only on the professional ability of the medical officer in charge of the work, but also upon such factors as well designed and conveniently arranged premises, adequate assistance (medical, nursing, and male orderlies), good organisation, and a steady dribble of patients spread over the several hours of a session rather than an overwhelming rush within a shorter period of time. It would seem somewhat trivial to lay so much 61c04 u 2 xii xiii emphasis upon such elementary principles were it not that detailed enquiry into the work of the venereal disease clinics in London has shown over and over again (as in the survey of tuberculosis dispensaries), the immense difference which well-designed premises, good organisation, and the determination to maintain a high standard of efficiency makes in the success of the work, and how gravely efficiency suffers by the attendance at each session of an excessive number of patients. The very nature of the diseases dealt with in these clinics must be the justification for dwelling so emphatically upon the absolute necessity of nothing less than 100 per cent. efficiency. Anything less is in truth not only largely wasted effort and wasted money, but, most important of all, the loss of perhaps the best opportunity for the prevention of the spread of venereal disease. Apart from its harmful effects upon the efficiency of the work, overcrowding also has other serious disadvantages. Thus complaints have not infrequently been made that large numbers necessarily entail long periods of waiting for some at least of the patients, and it is believed that this is a considerable factor in preventing patients from attending regularly, especially if their attendance involves in addition a long journey. Moreover, it is stated that, especially amongst women patients, an aggregation of large numbers of waiting patients is often associated with a lack of discipline and decorum in the waiting room, resulting in foul language, filthy stories, and other forms of offensive conduct which are resented so greatly by many patients that they discontinue their attendance. For these and many other reasons, it is clear that every possible effort should at once be made to prevent the overcrowding, which is already obvious in certain of the venereal disease clinics. There are several methods which might be suggested for overcoming these difficulties. (1) Increase in the number of clinics. (2) Increase in the number of sessions. (3) Increase in the number of hours daily when treatment is available. The last method is the one which has been adopted at St. Thomas's Hospital, and is undoubtedly the best of all for meeting the difficulties indicated above and certain other matters in need of improvement which will be referred to later. The throwing open of the clinic to all those who choose to avail themselves of the facilities at any hour of the day, say, e.g., from 8 a.m. to 10 p.m., has the following advantages:— (1) It enables the patients to attend at the times most convenient to themselves. (2) It affords the medical staff of the clinic every opportunity for systematic examination and carefully considered treatment of all the patients—the essential factors of a high standard of efficiency. (3) It avoids overcrowding and at once does away with all complaints in regard to long periods of waiting, offensive remarks and conduct of certain classes of patients who must inevitably frequent venereal disease clinics. On the other hand, it is fully recognised that all the venereal disease clinics in London cannot at once provide "all day" facilities for treatment, etc. In certain instances, indeed it would be true to say that the additional expenditure involved in the provision of such facilities would not be justifiable at present. But substantial increase in the number of hours per week during which the clinics are open would be justifiable, and the provision of the facilities for a longer period daily would greatly increase the efficiency of treatment and, at the same time, largely do away with certain of the disadvantages already referred to. The other alternative would be to increase the number of sessions per week at each of the clinics without increasing the number of hours per session during which the clinics are open. The decision as to which of these methods would be the most effective for meeting the particular circumstances and conditions of each clinic, is clearly a matter for consideration and consultation with the hospital staff of each venereal disease clinic. It is perhaps worthy of note at this point that in London the minimum number of sessions per clinic per week recognised by the Ministry of Health and the Council for approval is three, and it is certainly an open question whether the minimum should not be raised immediately to one session daily of not less than three hours' duration, according to the special circumstances of each clinic. In this connection it will be convenient to draw attention to the fact that the facilities available at the clinics for intermediate treatment, although much improved within recent months, are still very far from satisfactory. It may be taken as an axiom that no venereal disease clinic can be considered to be efficient unless facilities are provided for daily irrigations of males and for such intermediate treatment for females as can properly be applied by nurses. There is no need to dilate upon the immense value of such facilities, as they are so well known and so fully realised by everyone who has any large experience of the treatment of venereal disease. It should be borne in mind that the supervision of intermediate treatment can largely be left in the hands of trained male orderlies and female nurses and that the attendance of medical staff for a large number of hours daily for this purpose only is not necessary. It is desirable, however, to emphasise again the importance of securing well trained male orderlies and female nurses for this work. In connection with the discussion of the facilities available at the various clinics for diagnosis and treatment, it was pointed out above that none of the clinics are open for this purpose on Sundays. An exception should be made in the case of intermediate treatment. As already shown, provision for this purpose is a factor of great importance in successful treatment, and the value of the work done in the venereal disease clinics would be greatly increased if facilities for this purpose were provided on Sundays during certain definite hours. In some clinics it is found convenient to set aside certain sessions weekly for the administration by injection of Salvarsan substitutes and other forms of special treatment, and again in a still more limited number of instances, certain sessions or portions of sessions are devoted to the examination of special cases, e.g., cases of chronic gonorrhœa. There is no objection to such arrangements. On the contrary, under present circumstances it may be a practice to be commended, but xiv where the growth of the work of a clinic is such as to demand such special arrangements there probably exist simultaneously other circumstances indicating that the work of the clinic has reached what might be termed its " breaking point," and that the best way to deal with these is in the manner already indicated above, i.e., by opening it daily for a longer number of hours or by increasing the number of fixed sessions per week, and by attending to various other matters concerned with the maintenance of a high standard of efficiency, such as adequate and competent medical nursing, and male orderly staff, properly designed premises and good organisation. Before concluding this section, reference must be made to the practice which exists in a number of clinics of seeing cases of venereal disease at the same time, and during the same hours as patients suffering from other diseases, such as diseases of the skin, genito-urinary cases, gynaecological cases, etc. It is claimed for this practice that, by not restricting the work of the session to cases suffering, or suspected to be suffering, from venereal disease, the attendance is secured of a number of patients suffering from venereal disease who would otherwise neglect to apply for treatment; there is, in fact, an element of "camouflage," which has a real practical value. There are no grounds at present to dissent from this view, which is strongly held by some, but the important question is whether such venereal disease patients do in fact receive adequate treatment in clinics of this description. In certain cases it is believed that patients do not receive adequate treatment under these circumstances, and would recommend that this practice should be allowed only where there is satisfactory evidence that the physician or surgeon in charge of the composite department is competent to give such adequate treatment, and that he or she shall be specially approved for this purpose. There is no desire to interfere in any way with the physician or surgeon who wishes to retain cases of venereal disease for treatment under his or her care, whatever the nature of the particular department may be, but, as a rule, where grants in aid out of public funds are made to hospitals for the specific purpose of treating cases of venereal disease, only such patients should be paid for as are referred to and taken over by the clinic specially set up for this purpose. The staff.—Before proceeding to the consideration of what is probably one of the most important, if not the most important, factor in the efficiency of the venereal disease clinic, it would be well to bear in mind that the circumstances under which the scheme for the diagnosis and treatment of venereal disease was launched were such as to militate seriously against the opportunity of securing highly competent as well as adequate staff, whether medical or nursing, male or female. In the middle of 1916, and for more than two years thereafter, we were engaged in the Great War, and it is only necessary to mention this fact to enable everyone to appreciate the immense difficulties which had to be overcome in securing competent and adequate staff for the 22 clinics which came into operation on 1st January, 1917. These difficulties became even greater throughout that year, and in 1918. In many instances medical and nursing staff engaged in carrying out the work of the clinic were called away to war service, often at a very short notice, and the constantly increasing difficulty in maintaining the clinics in operation, not only owing to the lack of staff, but also to the consistent growth of the work from the day of opening onwards, needs only to be mentioned in order to be fully appreciated. It should also be remembered that, prior to the year 1917, only a very limited number of the London hospitals had ever undertaken the provision of an organised department for the diagnosis and treatment of venereal disease. It will be easy, therefore, to realise that those who were responsible for the provision of an efficient scheme were faced, not only at its inception, but also for a long time thereafter, with a combination of adverse circumstances which might well have wrecked such a vast undertaking at any time between 1st January, 1917, and 31st December, 1918. In the early part of 1919, some slight relief to the strain became perceptible by the gradual demobilisation of various members of hospital staff who had joined the Royal Army Medical Corps for war service, some of whom had special knowledge and experience of the treatment of venereal disease. In addition to these, a certain number of demobilised medical practitioners who had gained considerable experience of venereal disease during war service came forward and desired to take part in the work of the clinics. On the other hand, the circumstances of demobilisation, for various reasons which need not be detailed here, threw a large additional amount of work upon the clinics, and the number of new patients and the attendances of new and old patients showed a great increase throughout the year as compared with 1917 and 1918. So far as it has been possible to form an estimate, the growth in the attendances of new and old patients will also show a considerable increase in the year 1920, as compared with the year 1919. Bearing these facts in mind, the question we have to put to ourselves to-day is this: Can it be said that satisfactory provision is made for medical, nursing, and male orderly staff at the London venereal clinics at the end of the year 1920 ? After giving most careful consideration to all the facts resulting from the special enquiries made during this year, one cannot but come to the conclusion that the position, more particularly in regard to the medical staff, is not by any means satisfactory, and this is all the more to be regretted, because, in the case of the County of London, one ought not to be forced to this conclusion. The grounds for these conclusions are as follows:— In the first place, there has been an unfortunate tendency on the part of some of the hospitals to regard the position of medical officer or officers in charge of the venereal diseases clinic as the rightful possession of one or more members of the honorary staff, without any regard to the dominant consideration that ability to do the work properly and to be able to give up the necessary time to the work, should be the foremost considerations. In one instance, for example, the practice of the hospital is to change the staff of the clinic annually. It is clear that in such a case the clinic cannot possibly attain a high degree of efficiency, and such an arrangement should not be permitted to continue. In other instances, the practice is to appoint one member of the honorary staff xv as the chief medical officer of the clinic, and to appoint certain junior and insufficiently experienced medical officers as assistants. One practical effect of this arrangement is found not infrequently to be that the head of the clinic attends only as an exceptional event, and then only for a short period of time, and the real work of the clinic devolves upon an assistant who is not sufficiently competent to undertake the full responsibility of the work. It is true that these cases only obtain in a minority of the hospitals, and that in the majority the standard of the staff engaged in the work is, on the whole, a high one. Indeed, in a few. instances, the men undertaking the work and actually seeing it through are of international standing and reputation. But the fact remains that there is considerable scope for the introduction of a much higher standard of competence in some of the clinics, and, above all, men and women who, in addition to possessing the ability to do the work, are also able and willing to give up the necessary time. The time has undoubtedly now come not only to call for the appointment of men and women whose skill, knowledge and experience in the diagnosis and treatment of venereal disease is beyond all question, but also to insist that those appointed should be able and willing to devote the time and attention which is really necessary for the efficient performance of the work of the clinic. It is believed that it will be found necessary, except perhaps in a few special instances, to make a definite departure from the established tradition and practice of many of the London hospitals, and, instead of regarding the venereal diseases as sub-departments of dermatology, genito-urinary surgery, and gynaecology, to appreciate the fact that the time has come when these diseases must be regarded as the province of a specialist department to be known as the venereal diseases department. The work must be carried on in a portion of the hospital which must be just as carefully designed for its special needs as the throat department, the eye department, the radiological department, or, indeed, any other specialist department of the hospital. Moreover, the staff, whether medical, nursing or male orderly, must be specially trained for the work of the department, and the medical officer in charge must be given the same rights and privileges and status on the. staff of the hospital as the honorary physicians and surgeons and heads of specialist departments. Until these steps are taken, the work of venereal disease clinics in the several London hospitals will continue to suffer. It should also be remembered that the present conditions react unfairly upon the nursing and orderly staff in the same way as they do upon the medical staff, and for similar reasons. These are considerations which must also be taken seriously into account in determining the policy to be adopted. In this connection, it is only right to point out that the work is paid for out of public funds, and, therefore, public authorities, responsible as they are to the taxpayer and ratepayer for the proper use of grants in aid, are fully entitled to take into consideration any factors which may militate against securing the high standard of efficiency which is rightly and justly expected from the hospitals undertaking the work, and which, indeed, must be secured in any measures taken for dealing with diseases of such grave national importance. The provision of teaching facilities.—Each hospital included in the scheme is bound by the terms of the agreement to provide facilities for the instruction of medical practitioners and medical students free of charge. The actual provision made varies from very little, if any, in some of the clinics, to a considerable organisation for the purpose in a few of them. Naturally the latter are usually hospitals with medical schools attached. There is no doubt that broadly speaking the medical practitioner and the medical student take very little advantage of the facilities available, despite the fact that some of the clinics have made special efforts from time to time to attract their attendance. The usual explanation given is that neither the medical practitioner nor the student have time to devote to the purpose. It is frequently stated that both practitioners and students turned up occasionally, perhaps two or three times, and then disappeared. The practitioners are too busy and the medical student complains that the medical curriculum is already so overloaded, he cannot "take on" venereal disease, beyond making a passing acquaintance with some of its manifestations and treatment as he threads his way through a maze of departments to his "Final" examination. In these circumstances, it is very doubtful whether any. useful purpose can be served at present by stimulating the staff of venereal disease clinics to provide any greater facilities for the busy practitioner or the medical student. There would appear to be greater prospects of doing permanently useful work by concentrating upon those medical men and women who are willing and anxious to work in the clinics for limited periods of time, either as "paid clinical assistants," or postgraduate students, and therefore, although no difficulty should be placed in the way of either the busy general practitioner or the medical student, attending the venereal disease clinics when he can, the best course to adopt is to cater for those who will give up some weeks or months to the continuous study of the diagnosis and treatment of venereal disease. Payment of the staff (medical) of the clinic.—Attention has been drawn from time to time to the somewhat chaotic conditions which prevail with regard to payment of the medical staff of venereal disease clinics, whether at the treatment centre or the laboratory. The remuneration of the staff is found to vary from nil up to four guineas per session, where payment is per session, or a salary of £600 to £800 per annum as a whole time medical officer at St. Thomas's Hospital (with right to private practice, so long as this does not interfere with hospital clinic duties). The London County Council and the other local authorities participating in the scheme decided at the inception of the scheme to make their payments to the hospitals by block grant annually, and not to interfere in any way with the discretion of the board of the hospital in regard to the payment of the staff undertaking the work, although it should be clearly understood that, in calculating the amount of the grant in aid to each hospital, it was assumed that some payment would be made to the medical as well as other staff, unless, as in certain definite cases, it was intimated beforehand that the medical staff would not accept payment. It should also be stated that, in a few instances where requested, the xiv exact amount of the grant in aid available for the payment of the staff was made known to the boards of the hospitals by the councils of the participating authorities. It must be said, however, that the arrangements as a whole for this purpose have been devoid of any organised principles and have been allowed to drift on, mainly because the councils concerned have been anxious not to interfere between the hospital board and the medical staff, in so delicate a matter as remuneration, unless asked to do so by both parties. It appears to be open to question whether the present arrangements should be allowed to continue. The position is unsatisfactory, both to the boards of the hospitals and their medical staffs, and not less so, in some respects to the public authorities concerned with the work. From enquiries made it is believed that the matter is one which can quite easily be adjusted, and that the fixing of a scale of remuneration would be warmly welcomed by the hospital boards and the medical staff engaged in the work, both in the treatment centre and in the laboratories. It may be observed here that the British Medical Association issued an expression of opinion on this subject some years ago, and stated, inter alia, that they considered a fee of three guineas per session was a reasonable payment for the chief officer of the clinic, and some of the hospital clinics have adopted the scale suggested by this body. Treatment of gonorrhoea.—The most striking feature of this section is the lack of facilities for the intermediate treatment of gonorrhoea in both males and females. This must militate very strongly against the success of any measures adopted for the treatment of this very prevalent complaint. It is realised how difficult it is to induce patients to attend daily, and this is a strong argument for the establishment of facilities for daily intermediate treatment which will involve a minimum inconvenience and loss of time to the patient. In many clinics a lack of system was noted in the management of cases of chronic gonorrhoea. These are not subjected at periodical intervals to a thorough examination, but only to a section of that examination and that at uncertain intervals. For example, on one day the prostate may be examined, on another, some weeks later, the urethroscope may be used and so on, so that at no time is a complete picture of the patient's condition obtained. The result of this system, or rather lack of system, is that patients may be allowed to drift on for weeks under a haphazard form of treatment. No doubt this is due in the main to the unsatisfactory conditions under which the work is carried on, especially the overcrowding and the inconvenient arrangement of premises. Treatment of syphilis.—While there is great uniformity in the employment of "914" and mercury in the routine treatment of syphilis, the greatest divergence of practice was found in the matter of the total amount administered, which varied from six injections of "914" to thirty or more. Those who give the smaller amounts mentioned usually stop arsenobenzol when the Wassermann reaction becomes negative and may or may not follow up this course with mercurial treatment by mouth, or by regular courses of injections (generally the former) for one or two years. In such cases the arsenobenzol treatment is usually resumed if the Wassermann reaction returns to positive. Those who give large total amounts of arsenobenzol and mercury in successive courses usually do so regardless of the Wassermann test, proceeding on the assumption that the attainment of a negative Wassermann reaction does not necessarily herald the death of the last syphilitic organism, a fact which everyone will admit. There is much that is unsatisfactory in this diversity of practice, and it is earnestly to be desired that a closer agreement than prevails at present could obtain in the routine practice, with regard, especially, to early cases of syphilis. Whilst not venturing to lay down a course which should be carried out in all cases, since this is a matter for responsible clinicians, one cannot help feeling that in some cases there is a lack of consistency in the principles adopted. For instance, assuming that everyone admits that the first negative Wassermann reaction does not necessarily herald the cure, and that this is the reason for the continuation treatment with mercury alone, which is most commonly adopted. One cannot understand why, in a treatment which continues on the assumption that syphilitic organisms are still alive in the patient, the more powerful arsenobenzol remedies are not employed also. Alternatively, assuming that the clinician believes arsenobenzol to be only a symptomatic remedy, useful only for dissipation of skin and mucous membrane lesions (an opinion which has been expressed to us), it is difficult to discover the reason for a resumption of arsenobenzol by the same clinician when the only sign of a relapse is not a skin or mucous membrane lesion, but simply a positive Wassermann reaction. Again, some clinicians consider that it is unsafe to employ arsenobenzol in continuation courses, but again employ it if the Wassermann reaction returns to positive or clinical symptoms reappear. In mentioning the above difficulties reference is being made particularly to the practice in regard to early cases of syphilis, and it is felt that a closer agreement on principles than obtains at present is most desirable. In some hospitals there is almost as great a divergence of practice amongst the various members of the staff as amongst all the clinics, and here it seems to us that it would be a simple thing for the staff engaged in this work to meet together and thresh out the matter in discussion. It is noteworthy that arsenobenzol treatment does not now make the demand on beds which was formerly considered necessary. This is due to the use of "914," which is followed by immediate reaction in such a slight proportion of cases that hardly any patients need remain for rest after the injection. Recording of toxic results of arsenobenzol treatment.—Toxic results following arsenobenzol treatment appear to have been very rare in the London clinics. This probably accounts for the fact that, in many clinics, the existence of a form, V.20, on which such results are to be reported to the Ministry of Health was unknown. Attention is drawn to this fact here, as the rendering of this report enables a proper estimate of the proportion of side-effects to be formed., and it also assists those whose duty it is to control the quality of arsenobenzol compounds issued for sale to relate the toxic effects following injections of different batches of the products to the results of animal tests applied before they were xvii passed for sale. In this connection the importance of keeping a record of the batch number of the remedy given to each patient is highly important. This does not seem to be realised in many clinics where the batch number is never recorded. Standards of cure.—While in most clinics the medical officers stated they required satisfaction of a fair number of stringent tests before discharging a patient under Item 5 of the annual report ("discharged after completion of treatment and observation"), enquiries left, in the majority of cases, the impression that medical officers had made up the standard they required on the occasion of our inspection, and that the practice was not clearly defined. It appears desirable that medical officers of clinics should come to an agreement in regard to the tests which should be applied to a patient before discharging under Item 5 of the annual report, and note definitely on the case record the results of these tests. At present in most cases the decision is left to someone long after the patient has gone, and it does not appear to us that the records of most clinics under Items 3b and 5 are of any value. In private practice a medical adviser is asked to give a definite opinion on these questions, and will not do so if he is wise until he has applied certain definite tests. It does not seem too much to ask medical officers to apply just as stringent tests and to record their opinions just as definitely in the case of public as of private patients. In-patient accommodation.—Under the agreements between the participating authorities and the hospitals every venereal disease clinic must have at its disposal at least one male and one female bed for in-patient treatment. In the great majority of hospitals the in-patient accommodation for this purpose is far in excess of the minimum requirement, and the total accommodation for the 28 venereal disease clinics is not less than 250 beds. In certain hospitals it is stated that there is still an insufficient provision made for the in-patient treatment of cases of complicated gonorrhoea. It would be desirable to draw the attention of the hospitals concerned to this fact. Patients ceasing to attend before completion of treatment.—The statistics of new and old patients in attendance at the venereal disease clinics indicate that a very large percentage of the patients fail to complete the course of treatment. The average for the whole of the London clinics cannot be put at less than 30 per cent., and is probably higher. So serious a defect in the efficiency of the clinics has naturally called for very careful and detailed enquiry. The investigations on this point have not been confined to those institutions where the figures are exceptionally unsatisfactory, but the practice has been to conduct special enquiries into the matter at each one of the clinics. Although irregular attendance is a constant feature, actual disappearance of the patients at an early stage of treatment, whilst still in an acutely infectious state, does not make up a large proportion of those who fail to complete treatment. The really serious difficulty arises from the fact that so many patients, when they have got over the initial stages of the disease, think that it is unnecessary to continue attendance until the medical officer of the clinic discharges them. The practical outcome of this is that the patient remains a carrier of infection, and from the Public Health point of view the money is wasted. Even in those cases where the chances of infection have been considerably diminished the fact remains that late sequelae of the disease are not avoided. In the case of syphilis, this may mean that the subsequent development of conditions, such as locomotor ataxia, general paralysis of the insane, etc., which often result in the patients becoming inmates of public institutions, and consequently a charge upon the public. The following are a few of the many reasons given to us for patients failing to complete the course of treatment:— (1) The incurable optimism of patients who judge themselves cured as soon as their symptoms have markedly abated. (2) The difficulty of accounting for their repeated absences from work or from their homes. (3) Engagement in seafaring occupations which naturally involve in some instances long absences from London. Similarly in the cases of commercial travellers, race-meeting followers, etc. (4) Many patients visit the clinics and then leave or go on to other clinics or seek treatment elsewhere for a variety of trifling reasons, e.g., "Not satisfied with the treatment"—"Dislike of doctor or nurse"—"Hurt by injection," etc., etc. (5) Carelessness and ignorance on the part of patients are still, unfortunately, not infrequent causes. The above reasons account for a number of patients who fail to complete their course of treatment, but the overcrowding of the clinics, where it occurs, accompanied as it must be with long periods of waiting, and insufficient concentration upon the patient, is also a factor of great importance. It is obvious that in those cases where the medical officer of the clinic is unable, owing to great pressure of work, to give to his work the consideration and attention which it deserves and requires, there must arise in the mind of the patient the feeling that he is not, after all, suffering from a very serious disease. Moreover, in such circumstances, the medical officer is unable sufficiently to impress upon the mind of the patient the immense importance of regular attendance at the clinic and the absolute necessity for such attendance to be continued until informed that he may now safely discontinue attendance. The usual practice is to write a patient off the list after an absence of three months or more. In some of the clinics an effort has been made to induce a patient to return to the clinic for examination and treatment when it has been observed that attendance has been in default for some weeks. For this purpose a very carefully drafted non-committal letter is sent to the address given by the patient. In the vast majority of cases the letter is ultimately returned from the "Dead Letter" office owing to 61004 x viii the patient having given a false name or address or both, and although a few of the clinics think that such letters have been useful, the majority are clearly of opinion that, on the whole, the system of following-up letters is a failure, and may even have a prejudicial effect on the attendance of the patients. It would appear, therefore, that the most effective steps which can be taken to reduce the large percentage of failures to complete treatment are—(a) for the medical officer of the clinic to do everything he possibly can during his interview with the patient to impress upon him the seriousness of the disease and the absolute necessity for regular attendance until discharged; (b) to study, as far as possible, in every way, the convenience of the patients in regard to facilities for attendance by avoiding overcrowding, long periods of waiting, and inadequate attention during examination and treatment; and (c) by the use of prominent notices in the waiting rooms; leaflets to the patients, etc., indicating the serious nature of the venereal disease. These measures are of particular importance during the period when the patient, his symptoms and discomfort having abated, has ceased to feel in himself the necessity of regularly attending the clinic. It is at this time that powerful influences, such as loss of work or pleasure, begin to operate against regularity. It cannot be repeated too emphatically therefore that the battle for the public health has not been won until a patient has been rendered non-infective. The lady almoner and the nursing staff can be of great assistance to the medical officer of the clinic in securing the regular attendance of women patients. Attendance at more than one venereal disease clinic.—On several occasions during the last few years it has been ascertained that a patient may be in attendance at more than one venereal disease clinic. On one occasion a patient was found in the out-patient department of a venereal disease clinic who was actually at the same time an in-patient in the venereal disease ward of another hospital. Upon enquiry, it was found that this patient was allowed out on two afternoons per week, and that he utilised his time to put in attendances at another clinic. Further enquiry revealed the fact that this was by no means an uncommon practice among the in-patients of this hospital. The seriousness of such a practice is not confined merely to the question of whether there are any grounds for complaint, such as were made by the patient in this case, viz., that "he was not satisfied that he was getting proper treatment." The obvious danger to be borne in mind is one which arises where Salvarsan substitutes are being used. In this connection it may also be mentioned that it is a well-known practice for patients suffering from venereal disease to move about from one clinic to another without completing the course of treatment at any one clinic. For obvious reasons it is difficult to get hold of these patients in order to ascertain their reasons. In other cases where we have been able to get any information, the patients usually give some quite trivial reasons, such as, not liking "the new doctor," or "new nurse," or that "the injections hurt." The reasons are no doubt trivial in most cases, but there are often others, referred to elsewhere, such as overcrowding, resulting in long periods of waiting. Whatever the cause, however, of this practice, the lack of knowledge as to previous treatment is a serious handicap to the medical officer of the clinic, and may be a misfortune in more ways than one to the patient. It is fully realised that whatever steps are taken, even the most drastic, there will always be a certain number of patients who will drift from one clinic to another, and perhaps attend two at the same time, just as everyone knows of patients amongst their own friends who will do exactly the same thing with their own private doctors, consulting and general. These facts, however, do not absolve us from doing everything in our power to warn venereal disease patients of the dangers they are incurring by such practices, and therefore it is recommended that the walls of the waiting rooms in venereal disease clinics should be well posted with warning notices in regard to these matters. Statistical returns.—In very many cases the system of keeping records for statistical purposes is distinctly bad, and the records unreliable in consequence. The annual return required by the Ministry of Health contains information mainly as to the turnover of patients, their attendance, and their final disposal. It is in regard to the last section that the returns are unreliable, since we found in so many instances that medical officers had not interested themselves at all in the matter. They had left the decision as to whether a patient had ceased attendance before completion of treatment, or after satisfaction of tests of cure, to a clerk, who, obviously, could not be competent to judge the question. In a number of instances it was found that medical officers were totally ignorant of what it was they were asked to decide upon for the purposes of the annual return, and many have not even troubled to read, much less understand, its headings. While everyone is desirous not to load up medical officers with an unnecessary amount of clerical labour, returns are obviously necessary, and they require decisions as to results of treatment which, if they are to be reliable, must be made by medical officers and not by clerks. It does not therefore seem to be too much to require that medical officers should periodically go over the case records and indicate, by some symbol, on each of those relating to patients who have ceased attendance, under which category the patient should be classed. The rest can be done by a clerk. Supply of free Salvarsan substitutes.—Under the regulations made by the late Local Government Board in 1916, it will be remembered that the councils of the counties and county boroughs in England and Wales and the Common Council of the City of London, were required to supply medical practitioners with Salvarsan or its substitutes for the treatment of venereal disease. At a later date the Board issued further regulations defining the conditions upon which medical practitioners were entitled to receive Salvarsan or its substitutes from the local authorities. From these regulations it will be seen that it was necessary for the medical practitioner to be "approved." It will also be remembered that the Council was fortunate in being able to make arrangements with the hospitals, where venereal disease clinics were situated, to act on their behalf as distributing agencies for this purpose. Mention should also be made of the fact that the Medical staff of Poor Law infirmaries xix are entitled to obtain these drugs at the Council's expense for the treatment of Poor Law patients, and that they represent a considerable proportion of the annual cost. In view of the fact that a Poor Law infirmary may become an approved centre for the treatment of cases of venereal disease, and that in London seven such infirmaries have been approved for this purpose by the Ministry of Health and receive grants, it is not quite clear why they should not undertake the supply of their own Salvarsan substitutes instead of applying for them to the hospitals under the scheme. It is recommended therefore that where a Poor Law infirmary has been approved by the Ministry of Health as a centre for the treatment of venereal disease, they should also make their own arrangements for the supply of such Salvarsan substitutes as are required for the treatment of their own patients. Approved practitioners.- In a circular dated 29th August, 1916, the Local Government Board expressed the opinion that Salvarsan or its approved substitutes should be supplied free, for the purpose of intravenous administration to patients, to all registered medical practitioners who could produce satisfactory evidence of training or experience in the administration of these drugs. To comply with this requirement, the Board suggested that applicants for inclusion on the free list should possess one or other of the following qualifications:— (i.) Holds a certificate of having satisfactorily fulfilled the duties of clinical assistant in a hospital department recognised by the Local Government Board in connection with a local authority's scheme for the diagnosis and treatment of venereal diseases in their communicable stages. (ii.) Holds a certificate of satisfactory attendance at a course of instruction in the diagnosis and treatment of venereal diseases (including intravenous medication), in such a hospital department, or in a recognised medical school or post graduate college. (iii.) Is or has been within the last five years a member of the permanent staff of a hospital managed by a Committee, and containing not less than 50 beds. (iv.) Produces satisfactory evidence, other than that indicated in the foregoing paragraphs, that he has had adequate experience in the administration of these drugs by intra-venous injection. Evidence of having held an appointment or attended a course of instruction in a military hospital, for the treatment of these diseases, recognised by the Army Council, will be regarded as complying with the Local Government Board's requirements. The number of medical practitioners in the County of London placed on the list, after complying with the above requirements, during the year 1917 was 108, by the end of 1918 this number had increased to 178, and by December, 1919, to 240. The cost of the drugs supplied has been £510 in 1917, £1,356 in 1918, £2,200 in 1919. When a private medical practitioner in the London area desires to obtain a Salvarsan substitute free of charge for the treatment of a patient, he must (a) be on the approved list, (b) fill up form V2 and (c) write or send for the same to one of the hospitals at which a venereal disease clinic has been instituted under the London scheme. In view of the fact that all patients who are unable to afford to pay for treatment can obtain it free of charge at the venereal disease clinics, it has been suggested that a rule should be made that Salvarsan substitutes should not be supplied, free of charge, to a medical practitioner for the benefit of a patient who is well able to afford payment both for treatment and all drugs required. There is undoubtedly the further fact that in all cases it may not be known to the patient that the Salvarsan substitute has been obtained free of cost to the practitioner. It is therefore recommended that in all cases where medical practitioners apply for Salvarsan substitutes, free of charge, for the benefit of private patients they should be required to sign a form in the presence, and with the knowledge, of the patient, declaring that the patient is unable to pay the cost of the drug supplied. Laboratory facilities.—Generally speaking, the laboratory facilities provided for the London clinics are sufficient and they are freely employed. In some cases the pathologist attends to take his own specimens, but in most they are taken by the clinician. Most of the work consists in microscopical examination and Wassermann tests, and very little cultural or complement fixation work in gonorrhoea is carried out. With regard to microscopical examinations, it would appear that much more of this work should be carried out in the clinic itself than is done at present. Admittedly time is consumed and this may be precious during the rush of an evening clinic, but the advantages of an immediate examination are so great, particularly in securing an early diagnosis of syphilis, that it is often time very well spent. It appears also that much more cultural work might be carried out, with advantage. This is often stated to be impracticable because the pathologist cannot attend to take specimens just when they are required, but it is certain that, with a little training, the taking of cultural specimens could safely be entrusted to clinicians. It is notable that in no clinic are examinations made of the cerebro-spinal fluid as a routine measure. At present this cannot be expected to be carried out in view of the period which the patient must rest in bed after lumbar puncture. IV. Still Births. The following table gives the total number of still births notified in London during the years 1916 to 1919 exclusive. The fall in the numbers during 1918 and 1919 particularly is associated with the fall in the birth-rate consequent upon war conditions. The rise in the percentage of cases occurring in the practice of midwives is associated with the largely increased number of births attended by midwives. 61004 x 2 XX Still births. (a) Year. (b) Total number notified in London (including City). (c) Total number notified by midwives. (d) Percentage in midwives practice. Percentage of stillbirths or ordinary births. 1916 2,520 670 26.7 2.45 1917 1,972 551 28.0 2.45 1918 1,803 535 29.7 2.45 1919 2,067 686 33.2 2.50 The subject of still-births is referred to in this report because of the well-known fact that a considerable percentage of still-births is due to syphilis. The percentage is put at 25 per cent. by some authorities, and in the case of illegitimate births, at double that figure. Comparatively little attention has been paid in London to the importance of still-births in relation to syphilis, but, having regard to the truly remarkable results which have been achieved by the treatment of the pregnant syphilitic mother, the time has surely come for much greater activity in this direction. The Metropolitan Asylums Board and the Guardians of the City of London have carried on at Thavies Inn, since September, 1917, a hospital, equipped with 20 beds, for the treatment, as in-patients, of pregnant women suffering from venereal disease. All the patients come from various Metropolitan Poor Law authorities. Similar facilities are provided on a small scale under the Council's scheme at the Lock Hospital; the Royal Free Hospital and Hostel; Highbury Quadrant Hostel; and the hostel at 93, Grove Lane. Further accommodation of a similar character is needed, but the most urgent development should be in the direction of linking up the work of the maternity and child welfare centres, and the practices of midwives with the venereal disease clinics. There can be no doubt that many cases of still-birth take place where no attempt is made to ascertain whether syphilis is present. For this purpose the examination of the placenta (after-birth) and placental blood is one of the most valuable steps which can be taken, but without the co-operation of the midwife it is certain that this will be almost impossible. On the other hand, the co-operation of the midwife having been secured, it would become a comparatively easy matter, not only to conduct this examination in all suspicious cases, but also to secure the attendance of the mother at the clinic for treatment, if necessary. The Council, through the Education Committee, has for some years past periodically provided courses of instruction for practising midwives. As a rule, venereal disease forms the subject of at least one of these lectures, and we are of opinion, that by the medium of these courses of instruction, and the great influence wielded amongst practising midwives by the Council's inspectors of midwives, it would be possible to secure the examination of many of the suspicious specimens at the laboratories of the venereal disease clinics, and we recommend that steps should be taken as soon as possible for this purpose, and for the securing, through the agency of midwives, the attendance of infected mothers for treatment. V. Poor Law Infirmaries. Boards of guardians are entitled upon application to the Ministry of Health to obtain, under certain conditions, approval of their infirmaries as "treatment centres" under the Venereal Diseases Regulations, 1916. In London seven such infirmaries have been approved, with a total bed accommodation for this purpose of over 200 beds. Several of these infirmaries have been visited and conferences have been held with their medical superintendents with regard to the class of patients dealt with, the methods of treatment, etc., etc. Hiving regard, however, to the fact that such institutions do not come within the purview of the scheme, it was decided to make no observation thereon, but merely to place on record an appreciation of the courtesy of the medical superintendents in allowing their wards to be visited in order that some idea might be gained of the work carried on therein. VI. Publicity. In the circular by the medical officer of the late Local Government Board, which accompanied the Board's regulations, dated 12th July, 1916, the local authorities for carrying out these regulations were charged with the duty of:— (а) Informing all practitioners, within the administrative area, as to the facilities provided for laboratory diagnosis, for consultations respecting patients and treatment of patients at the clinics, and as to the method of utilising these facilities; (b) Making arrangements for informing midwives, the police, poor law authorities, prison doctors and chaplains, probation officers, clergymen, rescue workers, and all voluntary agencies concerned in the diminution of venereal diseases of the arrangements at the clinics with a view to securing co-operation in encouraging the attendance of patients. The Local Government Board circular also stated that any Council may make provision for giving instructional lectures and for the publication of information on questions of venereal diseases as the Council may think necessary or desirable. xxi With regard to medical practitioners, midwives and poor law authorities, the Council communicated all the information concerning the facilities for treatment, etc., direct by means of a circular letter enclosing copies of the scheme, etc. To the police and probation officers the same information was sent through the Chief Commissioner of the Police Service, and to prison doctors and chaplains by means of the Prison Commission. Information was also sent direct to the metropolitan borough councils, nursing associations, magistrates, the Central Midwives Board, the Midwives' Institute, maternity centres, hospitals and dispensaries not included in the scheme. The duty of disseminating the same information to all other agencies and individuals was delegated by the Council to the National Council for Combating Venereal Disease. The N.C.C.V.D. (National Council for Combating Venereal Disease) was indicated by the Royal Commission to be the most suitable body to supervise the production of literature for use as propaganda. For this purpose it appointed a Literature Committee, which included several exmembers of the Royal Commission. It also secured the voluntary services of a large number of medical men and women as speakers for the purpose of carrying on such a campaign, and it established training classes for lay men and women to undertake educational work on the social and preventive aspect of the question. The National Council also decided to carry on its work in close co-operation with the late Local Government Board and local authorities charged with the duty of providing facilities for treatment, etc., and secured the active support of the principal social and religious organisations. Early in the year 1917, the National Council decided to form a special branch to represent the areas of the local authorities participating in the "London scheme," to be known as the London and Home Counties branch, and the medical officers of health of these authorities were invited to become members of the executive committee of the branch. With regard to lectures and addresses, arrangements were also made for the payment of a grant-in-aid to the N.C.C.V.D. to enable them to carry out this work in the County of London. During the years 1917 and 1918 meetings were held in a number of the metropolitan boroughs, presided over by the mayors, at which addresses were delivered by speakers carefully chosen from the panel of lecturers provided by the N.C.C.V.D. These meetings were followed by the formation of a campaign in the boroughs concerned. Trade union branches, co-operative societies, friendly societies, factories, workshops, etc., were addressed at special meetings arranged to meet the convenience of the employees, and a great deal of attention was paid to munition workers in various parts of London. After consultation with the Education Committee, it was decided not to make any arrangements for special addresses on these subjects at elementary and secondary schools, training colleges and evening schools, but to include all information which seemed to be desirable in general health lectures. In the event, however, of any definite requests being made either by the students of training colleges or by a considerable number of teachers, such applications were to be considered on their merits. Finally, it should be noted that special posters giving full information of the days and hours of the venereal disease clinics at the various hospitals were displayed in the public lavatories and other suitable places. The arrangements for the dissemination of literature, notices in the press, the provision of lectures and addresses, etc., have continued since the inception of the scheme in January, 1917, with very little modification. The only notable exception has been the introduction of the "film." This method of propaganda was originally used to a considerable extent in the Canadian and United States Armies during the war, and more recently it has been introduced at cinema halls in this country. The N.C.C.V.D. applied to the Council for grants-in-aid for the purpose of providing speakers to explain the "films" and their application. At the same time the Ministry of Health was asked to express its approval of certain of the films for propagandist purposes. Strong representations having been made to the Council, both in its capacity as licensing authority for cinema halls and as the local authority under the Venereal Disease Regulations, as to the harmful effects which might result from the unrestricted exhibition of these films before unselected audiences, it became necessary, not only to draw up regulations with regard tc their use in such circumstances, but also to stipulate in definite terms the conditions upon which any grant-in-aid to the N.C.C.V.D. for addresses in connection therewith should be used. For these purposes consultations between the Theatres and Music Hall Committee and the Public Health Committee took place, and the Council on the 27th July, 1920, resolved as follows:— That, subject to the approval of the Minister of Health, the purposes for which the National Council for Combating Venereal Diseases (London and Home Counties Branch) is permitted, under the terms and conditions of the resolutions of 30th March and 18th May, 1920, to exercise until 31st March, 1921, certain powers in respect of publicity in connection with the Council's scheme for the diagnosis and treatment of venereal diseases, be enlarged so as to include introductory addresses at some commercial exhibitions of propaganda films; and that the exhibition of such films, whether addresses thereon be given or not, be allowed only on the following conditions— (i.) Licensees shall be required to notify the Council of their intention to display any such films: setting out their character, the times at which, and the conditions under which they will be shown and stating any recognised organisation by which they have been approved. (ii.) At the time of the display of any such films, notices of a specified size and style must be displayed at the entrance to the cinema, so that no person can enter the cinema without being made aware of the subject matter of the performance, and the name of the organisation by which it is approved. The same information must be given in all advertisements, notices, programmes, etc., relating to the performance. xxii (iii.) When any such film as herein mentioned is shown no other film may be used without special permission. (iv.) Nothing herein is to be taken to limit the Council's right to object to the display of any film or any part thereof, and to require the exclusion of persons of any age (or class) from premises on which any films of the above-mentioned character are shown. (v.) Children or young persons under the age of 18 years shall not be admitted to the display of such films. (vi.) As regards the public health or educational aspect of such films, such further conditions as may be prescribed by the Council on the recommendation of the Public Health Committee or the Education Committee. In connection with the future arrangements for publicity, we think it desirable that some of the money now voted for this purpose should be used by the Council itself for circulating valuable information at its disposal amongst voluntary societies concerned in hostel and rescue work generally, such as the Women Police, Police Court Missionaries, Young Men's Christian Association, Young Women's Christian Association, Church Army, Salvation Army, and other bodies interested either, directly or indirectly, in dealing with venereal diseases. GRANTS TO N.C.C.V.D. Year:— 1117 £300 for lectures. 1918 £300 for lectures. 1918 £2,000 for press campaign, 1919 £800 for lectures. 1919 £2,000 for press campaign 1920 £1,000 for lectures. 1920 £2,000 for press campaign VII. The Social Aspects of the Venereal Diseases Problem. Hostels.—In connection with the development of the venereal diseases scheme in London, reference has already been made to the institution of hostels for girls and young women in attendance at the clinics, and it has been pointed out that it was agreed to contribute a grant-in-aid to these hostels, on the grounds that they increased the efficiency of treatment and reduced the possibilities of the spread of infection. At the end of the year 1920 there were seven such hostels actually in operation, with a total accommodation of about 80 beds, and although, as must inevitably happen, some fluctuation occurs in the demand for accommodation, it may fairly be stated that, as a rule, the whole of the beds are more or less in constant occupation. Indeed, there is ample evidence to show that there is a real demand for more accommodation of a similar kind. All the hostels are managed by committees of voluntary workers, and the grant-in-aid represents about one-quarter of the total cost of maintenance. The whole of the original capital outlay is provided by funds raised by the voluntary committees, and the balance of the annual cost of maintenance is made up by weekly contributions from the inmates, and subscriptions and donations secured by the same committees. The actual all-in cost per bed per week is remarkably low, averaging from 25s. to 30s. per week (or rather less than half of the cost per week of a hospital bed). The staff usually consists of a matron (who may or may not be a trained nurse, and may or may not have some special experience of venereal disease), and a small domestic staff. The bulk of the domestic work is done by the patients themselves. A certain amount of attention is given to the moral and spiritual welfare of the inmates, but the hostel differs from the rescue home in that this is not the dominant characteristic of the life of the institution, though it is desired to emphasise the fact that this important consideration is by no means an insignificant feature. Too much importance cannot be attached to the opportunity afforded by a girl's prolonged residence in a hostel for the good influence exercised by a matron of the right type, and it is satisfactory to be able to place on record the opinion that in this respect, the good influences resulting from the kindness, sympathy, tactfulness, and, above all, motherliness of the matrons in charge, are obvious to any one who takes the trouble to visit these institutions and enquire into their records. It should be stated that in three of the hostels the patients are, either entirely or mainly cases of pregnancy complicated by venereal disease, and it would be difficult to exaggerate the value of the work done in cases of this kind both for the mother and the unborn child. During the year 1920, the attention of the Public Health Committee of the London County Council has been drawn on several occasions to the need for further accommodation (a) for girls and women patients in attendance at venereal disease clinics, and (b) also girls rescued from the streets by rescue workers. Accommodation for the latter class may be said to be more or less available in refuges and rescue homes, but it is contended by some persons, who speak with a knowledge resulting from a long experience, that refuges and rescue homes do not entirely meet the real need. Inasmuch as refuges and rescue homes are numerous, their total bed accommodation considerable, and that they are well scattered over the area of the County of London, it was felt that some enquiry into the work actually undertaken by these institutions was necessary before any further action in the direction of the further accommodation suggested could be taken. Moreover, the question xxiii was raised as to whether in fact some at least of the refuges and rescue homes could not undertake the kind of work for which hostels were instituted. It was also felt that the time had come when what might be called the preventive aspect of the venereal diseases problem, from the sociological point of view, ought to be considered, and, if possible, co-ordinated with the scheme for the treatment of venereal disease. An effort was made, therefore, in the latter half of this year, to investigate, so far as was possible in the short time available, the work actually being done at the refuges and rescue homes, and by various religious and charitable societies in the same direction. Accordingly, a fairly representative selection of refuges and rescue homes, etc., was made and each one visited. In addition, the official representative of several of the societies, and a number of persons actively engaged daily in rescue and preventive work, were interviewed. Several conferences were also attended, which were specially convened for the purpose of discussing certain aspects of this work, and the practicability of its co-ordination with the venereal diseases scheme. By these means a vast amount of extremely valuable and useful information has been accumulated, and although it is impossible within the limits of this report to deal adequately with all these important activities, it is proposed to indicate in broad outline some of the more important features of the work which is going on in London. Refuges and rescue homes.—There is a very large number of refuges and rescue homes in London, probably 100, or more. It is difficult from the incomplete information available to say what their total accommodation amounts to, but probably 2,000 beds would not be an over-estimate. They are managed and financed by quite a number of different bodies, e.g., the Church of England, the Church of Rome, the Church Army, the Salvation Army' the Wesleyans, the Young Women's Christian Association, the Jewish Community, etc., etc. The general principles which animate the various bodies managing the homes are much the same, though, in certain respects, there are important distinctions to which attention should be drawn. In a small number of the homes, strict isolation from the outer world is the rule, whilst in others, the practice varis from occasional outings and visits from relatives and friends to a considerable amount of outdoor freedom and latitude in regard to visits from relatives and friends. The truth seems to be that there is a definite tendency nowadays in the direction of a modification of the old regime of strict isolation and an iron discipline within the four walls of the home. There is still a good deal of difference of opinion as to which is the right policy in the best interests of the inmate, and owing to the very limited amount of reliable information available as to the after history of women who have been inmates of these institutions, it is impossible at the moment to express any opinion on this point, further than to say that it is believed that the policy of strict isolation and rigid discipline is probably not the one best calculated to deal successfully with girls of the present day. The usual practice is for a girl to remain in the rescue home for a long period of time—eighteen months to two years is common—and even much longer periods in certain cases. In this connection it is very important to note what appears to be an outstanding defect in the rescue homes, viz., the fact that very little advantage seems to be taken of this long period of residence to train the inmates for some definite occupation which would enable them, on leaving the home, to earn an honest, independent livelihood. In practically all rescue homes the inmates carry out all, or most, of the necessary domestic work, and, apart from religious and moral instruction, this may actually represent the routine of their daily lives. In a limited number of homes a special feature is made of laundry work, and this in addition to giving useful instruction and much needed exercise to the inmates, is generally a considerable, and indeed, it may be, a vital source of revenue to the home. In still others, efforts have been made to instruct the girls in needlework of various kinds, etc., but it will be obvious that the amount of training available is on the whole very limited. In any event, however useful a good training in domestic work, laundry or needlework may be to the majority of the girls, there must be many to whom these occupations are unsuitable, and in view of the immense importance during such a long period of residence of doing everything possible to place them in a sound economic position at the time of leaving the home, it is highly desirable that an effort should be made to introduce into the homes some more comprehensive system of education and training. In making this recommendation, the fundamental importance of the moral and spiritual training and instruction provided in rescue homes is full recognised. But it is suggested that the economic value of the girl at the moment she leaves the home is a factor of immense importance in her own interest, and that she would be greatly assisted on re-entering the world, after a long period of seclusion, freedom from temptation, anxiety and worry, etc., if during this period something could be done to place her in a position to secure her own economic independence. The gravity of this question has been greatly increased recently by the higher cost of living, accompanied, as it is also, by a greater demand for higher standards of educational attainment and technical skill on the part of all wage earners. It is not proposed to indicate in this report the kind of training and education which is needed or the methods by which they should be made available to the inmates of rescue homes, as this is clearly a matter for investigation and report by educational experts. Rescue homes and venereal disease.—Enquiries show that as a rule rescue homes exclude girls suffering from venereal disease. It is interesting to note that in many of the homes the exclusion is based not upon the result of a careful medical examination, but entirely on the opinion of the matron, or some other lay person in charge of the home, as to the presence of venereal disease. It need hardly be pointed out that on the one hand, such a practice must lead to the exclusion of some who are not suffering from venereal diseases, and, on the other, to the admission of others who are suffering from venereal disease. The principal reasons for the policy of exclusion appear to be:— (а) The fear of infection being transmitted from sufferers to non-sufferers. (b) To objections raised by the inmates to the presence of girls suffering from venereal disease amongst their number. xxiv No doubt the latter objections are also based upon the fear of infection. In view of the importance of these considerations in connection with any future developments in the direction of the use of rescue homes for the temporary accommodation of girls in attendance at venereal disease clinics, it appears to be desirable to express the opinion that the fear of infection is greatly exaggerated and that, with reasonable and easily carried-out precautions, the risk is practically nil. The fact that girls who have freely exposed themselves to the risk of contracting venereal disease, have for many years past been admitted to rescue homes, with no other safeguard to exclude venereal disease cases than the opinion of an untrained lay person, and that no case has ever been recorded in such homes, so far as can be ascertained, of the transmission of infection from one inmate to another, is surely very strong evidence of the slight nature of the risk. If, however, suitable arrangements were made, where necessary, to adopt the simple precautions which are desirable, no doubt many of those responsible for the control and management of rescue homes would be prepared to modify the present restrictions, and any additional beds thus made available to those provided in hostels, would be of great practical assistance to those responsible for carrying on the work of the London venereal disease clinics. On the other hand, it may be a simpler plan for a central committee to be established, representing the various bodies interested in rescue home work, and for such a committee to devise a scheme whereby a limited number of the rescue homes in carefully selected areas of London would reserve all their accommodation for cases of venereal disease, and so avoid altogether the difficulties which they may fear will arise in homes where mixed cases are taken. Other forms of rescue work.—During the last few months, there have been numerous opportunities for interviewing and conferring with a large number of persons representing a great variety of agencies all occupied actively in rescue and prevention work in the streets of London. Amongst these may be mentioned the Women Police, the Police Court Missionaries, the Church Army, the Salvation Army, the Young Men's Christian Association, and Young Women's Christian Association, and many others. Some of these agencies have been at work for many years, others sprang into existence during the war, and occupied themselves mainly with the protection of the sailor and soldier, not only from the risk of the contraction of venereal disease, but also theft, etc. (vide Appendix "C"). After the war was over, • there was a strong feeling that the work should be continued for the benefit of the demobilised service men, and owing to the fact that many of these men were often in the possession of quite large sums of money and on their way home, there were very good reasons for the continued activities of the rescue worker in the streets of London. Moreover, with the close of the war, there came a gradual cessation of munitions and other war work, with the result that many girls, unable to earn the high wages they had become accustomed to, went on to the streets either to supplement their smaller earnings in other work, or because they said they had no other opportunity to earn money. It is noteworthy that many of these were girls who had been attracted to London from various parts of the country during the war, owing to the high wages paid in the munition factories, and for various reasons of their own found the life of London so much more attractive than the country, that they decided to remain on the chance of getting some other employment. According to the testimony of many reliable rescue workers, a very large percentage of these girls are quite young (16—20), and suffering from venereal disease. In addition to these girls, many of whom might be regarded as "temporary" prostitutes, there are, of course, the usual quota of regular prostitutes. It would be possible to give numerous instances of the various types of girl prostitute with whom rescue workers have to deal daily either in the streets or courts or coming out of prison after short terms of imprisonment for various offences, but it will suffice here to direct attention to certain reports in the appendix for fuller information on this point. It is important, however, to draw attention to the universally expressed desire amongst rescue workers for the provision of what may be conveniently termed "reception houses. "The Women Police, Police Court Missionaries, Young Men's Christian Association, Young Women's Christian Association, and other rescue workers bear emphatic testimony to the fact that such houses are the overwhelming need of the moment in connection with rescue work. What is meant by the "reception house."—To understand the importance of the" reception house " to the rescue worker, it is necessary, first of all, to grasp firmly the fact that to be able to seize and to take full advantage of the "psychological moment" is an essential factor for successful rescue and preventive work. Every rescue worker can quote innumerable instances of cases where, if they had been able to provide immediate shelter for a girl, she would have gladly taken advantage of the opportunity and would either have been saved from going on the streets or have left the streets, if she were actually a prostitute. The oft-told tale of the failure to obtain such accommodation, even after the rescue worker has toiled about for hours in trams, buses and taxicabs all over London, trying to get the girl first into one place and then another, and still another, and finding every one full, and finally having to admit failure, is a terribly sad one, more especially when the failure to find such shelter has resulted in the girl becoming tired and disgusted and, in this reckless and despairing mood, going on or returning to the streets. Similarly girls who are pregnant and suffering from venereal diseases, and for whom no accommodation but the workhouse is available, present a difficult problem. Many instances have occurred where women in this position have actually carried on the life of prostitution until just immediately before their confinement. Other examples quoted were those of girls who had come up to London in response to advertisements for situations, found them to be undesirable and left hurriedly. Perhaps their slender resources are stolen or exhausted before another situation is found, with the result that they stray into undesirable lodging houses, or get into bad company, or are picked up by men, etc. Fortunately, some cases of this kind come to the notice of rescue workers before they get into trouble ; many more, unfortunately, have already fallen. For such cases immediate shelter is wanted until suitable and proper provision can be made for them. XXV Girls who have fled from home because of betrayal by their lovers or because of a "row with their parents"; deserted wives; penniless widows; discharged prisoners; girls charged in the courts with solicitation and unseemly behaviour and placed on remand by the magistrate; girls who have been on the streets for some time, and who are "sick of the life," are often found to be willing to listen to the earnest persuasions of the rescue worker, and to leave their horrible lives. They will do so the more readily if they are given a fair chance of a new start in life at once, instead of being dragged about all over the place from one home to another, and, in the end, failing to obtain admission. These are some of the many examples which rescue workers quote in their universal appeal for a reception house to which a girl can be taken at once, and thus be provided for until the rescue worker and the agency she represents can decide the best course to adopt. Such an institution must have equipment for cleansing verminous bodies and clothing, and for the examination of those girls who are willing to be examined, to determine the presence or absence of venereal disease. The arrangements should also permit of the provision of separate accommodation for some of the girls according to the matron's discrimination. The period of residence should be as short as possible. Upon the foundation of the "reception house" would be built up the organisation for the future welfare of the great variety of girls who would pass through it. For these varied demands, whatever they may be, rescue homes must either be organised, or must organise themselves, into groups which will provide for certain classes of girls, e.g., there must be some discrimination with regard to their age, upbringing, educational attainments, technical skill (if any), in certain trades or business, presence or absence of venereal disease, etc., etc. During the short period of residence in the reception house, all these important matters would be carefully enquired into by competent persons, and the. future arrangements made accordingly. Any such re-organisation of the existing rescue homes would also enable such important questions as their adaptability for certain forms of educational training to be thought out and arranged. Thereafter the gaps still remaining in any direction could be filled up and the process of development of any such scheme would thus become an economical and an efficient one for everyone concerned. Presumably the educational training referred to could either be partially provided or subsidised by the local education authority, and any such provision would be of great assistance to the charitable societies engaged in the work. Careful consideration has been given to the large body of evidence submitted by rescue workers of all kinds as to the overwhelming need for the immediate provision of reception houses for the various classes of cases referred to above. Many independent enquiries on this subject have also been made by means of the staff of the Public Health Department of the Council, and as a result it would appear that "the overwhelming need of the moment" is not so much the immediate provision of new accommodation in the form of reception houses, as a careful survey of all the existing accommodation in refuges and rescue homes with a view to their adaptability to the varied needs of rescue workers generally. Judging from the enquiries made and the various conferences attended for the discussion of rescue work, there appears to be a remarkable lack of knowledge amongst many rescue workers with regard to the existence and activities of the numerous refuges, rescue homes, etc., engaged in similar work to that of their own society or association. This lack of information is accountable to some extent for their too frequent failure to obtain the kind of assistance which from time to time they urgently need, and that very great benefit would accrue from the publication and distribution amongst all rescue workers of a compact volume containing a complete statement of all these activities, in the shape of refuges, rescue homes, etc., where situated, and the conditions of admission, etc. If, in addition to this, it were possible to connect up every refuge and rescue home with the telephone exchange, an enormous amount of unnecessary travelling, with consequential waste of time and money by rescue workers, looking for immediate shelter for a young girl or woman, would be prevented. Provided then that such a survey has been carried out there is no doubt that the re-organisation of existing refuges and rescue homes on a properly grouped basis; the introduction of education and training with a view to securing an independent means of livelihood for the rescued girl; the relaxation to some extent of the rigid discipline of the past, and the allocation of some of the refuges and rescue homes, or some of the beds at either or both, for girls suffering from venereal disease, would all prove to be steps well worthy of consideration in the near future. The formation of a central committee of all the bodies engaged in this work with a view to the careful reconsideration of the present position in the light of experience acquired during the last 25 years, and thereafter, the drawing up of a comprehensive scheme for the purpose of coping if possible, more adequately with the complex problems associated with rescue and preventive work, than is possible at present, would be an extremely valuable and practical first step at this moment. The Metropolitan Asylums Board Institution, Sheffield-street, W.C.—In this connection it might be of interest to refer to the fact that in November, 1919, the Ministry of Health informed the Metropolitan Asylums Board that they had been approached by the Home Office with a view to the immediate provision of accommodation for the reception and treatment of young girls and women suffering from venereal disease who come into the hands of the Women Police patrols and who are willing to undergo treatment. The Asylums Board thereupon agreed to set aside for this work the small hospital of 52 beds in Sheffieldstreet, W.C'., which, during the war, had been used as an observation hospital and dispensary for war refugees. Prostitution.—It is impossible for anyone to study venereal disease day after day without the question constantly recurring in his mind, " Why do women prostitute themselves?" When one sees quite young girls of 13, 14, 15 and 16 years old appearing as patients suffering from syphilis or gonorrhoea or both, and boys and young men suffering similarly, it is natural to enquire into the circumstances which led to their infection, and to wonder why so much attention is being given to 61004 Y xxvi treatment and so little, comparatively speaking, to causation. It is not proposed to make any comprehensive study of the social aspect of venereal disease in this report, but merely to refer to some of the factors, as the time has certainly come when those authorities which have been charged with the duty of providing for treatment should turn their attention also the study of certain conditions which continue to keep venereal disease clinics supplied with patients. Undeniably prostitution is the outstanding factor in the causation of venereal disease, and the Great War must have drawn the attention of all thinking persons to its wide prevalence, as also to its very serious effects in a hundred ways upon the health of our Navy, Army, and Air Forces, as well as on the community generally. All who have any knowledge of the history of venereal diseases know that the number of cases has always increased rapidly during and after a war, and this has been the experience in London and in England generally during recent years, as it has been the experience of all other countries involved in the recent war. Beyond question, increase of prostitution in one of its many forms—professional, clandestine, etc.—has been the cause of this increase in venereal disease. A study of the causation of prostitution may, therefore, be not unprofitable. The causes of prostitution are multitudinous. In defining some of them, it is better to confine ourselves to those in operation during what may be termed normal peace conditions, since the factors dependent on the changed general mentality during the war are disappearing naturally. Amongst the conditions leading to prostitution the following are notable and preventable. (1) Bad housing.—The conditions of home environment during the early years of life are amongst the most powerful of all those influences which press a girl or young woman towards a life of prostitution. In this respect it is evil influences, rather than harshness, carelessness and neglect, which are to be feared. By evil influences is meant intimate association with the sexual side of life and premature sex experience of every kind, e.g., prostitute mothers, violation, and even incest. These vices are to a great extent the products of environment and both bad housing and overcrowding must be given a foremost place as factors in the prevalence of irregular sexual relationships. The loss also of those amenities of the home which conduce to the preservation of a sense of modesty, which results from overcrowding is undoubtedly a primary cause of subsequent prostitution. It should be remembered in this connection that children who have been tampered with are often sources of contamination to their playmates and spread the evil effects of criminal and indecent assault far beyond themselves, even into decent and carefully guarded homes. (2) Bad companions.—Prostitutes themselves, as a rule, commonly lead other girls into danger. Not infrequently the choice of bad companions is simply the result of loneliness, particularly so in the case of young shop girls and domestic servants from the country. If they have nowhere to go to in particular on their day out, they take walks with any companion who shows a desire to be friendly and sympathetic, in places where they are frequently accosted by men. It is also stated by those who have studied this question that prostitutes are attracted by young and uncorrupted girls. Such a prostitute may, of course, be merely a decoy, but more frequently she is attracted by the prospect of companionship of young girls, who are not infrequently corrupted in turn by the friendship. Here again it should be remarked that experience goes to show that the danger is greatest to quite young girls. (3) Temperament.—Rescue workers frequently state that "the girls who come to us at the present day are largely of an emotional temperament, and that they are often artistic, musical, goodnatured, and very lovable." "The strong, hard-working woman who used to come to us is a thing of the past," and has been "replaced by the better educated, but also weak-minded, pleasure-loving girl, unable to battle with the difficulties of life." On the other hand, other workers of many years' experience say that "the modern prostitute is more temperate, more cautious, more thrifty, and less hysterical than the prostitute of thirty years ago," (4) Drink is generally thought by those of long experience in rescue work to play little part in inducing the young to choose prostitution as a career, though it is used by those who desire to seduce a girl to overcome her first resistance, and there can be no doubt that, in many cases, seduction is the determining factor which leads to a life of prostitution. (5) Homelessness is a material danger to many girls. They frequently find it difficult to obtain suitable lodging, with the result that they drift into houses of an unsatisfactory character. Similarly, a girl out of a situation and living away from home, may get among bad companions; she may share a room with such a companion, not knowing she is a prostitute, and thereafter may follow in her footsteps. It is also stated that sometimes a girl may have to go to a woman's common lodging-house, where she may easily meet companions of an undesirable character, with disastrous results to herself. The mental and emotional dangers of the homeless girl searching for another situation, astray and bewildered in a large town, often with a rapidly emptying purse, should also be remembered, and it is easy to understand how a girl in such a position may succumb to temptation. (6) Unhappy homes are often stated to be another cause, especially where parents are too strict, religiously or otherwise, or again where there is a step-parent; in either case the commission of a slight fault and the fear of severe punishment may drive a girl from home. In cases of these kinds girls, having run away from home, frequently become prostitutes. (7) Seduction and desertion frequently operate as causes of prostitution. Their psychological effect in this direction depends greatly on the attitude of family and neighbours. Where these hold unchastity to be an unforgivable sin, the seduced and deserted girl may regard herself as almost a prostitute already, and little more is needed to make her become one. Under the fear of local censure she may cut adrift from her home and all those influences which are more necessary at such a time than any other to help her to regain her self-respect. Once adrift, nothing short of a miracle can save her under present-day conditions from adopting a life of prostitution. A girl who has been seduced and xxvii deserted when in trouble is fortunate indeed if she finds in those around her a ready willingness to help her back to a life of chastity, a task of no small difficulty in her already half-desperate state. The economic effects of seduction and desertion are powerful accessories to prostitution, since they frequently lead, especially in domestic service, to loss of employment without the reference which would help to re-employment in another situation. A hungry, friendless girl is ripe for temptation and persecution from unscrupulous persons; her resistance may be worn down by repeated attacks, and she is quickly driven into still lower depths of degradation. All the factors in seduction and desertion are enormously emphasised when seduction results in a child. The emotional shock is intensified, the economic burden is doubled, and unscrupulous persons have a more helpless victim to persecute. The unmarried mother with her child is the most pitiable figure in the modern social system. It is worthy of note here though that a woman is not often driven to prostitution for the sake of keeping her child. It is said that such a woman will more often submit to almost any service, however burdensome, which will enable her to keep her child, even if it is placed out with a foster mother. But if the child dies, or is entirely taken away from her and placed where she may never see it again, she is much more likely in the end to take to prostitution. All the experience of rescue workers goes to prove this statement. (8) Compulsion and exploitation.—Prostitution is stated by some persons to be largely in the hands of middlemen, merchants, dealers, petty traffickers, and independent women who work on their own account. Some of these act as advisers, attendants, instructors, protectors, or intermediaries, Some employ force, fraud, and any possible means of obtaining influence over their victims in order to procure girls and women. Hence the aims of those who seek to settle the problem of prostitution by means of the Criminal Law. It is difficult to state in definite terms the extent to which these various agencies are responsible for the production of prostitution. The evidence is very conflicting, but the balance of opinion seems to favour the view that their combined influences do not account for the production of more than a small percentage of the total number of prostitutes. (9) Feeble-mindedness.—During recent years a great deal of attention has been devoted to the part played by mental deficiency in the making of prostitutes. The report of the Royal Commission on the Feeble Minded added greatly to our knowledge. There are two types of feeble-minded girls concerned with this aspect of the problem. Those whose sexual inclinations are abnormally strong or whose power of self-control over natural impulses is abnormally weak (see report by Dr. James Kerr to the Education Committee—London County Council, 1908). There are also those who have no active impulse to seek out men, but will yield to anyone who approaches them. It is stated that there are three important factors that drive the feeble-minded into prostitution by excluding them from other occupations:— (а) They often lose their character at an early age. (b) They easily get and keep light, unskilled and irresponsible work at very low wages, but do not pass to any higher or more responsible work with correspondingly higher wages. Therefore they become discontented with their monotonous work just at the period of life when their sexual impulses are at their strongest, and flee from the tedium of monotonous employment to the excitement of a new life with the easy gain in money which offers itself. (c) Even in those cases where such girls are placed in responsible situations with good environment, and do their work satisfactorily, it is said they have a curious distaste for remaining long in one situation, with the result that they wander from place to place until, ultimately, their records become known to employers, who will not engage them, and they turn to prostitution. Their mental deficiency also soon makes them unsuccessful prostitutes. Their lack of inhibitory powers leads rapidly to alcoholism; it is said that 50 per cent. to 60 per cent. of the inmates of inebriate homes are feeble-minded, and that the vast majority of them have been prostitutes. It is to be hoped that in the course of time women of this type who are prostitutes will be swept from the streets by means of the Mental Deficiency Act, 1913. (See Appendix F.) (10) The economic question.—It has frequently been said that prostitution is not an economic question. There are others who hold that this view is entirely erroneous. There is a mass of evidence to show that unemployment, low wages, and bad occupational conditions are definitely associated with prostitution. In the case of unemployment, it has been shown that, in what are known as the seasonal trades, these are many workers who take to the streets to tide over the slack times. Examples of such trades are millinery, dressmaking, tailoring, mannequins and the lower ranks of the theatrical and music hall profession. In all these trades, good clothes and a smart appearance are necessary for the effective seeking of a new engagement. Low wages, not necessarily so low as to preclude the provision of food and clothing and shelter, but insufficient to allow of any form of enjoyment without curtailing the necessaries of life have certainly been shown to be a factor tending in the direction of prostitution. Wages on a subsistence level give very little protection to certain temperaments from the temptation to buy with the proceeds of prostitution the pleasures so much sought after. Occupational conditions form an important influence in leading women into prostitution. This is particularly the case where girls are liable to suffer when dependent upon the pleasure of a person of the opposite sex for the opportunity to gain a livelihood, or again, to obtain promotion in their work to positions with higher remuneration. These factors have been frequently shown to be an influence in the cases of shop girls, factory girls, theatrical and music hall artistes. 61004 Y 2 xxviii The fact that domestic servants provide such a large proportion of known prostitutes is certainly not due to low wages or unemployment. It is said by some experienced rescue workers to be due to the kind of woman who becomes a domestic servant, and the conditions of domestic service. On further and more detailed enquiry, it will probably be found that it is a comparatively rare event for intelligent, well-educated domestic servants, living with families under reasonably good circumstances, to become prostitutes, and that the truth is that in the vast majority of cases the domestic servant who becomes a prostitute is feeble-minded, and for this reason also is occupied in service in poorer families, boarding houses, hotels, restaurants, and other places where the risks of seduction, etc., already referred to, are common. The two accompanying extracts dealing with the question of prostitution are of interest in this connection:— Extracted from "Downward Paths." "The enormous price that the nation as a whole pays for the presence of the prostitute class in its midst is a factor which should not be lost sight of. The financial cost must run into millions, but cannot be even approximately calculated when the number of women concerned and the fees they receive are necessarily unknown. Further, there must be included the cost of maintenance of thousands of women during frequent illness and premature decay, in rescue homes, workhouses, hospitals, asylums, and prisons. The diversion of thousands of women from productive labour to destructive idleness is an item of national waste which it has now become more imperative than ever to check. "But an even greater price is represented by the spread of venereal disease, not only among participants in the trade of prostitution, but to their innocent husbands, wives and children. Insanity, deafness, blindness, sterility and various other innumerable evils affecting the physique of the nation follow in its trail, and the foul stream falls on the just and the unjust alike. "Equally widespread and deplorable is the moral damage caused by prostitution. The effect on the woman is proverbial, and is reflected in the phrases popularly used to describe her condition, but it is not so commonly recognised that her casual male associates may suffer profound moral and intellectual damage from contamination. Much that is puzzling and distressing in the relations of the sexes, both in family and in public life, might be traced to the emotional havoc wrought in young men who have had their first and most vivid experience of sex in the sordid surroundings of commercial prostitution. "The cost being so incalculable and universally disastrous, it follows that for self-interested reasons alone, civilisation must endeavour to reduce prostitution to the lowest limits consistent with the personal liberty of responsible adults. It is commonly urged that the attempt is an impossible one, as reformers are here up against 'the fundamental fact of human nature,' and the trade is as 'old as humanity itself.' It is well to remind this school of critics that prostitution is not synonymous with immorality, and the problem is not that of securing perfect continence (outside marriage) in both sexes. On religious and ethical grounds some such ideal must form part of every campaign against prostitution, but the goals are not identical. Prostitution is promiscuity for gain, and while recognising to the full the force and power of the sex instincts on human conduct, it is yet possible to maintain that only in rare instances does natural instinct acting alone lead a woman to adopt a life of promiscuity. Still more rarely does it keep her in it, if she is given a reasonable chance to earn a decent living in any other way. Prostitutes in the majority of cases come from regions where economic conditions cramp and deform human beings to such a degree that we can only guess what stature ' nature ' intended them to attain." Extracted from Flexner's ''Prostitution in Europe." "The outcome of European experience.—If the preceding pages may be assumed to have exhibited the present condition of prostitution in Europe, the reader need not be long detained for the purpose of summarising the main inferences to be drawn from them. It must be clear that prostitution is far more widespread than superficial appearances indicate; that its roots strike deep, socially and individually; that police regulation has proved unnecessary, in so far as the keeping of order is concerned, and positively harmful in its bearing on the problem of venereal disease. Further elaboration of these points would involve needless iteration. But we may well ask whether European experience suggests any broader reflections with which this study may appropriately be brought to a close. "Whatever one may hold as to ultimate dealings with the subject, it is clear that prostitution is at any rate a modifiable phenomenon. For example, no matter what conditions exist at this very moment, they are capable of aggravation. If bawdells are established and allowed a free hand in procuring inmates and business, if a community ceases to be concerned as to the condition of the streets, as to the conduct of the liquor and amusement traffic, there is no doubt that under these circumstances the number of prostitutes and the volume of business transacted by them would at once increase, and, in consequence, also the amount of waste and disease traceable thereto. "The converse of the proposition is equally true. If prostitution and its evils can by social arrangements be increased, they can also by social arrangements be lessened. If unhampered exploitation and prominence make matters worse, then interference with exploitation and prominence makes matters better. I am not suggesting that such interference has unlimited possibilities. Making every allowance, however, I believe that the student of prostitution in Europe is warranted in declaring that, with the suppression of bawdells and the white slave traffic, and the maintenance of improved external order, a substantial amount of good has been accomplished, even if new problems have simultaneously developed in consequence of the growth of cities and the accumulation of wealth; further, it may safely be maintained that these efforts have not yet reached their limit. xxix "What are we fairly justified in expecting from directly repressive action on the part of the community ? Prostitution is, as I endeavoured to show in the chapters on demand and supply, a phenomenon arising out of the complicated interaction of personal factors and social conditions. Looked at from this point of view, the attempt to stamp it out completely by summary, even though persistent, action, cannot be hopefully regarded. The instrument which a municipality must use to that end is the police. Now the police is an instrument which, serving, as it does, many useful purposes, must be preserved as nearly intact as may be. We have seen that contact with prostitution threatens its integrity and efficiency. On the police, therefore, no more can be laid than it is capable of bearing. Just what this load is must be separately determined for every community, and, in large cities, for different parts of the same community. Where the general level of administration and discipline is high, more can be safely demanded than in communities in which the level is lower; where public sentiment is active and definite, the burden may be further increased; where the local organisation observe, complain and follow-up, the danger of a police breakdown is still further diminished. "It is evident, however, that, even amidst favourable general conditions, the very nature of the instrument employed involves, under the complicated conditions of modern life, limitations against which one soon runs. Police repression can be directed mainly against professional prostitution and its exploiters. Unquestionably it has a valuable function to discharge in removing stimulation and reducing suggestion, as also in minimising opportunities for demoralisation. But in so far as the prostitute herself is personally concerned, repression becomes operative only after the woman has been wrecked. It penalises an accomplished fact. Powerless to crush this fact out of existence, powerless for the most part to transform the fact, sheer repression might still hope to deter the beginner by its forbidding prospect; but, unfortunately, the beginner is less affected by the penalties awaiting her, because she never believes, at the start, that she is destined to end in the mire. If, therefore, prostitutes are manufactured by unschooled human nature and imperfect social institutions, they cannot in the mass be stamped out by brute force ; they must be prevented rather than suppressed—prevented, too, on both sides, in the sense that the sources of supply must be closed and the demand diverted into other channels. "Moreover, repression, in order to realise its full possibilities, requires an abundance of institutional facilities such as now nowhere exist. I have repeatedly adverted to the utter futility of the fines and short term sentences hitherto generally imposed. Repression, successful up to the limits of its inherent possibilities, must involve the endeavour to wean the professional prostitute from one way of living and equip her for another. Reformatories, labour-colonies, hospitals, and similar institutions have, therefore, to be made adequate to the load which an aggressive policy places upon them. At this moment no city sustains even what it now requires. "It is a further limitation of the repressive policy, as ordinarily conceived, that it operates almost altogether upon the woman. We are reminded of the dual nature of prostitution. It involves two partners. Imagine every brothel closed, every street-walker incarcerated. To the extent that stimulation and suggestion have by these measures been reduced, demand has suffered a check. But a strong demand still remains, unaffected by repressive measures directed merely against dissolute women. Certain stimuli have been removed; otherwise appetite is left where it is. Its gratification is impeded made more difficult and more expensive. But these are not insuperable obstacles in the presence of that volume of supply which, if inoffensive, is hardly reached by repressive police measures. Indeed, part of what was offensive is changed in form rather than entirely driven from the market. "Repression encounters difficulty at still another point. Prostitution is all too frequently a parasitic phenomenon that attaches itself to other phenomena, sometimes innocuous, sometimes necessary, sometimes part and parcel of national life or social tradition. Street-walking and the bawdell are not thus intertwined with other activities; they represent prostitution in its barest, simplest, most undisguised form, and as such may be, with comparative ease, successfully attacked by police methods. But when prostitution insinuates itself into the ordinary life of the community, subtly, inoffensively, imperceptibly taking advantage of the forms in which business is transacted, sociallife carried on, or recreation enjoyed —then the difficulties in the way of effective action are more serious. The crudest forms of prostitution are easily reached; easily, I say, because, even though the task has been nowhere achieved, there is, in the nature of the case, no reason why a well-governed community should fail to achieve it; but the subtler forms present problems so different in kind that in dealing with them agencies and influences of a totally different character must be employed. "I do not mean that repression will have accomplished little. On the contrary, important good is achieved at the moment, and still more in the long run. But prostitution as a formidable problem will still remain. Repression is, on the whole, what physicians call symptomatic treatment; it may achieve something more than alleviate the ravages, but it does not cure the disease. It does not necessarily decrease the thing in the same ratio in which it alters appearances. "What would conceivably happen in a city like London if the police, spurred and controlled by an active popular impulse, accomplished all that could be humanly expected? Street-walking of a provocative character would disappear; the advertised brothel would cease to exist; the public house (saloon) would strictly enforce the law against the harbouring of prostitutes; the obvious forms of spurious employment would be dispersed—rendered more circumspect and much less readily accessible; prostitutes would disappear from the lobby and promenade of the variety theatres, etc. The pimp, the exploiter, the third-party interest would be severely checked, and, with that, the tropical growth due to them. We may also assume that a vigorous and adequate hygienic policy would lessen the volume of disease, and effect quicker and completer cures. In a word, prostitution as an offensive and aggressive activity would be more or less done for, and the loss through disease would be minimised. XXX "What would be gained? The inducement to enter the life or to persist in it would be lessened; the total volume of business and the volume transacted by any one woman would be decreased; the financial waste would be less; the amount of disease disseminated would be less; the demoralisation of the woman would often be less complete, less overwhelming, less irretrievable: surely, very important gains. "Well drawn, well codified, well executed laws could accomplish this. Any civilised society utilising the resources and instrumentalities that every such society has within its reach, can, if really so minded, ultimately reduce prostitution and its ravages so far by direct action. "It is well worth doing; it is, humanly speaking, a possible undertaking, even though, I repeat, nowhere as yet by any means accomplished. Let us not, however, deceive ourselves into thinking that such a direct frontal attack absolves us from effort in other and different directions. Further achievement depends upon alterations in the constitution of society and its component parts. In so far as prostitution is the outcome of ignorance, laws and police are powerless; only knowledge will aid. In so far as prostitution is the outcome of mental or moral defect, laws and police are powerless, only the intelligent guardianship of the state will prevail. In so far as prostitution is the outcome of natural impulses denied a legitimate expression, only a rationalised social life will really forestall it. In so far as prostitution is due to alcohol, illegitimacy, to broken homes, to bad homes, to low wages, to wretched industrial conditions—to any or all of the particular phenomena respecting which the modern conscience is becoming sensitive—only a transformation wrought by education, religion, science, sanitation, enlightened and far-reaching statesmanship can effect a cure. Our attitude towards prostitution, in so far as these factors are concerned, cannot embody itself in a special remedial or repressive policy, for in this sense it must be dealt with as part of the larger social problems with which it is inextricably entangled. Civilisation has stripped for a life-and-death wrestle with tuberculosis, alcohol, and other plagues. It is on the verge of a similar struggle with the crasser forms of commercialised vice. Sooner or later, it must fling down the gauntlet to the whole horrible thing This will be the real contest—a contest that will tax the courage the self-denial, the faith, the resources of humanity to their uttermost." F. N. Kay Menzies. The questions of immediate self disinfection and ablution centres have not been dealt with in this report as they have formed the subject of separate reports to the Council. APPENDIX A GRANTS-IN-AID MADE TO EACH HOSPITAL FOR THE FOUR YEARS, 1917-1920. Hospital. 1917. 1918. 1919. 1920. (a) (b) (a) (b) (a) (b) (a) (b) £ £ £ £ £ £ £ £ Albert Dock — — — — 600 200 1,000 250 Bolingbroke — — — — — — 750 250 Charing Cross 1,250 250 1,250 250 1,500 500 2,250 750 Diseases of Skin, Blackfriars-road — — 400 100 200 100 600 150 Hospital for Sick Children, Great OrmondStreet 300 200 300 200 350 250 750 250 Great Northern 1,000 250 1,000 250 900 350 2,375 750 Guy's 1,700 800 2,250 750 2,750 750 4,000 1,000 King's College 1,250 250 1.250 250 1,300 350 1,500 500 London Lock (male and female) 5,500 500 7,000 500 8,500 750 13,000 1,000 London 2,250 750 2,750 750 3,250 750 5,000 1,000 Metropolitan — — 750 250 900 350 2,000 500 Middlesex 1,250 250 1,250 250 1,750 500 2,250 750 Miller General 500 — 600 — 1,000 — 2,000 — Elizabeth Garrett Anderson 750 250 750 250 900 350 1.500 500 Royal Free 1,250 300 1,250 250 1,750 500 4,250 750 Royal London Ophthalmic — — — — — — 750 250 St. George's 1,250 250 1,250 250 1,400 400 2,000 500 St. John's Skin, Leicester-square 300 200 450 200 500 250 1,000 250 St. John's (Lcwisham) — — 600 150 900 350 1,450 250 St. Mary's 1,250 250 1,250 250 1,400 400 2,250 750 St. Paul's 500 — 500 150 750 250 1,150 350 St. Thomas's 1,500 500 2,000 500 2,250 750 11,000 1,000 Seamen's 1,250 350 2,250 350 2,250 750 4,000 1,000 South London for Women 750 250 750 250 900 250 1,150 350 University College 1,250 250 1,250 250 1,300 350 2,000 500 West London 1,250 250 1,250 250 1,750 500 4,000 1,000 Westminster 750 250 750 250 950 300 1,500 500 (а) Treatment (including laboratory work for treatment centre). (b) Laboratory work for medical practitioners. XXXi APPENDIX B RECORDS OF ATTENDANCES. London. Middlesex. Essex. Surrey. Kent. Herts. Bucks. East Ham. West Ham. Croydon. Total. 1917. Syphilis 6,057 499 308 274 242 82 44 70 130 72 7,778 Soft chancre 174 9 7 8 9 — — — 2 1 210 Gonorrhœa 4,098 304 141 132 170 26 8 60 68 30 5,037 Not venereal 1,882 178 55 77 74 13 7 25 34 15 2.360 Total 12,211 990 511 491 495 121 59 155 234 118 15,385 Total attendances 96,398 8,934 3,306 4,062 3,164 766 315 1,086 1,610 1,018 120,659 Number of in-patient days 48,860 3,336 2,772 2,420 3,335 1,599 454 245 672 230 63,923 Salvarsan substitutes—doses 20,377 2,125 833 1,104 993 277 184 185 460 258 26,796 Pathological examinations— Treatment centre 11,066 934 459 383 460 119 59 149 227 132 13,988 For medical practitioners 2,992 190 164 83 35 20 9 39 111 6 3,649 Total 14,058 1,124 623 466 495 139 68 188 338 138 17,637 1918. New patients— Syphilis 5,167 516 282 213 248 61 26 60 140 53 6,766 Soft chancre 96 5 6 5 9 1 1 1 4 1 129 Gonorrhœa 5,222 60S 234 185 272 32 33 83 84 31 6,784 Not venereal 2,053 242 111 77 96 19 13 21 43 18 2,693 Total 12,538 1,371 633 480 625 113 73 165 271 103 16,372 Total attendances 131,869 14,808 5,676 4,612 5,660 1,130 775 1,495 2,605 855 169,485 Number of in-patient days 49,590. 2,892 2,155 2,965 4,740 1,832 681 249 604 387 66,095 Salvarsan substitutes—doses 23,627 2,582 1,168 1,080 1,112 299 152 248 524 262 31,054 Pathological examinations— Treatment centre 20,372 1,801 1,020 747 867 244 125 255 406 136 25,973 For medical practitioners 5,122 467 278 145 15 45 13 46 204 45 6,380 Total 25,494 2,268 1,298 892 882 289 138 301 610 181 32,353 1919. New patients— Syphilis 7,128 615 352 321 230 94 54 113 384 63 9,384 Soft chancre 331 19 18 12 16 6 5 2 21 2 432 Gonorrhœa 9,635 982 476 345 232 85 50 173 473 81 12,532 Not venereal 3,814 407 196 162 119 50 20 46 160 42 5,016 Total 20,908 2,053 1,012 840 597 235 129 334 1,038 188 27,364 Total attendances 232,659 23,710 9,813 9,127 5,620 1,955 1,330 2,848 9,302 1,702 298,066 Number of in-patient days 54,431 2,242 2,125 3,174 3,042 892 763 271 1,010 473 68,423 Salvarsan substitutes—doses 41,894 3,817 1,835 1,826 1,409 462 414 472 1,405 443 53,977 Pathological examinations— Treatment centre Information not available. 39,662 For medical practitioners 8,258 546 578 287 168 44 14 166 213 190 10,464 Total 50,126 1920. New patients— Syphilis 7,917 701 392 285 206 89 58 121 324 80 10,176 Soft chancre 570 26 19 11 21 — 2 4 26 3 683 Gonorrhœa 10,127 872 443 293 182 87 53 164 363 71 12,655 Not venereal 4,998 534 237 165 113 39 32 72 229 58 6,477 Total 23,612 2,136 1,091 755 522 215 145 361 942 212 29,991 Total attendances 365,478 34,011 12,386 12,190 7,282 2,436 1,946 3,434 10,278 2,480 451,921 Number of in-patient days 54,529 1,846 2,924 1,900 3,505 1,324 1,209 332 963 405 68,937 Salvarsan substitutes—doses 51,266 4,635 2,164 2,666 1,565 643 603 603 1,662 552 66,359 Pathological examinations— Treatment centre 44,706 3,584 2,263 1,642 954 406 225 755 1,934 412 56,881 For medical practitioners 11,234 686 864 470 70 44 22 152 279 193 14,014 Total 55,940 4,270 3,127 2,112 1,024 450 247 907 2,213 605 70,895 xxxii APPENDIX C. REPORT ON MY WORK AMONGST THE GIRLS ON THE STREET, BEING A PLEA FOR A CENTRAL GIRLS' HOME AND CLEARING STATION. Sir, I herewith beg to tender you a few notes on my experiences as a street patrol. For the past eighteen months I have been engaged with others in work on behalf of the Young Men's Christian Association in an effort to protect soldiers, sailors, and now, demobilised men, from the dangers of the streets. In practical experience it has been found impossible to deal effectively with the problem without also giving attention to the girls and women into whose hands the men fall. Many of the girls are not confirmed or hardened prostitutes, and scores of them can be persuaded to leave the streets if only provision could be made for their future. It is a common experience for a soldier or civilian to agree to leave a girl, if I am able to give an assurance that I will provide for her. It is just here that the great difficulties arise. My work is night work, and mostly late night work, for that is the best and most effective time to carry on our mission. It is hard enough to find accommodation that is suitable during the day; it is infinitely harder late at night. A bed is the first necessity, coupled with some motherly supervision; perhaps a hospital the second ; a home and employment following after. It is in these matters that help is urgently needed. It is appalling at times to have to close one's eyes to a vast number of cases, or to take away everything from the girls with one hand and have nothing to offer with the other. For instance on an average we have 45 to 50 separations per week, and when I have successfully got the boy away from the girl, whom I may know to be a prostitute, I then approach the girl, who will say, "I have no home, no money, no work." Here comes the problem. What am I to do with her? I have practically to tell her to carry on till I can do something for her, thus running great risk of losing her altogether, whereas if I could take her to some suitable place there and then, supervised by an experienced matron who would co-operate with me, and carefully deal with the case, undoubtedly that girl could be saved. I believe there are hundreds of young girls of 15 to 24 years of age on our streets to-day, obtaining their existence as prostitutes, who would gladly return to a life of respectability if we could say to them: "Now, girlie, no matter what the position is, I can help you right now." * * * * * * * It is a terrible fact, but I can state from my experience, that the prostitutes of my district are practically all diseased and need treatment. All my girls consent to medical examination with very little persuasion if tactfully dealt with, and many to-day are healthy and doing well, who were once badly diseased and also frequently prisoners in Holloway. These girls live at the common lodging houses, but, after getting anyone of them to the stage of willingness for examination, and taking her to the hospital, she has no means of following up the treatment or carrying out the doctor's instructions, because in these types of houses there is no privacy whatever. The girl becomes sickened with the situation, disheartened with herself, and does not, because she cannot, proceed with the personal treatment which is so essential. If she turns again to her former mode of life she thus infects every man with whom she comes into contact, and it may be innocent people as well. Further, whilst she is in this condition we cannot get her work, however willing she may be to make good. The venereal disease maternity case is another serious problem for the rescue worker. We have practically no place but the workhouse to offer her, and this she positively refuses until the very last moment, and continues her life on the streets in spite of the unborn child. I have known cases where girls of 17 and 18 years of age have thus remained on the streets as long as 8i months in pregnancy. The unmarried mother, who leaves the infirmary after confinement with no prospects either of home, money or work, and very little hope of getting them, and with her baby to support, turn again in nine cases out of ten to the streets, not from choice but in desperation; she may not previously have been a prostitute, but the victim of misfortune, or deception, and with her shame still green in her memory, will not return to her friends or relatives even should they be willing to have her. * * * * * * * Recently I dealt with a case where the girl had only left the infirmary four days, and as a last resource had accepted the vile proposition of a strange man, near a coffee stall, in order to find shelter for herself and her child. Fortunately I saw her and the child accompanied by the man enter a hotel restaurant where rooms are let. The time was 1.30 a.m., and my suspicions were aroused. I obtained admission and got consent to go to the room which they had taken, and after great difficulty shamed the man into leaving the girl, and, as it was so late, left the girl and the baby by themselves in the room for which the man had paid 12s. Only a week or two since, I had a letter from a maternity home from a girl I have never yet met, but who must have heard of my work, asking me what she must do after her child was born. She said she had been told that girls like her often ended on the streets and was aghast at the thought of it. I have written her, and hope soon to see her and try to help her to a brighter life. When our girls are forced, through such circumstances, to contemplate practising what even animals would not countenance, surely something must be done. xxxiii I have a case at the present time of a girl who is seven months pregnant; the common lodging house and the Church Army shelter cannot give her a bed as their licence forbids then to receive girls . over six months' gone, and I have nothing to offer her but the workhouse, because she is a married woman. She cannot live with her husband on account of his violence. This I know to be true. He is an habitual methylated spirit drinker, and I have unfortunately myself witnessed some of his brutal attacks on his wife. I asked her the other day where she had been sleeping, and she replied "On the Embankment." * * * * * * * The rise in the number of girls on the streets I consider is due to the high wages they had been receiving on munitions and their inability now to obtain situations to enable them to live as they had been during the war. Many of the girls have come from the Midlands or Ireland to London with the inflated idea that they could easily get situations and high wages here. Some of them work during the day, and have told me they make up the financial deficiency on the streets at night; this is highly dangerous to the public, as I am convinced many of them are infectious. Night coffee stalls are often the meeting places of prostitutes and undesirable men, and these eventually persuade this class of girl into other sins in addition to prostitution. Some of them act as decoys and lead soldiers and others with money into pre-arranged places for the purpose of robbery. Great danger of infection must exist at many of these coffee stalls and the hard-working carman or traveller must frequently fall an innocent victim thereto, and even possibly carry the scourge home to his family. I have counted as many as 30 prostitutes at one stall at one time. Rescue work has its disappointments, but assuming we can save 75 per cent. of our girls, and by so doing protect large numbers of our boys, surely our work merits proper facilities in the way of immediate accommodation for those whom we have a chance of saving. * * * * * * * If we could have a properly equipped and staffed building where we could take a woman or a girl, no matter what the hour of night or day, and no matter what her condition—pregnant, venereal disease, or verminous—I am more than convinced that not only the girl but the community at large would eventually benefit. We want a place where the cases could be investigated and the proper measures taken at once— measures that will mean permanent good; the girl must be persuaded to have medical treatment and first got into a healthy condition, and although the battle seems rather difficult, I am positive it is not so, if the case is handled with care and tact. Many of them are like putty in our hands if met and dealt with at the proper moment. From this clearing and rest house, after the girl has been medically treated, she could later pass to existing agencies. I find after putting the whole position up to the girl, her past, her present, and her future, and being able to say to her, " Now, girlie, in six months you will be a clean girl once more; in time you will live down the past and become as good a citizen as anyone," she becomes interested and turns to my point of view. At the end of this period of medical treatment, if there is any grit in her, the girl will want her independence, and this is quite understandable. She has been under the influence of the right kind of people, she has been in wholesome moral and spiritual surroundings, has been helped again to lead a well regulated life, and at the close of six months' training, she will be ready to go to some post with a cleaner mind and a new outlook on life. Of course there are exceptions, and there must be some failures. There are some who are morally imbecile, and they must be dealt with by quite a different method. * * * * * * * Many cases could be cited to prove the need for some such home as is suggested. Two or three must suffice. A young Irish girl, not yet 20, recently came to us saying she would give up the life and take a situation if we would help her. It was very late at night, and there was nowhere we could take her to at that time. Had we had the proposed home, we could at once have placed her under the matron's care and got her off the streets right away. We have seen her since, but she is wavering in her desire and has gone wrong again. We hope still to save her, but the case is just hanging in the balance owing to our not being able to provide for her promptly the first time she came. * * * * * * * A few weeks ago a shop girl was handed over to us by the police from whom she had been making enquiries for a maternity home. This was her story. She had been betrayed by a man at a dance. She had carried on at work as long as she was able, and then had to seek a place for her confinement, and did not know what to do or where to go. We were making arrangements for her to go to a maternity hostel when a medical inspection, which they required, revealed disease, and they could not take her. We could do nothing but place her in the workhouse infirmary, though in one sense the girl was too respectable for it. (There has been a happy ending here, for after the baby was born the man was found and has married the girl.) In this case the proposed home would have been invaluable. * * * * * * * 61004 z xxxiv Only a day or two ago a girl, whom we have helped, and who is a day worker at a hospital, but for economy's sake has to sleep at a night hostel, had an attack of influenza. The doctor told her to rest for a few days, and she was in this difficulty : at the hostel she has to be up at 7 a.m. and there is no day accommodation. The proposed scheme would have been a Godsend in such a case. * * * * * * * Quite recently we had another type of case for which again the proposed home would have been most useful. Very late one night a woman with three children (and a perambulator) came to us for lodgings. It was a case complicated by matrimonial and divorce troubles. We tried our best to get her shelter. The M.A.B. could not do anything, as she had a few shillings she was keeping for food for the children. At last we were obliged to take her to St. Martin's Church for the night. Up to 5 p.m. the next day she was unable to get any room; we recommended a Salvation Army shelter, where she went, only to find it full. She walked about with her three children till 2 a.m., when a widow, with four children of her own, took pity on her and found her accommodation. Again she came to us wanting provision for the children till she obtained work. We passed her on to the women and children's department of the Church Army, but with what result we have not yet heard. * * * * * * * A girl we are helping to get through her confinement was found to have a verminous head, and it was essential this should be clean before we could place her. As she lives in a night shelter, there is no kind of privacy at all, so that she could drastically tackle the problem, and owing to the difficulties of this environment, it took her three weeks to get fit to go to the maternity home, and meanwhile her time was getting perilously near. Under the proposed scheme this could have been accomplished in a few days. * * * * * * * A few days ago a girl who had been a domestic servant at a local hospital came to us to ask if We knew anything of a certain soldier. She was very troubled and excited. According to her story, some three months ago she had accidentally met the man in question one evening, accompanied him to Hampstead Heath and misconduct had taken place. She declared that till then she had been a virtuous girl. According to her statement she was pregnant and in great mental distress. The man had promised to marry her, but had not kept the promise. It so happened the man had passed through our hands over questions of employment and emigration. As our enquiries progressed the case became a very difficult one owing largely to the girl's hysterical condition. Conferences were held with both sides, and at the time of writing the case is still being dealt with, with some prospects of an equitable settlement being reached. Meanwhile the girl had to be housed, and this was only accomplished with considerable trouble. Had we been able at once to place the girl in the proposed home, we could have kept her under observation, have had her medically examined, and then mothered her in a way that seemed very essential. * * * * * * * In another case a girl 18 years of age, previously unknown to us, came in to consult us, and this is the story she told:— She was a year in the Land Army, then in a situation for some ten months near her home at Bristol. She left that against her mother's wish, came up to London and obtained another place, but whilst there was led astray frequently by a sailor. She lost her position, and unfortunately got in touch with a companion a street girl of very bad character, who helped her to spend her savings. One night, having no money left, this girl persuaded her to accompany herself and a sailor to Chatham. He paid the fare and had associations with our case in the train in presence of the companion, but not with her also. Later the next day the companion told the first girl that the sailor was diseased, but she did not suggest a visit to the hospital. The girl came to us, and we found great delay in getting her to a hostel, as they were all full. The girl says she has kept straight since we first saw her, but had we had the suggested home we could have dealt with this urgent case in a much prompter manner. Two incidents that occurred one night whilst this report was being drafted have a similar bearing on the point at issue. A girl known to me for many months had come out of Holloway Prison the previous day, and by appointment came to see me for guidance. I was unable to place her at a proper hostel, and was obliged to let her go for the evening on the understanding she would stay with some relative whom she said would put her up the one night. Instead, she went on the Strand and was arrested, having been found in the company of a drunken soldier she happened to meet. (The problem of placing girls just out of prison is, I believe, a very acute one, but only comes under my observation in connection with girls I have previously known.) * * * * * * * The second is a very sad case. A postman, who knows our work, brought to us a girl who had asked him where she could get shelter, This was her story. XXXV About 18 years of age, she was a travelling theatrical chorus girl. Losing her position owing to reduction of staff, and being without money, she had gone to Walthamstow with a chance man she had met. Late at night he told her he could not get her a single room, but knew of a double one, and this she shared with him, with the usual result. It was her first fall, so she declared, and she dared not go home to her mother. The only suitable hostel was full, and all we could do was to send her to a shelter for the night, always a risky proceeding in such cases. Fortunately the next day she came back to us, and we were able to place her suitably, and have every hope of being helpful to her to redeem her position. In both these striking cases the proposed home would have been of inestimable value. (In the last six weeks hardly a night has passed but we have had cases for which the home would have been an immediate and helpful haven.) * * * * * * * I have ample proof of the success of our work and one girl's recent letter is well worth quoting. Only 20 years of age, she had spent 18 months of her first three years in London in Holloway; she was rescued after a hard struggle; treated for disease, cured, and then found a position as a general servant. She is making a brave fight in a hard place, and is determined to go straight. At one time in her career she was in receipt of £15 a week from an officer; now she tells us with pride that she has in six weeks saved and put in the Post Office Savings Bank 14 shillings out of her wages and is also paying back money lent her during her illness. She writes: "I would not go back to the old life for anything, but I never had a real chance till I met you. Hundreds of girls like I was are seeking the same chance. No one could have had a blacker life than mine. Do carry on, and help others like you helped me." ******* Many other typical instances could be given if required to prove the immediate need of the proposed home, so that we could strike while the iron was hot, and thus almost certainly rescue the girls. It is of interest to note that our work and duties are known to the girls and that, though at first they may, and do, resent our interference with their vicious traffic, yet when they are in trouble, in the hands of the police, in prison, ill, or distressed, they often come to us for help, advice, and succour. They know we are their real friends in time of need. In this way, inter alia, we have been able to reconcile a number with their mothers, occasionally to bring husband and wife together, and in these and other ways get them away from the streets and on the path to reformation. At times we have even had boys bring to us girls who they themselves knew were in need of help. ******* The area in which we work should, in my opinion, receive special attention, so that precautions might be taken against the diseased prostitute on account of the large soldiers' and sailors' club situated in it—a club which is filled night after night—and is the home of scores of boys on leave. These men on leave often take much more to drink than usual, consequently are not themselves, are out for what they call a good time, and have no idea of the woman and her condition. She makes certain suggestions to them, their brain is too dazed to realise what they are up against, and they go with her, and the result too often is "hospital" on return from leave, and possibly months of misery and shame. We do all we can to separate them, and thus avoid this danger. A word at the right moment has proved very valuable to many of our boys in hundreds of cases. The patrols in this one district, during 1919 alone, persuaded over 3,700 men to leave the women with whom they were found in the streets. We tell them to remember the girl they will one day marry and who is to be the mother of their children, and thus putting it to them, it is very seldom the boy will obstinately take the risk in face of such an appeal. * * * * * * * The above experiences relate mainly to the special district in which my work lies, and where that amongst and on behalf of the girls has grown with considerable rapidity, specially during the last few months as it has become known to them. For every girl who was willing a year ago to leave the streets there are at least six to-day. The time is ripe for a great effort to meet this tremendous problem so fraught with danger to young life and to the community at large. I have practical knowledge of similar work in other parts of London, and know the need to be just as great, and am certain that a centrally placed home of the kind suggested would serve several of these districts in the S.E., S.W., W. and W.C. areas. I have found, too, that any fellow workers, who have gone into the facts, and who have, first hand knowledge of the conditions I have indicated, all agree how much our efforts are hampered by the want of such a home, and are convinced the street problem is one of the most dangerous, perplexing and difficult that exists at the present time in our great cities, and particularly in London itself. To cope with it requires energy, tact, patience, and, at times, calm faith under disappointments, which are inevitable in some cases. Opportune prompt action, taken sometimes on the spur of the moment, when the girl's feelings are tuned to the right pitch, when the heart is stirred to the very depths, can well be the turning point to higher, brighter, better things, and to seize this opportunity when the occasion offers it is of primary imporrtance to have at hand the means to begin the cure without an hour's delay. I came into the street patrol work little knowing the ravages that immorality and its consequent 61004 z 2 xxxvi disease were making amongst the fair youth of our England. As my knowledge increased, as opportunities arose on every hand for advice, for help, for reclamation, my heart bled for the poor unfortunate ones enmeshed in the toils and the call has come with a clarion note, to leave no stone unturned, no channel neglected, no opportunity missed to further the uplifting of these poor girls, and to bring them back once more into the warmth of God's own Love, into the fullness of real womanhood, and make them the credit instead of the despair of the land. Imperfect as these notes may be, they are written with a real enthusiasm for the work, and with a very real and terrible knowledge of the problems to be faced and overcome, and they come straight from the heart, A girls' home of the kind suggested, in some convenient central situation, planned to meet typical cases like those I have quoted, would be a veritable boon to rescue work such as ours, and seems to me an absolute necessity in order that we may be in a position to save most of them. I know an ideal building now vacant, if it could be secured, and I am convinced that on the proper lines it would solve many of the present difficulties, and well repay the outlay, in the purification of the streets, and more important still in the salvation of many of our present-day outcasts among the young womanhood of our country. (Signed) N. I. D. 16.4.20. APPENDIX D. REPORT ON SOME ASPECTS OF THE PROBLEM OF DEALING WITH THE GIRLS OF THE LONDON STREETS. By Mrs. D. and Mr. S. W. October, 1920. After a conversation with Mr. G . . . , who outlined some of the points on which he felt we could supply information for his investigation, we have prepared the following notes in the hope they may be of use for we are deeply interested in this vital question, and, as the previous report showed, are much hampered in many ways in our endeavours to help these girls owing to the great difficulty of effectively and promptly housing them when they come to us. We rejoice that a full investigation into all sides of the question and all the points involved is being made, and sincerely trust that the authorities may see how urgent is the need for a firm grasp being taken of the whole situation both for the sake of the health of the community and for the moral improvement of the present deplorable conditions. The opening of Sheffield Street has, in our opinion, provided for a distinct need, and is one important link in the chain that seems required to assure prompt dealing with some of the many and varied cases that come to us for help and guidance. The known or suspectedly diseased girl can be sent there immediately, and so long as she will not prove too fractious is assured proper and sympathetic treatment even though it takes months to effect a cure. In very few cases, too, have these girls any financial means, and the free hospitality is invaluable, and we are very grateful for this response to one of our pressing needs. We have also found that the wide interpretation given to the use of Sheffield Street has enabled us to send there girls off the streets who are stranded and homeless for whom no other place could be found at the moment even though we have no strong reason to believe they are diseased, but this is only used very sparingly because we recognise that the clean street girl (if such a term may be used) should not be housed there for obvious reasons; though, on the other hand, it is quite advisable even in her case there should be a medical examination to prove her freedom from the contamination. ******* But in addition there are many other and varied cases which come to us for which prompt help is very necessary, and often these cases are the most deserving. This great variety present most difficult problems. Whilst we recognise that the scope of this investigation is to solve the problem as it affects the health of the community by attacking the insidious spread of disease, it must be remembered that our Y.M.C.A. work is also concerned with all kinds of appeals that come to us, and below we enumerate some of them, and we should be failing in our duty if we left these out of the question at issue. So to guide and direct such by advice, and housing in proper conditions in order to protect them from unseen, and often unknown, dangers they might incur by association with the diseased, and, where possible, to prevent any risk of infection by letting them use the hostels and lodging-houses frequented by the other class, is undoubtedly a very great help to the health of the community, and therefore affects the welfare of the race in a very real way, and hence is another side of the problem that must not be lost sight of. Here are some such cases that come under our notice:— (1) The stranded respectable girl who has come up to London to find work (often a complete stranger to the great city), her slender resources are exhausted, or perhaps stolen from her, before she has succeeded, and before she has been brought into touch with the right kind of agencies. xxxvii (2) The girl who has fled from her home or her own locality because she has been betrayed by her lover, or some man, and to hide her shame, she comes to London, and needs prompt and proper handling of a sympathetic character and a suitable place found for her confinement and then setting up again in life. (3) The girl with a little child she has to support out of her earnings, and whom it often takes some time to place in a situation because of the difficulty of providing for the child. (4) The deserted wife and the penniless widow. (5) The wife generally young who has left her husband because of his cruelty, legal or actual, or for a petty quarrel, and so on. (6) The stranded husband and wife, often with children, the first generally an ex-soldier out of work, the woman very often able, because of previous experience, to take domestic service. (7) The discharged prisoner, naturally presenting exceptional difficulty. Such problems as these are increasing and hardly a night passes at the bureau, but we have one or more of such cases with which to deal. Under existing conditions it means 'phoning round to various and sundry agencies, often to find them full, frequently to be told they do not come under their rules, at times to have to plead for accommodation even for the one night, and hence often it happens that a single case may take two hours before it is disposed of. ******* No. 1 is perhaps the most difficult of all to place satisfactorily, for it does not seem right to offer such shelter that means mixing with those of immoral tendencies, and there is an undoubted lack of free accommodation for this class of girl. No. 2.—We find these, when a genuine first fall, the easiest and most grateful to deal with, and the kindly help often given by the Y.W.C.A. at Warwick-square has been of very great assistance to us. No. 3.—The difficulties to be faced here are obvious; the girl herself from whom her full story can only be obtained by degrees; then the placing of the baby either in a creche or by adoption ; and finally the situation to be obtained. No. 4.—Each case may be dealt with on its own merits; no one story is exactly like the other, but if the woman is capable, we can generally soon find her work, through one or other of our agencies. No. 5.—Our general rule is wherever possible to effect a re-conciliation for obvious reasons, though sometimes we find a period of waiting till we can hear both sides, is advisable, and meanwhile the wife has to be provided for and guided. No. 6.—We find it much more difficult to deal satisfactorily with such cases especially where there are children, and at times we have to exercise all our ingenuity to do so. Very few hostels will take cases with children, especially if stranded, and usually in any case their financial means are very small and the outgoings large. The House of Charity, Soho, has been very good to us, but often they are full. At our wits end, we frequently have to transfer them to the Church Army Headquarters, as they have a larger organisation for the women and children's provision. We are often faced with these problems late at night, and then, of course, our difficulties are intensified. Sometimes we have been obliged to send women and girls to the M.A.B. office on the Embankment, but we shrink from such a course for many reasons—first, the publicity attached to it, then the long wait and the probable dispatch to some S.A. hostel, generally in the City ; it also means one of our lady patrols going with them (if a girl) to guard her from other dangers. A clearing house centrally situated, a hostel such as is outlined in our previous report where at any time, day or night, whatever the case, it could be taken, at all events for that evening (we are referring, of course, to the women and girls) straight away would be a great boon, of inestimable value and a real service to the community. ******* At the other end of the chain comes the after care, more particularly of the cured girl and the maternity cases. The girl declared free from infection, the mother after her confinement, the delicate ones, and the inexperienced who need training for domestic service—all want after care. The ideal would be a country home (with proper provision for training where needed), and where the convalescence, both physical and moral, could be spent in congenial surroundings, and under the right influence. It is most disheartening when, after months perhaps in hospital, a girl is discharged only to find her in a few weeks, even days, sometimes, back at her old life and exposing herself to all the risks of fresh infection, besides which all that has been done seems to have been wasted. Much of this could be avoided if she could have been placed as above. There is also the brighter side which must not be lost sight of. These girls who have or are making good. Many of them have no home or friends of the right kind except ourselves, and actually their greatest enjoyment on their night off is to come down to the bureau (not a very enlivening place) and spend two or three hours in talk with those who have helped in their rescue. Recently one such spent her 21st birthday, and another her 18th. A club for such would be a great boon, and though perhaps outside the scope of this enquiry, would be a final link to completely provide for all sides of the great problem. After note.—A careful co-ordination of all the efforts on behalf of the girls would be one immediate xxxviii help of a temporary nature; but such, as often proved in many other movements in England, is not very easy to obtain, and moreover one ever present difficulty is the personal factor at stake. The girl has first come under the observation of a certain worker and gradually confided to that worker her life story. Moved about from one institution to another, she has to repeat the story of her shame and degradation over and over again to strangers, and the worker first brought into contact with her loses sight of her to a great extent. We frequently find that it is to one individual worker that the girl feels specially drawn, and this one it is who has the most influence with her. This is a problem that does not present any easy solution, and though it is an undoubted factor in successfully dealing with the girls at the moment, no plan presents itself by which it can be completely solved, but it is mentioned because we know it exists. It is also worth considering whether under some scheme of co-operation it would be feasible to have all the names of the women dealt with by the various agencies reported weekly to some central authority in order to prevent overlapping, and also to prevent, what has happened at times, a girl obtaining help and guidance from two places at once without their knowledge and, we are afraid, occasionally playing the one off against the other. Where a branch considers a case, for good reasons, should not be further helped, such should be placed on a black list of warning. In any case found on either list by another branch with whom a girl is in contact a telephonic communication should at once be sent to the bureau on whose list the name appears, to obtain the latest information and for purposes of consultation. ******* We have refrained in this report from quoting any individual cases of which we gave many examples in the earlier one of some months ago, but if further details of this nature are needed we will willingly supply them from fresh ones that have been dealt with since the previous report was issued. From our experience we very fully recognise the extreme gravity of the situation, and are very grateful that these further investigations are being made, and will only be too glad to render any help in our power. STATISTICS. Months, 1920. Appeals to girls. Separations. 8 London bureaux, (including Waterloo). Waterloo (only). 8 London bureaux (including Waterloo). Waterloo (only). January 306 170 543 118 February 562 179 737 171 March 926 190 757 155 April 831 192 832 96 May 755 303 692 300 June 728 286 543 154 July 770 309 646 170 August 638 227 500 62 September 720 210 414 60 During the above months the lady patrols have dealt with the following cases (Waterloo only):— 1920. Taken to hospital for treatment. Found lodgings at hostels, etc. Found employment. January—September 116 104 71 Notes:—During the above period the eight bureaux have been cut down to six. Appeals to men (which are probably greater than those to girls) are not given, as in many of such cases these are over other than questions of immorality. During the period of the war the above figures were probably three times the totals now given. In the second schedule it does not follow that the figures relate to different girls every time, but they are separate transactions, though it may be the same girl would appear under each heading. I think it may be fairly and moderately estimated that the patrols have taken 100 girls off the streets in the nine months in Waterloo alone. APPENDIX E. INFORMATION RECEIVED FROM THE COMMISSIONER OF POLICE OF THE METROPOLIS. (a) During the year ended 31st August, 1920, the Metropolitan Police Women Patrols have cautioned 6,676 girls for loitering and accosting men. (b) Of this number, 652 girls asked for assistance to escape from their mode of life, and 112 of these were, at their own request, placed under treatment for venereal disease. (c) The average age of the girls referred to above was 20 years. xxxix APPENDIX F. This table sets out the number of cases notified under the Mental Deficiency Act, 1913, with regard to whom there is clear evidence of immorality. It has been divided to distinguish between public and casual immorality. For each category the number who showed evidences of recent venereal disease is indicated, but this must not be taken as a statement that the others in the past have not suffered from this condition. The table also indicates the ages of the subjects and their class so far as the Mental Deficiency Act is concerned. Source of notification. Class and age. Prostitutes. Others. Total. Number with recent venereal disease. Total. Number with recent venereal disease. Total. Prison Feeble-minded 16-21 2 1 - - 99 21 and over 1 1 — — Police Court Feeble-minded Under 16 3 __ _ 16-21 10 3 - - 99 21 and over 26 9 5 Moral imbecile 16-21 5 1 1 — 99 21 and over 3 1 — _ Not defective 21 and over 4 1 - — Poor Law Feeble-minded 16-21 6 3 9 99 21 and over 22 10 38 2 Moral imbecile 16-21 1 1 — — 99 21 and over 1 1 1 Not defective 21 and over 1 1 2 — Refuges Feeble-minded 16-21 6 5 27 2 99 21 and over 9 2 24 2 Moral imbecile 16-21 1 — 1 — Not defective 16-21 2 — 1 — 99 21 and over 2 1 1 — Miscellaneous Feeble-minded Under 16 1 4 - 99 16-21 7 3 14 2 99 21 and over 3 — 17 1 Moral imbecile Under 16 — — 1 — 99 16-21 1 1 1 — 99 21 and over 1 1 — — Totals 118 46 147 9 265 APPENDIX G. INSURANCE ACT AND VENEREAL DISEASE. Under Section 14 (2) of the National Insurance Act, 1911, Approved Societies were empowered to make rules governing the payment, etc., of sickness and disablement benefits, subject, however, to Sub-section 4 of the same Section, which provides that where the payment of sickness and disablement benefit has been suspended on the ground that it was caused by the misconduct of the person claiming the benefit, such person shall not thereby become disentitled to medical benefit. All Approved Societies included in their rules, what is known as the "misconduct" rule, to the effect that "any member rendered incapable of following his employment by immoral or disorderly conduct, or by engaging in wanton quarrels, or by accident arising from intoxication, shall not be entitled to sickness or disablement benefit." Although societies generally never pressed this section, it was effective in so far that insured persons who had contracted venereal disease as the result of misconduct never or rarely applied for benefit. In 1916 and 1917 an agitation, based on the findings of the Royal Commission, grew to large dimensions, and a widespread feeling in favour of making this rule non-operative in the case of venereal diseases became evident. The National Insurance Act, 1918 (Section 46) provided a simple means whereby those societies who wished to do so could amend the rule, whilst the Insurance Commissioners in August of the same year issued a circular (A.S. 196) in which they not only advised such a course but drafted an amendment of rule to bring it about. ' ..