L.CC 30 London County Council. ANNUAL REPORT OF THE COUNCIL, 1921. VOL. III. PUBLIC HEALTH. (INCLUDING THE REPORT FOR THE YEAR 1921 OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER, MAIN DRAINAGE AND HOUSING). 875—(11720)—19.7.22—61742 CONTENTS. Chapter XXIII. page Public Health Reports.—Report of the County Medical Officer of Health and School Medical Officer for the year 1921—Part I. (Vital Statistics and Administration). Introductory Note 1 A—Vital Statistics.—Population—Marriages—Births—Deaths—Infectious diseases—Smallpox— Typhus fever—Plague and cholera—Anthrax—Tuberculosis—Measles—Scarlet fever— Diphtheria—Diarrhœa—Typhoid—Influenza—Cerebro-spinal fever—Poliomyelitis and polioencephalitis—Laboratory work 3 B—Administration.—Tuberculous milk—Offensive trades—Common and seamen's lodging houses— Homeless persons—Housing of transmigrants—Housing—Sanitary staffs—Venereal diseases— Tuberculosis—Mental Deficiency Act, 1913—Blind persons—Midwives Acts—Lying-in homes— Children Act, 1908—Work of the chemical branch 16 Statistical Tables.—I. Vital statistics—II. Administrative work—III. Tuberculosis dispensaries 24 Chapter XXIV. Public Health Reports (continued)—Report of the County Medical Officer of Health and School Medical Officer for the year 1921—Part II. (Education). Introductory Note.—Medical inspection and treatment—Personal hygiene—Infectious diseases— Special schools 28 Results of Medical Inspection 29 Following-up 35 Employment of School Children 36 Children Absent on Account of Ill-Health 37 Medical Treatment 37 Nursery Schools 39 Open-Air Education 40 Personal Hygiene 41 Infectious Diseases 43 Dietaries 48 Examination of Candidates 48 Defective Children 49 Statistical Tables.—I. Inspections—II. Defects—III. Exceptional children—IV. Treatment of minor ailments, visual defects, defects of nose and throat, dental defects—V. Summary of treatment—VI. Summary—VII. Routine inspections—VIII. Summary, elementary schools —IX. Summary, secondary, etc., schools 53 Chapter XXV. Public Health—Tuberculosis—Venereal disease—Infant life protection—Lying-in homes— Midwives—Houses let in lodgings—Housing of transmigrants—Homeless persons— Lodging houses—Offensive businesses—Milk—Measles and verminous conditions— Dead bodies at undertakers'—Appeal Committee—Health administration in London— Diseases of animals 61 Chapter XXVI. Main Drainage 69 Chapter XXVII. Housing 72 Chapter XXVIII. Housing Accounts and Statistics.—Memorandum by the Comptroller of the Council (Mr. C. D. Johnson)—Memorandum by the Valuer (Mr. F. W. Hunt, F.S.I.) 78 Diagrams and Drawings. Marriages, Births, Deaths (1841-1921) 2 London mortality—smallpox (1841-1921)—typhus (1869-1921)—diarrhœa and enteritis (1862-1921)—infantile mortality (1858-1921)—typhoid fever (1900-21) 6 Seasonal prevalence of scarlet fever, diphtheria, typhoid, erysipelas, puerperal fever, measles and whooping-cough (1911-1920) 9 Summer infantile mortality 9 Seasonal incidence of measles, whooping-cough, scarlet fever and diphtheria (1891-1921) 44 Weekly prevalence of scarlet fever and fleas and mortality of scarlet fever (1909-21) 46 London County Council. ANNUAL REPORT OF THE COUNCIL, 1921. CHAPTER XXIII. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. W. H. HAMER) FOR THE YEAR 1921. In the Annual Report for 1916, it was noted that the year" was one in which in a literal and perhaps in a metaphorical sense also, more water than ever before known flowed under London Bridge." Last year stands in marked contrast to this; it was a year of excessive drought. In the lower Thames valley, where during a normal year a fall of 20 to 25 inches of rain is registered, the amounts recorded were below 12 inches; February and October were almost unprecedently dry months and June was actually the driest month hitherto known in the London area. The year was warm as well as dry, every month except November having a mean temperature in excess of the average. The Camdensquare results indicate that "The record of evaporation from a free water surface is unique, showing a loss of 5.09 in. in excess of the rainfall. Never before since records of evaporation began in 1885," says Mr. Salter, "has the total for the year exceeded the rainfall, the nearest approach being in 1893, when the rainfall margin was only 1.62 in. The normal excess of rainfall over evaporation is about 11.50 in." The influence of these phenomenal records will be found later to be reflected in the behaviour of certain epidemic diseases. The year was also an exceptional one in other respects; at its beginning the trade union returns showed 6.1 per cent. of members unemployed and the figure had risen to 10 per cent. by the end of March. From April to early in July the coal strike supervened and by the end of June unemployment reached 23 per cent., an unprecedented figure. It is further specially to be noted that during 1921 considerable numbers of transmigrants on their way from eastern Europe to America passed through London. The marriage rate was 19.5 per 1,000 as compared with 22 in the two preceding years. Marriages. The Registrar General estimates the birth rate to have been 22.1 as compared with 26.4 in 1920, and 18.2 in 1919. Births. The death rate was 12.5, a record rate. The lowest previously reported was 12.6 in 1920. The rate in 1919, was 13.6. The mortality among infants under one year of age was 81 per 1,000 births, a slight increase upon that of the preceding year—76 per 1,000 births—a rate considerably below any previously recorded in London. Deaths. Despite the phenomenal prevalence of epidemic diseases in Eastern Europe and the resumption on a considerable scale of westward emigration, there was no development in London of cholera or typhus; and although smallpox obtained a footing and smouldered in the north and midlands of this country, only two cases were encountered in London and there was no spread. Typhoid fever continued at a very low ebb and it is noteworthy that in 42.5 per cent. of the cases received in the Metropolitan Asylums Board Hospitals the diagnosis was not finally confirmed; scarlet fever and diphtheria attained exceptionally high prevalence in the Autumn, but the mortality happily was not proportionately great; 1,150 deaths from diphtheria were, however, registered. Pulmonary tuberculosis accounted for 4,813 deaths. Diarrhoea, as might have been expected in such a year, was very prevalent, and 2,152 deaths of children 0—2 were registered; this is less than half the mortality, however, of the last hot year 1911. The deaths from cancer numbered 6,008, the highest number hitherto recorded. On the other hand, bronchitis with 4,479 deaths yields the lowest rate previously known in London. Infectious disease. The behaviour of influenza was watched with special concern, having regard to the record of this disease in 1918, and 1919. The total number of deaths ascribed to influenza in 1921, was 1,024 as compared with 1,364 in 1920. The number of notifications of cerebrospinal fever, poliomyelitis and polioencephalitis, as was anticipated, remained low during the recent years of special influenza prevalence. The notifications of encephalitis lethargica, however, which in 1920 numbered 140 underwent some increase in 1921 to 233. Many and varied forms of manifestation of influenza were again met with in 1921. In the report for 1920, it was noted that "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 cerebrospinal fever of 1920 were in fact of influenzal origin." Occurrence during that year and in 1921, of glandular fever and anomalous throat illness, with an eruption resembling that of scarlet fever, is commented upon in the second part of this report (p. 45). Epidemic hiccough has not again been commonly observed; but confusion has undoubtedly existed with regard to diagnosis between whooping-cough and influenza, just as raised mortality from "whooping-cough" was associated with the influenzas of the early months of 1918 and 1920. "False mumps "has, moreover, been an occasional source of difficulty in diagnosis. The strange disguises of influenza have further, as in previous years, included gastro-intestinal disturbance, stiff neck, lumbago and other myalgias, as well as the now commonly recognised nervous manifestations of the disease. While these forms of the protean malady have been encountered in large urban centres, the characteristic pandemic type of influenza has continued to manifest itself in outlying places, e.g., in St. Kilda late in 1920, among army recruits in various parts of France in 1921, in the Faroe Islands epidemic at the close of 1921, and in the outbreak in the Azores a few months later. 61742 B 2 Lo/ipon MARRIAGEg»BlRT/-\f?«AA1DwD£AT7-\g 3 A.—Vital Statistics. The population of London County at the census of 19-20th June, 1921, was 4,483,249 or 38,436 less than at the census of 1911. The total includes members of the armed forces in London, but does not include Londoners on service elsewhere. The census shows that the decentralisation of the population, which commenced some twenty or thirty years ago still continues, and in the principal areas in which dwellings have been replaced by commercial premises, namely the City of London, Holborn, Finsbury, Stepney, Westminster and St. Marylebone there was a decrease in population of 87,364 between 1911 and 1921; this is about the same as in the previous decennium. Only two boroughs north of the Thames, Fulham and Hammersmith, show any substantial increase during the past twenty years, the increase being 38,703. The total population north of the Thames has fallen in the past twenty years by 201,151, while on the south (including North Woolwich) there has been an increase of 148,133. During the same period there has been an increase in the population of the outer ring of Greater London of 947,784 of which 699,386 belonged to the segment north of the river. The effect of the movement of population indicated by these figures upon the death rates is difficult to assess, but has to be borne in mind especially in comparing rates in the inner areas of decreasing population with those of the growing outer districts. The number of families or separate occupiers in 1921, was returned as 1,141,269 or 107,408 more than in 1911. As in the case of the total population the inner areas showed decrease or only slight increase, the total increase being mainly contributed by the outlying boroughs, especially Hampstead, Lewisham and Wandsworth. The above figures are provisional, and may be modified in the final results, which, however, will not be available until later in the year. The excess of births over deaths in London between the census of 1911 and that of 1921, was about 290,000. Up to the end of 1914, it was about 170,000; from then to the end of 1919 about 35,000; and thereafter up to the census of last year about 85,000. The figures are only approximate as exact data relating to war losses of the London population are not available. The marriages registered in London during 1921, numbered 43,921 as compared with 49,185 in 1920, the approximate marriage rate being 19.5 per thousand of population. It will be seen from the diagram facing this page that the marriage rate for 1921 was only slightly above the average of the last seventy-one years. Marriages. The births in London during 1921, numbered 99,839, the corresponding figure for 1920 being 120,529. The birth-rate was 22.1 per thousand of population. The births of 1921, show a substantial decline upon those of the preceding year, and are below the level to which they had fallen just before the war. The births registered during the first quarter of this year numbered 25,576 as compared with 26,170 last year. The greatest decrease in the births in 1921, upon 1920, occurred in the poorer populations, the decrease varying from 22 per cent. in Bethnal Green to 12 per cent. in Stoke Newington. Births. The deaths in the civil population of London during 1921, numbered 56,259, as compared with 57,232 in 1920. The death-rate per thousand living was 12.5 as compared with 12.6 in 1920. This is the lowest death-rate recorded in London. It is calculated upon the census population of June, 1921, approximately corrected by the inclusion of London residents temporarily absent at the date of the census. It may be observed with regard to the London death-rate that although the population has remained practically stationary during the past twenty years so far as actual number is concerned, its constitution has undergone considerable change. In the twenty years the births among Londoners have exceeded the deaths in London by more than 800,000. This number of Londoners and more besides have moved out of the county ; more than this number, because London attracts young adults of both sexes, but especially young females (for domestic service) from other parts, and the total number of immigrants in the past twenty years roughly corresponds with the number of outgoing Londoners. Owing to this changing constitution of the population the death rate does not measure the risk of life in London. About seventy per cent. of the population of London in 1911 were born in the county: that is to say nearly one and a half millions were immigrants. In the decennium 1901-1910, the London death-rate averaged 15.6 per thousand, but the life-table for London shows that the death-rate of a population of stationary age constitution in the ten years was 20.4 per thousand. Deaths.. The distribution of deaths by ages during 1921, is shown in the following table together with corresponding figures for other recent 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 1921 8,077 1,963 1,360 1,324 808 1,160 1,218 2,732 3,984 6,146 8,083 19,404 56,259 Increase (+) or Decrease (—) 1921 upon 1920 —1,064 + 69 —544 —143 —37 + 1 —73 —326 —239 —70 + 297 + 1,156 —973 The increase in deaths at age 1-2 years results from the high birth-rate of 1920, and much of the decrease shown at ages 0-1 and 2-5 results from the reduced births of 1921, and the war-years. The death-rate among infants under one year of age was 81 per thousand births, the rates for 1920 and 1919 being 76 and 85 respectively. It will be seen from the table given below that there was 61742 B 2 4 a decline in the mortality from most of the principal causes of infant mortality; diarrhoea is a striking exception, the mortality from" summer diarrhœa" was considerable owing to the temperature being above the average throughout the summer. The relationship between summer temperature and infant diarrhoea is discussed on page 10. The infant mortality in the four quarters of 1921, was 85, 59, 93, and 78 respectively, and in the first quarter of 1922, 99. This latter figure is somewhat high owing to the epidemic of influenza. Table showing the deaths per 100,000 births among infants under one year of age, from the principal causes of death 1911-1921:— Disease. 1911. 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921 Measles 475 334 299 254 481 174 492 389 67 202 55 Whooping cough 387 394 295 377 472 354 251 702 87 289 236 Influenza 17 22 33 35 31 16 27 365 138 46 23 Phthisis 63 57 53 56 56 38 81 51 34 35 20 Tubercular meningitis 172 134 119 125 140 129 149 128 93 80 73 Other tubercular diseases 173 139 130 142 152 114 158 86 39 37 50 Meningitis 172 114 115 124 198 162 197 135 109 95 94 Bronchitis 724 618 681 550 660 529 696 702 510 565 305 Pneumonia 1,235 1,130 1,381 1,166 1,610 1,169 1,528 1,678 1,025 1,262 1,130 Other respiratory diseases 81 58 71 63 60 48 60 38 41 41 36 Diarrhœa 3,978 1,081 2,280 2,372 2,082 1,389 1,603 1,367 1,475 898 1,843 Premature birth 1,842 1,826 1,768 1,819 1,760 1,640 1,722 1,847 2,042 1,532 1,599 Congenital defects 1,729 1,393 1,385 1,371 1,518 1,386 1,522 1,439 1,270 1,153 1,107 The deaths from scarlet fever and diphtheria were more numerous in 1921, than in recent years owing to the exceptionally high prevalence of these diseases. Of other causes of deaths which show increase in 1921, mention may be made of cancer which caused 6,008 deaths being 418 more than in 1920, and higher than in any previous years; the diabetes deaths, and still more strikingly those from appendicitis were also high. The number of suicides was above the average. Deaths from poisons and poisonous vapours were much above the average and indeed in excess of any year since 1910; a certain number of these deaths were attributable to coal gas poisoning, there being a number of inquests into this cause of death in the latter half of the year. The death rates in each metropolitan borough in 1921 from all causes and certain specified causes will be found in Table I. appended to this report. Smallpox. Infectious diseases. The number of deaths registered in London has remained quite small since 1901 and 1902, the epidemic years. In the last seven years the deaths have been 3, 0, 0, 0, 5, 4, 0 respectively. These figures may be contrasted with the corresponding numbers for British India which have ranged from 60,642 for the year 1916, to 136,077 for the year 1919. In London the numbers of notifications in the last seven years have been 13, 3, 0, 36, 27, 18, 2. Only two cases of smallpox occurred in London during 1921, neither of which proved fatal. The first was a stewardess from a ship on which smallpox had occurred and who was under observation as a contact. In the second case the patient had just returned to this country from Russia where he had been engaged on relief work and where there is no doubt the disease was contracted. Dr. Wanklyn was called in to see the case a few days after the patient's return home and at once diagnosed smallpox. All the contacts were vaccinated and prompt administrative measures were taken with the result that no further cases resulted. Passengers and members of crews of 7 ships on which smallpox had occurred, and of six ships which arrived from infected ports, were kept under observation. Of these one woman, referred to above, developed the disease. In order to represent the existing smallpox position with accuracy, a few words are necessary to draw attention to its main features. On the one hand is a mass of smallpox infection widely distributed throughout the world,—witness India, for example, the prevalence of smallpox in which country is of immediate interest to London, since smallpox is apt to be imported from there—and on the other hand is a population so highly susceptible to the disease that four-fifths of them would be attacked, if thoroughly exposed; that is to say, that if the population of the County is no better vaccinated than that of the country generally, as probably is the case, 3,500,000 of the population of the County are liable to take smallpox. In this exceedingly insecure position, between the positive external pressure of infection and the predisposing influence exerted by susceptibility, the only effective barrier interposed is that of the Public Health Services of London, which have the duty of detecting smallpox as soon as a single case occurs, and of suppressing it as promptly. The penalty of failure in this service is exceedingly severe, and may result, as has often happened before, in a sudden inrush and spread of smallpox. An epidemic of this would not only cause the death of some hundreds or thousands of victims, but indirectly would inflict an additional heavy loss of health and life. This would arise chiefly in three ways, by producing panic, unemployment, and poverty; by interfering with normal public health activities; and by incurring an expenditure which almost certainly would run into millions of pounds sterling, the 1902 epidemic having cost the Metropolitan Asylums Board alone £500,000. Such are some of the evils to which the non-vaccinated condition of the population renders it continuously and closely exposed. The work of prevention falls mainly under three heads. 1. Arrest of infection at the 'port.—Much depends on this. For instance, in the year 1919, 23 smallpox-infected ships came to the Port of London; 16 of these came from or via India. Most of the actual cases had been removed before arrival; but 12 cases came to the Port with the rash upon them. These were all stopped there by the vigilance of the Port Authority. Two cases came through the Port and actually entered London. Each of these was reported to have passed the Port in the incubation 5 stage, when, of course, there was nothing to attract attention, and subsequently to have developed the disease while residing in London. 2. The Council's diagnosis arrangements for London and Home Counties.—A striking instance of the value of this service is afforded by one of the foregoing cases which passed the Port in the stage of incubation. This man proceeded to Hammersmith, and the borough medical officer of health having his attention drawn to the patient when he fell ill, called Dr. Wanklyn, who at once diagnosed the case to be one of smallpox. This consultation having been held while the patient was in the early stages of the disease, enabled all necessary measures at once to be taken. A similar consultation at an early stage of another case, which occurred at Hampstead in 1920, also resulted in all necessary measures being taken. So also with a case which came to light in Holborn in 1921. So, too, with a case in Wandsworth in 1921. In each of these cases, owing probably to the effect of warnings issued by the Council at various times, the practitioners in attendance had smallpox in mind, and promptly sought the advice of the local medical officer of health, who, being uncertain of the exact diagnosis at that early stage, called Dr. Wanklyn. Thus the procedure initiated by the Council in the year 1904, has again been of the greatest value in checking smallpox. 3. Executive measures taken in co-operation by the county and borough medical officers.—Locally all necessary measures of vaccination, segregation and observation of contacts, disinfection and other steps were initiated by the medical officers of the respective localities; Dr. Wanklyn afforded every possible assistance and information that was in his power; the Council's health department circularised a note of the occurrence to all concerned in and near London. The result was, that in each of the above-mentioned cases in Hammersmith, Hampstead, Holborn, and Wandsworth, the consultative and executive steps taken were so prompt and thorough that not a single secondary case occurred from any one of the four. This is a great contrast to what formerly used to happen, when almost every case that occurred was followed by a group of secondary cases, numbering anything from 3 or 4 to 15, 20 or more. A similar satisfactory result has followed the loan of Dr. Wanklyn's services to the councils of the adjoining home counties. Such is briefly the manner in which smallpox is kept in check; but it is always to be borne in mind that the outside pressure of smallpox in the world at large remains about the same, while the liability to smallpox of the population of the County, owing to the decreasing use of vaccination, is increasing : the difficulty of keeping smallpox out by this method therefore continually increases. Only one case of typhus fever was notified during 1921, and another case was removed to hospital on suspicion. In neither instance was the diagnosis upheld. Typhus fever. No cases of plague and only one of cholera were notified during 1921, and in the latter case the diagnosis was subsequently withdrawn. During the year passengers from four ships on which plague had occurred came to London and were kept under observation as contacts. An arrangement has been made whereby the Lister Institute acts in a consultative capacity, both clinically and pathologically, in connection with suspected cases of plague or cholera. Plague and cholera. During 1921, only 3 cases of anthrax occurred in London none of which proved fatal. In two cases the source of infection was attributed to the nature of the patients' employment, whilst in the third case a shaving brush was deemed to have been the cause. Dr. Howarth took all necessary measures in the City as regards tracing the source of supply of the suspected brush, and it is satisfactory to record that the restrictive measures employed in regard to the importation and supply of cheap shaving brushes from Japan and elsewhere have minimised the risks of infection from that source. Anthrax. The death-rate from pulmonary tuberculosis in the civil population of London during 1921, was 1.07 per 1,000 living, the deaths numbering 4,813 as compared with 4,675 in 1920. Tuberculosis other than pulmonary caused 964 deaths, as against 1,071 in 1920. The number of primary cases of tuberculosis notified in London during 1921 (52 weeks) was 12,214 as against 13,163 in 1920. Of these 10,015 were pulmonary and 2,199 were other forms of tuberculosis. These figures compare with those published in previous reports, but further corrections (by rejection of cases notified as primary but eventually found to have been previously notified) reduce the total of primary cases to 10,648; the corresponding figure for 1920 was 11,663. Tuberculosis. The following is an analysis of the corrected notifications in London during 1921 (52 weeks):— Form of tuberculosis notified. Sex. Notifications on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, infra.) 0— 1— 5— 10— 15— 20— 25— 35— 45— 55— 65 + Age not stated. Total. Pulmonary tuberculosis M. 7 44 174 164 377 565 1,093 1,020 801 400 126 — 4,771 F. 10 51 176 215 382 585 932 622 352 169 87 — 3,581 Other tuberculosis M. 45 179 309 160 84 74 83 60 37 19 11 — 1,061 F. 28 167 235 170 114 80 102 53 29 20 18 — 1,016 All forms of tuberculosis M. 52 223 483 324 461 639 1,176 1,080 838 419 137 — 5,832 F. 38 | 218 411 385 496 665 1,034 675 381 189 105 — 4,597 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 + Total. Poor Law. Other. Pulmonary tuberculosis M. 3 28 25 56 1,073 3,172 F. 2 31 19 52 815 1,969 Other tuberculosis M. 4 37 18 59 123 274 F. — 27 25 52 91 262 All forms of tuberculosis M. 7 65 43 115 1,196 3,446 F. 2 58 44 104 906 2,231 6 London ANNUAL MORTALITY UNDER VARIOUS HEADS 7 It will be seen that at ages 10-15, the female pulmonary cases exceed the male by 51, or 31 per cent. The contrast between the sexes at this age in mortality is even greater than in the cases, the excess being 150 per cent. in 1921. Generally speaking the deaths from pulmonary tuberculosis in London at the age 10-15 among females are about twice the figure for males, while on the other hand the cases are not more than about 30 per cent. in excess. The difference between the mortality of the sexes at the age group does not appear to vary in any marked degree with social condition. Reference may be made on this point to the table in the report for 1911. p. 42. The question of the influence of migration of population upon rates of mortality and especially upon phthisis death-rates has been examined from time to time by statisticians. Thus Noel A. Humphreys (Statistical Journal, March 1897, p. 76) observed that "Dr. Wm. Farr, formerly President of their Society, very frequently referred to this migration into towns in his reports. He pointed out that the deleterious effect of residence in towns was masked to some extent by this migration; that there were undoubtedly a certain number of these healthy country migrants, domestic servants, shop assistants and the like, who after a few years of town residence, under the influence of failing health, returned to the country and in some instances died there." In the Journal of the Institute of Actuaries (vol. XVI., 1872), there is a paper by Thomas A. Welton "On the effect of Migrations in disturbing Local Rates of Mortality, as exemplified in the Statistics of London and the surrounding country for the years 1851-1860." This paper, starting from the standpoint of Farr, is devoted to study of the effect of resort of sick persons to country districts upon the mortality of such districts. Beginning with researches into the comparative mortalities in different parts of Lancashire and Cheshire, Mr. Welton was led to compare the figures for the Metropolitan Division with those obtained for Liverpool and its neighbourhood. The analysis of the 23 Tables appended to his paper is replete with interest and suggestion. The main outcome may be expressed in the words of Mr. Sprague, one of the speakers in the discussion on the paper, who said: "It showed how the rate of mortality in country districts at certain ages was increased, not only by the migration of unhealthy persons from London to them, but also by the migration of healthy persons from them into London. It was obvious that the migration of unhealthy persons from London into the country would have the effect of lowering the mortality in London and increasing it in the country; but it was not quite so obvious at first sight that the migration of healthy persons out of the country into London would have the same effect of raising the rate of mortality in the country. But when attention was directed to that point, it became quite clear that the migration of healthy persons out of the country would leave behind a body of persons whose vitality and whose health were not up to the average, and therefore the rate of mortality amongst these persons would be higher than if there had been no migration." Ideas with regard to the influence of migration have undergone considerable development in recent years and the subject has been referred to from t) time time in these annual reports. In the report for 1920 (pp. 14 and 15) the extent to which the London phthisis death-rate at higher ages may be raised by immigration of phthisical men is studied. The whole question of "internal migration" has, moreover, been recently considered by Dr. M. Greenwood in his Milroy Lectures, in which he has examined more particularly the effect of life in towns on young country people. It is hoped that at no distant date he will also discuss external migration, i.e., the influence upon phthisis death rates exerted by movement of population between the several countries and continents of the world. In last year's report (p. 13), two points of special interest with regard to alterations in the phthisis death rate were commented upon:—(i.) The development of a marked increase in the death rate, subsequent to 1914, in contrast with the decline exhibited for half a century previous to 1914; this rise was no doubt in part due to the fact that the outbreak of the war practically stopped emigration from the country. (ii.) Dr. Tatham some fifteen years ago commented upon the shifting of maximum age incidence of phthisis from young adults to middle life; the phenomenon noted by him may be due to the increasing outward movement of phthisical persons, especially at the young adult ages, from the middle of the last century onwards; since 1914, a backward movement had, it was pointed out, set in, the maximum rate of mortality reverting again towards the younger ages (p. LXX Ann. Rep. Reg. Genl. for 1918). The question of special interest which now arises is that since the resumption of intercommunication and traffic between the civilian population of this country and the outer world, there has been manifested a tendency for the statistics to show a reversion (in respect of both the phenomena just referred to) to the pre-war conditions. Study of the actual deaths in men and women at the different ages in the years 1911-21, shows this, and the facts afford strong support for the view that the influence of migration is a very important one. Thus considering first the war period, 1914-18, the increase in the number of deaths among females aged 20-40 in these years was marked, and the deaths among males aged 20-40 remaining in the country showed but little decrease despite the great reduction in the numbers of such males owing to military exigencies. This tallies with the fact that persons who would at ordinary times have left the country because of incipient phthisis were prevented from doing so by the war. Again, in the years 1919,1920 and 1921, there was a marked fall in the numbers of female and male deaths at these ages, owing in part to resumption of ocean traffic and the migration of persons with early phthisis from this country. Turning now to ages over 50, in women the rise up to 1918, and the subsequent decline, in the numbers of phthisis deaths were both much less marked than in the women 20-40. As regards the men over 50, there was some increase in the deaths from 1914-18, and a decline since 1918, more marked than in the case of the women. The figures suggest that phthisical men at these older ages were to some small extent held up in this country by the war, but that this was much less marked in the case of women. The London figures for male deaths 40-50, show less rise during the war years than those for men over 50, but, of course, the class 40-50 would be more depleted for war service than the later ages. The decline in phthisis deaths at 40-50 since 1918, is fairly well marked; men at this age have during the 8 last three years been once again able to emigrate. Furthermore, the reduction in London during the last 10 or 12 years of the number of men of the homeless class has probably had some slight influence also on the trend of male deaths at ages 40 and upwards. Measles. The deaths from measles in London during 1921, numbered 244, as compared with 1,016 in 1920. The mortality was .05 per 1,000 living, the lowest rate recorded in London. The monthly deaths from measles in London since 1890, are shown in the diagram on page 44 in Part II. of this Report. Scarlet fever. There were 32,738 cases of scarlet fever in London in 1921 (52 weeks) as compared with 22,705 in the preceding year. The deaths numbered 292, giving a death-rate of .065, the corresponding figure for 1920, being .045. The monthly incidence of scarlet fever cases in London since 1890, is shown in the diagram just referred to, and in connection with it the prevalence of 1921 is discussed. During the first quarter of this year there have been 5,486 cases; this is very much in excess of the average for the quarter and has indeed only been exceeded twice since 1890, i.e., in 1908 and last year. Diphtheria. The number of cases of diphtheria notified in 1921 (52 weeks) was 16,319, as compared with 13,780 in 1920. The deaths in the calendar year were 1,150, the corresponding figure for 1920, being 1,023. The number of cases of diphtheria in London in the year 1921, exceeded that in any year since 1890, when notification of the disease became compulsory. The annual returns of the Ministry of Health on the incidence of notifiable infectious disease show that the excess in incidence of notified diphtheria in London over administrative counties in the rest of England and Wales has increased since 1911, the year when the returns were first prepared. In the first quarter of this year the cases notified numbered 4,177 which exceeds the corresponding figure for last year by 34 cases and is the highest ever notified in any first quarter. Seasonal incidence The seasonal incidence of the principal infectious diseases in the period 1911-1920 is shown in the diagram on page 9. It is interesting to make comparison between these contours and those for the preceding decennium, shown in the report for 1910, page 50. The number of cases of smallpox was too small to give a seasonal contour. Report by Dr. J. Graham Forbes on virulent and avirulent Loeffler bacilli (K.L.B.) At the end of March, 1921, application was made to the school medical officer by Dr. R. A. O'Brien, Director of the Wellcome Research Laboratories, Brockwell Hall, for the supply of strains of diphtheria bacilli obtained in culture from the throat or nose of school children not suffering from clinical diphtheria, for the purpose of testing such strains for virulence and comparing them with strains from cases of the genuine disease. Dr. O'Brien's request was very readily complied with as providing a much needed opportunity of dividing the school children, who were found to yield morphological diphtheria bacilli in culture, into groups of virulent and avirulent carriers. By means of the virulence test it has been possible to allow the immediate readmission of all those found carrying the avirulent organism, without the delay of repeated bacteriological examination. The return of children, though carrying organisms morphologically and culturally indistinguishable from the diphtheria bacillus, but avirulent, has led to no harmful results. There is, moreover, no evidence yet forthcoming that the avirulent strain of diphtheria organism can become virulent. It is, however, recognised that in exceptional instances virulent and avirulent strains may exist at one and the same time and be obtained in the same culture from the throat or nose. This exceptional occurrence has been found in two cases (L.S. and W.P.) out of a total of 246 children, or less than 1 per cent., whose diphtheria cultures were sent to the Wellcome Research Laboratory for the virulence test during the past year. The two strains may also uncommonly alternate. The rare co-existence or alternation of the two types is regarded as being due to reinfection with one or the other strain of organism. The risk of the carriers of the avirulent organism becoming infected with virulent K.L.B. is of course no greater than that of an ordinary person becoming infected with virulent diphtheria germs. "Though indistinguishable morphologically and culturally," says Dr. Eagleton, "efforts at the Wellcome Research Laboratory have quite failed to change the virulent into the avirulent and vice versa in the test tube." Further, no success has attended the attempt to produce immunity to virulent strains by the injection of massive doses of the avirulent strain. Guthrie and his associates, publishing the results of their observations on diphtheria carriers in the Johns Hopkins Hospital Bulletin, November 1920, find no proof that avirulent bacilli can acquire virulence or give rise to clinical diphtheria, hence avirulent carriers are not a menace to anyone ; but the carrier of virulent K.L.B. occupies quite a different position. Needless to say the rare combination of virulent and avirulent strains is a complication difficult otherwise to explain or guard against save by the aid of periodical re-examination. Five cases or 2 per cent. of the total 246 tested, which were originally proved to be virulent by 9 separate examinations, yielded avirulent strains in 11 subsequent re-examinations and were in consequence re-admitted to school without harmful results. The children whose cultures prove virulent are excluded until re-examination on three successive occasions proves negative or until (as in the five cases quoted) the diphtheria bacillus isolated proves to be avirulent. For the 12 months between April, 1921, and March, 1922, a total number of 6,973 bacteriological examinations in stained film preparations from cultures from the throat and nose were made, of this total 5,795 were passed as negative. In 697 or 10 per cent. K.L.B. were found and in 481 or 7 per cent. suspicious organisms resembling K.L.B. were reported, or in a total of 1,178 K.L.B. were found or suspected. With the object of isolating the diphtheria bacillus in pure culture, where possible, for transmission to the Wellcome Research Laboratory for virulence tests, detailed investigations by plate culture and sub-culture were carried out in 568 cases represented by a total of 802 separate examinations, and selected from the 1,178 in which K.L.B. or suspicious organisms were found in the preliminary cultures from the throat or nose. The diphtheria bacillus was successfully isolated in 334 examinations of 246 cases, including 74 which had originally been reported as suspicious. In 171 where the organism was found in preliminary cultures attempts at isolating in pure culture failed, the plate cultures yielding diphtheroid organisms 9 London1911-1920 SEASONAL PREVALENCE OF TE PRINCIPAL NOTIFIABLE DISEASES AND DISEASES OF INFANTS 61712 c 10 or B. Hoffmanni only. 310 detailed examinations were made of cultures from the throat or nose originally reported suspicious: in 47 of these the K.L.B. were isolated and in the remainder only diphtheroids or B. Hoffmanni were obtained in sub-culture. Twenty-two examinations were made of cultures from the ear in cases of discharging ears, but in no case was true morphological K.L.B. isolated, the majority yielding diphtheroid organisms. A case of conjunctivitis and one of whitlow also yielded diphtheroid organisms only. In addition to isolating the K.L.B. and bacilli belonging to the diphtheroid group useful confirmatory biochemical tests were applied to a large number of the strains, involving sub-culture in tubes containing Hiss' fluid serum with glucose, saccharose and dextrin, respectively, and blue litmus to indicate fermentative changes. B. Diphtheriæ ferments glucose and dextrin-with production of acid, but causing no change with saccharose, whereas a common diphtheria organism, such as B. Xerosis, produces acid in the glucose and saccharose but not with dextrin, and B. Hoffmanni the commonest of the diphtheroids fails to change any of the three. The isolated cultures of K.L.B. obtained in 334 separate examinations of 246 cases were sent to the Wellcome Research Laboratory for virulence tests with the following results. Examinations Cases. K.L.B. virulent in 205 158 K.L.B. avirulent in 129 88 including 5 cases in which the original cultures were found to be virulent in 9 examinations and later cultures avirulent in 11 examinations. In addition to the cultures of morphological K.L.B. 54 cultures of diphtheroid organisms from the throat and nose and four from the ear (from 65 cases) were also sent for virulence testing and in every instance proved avirulent. The total number of strains of diphtheria bacilli and diphtheroid organisms tested for virulence between April, 1921, and March, 1922, amounted to 397 from 304 cases. In 230 of the 246 cases in which the K.L.B. were tested for virulence particulars were stated— concerning abnormalities of the throat, nose or ear; history of sore throat or other illness; history of sore throat or diphtheria carriers in members of the family or contact with cases of diphtheria.. 140 out of the 230 belonged to the first of these categories, those showing various abnormalities, e.g., tonsillitis, enlarged, unhealthy or congested tonsils, congested fauces or uvula, pharyngitis, nasal discharge, excoriation of the nasal passages, nasal crusts, or adenoids. The diphtheria bacillus was virulent in 90 of these and avirulent in 50. Analysis of the other conditions showed as follows:— K.L.B. virulent K.L.B avirulent History of sore throat or cold. 21 13 History of having been in hospital with diphtheria. 10 2 Family history of sore throats or carriers. 7 0 Contacts of cases of diphtheria. 23 7 No history obtained as to contact with infection. No defects recorded. 19 10 Diarrhœa and Enteritis. There were 2,152 deaths among children under two years of age from diarrhoea and enteritis in London in 1921, giving a mortality rate per thousand births of 21.55; this rate is in excess of that for the four preceding years, but is very slightly below the average for the ten years 1911-1920. In view of the high average temperature of the summer, the mortality from infantile diarrhoea was remarkably low. The relationship between summer temperature and diarrhoea mortality has been the subject of much study. From the earliest days of death registration the London records have shown so close a dependence of diarrhœal mortality upon the excess or deficiency of summer temperature that it has been possible until recent years to deduce from the temperature records for a given summer the approximate total deaths from summer diarrhœa. In order to determine how far the relatively low mortality from summer diarrhoea of recent years results from reduced temperature, or is due to other circumstances, the relationship between the deviations from normal of temperature and summer diarrhœa mortality among infants under one year of age, has been calculated from the records of the years 1881— 1900, and the results have been applied to the period 1876-1921. The actual and the calculated deaths for a period including the summer months (July, August and September) of each year are shown at the foot of the diagram on page 9. It will be seen that for the thirty-eight years up to 1914, the calculated deaths are in very close agreement with the numbers recorded; the agreement is indeed remarkable when regard is had to changes in classification which occurred in the course of the period, more especially late in the nineties. In 1914, and subsequent years there is a remarkable difference between the actual and estimated mortality, and as this takes in the whole of the war period, the probability that the conditions brought about by the war have been responsible for the reduced mortality at once suggests itself. There will, however, be found some indication in the diagram that the change which appears at first sight to have occurred abruptly in 1914, is really foreshadowed some years earlier. Up to 1905, the actual deaths are sometimes below and sometimes above the number calculated from the temperature; but after 1905, with the exception of 1913, the calculated deaths always exceed the actual number, and the excess in 1912 (a wet summer), was actually greater than in 1914. Again the excess in 1914 can scarcely be attributed to war conditions in any large measure, even taking into account the fact that most of the deaths occurred in September; in the earlier months of the war there was no scarcity of food, and therefore no great change of diet affecting infants although the immediate increase in the price of sugar may not have been without its effect upon the feeding of children of the poorest classes. The period 1916-19, is that in which the effects of the war would be expected to be most apparent, and although the divergence of the calculated from the actual mortality in this period is very conspicuous, it is just as apparent in the two succeeding years. There is no doubt that the separation allowances made during the war, combined with the rationing of food, improved the quality and also even the quantity of food supply of the very poor, of the class that is in which the mortality from infantile diarrhœa is greatest. In addition there have been the special administrative measures, directed to the care of expectant and nursing mothers, as well as of their infants; these were inaugurated before the war, and were further developed in spite of war conditions. Over and above these direct influences upon child welfare, there is 11 the effect of the introduction of national insurance in bringing the practitioner into closer relation with the homes of the poor. The divergence of the calculated from the actual deaths from summer diarrhoea is not the only change which has occurred in recent years. There is an interesting point with regard to the time relations of the curve of summer temperature and that of diarrhœal deaths. to which attention was particularly directed recently by Dr. John Brownlee. The relationship of the two curves can best be studied in years in which the temperature has risen sharply well above the normal, and then fallen so as to give a well-defined peak to the curve, as in the years 1881,1886,1896-7,1904-5, and 1911. In the more recent similar years, 1916, 1919 and 1921, while the relationship as to contour is still fairly maintained it is remarkable that the peak of the mortality curve instead of lagging behind that of the temperature curve by a fortnight or so, is actually as much as from seven to eight weeks later. In 1842 and 1852 both years with extreme summer temperature, the lag was about one week; 1911 was, however, hotter than either of those years yet there was a lag of about three weeks, so the amount of lag does not depend entirely upon the excess of temperature, although it is noticed that in a series of proximate years the lag tends to be shorter in those with excessive temperature. At the foot of the diagram (p. 9) approximate curves are shown representing the actual summer deaths and the number estimated from the temperature readings in three successive ten year periods ended 1920. The increase in the lag of the mortality curve appears to have commenced after 1900, and it was about this time that the marked decline of infantile mortality generally commenced. When the deaths from all causes other than diarrhœa during successive summers since 1876 are examined it is found that after remaining constant for twenty-five years 1876-1900, the mortality falls down to the present time. The change cannot be due to differences of classification, since the diarrhœa mortality also falls, nor can administrative measures for promoting infant welfare come into account so far back. There can be no doubt, however, that during the closing years of the last century a steadily increasing amount of attention was directed to infant mortality, and it was also about this period that the critical movement of population north of the Thames began to assume considerable proportions thus lessening overcrowding in certain poorer localities, Thus infants born after 1900 seem to have been rendered more resistant, and in correspondence with this there was improvement in the death-rate at parental ages. Herein lies perhaps the explanation of the gradually increasing lag of summer diarrhceal mortality upon the temperature excess, namely increased power to withstand the strain of abnormal conditions. The late Dr. G. B. Longstaff was disposed to insist upon the effect of hot weather upon the nervous system plus the influence of "products of putrefaction which are dependent upon prolonged high temperature"; the lag of the mortality after the summer temperature does not seem consistent with the hypothesis of perverted nervous influence alone, though there is the possibility that the strain caused by bodily adjustment to abnormal temperature may open the way to zymotic processes in the intestines resulting perhaps eventually in development of so-called specific organisms. At any rate the similarity of contour of the temperature curve and that of the diarrhœal mortality, maintained in spite of the lag being increased from two to as much as eight weeks, shows that the temperature is the fundamental factor; with the increase in lag the fatality of diarrhœa has diminished, and both circumstances appear to be due to improved physical conditions. A possible explanation of the decrease in summer diarrhœa mortality in recent years is the replacement of horse traction by mechanical traction, and the resulting decrease in the amount of horse manure. The relationship between summer diarrhœa, and fly prevalence, both generally and in selected areas in the neighbourhood of stables, is discussed in the report for 1907 (Appendix II. Report on Nuisance from Flies, pp. 8-9). During 1921 (52 weeks), there were 329 cases of typhoid fever notified in London, as compared with 387 in 1920. The deaths numbered 60, as against 48 in 1920. Of the total cases notified, 193 were admitted to the hospitals of the Metropolitan Asylums Board, of these it was found that 82 or 42.5 per cent. were not typhoid fever. Of the 60 deaths occurring among Londoners 14 were inmates of County asylums outside the county boundary, and as the cases occurring in these institutions are not notifiable in London the deaths comparable with the notifications become reduced to 46. Typhoid fever. In 19 instances more than one case was notified in the same house. In Kensington six cases occurred in one house, in Stepney and Poplar four cases; in St. Pancras (twice), Chelsea, Wandsworth and Finsbury three cases; and in the eleven remaining instances there were two cases. In the Kensington group one of the cases proved fatal; the source of infection was not established. The four cases in a Poplar house were all children of one family of ages from 7 to 15 years; the first case was thought to have arisen from river bathing, and the other three were considered to have been infected by this case. In respect of the household of four attacked in Stepney, no information could be obtained as to the possible source of the first case; the time relation of the onset in the other three cases was held to be suggestive of infection by the original case. In one of the St. Pancras houses in which three cases occurred the question of possible infection by a carrier, a cook employed by the family was considered; it was, however, not possible to complete the investigation. In the other St. Pancras household with three cases, fish obtained from a barrow is mentioned as a possible source, but there is also the possibility that an illness which preceded the three notified cases was typhoid, although not recognised as such at the time. Nothing was elicited to account for the three cases (two nurses and a maid) in one house in Wandsworth. In the Chelsea instance of three cases in a family the information points to the disease having been acquired while away from London; in Finsbury, where three children of school age were simultaneously attacked, wet fish is mentioned as the possible source of infection. In the 50 cases in respect of which confirmatory bacteriological results were obtained, the presence of B. Typhosus was shown in 7 cases; 25 were described as "Paratyphoid"; while 6 were described as Paratyphoid A and 12 as Paratyphoid B. 61742 C 2 12 Of 172 cases in which a possible source of infection is mentioned, reference is made in 30 to shellfish, in 20 to fish, in 10 to watercress and in 23 cases to other food. Infection is attributed in 31 instances to contact with other cases, and in 34 cases the disease was thought to have been contracted during residence outside the County Antityphoid inoculation. Reference was made last year to reports on Antityphoid Inoculation of Civil Populations" in various parts of the world; and more particularly to some French and American experiences relating to groups of men and women coming under review in particular institutions and in "a number of localities." These results were contrasted with those yielded by the London population male and female, at ages 20-45. The last named data did not, it was pointed out, "lend support to the view that inoculation has afforded any appreciable lasting protection to the men at risk." A paper by Professor Charles Achard has recently been published (Lancet April 15th, 1922), giving a " Detailed Statistical Study" of the figures published by M. Chauffard and M. Em. Sergent; also Professor Achard's own experiences. The numbers dealt with are, however, quite small. The first series, that of M. Chauffard, contrasts 11 men and 42 women attacked in 1912-13 with 10 men and 23 women attacked in 1918-20. The average age in the men had fallen from 24 years before the war to 17½ years in 1918-20; in the case of the women the average age remained the same in both periods, 27 years. In the second group, that of M. Sergent, there were 18 men and 9 women (average ages 27 and 26 respectively), attacked during 1911-13, and 4 men and 13 women (average ages 24 and 26 respectively) attacked in 1918-20. " These figures differ from those of M. Chauffard," says Professor Achard, "in that they show a much reduced total male incidence relative to that of females." Professor Achard's own figures relate to 30 patients, 21 women and 9 men—3 of the women (14 per cent.) and 3 of the men (33 per cent.) were under 20 years of age. In the absence of particulars as to the age constitution of the populations from which the patients in the three series were drawn, it is difficult to judge how far significance can be attached to the altered average age in the men as compared with the women. The London figures for 1921, on the other hand, which relate to the civilian population as a whole, confirm the impression yielded last year. In 1921 there were 65 cases among men aged 20-45 and 92 among women of the like ages. These figures represent rates which, having regard to the calculated excess of the numbers of women over men at those ages in the London population, do not very markedly differ in the two sexes. It is interesting to find that Professor Achard states "It is particularly in towns, where outsiders make short stays, and in certain bathing resorts, that typhoid is prevalent"; hence he says, " it is in these places that vaccination should be widely applied." The experience in this country corroborates the former finding ; but while the premises are thus the same an entirely different conclusion must follow; here (as in France also) in towns and in certain seaside resorts typhoid is apt to be prevalent; but typhoid in this country is as a rule food-borne, in fact attributable to infected fish and shellfish; there is in fact, no evidence, so far as London is concerned, that vaccination protects against the incidence of typhoid, for the figures show very much the same incidence of the disease upon men aged 20-45, a large proportion of whom were vaccinated during the war, and upon women 20-45 who only in rare instances had been vaccinated. Water and food borna typhoid fever. In last year's report reference was made to the instructive figures given in the ninth annual report on " Typhoid in the Large Cities of the United States in 1920." The corresponding tenth annual report is now available (Journal of the American Med. Assoc., 1922, p. 890). There is a slight set back manifested in these large cities during the last 10 or 15 years. The report states: "There is no doubt that 1921 was relatively speaking a 'typhoid year.' Not only did the majority of cities experience an increase—although generally slight—over the typhoid rate of the previous year, but the Honour Roll, including cities with a rate under 2.0 per 100,000 numbered only 5, as against 10 in 1920 and 8 in 1919. Cities with a rate over 10.0 increased in number from 5 in 1920 to 11 in 1921." The rate for all the cities was, however, "less than half the rate for 1916." The decrease is mainly attributed to improvement, and in many cases to chlorination, of water supplies. In some instances " immunisation was given to persons exposed to typhoid cases, but relatively few persons in the general civilian population voluntarily sought immunisation." Stress is laid upon the fact that many persons were infected in "out of town localities." Mention is made, too, of contamination of food, of milk outbreaks and of an outbreak at a "country club luncheon," but there is a curious absence of reference to shellfish infection save in the case of New York where five cases were so ascribed. Allusion is made in the report to risk connected with indulging in swimming in polluted harbour water in New Haven, Connecticut, a place familiar, as being associated with the original oyster outbreak reported upon by Professor Conn. Judging by other reports from America, however, a large measure of attention has been devoted to the question of pollution of tidal waters with special reference to shellfish bearing areas. It may be that the diminution of typhoid in American cities is largely ascribable to improvement in this respect, as is undoubtedly the case in this country. Typhoid fever caused by shellfish. The practical issue in regard to typhoid fever, which presses for decision at the present time, is whether the control over spread of this disease is to be maintained and further strengthened by working on the epidemiological lines, first laid down by Dr. Bulstrode in his classical oyster report of 1896, or on rival bacteriological lines, in compliance with which the stress is placed upon the supposed risk from healthy carriers and the need of combating this by vaccination. In a paper read before the Metropolitan Branch of the Society of Medical Officers of Health last year (Public Health, December, 1921), an attempt was made to show that the mischief responsible for typhoid fever in London during at any rate the last 25 years had been traced to remote estuaries and distant foreshores, and that full control of the disease is to be secured by cutting off polluted supplies of fish and shellfish, and not by attempting to segregate healthy carriers of bacilli, or advocating the general practice of antityphoid vaccination. This thesis may be supported by the following experience from America. 13 During the war (March, 1916), the result of an "Investigation of the pollution of tidal waters of Maryland and Virginia with special reference to shellfish bearing areas," by Hugh S. Cumming, was published by the Government Printing Office, Washington. The report is a fitting sequel to Dr. Bulstrode's study of the same problem in this country in 1896. Chesapeake Bay is the largest bay on the Atlantic seaboard of the United States, it is about 170 miles long and from 2¾ to 20 miles broad, on it are the ports of Baltimore, Norfolk, Newport News, Richmond and Washington, and near its mouth are Hampton Roads, one of the most important naval and military bases on the Atlantic coast. Baltimore is said to be "the greatest oyster market and distributing centre in the country." Hampton is "one of the most important oyster, fish and crab centres in the United States." Norfolk is "one of the great oyster shucking and shipping centres of the world." Here on the great scale, for the drainage area of Cheapseake Bay now has living upon it a population exceeding 6,000,000, there have been exhibited during the last 70 years phenomena like those with which Bulstrode made epidemiologists in this country familiar 25 years ago. Maryland, the State including the northern part of Chesapeake Bay, had reached an output of 15,000,000 bushels of oysters in 1884, this had fallen to 3,500,000 bushels in 1911; quite early in the middle of the 19th century pioneers established " wagon lines as far west as Pittsburgh—distribution was enormously facilitated with the construction of the Baltimore and Ohio and other railroads." Virginia, the State including the southern part of the bay, was later in the field ; it had, however, attained to an output of 10,000,000 bushels in 1907, and then (after a marked fall in 1908) reached a total of more than 13,000,000 bushels in 1912. "The State of Maryland has laws authorising the State Department of Health to direct and regulate the construction of sewage disposal plants where necessary for the prevention of pollution. Although more vitally affected than any other State by injury to her shellfish industry, and despite the millions of dollars brought into the State by this industry, Virginia has no laws regulating the pollution of her water." The survey shows the need for a great deal of improvement. In Chincoteague Island, from which place alone between 300,000 and 500,000 bushels of oysters and several million clams are shipped annually all over the country, "a condition was found which was particularly dangerous and must eventually have resulted in disaster In Hampton Creek conditions existed which were intolerable; cases of illness have doubtless been caused for years by eating oysters from the Creek In Mill Creek similar conditions existed In Annapolis Harbour and especially in Spa Creek conditions were found similar to those in Hampton In Norfolk Harbour certain beds used were found dangerously polluted and the State and Federal authorities notified Of the 400,000 or 500,000 acres of shellfish producing areas in the waters of Maryland and Virginia about 2,000 to 2,500 acres or one half of 1 per cent. have been found polluted The principal problem is how to prevent absolutely the taking of oysters from beds which have been condemned." The report to be fully appreciated must be very carefully studied. The considerable prevalences of typhoid, particularly in July and August in communities with a few thousand inhabitants, are significant; they constitute as is stated, for example, "a menace to numerous oyster beds half a mile away"; evidence, moreover, of serious injury to fish life generally is given. There is, in one instance, the statement "there is no local health officer and no health authority other than the Mayor and sergeant. These men are energetic and conscientious but they are not physicians nor trained sanitarians." Again, it is noted, "the town is said to be in a receptive mood with regard to the installation of a complete sewage system, preliminary plans for which have been drawn." In another case, "all other considerations aside," it is said, "the City can hardly afford to jeopardise in this way an industry which is of so much importance to its prosperity." The custom of keeping oysters on the foreshore near privies "is deprecated, and so is the keeping of oysters in a pile on a bed not far from a sewer outfall." "Surface privies are certainly," it is agreed, "safer than would be a sewer discharging fresh sewage directly over the beds." The set of tides and currents is studied, a river flowing through a harbour which forms a "collecting basin and (sewage) disposal plant," is traced, all save the last hours of ebb flow, into Chesapeake Bay, and is then carried towards two strands near by, where the shellfish have been found to suffer from "green gill," and the local oyster trade "has been practically negligible for several seasons:" Then, too, there are detailed descriptions of float experiments, with the comment" These results together with the topographical study left no doubt that oysters from such a source were unfit for human consumption." Considerable improvement had apparently resulted from the investigation and report. The writer says: "For the past eight or ten years the consuming public all over the country has had the opinion that the oyster is a rather dangerous article of food"; and he adds "The immediate result of this condition has been injurious to the shellfish industry; the ultimate result will be a great good to the industry." It seems difficult to escape the conclusion that the marked decline in typhoid fever in the large American cities and presumably in smaller places in the neighbourhood of shellfish layings too, during the last ten or fifteen years, has resulted from recognition of the need of "preventing the taking of oysters from infected waters and the handling of oysters in an insanitary manner." A considerable measure of improvement was effected in this country 10 or more years earlier than in America, with corresponding beneficial influence as regards the typhoid death-rate; but here, as there, remains the difficulty of "preventing absolutely the taking of oysters (and of certain other shellfish also) from beds which have been condemned." In one such instance cited for example, the State of Virginia "several years ago forbade the taking of oysters for sale as food from a particular area In 1916, there had been no enforcement of the law," and Surgeon Hugh S. Cumming writes, "tongers were observed daily all over the forbidden area." "From a commercial standpoint," he adds, "the oysters 14 actually taken are not an important factor. So long, however, as the oysters from these dangerous areas are allowed to be sold by ignorant or unscrupulous men, suspicion will rest upon all shipments from the port." Study of the Report as a whole incidentally causes the reader to wonder how it comes about that importance is still attached, perhaps more largely in America than here, to the healthy carrier hypothesis. Influenza, A severe epidemic of influenza occurred practically throughout Europe towards the end of 1921. In England the areas earliest attacked were certain parts of the West Riding of Yorkshire and of Nottinghamshire and Derbyshire, where the epidemic began in the latter half of November ; other parts of these counties were attacked about the same time as London, where epidemic influenza was not clearly present until more than a month later. In the areas first affected the epidemic had practically run its course before there was general incidence in the rest of the country. In London during November the mortality from bronchitis was exceptionally high for the time of year, but this was accounted for by the period of very cold weather which followed upon a warm and dry autumn. There were, nevertheless signs and portents of the approach of influenza, sporadic outbreaks in the schools being observed from about the middle of the autumn term. It is of interest to note that in Franklin Parsons' paper* on the first four epidemics of the nineties of last century, Yorkshire is mentioned as among the first areas affected in the great epidemic of 1891. So far as may be judged from the mortality returns, influenza became epidemic in Yorkshire earlier in 1921 than in any of the principal cities on the continent. During the course of the epidemic, about 2,200 deaths in London, were attributed to influenza and taking into account the deaths from complications it is estimated that not less than 5,000 deaths were caused by the epidemic. This is the same as the similar estimate for the epidemic of FebruaryMarch, 1919. The two epidemics of 1918, were estimated to have caused 18,000 deaths in London. The proportion of deaths due to pneumonia and bronchitis as compared with those certified as due to influenza was greater in the 1921-2 prevalence than in any of the 1918-19 epidemics. The temperature during the course of the epidemic was rather above the average, and therefore it is justifiable to assume that the excess in mortality form these causes which, except in influenza epidemics,depend directly upon low temperature, was the result of the epidemic alone. The contrast in the age-incidence of mortality in the epidemic of 1919, and in that of last year is remarkable : in the earlier epidemic the maximum mortality occurred at the ages between 25 and 35, and at these ages the deaths stood out clearly from those at other ages, giving rise to the opinion that the incidence among munition workers had been excessive and was responsible for this feature. In the epidemic of 1921-2 the excess at ages 25—35 is practically absent, the age of highest mortality being 65—75, as in the epidemics of the nineties ; though it must be added that the excess at the higher ages is nothing like as great as in those epidemics. Ihe actual and relative incidence of death at various age-periods certified as due to influenza in the periods of marked epidemic prevalence in 1921-2, and in the three preceding epidemics was as follows:— Age. Summer, 1018. Autumn, 1918. Winter, 1919. Winter, 1921-22. Deaths. Total, =1,000. Deaths. Total =1,000. Deaths. Total. =1,000. Deaths. Total, =1,000. 0— 16 17 228 20 87 26 82 37 1— 12 12 359 31 61 19 102 46 2— 21 22 839 72 110 34 67 30 5— 76 79 1,066 91 109 33 39 18 15— 183 190 1,849 158 397 121 82 37 25— 212 219 2,992 256 792 242 206 93 35— 121 125 1,420 122 415 127 216 98 45— 122 126 1,150 99 430 131 326 147 56— 97 100 766 66 384 117 364 165 65— 72 75 713 61 326 99 446 202 75+ 34 35 281 24 168 51 281 127 Total 966 1,000 11,663 1,000 3,279 1,000 2,211 1,000 It would appear from the records of school attendance that the number of children attacked in 1921-2, was greater than in the winter epidemic of 1919, the percentage of attendance being particularly low in the City, Stepney, Bethnal Green and Poplar. On the other hand the number of cases of sudden illness attributed to influenza, in the streets, necessitating removal in the Council's ambulances, did not exceed 25, the greatest number in any week being 13, in the second week of this year. In the winter epidemic of 1919, there were more than 120 such cases, the maximum number in one week being 32. The influenzal group of diseases. Reference was made last year to the Ministry of Health Report on the great pandemic of 1918-19, and to the description given therein of the "setting" of an influenza pandemic in the midst of " parallel or allied clinical maladies" of nervous, gastro-intestinal and respiratory illnesses. The improved facilities of recent years for dissemination of information with reference to such obscure epidemic prevalences and " new diseases " have brought to light further instances of the truth of the observation made last year that quite a revolution is being worked in regard to the epidemiology of diseases of the influenzal group. As was stated in the Ministry of Health report" The admittedly vague concept of an 'epidemic constitution' does indeed correspond to something in nature there really is a development over a series of years of various clinical forms of infective disease, which tend to assume a generic type and to prevail before and after an epidemic of influenza." In 1919 and 1920, it was, of course, only possible to consider forerunners of the pandemic, now particulars are coming to * Transactions of the Epidemiological Society, N.S., vol. xiii., p. 116. 15 hand respecting the "trailers," to use Leichtenstern's term. With regard to these, new facts emerge almost day by day. In the years round about the pandemics prior to that of 1890, attention had been more especially focussed upon the relationship of certain respiratory diseases to influenza, though one plain instance, that of the "cold plague" of 1812-14 (Lancet 11th Mar., 1922, p. 512), remained unrecognised until it was recently unearthed by the Hon. W. R. Riddel!. In the years prior to 1918, there was intensive study of the nervous diseases associated with influenza. Recent experience goes to emphasise anew the fact that the gastro-intestinal forms of influenza also merit more careful consideration than has hitherto been accorded to them; moreover, careful study of "scarlet fever" in London and elsewhere during the last two years has led to recognition of failure to recognise the influenzal nature of outbreaks of febrile illness accompanied at one time by sore throat and glandular enlargement, at another by vomiting or diarrhoea, and yet further occasionally associated in particular instances with a rash simulating scarlet fever, measles or rötheln; while again in other cases, during the last two or three years, influenza has mimicked appendicitis or one of the fevers of the typhoid group, particularly paratyphoid B. The records of epidemic disease in parts of the world which apparently suffer comparatively lightly from influenza, for example the sparsely inhabited areas, still need to be much more carefully explored than has hitherto been found possible: work such as that done by Brorström in rural Sweden was largely responsible for bringing to light the close association between influenza and poliomyelitis. Again, influenza in the tropics has been comparatively speaking little studied; it has been described as "dengue" or as "3 day" or "5 day fever," and has been supposed to be as peculiar to Durban, or Sierra Leone, or some far Eastern port, as the "sweating sickness" was held to be characteristically and indeed exclusively "English" in the 15th century. Inter-pandemic periods of years in tropical regions are for the most part left blank so far as influenzal prevalences are concerned in all the records; the nervous or other forerunners of influenza, and its trailers, have been lost among prevalences of typho-malarias, paralytic beri beris, or have otherwise gone astray; again, for examples of gastrointestinal forms of influenza one would naturally turn to hot countries, but as to any such the records remain silent. The study, however, of the behaviour of influenza in the large cities of Europe, and of the United States and Canada, clearly shows that while epidemiology cannot fail to take account of years in which influenza prevails in pandemic phase, note must also be made of the years shortly preceding and following the pandemic years, which also bear the impress of the "influence" though in considerably modified form; and, thereupon, it may be inferred with some show of probability that at the midpoints between pandemic and pandemic, in the troughs of the pandemic waves, the " influence " is also there, but is, so to speak, in mufti, exhibiting mainly its immunising effects, and thus appearing to play a far less important part than it assumes when the population has become susceptible to influenza in pandemic phase. Much further light upon this question of immunisation would doubtless be forthcoming, were it only possible to learn something of the behaviour of the influenzal group of diseases (not omitting reference to some of the so-called dengues and beri beris) in the great aggregations of populations in British India or in China; or again, if it were possible to examine the influenza history of some of those remote and barely populated areas, such as Greenland or the Kirghiz Steppes, which never seem to figure in reports on influenza unless it be as suspected sources of origin for one or other of the pandemic waves. It may here appropriately be mentioned that a letter (dated 29th October, 1921), was received from Dr. Chas. Porter, Medical Officer of Health of Johannesburg, in which he states that following upon outbreaks in that city, in 1918 and 1919, of encephalo-myelitis with or without lethargic symptoms, a recrudescence of the condition had occurred during the preceding six weeks. He says, "Complaint has been of influenza, but instead of symptoms being pulmonary, gastric or in the back or legs they are cerebral, e.g., headache, diplopia, meningitis, paresis of limbs, mental obfuscation, etc., 40 per cent of the graver attacks being fatal." He adds, "The illness referred to has been variously diagnosed as influenza or typhoid or cerebrospinal meningitis. Against the latter diagnosis, however, are the facts that in nearly every case, examination of the cerebrospinal fluid has been negative and lumbar puncture and Flexner's serum have proved useless." In previous reports reference has been made to recent laboratory work on lines which run parallel with those representing the trend of epidemiological observation regarding the influenzal group of diseases during the last few years. F. d'Herelle whose work, originally carried out in connection with dysentery, has aroused considerable interest, has just published a monograph on the subject ("Le Bacteriophage son rôle dans l'immunite," Paris, 1921. Masson et Cie.). His contention, briefly expressed is as follows: Bacteriology has hitherto been concerned merely with the " problem of two bodies —bacterium and cultivating medium—the latter being either the actual host invaded by the bacterium or the medium in which the germ is cultivated. This problem was already a sufficiently complex one; far less complex, however, than the "problem of three bodies " with which bacteriologists are now confronted. In this latter case d'Herelle contends that it is necessary to study the interactions between first the medium (whether the cultivating medium or the invaded host itself), second the bacterial parasite, and third the ultra-microscopic bacteriophage which grows at the expense of the bacterial parasite. These observations have particular interest in connection with recent work on influenza and the influenzal group of diseases. The number of cases of cerebrospinal fever and post basic meningitis notified during 1921 was 109 as compared with 164 for the previous year, thus continuing the steady decline which has taken place in the incidence of the disease in the past five years. Of the 109 cases notified, 20 were not confirmed as cases of cerebrospinal fever or post basic meningitis; on the other hand 25 cases were recorded, mainly through the Registrar General's Death Returns, which were not notified under the Act. The actual number of cases was therefore 114, of which 89 (78 per cent.) proved fatal. Cerebrospinal fever. 16 Poliomyelitis Polioencephalitis and Encephalitis Lethargica. The number of cases of poliomyelitis and polioencephalitis notified during 1921 was 59. In three cases the diagnosis was revised, whilst another was considered to be doubtful. During 1921, there were 243 cases of encephalitis lethargica notified of which 87 were notified during January, and 50 in February. The disease had already commenced to increase in prevalence in December, 1920, and reached its climax during January 1921. Of the 243 cases notified 45 proved not to be genuine cases and in 9 others the diagnosis was considered to be doubtful. Two further cases were recorded but were not notified officially. Of the 191 actual cases, 60 (31 per cent.) proved fatal. The following table shows the age distribution of actual cases of cerebrospinal meningitis, poliomyelitis and encephalitis lethargica during 1921. Under 3. 3-5. 5-10. 10-20. 20-30. 30-10. 40-50. 50-60. Over 60. Total. Cerebrospinal meningitis 73 3 11 9 8 1 4 4 1 114 Encephalitis lethargica 3 3 17 54 31 33 28 16 15 191 Poliomyelitis 24 6 10 12 1 1 1 - - 55 The following table shows the yearly incidence (of cases notified) of cerebrospinal meningitis and poliomyelitis since 1912, and of encephalitis lethargica since 1919, when it was first made notifiable. 1912. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. Cerebrospinal meningitis 105 92 73 674 432 430 265 199 164 109 Poliomyelitis 132 145 93 97 197 53 53 96 55 59 Encephalits lethargica Not made notifide untill 1st January, 1919. 86 149 243 Laboratory work and assistance in diagnosis During 1921, as in former years, the services of the Council's medical staff were placed at the disposal of medical officers of health and medical practitioners in suspected cases of cerebrospinal meningitis, encephalitis lethargica, etc., and in this connection 104 cases of illness associated with cerebral conditions were investigated. The diagnosis was thus established in instances in which, without the expert advice and pathological enquiry, it could not otherwise have been arrived at. B.—Administration. It may be noted at the outset that certain statistical infoimaticn available is summarised in Table II. on page 25, and details connected with the administration of the General Powers Acts (Tuberculous milk) and with the supervision of slaughterhouses, cowhouses, and offensive trades, will be found in Chapter XXV. Nuisances. Correspondence ensued between the Council and the St. Pancras Metropolitan Borough Council on a complaint by inhabitants of that district, as to nuisance experienced from the emission of dust and grit from the chimney shafts of the borough council's electricity works and dust destructor. An improvement was effected and steps were taken to prevent a recurrence of the nuisance. Offensive trades. During the year the right to carry on the following offensive businesses lapsed by reason of their discontinuance for the statutory period of nine months, viz., the business of a fat melter in Wandsworth, a manure manufacturer in Bermondsey, and a tripe boiler in Southwark. Common and seamen's lodging houses, The supervision of the 181 common lodging houses licensed by the Council entailed 11,98? day visits and 468 night visits by the inspectors. In connection with the supervision of 51 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, the Council's inspectors paid 1,387 visits by day and 146 by night. Census of homeless persons. A census of homeless persons in London was taken on the night of 11th February, 1921. 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 (2 males and 8 females) were found sheltering under arches or on staircases. In the streets 48 men and 8 women were found, as compared with 28 men and 13 women in 1920, and 296 men and 76 women in the early part of 1914 before the war. In the common lodging houses, 14,000 persons were accommodated as compared with 14,333 in 1920, and 20,173 in 1914. In the free shelters and labour homes not licensed as common lodging houses there were 747 men, 165 women and 22 children, as compared with 86 men, 61 women and 2 children in 1920. The number of persons in London casual wards on the night in question was 176 males and 12 females and there were 263 vacant beds. The number of inmates at the date of the last census was 88, and the vacant beds numbered 308. At Rowton Houses 5,041 men were accommodated as aeainst 5.054 in 1920. and there were 5 vacant beds as against none in 1920. Housing of transmigrants. The Council's action with regard to the housing of transmigrants is dealt with in Chapter XXV. The traffic has been watched with the closest attention by the Council in view of the prevalence on a great scale of epidemic disease in Eastern Europe. The incidence of typhus in Russia in the years 1919 and 1920. has been given as exceeding two and three million cases respectively ; in 1921, the numbers had, however, fallen to approximately half a million. Relapsing fever, typhoid fever, and dysentery were also reported as very prevalent, but there was probably some confusion as regards diagnosis. 177,000 cases of Asiatic cholera had been reported up to the end of October, 1921, in Russia. In Poland 219 cases of smallpox were reported during the last 5 weeks of 1921. Housing Acts. Details of the progress made with the several represented insanitary areas and the housing schemes undertaken by the Council are specially dealt with in Chapter XXVII. The following table shows the houses in each borough in 1921 ; the number repaired under Section 28 of the Housing Act of 1919 ; certain other particulars as to conditions in 1921; and the action taken by the metropolitan borough councils under the provisions of Section 17 of the Housing and Town 17 Planning Act with regard to the making of representations and closing orders—the figures for the years 1914, 1915 to 1919, inclusive, and 1920, 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. 1921. 1921. 1921. 1921. 1921. 1914. 191519. 1920. 1921. 1914. 191519. 1920. 1921. 1914. 191519. 1920. 1921. Battersea 26,124 23,252 6 52 185 1 11 1 38 11 1 Bermondsey 19,170 18,880 20 30 — 13 — 1 46 — 1 36 — Bethnal Green 14,762 mainly — — 179 31 34 5 25 19 2 4 Camberwell, 41,018 — 1 236 159 3 — — — — — — 3 — Chelsea 11,433 2,455 — — — 3 — — - — — — - — 8 — — Deptford 16,966 — 7 109 119 & 18 flats 5 8 — - 5 7 — - 6 2 — —- Finsbury 11,157 — — — 30 tenements — 17 — - — 17 — - — — — 46 Fulham 20,200 26,700 t'm'nts — 9 350 tenements — 1 — - — 1 — - - - — — Greenwich 16,377 — — 73 135 193 - - - — — — — — — — — Hackney 34,710 13,000 — 40 40 — 29 — 16 — 34 — — — — — — Hammersmith 20,842 12,639 27 335 — 37 26 — 2 6 38 1 4 — 25 — 2 Hampstead 11,194 1,833 — — — 9 17 16 1 9 17 14 1 5 — 10 — Holbom 9,416 tenements 9,021 t'm'nts. — — — 2 4 1 — 2 2 1 — — — — Islington 40,000 26,700 — 148 flats 236 flats 21 10 1 — 1 8 1 — 6 1 — — Kensington. 27,699 8,087 — 67 54 13 9 — — 3 9 17 — — — — — Lambeth 37,710 28,282 — 140 70 7 38 17 — 7 — — — 7 — 6 67 Lewisham 35,000 — — 186 — — 9 — — 3 19 15 — 6 3 — — Paddington 17,610 9,443 9 — — 5 17 15 8 5 10 — 5 — — — 1 Poplar 22,472 22,472 — 120 & 15 t'm'nts. — 10 39 — 1 10 33 — 3 2 1 — — St. Marylebone 21,400 7,266 - - 1 20 19 6 3 — 1 St. Pancras 23,345 20,000 — 12 flats 254 flats & maisonettes 37 53 — — — 56 — — — — — Shoreditch 13,000 12,400 — 54 25 — 9 — — 3 17 — — 7 — — Southwark 18,470 12,116 — 160 — — 4 37 226 — — — 3 — 32 15 19 Stepney 38,914 38,914 31 17 15 6 27 2 — 6 59 — — — 6 — — Stoke Newington 8,042 6,430 — 18 flats — — — — — — — — — — — — — Wandsworth 66,189 42,316 — 718 246 - 1 - - - - - - - - - - Westminster, City of — - - - 2 blocks - 7 - 6 — 11 39 — — Woolwich 26,428 22,289 205 60 18 40 5 — 9 32 4 -j 7 5 2 — The subjoined table shows the number of sanitary officers and health visitors employed by the Sanitary sanitary authorities in London:— Sanitary area. Sanitary inspectors. Male. Female. Health visitors. Whole time. Part time. Whole time. Part time. City of London 9 1 — Battersea 11 - 2 5 2 Bermondsey 11 - 8 — Bethnal Green 10 10 — Camberwell 12 3 2 — Chelsea 4 1 1 1 Deptford 8 - 6 — Finsbury 8 1 5 — Fulham 9 1 - 5 Greenwich 6 1 - 6 1 Hackney 18 2 - 9 Hammersmith 9 1 - 3 — Hampstead 7 1 - 3 - Holbom 3 - 1 1 1 Islington 20 2 - 7 — Kensington 11 4 4 5 4 Lambeth 15 - 2 6 2 Lewisham 9 - 2 7 2 Paddington 9 2 - 2 - Poplar 10 1 - 9 - St. Marylebone 11 - 3 3 3 St. Pancras 14 4 2 4 2 Sboreditch 12 - - 5 - Southwark 14 2 - 10 - Stepney 20 - - 11 - Stoke Newington 2 - - 3 - Wandsworth 12 1 2 4 2 Westminster, City of 10 1 — 5 — Woolwich 10 1 2 5 2 London County 304 29 21 150 22 61742 D 18 Venereal diseases. Tuberculosis, Particulars of the Council's scheme for the treatment of venereal disease are given later in Chapter XXV. The Council's scheme for the treatment of tuberculosis is described later in Chapter XXV. Details of treatment, etc., are as follows:— The number of beds occupied in the winter season is always below the number occupied in the summer season. The average bed occupation for the year is approximately equal to the figure provided in the estimates, viz., 2,550. The total number of beds actually in use on 31st December, 1921, was as follows:- Adults. Metropolitan Voluntary Institutions. Asylums Board Insured. Ex-service. Uninsured. Children. Total. Total 240 209 86 460 995 487 221 139 209 1,056 727 430 225 669 2,051 Dr. Bards- well's Report Residential treatment of adults suffering from pulmonary tuberculosis First applications for treatment were received from—males (ex-Service men), 892 ; civilians, 1,765; females, 1,846 ; total 4,403. Applications for further treatment were received from—males (ex-Service men), 443 ; civilians, 241 ; females, 182 ; total 846. Of this total of 5,269 applications, 770, for various reasons were not proceeded with. Some applicants preferred to make their own arrangements, others proved unsuitable, some were found not to be suffering from tuberculosis, and others again were not London cases. The latter group were referred to their own authorities. A considerable number of the patients (1,636 in all) were sent direct to various institutions, without passing through observation beds. This group is made up largely of the surgical cases for which no observation beds are available, and advanced cases, as to the best disposal of which there was no doubt. The remaining applications, 2,863 in number, were passed through the Council's observation beds. A stay of a few weeks in these beds allowed the exact condition of the patients to be ascertained and the most suitable form of treatment to be determined. As already noted, a large number of cases of advanced disease were sent direct to institutions. The 2,863 observed include, therefore, the more favourable cases dealt with during the year. As a result of the observation, pulmonary tuberculosis was not confirmed in 434 cases, and confirmed in 2,429. The classification of the 2,429 tuberculous cases (including 12 surgical cases) was as follows:— Group A 478 cases or 19.7 per cent. Group B. 2 .. 1,093 cases or 44.9 per cent. ,, B. 1 .. 331 „ ,, 13.6 per cent. „ B. 3 515 ,, ,, 21.2percent. Thus of the total number observed, 809, or some 34 per cent, only, were "early cases"—the "true sanatorium case." The moderately advanced group accounted for 45 per cent. Many patients of this class were capable of substantial immediate benefit. The disposal of the 2,429 observed cases was as follows :— Further institutional treatment not needed 247 Transferred to training centres 3 Made their own arrangements for treatment 170 Died during observation 82 Transferred to institutions for advanced cases 195 Discharged for misconduct. 11 Elected to go to infirmaries 32 Transferred to sanatoriums 1,677 Transferred to surgical hospitals 12 Total 2,429 With respect to the distribution of the 1,677 patients sent to sanatoriums, the most favourable cases—Groups A and B 1, were sent to Frimley (183), The Downs—M.A.B. (100), Pinewood—M.A.B. (95), Winchmore Hill—M.A.B. (59), Great Baddow (34), Hermitage (28), Grosvenor (45), etc. The moderately advanced cases were sent chiefly to—The Downs (M.A.B.) (342), Winchmore-hill— M.A.B. (159), Pinewood—M.A.B. (62), Frimley (66), Great Baddow (67), Hermitage, Isle of Wight (54) etc. The following table shows the length of stay of the 2,863 cases (1,816 males, 1,047 females), passed through the observation beds. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. 4-5 weeks. 5-6 weeks. 6-7 weeks. 7-8 weeks. 8-9 weeks. 9-10 weeks. 10-11 weeks. 11-12 weeks. More than 12 weeks. Total. Tuberculous 48 78 189 421 592 363 232 174 93 60 46 30 103 2,429 Non-tuberculous 22 21 60 110 104 51 26 9 5 5 3 2 5 423 Doubtful 2 — 3 — 1 — 3 2 — — — — — 11 Included in this table are a considerable number of cases which, admitted for observation, were subsequently retained for special treatment, such as artificial pneumothorax, operative measures, etc. From time to time, also, patients after having been graded and marked out for disposal, had to be retained owing to the sanatorium accommodation being fully occupied. Incidentally, it may be stated that the observation beds arrangements have worked most satisfactorily. Results of sanatorium treatment. The results of sanatorium treatment are shown in the next table. Attention is drawn to the definition of the terms expressing these results, namely :— Q. Quiescent—i.e., no symptoms of tuberculosis and no signs of tuberculosis except such as are compatible with a completely healed lesion and in which sputum if present is free from tubercle bacilli. M.I. Much Improved—i.e., the condition is not quiescent, but (1) the general health is good; (2) working capacity is more or less restored ; (3) the signs and symptoms of tuberculosis are materially diminished. N.M.I. No material improvement. Quiescent and Much Improved represent a highly satisfactory response to treatment. Of the early cases, some 50 per cent, were discharged in these two categories, and of the moderately advanced cases, 30 per cent. 19 The large group made up of 50 per cent, to 60 per cent, of all the cases treated in sanatoriums discharged as " not materially improved," includes those whose condition was unchanged, those who became definitely worse, and those who made some trifling improvement only. Classification on admission to the institution. Condition at time of discharge. Duration of residential treatment. Totals. Percentage of class. Under 3 months. 3-6 months. 6-12 months. More than 12 months. Class A. 607 cases. 15.6 per cent. Quiescent 78 55 11 — 144 23.7 Much improved 81 73 21 3 178 29.3 No material improvement 175 90 18 1 284 46.8 Died in institution — 1 — — 1 0.2 Class B. Group 1. 448 cases. 11.5 per cent. Quiescent 23 23 8 - 54 12.1 Much improved 68 69 16 2 155 34.6 No material improvement 130 69 35 — 234 52.2 Died in institution 2 2 — 1 5 1.1 Class B. Group 2. 1,641 cases. 42.3 per cent. Quiescent 42 47 15 1 105 6.4 Much improved 171 161 56 4 392 23.9 No material improvement 606 351 136 10 1,103 67.2 Died in institution 23 13 3 2 41 2.5 Class B. Group 3. 1,190 cases. 30.6 per cent. Quiescent 7 5 — 1 13 1.1 Much improved 9 11 3 2 25 2.1 No material improvement 410 222 93 25 750 63.0 Died in institution 252 71 61 18 402 33.8 The demand made upon the Council for beds for children at the commencement of the Scheme in 1914, was greater for pulmonary than for non-pulmonary cases. This was probably due in some measure to the difficulty of securing sanatorium accommodation, many of the cases having to be limited to treatment in hospital followed by short periods in ordinary convalescent institutions. Since increased accommodation has become available there has been a steady growth in the surgical cases referred to the Council. On the other hand the number of pulmonary cases has declined. To some extent this is due to the accommodation available in open air day schools. For the purpose of comparison the same number of applications for treatment of children were examined for the years 1918 and 1921. The result shows that in 1918, the percentage of these applications were 68.6 per cent, pulmonary cases and 31.4 per cent, non-pulmonary cases. In 1921, the percentages were 56.7 per cent, and 43.3 per cent, respectively for pulmonary and non-pulmonary cases. The percentages of cases treated in the same periods were 72-4 per cent, pulmonary and 27.6 per cent, non-pulmonary in 1918, and 62.1 per cent, pulmonary and 37'9 per cent, non-pulmonary in 1921. The numbers receiving treatment on the 1st January, 1918, were 270 pulmonary and 107 non-pulmonary ; and on the 1st January, 1921, the numbers were 366 pulmonary and 338 non-pulmonary. The Council continued the scheme of co-operation with the Invalid Children's Aid Association under which, in return for a grant, the Association provides convalescent treatment for children and also assists 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 £2,250, which included a special grant of £150 to enable the Association to provide convalescence for children of necessitous parents, who, by reason of lack of employment, were unable to pay the usual contributions expected by the Association. During 1921 the Association received 379 applications for convalescent treatment and 355 children were sent away with assistance from the Council's grant. The remaining 24 were found to be ineligible. In addition to the above, 43 tuberculous children were sent away, the cost being met by the parents, so that no help was required from the grant-in-aid ; 27 children were supplied with surgical appliances with the help of the Council's grant. At the commencement of the year 1921, the Council had in use 704 beds for children, of which 278 were in voluntary institutions, and the remainder in Metropolitan Asylums Board institutions. The number under treatment on 31st December, 1921, was 665. On 1st January, 1921, 371 boys and 333 girls were under treatment, and 394 boys and 416 girls were sent away during the year. The total number treated during the year 1921, was therefore 1,514, as compared with 1,522 in 1920. In addition 355 children had the advantage of convalescence through the Invalid Children's Aid Association with financial assistance from the Council. The Council has provided five open-air schools for children notified under the Tuberculosis Regulations, 1912, as definitely suffering from tuberculosis of the lungs, or from tubercular glands without discharging sinuses. Kensal House (Paddington), Stormont House (Hackney), Springwell House (Battersea). the Elizabethan School (Fulham). and drove Hill-road School (Camberwell) Residential treatment of tuberculous children. Open-air schools for tubercu'ous children. The two last-named schools were opened during 1921, the former on 28th May and the latter on 28th November. Number on roll. Reasons for discharge. Gain or loss in weight. Accommodation. 31.12.20. 31.12.21. Admitted, 1921. Discharged, 1921. Fit E.S. Fit for work. Transferred to hospital or sanatoria. Removed from district. Transferred to special school. Other reasons. No. gained. Average gain in kilos. No. lost or stationary. Average loss in kilos. Elizabethan 50 - 56 33 6 5 1 - - - - 23 3.8 — — Kensal House 90 91 102 43 33 14 11 2 3 2 1 47 2.6 — — Springwell House 125 130 150 63 46 17 16 6 7 - - 101 2.9 — — Storraont House 75 83 84 31 31 14 15 3* 2 - — 54 3.5 — — * These were not discharge!, but transferred to the suspense roll. 61742 D 2 20 In the above figures concerning the gain in weight, only children who have been at the school for more than twelve months are included. The medical officer of Stormont House reports as follows :— " The progress of the children at the school has been most satisfactory. The above statistics show that every child has gained in weight, while the numbers discharged as fit for work together with those who have regained sufficiently in health to enable them to attend the elementary school, are distinctly encouraging. In view of the satisfactory results of treatment at this school it is regretted that the accommodation could not be increased by the formation of an additional class." The following report was received from the Medical Officer of Springwell House School:— " The general health of the children attending the School is good. There have been few cases of any serious illness amongst the children during the last year. The amount of infectious disease has been very small .... During 1921, an old scholars' club was formed on the initiative of the Head Teacher. The club meets in the evening six times during the year, and I am informed that about twenty-five usually attend." As in 1920, the Council arranged with the I.C.A.A. for children attending the Council's open air schools for tuberculous children, whose parents were unable to take them away for a holiday, to be sent for a fortnight's holiday. 220 children were sent away, the Council making a grant of £550 towards the cost of maintenance and travelling expenses. 129 boys were sent to Ampthill and 91 girls were sent to St. Leonards-on-Sea. Tuberculosis dispensaries. Reference was made in last year s annual report (Vol. 111., pp. 36-7), to the Council s action for the improvement and development of the tuberculosis dispensary service. The reforms were directed principally towards securing that the dispensaries are used as specialist consultation centres and as the medium for the early detection of the disease and other preventive work, treatment being limited to cases requiring special knowledge or skill or for persons who are not in a financial position to obtain private medical advice. A further inspection of the dispensaries made by Dr. Knobel during the autumn of 1921, indicated that the Council's action had reduced the congestion caused by prolonged periods of observation in doubtful cases and by extensive treatment by patients with drugs, but that there were still misconceptions as to the functions of the dispensaries. In this connection the problem of the advanced case is once more brought into prominence. Both on grounds of humanity and for precautionary purposes the tuberculosis officers feel it incumbent to visit these patients and to keep in touch with home conditions, with the result that a good deal of time, which could be more effectively devoted to the fundamental purposes of the dispensary service, is occupied with these cases. No satisfactory solution of this problem in London has yet presented itself. Segregation in small local Homes for advanced cases was at one time favoured, but it is now feared that, apart from the high cost of running small institutions, the stigma of being labelled Homes for the Dying would make them unpopular. It is now felt that large institutions at a long distance from the patients' homes would be equally unsuccessful owing to difficulty of visitation by friends. In Paddington as an experiment the tuberculosis officer has been appointed as a visiting consultant at the Infirmary, and it would appear that as the patients come under his personal observation they are less reluctant to enter the institution. This matter is engaging the attention of the Council. There is evidence that the tuberculosis officers are not yet fully acquainted with the incidence of tuberculosis in their areas. Many cases are notified under the Tuberculosis Regulations, 1912, only a short period before death, or even at death. Closer co-operation between the medical practitioners and the tuberculosis officer is necessary in order to secure consultation with the tuberculosis officer at an earlier stage when general practitioners have patients who present suspicious symptoms, and also examination by the tuberculosis officer of contacts of definite cases. It has not been possible to carry out the arrangements referred to in the last report for grouping three or four dispensaries with a hospital equipped with observation beds for purposes of obtaining prompt diagnosis in difficult cases. Observation beds have been mainly obtained by the Council in two hospitals (Brompton, and City of London Chest Hospital, Victoria Park) and it has been found necessary to revert to the original requirement that all the dispensaries shall be linked with the out-patients' departments of hospitals for the purpose of securing the necessary aids to diagnosis (e.g., X-ray), and special forms of treatment in difficult cases. The recent inspection of dispensaries, already referred to, has further shown that for various reasons some tuberculosis officers are still reluctant to take full advantage of these special facilities. On the other hand, there has been a tendency in some cases to make unnecessary use of X-ray examinations for purposes of diagnosis. As a rule, patients should not be referred for X-ray examination for purposes of diagnosis if tubercle bacilli have been found in the sputum, and three examinations of sputum with negative results should be made before resorting to X-ray examination. Mental Deficiency Act, 1913. Action with regard to dispensaries is described in Chapter XXVII. On 31st December, 1921, of the 2,455 cases being dealt with at the expense of the Council there were—in institutions, 1,062 ; under guardianship, 16 ; under supervision, 1,355 ; in places of safety awaiting other action, 22. There remained 2,446 out of the total number of 4,901 cases of alleged mental defect, of which notice has been received since the Act came into operation. These cases include 286 in which no action could be taken ; 917 ascertained to be not defective, or to be not London cases ; 413 dealt with through the Poor Law ; 482 removed from the register (died, discharged, or removed to mental hospitals or state institutions) and 348 still under consideration. During the year, 772 cases were examined with the following results:— Type. Mule. Female. Total. Type. Male Female. Total. Idiot 15 14 29 Not defective 21 41 62 Imbecile.117 87 204 Insufficient evidence 1 15 16 Feeble-minded 219 238 457 Total 375 397 72 Moral imbecile 2 2 4 21 The Council's scheme for the carrying out of the provisions of the Blind Persons Act, 1920, provides, inter alia, for the examination of persons by the Council's medical officer. In this connection, most of the examinations made are of children of school age and information in regard thereto is given on a later page. The other persons examined were few in number. Reports have also been made as to the suitability of premises suggested for the purpose of workshops in which blind persons might be taught trades and the question of institutional treatment of blind or partially blind persons has received consideration. Blind Persons Act, 1920. The number of midwives with London addresses whose names appear on the Roll of Midwives exceeds 5,000. Of this number 758 notified their intention to practise within the County during the whole year or for shorter periods. This is an increase of 24 on the previous year. At any 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 entirely within hospitals under medical supervision, are subject to inspection by the Council's officers in order to ensure that the proper standard of efficiency is being maintained. This work of supervision is carried out by four women medical inspectors. Special visits are also paid to the midwife if any case of a septic nature or a persistent high temperature occurs in her practice and in all cases of inflammation of the eyes. Advice is given where necessary to midwives on any point of difficulty which may arise in connection with their work. The medical inspectors paid 1,913 visits during the year to midwives or institutions employing midwives. Midwives and lying-in homes. In 129 cases there were infringements of the rules of the Central Midwives Board. 54 of these were slight, and a verbal caution was deemed sufficient. 55 cases were of a more serious nature, and were dealt with by a written caution. Of the remaining 20 cases 11 midwives were interviewed by the committee, and personally cautioned, and 9 cases were reported to the Central Midwives Board, and were investigated with the following results; (a) 3, no further action; (b) 1, charges not proved; (c) 3, cautioned by Board ; (d) 2, struck off the roll; 4 midwives were suspended from practice in order to prevent spread of infection, and payment in compensation was authorised in 2 cases. The fee a midwife receives varies in different localities from 15s. per case upwards, but usually 20s. to 30s. is expected. It is computed that about 45 per cent, of the total births in London were attended by midwives, excluding the cases attended bv midwives in infirmaries. Infringemerits of rules. by section 1 (2) ot 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 possibly a dehvery had been conducted by an uncertified woman. In 8 of these cases it was decided to take no further action—the remaining 6 were dealt with by a verbal or written caution. Uncertified women, * The rules of the Central Midwives Board provide that in certain emergencies which are specifically enumerated, a midwife must advise in writing that medical help be obtained and must also see that such help is obtained. The form on which this advice is given is sent to the doctor and a copy must also be forwarded to the local supervising authority. During the year, 7,269 of these notices were received, as against 7,458 in the previous year. The figures for the previous years were 1917, 3,159 ; 1918, 2,738 ; 1919, 5,347. The general rise in the figure is no doubt due 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 the 1st January, 1919, the Council has been responsible for the payment of the fees of the medical practitioners called in. Assuming that 46,000 births were attended during the year by midwives, it is estimated that medical assistance was required in nearly 16 per cent, of the cases ; in 10 per cent, this was on behalf of the mother and in 6 per cent, on behalf of the child. Medical aid. During the year, 684 still-births were reported by midwives in their practice. The figures for pre- Still-births, vious years were, 1918, 535; 1919, 686 ; 1920, 896. Of these infants 358 were males, 321 females and in five cases the sex was not stated. Of the 684 children, 380 were reported macerated, 300 not macerated and there was no statement with regard to the remaining four. During the year, 355 cases of puerperal fever were reported in the County of which 111 proved fatal, a case mortality of 31'3 per cent. In addition to these cases the Registrar General records 37 deaths from puerperal septic disease, which were, however, not notified as puerperal fever. The distribution of the notified cases was as follows :— Puerperal fever. Delivery conducted by Cases. Deaths. (а) Medical practitioners 132 39 (b) Certified midwives 127 42 (c) Medical practitioner and certified midwife 3 1 (d) Hospitals and poor law institutions 78 26 (e) Cases of miscarriage or abortion where no attendant was engaged 12 3 (/) Uncertified woman 1 (?) Unascertained 2 Total 355 111 Great stress has been laid by the Council on the importance of strictly observing the rule that midwives should advise medical help and see that it is obtained in all cases of inflammation of the eyes however slight in infants. 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 this assistance and the local medical officer of health 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 and questioned as to the particulars of the case. In connection with the treatment of ophthalmia neonatorum, the voluntary nursing associations have rendered most valuable assistance. Practically Ophthalmia Neonatorum. 22 every street in London is now covered by the activities of one or another of these, and arrangements exist by means of which a nurse can always be obtained when wanted for the home treatment of this disease. Considerable use has been made of St. Margaret's Hospital assigned by the Metropolitan Asylums Board for the reception of cases of ophthalmia neonatorum. This provides accommodation for 30 infants and 18 mothers, and up to the present has proved adequate to meet the calls made upon it. During the year 1,219 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 105 other cases came to light in which either medical help was not called in by the midwife or in which she did not notify the Council of having done so. Of these 1,324 cases 665 proved to be ophthalmia neonatorum. In addition, 408 cases of ophthalmia neonatorum not occurring in the practice of midwives were notified, making a total for the year of 1,073 cases. The percentage occurring in the practice of midwives was thus 62. The Council's inspectors investigated all cases occurring in the practice of midwives. 622 cases were reported to be completely cured. 13 cases died while still suffering from the disease. In 7 cases there was serious impairment of the vision or injury in one or both eyes, in 16 cases there was slight impairment,whilst in 7 instances the result could not be ascertained owing to the removal of the patients, who could not be traced. 88 cases received in-patient hospital treatment at St. Margaret's. With regard to instances in which impairment of vision occurred, in 3 cases there was total blindness in 3 cases, blindness of one eye; in one case, serious injury to one eye; and in 16 cases slight impairment to vision in one or both eyes. Lectures to midwives. Lying-in homes. The classes arranged by the Council for the further instruction of midwives have met with much success. The Council's action with regard to the registration of lying-in homes is dealt with later. All registered premises are regularly inspected by the Council's medical inspectors to ensure that a proper standard of cleanliness and general efficiency is maintained and during the year 506 inspections were thus made. Children Act, 1908— Part I. The Council s powers, etc., under the Children Act, 1908, with regard to infant life protection are dealt with later in Chapter XXVII. The inspection work under this Act is carried out by 14 female visitors and 2 male inspectors. The number of nurse infants who were removed to poor law institutions during 1921, was 20 as compared with 15 in the previous year. Partial exemptions from inspection limited to one or two a year were granted in two cases as compared with seven in the previous year. A very important point is the ascertainment that the sanitary condition of the home of the foster mother is satisfactory. All new premises or premises to which a foster mother has removed after registration, are therefore inspected by an officer of the Council's sanitary staff. Similar action is taken if doubt subsequently arises as to the suitability of the premises, or if any complaint is made as to any serious defect or nuisance. The number of such reports during 1921 was 1,006 as compared with 966 during 1920. In 668 cases the premises were found to be satisfactory as compared with 573 in the previous year. In 146 homes sanitary defects were discovered as compared with 186 in the previous year; over-crowding was reported in 131 as compared with 138 homes in the year 1920. Both over-crowding and sanitary defects were discovered in 29 homes as compared with 22 in the previous year. In the remaining 32 homes no action could be taken owing to the removal of the infant before the visit of the inspector. Where serious sanitary defects are discovered the attention of the borough council is drawn to the matter. In a case of overcrowding it may be possible by re-arrangement of the accommodation to secure an improvement of the conditions, but if this is found not to be possible, the foster mother is instructed to obtain more suitable premises, or return the nurse infant to its parents. Attention may be drawn to the fact that the present shortage of housing accommodation renders the enforcement of this requirement difficult in some instances. The assistance of the local Infant Welfare Centre is frequently obtained in the case of illness of a nurse infant. Foster mothers are urged and encouraged to take ailing infants there and to follow the advice given. The visitors watch such cases with a view to making sure that the treatment advised is duly carried out. The Children Act provides that the infant shall remain under the care of the infant protection visitor until it reaches the age of 7 years, but as is well known the child generally goes to school at the age of 5 years and as a consequence comes under the supervision of the school medical service. The number of deaths of nurse infants was greater during 1921 than in 1920, viz., 42 cases as compared with 26 ; the number of deaths during 1920 was exceptionally low. Inquests were necessary only in six cases, while the verdict in every case was death from natural causes. In 1920 the Home Secretary appointed a Departmental Committee to deal with the question of child adoption. One of the Council's medical officers gave evidence. During 1921 the Committee made a report [Cmd. 1254] indicating (a) proposals for legalised adoption and (b) proposals for the amendment of the Children Act, 1908. Generally speaking, it may be noted that the Committee appear to be of opinion that the sanction for adoption should be given by a regular judicial authority rather than by an administrative department or local authority. With regard to the proposals for an amendment of the Children Act the Committee suggested, inter alia, that the age limit should be extended to 14 years and should cover cases of children below the age of 14 years received without payment. With regard to adoptions for lump sums, the Committee were of opinion that the local authority should be empowered to see that the sum so paid is applied for the benefit of the child. In connection with this question of lump sum adoptions a considerable number of children coming under this heading were examined during the year by a member of the medical staff of the public health department in order to ascertain the general standard of maintenance as compared with foster children for whom periodic payments were being made. The results 23 were very satisfactory : the children seen were well cared for and in many instances it was evident that a bond of real affection united the foster parent and the child. The Departmental Committee also recommended that Section II of the Children Act should be so amended-as to render liable to inspection all homes and institutions undertaking, whether for payment or not, the entire control and custody of children up to the age of 14 years, unless such custody and control be given by order of the Court. So far the proposals of the Committee have not been embodied in any Bill. The work ot this branch was carried out at tour laboratories, viz. the Central Laboratory at feavoyhill, Greenwich Power Station and the Northern and Southern Outfalls. During the year a large number of samples submitted by departments of the Council have been examined, in most cases as to their compliance with specified conditions or general suitability for use ; among these were 200 samples of cement, a similar number of petroleum (under the Petroleum Acts), 158 of paints, colours and varnishes, 201 samples of coal, 68 of soap and 47 samples submitted under the Fertilizers and Feeding Stuffs Act, as well as 1,100 samples of milk and 128 other meals supplied to necessitous children. Analyses in connection with the control of the use and storage of petroleum were made of 124 samples of gases used at works in the County for creating a definitely non-explosive atmosphere in dry-cleaning and de-greasing plants in which petroleum was used. In addition to the above, the work of the staff at the Central Laboratory includes the carrying out of analytical work in connection with a variety of investigations, such as corrosion of condenser tubes, heat insulating materials, etc. W ork of the Chemical Branch. Central laboratory. The work of this laboratory, commenced temporarily some years ago and placed on a permanent basis in May, 1920, has been continued. The ordinary work consists of the examination of a large number of hotwell, condenser, softener and boiler waters, and samples taken from the fuel burnt each day ; also examinations of flue gases and special deliveries of lime, soda, coal and of ash from the furnaces. Greenwich Power Station Laboratory, At the Outfall Laboratories, the systematic daily examination of sewage treated and the resulting effluent and sludge, as well as the water of the river Thames at both high and low tide, has been continued. Experimental work on methods of treatment likely to be more effective than those in use at the Council's Outfalls was authorised in June, 1920. Three distinct methods of applying the same principles of purification were selected for comparative experiment. So far, only one plant has been erected and brought into operation. This is of a type which has been set up and used elsewhere and it is hoped by a comparison of the working of the other plants to be erected to obtain guidance as to the most suitable means of carrying out anv desired improvements at the Outfalls. Outfalls. Sewage treatment. The special examination of the river was continued in a modified and reduced form in 1921. Arrangements were made for examination of river water daily at Waterloo Bridge and weekly at each of three places between this point and the Outfalls where examinations have been made for many years at high and low water daily. The effect of the phenomenally dry season was very marked in the tidal reaches of the Thames. From February onwards there was a marked deficiency of rainfall, which led to a decreasing fresh water flow of the river. One result of this was that salt tidal water found its way to the upper part of the tideway to a more marked degree than in any recent summers. A statement in the public press to the effect that the use from motives of economy of river water for watering purposes at Kew Gardens led to the wilting of the plants so watered and that analysis showed this to be due to the saltness of the water illustrates the marked increase of salinity in these upper reaches. Examinations made of samples collected as far up as Teddington during the summer, when a launch was available for this purpose, fully confirmed the great excess of salinity of the river water at Kew and above. This increased salinity caused considerable trouble at Greenwich Power Station and some of the pumping stations of the main drainage service where extreme corrosion, leading to piercing of condenser tanks, could be attributed only to this cause. River Thames. An unusually dry season has other effects on the water of the Thames than causing an increase of saltness of its waters. A less rapid flow downwards towards the sea means that the various pollutions, mostly sewage effluent, accumulate in the upper reaches in a more or less concentrated form, instead of being diluted and carried seaward. As a consequence of this, a very long stretch of the river was for most of the latter part of the year in a less satisfactory state than it has been for many years. The pollution of this river by the effluent from Enfield was the subject of proceedings on the part of the Lee Conservancy Board, which were continued into 1921. No very definite result ensued from these proceedings. The Lee has been kept under observation for some years and the Council's officers and those of the Conservancy Board have been in close touch. Examinations made in 1921 showed that the condition of the Lee below Tottenham Lock—that is, where the Lee joins the County of London—has been invariably bad. Certain sources of pollution were discovered and examined and the relatively large tributary, the Pymmes Brook, was examined for many miles by the chemist. His report, which showed on analytical and other evidence the existence of many sources of pollution was, by order of the public health committee, communicated to the Lee Conservancy Board, who are following up the matter. Owing to the very dry season, the condition of the Lee was unusually bad in the Summer of 1921, and the metropolitan borough of Hackney called public attention to the matter. River Lec. The work initiated in conjunction with the chief engineer last year on the condition of the River Wandle, engaged attention. Recommendations were made with a view to preventing the accumulation of vegetable and other organic matter in the Mill Pool at Pimms' Mills. It appears, as a result of the investigations, that the condition of the Wandle below the Power Station is due partly to the very strong effluent discharged by the Croydon rural authority and partly to the acceleration of chemical change by the increase of temperature of the water whilst passing through the condensers at the Power Station of the L. & S.W. Rly at Earlsfield. These two causes are aided by the opportunity for sedimentation above Pimms' Mills. River Wandle, 24 TABLE I. COUNTY OF LONDON. Vital statistics for the several metropolitan boroughs and the Couuty of London in the year 1921. (Rates per 1,000 of civil population). Metropolitan borough, In topographical order). Estimated civil population. 1921.* Births. Deaths. Infant mortality (per 1.000 births). Measles. Scarlet fever. Diphtheria. Whooping oough Typhoid fever. Diarrhœa and Enteritis age 0-2 (per 1,000 births). Phthisis. Cancer. Cases of notifiable infectious disease. Smallpox. Scarlet fever. Diphtheria. Typhoid fever. BrysipeJas. Puerperal fever (per 1,000 births). Cerebrospnal fever. Pneumonia Western Paddington 145,600 19.8 12.1 91 .02 .01 .15 .14 .01 27.4 .70 1.57 5.74 3. 13 .09 .57 5.6 .01 .91 Kensington 177,300 19.3 13.8 107 .01 .05 .15 .12 .02 30.4 .87 1.62 - 5.19 2.13 .14 .47 2.3 .01 .51 Hammersmith 128,708 21.1 12.7 88 — .12 .18 .09 .02 24.1 1.16 1.47 - 10.52 3.44 .03 .40 4.3 .02 1.18 Fulham 159,400 22.2 11.8 84 .01 .09 .28 .18 .01 21.0 .97 1.36 - 6.05 3.64 .04 .59 7.7 .03 1.46 Chelsea 64,290 17.1 13.6 82 — .02 .11 .03 — 16.4 .95 1.76 - 3.67 1.78 .14 .31 6.4 .02 .44 Westminster, City of 139,893 13.5 11.7 81 — .04 •20 •06 .01 18.8 .86 1.48 - 4.87 1.90 .07 .37 4.2 .01 .45 Northern St. Marylebone 105,200 16.7 12.9 73 — .05 .23 .09 •02 13.1 1.04 1.56 - 4.67 2.25 •12 .46 2.3 .05 .52 Hampstead 86,890 15.4 11.2 66 .05 •06 .40 .07 •01 11.9 .74 1.54 - 4.43 5.15 .13 .30 2.2 — .63 St. Pancras 212,900 22.3 13.0 76 11 .03 .24 •18 .01 17.7 1.17 1.40 - 8.03 3.41 .13 .41 2.1 .01 1.59 Islington 333,000 23.5 13.2 82 .09 .06 .33 .13 .00 20.7 1.05 1.48 - 7.89 4.68 .03 .37 4.4 .02 .22 Stoke Newington 52,590 20.4 12.1 54 - - .42 •06 .04 12.1 .80 1.79 - 8.68 3.13 .04 .29 2.8 - - Hackney 224,200 22.2 11.5 66 .02 .06 .21 .09 .01 20.7 1.01 1.31 - 8.49 4.26 .05 .40 3.6 .01 .22 Central Holbom 43,520 14.9 12.8 79 — .07 .09 .09 — 12.3 .97 1.29 .02 4.56 3.92 .18 .39 1.5 .05 1.01 Finsbury 76,690 25.9 14.8 91 .04 .08 .48 .17 — 20.1 1.53 1.38 — 7.98 4.72 .07 1.11 3.0 .10 .46 London, City of 13,820 9.6 12.0 106 — — .07 — — 15.2 1.09 1.37 — 6.60 2.47 .07 .44 — — .51 Eastern Shoreditch 105,200 29.1 14.2 111 .17 .07 .38 .19 .02 38.6 1.40 1.06 — 8.86 5.60 .07 .69 4.3 .04 1.76 Bethnal Green 118,300 25.4 12.9 100 .18 .08 .28 .15 .02 38.3 1. 33 1.05 — 8.47 4.83 .03 .81 3.7 .03 1.39 Stepney 252,000 24.6 13.1 90 .17 .10 .35 .10 .01 29.0 1.23 1.07 — 8.13 4.30 .08 .53 3.7 .02 1.33 Poplar 164,100 27.3 12.8 83 .26 .08 .37 .19 .03 21.9 1.05 1.13 - 8.75 3.97 .10 .58 3.6 .05 2.14 Southern Southwark 186,000 27.1 14.3 90 .03 .07 .16 .15 .01 25.8 1.43 1.23 — 6.83 2.90 .04 .78 3.2 .03 1.41 Bermondsey 120,500 27.6 13.8 93 .02 .15 .57 .12 .02 21.9 1.29 1.29 — 9.58 612 .07 .42 1.8 .01 .32 Lambeth 305,700 220 12.2 76 .05 .06 .15 .11 — 22.1 .99 1.22 — 5.74 1.80 .02 .41 3.9 .03 .78 Battersea 169,200 22.1 12.2 74 .01 .04 .37 .18 .01 16.6 100 1.12 — 8.46 4.59 .06 .43 4.0 .02 2.03 Wandsworth 331,500 18.7 10.7 67 .01 .06 .19 .08 .02 14.7 1.01 1.25 .00 5.99 3.09 .10 .37 1.8 .03 1.39 Camberwell 269,600 23.3 12.1 74 .02 .08 .25 .13 .02 16.9 1.07 1.32 — 7.31 3.21 .06 .42 2.2 .01 .40 Deptford 113,500 23.5 12.2 88 .01 .11 .11 .12 .02 20.6 1.07 1.28 — 8.23 3.15 .10 .52 4.1 .03 .42 Greenwich 101,400 23.0 12.2 75 .05 .06 .28 .10 .01 13.7 1.19 1. 23 — 9.49 5.99 .11 .59 4.7 .01 1.27 Lewisham 175,800 19.7 10.5 56 .02 .03 .16 .06 .03 15.6 .80 1.42 — 6.42 305 .06 .33 2.6 .02 .47 London Woolwich 137,604 22.6 11.6 62 .03 .07 .29 .12 .01 18.8 1.22 1.32 — 9.84 4.26 .08 .42 4.4 .02 1.59 4,514,405 22.1 12.5 81 .05 .06 .25 .12 .01 21.6 1.07 1. 33 .00 7.27 3.62 .07 .47 3.5 .02 .96 * Based upon the preliminary figures of the census of 1921, approximately corrected by the inclusion of London residents temporarily absent at the date of the census. 25 Oi I—» rc TABLE II. COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1921. 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 placcs. No. of inspections. City of London — — 7 — — — 94 10 2 — — 1 1 140 cal — 1 455 22 1,134 3 — 557 221 — — 925 1,347 Battersea 1 2 2 339 3 4 145 22 14 1 1 12 12 85 85 — 2 147 340 4,607 5,020 31 132 410 122 464 239 1,357 Bermondsey — — 1 31 13 119 12 11 8 — — — — 223 446 — 3 1,153 43 — 3,227 — 308 849 116 136 341 8,043 Bethnal Green 12 64 3 19 1 2 20 1 1 1 1 12 8 219 712 — 7 395 — — 3,098 — 196 732 133 296 269 1,587 Caraberwell 1 9 6 39 2 3 74 10 5 — — 15 9 316 71 — 5 447 83 3,167 96 — 414 874 270 293 269 491 Chelsea — 3 26 — — 6 — — — — — — — — — 3 207 56 40 1,497 — 67 95 17 30 73 80 Deptford — — 2 24 4 15 25 7 7 — — 3 3 189 578 — 4 1,078 — 2,213 1,845 — 136 439 78 225 112 308 Finsbury — — 2 4 1 33 34 24 5 2 2 7 7 949 3,579 — 1 98 1 — 59 — 134 146 71 79 199 258 Fulham — — 2 18 1 20 — 30 12 2 2 — — — — — 2 94 — — — 40 120 300 65 220 — — Greenwich 3 † 4 21 3 1 17 11 — 3 3 4 4 — — — 2 90 51 1,396 18 — 89 107 82 96 179 389 Hackney 9 122 19 294 — — 83 68 21 — — 18 8 463 — — 4 313 118 1,627 185 2 227 1,587 153 157 123 146 Hammersmith — — 7 212 — — 136 23 16 6 6 27 13 2,704 79 — 1 292 — — 202 18 76 1,619 1 12 249 — 3,023 Hampstead.. — — 4 26 — — 33 3 1 16 16 2 2 — — — — — 29 1,460 53 82 86 271 68 161 515 1,554 Holborn — — 1 8 — — 161 10 9 6 — 1 1 601 905 1 14 1,089 165 — 69 7 154 174 64 279 232 1,929 Islington 4 42 18 925 9 61 84 114 3 3 3 6 6 1,033 8,761 3 23 805 18 4,635 7,348 63 625 468 242 62 606 17,246 Kensington. . — — 6 260 — — 340 7 3 5 5 15 15 2,079 6,117 2 9 467 60 1,368 1,172 32 163 851 181 225 790 859 Lambeth 3 10 12 168 3 49 204 12 136 6 6 42 42 372 4,464 — 5 469 — — 460 122 316 1,896 165 165 3 3 Lewisham 9 66 9 158 — — 23 3 3 — — 17 17 2 2 — — — — — — — 137 376 — — — — Paddington. . 1 4 5 174 — — 413 10 4 8 — 4 4 1,404 4,382 2 3 165 — — 488 4 96 282 87 102 426 1,334 Poplar 10 27 9 44 4 23 39 38 16 — — 22 22 1,450 481 — 6 985 161 3,600 695 — 185 169 97 22 365 1,000 St. Marylebone 3 66 3 154 2 68 40 14 4 11 11 1 1 1,152 10,014 — 5 763 4,773 3,517 599 32 159 362 110 156 376 1,259 St. Pancras 2 18 8 159 2 96 704 74 5 1 1 36 25 2,364 5,863 — 3 108 575 6,025 2,103 15 211 563 163 247 4,565 Shoreditch 2 21 3 30 1 4 58 26 2 — — 36 10 331 391 — 5 324 — — 1,118 24 203 1,341 72 149 210 485 Southwark — — 5 5 2 8 27 14 4 2 2 51 51 1,349 1,245 — 23 2,820 175 2,952 31,056 100 276 1,761 26 26 329 1,122 Stepney 24 109 3 9 8 26 318 79 38 11 11 56 56 2,512 4,028 — 27 3,905 465 302 3,032 2 419 1,442 137 260 461 1,263 Stoke Newington 1 — 4 29 — — 15 44 4 — — — — 259 — — — — 1 330 58 — 68 68 8 24 — 541 Wandsworth 3 19 10 121 3 121 15 3 3 — — 30 30 292 446 1 6 173 271 — 620 — 446 375 316 338 865 1,335 Westminster 1 10 — — — — 1,838 52 52 19 1 20 3 1,150 1,784 — 5 1,586 114 1,294 323 44 473 642 150 210 6,000 1,340 Woolwich 13 57 8 42 — — 25 6 - 3 3 353 125 439 431 — 13 399 26 2,331 296 — 72 148 91 195 199 226 Note.—In the columns above a dash signifies a nil return. Common lodging houses. license number, 182 ; lodgers, 18,827 ; visits—day, 11,987, night, 468 ; prosecutions, 1 ; penalties and costs, £2 18s. Seamen's lodging houses, licensed number, 61; Bermondsey, 6; Deptford, 1 ; Poplar, 12; Stepney, 32; lodgers, 1,281. Visits—day, 1,387 ; night, 146; convictions, 11 ; penalties, £130 10s. 6d. Prosecutions—Smoke Nuisances: Poplar, 1. * ' * Continuous supervision during slaughtering. Milkshops : Bermondsey, 9 ; Bethnal Green, 1; City Corporation, 4; Hackney, 1 ; St. Pancras, 1. †Included in milkshop inspections. 26 27 TABLE III. Tuberculosis Dispensaries—Analysis of Returns, Jan.—Dec., 1921. 1 Borough. 2 Examined for the first time. 3 No. included under (2). Suffering from Pulmonary Tuberculosis. 4 No. included under (2). Suffering from NonPulmonary Tuberculosis. 5 No. included under (2). Found to be NonTuberculous. 6 No. included under 2 in which Diagnosis was 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 Visits 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. Un-, insured. Insured. Unin sured. Insured. Unln. 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 72 43 39 67 54 37 15 17 27 7 2 4 - 1 3 26 23 16 37 39 7 1 6 2 5 1277 1129 366 410 3 1 164a 507 21 21 94 71 Battersea 265 119 44 148 456 87 28 12 32 11 4 3 1 1 16 93 46 11 55 202 81 42 20 60 227 1894 4111 1335 1811 131 138 957 2642 160 111 434 257 Bermondsey 233 108 11 129 729 96 47 5 34 66 6 4 - 1 26 69 25 3 55 367 62 32 3 39 270 2719 7824 1406 2991 34 363 1656 2490 86 92 740 320c Bethnal Green 200 89 35 111 296 65 21 16 25 13 5 3 1 3 28 111 55 10 75 244 19 10 8 8 11 2718 2160 1028 786 52 22 760 615 54 29 455 117 Cainberwell 394 168 67 256 746 124 46 23 65 24 19 7 7 9 46 136 64 23 135 582 115 51 14 47 94 5356 7309 3747 4597 392 675 1932 1720 69 167 860 275 Chelsea 91 49 13 136 283 18 9 1 9 5 2 — — — 11 57 33 10 114 252 14 7 2 13 15 897 2313 371 1002 18 17 657 2624 - - 427 397 Deptford 172 59 50 160 268 68 27 17 30 7 3 3 — 6 8 65 21 16 82 189 36 8 17 42 64 2171 2882 820 1109 125 156 1163 1838 - 2 571 288 Finsbury 1U 123 65 31 86 201 55 20 10 27 11 2 2 1 — 7 57 35 17 50 173 9 8 3 9 10 3069 1878 681 678 133 123 1299 1244 — - 132 89 Fulham 168 89 28 204 509 59 22 9 19 5 4 3 1 1 13 73 48 13 146 416 32 16 5 38 75 2035 5426 1267 2244 628 1589 2056 3584 5 474 233 Greenwich 156 82 12 156 519 67 23 6 25 40 4 3 2 5 43 72 44 3 110 376 13 12 1 16 60 3059 4295 561 1357 87 60 2135 3673 - - 265 109 Hackney— (1) Victoria-park Hospital 193 106 45 151 315 61 19 20 32 5 8 2 2 1 20 100 76 19 103 281 24 9 4 15 9 3124 3235 1209 1100 52 24 1478 1654 64 51 495 153 (2) Metropolitan Hospital 116 58 39 92 197 44 13 16 23 5 7 2 — 4 17 39 32 16 49 147 26 11 7 16 28 1463 2207 361 362 16 6 1623 1414 63 66 244 111 Hammersmith 238 105 37 149 331 127 42 10 35 16 6 4 4 5 24 93 50 22 98 257 12 9 1 11 34 1438 2293 803 950 100 81 2050 1982 - - 387 171 Hampstead.. 117 38 13 119 192 41 16 2 21 1 2 2 - 6 27 26 5 7 46 100 48 15 4 46 64 670 1657 474 724 29 19 125rZ 267 4 17 149 122 Holborn 58 21 7 12 39 24 9 5 5 3 4 — — — 3 10 8 1 3 22 20 4 1 4 11 648 404 362 219 9 1 821 628 5 4 100 19 Islington— (1) Ryl. Northern Hospital 191 96 40 82 207 86 29 22 29 5 4 2 — — 9 99 64 17 50 187 2 1 1 3 6 1879 1333 943 699 118 65 614 680 6 1 224 84 (2) Royal Chest Hospital 254 109 46 127 222 120 35 19 35 13 5 3 3 — 13 114 58 18 74 187 15 13 6 18 9 4433 2597 1240 691 165 136 1407 649 — — 316 123 Kensington— (1) Ladbroke-gr. 150 83 33 127 361 63 18 21 17 12 4 1 — 3 36 65 44 9 79 264 18 20 3 28 49 1171 3155 632 1226 56 53 1245 2936 - - 389 121 (2) Brompton 24 26 8 46 77 10 6 3 4 4 1 — — — 3 9 15 5 34 62 4 5 8 8 487 827 140 260 3 - 172 400 - - 35 22 Hospital Lambeth— (1) Central Dispensary 203 80 18 145 199 68 18 7 27 8 5 2 1 1 10 22 11 3 23 54 108 49 7 94 127 1869 4475 910 771 54 43 1255 1551 293 401 298 131 (2) St. Thomas's Hospital 389 167 48 214 349 131 35 18 46 6 14 3 3 9 32 221 117 24 140 284 23 12 3 19 27 2832 2971 1377 1338 — — 412 484 310 369 339 158 Lewisham 155 72 28 87 223 75 33 16 27 9 6 1 1 6 18 66 35 9 52 180 8 3 2 2 16 1209 1614 652 620 45 45 1378 1065 2 - 35 17 Paddington— (1) Talbot-road 125 69 29 123 277 38 15 15 14 3 6 1 — 2 26 63 48 13 91 205 18 5 1 16 43 1885 3418 268 431 325 307 830 1003 3 5 56 11 (2) St. Mary's Hospital 86 35 17 52 82 28 8 4 12 4 11 6 6 8 20 27 8 3 19 33 20 13 4 13 25 1628 3229 542 755 133 99 260 549 86 83 67 63 Poplar 255 64 22 382 818 79 22 8 74 15 4 1 - 3 13 54 21 3 174 478 118 20 11 131 31 1440 5902 1110 2290 31 6 2359 3921 - - 393 295 61742 St. Marylebone— - 37 19 3 12 66 1616 2925 240 374 245 233 570 1039 3 - 267 87 (1) Marylebone -rd 134 65 18 72 16/ 62 24 9 23 12 5 - - - 22 6 - 78 31 j - 1 9 2 5 1 - 4 — (2) Middlesex Hospital 3 2 — 1 - 2 - - - - - - - - 1 1 - 7 - - 2 1 3 3 88 153 55 134 - 4 5 (3) Margaret-st. Hospital 7 6 2 12 9 1 2 1 2 - - - - - 1 4 2 - 5 20 St. Pancras— - - - - 2 25 88 11 1 33 - 1 2 1 5 22 1760 1126 1354 769 123 64 96 115 12 99 817 173 (1) Oakley-sq. .. 222 32 4 60 144 105 16 o 2 q 20 12 9 3 3 1 2 3 3 1 1 5 15 - - 3 83 356 74 248 — — 17 68 14 24 - — (2) Maiden-road 13 5 2 12 30 8 2 2 7 2 1 - 1 - 85 24 6 9 755 577 443 323 2 4 571 405 3 5 86 14 (3) UnivcrsityCollege Hospital 70 19 8 23 54 43 8 5 13 8 4 3 1 3 6 8 2 2 4 17 77 16 1 3 18 10 5272 3090 1217 818 138 127 1015 856 - 277 119 Shoreditch 209 106 31 121 277 80 32 10 21 9 3 - 3 - 14 102 1 <\7 56 19 82 30 109 34 6 19 9 3718 2509 124 1080 4 2 1482 1555 10 12 361 57 Southwark 371 178 26 186 499 129 58 16 34 16 8 1 3 51 89 3 130 245 12 Stepney— - - - (vi 54 86 389 19 29 43 2 1320 6106 512 1302 150 93 329 1962 1 1 81 136 (1) Stepney-green 275 114 58 139 636 76 23 15 23 24 — - 1 1 21 90 27 24 135 399 36 2 24 192 8 743 2129 506 1340 67 197 203 1090 1 7 141 187 (2) St.George's-inthe-East 102 40 31 180 390 40 7 9 18 5 - - 3 3 14 50 26 20 333 7 9 31 38 6 724 2765 51 232 210 1608 - 8 8 152 (3) Whitechapel 73 49 69 202 378 22 16 15 17 — 1 - - - 6 35 45 154 296 15 3 2 26 887 213 935 15 9 500 329 46 30 138 49 Stoke Newington .. 61 23 18 30 97 25 4 7 7 6 1 1 - — 10 16 11 7 17 61 19 5 3 28 5218 5291 1 77 155 213 139 1813 1608 91 69 585 5 934 Wandsworth 397 208 79 270 601 134 60 40 46 27 17 3 10 10 26 194 116 33 186 496 52 6 4 3 52 1548 2147 1771 2125 96 224 158u 2547 12 25 246 67 Westminster 153 69 33 87 267 67 31 13 35 12 3 1 2 2 15 oo 28 15 47 216 20 24 808 898 257 2087 3392 5 445 269 Woolwich 264 121 39 242 530 69 30 8 35 9 3 2 4 4 8 84 41 18 105 300 108 46 11 98 213 3 3946 4849 1341 1896 623 - (а) Not including 81 visits made for nursing purposes. (C) Not including 95 not divided between insure and uninsured. (b) Not including 1,924 visits not divided between insured and insured. (d) Not including 1,000 visits by lady sanitary inspector. 28 CHAPTER XXIV. REPORT OF THE SCHOOL MEDICAL OFFICER (DR. W. H. HAMER) FOR THE YEAR 1921. PART II. (EDUCATION). Introductory Note. In the Annual Reports, for 1916 and 1920 reference was made to some of the influences which had determined the notable decline in the general death-rate in the last forty and in infant mortality in the last twenty years. The general death-rate and the infant mortality per 1,000 births in London, were, indeed, lower in 1920, than they had ever been before ; moreover, recently available school re-inspection results showed that the school children originally found defective, whose defects had been or were being remedied during 1920, yielded the highest percentage attained up to that time. Of the three records, two, the first and third, were again broken in 1921 ; as regards the second, infant mortality, however, there was a very slight set-back last year, the rate just exceeding the low rate of 1920, owing mainly to the higher mortality from epidemic diarrhoea during the phenomenally hot and dry summer season of 1921. Taking a broad view it will of course be recognised that these satisfactory figures are the outcome " of no spasmodic or haphazard efforts and influences, but of many years of steady work. " Results " we have been told, " should not be too voluntarily aimed at or too busily thought of. They are seen to float up of their own accord, from a long enough daily work at a given matter." The daily work in this case was commenced more than half a century ago, and " the work as a mere occupation was a primary interest " with the Victorian builders, who actually builded even better than they knew. In a review of more recent progress the statement is made by the author of "The Hygiene of the School Child " that, " The rapid development of health work in the schools during the last two decades is not to be regarded merely as an educational reform, but rather as the corollary of a widespread realisation of the importance of preventive measures in the conservation of natural and human resources . . . The modern crusade for medical and hygienic supervision of schools, began as a reflection of the popular interest in matters of health ; it will end by becoming the most effective and convenient instrument for the attainment of a higher national vitality . . . But," he adds, " we cannot rely altogether upon the progress of medical science and upon reforms of public health administration. These measures must be supplemented by a never ending campaign for the enlightenment of the young in matters of personal and social hygiene. The practice of hygiene in the average home follows far in the rear of medical discoveries." The correctness of this statement is very well illustrated when careful examination is made of the slow, but fairly steady improvement, now recorded for a number of years, in the conditions set out in the table on page 30. Medical inspection. During the year 217,333 children in the age groups were examined by the school doctors in elementary schools, and, of these, 85,687 were found to require treatment for one or more defects; 38,822 boys and 38,397 girls approaching the age of 14 were examined prior to their admission to day continuation schools. A further 2,255 children in the age groups were inspected in the special schools and 73,572 children not in the age groups were specially examined. In addition the school medical staff inspected 5,646 children for scholarship awards and 17,305 children in connection with their specific defect in special schools. A detailed analvsis of results by Dr. C. J. Thomas is given on pages 29—34. Medical treatment. The number of children treated was 212,579 as against 197,700 in 1920. During 1921 children were sent by arrangement with the Metropolitan Asylums Board to Swanley. At the Cyril Henry centre where child patients are retained for two days after removal of tonsils or adenoids 2,366 operations were carried out. Moreover, children from certain centres in west and south-west London are now conveyed home by motor ambulance. Be-inspections. The number ot re-inspections was 175,090. the combined results ot nrst and second re-inspections showed that 78'2 per cent of the cases reviewed had been dealt with, the highest proportion ever obtained since the Council undertook the inspection and treatment of children. Personal hygiene. The modifications maae in the cleansing scheme, referred to in tne report of 1920, consisted in arranging for the treatment of slight cases of head infestation at minor ailment centres instead of at the ordinary cleansing stations ; in the abandonment of the policy of hair cutting which had given rise to so much difficulty in the past; and in the use of an improved technique, viz. : a newly devised comb and an improved shampoo soap, which have proved very efficacious in removing nits without making it necessary to cut the hair. Moreover, ten new stations for the treatment of slight cases were authorised by the Council and seven of these were established during 1921. Further, as the outcome of a conference with representatives of the City and metropolitan borough councils held in February, 1921, it was decided to apply to Parliament in the session of 1922 with a view to strengthening the Council's Powers relating to infestation with vermin (including fleas, bugs, lice and itch mites). There has been material improvement as regards prevalence of scabies. The results obtained at medical inspections show, moreover, that as regards body lice a notable advance has been made. There is, however, a definite though small increase in the percentage (more particularly of girls) found to present nits in the hair. The possible causes of this are carefully examined by Dr. Thomas on p. 31. The main factors which seem to have been responsible are an increased standard of 29 liness, the possible effect in some cases of the removal of apprehension on the part of the girls and their mothers lest the hair might be cut, and the prevalence of unemployment with associated deterioration in home conditions in the poorest boroughs. On a broad view, as Dr. Thomas says, it is clear that the efforts of nurses and teachers have brought about a veritable revolution, for children manifesting gross conditions of uncleanliness are now rarely met with, even in the worst neighbourhoods. The behaviour of epidemic diseases during 1921 particularly deserves study. The dry hot summer favoured the spread and fatality of summer diarrhœa ; in December a prevalence of influenza was noted in the schools and elsewhere ; but the most striking phenomenon of all was the development of a marked wave of prevalence of the epidemic throat maladies, scarlet fever and diphtheria, which reached its height in October and November. The altered behaviour in the last quarter of a century, as compared with an earlier period, of these two epidemic diseases especially calls for comment. Seventy or eighty years ago in the fifties, sixties and seventies the waves of throat epidemics swelled to their successive crests at intervals of some 5 or 6 years, and in the years of maximum mortality considerably more than 1,000 deaths per million of the population of the country were recorded from scarlet fever and diphtheria together. In the last twenty-five years the following changes have come about—(a) the interval between the crests has sensibly lengthened to 7, and on the last occasion to 8 years ; (b) there has been an increasing tendency (emphasized at the crests of the seven or eight year waves), for the proportion of cases described as diphtheria to grow as compared with the cases described as scarlet fever ; (c) but especially significant is the remarkable decline in deaths from these throat epidemics, and while the fall in the mortality rate is greater in scarlet fever than in diphtheria the decline in case-mortality is fairly equally marked in both. Instead of more than 1,000 deaths per million of population the death rates now in the worst years are not one-tenth of those of 70 or 80 years ago. It is instructive, therefore, to look back sixty years and note that the London epidemiologists of that day had already probed to the root of the matter. Reference was made four years ago (Annual Report 1918, p. 47) to Mr. J. Netten Radcliffe's paper in the Epidemiological Transactions of 1864-5, p. 262. He spoke of the scarlatinal fields which were the foci of infection in the crowded courts of great towns, and he urged that if cases of the disease could be weeded out of the denser masses of population as they occur, it would be to the incalculable gain of the people. This weeding out process had commenced on a small scale in Mr. Radcliffe's time ; it was steadily proceeded with until, in the early nineties, nearly half the cases of scarlet fever occurring in London were being removed to the Metropolitan Asylums Board Hospitals ; further progress continued and in the recent epidemic over 90 per cent, of the cases of scarlet fever and nearly all the cases of diphtheria were isolated in the Metropolitan Asylums Board Hospitals. Special interest, however, attaches, so far as 1921 is concerned, to the fact that the combined waves of prevalence rose above the height attained in the preceding year. In the report for 1920 the possibility of such an occurrence was considered, and suggested explanations of the phenomenon are examined on p. 43 of the present report. With regard to other diseases incidental to school life measles was fortunately comparatively quiescent. There was a marked rise in the prevalence of whooping cough, the numbers of cases of this disease during the year exceeding by upwards of 1,200 those recorded for measles, a most unusual occurrence. Mumps and chickenpox were considerably more prevalent than usual. There was a welcome reduction in the number of scabies cases due no doubt partly to the improved facilities for treatment provided by the Council, and to the cessation of introduction of the disease by returning soldiers. As regards ringworm there was a noticeable reduction in the number of cases reported during 1921 as compared with the preceding year. Infectious diseases. Special references are made on pp. 50—52 to causes of deafness, mental deficiency and mental tests of normal children, encephalitis lethargica, and a comparison of the offences committed by normal and defective children. The results of medical inspection. Special schools. Routine inspections were arranged 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 actually inspected were 41,304 entrant boys, 40,398 entrant girls, 33,494 boys and 33,530 girls at age eight, and 34,587 and 34,020 girls at age twelve, a total of 217,333 compared with 208,924 in the previous year. At these ages also a corresponding inspection was made of 2,255 children in the special schools. Number of children inspected. 39,270 children outside the age groups were presented to the school doctors for examination as special cases and 34,302 children as general cases i.e., in the course of general examinations for specific purposes, such as the investigation of outbreaks of infectious disease or in the course of selection of children for open air schools, camp schools and the like. Special schools. 00,687 of the children in the age groups were found suffering from ailments for which treatment was considered necessary or 39.4per cent., compared with 39.6 per cent, in 1920, 42.6 per cent, in 1919, and 44 per cent., in 1918. Last year's improvement has therefore been maintained. In addition 26,425 children were referred for treatment from snecial insnections. Number of ailing children. The attendance of parents at the examinations of entrant children were especially good amounting to over 80 per cent, of the cases. Less interest is shown, however, by the parents in the inspections of older children especially of boys. The percentage of parents attending at the examinations of 12 yearold boys was 40.3 and of 12 year-old girls 51.8. The presence of the parent at the inspection is of great importance and although the good attendance at the examinations of infants is especially gratifying, and renders these examinations very valuable, it would be a great advantage if more parents attended at the inspections of older children, amongst whom many defects are found. Attendance of parents. 30 Although minor fluctuations take place each year in the figures, the results of medical inspection viewed broadly over a period of years, show a steady and continuous improvement in the general social and physical condition of the children. The following tables exhibit the general state of the children in regard to clothing, nutrition and cleanliness as found in the years 1913-1921. General conditions. ENTRANT INFANTS. clothing and Footgear. n utrition. Cleanliness (Head). Cleanliness (Body). Year. Good. Fair. Poor. Excellent. mal norm10al Clean. Nits Verminous. Clean. Dirty minous. 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 81 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 580 40.3 1.7 31.4 63.9 4.7 92.9 7.0 0.1 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. 3 379 1.8 26. 1 67. 5 6.4 93. 8 5.9 0.3 90. 9 8.7 0.4 1921 62.3 35.9 1.8 23.6 71.0 5.4 93.9 5.9 0.2 92.6 7.2 0.2 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 38. 0 1.3 26. 6 67.5 5.9 82.2 16. 5 1.3 90. 6 9. 0 0.4 1921 627 358 15 24.8 70.4 4.8 81. 8 16.9 1.3 92.4 7.4 0.2 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 10.0 86.9 12.6 0.5 75.3 22.9 1.8 1915 51.4 44.6 4.0 21.1 69.8 9.1 88.4 11.4 0.2 76.6 22.0 1.4 1916 52.4 44.1 3.5 23.6 67.0 9.4 89.2 10.6 0.2 79.3 19.7 1.0 1917 51.7 44.8 3.5 20.9 70.6 8.5 89.4 10.4 0.2 79.8 19.1 1.1 1918 51.3 45.6 3.1 19.7 73.1 7.2 91.6 8.3 0.1 85.6 13.8 0.6 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 40.6 3.6 16.8 74.2 9.0 93. 4 6.4 0.2 88.5 11.1 0.4 1921 586 385 2.9 16.6 76.2 7.2 93.1 6.7 0.2 90.3 9.4 0.3 Girls 1913 51.4 43.9 4.7 25.1 61.4 13.5 67.3 30.3 2.4 73.7 24.2 2.1 1914 51.6 45.0 3.4 22.8 68.2 9.0 66.3 31.6 2.1 77.8 20.8 1.4 1915 55.0 43.0 2.0 23.3 69.0 7.7 69.2 29.4 1.4 77.6 21.4 1.0 1916 55.6 43.8 1.6 26.4 65.6 80 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 24.0 1.8 89.5 10.2 0.3 192 58.2 39. 8 2.0 18.2 74. 0 7.8 76.5 21.9 1.6 88.6 10.9 0.5 1921 58.9 39.1 2.0 19.1 74.2 6.7 74.9 23.3 1.8 91.0 8.8 0.2 OLDER CHILDREN (AGED 12) Boys 1913 491 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 1921 54.4 41.9 3.7 19.0 74.9 6.1 93.7 6.1 0.2 89.4 10.3 0.3 Girls 1913 51.8 44.8 3.4 30.6 55.1 14.3 67.2 30.4 2.4 74.8 23.1 2.1 1914 55.9 40.8 3.3 29.9 58.6 11.5 68.8 29.3 1.9 78.0 20.7 1.3 1915 58.2 40.1 1.7 32.8 60.9 6.3 72.6 26.2 1.2 80.7 18.5 0.8 1916 58.9 39.8 1.3 31.4 62.3 6.3 70.8 28.1 1.1 81.7 17.8 0.5 1917 55.3 43.3 1.4 28.5 65.2 6.3 70.2 28.7 1.1 81.7 17.6 0.7 1918 54.6 43.7 1.7 26.9 67.8 5.3 72.8 26.4 0.8 85.3 14.2 0.5 1919 56.0 42.2 1.8 27.7 67.3 5.0 74.0 24.7 1.3 89.0 10.7 0.3 1920 58.5 40.5 1.4 25.4 69.0 5.6 75.8 22.8 1.4 88.4 11.2 0.4 1921 57.6 40. 7 1.7 21.4 72.8 5.8 73.2 25.0 1.8 91.2 8.6 0.2 Nutrition. The figures for nutrition require very careful consideration in view of the existing economic conditions. There were indications of hardship making itself felt in the figures for 1920. Those for 1921 show how the situation has up to the present been met by concerted measures of children's care and general relief. The general effect of these measures has been to reduce the percentage of children with sub-normal nutrition in spite of the increasing stringency of conditions. On the other hand there has been a distinct lowering of the general nutrition and a smaller proportion of children are returned with " excellent " nutrition. It may be claimed, therefore, that while generally there has been a lowering of the nutritional state of the children, on the other hand cases of distress have been adequately dealt with and very few cases of suffering amongst children in regard to want of food occur and these are promptly dealt with when found. * 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. 31 In regard to general personal cleanliness the conditions found show continuous improvement. In fact from this point of view the state of the schools to-day contrasts in a marked degree with their state say twenty years ago. In fact there is no comparison to be made. Intensive effort on the part of school nurses (the London School Board appointed a nurse in 1902) and teachers has brought about a veritable revolution, and whereas formerly children were found attending school in an indescribable condition of uncleanliness, such children are now rarely met with, even in the worst neighbourhoods. While the presence of body vermin, in children attending school, has been reduced to almost vanishing proportions, the state of the hair in girl scholars is still a source of some concern. The figures for 1921 show unfortunately a slight set-back compared with those of 1920 although they still indicate much improvement compared with those of former years. Personal hygiene The explanation ot this falling on, following as it does a number ot years in which the hgures showed a steady general improvement must be sought. At the outset it must be pointed out that all cases where nits are found are placed in the second column, but the fact that 25 per cent, of girls of twelve are placed in this category does not mean that such children are in a grossly verminous or even in an infectious or possibly infectious condition. The results of a single accidental infection often cling to the hair for months after all infection or possibility of infection has ceased, yet according to the London standard, children presenting the slightest trace of vermin (and these form the vast majority of the 25 per cent.) are placed in this category. Still the persistence of the signs of past infection has its value in the estimation of the general level of cleanliness attained. There are five possible explanations of the rather disappointing figures for 1921. In the first place it should be realised that a change in the method of dealing with girls was necessitated at the beginning of the year. In previous years it was necessary, in order to comply with the provisions of the Children Act, to cut the hair in order to effect a cleansing, and the original notices delivered to parents drew attention to the possibihty that it might be necessary to cut the hair compulsorily if unsatisfactory conditions persisted. That the fear of this occurring had a very potent effect upon the attitude of careless parents there can be no doubt. During 1920 it was demonstrated that cutting the hair was not necessary to efiect a cleansing in one operation, and as it might be held that the Council, therefore, no longer had a legal right to have the hair of children compulsorily cut the notices and the practice were both withdrawn. In the second place increasing economic stringency and distress may have had some effect, as poverty and dirt from time immemorial have been close bedfellows. In the third place the attention of the staff has been of late strenuously directed towards this condition, and it is probable that fewer cases have been missed. In the fourth place, during 1921 some thousands of transmigrants passed through London, and this may have been a factor in lowering the standard previously attained. It is known that transmigrants kept under surveillance during their temporary residence in London have been in a very verminous state. In the fifth place, from 1918 onwards, much additional work was thrown upon the cleansing stations in connection with prevalence of scabies, and this led to considerable interference with the efficiency of the work relating to pediculi. During the closing months of 1921 the pressure caused by scabies cases very materially lessened. In those months scarlet fever and diphtheria were prevalent and this involved a certain number of exclusions from school with consequential interference with the cleansing operations. When analysed in districts, it is found that it is the poorer areas, or areas in which there is a particularly poor district included, which shew a lowered standard of personal hygene amongst girls. while the better districts have continued to imnrove. In the following table are shown the figures giving the percentages of twelve-year old children (1) with sound teeth, (2) with slight or moderate dental caries and (3) severe dental caries. 1913. 1914. 1915. 1916. 1917. 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Boys, twelve year old 50.0 40.0 10.0 51.9 38.9 9.2 53.1 39.7 7.2 53.1 40.4 6.5 55.2 38.6 6.2 Girls, twelve year old 52.4 39.0 8.6 54.1 38.2 7.6 55.5 37.8 6.7 55.0 39.2 5.8 56.4 38.1 5.5 1918. 1919. 1920. 1921. 1 2 3 1 2 3 1 2 3 1 2 3 Boys, twelve year old 48.8 43.9 7.3 55.1 39.7 5.2 58.0 37.6 4.4 60.3 35.7 4.0 Girls, twelve year old 49.8 43.3 6.9 56.5 39.1 4.4 59.7 36.7 3.6 63.5 33.3 3.2 Dental conditions. The continued improvement of the teeth of the older children, as shown in this table, is very gratifying. It is clearly correlated with the progress in dental supervision during school life which has been so marked a feature in late years. As further dental centres have been opened more schools have been brought under proper dental supervision, and it is perhaps a noteworthy achievement that ten per cent, more boys and girls (8,000 children in London) now leave school during the year with sound teeth than was the case eight years ago; especially as the condition of the teeth of entrant children shows no corresponding improvement. Chronic catarrhal conditions of the nose and throat are exceedingly common in the child population of the county. Out of 217,333 children examined 35,784 or 16.5 per cent, were found to be so suffering in one form or another. The majority of these were affected in only a minor degree, and special advice to the mother on hygiene was alone necessary. 10,362 (4.8 per cent.) were referred for further treatment for tonsils and adenoids. The number of children thus sent diminishes year by year, in 1920 the percentage was 55 per cent, and in 1919 was 61 per cent. Tonsils and adenoids. Much discussion has taken place of late on the question of operative treatment for these ailments, The fact that only one-fourth of the children who are found to have some degree of unhealthiness of the 32 nose and throat are referred for further treatment proves that a careful selection is made of those who really require special treatment. In fact, the number referred for treatment for adenoid growths, is only 4,571 or 2.1 per cent., more children being referred with tonsils alone than with tonsils complicated with adenoid growths and with adenoid growths alone. The probability is, judging from these figures, that if anything the school doctors err on the side of caution, in referring for further examination or treatment cases of adenoid growths, and the charge made that there is indiscriminate resort to operations rests on no sure foundation in fact. The immediate good results from operation in certain cases are illustrated by a series of cases where children have been suffering for lengthened periods from serious and painful eye disease, and in consequence have been proposed for admission to Swanley under the Council's scheme. They have been seen by Mr. Bishop Harman, with a view to ascertaining their fitness for Swanley, and he has discovered the presence of unhealthy throat conditions. He has, therefore, directed that treatment should first be obtained for the throat before final decision be made in regard to Swanley. In some of these cases, almost immediately after the operation for throat disease, the eye conditions have been spontaneously cured, and the question of admission to Swanley no longer arose. The notes of two illustrative cases follow : Mary B., aged 12, had been suffering from ulcers of the cornea for three years, and was proposed for Swanley. She was seen by Mr. Harman on the 3rd May, 1921, who noted central depressed ulcers of the cornea of very long standing ; she also had " huge " tonsils, and Mr. Harman recommended throat treatment before decision on Swanley. The child was taken to Shadwell Hospital and had her tonsils and adenoids removed on 25th May, 1921. On 21st June, 1921, she saw Mr. Harman, who reported that the throat was satisfactory and the eye disease cured. She was able to return at once to the elementary school. Esther M., aged 8, was proposed for Swanley for chronic ulcers of the cornea. She was seen by Mr. Harman on 13th September, 1921, who found that there was a large white ulcer on the left cornea, with considerable infection. He also found the tonsils verv large and unhealthy. He postponed decision as to Swanley until treatment was obtained for the throat. The throat was operated upon on 14th October, and on 8th November Mr. Harman found the eye disease quite cured and sent her back at once to the ordinary school. Ear disease and hardness of hearing. Closely associated with the prevalence of enlarged tonsils and adenoid growths are discharging ears and hardness of hearing. As in the case of enlarged tonsils and adenoids, there is no difference in the incidence upon boys and girls. Both the incidence of tonsils and adenoids and that of discharging ears diminish during school life as the result of care and attention, but unfortunately the results of these conditions—chief among which are hardness of hearing and deafness—remain permanent and so accumulate that they show a greater incidence upon the older than the younger children. It is therefore very gratifying to note that not only the percentage of children suffering from the causes here considered is, as the result of continued medical care, becoming less frequent, but that permanent results also are becoming rarer. During 1921, 1*9 per cent, of children were found to have ear disease and 0.8 per cent, were found to have noticeable hardness of hearing, both figures being a slight improvement on those of 1920 which, in turn, showed an improvement on the figures of 1919. In addition to 3,231 children in the age groups suffering from otorrhœa and otitis, there were 1,792 such children brought forward by the teachers, nurses and care committees at special examinations. Visual aouity 14,601 children were referred for treatment for visual defect or 10'7 per cent, of those examined in the eight and twelve-year old groups. This is a distinct improvment upon 1920 when 11 "6 per cent, were so referred. The following table sets out the figures for visual acuity from 1918-21 and shows that there is an improvement in this respect at each age. 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 1921 47.1 33.5 19.4 43.7 35.1 21.2 56.9 22.8 20.3 52.0 25.9 22.1 Bad cases of defective vision are commoner at twelve than at eight, but the deterioration between these ages is being diminished and is now much less than it was in former years. The most striking result, however, is the heavier incidence of visual defect upon girls, and, though this is not so marked as formerly, it yet appears that the habitual employment and methods of instruction to which girls are subjected, particularly as regards the teaching of fine sewing, are harmful. Squint. 3,176 children (15 per cent.; were found to suffer from squint, the percentage is especially high in entrant infants and grows progressively less throughout school life. Heart defects and anfemia. 6,229 children, or 2.9 per cent., were found suffering from heart defects, which is a distinctly better result than in former years (3.4 per cent, in 1920 and 1919). 7,974 children, or 3.7 per cent., were marked with anaemia, again an improvement on the previous year when 4.1 per cent, were found. The heavier incidence of heart defect and anaemia in the older girls is still particularly noticeable. 4 per cent, of twelve year old girls have heart defect as compared with 3 per cent, of boys ; and 4.2 per cent, of older girls suffer from anaemia as compared with 3.4 per cent, of boys of the same age. The remarks upon the heavier incidence of visual defect upon the older girls need to be repeated here. 33 Girls require more opportunities for play than they get and boys should share necessary domestic tasks with the girls. 9,109 children or 4.2 per cent, were tound to be suffering from lung complaints the greatest proportion by far was among the entrant infants, where the percentage is 6.6 per cent, as compared with 2.3 per cent, in the older children. The complaints in infants are almost entirely instances of simple bronchitis associated with rickets and other conditions of malnutrition of infancy. Fortunately these complaints rapidlylessen during school life and only a very small proportion lead later to Lung complaints. culosis or other serious mischief. In fact, phthisis remains among the rarest of diseases, as only one child out of every thousand examined is found suffering from this disease, and an identical proportion from "other tuberculous complaints." Many additional children are, however, referred under the arrangement with the tuberculosis dispensaries for further examination, for under the conditions obtaining in school it is often impossible to make a definite diagnosis. Phthisis and tuberculosis. Although a larger number ot children have no doubt a neuropathic tendency, definite nervous disease is found only in 1 per cent., and speech defects (chiefly stammering) in an additional 0.5 per cent. While stammering is found more frequently in boys, other nervous conditions are found more frequently in girls. 242 children in the age groups and 423 at special inspections were found to be epileptic, while 218 in the age groups and 548 at special inspections were found suffering from chorea. Nervous diseases and speech defects. Rickets was noted in 4,733 children or 2.1 per cent. This represents an increase over 1920 when the percentage was 1.3 per cent. The chief incidence is upon entrant boys. 2,994 children, or 1.4 per cent., were found to suffer from deformities due to other causes than rickets, a lower percentage than in the previous year. While rickety deformities are found chiefly in entrant boys these other deformities press most hardly upon older girls, of whom 2"9 per cent, are found to suffer from deformities —chiefly the slighter degrees of lateral curvature of the spine. Deformities. There are thus three conditions found pressing most hardly upon older girls, detective vision, heart disease and anaemia and spinal curvature, and they are all to be traced to the same set of causes, viz. :—less opportunity for play than boys, less time spent in the open air, the performance of household drudgery, and, in regard to school, a different curriculum. 3,250 children (1.5 per cent.) were found with skin diseases, a diminution in the numbers for recent years. 6,415 suffered from external eye disease, or 3 per cent, compared with 3 per cent in the previous year. These diseases are largely due to dirt and unhygienic home conditions. Skin diseases and external eye disease. A far greater number of children are found outside the age groups at special inspections suffering from skin disease. The plague of scabies showed signs of abating in the latter part of the year, but while 327 cases were met with at the routine inspections, no fewer than 3,259 children suffering from scabies were brought forward by the teachers as special cases to see the doctor. This is a larger number than in the previous year. summing up the results of medical inspection it is found that in the three most prevalent classes of ailments for which it has been necessary to provide treatment on a large and organised scale, namely dental defect, defective vision and diseases of the throat and ear, a steady betterment has been produced and large numbers are now saved from the crippling consequences of these conditions, who formerly would have found no alleviation or relief. The nutritional state of the children has also improved, but during 1921 there were difficulties owing to economic conditions. Relief measures promptly applied have prevented any serious suffering, so that even fewer children were reported as undernourished than in the previous year. While, in general, the ailments from which children suffer are shared equally by boys and girls, there is constantly a particular set of ailments which press most hardly upon older girls due largely to the less hygienic mode of life followed in general by the girls as compared with the boys. Summary of results. 2,255 children in special schools were inspected at the same ages and in the same way as the children in elementary schools. In general it was found that these children suffer to a greater degree than others from every kind of bodily ailment, and this is specially marked in regard to ear disease and deafness. Routine inspection of children in special schools. Day Continuation schools were established in London at the commencement of 1921. Subsequently it was decided that for the present, young persons leaving elementary schools at the age of 14 should attend compulsorily at continuation schools only for one year. In the last annual report particulars were given of the results of inspection of the first batch of these children. During 1921 the medical examination of all entrants to these schools has been continued; 38,822 boys and 38,397 girls have thus been examined on approaching the age of 14. Of these 13,678 boys (35.2 per cent.) and 14,367 girls (37.4 per cent.) were noted with ailments for which some form of medical treatment was desirable. Continuation schools. The general inspection of this age group enables an estimate to be made of the effect of remedial measures carried on during the last two years of elementary school life. Attention to treatment of dental caries produces further improvement in these years and 63.8 per cent, of boys were found with sound teeth in comparison with 60.3 per cent, at the age of 12, while in the case of girls 64'4 per cent, had sound teeth in comparison with 63.5 per cent, of their twelve-year old sisters. The general nutritional condition of the fourteen year old boys and girls was also superior to that of the twelve-year old group, 4.7 per cent, of boys and 3.8 per cent, of girls being found undernourished as compared with 61 per cent, and 5.8 per cent, at 12 years. In regard to personal hygiene the older children too showed a superiority. 77'7 per cent, of the fourteen year old girls were perfectly satisfactory in regard to the condition of the hair (freedom from nits or vermin) in comparison with 73.2 per cent, at the age of 12. Acuity of vision also improves in the last two years, for 60.4 per cent, of the boys attain to normal acuity in comparison with 56'9 per cent at the age of 12, while in the case of girls 56.2 per cent, have normal vision in comparison with 52.0 per cent, at 12 years. The superiority of the boys over the girls is still apparent. 61742 34 Adenoid growths and enlarged tonsils are distinctly less prevalent, so are external eye disease, and ear disease. There is, therefore, a diminished incidence in what are termed minor ailments. There is no diminution on the other hand in cardiac trouble or deformities other than rickets, and the girls approaching 14 show a further increase in the amount of deformity (2.9 per cent, as compared with 2.4 per cent, in the twelve year old group). The consideration of the results of these entrance examinations seems therefore to clinch and emphasise the conclusion derived from the analysis of the results of the routine age group examinations in the elementary schools. Examinations in da; continuation schools. All the day continuation schools have been visited by the school doctors at regular times, lhe work has chiefly been that of keeping under review young persons who were marked for observation for defects and tendencies which might lead to disease later on, and that of re-inspecting those who had previously been found to suffer from ailments requiring treatment. 1,869 male and 1,655 female students were specially examined, including many upon whom the principals of the schools wished to have the opinion of the doctor. A number of these students suffered from ailments requiring attention, but being picked cases the figures have no general applicability and are, therefore, not here discussed. The care committees have followed up the cases and in many instances the employers of the children who were in work have been communicated with. Medical inspection of students in secondary schools, etc. The regular inspection of students in institutions for higher education has been continued. A new schedule has been introduced modelled upon that advised by the Board of Education in its circular. 10,833 students were inspected during the year. The governors of a number of aided secondary schools have applied for the extension to them of the Council's facilities and this has in every case been granted. All pupils in secondary schools have been inspected according to the schedule at the ages of 12 and 15, while in preceding, intervening and subsequent years, a full inspection has only been made in special instances. 1,900 boys and 2,119 girls were fully examined in secondary schools at the ages of 12 and 15. In regard to nutrition, clothing and personal hygiene a marked superiority over the children generally in elementary schools was shown. 49 boys (2.6 per cent.) and 73 girls (3.5 per cent.) were found in a state of unsatisfactory personal cleanliness ; pediculi were noted in 3 cases, all girls. Condition of the teeth. 75 per cent, of boys in secondary schools and 73.3 per cent, of girls are found to have sound teeth ; their teeth are in a much better condition, therefore, than those of children leaving the elementary schools, where 63'8 per cent, of boys and 60'3 per cent, of girls were found with sound teeth. This does not necessarily connote a greater primary incidence of caries upon elementary school children, as the results reflect rather the amount of dental care and treatment obtained in each case. Nose and throat. Ailments of the nose and throat were found in per cent, ot the boys and 5'8 per cent, ot girls as against 8'4 per cent of elementary school boys and 9 2 per cent, of elementary school girls. The superiority in this respect is, therefore, marked, but in both cases girls suffer more from catarrhal conditions than boys, and thus again the question of outdoor sports and, pastimes and open air life is raised. Vision. 73.5 per cent, of boys and 69.1 per cent, of girls were found to have normal vision as compared with 60.4 per cent, of elementary school boys and 56.2 per cent, of girls. Here again while the secondary school pupils have a very considerable advantage, the constant superiority of boys in regard to vision is still distinguishable. The number of pupils wearing spectacles was for the first time carefully recorded and once more those who require artificial aid for vision are found to be more numerous amongst girls, the percentages being 12.8 for boys and 15.2 for girls. External eye disease is, as might be expected, very much less prevalent in the secondary schools, only 0.75 per cent, of the pupils being recorded with blepharitis, corneal scars, etc., in comparison with double that percentage in the elementary school children of approximately the same age. Ear disease and hearing. Ear disease also is less common and is identical in amount with external eye disease in both sets of pupils. The secondary school girls were, however, found to have an excess of hardness of hearing, no less than 3 per cent, being so recorded as against 0'5 per cent, of boys. Heart and circulation. 2.9 per cent, of the boys suffered from heart defects and 3.2 per cent, from anaemia. In the case of girls the percentages were much higher, 5 per cent, were marked with circulatory troubles and 7.8 per cent, were marked with anaemia. This seems a high proportion as it is much above the elementary school numbers. There is no doubt, however, that home work and preparation for examinations tell very hardly upon many girls who are found in a neurotic condition and in a depressed state of health. In one girls' secondary school the medical officer reports that there is school until 12.30 on Saturdays and then home work in seven subjects which takes 3 A to 4 hours to prepare. Deformities. lhe girls at secondary schools are rapidly growing and are particularly liable to detects of growth connected with adolescence. These conditions are much affected by over pressure and mental strain. The number of girls who are placed under observation for defects of growth is much higher than it should be. No less than 16'7 per cant, were noted with postural deformities of the spine, including round shoulders, stooping, as well as slight degrees of lateral curvature. 7.1 per cent also were noted with flat feet. The percentage of similar deforniities amongst boys is so much less as to be almost negligible. It is obvious from these figures that the danger of interference with healthy growth that secondary education entails, requires very careful oversight of the pupils from a medical point of view. Distribution of the work of inspecting doctors. An analysis has been made of the time spent by school doctors in one division in the various spheres of work during the course of a term with the following result:—Medical inspection (Elementary schools), 58.4 per cent, of time; medical inspection (Secondary schools), 2.6 per cent. ; work at Special schools, 8.5 per cent. ; re-inspections, 15.4 per cent. ; infectious disease enquiries, 8.9 per cent.; miscellaneous (cleansing stations, remedial exercise classes, open air classes, etc.), 5.6 per cent. 35 Following-up and re-inspection of ailing children. The work of following-up and securing treatment for ailing children is essentially the most important branch of school medical work. In London this is entrusted to the care committee organisation. Each school has a committee of voluntary workers who interview the parents and help them to carry out the advice of the doctors. The number of these workers is 4,850; they are supported, guided and recruited by a staff of 129 organisers. The work includes feeding of necessitous children and after-care. The organisation is placed under the direction of a principal organiser, who is a half-time officer in both the Public Health and the Education Departments, and while the organisers are allocated for financial purposes to either department the organisation functions as one and the staff is in effect a pooled staff. The organisation has been extended to the day continuation schools. During 1921, including the entrants to day continuation schools, 294,552 children were examined in detail at elementary schools ; 113,732 or 38.6 per cent, required treatment for one or more defects. In addition 2,255 children were examined in detail at Special schools, and 40 6 per cent, were found in need of treatment. 73,470 children were seen as urgent cases, of whom 26,425 required treatment, thus 141,072 children were advised to have treatment. The results of following-up are obtained from the returns of re-inspection, and a complete system has been devised whereby each child referred to the care committee is re-inspected after a definite interval. The first re-inspection takes place four to six months after the primary inspection. During 1921, under this arrangement, 112,776 children were re-inspected; of these 452 per cent, were discharged as satisfactorily dealt with. The remaining 54.8 per cent., who were still undergoing treatment or in whose cases treatment had been neglected, were referred for further re-inspection. The second reinspection takes place four to six months after the previous one. Special attention is drawn to neglected cases, and every endeavour made to secure the parents' co-operation. In cases of difficulty a special officer in the education officer's department assists the care committee. In serious cases where all attempt at persuasion fails, the N.S.P.C.C. are informed and take action, in some cases involving prosecution. Mr. Robt. J. Parr, the Director, states that during the year ended 31st March, 1922, of 484 cases involving 586 children referred to their medical branch, cases affecting 296 children had been dealt with successfully, while those affecting 290 other children were still pending. 62,320 children were submitted to second re-inspections, and 603 per cent, of the children were found to be satisfactorily dealt with. Combining the results of the two inspections it is found that 78'2 per cent, of the children coming for review during the year had been satisfactorily dealt with. This result is an improvement on the previous year, and is the best that has hitherto been attained; considering the constant growth of the work carried on, this result reflects great credit upon the efforts of the voluntary workers. The growth in importance of the Council's provision for treatment is shown by the fact that 73 per cent, of children treated receive their treatment under the Council's scheme, while only 27 per cent, are able to obtain treatment by private practitioners or at hospitals not included in the scheme. Under the direction of Dr. Chaikin the twelve assistant medical officers working in the Eastern division have carried out a concerted investigation into the incidence of rickets among school children. 10,000 children were examined, of whom 2,099 (21 per cent.) were found to show some evidence of rickets. Of these 1,717 (17.17 per cent.) showed slight and 382 (3.82 per cent.) showed marked, signs of the disease. The children were distributed throughout the age groups. 3,114 of the children were those born in 1913 ; 1,196 of these were boys, and 393 were found rickety or 32.9 per cent.; of 1,372 girls 312 were rickety or 22.7 per cent. Thus the incidence is much higher on boys than on girls. 70 of these boys, or 5.8 per cent., and 43 girls or 3.1 per cent., showed marked rickets. It is these marked cases alone that would be recorded at ordinary routine inspections, and here again the incidence is heavier on boys. The heavier incidence of course is a long established observation. Of 705 children born in 1913, in whom the incidence of rickety manifestations in particular organs was investigated and the results analysed, 90.63 per cent, showed rickety chests, 35.3 per cent, rickety crania, 109 per cent, rickety long bones, 52'15 per cent, caries of the teeth, and 34.6 per cent, other defects of the teeth (pitting of enamel, irregularity, etc.). Incidence of rickets. inquiries showed that at least half the children who exhibited rickety signs had been poorest fed. With regard to racial incidence, the schools investigated were divided between schools mainly Jewish and schools mainly non-Jewish. The incidence of rickets in the former schools was considerably less than in the latter. Total examined. Slight rickets. Marked rickets. Total rickets. I.—Non-Jewish schools 5,855 1,172 235 1,408 II.—Jewish schools 4,145 544 147 691 Thus while 24 per cent, of children in " non-Jewish " schools were found rickety only 16.6 per cent, of children in " Jewish " schools were rickety. This classification is, however, rather misleading for it by no means follows that all the children attending such schools are indeed Jewish or non-Jewish. In fact where purely Jewish schools were taken the incidence of rickets was specially high (38.25 per cent.). It appears that the above classification of schools is complicated by another factor. The first set of schools (classed as non-Jewish) contained children in the main from poorer homes than in the second set of schools, and family circumstances appear heavily to outweigh racial differences. The school doctors considered carefully the question of breast-feeding, and it was a matter of surprise that such a large proportion of the rickety children were breast-fed. These, they say, are cases of too prolonged breast-feeding; irregular feeding and the health of the mother are contributory. There is still much room for instruction of mothers on the correct feeding of infants, as much on the breast as otherwise. The heavy incidcnce of rickets upon the walls of the chest, producing well-known deformities is pointed out by the doctors. They associate this special incidence with the presence of adenoids to 61742 F 2 36 excess in rickety infants. As children grow older many of the signs of rickets disappear, but there is a residuum. These children left with deformity indicate the special need for physical exercises and especially breathing exercises in the schools. The incidence of rickets on children born during the war and on those born previously was carefully compared. There is distinctly a lower percentage of rickets in entrant children who were born during the war (14.12 per cent, compared with 22.64 per cent, in children born in former years). This confirms the findings as to the improved nutrition of the children which were made in these reports during the war years. The figures were all the more remarkable inasmuch as it is in the entrant children that the signs of rickets are always the more marked. The doctors in the concluding paragraph of their report consider the directions in which effort should be made to counteract the evils which result in so many children being found at school with evidences of the effects of infantile rickets. The chief things they lay stress upon are improvement in home conditions, more open spaces, instruction of mothers in infant care, safeguards for maternal health, and in school more physical exercises in special classes and continued attention to the teeth which, in association with nasal obstruction, must be "treated together to prepare the healthy mouth and throat essential for a healthy chest. Dr. C. N. Atlee independently made observations upon 5,000 children in the Greenwich area. While he attended only to the more marked manifestations, he also confirms the East End results, finding considerably less rickets among the entrant infants than in the eight year-old group, and he attributes this entirely to the full employment and good wages earned during the war. Co-operation between the school medical service and tuberculosis officers. in 1920 a scheme for co-operation between the school medical service and the tuberculosis officers was drawn up. The following report from Dr. Chaikin, divisional medical officer in the eastern division, illustrates the way in which the work is being carried out. The scheme provides for the observation by the school doctors of the children of school age nominated by tuberculosis officers. The periods of observation vary. They are either fixed by the tuberculosis officers at the time of nomination, or are left to the discretion of the divisional medical officer During the period stated the child does not attend the dispensary but is examined and re-examined at intervals of not less than three months. The tuberculosis officer, on nomination, makes a clinical report with recommendations. The latter refer to school attendance, nourishment and general treatment. The district organiser of care committees is informed of every case so nominated. Arrangements are made for examination by the school doctor. At the end of the period of observation a report is sent to the tuberculosis officer and the child attends the dispensary. It is open to the tuberculosis officer to re-nominate a case if he thinks fit. A child, who is under observation, may return to the dispensary any time before the expiration of the period of observation, if treatment becomes necessary through a change in condition. No child, however, returns to the dispensary under the scheme without the knowledge of the School Medical Service, and without a report to the tuberculosis officer. The scheme has worked very well administratively and provides a complete chain of observation. The tuberculosis officers have been able to refer cases to the school doctor and thus to relieve the dispensaries. Altogether 250 cliildren were nominated by the tuberculosis officers for observation by the school doctors. Of these the largest number were from Poplar. 115 children are still under observation and 135 have been returned to the dispensaries after observation has been completed. The number of examinations carried out in different cases varied from one to four. The usual number was two. In 13 cases children relapsed and were sent back to the dispensaries before the observation period had been completed. 549 appointments were made for examination, and the actual number of examinations made was 426. Children were re-examined by the school doctors at periods varying from three to twelve months. Most children were seen at intervals of three months and many at six months. Very close co-operation with the tuberculosis officers has been secured and in every respect the scheme has worked very well and smoothly. Employment of school children. The introduction in July, 1921, of the new by-laws in London regulating the employment of children has placed upon the school medical service additional duties, inasmuch as no child of school age may now be engaged for wage-earning employment unless a certificate of health signed by the school medical officer has been obtained. The number of children dealt with between July and December inclusive was 4,649, of whom only 152 were girls. In 37 cases, medical certificates were not given for the following reasons :—heart disease, 9: tuberculosis, 4; dyspnoea on exertion, 2 ; debility, 4 ; defective vision, 1; bronchitis, 1; otorrhcea, 1; hernia, 1; hip disease, 1; rheumatism, 1; tonsillitis, 1; Graves' disease, 1 ; under age and other causes, 8. In addition, 154 conditional certificates were given. The conditions stipulated for comprised necessary treatment, special feeding, limitations of work, special care, etc. The number of children seen in each district was : North-eastern, 869 ; North-western, 1,252; Eastern, 123; South-eastern, 1,003; South-western, 1,402. The small number of children submitted for examination in the East End is rather surprising. The number of examinations exceeded the number of children as many certificates were granted on condition of periodical re-examination. Particulars were given in the last annual report in regard to the medical supervision of children employed in public entertainments. This supervision has been continued, and entails considerable work, inasmuch as the children must be re-examined at intervals of three months. A large number were found in the spring months to be suffering from scabies, and this was found to extend to children licensed by education authorities in the country and examined on passing through London. It appears that as troupes move about the country, they regularly occupy lodgings vacated by previous troupes, and no doubt in this way a large proportion of children at that time employed by touring companies contracted the disease. Apart from this trouble, it has been noticed that the condition of children employed in entertainments who come from elementary schools has greatly improved since the coming into force of the Order. 37 Children absent from school on account of ill-health. In the report of the Chief Medical Officer of the Board of Education for 1920, it was pointed out that in general out of 100 children on the roll of elementary schools, 10 will be absent at any one moment, and of these 10, 8 will be absent on account of illness. This accords with the results of an enquiry made by the Council's staff so long ago as 1907. In London, the co-operation between the school medical service and the school attendance department is thorough, joint action is maintained to ensure that all children out of school on account of ill-health are followed up, and that unsatisfactory cases are reduced to a minimum. A census is taken in November each year in regard to children who have been absent for long periods—three months and upwards—on account of medical reasons. The results for the past three years are given in the appended table. When the ages of children who are habitually out of school for alleged ill-health are plotted, it is found that the proportion steadily falls from the age of 5 to 11, and then again rises, but the rise at the ages of 12 and 13 is far more marked in the case of girls and the conclusion can hardlybe avoided that the usefulness of the older girls to their mothers in the home is a factor in non-attendance. CHILDREN ABSENT FROM SCHOOL THREE MONTHS OWING TO ILLNESS REPORTED IN NOVEMBER, 1919, 1920 AND 1921. Complaint. Children Percentage of Total. 1919. 1920. 1921. 1919. 1920 1991. Rheumatism, heart and chorea 412 537 659 14.43 21.12 21.61 Nervous disorders 211 219 238 7.38 8.21 7.80 Tuberculosis (pulmonary and other) 586 595 613 20.51 22.33 20.10 Anaemia and debility 226 155 219 7.91 5.52 7.18 Ringworm 129 125 231 4.51 4.69 7.57 Skin complaints (other than ringworm) 161 102 77 5.63 3.83 2.52 Eye complaints 180 167 150 6.30 6.27 4.91 Other diseases 951 765 862 33.29 28.70 28.27 Totals 2,856 2,665 3,049 — — — While skin complaints and external eye disease which were so rife during the later years of the war have diminished, the number of chronic ringworm cases has increased. These form a small proportion of the total number of cases of ringworm, which occur, and represent the residue in which the parents object to X-ray treatment, and are content with the application of ointments and other external medicaments, whose action is slow and uncertain. Medical treatment. 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 1912. At the end of 1921, the scheme included 14 hospitals, 56 treatment centres, and a dental centre at Bushy Park Camp School. The treatment centres are managed by voluntary local committees of medical practitioners, nursing associations, and dispensary and other committees. These 71 centres at the end of 1921 had available accommodation for the treatment of 208,298 children, the arrangements including the following ailments : eye (refraction, 30,530 ; eye diseases, 2,150); ear, nose and throat, 17,230; ringworm, 2,628 ; minor ailments, 51,040 ; teeth, 104,720. The facilities are available for elementary school children and scholarship holders in secondary schools at a charge of 2s. for each ailment treated, except that for minor ailments a charge of Is. is made after the first fortnight's free treatment. 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 scale of charges based on the average cost was for 1921 fixed at the following rates : aural operations, 9s 8d.; minor ailments, 9s 2d.; X-ray treatment of ringworm, 25s. 4d. ; and dental treatment, 7s. 7d. The cost of equipment of new centres has not materially lessened during the past year, and no alteration has been made in the scale of allowances set out in the report for 1920 (p. 67). It has, however, been necessary to modify the salaries of doctors and dentists to accord with economic conditions, and they are now as follows :—Surgeons, £80 a year for one session of 2½ hours a week, and proportionately ; anaesthetists, £75 a year; minor ailments doctors, £66 a year for a session of 2 hours onlv each week; and dentists £60 a year for one session each week. The maintenance grants referred to in the last report have been continued for one year. The number of children actually treated under these arrangements is the highest yet recorded, being 212,579, as against 197,700 during 1920, which again may be compared with the 27,647 children treated in the year ended 31st July, 1912. More detailed particulars of the separate ailments are here summarised. (a) Minor ailments.—Notwithstanding the large increase in the provision for minor ailment treatment during 1921 (i.e., from 44,440 to 51,040 cases), the number of cases treated, 68,283, was still in excess of the nominal provision. The attendances numbered 1,274,613, which shows an increase to 13'7 per cent, on the figures for 1920. In addition, 5,863 cases of scabies were treated at the cleansing stations. The figures are a striking testimony both to the need for, and the popularity of, the Council's provisions for ailing children. Reference here should be made to the very helpful arrangements with the Metropolitan Asylums Board, whereby children suffering from chronic ophthalmia and other external eye conditions are sent direct by the school medical service to the Board's convalescent home for ophthalmia at Swanley. This 38 arrangement has been a great boon, and has enabled the Council to deal with a large number of children who were under supervision, though out of school for interminable periods, owing to painful and distressing eye disease. Previously nothing could be done in these cases, except watch them month after month struggling in unhygienic surroundings with palliative treatment. The number of children sent to Swanley under this arrangement from its commencement in May to December was 108. (b) Aural defects (including enlarged tonsils and adenoid growths).—Attention has been continuously directed to this sphere of the Council's remedial work. Greater interest and solicitude are now shown generally in all questions relating to the care and treatment of children and public criticism, welcome and sometimes well informed, is now readily forthcoming. The arrangement at the Cyril Henry centre, whereby children are kept in for two days following minor operations upon the throat, has been greatly appreciated. The consent of the Board of Education has been obtained to the use of an ambulance in the case of other centres, and it is hoped before long that a centre may be established in Highgate New Town whereby the benefits at the Cyril Henry centre may be extended to children living north of the Thames. As has been shown in the section on inspection, an undue number of children has by no means been referred for further examination and treatment for nose and throat disease, and there can be no doubt that operation is advised only where the child's health is seriously threatened. Dr. A. G. Wells, who has made a series of visits to the treatment centres, has drawn up the following statement in regard to the indications for operation for tonsils and adenoids :— Tonsils should not be removed simply because thay are enlarged. Generally speaking, no operation for tonsils and adenoids should be performed unless there are very definite symptoms present, the persistence of which would be likely to act prejudicially upon the health of the child, and the treatment of which by more conservative means would be likely to be ineffective. Each case must be judged on its merits, and while the following recommendations are not exhaustive as to when operation is indicated, they are meant to serve as a general guide in arriving at a decision at the Council's treatment centres. Indications for operation in cases of adenoids :— (1) In cases of recurrent attacks of earache. (2) In cases of recurrent attacks of deafness. (3) In cases of otorrhcea. (4) Marked snoring, mouth breathing and restlessness at night, when the cause can be attributed to adenoids. (5) Frequent repeated colds and coughs not due to other factors. (6) General malnutrition where other causes can be excluded. Indications for operation in cases of tonsils:— (1) Frequent sore throats, not prevented by conservative treatment. (2) Cases of diseased tonsils—e.g., fibrosis of the tonsils; tonsils in which small yellowish plugs are extruded into the throat, or those in which secretion from the crypts can be expressed by pressure on the tonsil. (3) When there is enlargement of the tonsillar glands. Dr. Wells has also drawn up the following recommendations in regard to immediate treatment after operations:— In order to minimise the risks of untoward results in operating for tonsils and adenoids, operators are recommended as follows:— (1) Take the precaution of inspecting thoroughly the area of operation in order to see that no " tags " of adenoid tissue remain after operation or other condition- exist which might detract from the success of the operation. (This necessitates inspection of the throat under complete illumination by direct or reflected light.) (2) See that the patient is not allowed to leave the operating table until all bleeding has ceased. (This usually takes place within three to five minutes of the completion of the operation.) (3) See that the child is placed in bed in the most suitable position after operation. (A lateral position with the head slightly extended ; the upper leg well flexed at the hip and knee and the arm so tucked against the chest that the upper shoulder is propped up to allow free respiratory movements of the chest.) (4) Nurses on duty in the ward or recovery room should see that the above described position is maintained. If much oozing escapes from the mouth, the nurse should acquaint the doctor at once. She should watch the movements of the larynx to see if any appreciable quantity of blood is being swallowed. If the child is restless, pale, has irregular, shallow, sighing respiration and rapid pulse, the . doctor should be immediately notified. Dr. Wells has continued to devote a session on one day in the week in each division to the oversight of cases of discharging ears. He saw during the year 924 children. The treatment of these cases by Dr. Friel by the method of ionisation has been continued at the Almeric Paget treatment centre, and has been extended to the Lissonia centre. At the Almeric Paget centre, 124 children were examined, and of these 86 were considered suitable for ionisation ; of these, 49 were cured, 11 referred for operation 10 still remain under treatment, and 16 ceased to attend. Of the 49 cases cured, 43 had one ionisation only. In suitable cases, therefore, ionisation appears to succeed far more often than any other form of treatment, and not only this, it effects a cure at once, whereas all other methods must be almost indefinitely prolonged. The arrangement with the Metropolitan Asylums Board for the admission of children needing mastoid operation to Cleveland-street infirmary has been continued ; 158 operations were there 39 formed, in 138 cases (87.3 per cent.) the operation was a complete success and effected a radical cure. This is a high figure, and the results are very gratifying. Ionisation has thus proved a valuable ancillary method. At the various centres in the Council's scheme, 20,237 appointments were made for the treatment of aural defects ; 15,543 children attended for medical examination, and operations were performed in 11,080 cases ; 11,372 children were discharged as cured. During the year, 2,366 children were operated upon at Cyril Henry Centre, Woolwich, and were retained at the centre for two nights after the operation. (c) (d) and (e)—The figures relating to ringworm and vision are given in table IV. (/) Dental defects.—Under the dental scheme, 66 part-time and 5 full-time dentists are now employed. Full particulars of the work done during the year are given in table IV. From the inauguration of the sale of tooth brushes to elementary school children in 1918, up to 31st December, 1921, 51,582 tooth brushes were sold ; in the same period, 18,984 tubes of tooth soap were also sold. Stammering children.—During the year arrangements were continued for remedial treatment of stammering children. The treatment is carried out at six of the Council's schools, where use is made of vacant rooms not required for ordinary teaching purposes. At each centre two groups of about 12 children each are dealt with twice weekly during one school session, each group receiving treatment and advice from special instructresses in speech training. In the course of the year 330 children passed into these centres. A number of the more chronic patients were sent to Margate and Bushy Park Camp Schools with beneficial results. The children are kept under medical supervision and are discharged when considered provisionally cured or when sufficient improvement is made to render further treatment unnecessary. As early as possible during treatment any physical defect which might aggravate the condition either directly by affecting speech or indirectly by lowering the general health standard is remedied as far as possible. Of the 330 children under review during the year 53 were discharged after having attended the centres for one term, 30 after two terms, 24 after three terms, 5 after four terms, and 8 after five terms, a total of 120 being discharged during the year. During treatment, reports as to progress are received from teachers and parents and also at definite intervals after discharge information is obtained as to the condition of the children. Throughout 1921 it was found necessary to arrange for 15 children to be re-admitted for further treatment as their reports appeared to show a tendency to relapse. Of these 15, 8 recovered after further treatment extending over one term, and 1 child after two terms ; 3 children had left school, and in 3 cases the parents declined to let the children re-attend. During the year some difficulty was experienced in finding enough girls to fill the girls' classes (figures quoted in a previous report showed that there were about three times the number of boy as of girl stammerers) and the experiment was tried of introducing into the girls' classes boy stammerers who were attending neighbouring schools. Only boys aged 8 to 11 were thus dealt with, it having been found at the commencement of these classes that mixed classes of older boys and girls tended to accentuate the nervous tendency of stammering children. The experiment was found to be a decided success; the elder girls showed a kindly interest in the younger boys and were always willing to aid them in any difficulties which arose. From the experience thus gained it appeared that quicker and better results are obtained the younger the subject and the less chance the stammering has of becoming stereotyped. The number of younger children dealt with so far is too small to base separate statistics on at present. Even when the cases are finally discharged the carrying out of the practical exercises is strongly recommended in order that possible relapses may be prevented. Arrangements are made for these cases at Bushy Park for half-an-hour's practice each day. The parents are invited to attend the centres, and efforts are made to obtain information as to the cause and mode of onset of the stammering. A note is also made as to family history. From information obtained in respect of the children dealt with in 1921 it appears that stammering began before 7 years in 100 cases ; stammering began after 7 years in 64 cases. Aetiology of the cases seen (i.e., causes elicited as far as can be ascertained):—Imitation, 19 ; shock, 82; physical causes, 25 ; congenital (i.e., with speech), 80 ; hereditary history of stammering, 53 ; bad physique, 49 ; neurotic history, 63 ; left handedness, 4. Nursery schools. In the whole of London there are only ten recognised nursery schools, accommodating altogether about 500 children, from the ages of two to five. Of these the Rachel McMillan voluntary school at Deptford accounts for 100 and the Council's new school on the adjoining site for another 100. Next in size comes the oldest of these schools, the Notting Hill, accommodating 50 children. Children over five are occasionally allowed, on medical grounds, to remain until six years of age; in the case of the Jellicoe School special permission to keep children until six has been given. The schools are all under medical supervision, and seven of them are visited daily by one of the Council's nurses, who attends to minor ailments, watches for signs of infectious disease and helps with the general hygiene and cleanliness of the children. Two-year-old children, on account of their exacting physical requirements, involve the greater amount of work, yet the proportion of these children bears no definite relation to the staff employed. Apart from the Deptford Schools, Kilburn Union Jack and the Passmore Edwards Schools appear to have the smallest staff and largest number of two-year-old children. Towards the end of September the Council's new nursery school at Deptford began admitting children, and later was officially opened by Her Majesty the Queen. This school adjoins the present Rachel McMillan voluntary nursery school and training centre. The two schools share the same Superintendent, Miss Stevenson, and the food comes from a kitchen common to the schools and the training centre attached. 40 Before the close of the year there were 91 names on the school register with over 70 children in attendance, which was as many new children as could be conveniently dealt with to begin with, as a large number of them were only two years old and the majority required training in cleanly habits and much special attention during the day. The school buildings here consist of two open shelters, and the children live under delightful health-giving conditions during the warm weather. Unfortunately during the colder months, from October to March, they are exposed to fogs and keen winds, and during these months means of modifying the rigorous open-air conditions are necessary. It has been found during the year that nursery schools, far from being the means of increasing the mortality from measles have had just the reverse effect. In Somers Town Nursery School, where measles occurred, the school was the centre for the control of the disease. The teachers were able to recognise the initial symptoms and to send the child home, at the same time advising the parent to keep the child in bed for at least a week. In every case the child was home and in bed before the appearance of the rash, with the result that there were none of the dreaded after-effects which are the cause of the high death rate associated with this disease. Open air education. The stringency of the times is threatening very seriously to check progress in the development of open air education. The schools at Stowey House (Clapham Common), Birley House (Forest Hill), and Shrewsbury House (Shooter's Hill) have been continued, and the school at Bow-road (Poplar) was ready to open at the end of the year. All other proposals for extension have been suspended. When open air schools were first established it was considered that they should continue throughout the year without a break, but of late it has been felt on educational and administrative grounds that school holidays are required. The slow increase in weight before the summer holidays compared with the relatively rapid increase afterwards has been cited as an added reason on physical grounds, but it is necessary to point out that in the northern hemisphere childrenjgrow in height in the spring while remaining relatively stationary in weight and grow in weight during the autumn while remaining relatively still in height, and the question of school holidays is not really involved in this respect. The weights of 50 girls and 50 boys in constant attendance at Stowey House open air school during 1921 bring out this peculiarity of the weight curve rather strikingly. Thus the average percentage increase in body weight monthly for boys was, April to May, 1.24, May to June, '34, June to July, — '25, July to August, 120, August to September, 1.57, September to October, 1.26, October to November, 1.60, and for girls April to May, '81, May to June, — 14, June to July, '04, July to August, 1.40, August to September, 1.77, September to October, 2.04, October to November, 1.93. In addition to the natural alteration in the rate of increase of weight it must be remembered that in May and June there is a shedding of garments owing to the increasing temperature. If open air schools are to be closed for summer holidays it follows necessarily that consideration should be given to individual children in open air schools to ensure that the interruption of the open air regime does not prejudice their health. In addition to the residential holiday camps at Bushy for boys (300 places) and Wanstead House, Margate, for girls (50 places), a third camp school was opened during the year at Barham House, St. Leonards-on-Sea. This institution was presented to the Council by Mr. Rainey, who had long been a care committee worker in Hoxton. There is accommodation for 50 children, and all schools in Hoxton are allowed to share in the privilege of sending pupils. Bovs and girls are taken for a month alternately. Open-air classes. During the summer of 1921, 94 open-air classes were authorised, in connection with elementary schools in London. These classes were additional to those which are held all the year round, viz., the classes at Rhyl-street school (boys), Sirdar-road school (girls), and Peckham-rye school (infants). As in previous years, the classes were of the following types :—Type A—A class held at a centre and composed of delicate children from neighbouring schools : Type B—A class of delicate children specially selected from various classes in the same school: Type C—An ordinary school class working in the open-air : Type D-Ordinary school classes working in the open-air, in turn, for a day, week, or month at a time. This year of classes of type A were held, 24 of type B, 32 of type C, and 27 of type D. The sanction of the Board of Education to the Sub-Committee's programme was given on the understanding that the expenditure incurred on open-air classes during 1920 should not be exceeded in respect of 1921. For this reason it was decided to restrict the total number of authorised classes to the same number as was approved for 1920, namely 94. The classes of types A and B were kept under close observation by the school doctors, whose reports show that the arrangements were, with few exceptions, well conceived, and the children benefited in health, even more than usual, on account of the exceptionally fine weather which was especially favourable to open-air work. It is to be hoped that it will be possible to continue the practice of holding open-air classes in playgrounds and open spaces, especially as the Council's programme for the development of the open-air schools is held up. A word of caution is necessary. What life in the open-air does is to speed up the bodily metabolism, and induce the need for additional food. There is a tendency in many circles to forget this, and to think that the fresh air of itself is sufficient without further consideration. But it must be insisted that to take children from poor homes and educate them in the open air without ensuring that the extra food supply is readily forthcoming, is a species of cruelty. It is this need for additional food which makes all open-air schemes costly, and this cannot be avoided. The Rhylstreet (boys), all the year round open-air class, " Windyheath," is one of the most interesting of the various attempts to utilise available spaces (alas ! too few) for open-air work, and the following is an extract from Dr. R. H. Norman's report upon it. 41 " This is an all the year round class, and contains 24 boys, ages varying from 9 to 13 years. These boys have been in the class the whole year. The summer and autumn terms are spent on the bandstand, and the winter and spring terms in a pavilion on Parliament-hill-fields. The boys, when originally selected, were about as weedy, needy and seedy a set of lads as could be picked up. To-day their appearance is the very opposite. " It is the best conducted class of the kind that I have ever come across, being blessed with a teacher full of enthusiasm and open-air ideals. During the summer, every week, from Friday to Saturday evening, 6 to 12 of the boys have camped out in Ken Wood with the teacher. Each boy contributes 2s. 6d., which covers the cost of the provisions. Two tents and a bivouac are provided. An occasional excursion is made to the sea, accompanied by the teacher. On Saturday, October 15th, 17 of the boys were taken to Southend, each paying his own expenses, which were surprisingly small. " There has been a singular absence of illness during the whole year. One sore throat, one case of chickenpox, and a blistered foot make up the total list of casualties. An average of 16 boys pay 7d. per day for a really decent dinner provided in the refreshment room at the pavilion by the proprietor. Roast beef, two vegetables, and boiled rice ; stew, two vegetables, and jam pudding are examples of the food given. Four boys living fairly near the fields go home to dinner, four others bring theirs with them." It may be mentioned that one of the boys in this particular class succeeded this year in passing the preliminary examination for the Junior County Scholarship. lhe aid given by the Council to school-journey schemes, gave a great nllip to the movement during 1920 and 1921. Applications during the latter year were received from 398 departments, and 303 journeys were authorised. The Education Officer draws attention to one successful journey of a novel type, organised from Wickham-lane school, Plumstead. This journey took the form of a tour through Kent, the boys and masters travelling by road, accompanied by a motor-lorry with equipment. Tents were pitched at spots previously arranged. Generally, accommodation was obtained at hostels, cottages, convalescent homes and camps. School journeys, lhe excellent cffects of a country or seaside holiday under proper conditions in restormg bodily tone and improving health, need no special demonstration, and it has not been thought necessary for children proceeding on school journeys to be specially examined as a routine by the school doctor on their return. In some cases, the school doctors found it possible to see the children shortly after their return, and in every instance they report upon the very beneficial results. Dr. Reginald Hanson applied to a set of children going on a school journey some simple tests based upon those now extensively used to determine the bodily condition of flight officers before and after an aerial expedition. The basis of his observations were the rates of return of the heart beats to normal subsequently to being raised by a measured amount of exertion. Seeing the children again on their return, he was able to prove scientifically that the school journey had markedly improved their general health, and in particular their cardiac tone. In all the official school journeys, arrangements were made for the school doctor to see the children before their departure. This is a necessary precaution in order to avoid the risk of spread of disease, and the chance of a school journey being spoiled through the breakdown in health of a child or children unfit physically to take part. Infectious disease has been unduly prevalent, but only in a few cases was any serious trouble caused by an outbreak of disease amongst children during the school journeys. It is a great responsibility for teachers to undertake the care of a number of children under strar.ge surroundings, and applications were made for a medical examination in the case of a number of extra unofficial school journeys; so far as possible the assistance sought was given by the medical officer's department. Isolated cases of infectious disease were reported from school journey parties at Heme Bay, New Romney, and Whitstable, but adequate precautions were taken and no serious spread took place. Cine of the most serious occurrences was in the case of a school journey to Littlehampton, during which the whole party seems to have been upset by some illness, at first thought to be typhoid fever, but of which the diagnosis remained obscure, it was found necessary for two little girls to be left behind in the charge of two of the teachers on the return of the others. It was unavoidable that with so many school journeys there should be a few mishaps, but they were reduced to their smallest possible proportions. The vast majority of the journeys were highly successful, and undoubtedly from the health point of view the results were highly satisfactory. Personal hygiene. The total number of examinations made during the year by the district school nurses was 2,113,463 ; verminous conditions were present in 435,282 instances or 20'5 per cent, as compared with 18'9 per cent, in 1920 and 22'6 per cent, in 1919. School nurses' rotJ visits. in the report for 1920, mention was made of the steps which had been approved by the Council for treating the slighter cases of verminous infestation at medical treatment centres, in boroughs in which thorough co-operation existed with the local sanitary authorities, and not at the ordinary cleansing stations. The first centre at which such arrangements were made was the St. Pancras School Treatment centre, where operations were commenced on the 24th January, 1921. Since that date six other centres have been opened in the districts of Hammersmith, Vauxhall, Hackney Wick, Poplar, Millwall and Plumstead. The original scheme approved by the Council provided for 10 centres but it has not so far been possible to arrange for the three outstanding centres, which it is proposed shall serve the districts of Stepney, Ishngton and North Kensington. During the year the number of children dealt with was 9,734. The work has received the general support of head teachers, particularly of girls' departments, and the arrangements have been made in every way as educational as possible. Children and parents have been instructed in the practice of cleanliness, and the added interest produced has 61742 G Cleansing at medical treatment centres. 42 undoubtedly raised the standard of cleanliness, as is testified by the observation of school nurses and teachers. A special point is that the local sanitary authorities act in close co-operation with the Council in taking steps to deal where necessary with any other members of the family. Thus in 28 per cent. of a series of cases reported to the Hammersmith Metropolitan Borough Council, "other members of the family" were cleansed; in St. Pancras the figure is given as 20 per cent. ; whilst in Stepney, Battersea and Kensington importance has been laid upon advising the parents and arranging for disinfestation of bedding or homes. The results of the work tor the several years 1912-1921 under the Cleansing Scheme are shown in the following table:- Year. No. of examinations made at Rota visits. No. of verminous conditions noted at Rota visits. Per cent. No. of verminous children referred to stations. No. subsequently cleansed by parents. No. of verminous children cleansed at stations. No. of scabies eases bathed at stations. No. of cleansings for vermin and scabies. 1912 - - - 23,573 10,179 10,340 - 26,913 1913 - - - 29,903 15,241 14,662 - 41,458 1914 1,053,218 286,664 27.2 28,361 14,392 13,969 589 42,557 1915 2,444,885 689,428 28.1 28,063 14,677 13,386 1,059 43,884 1916 2,399,280 612,659 25.5 24,705 11,314 13,391 3,213 54,945 1917 2,130,186 528,658 24.8 19,506 8,506 11,000 6,940 80,755 1918 1,921,762 465,608 24.2 13,237 4,912 8,325 9,624 95,033 1919 2,031,735 459,396 22.6 33,222 15,929 17,292 8,371 105,639 1920 1,944,105 368,732 18.9 43,764 16,355 27,409 9,675 123,975 1921 2,113,463 435,282 20.5 65,084 22,489 42,595 5,863 92,024 Work at cleansing stations. The number of cleansings given at cleansing stations proper during the year was 92,024 as compared with 123,975 in 1920. This decrease in the number of cleansings, not in the number of children cleansed, is due to the policy instituted at the beginning of 1921 of thoroughly cleansing each child at one attendance at the stations. In previous years it had been the practice (owing to the difficulty of eradicating the nits) to arrange for repeated attendances until the child was certified as clean. With the introduction of the special comb and the use of new shampoo soap (both referred to in previous reports) it was found that, by devoting a somewhat longer time than hitherto to each child, it was possible to effect complete cleansing in most instances at the one attendance. The great majority of children, therefore, now miss one attendance only at school; some exceptions are necessary in the cases of children suffering from impetigo, which, of necessity requires more prolonged treatment. Out of 65,084 children whose verminous condition was brought to the notice of the parents, 24,134 attended voluntarily at the cleansing stations, but in 23,989 cases it was necessary to serve statutory notices after a further examination. Following upon these statutory notices 7,380 children attended the stations voluntarily, but of the remainder 11,081 were found verminous after a still further examination and were compulsorily taken by the nurses for cleansing. Among the children who were compulsorily cleansed 913 were subsequently found to have relapsed and prosecutions under Sec. 122 of the Children Act were instituted in 833 cases. It is, perhaps, necessary here to comment upon the increase from 27,409 to 42,595 in the number of children cleansed at the stations. It was pointed out in the previous report that the work of dealing with such children was considerably interfered with during the war by the resort to the cleansing stations of children suffering from scabies. Additional help was provided to cope with the difficulties arising and more baths were provided, but from the table it appears that although the action taken has at length reduced the incidence of scabies, the task of dealing with verminous children apart from those suffering from scabies has been seriously hampered. With the reduction during 1921 in the numbers of children suffering from scabies, time and accommodation were available for dealing with a large number of verminous children who were formerly crowded out. During the year an agreement was made with the Stepney Metropolitan Borough Council for the use of their cleansing station, and the new cleansing station opened by the Kensington Borough Council commenced work in August. Agreements were in force with 17 of the local sanitary authorities for the use of their stations, and also with one voluntary committee, but the station of this last-mentioned committee was closed at the end of the year. A new Council station was opened in the Camberwell district in April and it was reserved entirely for head cases, body cases in that area being dealt with as hitherto at the borough council station. The number of cases attending at this new station up to the end of the year was 1,926, a figure which is not included in the total number of cleansings referred to above. During the year a noticeable reduction occurred in the number of children treated at the cleansing stations for scabies : whereas in 1920, 9,675 children were thus treated, in 1921 the number fell to 5,863 a decrease of 3,812. The number dealt with is lower than that of any year since 1916 and the reduction gives rise to the hope that this minor horror (due no doubt largely to contact with soldiers) is now definitely on the decline. Co-operation with local sanitary authorities. As in previous years the practice was continued of notifying to the borough medical officers particulars of children dealt with under the Council's cleansing scheme in order that where possible the home conditions might be remedied under the Act of 1904. During 1921 reports were received in regard to 4,882 homes visited ; out of this number disinfestation or destruction of bedding or disinfestation of homes was carried out in 1,792 instances. In 1920 the corresponding figures were 3,645 homes visited, action taken in 1,852 cases; whilst in 1919, 3,421 homes were visited and action was taken in 1,650 instances. Use of public washing baths during school hours. The scheme for bathing children at certain public baths was continued throughout the year, but the extensions of the scheme referred to in the last report were not put into operation. The number of baths arranged for during 1921, was 5,702 in Camberwell and 6,154 in Kensington. 43 Infectious diseases. The accompanying diagram on page 44, giving quarterly variations in death rates in measles and whooping cough and in notifications in scarlet fever and diphtheria, clearly shows that the years on the right hand of the diagram compare favourably with those on the left. In measles and whooping cough more particularly the declining birth rate is no doubt accountable in part for the decline ; this fall in the birth rate dates from about 1880, but was more marked after 1900. In scarlet fever and diphtheria the line between the years 1902 and 1903 seems to mark a descent from a higher to a lower plane of prevalence. In this later period there was a fairly rapid rise in the average attendance in the schools steadily maintained between 1900 and 1910; then followed a slight falling off in the succeeding three or four years, and the war had a marked effect in reducing school attendance. Since 1918 the percentage of attendance has been rising again towards a more normal level. Ignoring the effect of the war and making every allowance for the more efficient methods adopted for improving the attendance, it is significant that increased attention to control of infectious diseases in London schools has synchronised with a higher standard of school attendance. In estimating the causes of reduced prevalence of infectious diseases within recent years due weight must of course be given to hospital isolation and treatment, as also to what may be termed in a broad sense the public health conscience. It is impossible, however, to resist the impression that the systematised control of infectious diseases in the schools in recent years has also had marked influence. It will be noted that although, taken on the whole, the general prevalence of infectious illness was lower during the period of medical influence, epidemics have occurred from time to time in the later years, which bear comparison in point of magnitude with some of the earlier epidemics ; but it is noteworthy that the intervals between these abnormal prevalences have been extended, and it is reasonable to ascribe this postponement of the "major waves" to the protection of the individual child by the generally improved measures adopted within recent years. Rules of procedure for dealing with infectious diseases appear in 1885 in the School Management Code of the London School Board, and these were added to from time to time. On 12th March, 1891, the first mention is made of a form for notifying exclusions to the local medical officer of health and the superintendent of visitors. The Code for the same year refers to notification procedure under the Act of 1889 and the Public Health London Act, 1891. The Code of 1902 for the first time refers to " form 84" being sent by the teacher to (a) the medical officer of the board, (b) the divisional superintendent, and (c) the medical officer of health of the district. In 1904 the Council became education authority and the present procedure was gradually evolved, under which schools or departments are very rarely closed, but reliance is placed upon exclusion of particular scholars (actual sufferers) and upon a carefully regulated scheme of exclusion of susceptible contacts usually only from the same family, but in some cases also from the same house. Scarlet fever. The high incidence of scarlet fever which marked the closing months of 1920 was maintained and even intensified in 1921, the total cases notified in the latter year being 32,739. This figure was exceeded in 1893, but in no other year since notification became compulsory. The observed relationship between exceptionally dry summers and high scarlet fever prevalence is well exemplified in the records of 1921, and the high incidence in the latter half of that year may in part perhaps be ascribed to the extraordinary deficiency of rain. Judging, however, from past experience the recent prolonged incidence of scarlet fever will be followed by a period of diminished prevalence, mainly for the reason that immunity is conferred by attack and that, consequently, after a wide-spread and prolonged epidemic, the population contains a relatively small proportion of susceptible units. During the past twenty years there have been three great prevalences of scarlet fever in London, separated by intervals of approximately seven years. These major waves are also evident in the curves for the constituent boroughs of London, but there are intercurrent and quite localised prevalences. When these are severe the succeeding major wave is proportionately less severe in the locality of these outbreaks. If it may be assumed that the margin of susceptible units at any given time is a definite quantity and easily depleted, it would appear that the occurrence of these local and transient outbreaks is not readily reconcilable with an hypothesis that direct spread from child to child (by the breath or by epithelial scales or mucous discharges) is the sole cause of the major waves of scarlet fever prevalence. The exceptional character of the meteorological records lends particular significance to observations on the prevalence of fleas in school children and in common lodging house inmates. The conditions favouring the propagation of fleas have been examined in various laboratories, and it has been demonstrated that the flea at all stages in its life history is sensitive to relatively small deviations from an average degree of humidity and temperature. In 1911 and 1914 the summer rainfall was much below the average and the temperature high, and in both years there was a rapid fall in the latter half of the year in the recorded prevalence of fleas: the conditions were repeated with much the same results in 1921. On the other hand, in 1916-17 there was a marked fall in flea prevalence which cannot be accounted for in the same way. It will be seen from the diagram (p. 46) that in each of the years 1909-21, the flea maximum antedated the scarlet fever maximum by from one to as many as thirteen weeks, the intervals being shown by the hatched areas; the diagram further shows a general downward trend in the records of flea-marked children. Apart from special steps taken to cleanse verminous children there has undoubtedly been of late years an increase in the parents' concern generally with regard to the harmfulness of parasitic insects. The conclusions drawn from previous study of the flea question were summarised in the annual report for 1917 (p. 37), when nine years' records of flea prevalence were available; and in the report for 1918 (p. 47), the incidence of epidemic throat maladies in the metropolitan boroughs over a series of years was examined. The criticism has been made, that on the flea hypothesis there should have been higher autumnal 61742 G 2 44 45 flea prevalences recorded in 1920 and 1921 than were actually observed. In illustration of the complicated character of the issues arising a word may be said on a parallel instance, which is presented on study of the relation between rainfall and scarlet fever incidence. Referring to the diagram on page 41 the years 1890 and 1891 had been wet years with, it will be seen, scailet fever below the average; 1892-3 were dry years, with high prevalence of scarlet fever; then 1894 was wet, and although the rainfall was not excessive it came (see diagram) at the end of an exhaustive epidemic, with obvious effect. Then followed eight successive dry years 1895-1902 : The influence of deficiency of rain upon the scarlet fever in the first half of this period is clearly apparent; but in the latter half scarlet fever, notwithstanding the dryness, tended to fall below the average. The excessively wet year 1903 then followed, with marked effect upon the scarlet fever record even in the succeeding dry year. The four years thereafter were dry with the exception of 1906, which was sufficiently wet to restrain to some extent the then oncoming epidemic. In 1908 the rainfall was only just below the average, but in 1909 and, more especially, 1910 the rainfall was in excess, a fact clearly reflected in the scarlet fever curve. Then four years supervened of rainfall rather below the average, with epidemic scarlet fever, though the deficiency of rain in 1911 and 1914 was almost negligible. The four succeeding years 1915-1918 were all very wet, closing down perhaps prematurely the epidemic of 1913-1914. There then follow the years 1919-20 with rainfall below the average, and finally 1921 and its record drought and excessive scarlet fever. Although the effect of the rainfall can thus be broadly discerned from year to year, and is at times very clearly defined, the coefficient of correlation of rainfall and scarlet fever prevalence over the period of thirty-one years (-.57) is not very significant, the explanation offered being that the effect produced by an excess of rain depends upon the susceptibility of the population at the particular time. The relation between flea prevalence and the scarlet fever curve may be similar to that for rainfall. A high prevalence of fleas would not necessarily connote an excessive amount of scarlet fever or vice versa ; other determining factors, for example, the proportion of susceptible units in the population at the time, must also be taken into account. The size of a fire does not depend upon the number of sparks which light it. In this connection reference may be made to the contention of Professor Tendeloo of Leyden, that we must have in mind the "constellation" point of view in considering cause and effect relationships in medicine. The "Lancet" (1922, p. 410) explains this astronomical metaphor as being intended to indicate that there are "certain prominent factors and others less conspicuous, whilst beyond lie possibilities of still undiscovered influences." Under such conditions close correlation, say of scarlet fever prevalence with rainfall or with fleas, is not to be expected ; and yet both the latter may exert influence upon the epidemic waves. Certain special factors operating in the present case may be mentioned. In the first place it was suggested in last year's report (p. 54) that some proportion of the cases of scarlet fever notified among school children late in the year really belonged to the influenzal group of diseases, and that influenza was thus exerting a disturbing influence; a special report by Dr. Armstrong was prepared on the "catarrhal sore throat or glandular fever" prevalent in the schools at the close of 1920 (loc. cit. p. 89). At the close of 1921, moreover, it was again suspected that some of the cases of scarlet fever notified were really cases of influenza. The surmise that confusion between scarlet fever and influenza has been occurring is supported by the fact, to which Mr. Spear has called my attention, that a sharp rise in the case-mortality of "scarlet fever" has occurred in each of the recent influenzal prevalences ; this rise was quite a considerable one in the prevalence of February-March 1919 (see diagram). It is interesting to observe that the occurrence of skin eruptions was commented upon in the Times of 16th April, 1921, and 15th January, 1922. Moreover in a discussion in Manchester on scarlet fever and scarlatiniform rashes (Brit. Med. Journal, 18th February, 1922, p. 27) Dr. McClure remarked that "though he believed that the great mass of cases notified were truly scarlet fever yet there was a number in which differential diagnosis between mild scarlet fever and mild influenza was not clear." And then there is the second point, already glanced at in last year's report (p. 86), viz., the recent behaviour of the flea curve considered in its relation to prevalence of scarlet fever. The percentages of flea-bitten school children at the times of seasonal maxima of scarlet fever in 1919 and 1920 were about 17.5 per cent. at the time of the autumnal maximum of 1919, and 22 per cent, at the corresponding maximum of 1920. In 1921, a slight rise in the flea curve occurred a few weeks before the maximum of scarlet fever was attained (as had been the case in each of the preceding 12 years for which records are available), but the percentage of flea-bitten school children did not show an increase upon that of 1920, but reverted practically to the 1919 standard, although the scarlet fever of 1921 actually exceeded that of 1920. As was remarked last year, this phenomenon was perhaps only to be expected, for the question of the extent of accumulation of susceptible children here necessarily assumes considerable importance. It must be realised, in fact, that (as the diagram on page 46 shows) in 1920 the seasonal rise was from a plateau of some 300 cases a week in the early part of the year to a peak of some 1,000 cases a week, while the corresponding rise in 1921 was from a plateau nearly twice as high (five to six hundred cases a week) to a slightly higher peak still (1,200 a week). Moreover, and this is the main point, the level of scarlet fever prevalence in London from 1916 onwards until early in 1919 had been but rarely as high even as 200 cases a week. Thus it may be calculated that, at the commencement of the present major prevalence of scarlet fever in 1920, there were for this reason alone at least fifteen thousand more " susceptible children" in London than at the commencement of the preceding major prevalence of scarlet fever in 1913. Hence, in the main, the sustained prevalence in the early half of 1921, with a rise to a still higher level in the autumn. These occurrences in fact, illustrate Dr. Ransome's contention of some 40 years ago, that " a certain density of the population at susceptible ages is necessary before a disease can spread with the vigour of an epidemic." This law was made use of 16 years ago to illustrate the form of the London measles curve (Milroy Lectures 1906); it may be applied to epidemic throat diseases also, for here too 46 47 the curve of prevalence results in large degree form "interplay between the deflecting energy due to new infections and the restoring inertia due to resistance to spread of disease caused by acquirement of immunity and consequent increase in the amount of insusceptible material." It may be added that the failure of the flea curve in the latter part of 1921 to rise, in correspondence with the marked rise of scarlet fever, may no doubt in part be regarded as having been specially emphasised by the phenomenal rise in the birth-rate of the latter part of 1919 which continued in 1920. This latter happening threw fresh fuel in to the flame, and materially helped to accelerate the rise to the maximum point which was actually attained about a fortnight subsequent to the maximum reached by the flea curve. It was the tossing of this sword of Brennus upon the already weighted scale of the additional susceptible material, maturing from the higher number of births of the preceding 12 or 18 months, which decided the issue, and, despite the fall shown by the flea curve in the late months of 1921, determined the disturbance of the balance, and the lifting of the maximum of 1921 higher even than that of 1920. The incidence of scarlet fever among girls of school age is considerably higher than among boys, and this circumstance has generally been ascribed to the closer association of girls with infants. Under the age of five years there is not much difference in the attack-rates for the two sexes, but after five years there is a pronounced excess in attack among girls, increasing with age up to the end of school life. The excess as compared with boys at age 13-15 is smaller than at 10-13 ; yet the association with infants must if anything be rather more constant at the higher of these two age groups. At the age 15-20 the attack rate among males actually exceeds that among females. The geographical distribution of the 17,030 cases reported by head teachers may be compared with that in 1920, when the districts mainly attacked were in the east end, Stepney, Poplar and Bethnal Green, in the area contiguous to these boroughs on the south side of the river, Bermondsey, and to a less extent, in Fulham, Hammersmith, Stoke Newington and Hackney. Towards the end of the year Greenwich and Deptford were also affected. During 1921 the same areas were specially involved as were also Islington, Battersea and Woolwich. In the latter year 448 schools were affected, and 1,112 special investigations were conducted by the assistant medical officers into outbreaks of scarlet fever. Scarlet fever distribution. Cases of diphtheria among children in the public elementary and secondary schools during the year numbered 6,661 as compared with 16,288 (uncorrected) among persons of all ages. The total number of deaths recorded was 1,131, of which 495 occurred among children of school age The geographical distribution of diphtheria closely corresponds with that of scarlet fever. During the year, 287 investigations were conducted by assistant medical officers into outbreaks of diphtheria affecting 192 schools. Bacteriological examinations made in the department during the year numbered 6,606. In 609 Diphtheria. bacilli indistinguishable from diphtheria bacilli were found, whilst 456 aroused some suspicion. The remainder gave a negative result. Bacteriological investigations. Following upon the epidemic year 1920, measles was quiescent in 1921, only 8,317 cases being reported among school children, by far the lowest total for more than 15 years. " Unprotected " children were excluded, for periods varying from a few days to three weeks, from 165 classrooms during the course of the year, whilst in 7 schools all " unprotected " children under 5 years of age were similarly excluded. Measles. The number of cases of whooping cough reported in school children during 1921 was 9,584, as compared with 8,779, 3,397, 11,671, 7,117, 8,595, 10,959, 9,977, and 9,762 in previous years down to 1913. Notification of whooping cough is compulsory in Holborn, Wandsworth and Greenwich. Whooping cough. There was a marked drop in the number of cases of ringworm reported during 1921 as compared with 1920. There were 3,983 cases in 1920 and 3,473 in 1921. In 1911 the new cases numbered 6,214, whilst in 1918 there were only 2,639, the lowest number. Similarly the cases outstanding at the end of each year as still under treatment, fell from 2,458 in 1911 to 979 in 1918, rising in 1920 to 1,332, finally declining to 999 at the end of 1921. In 1911 only 30 per cent. of the cases received X-ray treatment, whereas in 1921 over 60 per cent. of the cases were cured during the year by means of X-rays at the Council's treatment centres. During 1921 the number of hair specimens examined in the laboratory was 3,071, of which 1,577 proved to contain ringworm fungus, 19 favus fungus and the remainder were free from disease. Ringworm. During the year 13 fresh cases of favus were discovered, 12 as a result of microscopic examination of specimens sent up by school nurses and one at a treatment centre. Of these cases 7 occurred in the •eastern division, four in the north-eastern and two in the south-western division. Favus. An outbreak of innuenza on a large scale began in me scnools in sporadic fashion in the late autumn of 1921, but its effect upon attendance was not specially noted until about the last week of the winter term (i.e., just before Christmas), when there was a considerable reduction, ascribed to influenza, in attendance in the western area (Kensington, Hammersmith and Fulham). Other districts were also affected. Cases reported from the schools during the weeks ending 14th, 21st, 28th January, and 4th. 11th. 18th February numbered 3,848, 5,791, 3,924, 1,343, 650 and 366 respectively. Influenza. The type of illness was not so severe as in the pandemic of 1918-19. Certain special symptoms were reported from various quarters, e.g., gastric and intestinal disturbances, rashes conforming to the character of scarlet fever, roseola or rubella (German measles), jaundice, etc. An interesting report on an outbreak of " jaundice " at Gipsy-road School (Norwood) in November, 1921, was made by Dr. AV. Slowan. He found that of 25 cases of infants to whom his attention was directed only 10 could be regarded as having suffered from jaundice, the remainder were absent from an indefinite condition described as "chill on the liver," or in some instances as "influenza." The affected children were from five different classrooms and eight different roads. In one group of three cases there was strong presumptive evidence of personal infection. Investigation was confined practically to the infant, junior mixed and girls' departments, the boys' department not appearing to have been affected to any appreciable extent, either by jaundice or influenza. 48 The main facts elicited at the inquiry were as follows :— (1) Jaundice affected chiefly the infant and junior mixed departments and showed itself in the infants' only before the mid-term holiday (31st October and 1st November), whereas in the junior mixed it was practically confined to the period between the mid-term holiday and Christmas. In the girls' department four of the five cases were before the mid-term holiday. (2) The incidence of " influenza " before Christmas was very small, there having been in the three departments under 20 cases. Since the Christmas holidays there have been 164 authenticated—so far as is possible—cases of influenza, and at present there are many children absent from actual or suspected influenza. (3) The departments which had most jaundice had least influenza before Christmas :— Infants 10 jaundice 3 influenza. Junior mixed 8 „ 5 „ While the Girls with 4 „ had 11 „ At Salter's-hill school in the near vicinity there were three cases of jaundice in the girls' department—(1) 14th October to 28th November; (2) 25th November to Christmas; (3) 13th December to 30th January. Information was also received that children—not attending Council schools—in West Dulwich bordering on the Gipsy-road area, were affected with jaundice., and mention was made of an epidemic of "suppressed mumps." amongst the Dulwich children—possibly another manifestation of influenza. Residential and industrial schools There are seven residential and one day industrial schools, two places of detention and six residential special schools (two for blind, three for deaf and one for mentally defective children) under the direct jurisdiction of the Council. The health of the children, so far as infectious diseases are concerned, was on the whole satisfactory. A few of the schools were placed in quarantine owing to the occurrence of cases of scarlet fever, diphtheria and certain minor infectious ailments. Physical education Major Gem, the Council s organiser of Physical Education refers to the work of the Council's College of Physical Education. By day this institution is devoted entirely to the training of teachers already in the service of the Council. Major Gem gives the following statistics of the work carried out up to September 1921. The number of teachers trained was 585 ; there were 390 schools with at least one trained teacher on the staff ; 520 schools had applied to attend the college, and 304 schools which had not applied. The schools who have not yet applied constitute the main problem for the coming year. In addition demonstrations have been held in the schools, and evening courses for teachers have been conducted in outlving areas. The question of organised games has been kept in the forefront. The coal strike led to some interference with the use of swimming baths, and with instruction in swimming, but it is hoped that the London Schools' Swimming Association new land drill, systematically introduced during the winter months, will lead to a large increase in the number of swimmers next summer. The special drill classes for children with minor or incipient deformities in elementary schools have been continued and even increased in number. Owing to their success it was intended greatly to develop these arrangements but owing to financial reasons the Council limited the extension to a degree which will not necessitate the appointment of additional staff. The importance of carrying out breathing exercises in school with careful attention to detail should be impressed upon all teachers. Dr. Octavia Lewin has pointed out how vital it is that each child attending school should be provided with a handkerchief and she attaches great importance to the special handkerchief pocket on the left breast which all children, boys and girls alike should wear. In this connection it is a curious point that Dr. Allan the medical officer of health of Westminster, dealing with a diphtheria outbreak, has reported the case of a secondary school, where few of the pupils had handkerchiefs because " pockets were not allowed " by the school authorities. Very particular attention has been paid to physical exercises and games in the day continuation schools, in each of which there is a master of physical education who takes his place in all respects on an equality with the masters of other subjects. Supervision of dietaries. In connection with the scheme for the supervision of dietaries of necessitous and other children, the systematic examination of milk meals has been continued during the year. The total number of samples dealt with was 1,098. The improvement noted in 1919 and 1920 in the general quality of the supplies has been continued, only 5.5 per cent. of those examined being reported to be unsatisfactory, whereas the corresponding figures for 1920, 1919 and 1918 were 4.9, 8.6 and 31 per cent. respectively. The maximum addition of water found in any one sample during the year was 30 per cent; as much as 38 per cent. was found in one sample examined during 1920 and 53 per cent. in 1919. The largest percentage of fat abstracted was 30 as compared with 33 per cent. reported in 1920 and 40 per cent. in 1919. It is noted that of the 321 samples examined during the last quarter of the year, only 2.2 per cent. were reported as unsatisfactory. Samples of meals other than milk meals have been systematically examined during the year. In a number of cases the result has shown the meal to be below the recognised standard in nourishing constituents, and steps have been taken to remedy the deficiency. Examination of Candidates. The number of candidates submitting themselves for first examination during the year was 6,937, as compared with 7,159 in 1920, a decrease of 3 per cent. The candidates may be classified as (a) candidates for entrance to the permanent service, (6) candidates for the award of scholarships. 49 The total number of candidates examined was 1,385 (474 males and 911 females), but some of these attended for their first examination in the previous year. There were, however, 1,535 examinations (509 males and 1,026 females); in 214 cases (58 males and 156 females) a second or third examination was necessary. Of the number thus referred remedial treatment was satisfactorily obtained in 183 cases, five were rejected and 6 withdrew their applications ; 20 were still under consideration at the close of the year. The total number of rejections was 17. Candidates for permanent service. The Council's scholarships and awards fall into three divisions, each of which requires different treatment 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. Candidates for the award of scholarships. Including some of the candidates who attended for their first exannnation in the previous year and were referred for further examination, the number of candidates examined was 5,646. There were, however, 6,945 examinations, the excess being due to the fact that in 1,254 cases a second or third examination was necessary. 1,184 (or 94 per cent.) obtained satisfactory treatment, and were on re-examination certified as fit. 100 candidates were found to be unfit, of these 12 were rejected (for two defects each); 75 were rejected as the result of their first examination, and 25 as the result of their subsequent examination. The reasons for rejection were :—defective vision 48; unsatisfactory personal hygiene 10; defective teeth 10; unsatisfactory general health 17; unsatisfactory condition of heart 2; miscellaneous 25. There are also referred to the Public Health department special cases of 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 ofteachers returning to duty after extended leave of absence (a) owing to personal illness ; (6) 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 H.M. 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 referred was 2,333 as compared with 1,806 in 1920, an increase of 527 or 29.2 per cent. Cases specially referred. The increase in the absences among teachers observed during recent years is obviously to some extent the combined result of the war and the influenza epidemics of 1918 and onwards. In the case of male teachers on active service, a considerable proportion of absences in 1920 was certified on medical examination to be due to war service. The effects of the influenza epidemics of 1918 and 1919 can scarcely, even now, be regarded as exhausted, there being little doubt that a number of cases of nervous debility owe their origin to a severe attack of influenza. From a comparison of the records of 1912 with those of 1920, it would appear that allowance must be made for the gradual ageing of the teaching staff. The average of a selected sample of women teachers examined in 1912 was 41.1 years, with an average length of service of 12.5 years. In 1920 the average age in a like sample was found to be 44.3 years, and the average service 17.8 years. In the census of 1901 the number of female teachers resident in London from 45 to 65 years of age was 2,418, while in 1911 they numbered 3,872. The amount of sickness increases rapidly with advancing age, especially after the age of 40. All applicants for admission to the Council s course of physical instruction, instituted during 1920 in order to train teachers to carry out the provisions of the Education Act, 1918, relative to the physical education of school children, were examined. 1,530 examinations were conducted, an increase of 51 per cent. on the number for the previous year. Over 9 per cent., actually 140 candidates, were found to be unfit to undergo the prescribed course. Physical education of teachers. Defective children. The total number of examinations conducted under the special Acts during the year was 6,015 as compared with 6,301 for 1920. 1,474 children (762 boys and 712 girls) were deemed suitable to attend elementary schools, 88 (47 boys and 41 girls) schools for the blind, 329 (141 boys and 188 girls) schools for myopes, 136 (54 boys and 82 girls) Swanley, 1,023 (534 boys and 489 girls) P.D. schools, 1,385 (784 boys and 601 girls) M.D. schools, 9 (8 boys and 1 girl) open air schools, 76 (34 boys and 42 girls) schools for the hard of hearing, 125 (73 boys and 52 girls) schools for the deaf, 53 (22 boys and 31 girls) were epileptic, 540 (250 boys and 290 girls) invalided from school attendance, 114 (74 boys and 40 girls) imbeciles, and 19 (8 boys and 11 girls) were idiots. Admission examinations- 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 85 67 152 Cerebral paralysis 12 13 25 Various paralyses 15 10 25 Tuberculosis of bones and joints 141 113 254 Congenital deformities 4 20 24 Other deformities 104 54 158 Heart disease— Congenital 26 23 49 Acquired valvular 114 155 269 Acquired non-valvular 3 10 13 Other diseases 30 24 54 61742 H 50 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 ; 273 returned on improvement to elementary schools, 1 to a school for the deaf, 1 to a school for the blind,17 from physically defective to mentally defective schools, 37 were excluded as imbecile, 35 were invalided on medical grounds, and 195, over 14 years of age, were excluded as no longer certifiable. In addition, 644 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. After careers. After careers of children formerly attending special mentally defective schools for the year ending 31st December, 1921. (Data furnished by the London Association for the Care of the Mentally Defective) M. F. Total. 1. Number of children born in or subsequent to1901, and have left special mentally defective schools and who have been on the books of the association 2,395 1,739 4,134 2. Number who— (a) have since died 22 9 31 (b) who are known to be incapable by reason of mental or physical defect of under taking employment 72 97 169 (c) are in attendance at an institution for further education not known. (d) are in other institutions 36 31 67 (e) were notified and placed under supervision 25 13 38 3. Number employed in— (а) Industrial or manual occupations (i.e., factory work, any trade or part of a trade) 930 699 1,629 (b) Agricultural or rural occupations 9 1 10 (c) Domestic occupations (i.e., servants sleeping in or out, lift boys and approximately 10 per cent. " Helping at home ") 49 415 464 (d) Commercial (i.e., shop assistants or selling behind a counter), professional (or Army or Navy), Clerical (office boys or girls) 192 35 227 (e) Blind Alley or other precarious occupations (i.e., van-boys, newsboys, errand boys or girls, selling from a barrow) .. .. .. .. .. .. 406 56 462 (/) Judged to be employable but out of work owing to industrial crisis .. .. 455 257 712 4. Number whose after careers have not been traced or who have left the neighbourhood 199 126 325 Totals 2,395 1,739 4,134 5. Number of children born in or after 1904, who, having left school at an early age during the war have not up to the present appeared on the After-Care Lists 2,948 2,164 5,112 The After-Care Association for blind, deaf and crippled children has furnished the following information in regard to cases referred to it, but attention is drawn to the fact that in the past the association was not notified of all children who left these schools. (1) Number employed in— (a) Industrial or manual occupations 495 (b) Agricultural or rural occupations 1 (c) Domestic occupations 29 (d) Commercial occupations 55 (e) Blind alley occupations 16 (2) (a) Who have since died 9 (b) Are known to be incapable by reason of mental or physical defect of undertaking employment 32 (c) Are in attendance at an institution for further education 43 (d) Are in any other institutions 1 (3) Who have left London or cannot be traced 22 (4) Who were found to be unemployed 70 773 Distribution of intelligence of children in special schools. During the year, enquiries were made into the distribution of the intelligence of children in the special schools with a view to noting the degree of improvement which occurred at different ages and noting if there were any marked difference in standard. For this purpose, Dr. F. C. Shrubsall has collected data of attainments in terms of mental and chronological age, calculated in such a manner as to give the results at the full age. The subjoined table indicates percentages of distribution of mental age for each chronological age. The results shew that at the earlier ages the children, on the average, gained at the rate of nearly ¾ of a year's intelligence—as estimated by tests—per year. This doubtless is due to the advantage derived from the greater individual attention they receive in the smaller classes of the special school. This figure subsequently falls off, and after the age of 13 the progress becomes very slight; the lower mean mental age found for the age of 15 being probably due to some of the better cases having been deemed non-certifiable at the age of 14, as they have reached a mental age of 10, coupled with school attainments equal to Standard II., together with adequate evidence of ability to fend harmoniously for themselves in the world. The experience acquired from the working of the Mental Deficiency Act suggests that those whose ultimate mental age does not exceed 7 are practically unemployable, while those whose mental age is 10 or over are fitted for a life in the world, unless they are also temperamentally of an unstable type. It will be noted, from the table, that the gain beyond the age of 14 is very slight, and it is probable that a large proportion of the cases may be described as having reached their mental limit at that age. The table, which is based on data derived from 6,900 children admitted to schools during the years 1918-1921 inclusive, has been compared with one obtained from individual schools, and the variations noted fall within the normal limit of probability. From this table a regression equation has been calculated showing that the mental age (years) = .454 X chronological age (years) + 2.08. The 51 efficient of correlation (r) between mental and chronological age is .757 ± .003. The standard deviation of mental age is 1.570 ± .009, and of chronological age is 2.615 ± .015. The mean chronological age = 9.837 ± .021 and the mean mental age = 6 546 ± .013. PERCENTAGE DISTRIBUTION OF MENTAL AGES OP CHILDREN EXAMINED AND DEEMED TO BE CAPABLE OP DERIVING BENEFIT PROM INSTRUCTION IN A SPECIAL SCHOOL (1918, 1919, 1920, 1921). Chronological age. Mental age. Mean mental age. Annual gain. 3. 4. 5. 6. 7 8. 9. 10. 11. 7 4.17 26.97 45.52 19.87 3.37 .09 — — — 4.92 — 8 .83 5.99 31.17 45.74 15.28 .99 — — — 5.66 .74 9 .39 2.53 11.45 36.97 43.76 4.90 — — — 6.36 .70 10 .89 1.25 4.11 20.71 47.86 23.04 2.14 — — 6.91 .55 11 .52 .26 4.40 13.99 40.93 35.23 3.11 1.56 - 7.20 .29 12 1.03 — 1.03 8.28 29.66 38.28 11.72 8.28 1.72 7.79 .59 13 — — .90 5.38 18.83 30.04 26.01 14.80 4.04 8.35 .56 14 — .16 .32 2.58 10.32 27.58 38.07 16.45 4.52 8.67 .32 15 — .17 3.12 7.06 15.76 27.42 28.57 16.75 1.15 8.26 .41 Mean chronological age 7.81 7.47 7.92 8.67 9.98 12.29 13.93 14.01 13.75 For children deemed to be incapable of deriving benefit in special schools by reason of being imbeciles or idiots, the corresponding data from 1,838 cases were as follows:—The regression equation becomes, mental age (years) = .265 times chronological age (years) + .76. The co-efficient of correlation (r) between mental and chronological age is .662 ± .009. The standard deviation of mental age is 1.055 ± .012, and of chronological age is 2.634 ± .029. The mean mental age is 3.41 ± .023, and the mean chronological age is 10.0 ± .041. Dr. Boome, with the assistance of the headmaster and headmistress of the Cork-street school, has investigated the use of the Healy B picture completion test, with a view to standardising its use as a test for defectives. The test consists of a series of pictures, depicting the incidents in a boy's day. From each picture a square piece has been removed, and the test consists in placing a suitable piece to fill up the gap, selected from the 60 like squares, each of which depicts an object or objects making up the set. For each picture there are some four possible solutions of varying value, the rest of the alternatives being quite illogical. For each picture an assessment was made of the respective values and marks from 5 to 1 assigned as the value. The total number of marks which could be obtained was 55, and from the results obtained it would appear that the test might be used, with reasonable precautions, for children of the age of 11 or over. The importance of the test depends not so much on its merits as an indicator of mental age as on the light it throws on the nature of the associations, the powers of planning and the degree of self-criticism shown by the subject. Standardising of Healy B picture completion test. During the year attention was attracted to the cases of children returning to school after suffering from encephalitis lethargica. Dr. F. C. Shrubsall and Dr. E. J. Boome have made investigations in regard to these cases, which are specially noted and indexed, and attempts will be made to follow them up so as to record the later history. Detailed notes are available in regard to 19 children, some of whom have been seen on several occasions. Encephalitis lethargica. As regards the type of case, in the majority the initial illness was characterised by fever and lethargy of varying degree. In three cases there were also symptoms difficult to distinguish from meningitis. Two cases showed marked choreiform movements, and two others showed marked tremors of the hand, and one presented a head-nodding tic. Most of the children affected attracted attention in school owing either to a falling off of the educational attainments or to marked irritability or disturbances of conduct. So far as a general description can be given of cases of such varied type, they may be said to show a combination of apathy with momentary irritability and with some failure of moral inhibitions. A marked feature is the rapid onset of fatigue and inattention ; the children fail at tests which require prolonged planning and concentration or much exercise of self-criticism. The intellectual impairment seems to arise chiefly from an inhibition of volition. The majority of the cases show a heightened sensibility to environmental stresses, a greater tendency to introspection and a heightened degree of suggestibility, so that in some instances there were definite neurotic symptoms. On the whole, the cases may be said to have made favourable progress towards recovery, the order being first of all an improvement in the physical conditions, the squint and diplopia disappearing within from one to two years of the onset, then a recovery in intellectual activities spread over a slightly longer period and lastly, often much later and slower, a recovery in the conduct. It should be noted that misconduct has shown itself chiefly in violent behaviour and wilful damage, but in some instances as petty pilfering. Of the 20 cases, 9 still show physical disabilities, 3 in the form of paralysis, 5 in the form of a tremor or choreiform movements, and 1 in a form of blindness due to optic atrophy. So far as the mental condition is concerned, there was little intellectual impairment to be noted in 11, a slight intellectual impairment in 4, and marked intellectual impairment in 5. On the temperamental side, irritability with outbursts of temper was to be noted in 9 cases, marked restlessness in 3, and no special features in 8. The lethargy has cleared up in all the cases, but 6 were reported from school to tend to sleep, particularly over uninteresting lessons. This condition was reported as improving on the occasion of subsequent visits. The condition is of particular importance, since there has been a tendency to notify such cases under the Mental Deficiency Act. Legally it is very doubtful whether such cases could 61742 H2 52 ever be regarded as coming within the purview of this Act; it may be noted that in most instances the age of onset was in the early years of the second decade of life, prior to which the subjects had shown evidences of normal mental development, so that there was no congenital failure of mental development. The mental arrest appears not to be complete. The youngest child observed had suffered from encephalitis in the second year of life and was in a lethargic condition in hospital for three weeks. Previous to this he had been described as a bright baby, but after his illness he became dirty, vicious, with a tendency to coprophagia. When seen at the age of 4½ his mental age on tests was from 2½ to 3 years, and from a description given it would seem that a slight improvement was being made. The encephalitis had not, therefore, caused a complete arrest of mental development, although this had been very seriously retarded. It has been suggested that some cases come within the category of moral imbecility, but in view of the definite relation between the onset of misconduct and the disease, coupled with the abundant evidences of improvement in many cases after a lapse of time, it would seem that it would be impossible to state that there was a permanent mental defect without very prolonged observation. The clash between an irritable child of somewhat introverted mentality and the stresses of environment readily gives rise to neurotic symptoms, which in many instances may amount to a definite conversion hysteria. While under observation some of these cases have been entirely cleared up, others have materially improved. Comparison of offences committed by normal and defective children. In connection with the work under the Mental Deficiency Act, attention has often to be paid to the circumstances whereby a given child commits a given offence and it seems that a comparison of the offences committed by normal and defective children would be of interest. Vice and crime are found among defectives of all grades as among normal subjects and in the case of the clearly feebleminded or imbecile, many delinquencies can be ascribed to lack of appreciation of the consequences or to an undue suggestibility. Any child may become a criminal if residing in an environment which favours that mode of life and the defectives are more easily led into crime ; their crimes having the hall-mark of inefficiency and thus being in themselves a sign of low mental status. Charges of wandering and being beyond the control of their parents are more common among defective children than the normal. It might have been expected that a considerable proportion of mentally defective children would have been found to have been associating with prostitutes or with criminal or drunken parents or guilty of sexual offences, the figures show that this is not the case. The following table shows in percentage form a comparison of the offences committed by normal and defective children :— Offences. Defective children. Normal children. Boys. Girls. Total. Boys. Girls. Total. Wandering 15.5 41.9.1 19.9 5.0 12.1 5.6 Begging 5.2. 3.2 4.8 4.3 3.6 4.2 Stealing 51.6 19.4 46.2 74.3 34.4 70.7 Soliciting - - - 0.2 0.9 0.3 Indecent exposure 0.6 — 0.5 — — — Attempted suicide — — — 0.2 — 0.2 Wound ng 0.6 — 0.5 — — — Living in a brothel — 3.2 0.5 0.7 6.7 1.2 Destitute 0.6 — 0.5 0.2 2.7 0.4 Frequenting company of reputed thieves 0.6 3.2 1.0 0.1 0.9 0.2 Education Act (truanting) 7.8 6.5 7.5 3.7 20.1 5.1 Improper guardianship, criminal or drunken parents — — — — 1.3 0.1 Minor offences — — — 6.2 3.9 6.1 Beyond control 17.4 22.6 18.2 5.1 13.4 5.9 Physically defective schools. A question has arisen as to the retention in special schools for the physically defective of children suffering from loss of a limb. There are 98 children in the schools for the physically defective who have lost a single limb, in 7 of these cases it is the arm and in 91 the leg. In addition, 1 child has lost both legs ; 2 children have lost both arms and 1 child has lost an arm and part of a foot Of the 7 children who have lost one arm; 2 are in need of further treatment; 2 have defects of lower limbs also and 2 others are said to be very unsteady on their feet, and to be unable to guard themselves from accident. Of the 91 cases who have lost 1 leg, 21 children had the leg amputated on account of tuberculosis and need specialised observation both on account of debility and, in some cases, of the manifestation of the disease. Of the total cases 21 have no apparatus and go about with crutches, and in several instances they are not yet fit for an artificial limb, and in others its successful application is prevented by the size of the stump. These children would be quite unsafe in an ordinary school. In 11 other cases a change, or adjustment, of apparatus is needed and in 47 a peg leg or suitable apparatus is being worn. No child is deemed suitable for a special school solely on the ground that it has a physical defect or has lost a limb but because of the resulting inability to get about in streets on bus or tram, or to carry out a reasonable part of the school curriculum. Children are examined at regular intervals and returned to the ordinary school whenever this can be done with safety and efficiency. Causes of deafness. Mr. Yearslev has made an analysis of causes of deafness in 158 cases seen for the first time in 1921. These may be divided thus :— Boys. Girls. Total. Congenital 23 18 41 Acquired 50 53 103 Doubtful 7 7 14 80 78 158 Of the congenital cases, 8 were instances of true hereditary deafness, 32 of sporadic deaf-birth and one was a case of congenital aphasia. 53 The acquired cases were due to the following causes:- Boys. Girls. Total. Meningitis (various forms) 6 7 13 Infectious fevers 14 5 19 Tuberculosis (suppuration) 2 0 2 Congenital syphilis 4 5 9 Primary ear diseases (catarrh or suppuration) 22 33 55 Injuries 2 3 5 50 53 103 There are 7 residential (industrial) schools, 6 residential schools (2 for blind, 2 for deaf, 1 for defective deaf and 1 for mentally defective children), with a total accommodation for 1,100 residential and 115 day scholars. To each institution is allocated a medical officer and provision has been made for dental inspection and treatment. During the year 900 boys were admitted to Pentonville-road Place of Detention and 306 girls and infants to Ponton-road. Residential schools. Classes in health subjects. In the first aid section of the handbook for classes in health subjects, concerning transport of the injured, instruction in the use of "Thomas' Splints" has been introduced with special reference to fractures of the thigh. The use of these splints makes safer transport possible, and allows of ready examination of the injured limb, and even, when necessary, of continued treatment without disturbance. The thigh or hip splint consists of a padded ring, through which the injured limb is passed until the pad rests on the seat. From this ring a wire frame several inches longer than the limb passes down, turns in a loop, and returns on the other side again to join the limb. TABLE I. Number of Children inspected 1st January, 1921, to 31st December, 1921. (a) ROUTINE MEDICAL INSPECTION, 1921. Entrants. Age 8. Age 12. Age 13. Total at routine medical inspection. 3. 4. 5. 6. Over 6. Total. Elementary. Special schools. Boys 3,544 10,991 20,840 4,875 1,054 41,304 33,494 34,587 38,822 148,207 1,226 Girls 3,189 9,935 21,004 5,182 1,088 40,398 33,530 34,020 38,397 146,345 1,029 Total 6,733 20,926 41,844 10,057 2,142 81,702 67,024 68,607 77,219 294,552 2,255 (6) SPECIAL INSPECTIONS. (c) TOTAL NUMBER INSPECTED. Special cases. General cases. Children examined. Boys 19,161 18,623 187,156* Girls 20,109 15,679 183,121* Total 39,270 34,302 370,277* *Only 102 children were noted as having been seen previously the same year; the "general" cases relate to examinations en masse and individual records are not kept. The number of children re-inspected was 180,699 (of these, 24,450 were inspected in the same year, and 16.391 were previously re inspected in the year). TABLE II. Return of Defects found in the Course of Medical Inspection in 1921. Defect or disease. Routine examination. Special. Number referred for treatment. Number noted for observation. Number referred for treatment. Number noted for observation. Malnutrition 964 1,674 581 339 Ringworm (head) 55 10 203 33 „ (body) 80 4 113 4 Scabies 327 8 3,237 22 Impetigo 518 19 814 24 Other skin defects (non-tubercular) 1,481 380 734 102 Blepharitis 1,215 158 384 31 Conjunctivitis 433 44 435 47 Keratitis 8 7 62 46 Corneal ulcer 23 9 114 44 Corneal opacities 14 36 40 12 Defective vision 23,098 8,157 3,198 382 Squint 1,705 684 610 31 Other eye defects 458 76 161 29 Defective hearing 897 519 390 71 Otitis and otorrhœa 2,327 904 1,606 186 Other ear defects 730 168 231 35 Enlarged tonsils 7,223 6,724 1,364 281 Adenoids 1,893 866 586 94 Enlarged tonsils and adenoids 3,186 1,057 472 40 Other nose and throat defects 1,893 723 1,161 386 Enlarged cervical glands 455 1.717 230 213 54 Defect or disease. Routine examination. Special. Number referred for treatment. Number noted for observation. Number referred for treatment. Number noted for observation. Defective speech 158 301 101 71 Dental disease 70,420 1,495 3,029 67 Heart disease— Organic 46 412 119 75 Functional 8 678 13 52 Not stated 298 5,333 454 890 Anæmia 2,363 2,155 1,803 432 Bronchitis 1,798 1,943 688 197 Other lung defects (non-tubercular) 478* 2,253* 248 523 Phthisis—Definite 143 81 162 67 Suspected - 168 180 174 Tuberculosis— Glands 54 50 88 61 Spine 3 1 12 6 Hip 4 16 36 24 Bones and joints 9 18 39 25 Skin 15 17 4 1 Other forms 51 29 64 37 Epilepsy 68 174 247 176 Chorea 88 130 340 208 Other nervous conditions 187 520 188 158 Rickets 190 137 108 31 Spinal curvature 975 827 168 55 Other deformities 312 273 347 138 Other defects 3,775 2,525 5,852 1,671 Number of children referred for treatment or observation{Routine, 138,833 Special, 32,249 *Probably some of these cases are suspected phthisis. TABLE III. Numerical Return of all Exceptional Children in the Area in 1921. 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) 21 27 48 Attending certified schools for the blind 511 598 1,109 Not at school (b) 17 22 39 Deaf and Dumb (including partially deaf) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893— Attending public elementary schools (a) 6 9 15 Attending certified schools for the deaf 453 396 849 Not at school (b) 15 10 25 Mentally Deficient. Feebleminded. Attending public elementary schools 34 29 63 Attending certified schools for the mentally defective children 4,034 3,268 7,302 Number notified to Local Control Authority by Local Education Authority during the year 37 86 123 In institutions of the Metropolitan Asylums Board (c) 383 277 660 Not at school (b) 87 81 168 Imbeciles— At school — — — Number notified to Local Control Authority by Local Education Authority during the year 95 80 175 In institutions of the Metropolitan Asylums Board (c) 558 354 912 Not at school (b) 577 466 1,043 Idiots (b) 74 77 151 In institutions of the Metropolitan Asylums Board (c) 161 152 313 Number notified to Local Control Authority by Local Education Authority during the year 13 14 27 Epileptics. Attending public elementary schools 395 384 779 Attending special (M.D.) schools 81 65 146 Attending special (P.D.) schools 18 11 29 Attending blind schools — 1 1 Attending deaf schools 1 4 5 Attending certified schools for epileptics 48 45 93 Not at school (b) 350 335 685 Imbeciles or idiots (c) 194 149 343 Physically Defective. Pulmonary tuberculosis— *Attending public elementary schools (d) 194 128 322 Attending certified day schools for physically defective children (day open-air schools for tuberculous children) 190 175 365 Attending certified residential schools for physically defective children 208 248 456 In institutions other than certified schools 280 357 637 Not at school (b) 104 138 242 Crippling due to tuberculosis— Attending public elementary schools (d) 353 263 616 Attending certified day schools for physically defective children 577 476 1,053 Attending certified residential schools for physically defective children 56 48 104 In institutions other than certified schools 463 388 851 Not at school (b) 180 191 371 55  Boys. Girls. Total. Crippling due to causes other than tuberculosis, i.e., paralysis, rickets, traumatism— Attending public elementary schools (d) 1,537 1,940 3,477 Attending certified day schools for physically defective children 1,062 840 1,902 Attending certified residential schools for physically defective children 79 65 144 In institutions other than certified schools 84 85 169 Not at school (b) 82 102 184 Heart. Attending public elementary schools (d) 306 464 770 Attending certified day schools for physically defective children 450 575 1,025 Attending certified residential schools for physically defective children 3 7 10 In institutions other than certified schools 31 35 66 Not at school (b) 93 172 265 Other Physically Defectives, e.g., delicate and other children suitable for admission to open-air schools— Attending public elementary schools (d) 4,921 5,420 10,341 Attending certified day schools for physically defective children 101 70 171 Attending certified residential schools for physically defective children 1 1 2 In institutions other than certified schools 50 42 92 Attending open-air schools 230 180 410 Attending playground classes 1,200 1,900 3,100 Attending certified holiday camps (c)— Bushy 3,089 — 3,089 Margate — 476 476 St. Leonards 240 240 480 Not at school (b) 748 1,142 1,890 Dull or backward— Retarded 2 years 8,707 8,894 17,601 Retarded 3 years 459 452 911 *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. 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 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 to 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 31.12.21—Bushy 300, Margate 64, St. Leonards 40). TABLE IV. Treatment of Defects of Children during 1921. A.—Treatment of Minor Ailments. Disease or defect. Number of children. Referred for treatment by school doctor. Treated. Under scheme. Otherwise. Total. Scabies 3,564 5,863 - 5,863 Ringworm—Head 3,473 1,703 1,729 3,432 Ringworm—Body 193 68,283 1,987 70,270 Impetigo 1,332 Other Skin Diseases and Injuries 2,215 Ear Disease and Hearing 6,181 Eye Disease 3,347 Total 20,305 75,849 3,716 79,565 B.—Treatment of Visual Defect. Number of children. Referred for refraction by school doctors. Submitted to refraction under scheme. Treated by private agencies. Total number treated. No. refracted. Spectacles prescribed. Spectacles obtained. Other forms of treatment. 28,611 32,663 24.363 20,427 8,300 1,935 34,598 C.—Treatment of Defects of Nose and Throat. Number of children. Referred for treatment. Treated under scheme. Treated otherwise. Total treated. Operation cases. Other cases. 18,463 11,080 4,463 2,319 17,862 56 [###[D.—Treatment of Dental Defect. I. Number of children. Inspected by dentist. Referred for treatment. Treated under scheme. Re-treated under scheme. Otherwise treated. By dentist. By school doctor. 151,395 111,250 73,449 94,177 15,404 5,403 II. Particulars of time given and of operations undertaken. Half-days given by dentist to inspection. Half-days given by dentist to treatment. Attendances made by children. Teeth extracted. Fillings. Other operations. General anaesthetics. Temporary. Permanent. Temporary. Permanent. 1,387 13,037 146,869 261,142 48,316 21,290 55,075 17,231 41,596* *Made up as follows:—Nitrous-oxide, 24,282; ethyl chloride, 14,959; other anaesthetics, 2,355. TABLE V. Summary of Treatment of Defects as shown in Table IV. Class of defect. Number of children. Referred for treatment. Treated. Under scheme. Otherwise. Total. Minor ailments 20,305 75,849 3,716 79,565 Visual defects 28,611 32,663 1,935 34,598 Nose and throat defects 18,463 15,543 2,319 17,862 Dental defects 184,699 94,177 5,403 99,580 Other defects 23,829 - 6,700 6,700 Total 275,907 218,232 20,073 238,305 *"Other defects" treated under the scheme are included in minor ailments. TABLE VI. Summary relating to Children Medically Inspected at the Routine Inspections during the year 1921. (1) Total number of children examined at routine inspections during 1921 296,807 (2) Number suffering from— Malnutrition 2,233 Heart disease, organic 465 Skin disease 4,223 Heart disease, functional 768 Defective vision and squint 101,694 Heart disease, not defined 7,962 Eye disease 3,993 Lung disease (not stated to be tubercular) 10,488* Defective hearing 2,536 Pulmonary tuberculosis, definite 143 Ear disease 5,201 Pulmonary tuberculosis, suspected 267 Nose and throat defects 42,928 Non-pulmonary tuberculosis 446 Enlarged cervical glands 13,739 Nervous diseases 2,917 Defective speech 1,630 Deformities and rickets 10,425 Dental disease 125,277 Other defects and diseases 7,746 Anaemia 10,226 (3) Number of children in (1) noted for observation (not including clothing or cleanliness) 24,186 (4) Number of children in (1) referred for treatment (not including clothing or cleanliness) 114,647 (5) Number of children in (1) reported at re-inspection to have received treatment for one or more defects 8,847t * Many of these cases are probably suspected phthisis, though not definitely stated to be so. †Only children referred for treatment during the first term of the year are re-inspected during the same year. 57 TABLE VII. Routine Inspections, 1921. 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— 41,304 Boys 25,723 14,837 744 9,741 29,337 2,216 10 38,756 2,456 92 38,273 2,956 75 21,959 13,597 5,748 - - - - - - % 62.3 35.9 1.8 23.6 71.0 5.4 93.9 5.9 0.2 92.6 7.2 0.2 53.2 32.9 13.9 — — — — — — 40,398 Girls 25,343 14,444 611 10,019 28,426 1,941 12 33,030 6,827 541 37,323 2,985 90 21,375 13,552 5,471 - - - - - - % 62.7 35.8 1.5 24.8 70.4 4.8 81.8 16.9 1.3 92.4 7.4 0.2 52.9 33.6 13.5 — — — — — — Intermediate (Age 8)— 33,494 Boys 19,628 12,880 986 5,559 25,510 2,417 8 31,196 2,228 70 30,247 3,154 93 17,545 12,327 3,622 15,349 10,919 6,333 32,108 1,370 16 % 58.6 38.5 2.9 16.6 76.2 7.2 93.1 6.7 0.2 90.3 9.4 0.3 52.4 36.8 10.8 47.1 33.5 19.4 95.9 4.1 0.0 33,530 Girls 19,767 13,102 661 6,396 24,874 2,255 5 25,106 7,833 591 30,525 2,930 75 17,545 12,417 3,568 14,281 11,451 6,916 32,423 1,098 9 % 58.9 39.1 2.0 19.1 74.2 6.7 74.9 23.3 1.8 91.0 8.8 0.2 52.3 37.1 10.6 43.7 35.1 21.2 96.7 3.3 0.0 Age 12- 34,587 Boys 18,835 14,488 1,264 6,586 25,880 2,118 3 32,383 2,123 81 30,914 3,562 111 20,846 12,340 1,401 19,595 7,854 7,015 32,944 1,639 4 % 54.4 41.9 3.7 19.0 74.9 6.1 93.7 6.1 0.2 89.4 10.3 0.3 60.3 35.7 4.0 56.9 22.8 20.3 95.2 4.8 0.0 34,020 Girls 19,567 13,861 592 7,270 24,787 1,961 2 24,909 8,513 598 31,031 2,922 67 21,615 11,318 1,087 17,642 8,805 7,497 32,474 1,546 — % 57.6 40.7 1.7 21.4 72.8 5.8 73.2 25.0 1.8 91.2 8.6 0.2 63.5 33.3 3.2 52.0 25.9 22.1 95.4 4.6 — Leavers for continuation school— 38,822 Boys 21,384 16,100 1,338 9,994 27,019 1,804 5 36,795 1,972 55 35,264 3,480 78 24,792 12,786 1,244 23,363 7,507 7,798 37,312 1,509 1 % 55.1 41.5 3.4 25.7 69.6 4.7 94.8 5.1 0.1 90.8 9.0 0.2 63.8 32.8 3.4 60.4 19.4 20.2 96.1 3.9 0.0 38,397 Girls 23,632 14,284 481 11,950 24,971 1,469 7 29,825 8,021 551 35,327 3,011 59 24,743 12,477 1,177 21,525 8,689 8,119 36,887 1,510 — % 61.5 37.2 1.3 31.1 65.1 3.8 77.7 20.9 1.4 92.0 7.8 0.2 64.4 32.5 3.1 56.2 22.6 21.2 96.0 4.0 — Total— Elementary schools 294,552 173,879 113,996 6,677 67,515 210,804 16,181 52 252,000 39,973 2,579 268,904 25,000 648 170,420 100,814 23,318 111,755 55,205 43,678 204,148 8,672 30 % 59.0 38.7 2.3 22.9 71.6 5.5 85.5 13.6 0.9 91.3 8.5 0.2 57.9 34.2 7.9 53.1 26.2 20.7 96.0 4.0 0.0 Special schools 2,255 826 1,245 184 420 1,538 297 — 1,683 513 59 1,736 499 20 1,110 938 207 598 719 544 — — — % 36.6 55.2 8.2 18.6 68.2 13.2 — 74.6 22.8 2.6 77.0 22.1 0.9 49.2 41.6 9.2 32.2 38.6 29.2 — — — 61742 Under clothing—1=good, 2=fair, 3=poor. Under nutrition—1=good, 2=normal, 3=below normal, 4=bad. Under cleanliness—1 —clean, 2=dirty (nits present), 3=pediculi. Under vision—1=6/6 in both eyes, 2= 6/9 in either of both eyes, 3 = 6/12 or worse in either eye. Mental condition—1 = normal, 2 = dull or backward, 3 = mentally defective. 58 TABLE VIII. Medical Inspection, 1921 (Rota Exams.). Entrants. Age 8. Age 12. Age 13.* Total Elementary Schools. Special schools. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Number examined 41,304 40,398 33,494 33,530 34,587 34,020 38,822 38,397 294,552 2,255 % % % % % % % % % % Skin disease (/) 844 20 668 1.7 506 1.5 392 1.2 464 1.3 376 1.1 457 1.2 477 1.2 4,184 1.4 39 1.7 „ (x) 505 1.2 410 1.0 311 0.9 230 0.7 277 0.8 199 0.6 263 0.7 246 0.6 2,441† 0.8 20 0.9 Teeth (x) 10,801 26.1 10,780 26.7 8,614 25.7 8,762 26.1 7,257 21.1 6,944 20.4 8,264 21.3 8,502 22.1 69,929 23.7 491 2.8 Enlarged tonsils (f) 0,204 12.6 0,176 12.8 3,457 10.3 3,586 10.7 2,530 7.3 3,000 8.8 2.321 6.0 2,723 7.1 27,997 9.5 172 7.6 „ (x) 1,307 3.2 1,280 3.2 802 2.4 965 2.9 644 1.9 793 2.3 610 1.6 778 2.0 7,179 2.4 44 2.0 Adenoids (f) 1,063 2.6 864 2.1 530 1.6 407 1.2 317 0.9 229 0.7 181 0.5 168 0.4 3,759 1.3 53 2.3 „ (x) 488 1.2 397 1.0 272 0.8 195 0.6 189 0.5 130 0.4 91 0.2 95 0.2 1,857 0.6 36 1.6 Tonsils and adenoids (/) 1,042 3.7 1,348 3.3 632 1.9 632 1.9 341 1.0 338 1.0 210 0.5 201 0.5 5,244 1.8 32 1.4 „„ (x) 868 2.1 796 2.0 365 1.1 399 1.2 220 0.6 252 0.7 144 0.4 123 0.3 3,167 1.1 19 0.8 Other nose and throat defects (f) 1,220 3.0 938 2.3 766 2.3 579 1.7 596 1.7 484 1.4 547 1.4 460 1.2 5,595 1.9 76 3.4 „ „ (x) 380 0.9 276 0.7 231 0.7 207 0.6 194 0.6 181 0.5 205 0.5 192 0.5 1,871 0.6 22 1.0 Glands of neck (f) 2,860 6.9 2,417 6.0 1,885 5.6 1,693 5.0 1,502 4.3 1,171 3.4 1,106 2.8 943 2.5 13,577 4.6 162 7.2 „ (x) 103 0.2 77 0.2 63 0.2 63 0.2 43 0.1 37 0.1 30 0.1 36 0.1 452 0.2 3 0.1 Vision (x) - - 2,913 8.9 3,132 9.6 4,309 12.5 4,247 12.5 4,163 10.8 4,114 10.7 22,878 10.9 220 11.8 External eye disease (f) 1,030 3.7 1,466 3.6 949 2.8 1,018 3.0 789 2.3 663 1.9 557 1.4 555 1.4 7,527 2.6 149 6.6 „ „ (x) 926 2.2 874 2.2 447 1.3 435 1.3 372 1.1 278 0.8 236 0.6 234 0.6 3,802† 1.3 54 2.4 Ear disease or defect (f) 880 2.2 900 2.2 557 1.7 647 1.9 591 1.7 490 1.4 542 1.4 490 1.3 5,102 1.7 99 4.4 „ „ (x) 501 1.2 511 1.2 348 1.0 376 1.1 377 1.0 287 0.8 340 0.8 277 0.8 3,007† 1.0 50 2.2 Hearing defect (/) 202 0.6 208 0.6 286 0.9 286 0.9 336 1.0 350 1.0 380 1.0 324 0.8 2,472 0.8 64 2.8 „ (x) 66 0.2 72 0.2 98 0.3 92 0.3 130 0.4 140 0.4 152 0.4 129 0.3 879 0.3 18 0.8 Speech defects (/) 234 0.6 162 0.4 220 0.7 125 0.4 267 0.8 137 0.4 282 0.7 147 0.4 1,574 0.5 56 2.5 „ (x) 10 0.0 2 0.0 18 0.0 7 0.0 54 0.2 12 0.0 39 0.1 15 0.0 157 0.0 1 0.0 Heart defects (f) 964 2.3 842 2.1 950 2.8 1,028 3.1 1,070 3.1 1,375 4.0 1,316 3.4 1,566 4.1 9,111 3.1 84 3.7 „ (x) 29 0.1 27 0.1 24 0.1 37 0.1 38 0.1 76 0.2 45 0.1 66 0.2 342† 0.1 10 0.4 Anaemia (f) 1,494 3.6 1,315 3.3 1,270 3.8 1,310 3.9 1,161 3.4 1,424 4.2 841 2.2 1,354 3.5 10,169 3.4 57 2.5 „ (x) 368 0.9 309 0.8 307 0.9 355 1.0 213 0.6 343 1.0 150 0.4 304 0.8 2,349 0.8 14 0.6 Lung defects (f) 2,769 6.7 2,626 6.5 1,118 3.3 1,013 3.0 861 2.5 722 2.1 659 1.7 616 1.6 10,384 3.5 104 4.6 „ (x) 706 1.7 664 1.6 216 0.6 200 0.6 137 0.4 137 0.4 90 0.2 97 0.3 2,247 0.8 29 1.3 Nervous disease (f) 403 1.0 450 1.1 340 1.0 395 1.2 263 0.8 437 1.3 196 0.5 377 1.0 2,861 1.0 56 2.5 „ (x) 48 0.1 50 0.1 40 0.1 48 0.1 43 0.1 43 0.1 18 0.0 43 0.1 333† 0.1 10 0.4 Phthisis (x) 66 0.2 46 0.1 62 0.2 46 0.1 55 0.2 41 0.1 45 0.1 47 0.1 408 0.1 2 0.1 „ (x) 19 0.0 14 0.0 22 0.1 19 0.1 23 0.1 10 0.0 22 0.1 14 0.0 143 0.0 — Other tubercular disease (f) 69 0.2 63 0.2 53 0.2 41 0.1 62 0.2 42 0.1 63 0.2 45 0.1 438 0.1 8 0.4 „ „ (x) 23 0.1 19 0.0 20 0.1 16 0.0 21 0.1 11 0.0 11 0.0 14 0.0 135† 0.0 1 0.0 Rickets (f) 1,420 3.4 755 1.9 961 2.9 580 1.7 659 1.9 353 1.0 464 1.2 163 0.4 5,360 1.8 38 1.7 „ (x) 98 0.2 49 0.1 18 0.1 10 0.0 3 0.0 2 0.0 8 0.0 - 188 0.1 2 0.1 Deformities (f) 357 0.8 245 0.6 406 1.2 438 1.3 714 2.0 834 2.4 821 2.2 1,124 2.9 4,939 1.7 88 4.0 „ (x) 76 0.2 54 0.2 98 0.3 112 0.4 163 0.5 251 0.7 177 0.4 344 0.9 1,275 0.4 12 0.5 Infectious diseases (f) 73 0.2 62 0.2 21 0.1 15 0.0 15 0.0 9 0.0 7 0.0 11 0.0 213 0.1 1 0.0 „ (x) 46 0.1 45 0.1 12 0.0 13 0.0 8 0.0 5 0.0 3 0.0 6 0.0 138 0.0 — Malnutrition (f) 443 1.1 355 0.9 379 1.1 361 1.1 220 0.6 230 0.7 108 0.3 114 0.3 2,210 0.8 23 1.0 „ (x) 187 0.5 168 0.4 156 0.5 138 0.4 93 0.3 98 0.3 60 0.2 48 0.1 948 0.3 16 0.7 Other defects (f) 1,386 3.4 1,203 3.0 840 2.5 891 2.6 747 2.2 958 2.9 561 1.5 896 2.3 7,482 2.6 50 2.2 „ (x) 736 1.8 670 1.7 433 1.3 450 1.3 329 0.9 416 1.2 228 0.6 354 0.9 3,616 1.2 21 0.9 Number of children noted for treatment 16,114 39.0 15,342 38.0 13,855 41.4 13,988 41.7 13,235 38.3 13,153 38.7 13,678 35.2 14,367 37.4 113,732 38.6 915 40.6 Number of parents present 33,361 80.8 32,983 81.6 19,911 59.5 22,226 66.3 13,945 40.3 17,635 51.8 11,049 28.5 15,041 39.2 166,151 56.4 787 34.9 *Children leaving elementary schools to attend continuation schools. †These cases are sub-divided in Table II. (f) Defects found. (x) Defects noted for treatment. 59 TABLE IX. Medical Inspection of Students in Training Colleges, Secondary Schools, and Trade Schools. Nutrition. Clothing. Skin and hair. Teeth. Nose and throat defects. Enlarged glands. External eye disease. 6/6 in both eyes. Vision. Ear disease. Hearing defective. Speech defects. Lung defects. Nervous system. Digestive system. Spine. Flat foot. Other deformities. Defects of U. G. system. Other defects. No. examined. Excellent. Normal. Below normal. Bad (i.e., malnutrition). Good. Fair. Poor. Clean. Dirty. Pediculi present. Sound. Less than 4 decayed. 4 or more decayed. 6/9 in either eye. 6/12 or worse in either eye. No. wearing glasses. Heart and circulation. Anaemia. L.C.C. Institutions. Training colleges— Males 200 <-NOT EXAMINED-> 161 33 6 - - - 136 7 57 59 1 3 - 4 - - - - 2 - 1 - 1 Females 898 746 99 2 8 3 10 560 151 110 212 - 7 1 26 40 1 2 8 208 35 52 37 7 Secondary schools— Males— Age groups 1,107 380 606 117 4 988 113 6 1,066 41 - 849 241 17 22 12 10 839 92 176 145 13 10 7 43 42 8 13 3 20 28 29 16 5 Other ages and specials 629 210 345 48 - 555 38 - 590 3 - 477 109 18 3 — 5 484 26 106 106 — 2 2 12 22 4 3 1 1 12 12 3 9 Females— Age groups 1,940 697 1,015 222 6 1,795 141 4 1,875 62 3 1,421 466 53 118 30 28 1,328 310 302 298 14 60 11 100 134 23 36 12 336 139 121 33 62 Other ages and specials 1,991 506 903 372 16 1,655 51 - 1,750 33 3 1,166 529 61 113 12 38 1,024 369 322 296 13 29 2 90 78 19 35 18 404 216 255 44 33 Trade schools— Males— Age groups 292 145 125 22 - 219 72 1 286 6 - 224 67 1 2 1 2 226 40 26 13 — — — 4 8 1 2 — 3 16 7 — — Other ages and specials 223 78 128 17 - 200 23 - 223 - - 178 44 1 3 — 4 174 25 24 13 1 3 4 3 5 1 1 — — 12 3 2 - Females— Age groups 222 60 134 28 - 199 23 — 213 9 - 163 57 2 15 2 2 156 35 31 29 3 5 — 12 12 2 4 1 46 10 18 3 5 Other ages and specials 167 47 79 29 2 153 12 - 148 10 - 114 33 1 6 — - 106 25 18 21 — 2 1 7 8 1 1 2 46 12 15 8 4 Aided by L.C.C. Secondary schools— Males— Age groups 793 261 442 90 — 789 54 — 785 8 — 588 178 27 22 4 8 556 115 122 99 3 - 4 13 18 9 4 1 13 27 7 17 4 Other ages and specials 930 274 549 88 - 875 36 - 903 8 - 622 261 47 28 14 8 709 82 130 87 3 7 9 23 18 20 4 — 8 27 8 35 1 Females— Age groups 179 38 124 17 - 163 16 - 171 8 - 133 45 1 6 — 1 135 17 27 25 — 4 1 6 31 3 — — 17 12 11 3 1 Other ages and specials 123 22 88 2 - 117 3 - 103 3 - 81 30 1 2 2 — 78 9 15 15 — — — 7 14 — 2 1 11 5 8 2 2 Trade schools— Males— Age groups 296 94 172 30 - 200 95 1 294 2 - 185 103 8 1 4 3 199 41 56 36 2 — 2 5 14 1 — — 3 8 9 6 3 Other ages and specials 238 51 181 6 - 196 41 1 232 6 - 160 63 15 1 2 3 188 23 27 28 1 1 — 1 5 2 — — 4 13 2 10 2 Females— Age groups 282 136 133 13 - 236 46 - 265 16 1 199 77 6 10 2 3 219 20 43 30 7 16 — 16 21 2 1 1 19 3 5 1 19 Other ages and specials 144 58 78 8 - 139 5 - 135 9 - 102 33 9 12 — 2 108 9 27 19 — 5 — 2 9 — 1 1 13 — 1 1 6 L.C.C. scholars at unaided institutions— Males 94 <- NOT EXAMINED-> 18* 1 — — — 80* 18 — — — 1 2 — — — — 1 — — 4 Females 85 8* — 1 — — 2* 2 — 2 — — 2 — — 3 — — — — — 10,833 3,057 5,102 1,109 28 8,429 769 13 9,039 224 7 7,569 2,168 276 373 89 127 7,225 1,396 1,619 1,551 61 156 44 375 483 97 109 52 1,154 576 564 221 168 *Omitted from totals as degree of defect not stated. 61714 12 €0 TABLE X. Medical Inspection in Day Continuation Schools. Nutrition. Clothing. Skin and hair. Teeth. Nose and throat defects. Enlarged glands. External eye disease. Vision. Hearing defective. Speech defects. Heart and circulation. Anaemia. Lung defects. Nervous system. Digestive system. Spine. Flat foot. Other deformities. Defects of U.G. system. Other defects. No. examined. Excellent. Normal. Below normal. Bad (i.e., malnutrition). Good. Fair. Poor. Clean. Dirty. Pediculi present. Sound. Less than -4 decayed. 4 or more decayed. 6/6 in both eyes. 6/9 in either eye. 6/12 or worse in either eye. No. wearing glasses. Ear disease. Males 1,869* 169 781 94 2 477 497 96 881 169 4 657 489 118 73 7 47 652 91 461 79 35 26 21 96 45 35 15 7 32 16 18 1 12 Females 1,655 170 461 40 — 230 196 26 402 136 24 237 608 121 125 38 33 303 118 500 85 26 32 6 115 92 25 14 4 36 1 14 9 33 *Including young persons brought forward for special examination. 61 CHAPTER XXV. Public Health. The responsibility in London for the public provision of treatment for tuberculosis rests on the Council, which in 1914 prepared a comprehensive scheme. Under this scheme the Council provides or arranges for the provision of residential treatment required through a public authority (other than poor law guardians), and the metropolitan borough councils provide or arrange for the provision of dispensary treatment. Treatment of tuberculosis— History Arrangements for the residential treatment of uninsured adults and children have been undertaken by the Council since 1914, and in 1920 the Council commenced to make arrangements for the provision of residential treatment of insured persons and discharged soldiers and sailors. The National Health Insurance Act, 1920, provided for the discontinuance of sanatorium benefit, and by the combined operation of this Act and the Public Health (Tuberculosis) Act, 1921, the responsibility for the institutional treatment of tuberculous insured persons was transferred, as from 1st May, 1921, from the Insurance Committees to the local authorities responsible for the institutional treatment of the remainder of the population. Becoming thus responsible for the residential treatment of tuberculous persons in London, the Council has been able to ensure that the best possible use is made of all existing accommodation. The number of cases awaiting residential treatment has also been reduced to a minimum. In securing accommodation it has been the policy of the Council to take advantage of all suitable accommodation already provided by hospital and sanatorium authorities, including the Metropolitan Asylums Board, the authority for the residential treatment of infectious diseases in London, and to take advantage also of such additional suitable accommodation as such authorities may provide by arrangement with the Council. Accommodation. The Council s improved method of selecting cases for residential treatment depends on the provision of observation beds. These have been reserved at the Brompton and the Victoria Park Chest hospitals, which possess the best available facilities for highly skilled expert diagnosis. Selection cases for treatment. Certain kinds of accommodation to which patients are sent after observation are available only in voluntary institutions ; for example there are certain voluntary institutions for patients who are Roman Catholics, or members of the Jewish community. It is necessary also to provide for the treatment of patients under certain climatic conditions, such as those at Ventnor and Bournemouth, and voluntary institutions afford the only present means of taking full advantage of climatic conditions, and of obtaining further knowledge of the influence of climate in the treatment. Great advantage is derived from the use of sanatoria linked to hospitals as is the case with Frimley Sanatorium and Brompton Hospital. Arrangements are made with the seamen's Hospital lor the treatment of tuberculous seamen. Special arrangements, apart from insurance committees, have obtained hitherto with regard to the treatment for tuberculosis, under the National Health Insurance Acts, of masters, seamen, or apprentices to the sea service or the sea-fishing service who were members of the Seamen's National Insurance Society. As empowered by section 7 of the Public Health (Tuberculosis) Act, 1921, the Minister of Health, on 30th September, 1921, made an Order constituting an advisory committee for the purpose of assisting the county authorities in making arrangements for the treatment of all masters, seamen, etc. The Council is empowered to appoint a representative on the advisory committee, and has appointed the chairman of the Public Health Committee (Captain O. E. Warburg, O.B.E., M.A.). Seamen. Payments to the Council by H.M. Government towards the cost of residential treatment for tuberculosis consist of (i) an annual grant payable from the Exchequer in consequence of the termination of sanatorium benefit; (2) the actual cost of approved arrangements for the treatment of exService men ; (3) a proportion of the moneys available to H.M. Government for distribution amongst local authorities in respect of the treatment of seamen ; and, (4) a contribution of 50 per cent, of the balance of the approved net expenditure of the Council on residential treatment after taking into account the Government payments under (1) to (3) above. Finance. Under certain conditions the Council requires a contribution towards the cost or residential treatment. In respect of both adults and children the amount is fixed in each case by the local Tuberculosis Care Committee; their assessments are reviewed by the Public Health SubCommittee. For children a small charge, roughly equivalent to the cost of maintaining a child at home is made, and the sums so received are applied by the Council towards such objects as accessories to treatment and after-care of child patients ; grants are also made to the Invalid Children's Aid Association. For adults a charge is made if the patient or the person legally responsible has an income not less than £160 a year, or if the patient, having no dependents is in receipt of an income less than £160 a year, and the circumstances of the case appear to justify the demand. If a patient is an insured person whose income is the main support of the family, or an ex-Service patient for whose treatment the Ministry of Pensions is responsible, no assessment is made in respect of the cost of treatment. The contributions received from adults are credited to the County Fund, but the proportion attributable to residential treatment in institutions of the Metropolitan Asylums Board is paid to the Board. Patients' contributions. 62 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 1921 1,215 1,050 2,265 225 669 894 The following table shows the provision for residential treatment in London for insured persons and ex-service men. Admissions during year. Beds occupied at end of year. Insured adults. Ex-service men. Total. Insured adults. Ex-service men. Total. 1914 3,593 Including ex-service men. 3,593 689 Including ex-service men. 689 1915 2,603 2,603 428 428 1916 2,215 2,215 348 348 1917 2,297 2,297 364 364 1918 2,257 1,426 3,683 392 291 683 1919 2,204 2,727 4,931 568 570 1,138 1920 2,320 3,045 5,365 712 618 1,330 1921 3,356 2,544 5,900 727 430 1,157 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 1921 was 331. At the end of 1921 there were 247 cases (181 adults and 66 children) on the waiting list for residential treatment. 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 1920.* As a result of the survey the Council, with the approval of the Ministry of Health, approved, as part of the comprehensive scheme a number of proposals to be brought into effect as soon after 31st December, 1920, as practicable. A further survey was made in the autumn of 1921, but the results had not been received before the close of the year. Development of the dispensary system. The development of the dispensary system was described in last year's report (vol. III., p. 110). By 1920 there were 29 approved schemes relating to 33 separate dispensaries provided by metropolitan borough councils, and two branch dispensaries. Thirteen voluntary dispensaries were included as part of the borough dispensary provision, and continued on a voluntary basis subject to compliance with the requirements of public authorities until 1920. In that year the Central Fund for the Promotion of the Dispensary System for the Prevention of Consumption in London intimated that it would not be able to continue after 31st March, 1921, its grants to the eleven voluntary dispensaries which it had established and supported. The metropolitan borough councils concerned had, therefore, to consider arrangements for the maintenance of adequate dispensary services. As a result, nine of the dispensaries were transferred to the borough councils concerned as from 1st April, 1921, and another (Kensington), as from 1st January, 1922 ; the remaining dispensary will be conducted on a voluntary basis with a grant from the borough council. Poplar Voluntary Dispensary was transferred to the borough council as from 1st April, 1920. Two hospital dispensaries were closed in 1921. There are now 20 municipal dispensaries, two voluntary dispensaries largely aided by the borough councils, and nine dispensaries—also aided by the borough councils—at hospitals. Two borough councils have branch dispensaries. The medical officers (or tuberculosis officers) of dispensaries in London number 41, of whom seven have part-time appointments. In order to co-ordinate 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. One half of the cost of approved arrangements for the dispensary service for uninsured persons is met by Exchequer grant. The Exchequer also makes an annual grant in consequence of the termination of sanatorium benefit. There are also Exchequer grants in respect of services rendered by the dispensaries in respect of ex-Service patients. 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, after deduction of Government grants for insured persons and discharged soldiers. During 1921 the numbers of new cases examined at the dispensaries were :—9,819 adults (insured), 6,176 adults (uninsured), and 12,029 children. Dental treatment Proposals for the provision of dental treatment in connection with dispensary treatment were submitted by several metropolitan borough councils, the Council having, in 1919, decided to regard dental treatment as an essential part of the tuberculosis dispensary service. During 1921 eleven of these proposals were approved. 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 co-ordinating 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 * Tuberculosis in London. Report of the Public Health Committee. 1st July, 1920. No. 2035. Price 6d. 63 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. Eight borough councils appointed care committees (two of these combining to form one committee) in place of the interim committees, leaving interim committees to be appointed by the Council in the remaining 20 boroughs. The Council urged upon the Ministry of Health the importance of an early decision as to the constitution and functions of care committees. At the end of 1921 it was hoped that the Ministry would be able verv soon to issue a circular on the subiect. The Council on 22nd March, 1921, decided to continue the scheme, in force since 1st January, 1917, for the diagnosis and treatment of veneral diseases. Under this scheme the Council has joined with the county councils 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 Kent) to provide laboratory facilities for aid in diagnosis and treatment. In the scheme for the year ending 31st March, 1922, a clause (No. 6) was inserted, with the concurrence of the participating authorities and the Ministry of Health, to enable the Council, within the general purposes of the scheme and the total approved expenditure for the year, and without reference to the participating authorities unless a question of principle is involved, to modify the arrangements as necessary, subject to the participating authorities receiving all necessary information. The object cf this is to enable the Council to make such necessary modifications without the delay, previously unavoidable, of obtaining the consent of all the participating authorities. Arrangements have been made for free treatment and diagnosis for in-patients and outpatients at 28 hospitals and for the reception of patients for treatment at nine hostels. Special provisior has been made for the treatment of pregnant women and very young children. Practitioners secure at the cost of the Council, scientific reports on materials from patients suspected to be suffering frorr venereal disease, and approved practitioners may obtain the supply, free of cost, of salvarsan or its substitutes. The cost of treatment and diagnosis at hopsitals is met by the local authorities affectec 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 Venereal disease. These facilities have been fully advertised. The following table shows the extent to which they have been utilised by London patients during the five years the scheme has been in operation. The number of beds available for in-patients is 245. Year. 1917. 1918. 1919. 1920. 1921. Number of hospitals 22 25 26 28 29 New patients 12,211 12,538 20,908 23,612 19,216 Attendances 96,398 131,869 232,659 365,478 400,416 In-patient days of treatment 48,860 49,590 54,431 54,529 54,244 Pathological examinations for practitioners 2,992 5,122 8,258 11,234 15,385 Practitioners on the approved list 108 178 240 297 332 The Council's scheme provides in general terms for lectures and addresses to selected audiences, and for the publication and dissemination of information. Since 20th March, 1917, a voluntary association—the National Council for Combating Venereal Diseases—has been permitted for limited periods to exercise on behalf of the Council certain of its powers relating to publicity and propaganda work ; the purposes for which the permission was to be operative for the year ending 31st March, 1921, were determined by the Council on 30th March, 1920. The National Council intimated, however, that its publicity work would be undertaken, after 31st March, 1921, partly by the National Council and partly by its London branch, which would deal only with London, East Ham, West Ham and Croydon. For the year 1921-22 the Council decided itself to undertake certain publicity work which could most usefully be directed through official channels. The Council also arranged for certain publicity work to be undertaken by the National Council, and for the London branch of the National Council to undertake certain propaganda work. Publicity arrangements. In the early part of 1921, the work of the venereal disease clinics at the various hospitals and institutions with which the Council had arrangements was carefully reviewed, the clinics being inspected by a representative of the Ministry of Health (Brevet-Colonel L. W. Harrison) and by Dr. F. N. Kay Menzies, representing the Council. As a result proposals were formulated for meeting the increased demand for treatment by extra sessions and other extensions of the facilities for treatment and by increasing the efficiency of the clinics in other directions. These proposals were forwarded to the Ministrv of Health for consideration. Improvement of the clinics, Proposals by the National Council of Social Service for securing closer co-operation between the authorities and voluntary agencies concerned with various aspects of the problem of women and girls in moral danger have been carefully considered, and on 14th June, 1921, the Council agreed, as a first step, to the formation of a joint committee for the London area. This Committee pointed out that there was reason to hope that a permanent central committee would shortly be established, as the various bodies represented on the provisional joint committee had assented to certain proposals outlined as necessary in a complete scheme for an urban area. These proposals included (i) the provision of a reception house or houses in which women and girls could be accommodated pending other provision for them; (ii) adequate provision of homes and hostels providing, amongst other things, adequate treatment and training facilities; (iii) similar treatment and training facilities for non-residential cases ; (iv) adequate after-care in connection with various institutions (hospitals, infirmaries, prisons and police-courts); (v) the establishment of a central bureau for the purpose of providing immediate information to rescue agencies as to the available accommodation in the various rescue homes. It had been considered for some time past very desirable that closer touch should be established with voluntary agencies dealing with rescue and preventive work, as the organisation of such work was a necessary Rescue and preventive work. 64 preliminary to effective touch between public and voluntary work in the campaign against venereal disease. The setting up of a committee capable of organising such work in London would afford the opportunity for effective co-operation of public authorities and voluntary agencies, and for interchange of information in matters of mutual concern. The Council, therefore, on 14th June, 1921, expressed itself in favour of the suggestion that a central joint committee should be formed representing public authorities and voluntary agencies concerned in rescue and preventive work in London. Prophylaxis. The Government have had under consideration the policy hitherto adopted in this country for dealing with venereal diseases, and the question whether any modification of that policy is required. It was pointed out that the national scheme is based upon the recommendations of the Royal Commission on Venereal Diseases. The question referred to was also considered by the Inter-Departmental Committee on Infectious Diseases in connection with Demobilisation, and, more recently, by a Special Committee of the National Birth-rate Commission. On the question of self-disinfection—-on which the views of these two committees (official and unofficial) were not completely in accord—the Government decided that they could not give official support to self-disinfection as a policy. In communicating this decision the Ministry of Health (Circular No. 202, 31st May, 1921), emphasised the importance of continuing and extending public instruction and enlightenment as to the disastrous consequences of venereal diseases, and urged local authorities not to curtail their expenditure on educational and nronaaranda work. Infant life protection. Part I. of the Children Act, 1908, provides that a person who undertakes for hire or reward the nursing and maintenance of an infant under the age of seven years apart from its parents shall, within 48 hours, give notice of such reception to the local authority, in London, the Council, and empowers such local authority to fix the number of infants which may be kept in any dwelling. If an infant dies the foster-mother must notify the coroner within 24 hours, and the Council within 48 hours. During 1921, 2,337 foster-mothers and 2,801 nurse-infants were notified.* Power is given 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 are so conducted as to render ordinary inspection unnecessary. Some particulars of the Council's work are as follows:— Year. Infants removed from foster mothers. Exemptions. Deaths. Infringements discovered. Cautions. Prosecutions. Convictions. 1919 33 11 51 432 416 16 16 1920 14 7 26 318 302 16 16 1921 20 3 42 302 285 26 26 On 1st March, 1921, the Council authorised officers of the Greenwich Metropolitan Borough Council to act as infant life protection visitors under the Act for a period of one year extending to 30th June, 1922. The authority is subject to agreed terms and conditions and to review at the end of the period. The Council on 18th May, 1920, expressed the opinion that Part I. of the Children Act, 1908, required amendment; and with that object made several proposalst to the Minister of Health, but during 1921 no definite action was taken bv him thereon. Inspection of homes. Towards the end or 1919, the London War Pensions Committee asked the Council to arrange for the inspection of homes in which the Committee proposed to place 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. In 1921 local war pensions committees were formed in the various metropolitan boroughs to carry on the work of the London War Pensions Committee and the Council agreed to continue the arrangement temporarily. Lying-in homes. The London County Council (General Powers) Act, 1921, came into operation on 28th July, 1921. Part IV. (Lying-in homes) repealed Part IV. (Lying-in homes) of the London County Council (General Powers) Act, 1915, but provided that any registration under that Act should be of the same validity and effect as if effected under the later Act. The Act prohibits any person from carrying on a lying-in home unless such person and the premises used are registered with the Council. In addition to specifying the particulars which must be submitted, the Act empowers the Council to refuse to register or to cancel registration if the (i.) person is under the age of 21, (ii.) person is unsuitable, (iii.) premises or their equipment are unsuitable, (iv.) premises are used or intended to be used for the accommodation at any one time of an excessive number of patients, and (v.) premises or any other premises used for any purpose in connection with such first-mentioned premises or with any business or occupation carried on therein are being used for any immoral purpose. The Council is authorised to make by-laws prescribing the records to be kept of the patients received and the business carried on and requiring the notification of any deaths, and is empowered to inspect any premises used or believed to be used as a lying-in home and the entries in any records kept in connection therewith. 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 registered medical practitioners are also exempt provided that the necessary approved certificate is submitted to the Council annually. At the beginning of 1921, 258 premises were on the register, 53 were added during the year, one registration was cancelled, and 32 entries were removed (owing to discontinuance of user, removal, etc.), leaving a net total of 278 on the register at the end of the year. Nine premises carried on by registered * Figures for 1915-20 are given in Annual Report of the Council, 1920, vol. III., p. 112. † See Annual Report of the Council, 1920. Vol. III. p. 113. 65 medical practitioners were exempted during the year. In 1920 the Ministry of Health issued a memorandum (151M & C.W.) which indicated the standards of measurements suitable for the accommodation of maternity cases. The space suggested was 960 cubic feet a bed for wards to contain patients with infants, 800 cubic feet a bed for wards to contain only the mother at night, and 600 cubic feet a bed for wards to contain ante-natal cases. The Council has decided that, when considering applications for registration, it will have regard to these standards. Under the powers conferred by Part IV. of the Act of 1915 as superseded by Part IV. of the Act of 1921, the Council on 1st March, 1921. delegated to the Greenwich Metropolitan Borough Council for one year extending to 30th June, 1922, its powers of inspection of lying-in homes in that borough. 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 midwives 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, 1921, to 31st March, 1922, the Council's expenditure under this head was about <5,000, of which about £1,000 was recoverable. Owing to the difficulty of assessing the sums to be recovered, the Council has adopted a scale of assessments graduated according to net income, after allowing a deduction in respect of each maintainable child or other dependant. Coupled with this, the practice in operation since the passing of the Act of 1918, of relying upon information as to means obtained by special inquiry officers was discontinued. 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 1921 was £474. Notifications during the year by midwives of intention to practise during the year numbered 721; of intention to practise for specific periods less than a year, 24 ; and of having acted in specific cases, 13. The number of births attended by midwives formed about 45 per cent. of the total number (99,839) of births registered. There were 355 cases of puerperal fever and 665 of ophthalmia neonatorum. Seventeen inquests were held on women, and 57 on children. Seven prima facie cases of negligence of misconduct were reported to the Central Midwives Board. In two of these the Board found that charges had been established and removed the name of the midwife from the roll; in two other cases the Board censured the midwife for neglecting to observe its rules, and in one case the Board cautioned the midwife as to strict observance of its rules. In one case the Board was of opinion that the midwife was at fault in certain respects, but that the matter could be satisfactorily dealt with by the Council, and in one case the Board found the charges not proved, as the midwife had acted as a maternity nurse and not as a midwife. Early in 1920 model by-laws under section 26 of the Housing, Town Planning, etc., Act, 1919, with regard to houses divided into separate tenements 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 for confirmation of the same. The by-laws are still being considered by the Minister. Houses divided into separate tenements. Many transmigrants arriving in this country from Eastern Europe on their way to America 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. On 25th January, 1921, the Council decided to ask the Minister of Health to receive a deputation, but he suggested in reply that, having regard to the companies' negotiations, the attendance of the deputation might be unnecessary at the moment, but that if at a later date the Council considered it advisable that a deputation should attend he would be pleased to arrange for its reception. A licensed common lodging-house in Poplar has since been converted into a hostel for the accommodation of transmigrants. These premises, although quite satisfactory for this purpose, are unsuitable for the reception of persons who have recently been in contact with dangerous infectious diseases, and the shipping companies have been approached with a view to all such cases being diverted to their premises at Eastleigh. Arrangements have also been made with the shipping companies to notify the Council's medical officer of health of all cases of transmigrants housed elsewhere than in the above-mentioned hostel. By this method information can quickly be obtained concerning the movements of these persons within London. Housing of transmigrants. 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 : Februarv, 1915, 178 ; 1916, 44 ; 1917, 28 ; 1918, 9 ; 1919, 8 ; 1920, 51 ; and 1921, 56. Census of homeless persons. 61742 K 66 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. 1919 198 20,139 1 1 £8 1 1920 186 18,763 1 1 £3 2 1921 181 18,503 1 1 £3 18s. 1 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 disease. 1919 57 1,381 17 17 £118 - 1920 53 1,298 9 6 £91 10s. - 1921 51 1,287 13 *11 £130 10s. 6d. 1 * One case was adjourned sine die, but defendant was cautioned against a repetition of the offence. In accordance with the powers conferred upon the Council by Part V. of the London County Council (General Powers) Act, 1907, the Council has during 1921 made and renewed agreements with certain metropolitan borough councils for the cleansing of verminous inmates of licensed common lodginghouses and their clothing. Offensive businesses. The following table gives particulars of licensed slaughterhouses, knackers' yards and registered offensive businesses for 1919-21:- Year. Slaughterhouses. Knackers' yards. Offensive businesses. 1919 174 4 53 1920 165 4 53 1921 158 4 60 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 a 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) (b) of the Public Health (London) Act, 1891, and the Minister of Health confirmed the Orders. The Council on 20th December, 1921, made by-laws for regulating the conduct of the business of a fur skin dresser, and has applied to the Minister of Health for confirmation of the same. Draft by-laws for regulating the conduct of the business of a slaughterer of poultry are under consideration. Cowhouses. The numbers of cowhouses licensed by the Council are as follows 1915, 154 ; 1916, 145 ; 1917, 141 ; 1918, 132 ; 1919, 116 ; 1920, 107 : 1921, 101. 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 1921, 1,956 samples from milk consigned to London railway termini from 33 counties were submitted for bacteriological examination. Of the 1,808 completed examinations 63, or 3.48 per cent., yielded tubercle bacilli, as against 59 per cent. in 1920, 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 78 farms and examined 2,410 cows. It was found that 47 cows, i.e., 1.95 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 329 farms and inspected 12,702 cows; all the animals examined at these re-visits were found to be in a satisfactory condition with the exception of 130 which appeared to be tuberculous. In each instance the owner undertook to have the animal removed. At the request of the City Corporation 18 farms, the milk from which was found on analysis to be infected with tuberculosis, were also inspected. Of the 710 cows examined, seven were found to be suffering from generalised tuberculosis and one from tuberculosis of the udder. The usual arrangements were made with the farmer for the disposal of the animals affected. During 1921 four inspections were made of the cows in 105 London cowsheds, and the total number of examinations made was 7,509. No tuberculosis of the udder was detected, but in 40 cases other unhealthv conditions were found. Milk supply and storage. The Milk and Dairies 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 July, 1919, the Council urged the Minister of Health, as soon as possible, to bring the Act of 1915 into operation and to exercise the powers therein conferred upon him to make Orders for preventing danger to health from the sale of infected, contaminated or dirty milk. No reply was received from the Minister. In the autumn of 1920, however, a Bill to amend the consolidating Act of 1915 was introduced bv the Minister, but was dropped before second reading. Measles and verminous conditions ir London. In February, 1921, a conference was held with representatives of the City Corporation and the metropolitan borough councils to consider measures for the better control of measles and the more effective prevention of verminous conditions. The chairman of the Public Health Committee of the Council (Captain O. E. Warburg, O.B.E., M.A.) presided over the conference. Resolutions were passed for the purpose of making more effective the existing powers with regard to the control of measles, and also with a view to further legislation for remedying verminous conditions. After careful consideration of these resolutions the Council on 12th July, 1921, passed resolutions as follows:— (a) That, if so desired by the metropolitan borough councils, the Council is prepared to send to the authorities of all hospitals and general medical dispensaries and to all private 67 medical practitioners in London a communication, in a form satisfactory to the borough councils, directing attention to the facilities available through the public health services for the nursing of cases of measles in London. (b) That the Council considers that until more experience has been gained of improved arrangements for the detection and notification of measles through the school organisation, it would not be desirable to adopt the proposal to make measles compulsorily notifiable by medical practitioners throughout London; and that a representation to this effect be made to the Minister of Health. (c) That application be made to Parliament in the session of 1922 for such amendment of section 19 of the London County Council (General Powers) Act, 1904, and sections 60 and 61 of the Public Health (London) Act, 1891, as may be necessary in order to secure, by simple and effective means, that in all cases in which a person is found to be infested with vermin (including fleas, bugs, lice and itch mites), or a child is found by the local education authority to be infested with such vermin or to be in a foul and filthy condition, the premises, bedding, clothing and other articles in use by such person or child shall thereupon be liable to be compulsorily cleansed, purified or destroyed. (fZ) That the attention of the Minister of Health be drawn to the desirability of— (i) An amendment of the Cleansing of Persons Act, 1897, requiring that the necessary provision for dealing with persons affected with vermin or in a foul and filthy condition should be made by each local sanitary authority. (ii) Legislation empowering local authorities to inspect second-hand wearing apparel in the hands of dealers, whether wholesale or retail; making it an offence knowingly to deal in, or to hold with the apparent intention of dealing in, second-hand wearing apparel in a verminous condition; and empowering local authorities to cleanse the same at the post of the owner, or to deatroy the same without comnensation to him In 1919 the attention of the Council was directed to the custom among undertakers of keeping dead bodies at their premises for a considerable time awaiting, interment. Such practices are to some extent regulated by section 89 of the Public Health (London) Act, 1891. After careful investigation, in consultation with the metropolitan borough councils, the Council decided that delay in such matters had not occurred with sufficient frequency to justify action to secure additional powers of control. Retention of dead bodies at undertakers' premises. 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 1921 the Committee decided three appeals under the Act of 1855. Appeal Committee. The Council on 25th March, 1919,.appointed a special Committee to 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 agreed to the Committee's recommendations †, and on the same date authorised them 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.‡ Early in 1921 the metropolitan borough councils held a conference on the subject and passed certain resolutions not entirely consistent with those passed by the Council. Health administration in London. The Diseases of Animals Acts, 1894 to 1911, the object of which is the suppression of 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 for the year 1921 the incidence of the principal animal diseases so far as London is concerned:— Diseases of animals. Disease Number of Number of animals outbreaks. attacked by disease. Glanders, including farcy 3 16 Swine fever 10 —* Anthrax 1 1 Parasitic mange 218 414 The munber of swine involved in these outbreaks was 427. Glanders is the disease in animals which has caused most trouble and expense to the Council. The disease is now dealt with under the Glanders or Farcy Order of 1920, which requires veterinary surgeons, etc., who consider that any horse, ass, or mule is affected with glanders, or was so affected when Glanders or Farcy. * Report of the Special Committee on Health Administration in London. No. 2000. Price 3d. † These are set out in the Annual Report of the Council, 1920, vol. III., pp. 116-117. ‡ Report of the Special Committee on Health Administration in London. No. 2029. Price 2d. 61742 k 2 68 it died, or was slaughtered, to notify the local authority. A fee of 2s. 6d. is payable by the local authority to the person giving such notice. The Order provides for the payment of increased compensation beyond that previously allowed, 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 accompanied by other extended powers to local authorities for dealing more effectively with the disease. Under the Glanders or Farcy (Metropolitan Police District) Order, 1911, the Council had powers to destroy nosebags and other stable material not capable of disinfection. This Order has been revoked, but its provisions were re-enacted in the Glanders Order, 1920, and the powers continue to be fully utilised after each outbreak. All infected material of this kind is burnt at one of the knackers' depots at the expense of the Council. During 1921, sixteen diseased horses were slaughtered, the compensation payable amounting to £340. Importation of horses, asses and mules. In order to prevent the introduction of contagious equine diseases, particularly glanders, the Ministry of Agriculture and Fisheries made an order, entitled the Importation of Horses, Asses and Mules (Great Britain) Order, 1921. This Order which came into operation on 1st August, 1921, prohibits the landing of equine animals from any other country except Ireland, the Channel Islands and the Isle of Man, unless accompanied by a certificate given by a veterinary surgeon at the place of origin, containing— (a) identification particulars ; (6) a declaration of freedom from any of the diseases specified; and (c) a statement that the animal passed the mallein test within ten days prior to shipment. Race horses, trained polo ponies, bona fide performing animals, and animals imported for re-exportation within 14 days are exempted. The Council is the authority in London for enforcing the Order, and the new requirements have been brought to the notice of persons concerned. Swine fever, owine lever nas Deen very prevalent throughout threat Britain during the past lew years, and no fewer than ten outbreaks were dealt with in London during 1921. In one case, when pigs were moved to infected premises before such premises were declared to be free from disease, the Council instituted legal proceedings against the owner, and a penalty of £5 was imposed. The work carried out during 1921 under the Swine Fever (Regulation of Movement) Order, 1908, which is designed to give local authorities powers of supervision over pigs brought into and removed from their districts, was as follows:—store pigs brought into London, 2,306; swine examined at feeders' premises, 29,529; infringements, 22; penalties and costs, £35 6s. Anthrax. Anthrax occurs occasionally in London, and so long as fodder is imported from abroad sporadic cases will probably 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 1921 there were three cases of anthrax among men, none of which proved fatal. In two of these infection was traced to the handling of imported hides, hair, etc., in the course of the patients' employment, and in the remaining case to the use of an infected shaving-brush. One case of animal anthrax in London was confirmed during 1921. Rabies. Ihe Uouncil is convinced that the most efficacious measures tor stamping out hydrophobia 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, 11,998 dogs were seized by the police during 1921 and 7,333 were destroyed. Particulars were given in the Annual Report for 1920 (vol. III., p. 118) of Orders issued by the Ministry of Agriculture and Fisheries consequent upon the detection of rabies at Byfleet in 1919, and at Acton in 1920. The Ministry subsequently issued the Middlesex (Acton District) (Control of Dogs) Order of 1921, which modified, as from 4th March, 1921, the restrictions on the control of dogs in the area around Acton and withdrew entirely the restrictions from the metropolitan borough of Woolwich between the Thames and Shooters-hill and Dover-road. At the end of 1921 no muzzling regulations were in force in any part of London. No fewer than 34 cases of suspected rabies in dogs in London were notified during 1921. In 3 cases the animals were allowed to live, the suspicious conditions being attributable to other causes than rabies. In the remaining 31 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 197 cases of suspected rabies since 1919, 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. No serious breach of the regulations was reported during 1921. Parasitic man Un the outbreak ot the war, the urder dealing with parasitic mange was temporarily suspended, with the result that the disease increased 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. During 1921, however, the returns of cases in London showed a marked decrease, and a satisfactory feature of this decrease was the fact that fewer animals were affected in each outbreak. The following figures relate to 1921.—Outbreaks, 218; horses affected, 414; infringements, 45; written cautions sent, 23; convictions, 22; penalties and costs, £95 8s. 6d. For the purposes of comparison, the number of outbreaks in 1920 was 469, affecting 1,201 horses. Sheep scab. Particulars were given in tne Annual Keport tor iynu (vol. ill., p. iiy; oi urders maoe Dy tne Ministry of Agriculture and Fisheries with a view to the eradication of sheep scab, a disease which has 69 increased during the past few years in Great Britain. No case has, however, been reported in London since 1901. To ensure that the requirements of the Animals (Transit and General) Urder, 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 1921 numbered 2,306, the animals examined being—horses 11,440, cattle 25,889, sheep 37,327, swine 6,176, making a total of 80,832. There were 28 infringements, 25 written cautions, and 3 convictions, with penalties and costs amounting to £48 lis. Animals in transit. The Diseases of Animals Act, 1910, as amended by the Exportation of Horses Act, 1914, prohibits the shipment of any horse, ass or mule to the Continent unless the animal, immediately before shipment, is certified by a veterinary inspector appointed by the Ministry of Agriculture and Fisheries to be capable of being conveyed and disembarked without cruelty and of being worked without suffering on arrival at its destination. The Ministry has provided for the veterinary inspection of horses shipped at London, Harwich, Hull, Goole, Folkestone, Southampton, Leith, Grimsby and Newhaven. During the year statements appeared in the press to the effect that illicit traffic was taking place in worn-out horses, and the Ministry of Agriculture and Fisheries accordingly asked all local authorities to renew their activities under the above named Acts. Exportation and conveyance of horaes. The existing machinery should render it impossible for horses to be shipped from any London dock without the veterinary examination required by law. With regard to horses conveyed by rail, the •Council's inspectors examine all horses which come to their notice, to ensure that they are fit to undergo the journey. A notice is served by an inspector on the railway company in respect of any horse which, in his opinion, cannot be sent without causing it unnecessary suffering. The railway companies cooperate with the inspectors and refuse to load any horse with regard to which any doubt is likely to arise. Most of the companies will not entrain horses in London until they have been examined by the •Council's officers. Drainage area and statistics. CHAPTER XXVI. MAIN DRAINAGE. The district drained by the Council's main drainage system has an area of nearly 149 square miles with a population (in 1921) of 5,333,387. This includes an area of nearly 32 square miles, with a population of 850,138, outside the countv. Ihe following statement shows the quantities of sewage, etc., dealt with during 1921 Sewage treated— Million gallons. Northern outfall 51,5316 „ „ (daily average) 141 2 Southern outfall 30,810-0 „ „ (daily average) 84-4 Sludge sent to sea— Tons. Northern outfall 1,270,000 ., „ (daily average) 3,479 Southern outfall 773,050 „ „ (daily average) 2,118 The sludge vessels made 2,044 trips, and travelled altogether 225,446 miles. London sewage system. The Council s by-laws prescribe the methods for the drainage of premises, and, subject to these, the metropolitan borough councils are charged with the control of house drainage. Disputants have a right of appeal to the Appeal Committee of the Council (see p. 67). The metropolitan borough councils provide local sewers for house drainage and surface water, the plans of these sewers being subject to the approval of the Council. From the point at which local sewers discharge into main sewers the Council becomes entirely responsible. The main sewers, many of which are on the lines of streams formerly discharging into the Thames, now connect with intercepting sewers which run roughly parallel to the Thames. In turn the intercepting sewers connect with the outfall sewers which convey the sewage to the outfalls, where after the extraction of solid matters, the effluent is run off into the river and the solids are sent to sea in specially designed sludge vessels. For the disposal of rain-water, storm-relief sewers have been constructed which discharge into the Thames by the shortest practicable route. Many main sewers also have storm water outlets to the river. Sewage and storm water flow principally by gravitation, but pumping stations are necessarv at certain places. Sewage treatment. The year 1921 was marked by a prolonged drought, and the flow of water over Teddington weir was abnormally low; only during January was the flow comparable with that of the average of the last 38 years. The worst month was July, when the average daily flow fell to 40 million gallons, or about 8 per cent, of the average for that month. The average flow for the whole year was about 43 per cent, of the general average. river, reaches he flow of upland water has a most important bearing upon the purity of the tidal portion of the During the summer the downward displacement due to the flow of fresh water from the upper was reduced to a minimum and the lower river showed signs of pollution, the effluent from the 70 Council's outfalls contributing to this. The Council, therefore, on 11th July, 1921, decided to resume the use of chemical re-agents. Proto-sulphate of iron was employed for about two months, and was discontinued towards the end of September, when the river had improved sufficiently to permit solids to be precipitated in the sewage by natural methods. The total expenditure amounted to about £7,220, of which £5,530 represented the cost of chemicals, £892 wages of staff, £650 additional stores, and £148 the hire of a launch. The special examination of the Thames from Teddington to the Black Deep deposit area which had been in operation for some years was reorganised and some economies were made. The s.y. Beatrice and the motor launch Cachalot were withdrawn, and their crews were absorbed as far as possible into other branches of the service. The estimated cost of the reduced service was £435 in respect of the employment of two samplers and incidental expenses. 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 £2,000. Mechanically operated filthscreens for removing solids from the sludge have been installed in place of the former screens, which were cleansed and the refuse removed by hand-labour. The filth is now taken out of the sludge and loaded into trucks by automatic means, and much labour, involving the employment of 16 men on rotating shift work, has been saved. The total cost of the new apparatus amounted to £2,845. The Council, on 1st December, 1921, accepted the tender, amounting to £470, of Messrs. F. and T. Thorne for repainting the overhead sludge tanks, and the tender of The British Scaling and Painting Company, Limited, Poplar, amounting to £550, for repainting the cottages at the outfall. Experiments have shown that lime is of little use as a chemical re-agent in the treatment of sewage. The liming station at the outfall has therefore been dismantled. 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. Sludge vessels. The Council has six vessels for conveying sludge from the outfalls to the Black Deep deposit area. The vessels are old, having been launched between 1887 and 1895. The oldest, the s.s. Bazalgelte, was found to be in a bad condition, but in view of the prohibitive cost of a new vessel the Council, on 8th May, 1920, decided to refit her and to instal new machinery. It was anticipated that these works would give her a further period of service of 15 years. The vessel was sent to Vickers, Limited, at Barrow, where the work was carried out; and she returned to the Thames in October, 1921. The total cost of refitting amounted to about £59,000. The s.s. Barking, which was launched in 1889, was laid off at the beginning of the year for overhaul and quadrennial survey by Lloyd's. When the vessel was opened out her condition was found to be extremely bad. The Council on 10th March, 1921, decided to continue the repairs to the hull, and subsequently to instal new machinery. The hull was repaired by the Glengall Ironworks, Limited, Poplar, at a cost of about £27,500. The s.s. Binnie, Belvedere and Barns were overhauled during the vear at an approximate cost of £11,683. Main sewers, etc. During 1921 repairs to main sewers were executed at approximate amounts as follows :—ileet sewer, £4,000; Eel-brook sewer, £1,050; Regent-street sewer, £1,550 ; Ranelagh sewer, £1,500 ; Ratclifi-highway sewer, £2,920; London-bridge sewer, £3,300; Marsh sewer, £1,900; Hackney-brook sewer, £1,500; Goswell-street sewer, £400; Southern high-level sewer No. 1, £1,070; Wandsworth aqueduct, £4,700. The beds of the river Wandle and of the Northern outfall sewer were cleansed by direct employment of labour at a cost of approximately £1,400 in each case. The middle-level sewer No. 1 is carried underneath Clerkenwell-road bridge over the Metropolitan Railway. The bridge was repainted during the year, and the cost was divided between the highways and the main drainage accounts, the charge against the latter being approximately £1,020. Pumping stations. lenders have been accepted tor the painting of pumping stations as follows:—Western pumping station, Vigor and Co. (Poplar), Ltd., £615; Heathwall pumping station, Messrs. Triggs and Co., £455; Shad Thames pumping station, Messrs. Triggs and Co., £667; Falcon-brook pumping station, John Marsland and Sons, Ltd., £598. Abbey Mills pumping- 6tation. Water from the Channelsea river has percolated through the river bank at Abbey Mills pumping station. To remedy this extensive repairs to the wall will be necessary, and the Council, on 13th October, 1921, sanctioned expenditure not exceeding £15,000 for the purpose. On the same date the Council authorised repairs, at a cost not exceeding £1,000, to the wall of the water reservoirs at the station. The tender, amounting to £553 10s., of the British Scaling and Painting Company, Limited, Poplar, was accepted on 1st December, 1921, for repainting and other works at the workmen's cottages. North Woolwich pumping station. ine additional works lor tne disposal ot tne sewage trom JNortn Woolwicn anu irom tne puruoiis of East Ham and West Ham south of the Victoria and Albert Docks were completed during the year, and the new main from North Woolwich pumping station to the Northern outfall was used for the first time on 18th August, 1921. The total approximate cost of the scheme is £81,000, including £14,550 for the enlargement of North Woolwich pumping station, £7,350 for machinery, pumps, etc., and £59,100 for the new 24-inch main. The condition of the old pipes was very bad, and frequent bursts have occurred therein. £600 was expended during the year in repairs. The disposal of screen refuse (i.e., solids intercepted by screens to prevent the clogging of pumps) has been carefully considered. Hitherto it has been removed by contractors at a heavy cost to the Council. The manufacturers offered to instal, at their own expense, a special furnace at North Woolwich pumping station for burning this refuse, and to remove the same if the apparatus failed. The Council accepted this offer on 6th October, 1921, but the apparatus was not fitted until nearly the end of the year, so that there has not been time in which to form an accurate judgment of its work. 71 Flood works. The council, on 22nd July, 1919, had before it a comprehensive scheme of works to mitigate' floodings in various parts of London on both sides of the Thames during times of heavy rainfall.* Part of this, a storm-relief sewer from Kelvin-road, Highbury, to the Thames at Shad well, was agreed to before the war. but had to be postponed. The work is the subject of two contracts. Contract No. 1 for the section from Kelvin-road to Bethnal-green-road has been let to the Metropolitan Tunnel and Public Works Company, Limited ; Contract No. 2, in respect of the remainder, has been let to Scott and Middleton, Ltd. Work was begun under contract No. 1 in May, 1921, and the construction of this section of the sewer, about 2 J miles long, is well in hand. It consists of a brick tunnel, circular in section and 8 to 9 feet in diameter, which is being driven from three working shafts. Work under contract No. 2 was begun in June, 1921. This section is designed as a cast-iron tunnel lined with concrete. It is about 1£ miles long, 11 feet 4 inches in diameter, and is being constructed from the Shadwell end, its outlet i nto the Thames being through the river wall fronting the new King Edward Memorial Park at Shadwell. During 1921 unemployment was rife, and the Council on 25th October, 1921, decided to accelerate the work on other portions of the 1919 scheme, particularly those which would provide work suitable for unskilled or partly-skilled labour. The works selected were (i) the improvement of the river Graveney, (ii) the Wandle Valley sewer, (iii) the Charlton storm relief-sewer, and (iv) flood relief works at Hammersmith. Details are given below. River Graveney. The improvement ot the river Graveney consisted ot forming a concrete aqueduct, partly open and partly covered, on the line of, or near to, the stream, and the provision of a new aqueduct about half a mile long to form another connection with the river Wandle. These measures should greatly facilitate the discharge of storm water. The estimated cost of the work, including provision for land, compensations and supervision, is £230,000. The Council, on 8th March, 1921, decided to expedite the preliminaries in order that the work might be begun without delay. H.M. Government, through the Unemployment Grants Committee, agreed to make a grant towards the cost. Tenders were invited upon the basis—(i.) the tenderer to submit an estimate of the net cost in the form of a priced bill of quantities, (ii.) an allowance of 2\ per cent, upon the estimate to be made for all plant, stores and material, other than timber, not forming part of the permanent work, (iii.) the actual cost of the works, as certified, to be paid, (iv.) 6 per cent, to be paid on the estimate, after adjustment for quantity and for variation in the rates of wages and cost of materials, in respect of head office expenditure and remuneration, (v.) any saving in actual cost below the adjusted estimate to be shared equally between the contractor and the Council, and (vi.) the contractor to lose one quarter of any excess in cost over the adjusted estimate. Ten tenders were received, and after negotiation a contract for the work was let to Messrs. John Price and Son. Work was begun in June, 1921, and during the year substantial progress was made. Wandle Valley sewer. The Wandle Valley sewer is designed both as a soil sewer and storm-water sewer, bewage will be carried into the intercepting sewers and so to the southern outfall, while the storm water will be discharged by gravitation into the Wandle. The sewer will be about 2 .'? miles in length and, if necessary can be extended to the Thames. The cost will be about £259,000. It was estimated that approximately 80 per cent, of the labour employed (not less than 300 men when the work has assumed its maximum) would be unskilled. Tenders were invited upon alternative bases of (i.) a fixed price, and (ii.) a fixed initial price with a provision that any variation in rates of pay or in the cost of materials should be adjusted in the final settlement, subject to the division between the Council and the contractors of any excess or saving on the prices for materials stated in the tender in the proportion of three-fourths to the Council and one-fourth to the contractor. The tender of W. G. Tarrant, Ltd., amounting to £172,794 upon the alternative basis (ii.) was accepted on 10th December, 1921, and work upon the sewer was begun in December, 1921. The work will occupv about two years. Charlton storm relief sewer. The Charlton storm relief sewer is designed to afford relief to the southern high-level sewer. It will connect with the high-level sewer at Charlton and will be constructed across Greenwich marshes to discharge storm water direct into the Thames. Owing to the recent development of land for building in Woolwich and Lewisham the construction of this sewer had become urgent. It is, generally speaking, a straightforward piece of work which would employ a fair number of men, estimated at not less than 200 at a time, of whom 80 per cent, would be unskilled. The actual time occupied in the work would be about one year. Tenders were invited for the work and they were under consideration at the end of the year. Flood relief works at Hammersmith. The low-level area in west London comprises about 2,500 acres in Fulham, Kensington and Hammersmith. The difficulty of draining this area is very great, even when comparatively moderate rainfall is experienced. The difficulty is accentuated when such rainfall coincides with the period of high water in the river. No discharge by gravitation is then possible and the storm water flows into the two low-level sewers. The sewage in the low-level sewer No. 2 flows direct to Abbey Mills pumping station, while that in the low level sewer No. 1 is pumped at the Lots-road and the Western pumping stations. In recent years the rapidity with which the rain water reaches these sewers has increased greatly. Any scheme for relief works must provide for the discharge of storm water by pumping. The relief scheme provides for the construction of a sewer about a mile in length having an outlet to the Thames near Hammersmith Bridge, and the erection of a new pumping station near the outlet. The sewer itself should be constructed in one year, but the building of the pumping station may take two years, and the construction of the machinery anything from two to three years. This last period may be reduced. It was anticipated that the construction of the sewer would take not less than 150 upon each shift, of whom 60 per cent, would be unskilled, and the erection of the pumping station about 100, 60 per cent, being unskilled. On 16th December, 1921, the Council accepted the tender for the * For details see Annual Report of the Council, 1920, vol. III., p. 121. 72 struction of the sewer by Messrs. Kinnear, Moodie and Co., amounting to £145,220 upon a fixed price basis. The preparation of plans, etc., for the erection of the pumping station and the manufacture of the machinery was pushed forward rapidly with a view to the work being begun early in 1922. Out-county drainage. The annual contribution by the west Ham corporation in respect of the drainage of the borougn into the Council's system was fixed by an arbitrator in 1904 at 2£d. in £ on the assessable value of'the borough (excluding government property). This contribution fell far below the cost of the service rendered and the Council therefore obtained authority in its General Powers Act, 1921, for the Minister of Health, after considering representations by the Council and others, to increase such payments or to prescribe the principle upon which such payments are to be determined. Any such order will remain in force for at least twenty years, and it is open to the Council or the corporation to make further representations within six months after the expiration of any period of twenty years. In accordance with these provisions the Council, on 20th December, 1921, decided to ask the Minister of Health to increase the payments of the corporation. The question of the reception into the Council's system of sewage from the urban districts of Leyton and Walthamstow was being considered before the war, but, owing to that event, the matter was not proceeded with. In January, 1921, the Walthamstow Urban District Council asked that negotiations might be resumed, but the Council on 14th April, 1921, decided that the question ought to be considered in relation to the comprehensive enquiry by the Royal Commission on London Government (see vol. I. of this report). Later, in consequence of complaints as to the polluted condition of the Lee, the Minister of Health summoned a conference, at which representatives of various riparian local authorities in the lower Lee valley, of the Lee Conservancy Board and of the London County Council were present, to discuss the practicability of a combined scheme for the reception into the Council's system from areas abutting on the lower reaches of the Lee. The conference took place on 4th November, 1921, when it was agreed that the technical experts should prepare a report for consideration by the authorities concerned. Local sewers. section 69 of the Metropolis Management Act, 1855, provides that no local sewer snall be made without the approval of the Council. During 1921, the construction or reconstruction of 145,736 feet of sewers of various sizes has been sanctioned. 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 1921 the Council gave its consent in 12 such cases. Dwelling houses on low lying lauds. Part 111. of the London County Council (General Powers) Act, 1920, takes the place of Prart 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. On 25th January, 1921, the Council made regulations prescribing the procedure to be followed. Consent to the erection of one house was given during 1921. Staff. In view of the increased costs ol the maintenance (including rates and taxes; ol quarters at main drainage stations the Council, on 11th October, 1921, decided for future occupations to raise the charge from 3s. 6d. to 5s. 6d. a week, including fuel and light, subject to any variations which might be necessary under the provisions of the Increase of Rent and Mortgage Interest (Restriction) Act, 1920, and to allow for the retention of a flat rate for such quarters. The occupation of quarters ceased to be reckoned as an emolument for the purposes of the Council's superannuation and provident fund. Powers and duties of the Council. 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. Apart from administrative duties, the main divisions of the work are (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. Outline of housing scheme. In conformity with section 1 (1) of the Housing, Town Planning, etc., Act, 1919, the Council in July, 1919, submitted for the approval of the Minister of Health a scheme for the provision of workingclass dwellings to meet the needs of London and for the improvement of housing conditions therein. Briefly the scheme* proposed— (i) the erection under Part III. of the Housing Act of 1890 of 29,000 houses with accommodation for approximately 145,000 persons, (ii) the erection of dwellings for 1,960 persons in fulfilment of a rehousing obligation in respect of the Tabard-street, Grotto-place, and Crosby-row areas (Southwark and Berinondsey). (iii) the clearance of the Brady-street area, Bethnal Green, under Part II. of the Act. (iv) immediate action under Parts I. and II. of the Act to facilitate the clearance of other insanitary areas in the county, provision being made for new accommodation in lieu of that to be destroyed. * For details see Annual Report of the Council 1920, Vol. III., p. 124. 73 It was agreed that the scheme should be carried out within five years from the date of the Act (31st July, 1919), or such longer period as the Minister might approve. The loss on this scheme as well as on schemes undertaken by the metropolitan borough councils, so far as it exceeds a rate of Id. in the £ ,will be borne by the National Exchequer. Much preliminary work, including the acquisition of sites, had to be done before the Council could proceed with the erection of houses, and, in the earlier stages of building, shortage of labour and materials delayed progress. As the estates were large and mostly situated in outlying districts the initial difficulties were greater than is generally the case in small local schemes, and more time was necessarily taken before building operations could be commenced. By the end of 1920, however, 270 houses had been completed and 1,500 others were in various stages of construction. About 3,500 men were then engaged and the work of organisation was being rapidly developed. In the early part of 1921, owing to the financial situation, the Government reviewed its financial obligations and eventually restricted the State aid for the building of houses by local authorities and public utility societies to those houses included in approved tenders on 14th July, 1921, and limited the grant of subsidy to private builders to houses in respect of which commitments were entered into before that date. So far as London was concerned the Minister of Health intimated in a letter dated 21st June, 1921, that the extent of the reduction was being considered and that, when it was decided, the whole situation would be reviewed and the special needs of London borne in mind as far as possible. He added that the new arrangement with the Council would supersede the original proposal for the erection of a total of 29,000 dwellings. At the end of 1921 the Minister had agreed to the provision of approximately 8,720 houses by the Council under the State-assisted scheme, excluding dwellings to be provided under the Tabard-street and other clearance schemes. The Government proposes to contribute a sum not exceeding £200,000 a year for the improvement of slum areas in England and Wales, and part of this will be allotted for work in London. The figures mentioned cannot, however, be regarded as final, as the Government intends to keep the problem under close review. In 1921 substantial progress was made with building operations. During the year 948 houses were completed, making a total at 31st December, 1921, of 1,220 houses erected since the war. The number of houses in course of erection was 5,100, and 1,090 others had yet to be commenced under contracts then in progress, in addition to the additional 1,000 houses in the south-eastern corner of Becontree (see later). The number of men employed rose to as many as 10,900 in October, 1921, and at the end of the vear this was still about 10,100. Details of work at the various estates are as follows:— Old Oak estate. At the beginning ot 1921 three contracts were being executed lor the erection of 639 houses and two shops on the remainder (32 acres) of the Old Oak estate, Hammersmith. On 23rd November, 1921, the Council accepted the tender of Messrs. Rowley Bros., amounting to £53,947 for the erection of 83 additional houses. During the year 218 houses were completed and occupied. In the development of the estate before the war the building frontages to Old OaK Common-lane were kept back so as to enable the road to be widened later if necessary. The Hammersmith Metropolitan Borough Council having decided to carry out the improvement of which the widening forms part, the land required was added to the public way. On 19th January, 1921, the Council sanctioned expenditure of £7,564 towards the cost of the making up and paving by the borough council of Ducane-road along the southern boundary of the estate. On 19th October, 1921, the Council accepted the tender of Messrs. T. W. Palmer and Co., amounting to £1,035 10s. 4d., for the erection, by arrangement with the Army Council, of fencing along the boundary between the estate and Wormwood Scrubs. Norbury estate. The remainder (11 acres) of the Norbury estate, upon which roads and sewers were constructed before the war, is being rapidly developed. Two tenders for the erection of 218 houses had already been accepted and by the end of 1921, 200 of these had been finished and occupied. The houses (144) included in the first instalment were similar in design, with some improvements, to those erected before the war, but the remaining 74 were of an improved type with larger rooms. The initial rents for the latter houses have been based on the rents charged for the former, with the addition of Is. a week corresponding to the increase of 10 per cent, leviable on pre-war houses in July, 1921, under the Increase of Rent, etc. (Restrictions) Act, 1920, and 3s. 6d. a week for larger floor space and improved amenities. The scale of weekly net rents, excluding rates, fixed by the Council on 28th June, 1921, with the approval of the Minister of Health is as follows:— Type of house. Accommodation. Net rent. s. d. Class A Livng room, two bedrooms, scullery, and bathroom 14 Class B Living room, three bedrooms, scullery, and bathroom 15 Class C Parlour, living room, two bedrooms, scullery, and bathroom 16 6 Class D Parlour, living room, three bedrooms, scullery, and bathroom 17 - White Hartlane estate. These rents are subject to reasonable variations by reason of position or other special amenities and the gross rents are liable to fluctuation in accordance with variations in the rates payable. During 1921 it was decided to carry out certain minor improvements to the pre-war houses, subject to the rents being increased under the Increase of Rent, etc. (Restrictions) Act, 1920. On 26th January and 2nd November, 1921, the Council sanctioned expenditure of £3,189 for the making up and paving by the local authority of a section of Tylecroft-road and the whole of Isham-road. About 56 acres of the White Hart-lane estate are being developed by the erection of 720 working class houses under a contract with Messrs. Fred and T. Thorne on a cost plus participating profit basis. Roads and sewers on the first section were constructed by John Mowlem and Co., Ltd., under a lump sum contract amounting to £39,016. The execution of two inter-dependent contracts simultaneously caused 74 inconvenience and delay, and the Council therefore on 21st June, 1921, decided to entrust the remainder of the road and sewer work to Messrs. Thorne on a cost plus participating profit basis. Their estimate amounted to £51,825, including their fee or profit, the use of plant, and provisional sums. Any saving of actual cost below the estimate will be shared in stated proportions between the Council and the contractors while any excess of actual over estimated cost will be deducted from the contractors' fee. On 16th November, 1921, the Council accepted the tender of John Mowlem and Co., Ltd., amounting to £2,195 for finishing certain roads on a small section of the estate developed before the war. On 9th November, 1921, the Council sanctioned expenditure not exceeding £1,000 for temporary paving to certain footways to meet the .convenience of tenants during the period of development. At the end of 1921, 45 houses had been completed and nearly 450 others had been commenced. As regards water supply the Council has given a guarantee to the Metropolitan Water Board of 10 per cent, a year on the cost of the service mains required, and a guarantee jointly with the Tottenham and Wood Green Urban District Councils of 10 per cent, a year on the proportionate cost of al2-inch trunk main. The Council has arranged with the Tottenham Light, Heat and Power Company for the supply of gas with the necessary mains, service pipes, fixtures and fittings (including gas stoves), subject to the Council paying £7 a house towards the cost of the installation. Roehampton estate. The Roehampton estate comprises about 147 acres, of which nearly 100 acres on the northern part are being developed for working-class houses. The construction of roads and sewers on the first section has been completed and the work is being continued on the second section under the contract with Henry Woodham and Sons, Limited, at prices pro rata with the prices for the first section. As regards buildings, tenders for the erection of 636 and 546 houses, or 1,182 in all, by Mr. F. G. Minter and Leslie and Co., Ltd., respectively, were originally accepted at agreed prices with an "up-anddown " clause in respect of rises or falls in the cost of labour and materials. Orders to begin work were issued on 19th May, 1920, but, for various reasons, progress was much slower than expected, and by 8th July, 1921, only 41 houses, out of 618 proposed, were completed, although 417 others had been commenced. In that month the Minister of Health suggested that it would be of advantage financially to curtail the contracts. After prolonged negotiations the contractors accepted £40 a house as compensation in respect of each house omitted, and the Council on 26th July, 1921, accordingly reduced the number of houses to be erected under the contracts from 1,182 to approximately 624. The Minister of Health agreed that the Council's position in regard to the future construction under the assisted scheme of the omitted houses, for which fresh tenders will be invited in due course, would not be prejudiced. The Council took over from the contractors materials already delivered and commitments properly incurred which were surplus to the requirements for the reduced number of houses. By the end of 1921, 220 of the 624 houses on the first section had been completed and occupied. Some houses have been fitted at a cost of £215 with experimental heating and cooking plant. It is anticipated that the results will prove of great value in assisting the Council to decide the most suitable and economical stoves for working class dwellings. Putney Park House has been adapted at a cost of £234 for use as a temporary estate office, and a site, 2J acres in extent, and valued at approximately £5,000, has been set aside for an elementary school. The frontage, about 435 feet, to Upper Richmond-road, has been let on lease for 99 years at a rent of £358 a year for the erection of shops or other approved buildings. Becontree. The council is acquiring unaer compulsory oraers a large estate, situated partly in tne urban districts of Barking Town and Ilford, and partly in the parish of Dagenham in the rural district of Romford. The total area scheduled is nearly 3,000 acres, but the exact extent of the land to be purchased has not yet been determined. Development 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 number of houses proposed on this section is 2,876. The original undertaking involved the building of a new township with an ultimate population of some 120,000 persons, and the whole work of organisation and the development of the site was entrusted to one firm of master contractors, C. J. Wills and Sons, Limited, the work being paid for on a cost plus participating profit basis. The contract provides for the payment of fixed sums as remuneration on stated amounts of expenditure or actual cost, and it is open to the Council to suspend or cease operations at any stage. Work was commenced on 1st September, 1920, and good progress has been made with the construction of roads and sewers and the erection of houses. At the end of 1921, 130 houses had been completed and about 2,200 others were in various stages of construction. Aggregate being available on the site many houses are being built in concrete, but, as the difficulties in obtaining materials and skilled labour which prompted this course have been very largely overcome, brick construction is being more generally employed. The limitation of the programme at the instance of the Minister of Health affected very largely the future development of Becontree. The Minister urged the Council to concentrate all effort on the development of the Ilford (No. 1) section, and on 9th February, 1921, he intimated that he was not prepared at that time to agree to any expenditure at Becontree other than that required for that section. The desirability of preparing plans for other sections was very fully discussed with the Minister and on 3rd October, 1921, he stated that he was prepared to authorise the Council to proceed with further houses up to the number of 1,000 in the south-eastern corner of the estate. The Council approved this proposal on 1st November, and lay-out plans for the section, which will be known as the Dagenham (No. 2) section, have been submitted for the Minister's approval. The question of sewerage and sewage disposal is being dealt with by the Romford Rural District Council. The proposal, provisionally agreed to in 1920, for the diversion and construction of the Ripple-road as an arterial road through the southern part of the estate was abandoned and subsequently, early in 1921, the Essex County Council decided to widen the existing road. The Council on 26th April, 1921, 75 agreed to surrender for the purpose part of the housing site, subject to the Essex County Council bearing the cost of fencing and also tenants' compensation. During 1921 the boundary between the estate and the Goodmayes recreation ground was adjusted, this involving the reconstruction of the entrance gates and the provision of fencing along the new boundary at the Council s expense. Action has been taken for the diversion of certain footpaths on the Ilford section. Central administrative offices with superintendent's residence, stores and workshops, and a subestate office, including residence for a second superintendent, are being provided on the Ilford section at an estimated cost of £5,770. A temporary estate office has been provided at a cost of about £80 including fittings. There is a nursery garden in which shrubs are grown in connection with the laying out of the estate. On 19th January, 1921, the Council authorised the erection, at a cost not exceeding £8,000, of huts for the skilled workmen employed and a canteen has been provided for the supply of refreshments. The initial weekly net rents for the new houses have been fixed, with the approval of the Minister of Health, on the following scale:— Type of house. Accommodation. Net rent. s. d. Class E Living room, parlour and four bedrooms with scullery and bathroom 20 - Class A Living room, parlour and three bedrooms, with scullery and bathroom 15 - Class B Living room and three bedrooms, with scullery and bathroom 13 - Class D Living room and two bedrooms, with scullery and bathroom 12 - Three-roomed flat Living room and two bedrooms, with scullery and bathroom 11 - Two-roomed flat Living room and one bedroom, with scullery and bathroom 9 - These rents, which exclude rates, are subject to variation by reason of position or special amenities. In accordance with an undertaking given to the South Essex Waterworks Company during the passage of their bill through the House of Commons in the session of 1921, an agreement was entered into with the Company for the supply of water to houses on the Ilford section, the Council guaranteeing 15 per cent, a year for five years on the cost of providing and laying distribution (not trunk) mains with a further guarantee of 10 per cent, a year on such cost after the period of five years until the water rates should equal such 10 per cent, for two consecutive years. The negotiations, begun in 1920, with the Gas Light and Coke Company for the installation of gas resulted in an agreement whereby the company undertook to supply gas to all the houses to be erected on the Ilford section, the company providing all necessary fittings, including gas cooker, water heater, hot water cylinder and piping with a connection to the boiler behind the stove in the living-room, in consideration of a capital payment by the Council of £22 a house and of the Council providing at its own cost a built-in gas fire in the second bedroom of each four-roomed house in which a coal grate had not. already been installed and building-in a gas fire in the second bedroom of each three-roomed house in which a coal grate had not been installed, provided that no excess in the cost of the latter installation over that of a coal grate would fall upon the Council. The company's offer to instal a gas fire in one bedroom of each five or six-roomed house on similar terms was subsequently accepted. Owing to the great cost involved in introducing both electricity and gas into the same house, the Council, after consultation with the Minister of Health, reluctantly abandoned the proposal for lighting some of the houses by electricity. The adoption of gas light for houses on the Ilford section will not, however, preclude the use of electricity on land which may be leased by the Council. The condition that the Gas Company shall provide a hot water cylinder and connect it with the boiler behind the stove in the living room or kitchen is a substantial consideration as it will relieve the Council of expenditure which it would otherwise have to incur. Bellingham. lhe Louncil has acquired at a cost ot an estate ol 252 acres at Bellingham between the Mid-Kent and Bromley branches of the South-Eastern and Chatham Railway. About 176i acres are being developed by the erection of 2,056 houses under a contract, on a cost plus participating profit basis, with Sir Robert McAlpine and Sons. The order to commence work was given on 23rd October, 1920, and by the end of 1921 more than 1,800 houses had been commenced, of which 125 were completed and occupied. The construction of roads and sewers is proceeding under the same contract. A workmen's canteen has been provided, the catering arrangements being the subject of a sub-contract. The Metropolitan Water Board has agreed to supply water on the terms usual in such cases, namely, that the Council guarantees one-tenth annually of the cost of laying the mains until such time as the water rate for domestic purposes amounts annually to that sum. In order to reduce the incrustation in pipes and boilers, which is excessive in this district owing to the nature of the water supplied, the Council has adopted a secondary heating svstem. Two sites, about 5 acres in extent and valued approximately at £7,570, have been allocated for elementary schools. Administrative offices with superintendent's residence, stores and workshops are being provided at an estimated cost of £3,740. The initial weekly net rents, excluding rates, for typical houses have been fixed, with the approval of the Minister of Health, a,s follows:— Type of house. Accommodation. Net rent. s. d. Class A Living room, parlour, and three bedrooms with scullery and bathroom 16 6 Class B Living room and three bedrooms, with scullery and bathroom 14 6 Class D Living and two bedrooms, with scullery and bathroom 13 6 Three-roomed flat Living room and two bedrooms, with scullery and bathroom 11 6 Two-roomed flat Living room and one bedroom, with scullery and bathroom 10 - 76 Tabardstreet, etc., scheme. These rents are subject to variation by reason of position or special amenities. The Tabard-street and Grotto-place, Southwark, and the Crosbv-row, Bermondsev, scheme* relates to areas of about 17 acres, comprising 875 houses with a population of 4,593. Rehousing accommodation has to be provided on the Tabard-street area for not fewer than 2,580 persons. Chaucer House, with accommodation for 620 persons, was completed in 1916, and Becket House, containing 90 tenements with accommodation for 500 persons, in 1921. Geoffrey House, a five-storey block of dwellings, comprising 54 tenements with accommodation for 300 persons, was commenced in 1920 and was approaching completion by the end of 1921. A dust shoot has been provided and an electric passenger lift is to be installed as an experiment with the approval of the Minister of Health. On 19th October, 1921, the Council accepted the tender, amounting to £29,302 of Messrs. Rowley Bros., for the erection of a fourth block of dwellings (Harbledown House) comprising 38 tenements with accommodation for 228 persons and also for the erection of administrative buildings with a cottage for the superintendent, repairs workshops and stores. By the end of 1921 the brickwork for the tenements had reached sill height and the ground floor was ready for concreting. The Council, on 14th October, 1919, agreed to surrender a small strip of land to the Southwark Metropolitan Borough Council for the construction of a footway 30 feet wide to connect Great Dover-street with Tabard-street. It has now been arranged to construct a public roadway in lieu of the footway. Temporary paving works in front of Becket House were carried out during the year bv the Southwark Metropolitan Borough Council on behalf of the Council at a cost of £228. The Minister of Health has given the Council authority to demolish the old buildings on the areas as required, when the new accommodation which is being provided becomes available for the persons to be displaced. Brady-street scheme. On —24th October, 1921, the Minister ot Health intimated that he was prepared to confirm, subject to certain modifications, the Council's scheme for dealing with the Brady-street area, Bethnal Green (seven acres), under Part II. of the Housing Act, 1890. The Minister also approved plans of a block of dwellings for erection on the site in Goldsmith's-row, Shoreditch, appropriated for rehousing accommodation for 90 persons under the scheme. On 7th December, 1921, the Council accepted the tender of Walter Lawrence and Son, Ltd., amounting to £678. for the laying of concrete foundations for the new building. At the end of 1921 working drawings, bills of quantities, etc., for the superstructure were being prepared. Cost of building. The magnitude ot the deficiencies to be met out of public funds in respect ot new houses has caused the Council great anxiety. The deficiencies, although mainly attributable to the increased cost of building, are no doubt due to some extent to the improved standard of accommodation and amenities offered since the war, and the Council considered during the year, in consultation with the Minister of Health, whether this standard should be modified. While many persons were desirous of renting houses of the larger type, the Council was satisfied that there was a substantial demand for. houses similar to those erected since the war on the Old Oak estate, which contained smaller rooms and were less expensive in construction. The tenants of the latter houses generally expressed themselves well satisfied with their accommodation and criticisms emanated mainly from those with furniture suitable only for larger houses. Revised type plans of houses of more economical design were accordingly prepared and were approved by the Minister of Health on 14th June, 1921. The accommodation in each type and the estimated saving in cost (April, 1920, basis) as compared with previous similar types with larger rooms are as follows, the approximate area of rooms in square feet being given in brackets :— Estimated saving in cost Accommodation. (April, 1920.priccs) as compare with previous similar types. (i.) Living room (166), kitchen (144), scullery (45), bathroom and three bedrooms (140, 100 and 96). End house or intermediate. Not comparable, (ii.) Living room (164), kitchen (144), scullery (55), bathroom and three bedrooms (146, 101 and 96). End house or intermediate. Not comparable, (iii.) Living room (145), parlour (105), scullery (73), bathroom and three bedrooms (145, 104 £ and 77). End house 70 (iv.) Living room (144), parlour (100), scullery (80), bathroom and three bedrooms (144, 102 and 73). Intermediate 71 (v.) Living room (157 to 159), scullery (87), bathroom and three bedrooms (144 to 148, 100 to 102, 67 to 69). Intermediate 66 (vi.) Living room (145), parlour (99), scullery (69), bathroom and two bedrooms (143 and 102). Intermediate 70 (vii.) Living room (185), scullery (110), bathroom and three bedrooms (144, 105 and 68). End house 50 (viii.) Living room (157), parlour (100), scullery (60), bathroom and two bedrooms (154 and 111). End house 42 (ix.) Living room (150 to 156), scullery (82 to 90), bathroom and three bedrooms (144, 102 and 96). Intermediate 70 (x.) Living room (164), scullery (100), bathroom and three bedrooms (144, 99 and 96). End house (xi.) Living room (144), scullery (76), bathroom and two bedrooms (155 and 100). End house 55 (xii.) Living room (144), scullery (73), bathroom and two bedrooms (147 and 100). Intermediate (xiii.) Living room (144), scullery (96), bathroom and two bedrooms (147 and 100). End house 160 (xiv.) Living room (157), kitchen (122), scullery (70) and three bedrooms (146, 102 and 98). End house or intermediate Not comparable. Some economy has been effected by a greater uniformity in type, by longer rows of houses and by shorter frontages. For the present, lavatory basins are being omitted from bathrooms thus effecting *For details see Annual Report of the Council, 1915-19, (vol. III., p. 116), and 1920 (vol. 111., p. 128). 77 a saving of about £8 a house. A movable shelf to rest on the top of the bath can be provided on which to stand a wash basin, and the bath taps will be carried up to a sufficient height to enable the basin to be filled when resting on the shelf. In order to effect economy in the lay-out of sites the Council contemplates the more extensive construction of narrow subsidiary roads, provided that the local authoritv will agree to take them over when completed and to maintain them as public highways. One plan already adopted provides for a central green surrounded by a roadway 8 feet wide, approached from the adjacent roads bv roadways 20 feet wide, the whole to accommodate about 40 houses. The central greens involve expense in maintenance, but, if of a size sufficient for games such as tennis or bowls, arrangements might be made for tenants' associations to undertake the upkeep. At Bellingham partition and party walls are being constructed in concrete, and external walls are being formed in concrete up to damp course level. On the Roehampton estate the walls of the houses are being constructed with the outer face in brick and the interior lining in concrete. These new methods effect economy in time, labour and cost. A number of minor modifications in construction have been approved bv the Minister of Health. Well Hill estate. The arrangement whereby the Council undertook, on behalf of H.M. Government, the maintenance and management of the Well Hall estate, Woolwich,* was terminated as on 1st October, 1921. Rants. On 27th July, 1920 the Council decided that tne rents charged in respect of its working-class dwellings, excluding lodging houses, should be increased by the full amounts allowed by the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. The permitted increases were (i.) an amount not exceeding 30 per cent, of the net rent after giving one month's notice to the tenants, and (ii.) a further amount not exceeding 10 per cent, one year after the passing of the Act (2nd July, 1920). The increase of 30 per cent, was put into force in September, 1920, and the additional 10 per cent, has been charged since 4th July, 1921. The Council decided on 9th February, 1921, to increase the rents of various sheds and cupboards at the dwellings by Id. and 2d. a week. The charges for accommodation at the Council's lodging houses were further revised and fixed as from 19th Februarv, 1921, as follows :— (a) Sleeping accommodation.—(i.) Bruce-house.—Ordinary cubicle, Is. Id. a night, or 7s. a week (number of weekly lettings not to exceed 400); special cubicle, Is. 4d. a night, or 8s. 6d. a week; special bedroom, Is. 7d. a night, or 10s. 6d. a week, (ii.) Carrington-house. —Ordinary cubicle, Is. Id. a night, or 7s. a week ; special cubicle, Is. 4d. a night, or 8s. 6d. a week, (iii.) Parker-street house.—Ordinary cubicle, Is. a night, or 6s. 6d. a week. (b) Baths and parcel storage.—(i.) Hot bath with use of towel, 2d.; storage of parcels at Council's risk—small parcels, 2d. a month, parcels exceeding 6 cubic feet, 4d. a month, provided that any payment for storage beyond one month on parcels already in store shall remain at the old rate. (c) Barber's and shoemaker's shops.—(i.) Bruce-house and Carrington-house, 15s. a week, (ii.) Parker-street-house (barber's shop onlv), 5s. a week. Allotments. The annual rent for the allotments provided on estates developed since the war has been fixed at 2s. a rod including rates. Some land on the White Hart-lane estate, pending its use for building purposes, has been laid out as allotments, which are let temporarily at Is. a rod a year. Biths. On 9th February, 1921, the Council revised the charges for baths on certain estates at which baths are not provided in the tenements, as follows:—hot bath, 2d.; cold bath, 1 id; Id. being charged for the use of a towel and Id. for soap. Applications for tenancies. In view ot the very large number (about 23,000) of applications for tenancies in hand the Council, on 26th July, 1921, in order to save unnecessary correspondence and inquiries, closed the list of applicants for a time. Tenants' deposits. The Council utilises for the benefit of the tenants the interest on sums deposited bv them on taking up their tenancies. During 1921, £20 was given to the London Gardens Guild and £5 to the Norbury Estate Cottage Garden Society for the provision of prizes for the best kept gardens, etc., on the Council's estates, subject in each case to a balance sheet being submitted at the end of the season showing how the money had been expended. Overcrowding. The annual enumeration of the occupants of the Council s dwellings at the end of March, 1921, revealed the fact that there were still a number of tenements or cottages occupied by a larger number of persons than the rules permitted. The maximum allowed is calculated on the basis of two persons for each habitable room, children under five years of age being disregarded for the purpose of this calculation, and two children over five and under ten years of age being reckoned as one adult. The number ot houses and tenements comprised in the enumeration was 10,361, and of these 216 or 2.08 per cent., as compared with 256 or 2'56 per cent, in the preceding year, were found to be overcrowded on this basis. The overcrowding in 11 cases has since been abated. All but nine of the overcrowded dwellings consist of two or three rooms and there were only four cases on the cottage estates. On the Boundary-street estate 62 out of 1,044 tenements, and on the Bourne estate 17 out of 537 tenements, were found to be overcrowded. In the majority of cases the tenants are ready to take larger tenements as soon as opportunities occur, but very few of them are willing to move far from their present dwellings, and in view of higher rents and the rarity of vacancies it will be some time before all the cases can be satisfactorily dealt with. Publications. The council has published a fully illustrated account ot housing in London up to 1912,† and also a detailed account, with seven illustrations, of its present proposals.‡ Workmen's trains, etc. 1 he Council,s action with regard to workmen s trains at cheap tares was dealt with in the last Annual Report (vol. I., p. 77). No special action was necessary during 1921. * See Annual Report of the Council, 1915-19 (vol. III., p. 120). † Housing of the Working Classes, 1855-1912, No. 1555, price Is. ‡ Housing, No. 2032, price Is. 78 CHAPTER XXV111. ACCOUNTS AND STATISTICS. Memorandum by the Comptroller of the Council (Mr. C. D. Johnson) relating to the Housing Accounts for the Year 1921-22. These accounts are prepared in advance of the Annual Accounts of the Council for the year ended 31st March, 1922. In order that the issue of this volume of the Annual Report may not be delayed, it has been necessary to insert certain provisional figures which will be subject to adjustment in the final accounts as prepared for audit. The accounts 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). The "Clearance Schemes" sections of the accounts cover the acquisition and clearance of unhealthy areas. The " Working-class dwellings " sections deal with the dwellings. The capital accounts of dwellings erected in pursuance of an obligation to rehouse persons displaced, include only 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. The capital accounts of the dwellings on estates under Part III. of the Act (schemes to provide accommodation for persons of the working classes, apart from displacements), include 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 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 the broad division between the " Assisted Scheme " under the Housing, Town Planning, etc., Act, 1919, and the earlier " Non-Assisted Schemes." The Accounts are 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). A.—Non-Assisted Schemes. This section comprises the accounts of schemes undertaken by the Council prior to the enactment of the Housing, Town Planning, etc., Act, 1919, and not ranking for State assistance under that Act. Clearance Schemes.—The aggregate net capital expenditure to 31st March, 1922, amounted to £2,736,947 Is. 5d. The net debt outstanding on the same date was £1,017,799 -s. 11d. The Revenue Account shows a deficiency of £61,414 8s. 7d., attributable to debt charges on the cost of acquisition and clearance works. Working-class dwellings.—The aggregate net capital expenditure to 31st March, 1922, amounted to £2,990,378 14s. 8d. (Housing Act, £2,246,838 2s. 8d.; Improvement Acts, £743,510 12s. -d.); the net debt outstanding on the same date after taking into account the accumulated sinking fund was £2.570.281 9s. 3d. The results of the year's working compared with those of the previous year are as follows:— Working-class dwellings— Dwellings— 1920-21. 1921-22. Housing of the Working Classes Act, 1890— £ s. d. £ s. d. Part I. Surplus 1,479 - 8 Surplus 7,951 2 6 Part II. Deficiency 51 13 6 Surplus 502 17 10 Part III.—Dwellings Deficiency 5,782 4 4 Surplus 3,460 5 9 Total—Housing Act Deficiency 4,354 17 2 Surplus 11,914 6 1 Improvement Acts Deficiency 2,390 9 8 Surplus 3,363 2 7 Total Dwellings Deficiency 6,745 6 10 Surplus 15,277 8 8 Acquisition of Lands Fund— Housing Act, 1890—Part III Deficiency 1,143 16 - Surplus 1,726 8 11 Total—Non-assisted Schemes Deficiency 7,889 2 10 Surplus 17,003 17 7 The above results have been arrived at after charging interest and sinking fund contributions, and after transferring substantial sums to the Repairs and Renewals Fund. Tlie purpose of the latter fund, out of which the actual expenditure on repairs and renewals is met, is to equalise the annual charge and to provide a surplus in the early years to meet the cost of the more extensive works which may be anticipated as the buildings grow older. The transfers to the fund during the last few years ha\e had to be increased to meet the high costs of an abnormal period, which have reduced the 79 accumulated balance of the fund. During the year 1921-22, however, the actual expenditure out of the Fund has been less by £17,379 2s. 5d. than the amount credited thereto. The gross rental amounted to £361,801 9s. 2d. in 1921-22, as compared with £314,665 10s. 5d. in 1920-21, an increase of £50,135 18s. 9d. This increase is the result of the rise in rents permitted by the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. 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, 1922, amounts to a surplus of £17,818 3s. £1,291 18s. 6d. has been contributed from Tramways Account in respect of certain rehousing obligations in connection with the Greenwich Generating Station, and £19,110 Is. 6d. has been transferred in relief of rates. 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, together with the losses incurred by the metropolitan borough councils as the result of their operations under the Act. 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 a penny rate will be met out of moneys voted by Parliament. The results for the year 1921 22 are as follows:— £ s. d. 1. Clearance schemes Deficiency 691 17 3 2. Working-class dwellings Deficiency 309,898 13 — 3. Housing schemes of Metropolitan Borough Councils Deficiency 208,488 17 3 4. Local Bonds (for housing) Deficiency 28,159 7 5 Chargeable to Special County account— Produce of a special county rate of one penny in the £ £168,020 -- Balance of deficiency to be met by the Ministry of Health under Section 7 of the Act of 1919 379,218 14 11 Total deficiency 547,238 14 11 In explanation of the above allocation of the deficiency it should be observed that the liability of the Ministry is limited to loss as defined in the Regulations and as approved by the Minister. Should any part of the deficiency not be approved, the difference will fall on the county in addition to the amount of a penny rate. The figure of £168,020 is also subject to correction ; the actual produce of a penny rate, for the special purpose of these accounts, is not capable of being ascertained until later. Clearance Schemes.—The total capital expenditure to 31st March, 1922, amounts to £2,654 17s. 5d., representing preliminary expenditure in respect of the Bell-lane and Ellen-street, Ware-street, and Brady-street areas. The Revenue Account shows a deficiency of £691 17s. 3d., mainly administrative expenses. Working-class dwellings.—The results for the year 1921-22 are as follows :— Dwellings— £ s. d. Part I. Deficiency 4,941 10 9 Part II. Surplus 61 17 3 Part III. Deficiency 25,870 6 9 Total—Dwellings Deficiency 30,750 - 3 Estates in course of development—Part III Deficiency 279,148 12 9 Total—Dwellings and estates Deficiency 309,898 13 - It will be seen that the bulk of the deficiency appears under the head of " estates in course of development," the debt and other charges in respect of which, less receipts in aid, are shown separately in the accounts. 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 1921-22 is £28,996 13s. 7d., as compared with £7,322 3s. 3d. in 1920-21, and £12 7s. 9d. in 1919-20. The aggregate capital expenditure to 31st March, 1922, amounted to £6,608,056 0s. 3d., and the net debt, including stock, etc., issue expenses, to £7,855,826 2s. 6d. Housing Schemes of Metropolitan Borough Councils.—Under the Act of 1919, the Council has to refund to the borough councils the losses arising in connection with schemes carried out by them under the Act. The Council's Housing Accounts will thus show the financial results of the assisted scheme for the County of London as a whole. The provisional accounts presented to the Council in June, 1921, showed £63,455 18s. 7d. as the charge to the accounts of the assisted scheme for 1920-21 under this head. Later information enabled a revised figure of £60,061 19s. to be substituted in the accounts as subsequently audited. Pending the settlement of points at issue between the Council and the metropolitan borough councils, which have been referred to the Ministry of Health, the final charge for 1920-21 has still to be finally determined. A sum of £208,488 17s. 3d. is provisionally included to cover the borough council's losses for the year 1921-22. It is impossible at present to fix the exact amount, but the Council will not be affected by any variation because its liability on the assisted scheme as a whole is limited to the amount of a penny rate. 80 Local Bonds (for housing).—The total amount raised by this means to 31st March, 1922, was £3,955,605. Deducting £106,373 6s. 2d. for expenses of issue, the net amount raised was £3,849,231 13s. lOd. £3,147,046 of this sum has been advanced on loan to the metropolitan borough councils for housing purposes. No part of the proceeds has been used for the Council's own capital purposes. The Ministry of Health have agreed to the expenses of issue being spread over a period of 5 years, and charged to the assisted scheme. Provision has been made 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, etc. (a total in 1921-22 of £28,159 7s. 5d.) fall wholly on the Council's assisted scheme account. C.—Coal Supply to Tenants. To meet the special conditions arising out of the war, 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. D.—Well Hall Estate. The arrangement with the Commissioners of H.M. Works, etc., under which the Council undertook the maintenance and management of this estate on certain agreed conditions, was terminated on 30th September, 1921: Demand for Accommodation. Housing Statistics—Memorandum by the Valuer. There has been no appreciable abatement during 1921-22 of the great demand for accommodation on the Council's housing estates. Apart from the large number of applications which had previously been received, 10,151 applications were received during 1920-21, although it was found necessary during that year to close the waiting fists of applicants for accommodation except as regards applicants entitled to preferential treatment (see below). In 1921-22, although the lists were practically closed for the greater part of the year 10,036 additional applications were received. Moreover, a very large number of persons made inquiries, both written and verbal, as to the possibility of obtaining accommodation and, being informed of the position, did not make formal applications which in the circumstances would have been futile. The difficulty is most acute in the cases of persons about to get married, newly-married couples and persons with families so small as to render them ineligible for accommodation in dwellings other than those of the smaller types. It is indicative of the situation that at one time during the year when an erroneous impression was created that the waiting list for one of the Council's new estates had been re-opened, thousands of inquiries and requests for forms of application were made in the course of one week. New dwellings provided during the year. The curtailment of the Council s programme at the instance of the Minister of Health, has already been referred to (see p. 73). The erection of houses under contracts already entered into was proceeded with and during the year 1,708 new dwellings were completed and let. Of these dwellings, 465 are situated on the Becontree estate, 312 on the Bellingham estate, 112 on the Norbury estate, 287 on the Old Oak estate, 342 on the Roehampton estate, 112 on the AVhite Hart Lane estate, and 78 on the Tabard Garden estate. These 78 tenements are of the block dwelling type, while all those on the other estates are of the cottage or cottage flat type. At the end of March, 1921, 368 dwellings had been erected so that the total number of post-war dwellings had by the end of 1921-22, reached 2,076 providing accommodation on the Council's basis of two persons a room for 15,604 persons. Accommodation provided. The pre-war dwellings comprised 0,543 tenements in block dwellings, 3,148 cottages, and 294 cottage flats. The total of all dwellings was, at the end of 1921-22,12,067 dwellings containing 36,587 rooms, besides 1,874 cubicles in lodging houses, affording, all told, accommodation on the basis of two persons a room, for 74,516 persons. There were also, on the estates, 110 shops, 97 workshops, 274 sheds and 12 stables. The actual population at the end of the year was 49,153 persons, including 1,729 at the lodging-houses, as compared with 41,544 persons on 31st March, 1921. Preference given to certain applicants. Before the war it was the general practice ior the Council, upon tne receipt ot satisfactory references, to accept tenants in the order in which their applications were received. Preference was given (i.) to persons displaced through the acquisition by the Council of property for clearance or improvement schemes or other public purposes and (ii.) to persons already residing in the county. This preference still holds good. Owing to the shortage of accommodation since the war the Council lias 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 required to vacate quarters at fire-stations; (iii.) to members of the Council's staff, to the extent of 5 per cent, of the houses provided; (iv.) on the Grove Park site and at Bellingham, to families from 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. This preference is granted in view of the accessibility of the sites to persons residing in the boroughs named and the fact that the Grove Park scheme was originally promoted by the local authorities. On the Old Oak estate special consideration is given, upon representations by the local medical officer, to the claims of persons living in overcrowded conditions in some neighbouring boroughs. With a view to facilitating the work of development limited numbers 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 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 81 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 to be allotted to a married couple without children or two single women living together. Rehousing. Owing to war conditions the Council did not during the years 1915-20 rehouse, in its own dwellings, 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, while in 1921-22, 192 persons who had been displaced by the Tabard Garden scheme were rehoused. The total number rehoused up to 31st March, 1922, was iust over 2,000. Transfers. During the year, 545 tenants were transterred to other tenements on the Council s estates. I hese 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 owing to an increase or decrease in the tenant's family. Whenever possible, tenants living in overcrowded conditions are transferred to larger dwellings, but this is specially difficult at the present time owing to the shortage of accommodation and to the unstable economic conditions. Removals and empties. During 1921-22, 439 tenants left, of whom 31 were given notice to quit, either for non-payment of rent, disorderly conduct or some other cause. The remaining 408 gave notice and left to suit their own convenience. Enumeration of tenants and overcrowding. The enumeration ot tenants was taken in March, 1922 and showed that the rooms (excluding lodging houses) available for lettings were actually occupied by 47,586, or an average of 1.3 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 at two adults a room, children up to the age of five not being taken into account for this purpose, and each child between the ages of five and ten being regarded as half an adult. This year the number of cases not complying with this standard was 232 or l-92 per cent, of the total number of tenements, as compared with 2-08 per cent, in 1920-21. The overcrowding is due in a measure to the increase, with the course of time, of the ages of tenants' children,but mainly, of course, 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 Acts. The overcrowding will be remedied as opportunities occur by transfers to larger tenements. Kent 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 were further increased as from September, 1920, by 30 per cent, of the net rents of 1914. In July, 1921, the Council, as permitted by the last-mentioned Act, increased the rents by an additional 10 per cent., thus making the full increase, namely 40 per cent., allowed by the Act. The amount produced by the increase in 1921-22, was about £62,550, and, operating over a complete financial year, the 40 per cent, increase would produce about £66,500. These permitted increases have not been made in respect of property forming part of slum clearance areas. It will be realised that the periodical revision of rents consequent upon alterations in the rates involves a great amount of work, the calculations affecting about 11,000 tenements with varying rents and rateable values and situated in the areas of rearly thirtv different local rating authorities. Financial results. In the Housing Accounts for 1921-22, prepared by the comptroller of the council (see beginning of present chapter), full details are given of the financial results of the Council's housing schemes up to 31st March, 1922, 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 the 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, 1922, was £2,990,379. The financial result of the year's working, after providing for interest and sinking fund charges on the capital expenditure, was a surplus of £15,277 or 4.19 per cent, of the gross rental of £364,801, as compared with a deficiency for the preceding year of £6,745, or 3"41 per cent, of the gross rental. To the surplus for 1921-22, may be added the balance (£1,726) of the Acquisition of Lands Fund, making the total surplus in respect of Non-Assisted Schemes, £17,003. The deficiency in 1920-21, was 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 Rest Restrictions Act, the rents could not be raised to meet these expenses until a considerable part of the year had elapsed. During 1921-22, it became possible to increase the rents to the full extent (40 per cent.) permitted by the Rent Restrictions Acts while the working expenses fell somewhat; these two factors combined to bring about a surplus instead of a deficiency. The interest and sinking fund charges amounted to £117,207 or 32.1 per cent, of the gross rental. Other outgoings amounted to £225,525 or 61.8 per cent, of the gross rental, including £91,750 (25-l per cent, of the gross rental) for rates and taxes. As regards the 2,076 dwellings erected under Assisted Schemes and in occupation during the year, the financial result after providing for interest and sinking fund charges, was a deficiency of £30,750. This deficiency will be included in the amount recoverable from H.M. Government. The interest and sinking fund charges amounted to £54,301, and the expenditure on other outgoings accounted 82 for (excluding rates and taxes) was £9,768. The amount paid in respect of rates, taxes, etc., was £11,500. Bene irrecovable. Some tenants left during the year witnout paying arrears ot rent. Every effort was made to recover these arrears, but £68 19s. 9d. or .017 per cent, (about 4d. per £100 of the rental) has been included in the accounts as irrecoverable, as compared with £385 8s. 7d. or .16 per cent. (3s. 2¼d. per £100) in 1914-15, and £13 Is. lOd. or -004 per cent, (less than Id. per £100) in 1920-21. Empties. The loss oy empties during 1921-22, was £3,334 or .008 per cent. of the rental as compared with .57 per cent, in 1920-21. The loss by empties was, as usual, mainly due to Carrington House not being fully occupied by lodgers, £3,119 of the total loss being in respect of Carrington House, the loss in respect of other dwellings and lodging houses amounting in the aggregate to £216 or .0006 of the gross rental. Repairs. The necessary repairs to the dwellings are carried out by the direct employment ot labour, lhe amount expended on this work in 1913-4, was £23,934. In 1920-21, this expenditure had risen to £68,572, this increase being due to the higher wages prevailing in the building trades, to the heavy rise in the prices of materials, and to the necessity of over-taking the arrears of painting and other work suspended during the war. During 1921-22, the expenditure on non-assisted schemes amounted to £58,261 and to £853 on assisted schemes. It will be seen that there was a substantial decrease on the expenditure under this head during the year, this being attributable partly to the fall in wages and the cost of materials. The work carried out included the external painting of 28 blocks of tenements and 847 cottages, the internal painting of the woodwork of 1,202 tenements and 603 cottages, and the cleansing and distempering of 5,901 tenements and cottages. Outbreaks of fire. During the year 27 small outbreaks of fire occurred. The cost of re-instatement, amounting to £30 12s. 6d., was covered by the Council's Insurance Fund. Vital statistics. owing to tne pressure on his staff the council,s Medical Officer of Health has been unable to supply statistics of the number of deaths of residents in the Council's dwellings during the year. The number of cases of infectious diseases reported during 1921-22 was 283, of which 133 were cases of scarlet fever, 102 cases of diphtheria, 45 cases of measles and 3 cases of chicken-pox. Well Hall Estate. In 1915, the Council undertook the administration, on behalt ol the Government, of the Well Hall Estate, Woolwich, the Council receiving for the work, a commission based on the gross rental. (See Annual Report of the Council, 1920, vol. III., p. 135). This arrangement was terminated on 30th September, 1921, when the management of the estate reverted to H.M. Office of Works. Printed by Odhams Press Ltd., Long Acre, W.C.2. . ■ -