London County Council. ANNUAL REPORT OF THE COUNCIL, 1923. Vol. II. MENTAL HOSPITALS AND MENTAL DEFICIENCY. Published by the LONDON OOUNTY COUNCIL, And may be purchased, either directly or through any Bookseller, from P. S. KING AND SON, Ltd., 2 and 4, Great Smith Street, Victoria Street, Westminster, S.W.I. Agents for the sale of the Publications of the/London County Council. 1924. No. 2349. Price Is. London County Council. ANNUAL REPORT OF THE COUNCIL, 1923. Vol. II. MENTAL HOSPITALS AND MENTAL DEFICIENCY. 525—(0.14146)—2.1.25—11556 CONTENTS. page Chapter XVIII. Position, powers and duties of the Council in regard to the care of the mentally afflicted 5 Chapter XIX. Report of the Mental Hospitals Committee for the year ended 31st March, 1924 5 Chapter XX. Sixth annual report of the Council to the Board of Control as to the performance of duties under the Asylums and Mental Deficiency Act, 1913, for the year ended 31st December, 1923, with financial statements for the year ended 31st March, 1924 18 Appendixes. I.—Financial statement showing the cost of administration of the Mental Deficiency Act during the year ended 31st March, 1924 26 II.—Return of expenditure (and cost a head) during the financial year ended 31st March, 1924, on maintenance of defectives at institutions provided by the Council 27 11556 B London County Council. ANNUAL REPORT OF THE COUNCIL, 1923. CHAPTER XVIII. During 1923 the position, powers and duties of the Council in regard to the care of the mentally afflicted have not been altered and the statement under these heads in the Annual Report for 1921 (vol. II., pp. 3-4), has therefore not been reprinted. CHAPTER XIX. Report of the Mental Hospitals Committee to the London County Council. 1. This is the seventh annual report (for the year ended 31st March, 1924) of the Committee to which under section 35 of the London County Council (General Powers) Act, 1915, stand referred all matters relating to the exercise by the Council of the powers of a visiting committee under the Lunacy Acts. It is the thirtysecond annual report as to the administration of the London County mental hospitals. Scope of the report. 2. During the twelve months under review meetings have been held as follows:—Mental Hospitals Committee, 11; visiting sub-committees of mental hospitals (as a rule, twice in four weeks, once to transact general business and once to discharge patients and to make statutory inspections), 242; other sub-committees, 34. M eetings. Accommodation. 3. On 1st January, 1924, the accommodation at the London County mental Accommodation hospitals, according to the requirements of the Board of Control as to bed space, was :— Table 1. Mental hospital. Males. Females. Total. Banstead 1,014 1,375 2,389 Bexley 1,020 1,071 2,091 Cane Hill 846 1,224 2,070 Claybury 924 1,229 2,153 Claybury Hall (for private cases only) 64 — 64 Colney Hatch 1,045 1,490 2,535 Hanwell 984 1,304 2,288 Horton 189 1,726 1,915 Long Grove 1,086 1,019 2,105 Ewell Colony (Epileptic Colony) 329 100 429 Total 7,501 10,538 18,039 Total (excluding Claybury Hall) 7,437 10,538 17,975 4. At Bexley, Cane Hill and Hanwell, as a result of alterations and the use as single bedrooms for patients of rooms formerly allocated to staff, the accommodation, as compared with that on 1st January, 1923, has been increased by 53 beds (11 males at Bexley, 39 females at Cane Hill, and 3 males at Hanwell, see corresponding table printed in the Annual Report for 1922, Vol. II. p. 6). 6 Patients. 5. The number of resident patients on 1st January, 1924, was:— Table 2. Mental hospital. Males. Females. Total. Banstead 1,009 1,374 2,383 Bexley 1,032 1,086 2,118 Cane Hill 923 1,245 2,168 Claybury 1,052 1,374 2,426 Claybury Hall (private patients only) 45 — 45 Colney Hatch 1,044 1,558 2,602 Hanwell 1,009 1,457 2,466 Horton 187 1,699* 1,886 Long Grove 1,093 1,019 2,112 Total 7,394 10,812 18,206 Total (excluding Claybury Hall) 7,349 10,812 18,161 *Includes 120 patients in the private ward. Charges for private patients. This table excludes the Ewell Colony, which on 1st January, 1924, was still in use as a Ministry of Pensions hospital. 6. The increase in the number of patients at Horton as compared with the number on 1st January, 1923 (see Table 2, on p. 6 of Annual Report for 1922), is due to the gradual filling up of vacant accommodation during 1923 as staff became available to allow of the opening of the wards. 7. Comparison of Tables 1 and 2 shows that the mental hospitals (excluding the Ewell Colony), taken as a whole, housed 615 patients (241 males and 374 females) more than the measured accommodation allowed for. Of this number, 78 (29 males and 49 females) were chargeable to parishes and unions outside the County of London and were awaiting removal to out-county mental hospitals. 8. The charge for the maintenance of a female private patient in the private ward before the war was 16s. l1d. a week; during the twelve months under review the charge has been 35s. a week. The charge for private patients at Claybury Hall before the war was 30s. a week for London patients and 40s. a week for out-county patients; during the same period the charge has been 56s. a week for London patients and 66s. 6d. a week for out-county patients. Patients for whom the Council was responsible. 9. The statutory returns to the Council by the London boards of guardians, taken with other available information, show that on 1st January, 1924, the Council was responsible to find accommodation for 18,918 insane persons, who were housed as follows :— Table 3. Males. Females. Total. Parish patients in London County mental hospitals 6,449 10,441 16,890 Parish patients maintained by the Council in other mental hospitals under contract 279 298 577 Parish patients in county and borough mental hospitals under arrangements made by guardians 129 129 258 Total Parish patients 6,857 10,868 17,725 Private patients at Horton mental hospital — 120 120 Patients in various London County mental hospitals on the private list (Lunacy Act, 1891, section 3), including soldiers classified as " service " patients 861 202 1,063 Total Private patients 861 322 1,183 Criminal lunatics in various London County mental hospitals chargeable to the Prison Commissioners 10 — 10 7,728 1 ,1 50 18,918 The sub-totals printed here in italics appear again in Table 5. [This table does not include male private patients at Claybury Hall, but it does include female private patients at Horton mental hospital, all of whom have London settlements and are received at a specially low rate, so that probably, if not dealt with thus, the Council would have to provide for them as parish cases. This is true also of the "private list" cases, all of whom are admitted in the first instance as parish cases and also of the majority of the "service" patients.] 7 10. Of the patients, therefore, for whom the Council was responsible to find accommodation, 835 were not being housed in London County mental hospitals, and as shown in Table 2, the London County mental hospitals were accommodating 537 more London patients than the measured space allowed for, so that (on the basis of measured bed space) the total number of patients for whom additional beds were required on 1st January, 1924, was 1,372 (620 males and 752 females), i.e., 365 more than the number surplus to accommodation on 1st January, 1924. Thus the continued use under contract of additional accommodation in out-county mental hospitals has been necessary, and four additional contracts have been entered into since 31st March, 1923. Arrangements for the termination of some of the contracts, as accommodation at the new West Park mental hospital becomes available during 1924, are in hand. Insufficiency of acoommo. dation. 11. Contracts in force at 31st March, 1924, were as follows:— Table 4. Mental hospital. Number contracted for. Charge a head a week provided for in the original contract. Charge a head a week made at 31st March, 1924. Date of commencement. Full term of contract. Date of expiry. M. F. t. £ s. d. £ s. d. Years. Leicester City - 115 115 1 18 6 1 4 6 16th July, 1924 5 15th July, 1929 (or earlier by three months' notice). Monmouth County - 90 90 1 10 0 1 4 2 8th January, 1924 3 7th January, 1927 (or earlier by three months' notice). Cornwall County 35 — 35 1 14 9 1 3 1 19th October, 1923 1 18th October, 1924 (or earlier by one month's notice). Three Counties 80 70 150 1 18 6 1 4 4 11th April, 1921 5 10th April, 1926 (or earlier by three months' notice). Worcester County and City 100 - 100 1 5 8 1 2 2 22nd February, 1923 5 21st February, 1928 (or earlier by three months' notice.) Bucks County 25 — 25 1 4 6 1 4 6 3rd August, 1923 5 2nd August, 1928 (or earlier by three months' notice). Oxford County 50 20 70 1 6 0 1 6 10 3rd September, 1923 5 2nd September, 1928 (or earlier by three months' notice). City of London 35 5 40 1 5 0 1 5 0 1st July, 1923 5 30th June, 1928 (or earlier by six months' notice). Yorks, East Riding 60 70 130 1 4 6 1 4 6 6th February, 1924 1 5th February, 1925 (or earlier by three months' notice). Total 385 370 755 Patients boarded out. Contract accommodation. 12. The numbers of lunatics for whom the Council has been responsible to find accommodation on 1st January in certain years since 1890 are as follows* :— Table 5. Date. Parish and county patients. Chargeable to Prison Commissioners. Patients on private list, etc., and private patients at Horton. Total. Increase. 1st January— 1890 10,100 4 - 10,104 - 1900 15,061 17 107 15,185 5,081 1910 19,288 39 587 19,914 4,729 1920 16,243 7 1,046 17,296 1,695 1921 16,557 40 1,219 17,816 520 1922 17,085 36 1,228 18,349 533 1923 17,343 15 1,142 18,500 151 1924 17,725 10 1,183 18,918 418 Statistics, 1890-1924. * Figures for 1890-1915 and 1916-19 are given in the Annual Reports for 1915-19 (vol. II., p. 15) and 1921 (vol. II., p. 6). 11556 C 8 13. The increase by 418 in the number of insane persons for whom the Council was responsible to find accommodation on 1st January, 1924, as compared with the number on 1st January, 1923, is the resultant of increases in the numbers of parish patients by 382 and of private patients by 41, and a decrease by 5 in the number of criminal patients. Insane persons within the knowledge of public authorities. 1890-1924. 14. Details of the number of lunatics (excluding private cases) under the care of public authorities in London responsible for dealing with them are as follows*:— Table 6. Date. L.C.C. Lunatics under reception orders. M..A.B. Lunatics in M.A.B. mental hospitals. Guardians.. Lunatics in workhouses or with relatives and friends Total number of lunatics. Annual increase or decrease of Lunatics under reception orders. Total number of lunatics. (i) (ii.) (iii.) (iv.) (v.) (vi.) 1st January— Increase Decrease Increase Decrease 1890 10,104 5,566 692 16,362 — — — — 1900 15,185 5,770 562 21,517 5,081 — 5,155 — 1910 19,914 6,676 413 27,003 4,729 — 5,486 — 1920 17,296 5,291 328 22,915 — 2,698 — 4.088 1921 17,816 5,385 326 23,527 520 6 12 1922 18,349 5,320 298 23,967 533 — 440 — 1923 18,500 5,101 279 23,880 151 — — 87 1924 18,918 5,148 312 24,378 418 — 498 — Increase in 34 years 8,814 — 8,016 — Average increase per annum 259 — 232 — Applications for admission. Applications for admission. 15. The applications for beds for cases of lunacy received from the relieving officers in the County of London and dealt with during each month of the period 1913-1924 are as follows:— Table 7. 1913-14 1914-15 1915-16 1916-17 1917-18 1918-19 919-20 1920-21 1921-22 1922-23 1923-24 April 285† 327 286 272 238 282 303 294 242 † 267 263 May 340 369 277 294* 275 313 347* 303 324* 337* 328 June 299 329 265 291 314* 271 314 347* 274 275 303 July 364 381* 273 260 314* 316 327 308 323 272 333* August 333 353 228† 264 250 259 317 292 263 300 297 September 331 312 230 225 247 256 265 261 257 282 238 October 322 320 257 226 233 286 270 298 287 233† 278 November 296 290 253 242 200† 343* 217† 231† 242† 261 289 December 335 314 258 222† 242 242† 228 287 286 291 256 January 371* 288† 301* 267 279 297 316 302 278 286 297 February 339 299 252 248 248 253 286 279 252 287 266 March 323 345 278 252 303 289 336 292 280 302 211 † Total 3,938 3,927 3,158 3,063 3,140 3,407 3,526 3,494 3,308 3,393‡ 3,359‡ Monthly average 328 327 263 255 261 283 293 291 275 282 280 * Highest in each year. † Lowest in each year. ‡Of the 3,359 applications for beds received during the twelve months ended 31st March, 1924, 163 were withdrawn either because the patients recovered before admission to a mental hospital or because other arrangements for their care were made. Vacant beds were allotted for 3,196 patients only. * Figures for 1890-1915 and 1916-1919 are given in the Annual Reports for 1915-1919 vol. II., p. 16), and 1921 (vol. II.., p. 7). 9 Readmissions. 16. The total number of patients who were readmitted to the London County Former mental hospitals during the year ended 31st December, 1923, after having previously been discharged " recovered " from one or other of the hospitals, was 297. Of this number, 105 were readmitted within twelve months of the date of their discharge. 17. Statistics as to recoveries and readmissions during the past 29 years are as follows:— Table 8. Mental hospital. Patients discharged "recovered" between 1895 and 1923. Number of such patients readmitted to any London mental hospital up to 31st December, 1923. Percentage of such readmissions to discharges " recovered." Number of 9uch patients readmitted to any London mental hospital within twelve months of their discharge up to 31st Dec., 1923. Percentage of such readmissions to discharges " recovered." (i.) (ii) (iii.) (iv.; (v.) Banstead 5,015 1,569 31.28 607 12.10 Bexley (from 19th September, 1898) 2,801 720 25.70 256 9.13 Cane Hill 3,606 1,182 32.77 401 11.12 Claybury 5,859 1,773 30.26 670 11.43 Colney Hatch 4,509 1,370 30.38 494 10.95 Hanwell 5,015 1,588 31.66 601 11.90 Horton (from 3rd March, 1902—out of use from May, 1915, to November, 1919) 1,460 375 25.68 123 8.42 Long Grove (from 18th June, 1907) 1,607 384 23.89 147 9.14 The Manor (from 8th June, 1899—out of use from July, 1916, to March, 1919 ; disused entirely as accommodation for cases of insanity since January, 1922) 742 200 26.9 69 9.29 Ewell Colony (from 19th August, 1903 —out of use since June, 1918) 104 16 15.38 7 6.73 Total 30,718 9,177 29.87 3,375 10.98 Recoveries md readmia lions. 18. The numbers alike of discharges "recovered" and of "readmissions" were greater during 1923 than during the previous year. The percentage rates also in columns (iii.) and (v.) prove to be higher. Admissions, Deaths and Discharges. 19. During 1923 1,180 patients died and 881 were discharged " recovered." Admissions The number of such deaths and discharges with statistics as to admissions (excluding dtoharges. transfers from other mental hospitals) during the years 1920-23 are as follows* :— Table 9. Year. Patients admitted directly. Weekly average. Deatlis. Weekly average. Discharges recovered. Weekly average. M. F T. M. F. T. M F T. M. F 'I'. M. F. T. M. F. T. 1920 1,486 1,704 3,190 28 33 61 654 571 1,225 12 11 23 325 534 859 6 10 16 1921 1,429 1,715 3,144 27 33 60 618 585 1,203 11 11 22 355 527 882 6 10 16 1922 1,415 1,720 3,135 27 33 60 653 797 1,450 12 15 27 338 540 878 6 10 16 1923 1,382 1,771 3.153 26 34 60 575 60 1,180 11 11 22 348 533 881 6 10 16 * Figures for 1914-1919 are given in the Annual Report for 1921 (vol II., p. 8). 11556 C 2 10 20. The weekly average of direct admissions and of discharges "recovered" remains very constant. There was an increase of 18 in the actual number of patients admitted directly during 1923, as compared with 1922 (51 more females and 33 fewer males), a decrease of 270 in the number of deaths, and an increase of 3 in the number of patients discharged "recovered" The total number of exits by death and discharge "recovered" therefore was 267 less in 1923 than in 1922. But the number of admissions must be balanced against the number of discharges. The number of patients admitted directly (as shown in Table 9) was 3,153, and in addition 147 were admitted indirectly, i.e., by transfer from out-county mental hospitals, making a total of 3,300. The number of discharges was 3,049 (including 600 patients discharged "relieved," 381 discharged "not improved," 6 discharged "not insane," and 1 discharged by " operation of law," of whom particulars are not given in Table 9), leaving a balance of 251 entrants over exits. This number is made up of 213 more London rate-aided patients, 58 more patients on the private list, and 4 more patients chargeable to out-county parishes or unions, less 16 fewer service patients, 5 fewer criminal patients, and 1 private ward patient and 2 private patients at Claybury Hall fewer than at 1st January, 1923. Patients on the '' private list." Classification and chargeability of patients. 21. The usual enquiries have been made as to all patients in respect of whom it appeared likely that there were means, and 200 patients have been found entitled to be classified as private patients in accordance with section 3 of the Lunacy Act, 1891, the cost of maintenance being recovered from the patients' estates or secured by undertakings to pay on the part of relatives or friends. 22. The following statement shows the action taken in regard to the classification of patients during the year ended 31st March, 1924:— Table 10. Number of patients on private list on 31st March, 1923 240 Number of patients transferred to private list during the year ended 31st March, 1924 200 440 Of these were— re-transferred to parish list 7 discharged 66 died 32 removed to The Hall, Claybury Hospital (males) — removed to private ward, Horton Hospital (females) 19 removed to private institutions 9 transferred to service (private) class 1 — 134 Number of patients on private list on 31st March, 1924 306 Chargeability of County patients. (These were located at Banstead 21, at Bexley 44, at Cane Hill 30, at Claybury 43, at Colney Hatch 29, at Hanwell 39, at Horton 56, and at Long Grove 44.) 23. Enquiries have been made as to settlements of all patients concerning whom the London boards of guardians have given notice of their intention to obtain orders adjudicating the chargeability of the patients to the County of London, with the result that 75 new notices were received, giving, with 15 cases standing over from last year, a total of 90 cases to be dealt with. In 19 cases settlements were found and the notices were withdrawn, in 57 cases orders were made on the County of London, and 14 cases are still under consideration. 11 24. The 57 patients adjudicated to the county appeared to belong to the following countries: England, 15; Ireland, 13; Scotland, 7; Russia, 7; Canada, 2; France, 2; India, 2; Italy, 2; Australia, China, Spain, Switzerland, Turkey (one each): unknown, 2. 25. The number of patients chargeable to the county, as compared with the total number chargeable to London boards of guardians and the county, for whom the Council was providing accommodation at the commencement of 1924, and of previous years, was as follows*:— Table 11. Date, 1st January. Chargeable to the County. Chargeable to London boards of Guardians and the County. Date, 1st January. Chargeable to the County. Chargeable to London boards of Guardians and the County. 1890 532 10,100 1921 436 16,557 1900 510 15,061 1922 448 17,085 1910 564 19,288 1923 459 17,343 1915 555 20,882 1924 478 17,725 1920 424 16,243 "Service" patients, and other ex-soldier patients. 26. During the year ended 31st March, 1924, eight soldier patients were admitted to London County mental hospitals directly from the Army under section 91 of the Army Act, and 443 men who had had military service were admitted through the parishes and unions. All these cases are considered by the Ministry of Pensions with a view to their classification as "service" patients should the Ministry be satisfied that the mental disability is due to or aggravated by war service. "Service" patients have private classification and are paid for by the Ministry of Pensions. During the year 9 patients who had already been transferred to the "service" class were admitted to the London County mental hospitals from other mental hospitals in order that their friends might more easily visit them, although these patients, had they remained chargeable to parishes and unions, would not have been eligible for admission to London County mental hospitals, For similar reasons some London "service" patients have been transferred to provincial mental hospitals. Service patients. 27. The following return gives particulars of ex-soldier patients at each of the London County mental hospitals during the year ended 31st March, 1924:— Table 12. Admission of patients with previous military service. Patients classified as "service" patients during the year. Discharged or transferred after classification as ''service'' patients. "Service " patients remaining at 31st March, 1924. Under section 91 of Army Act. Under summary reception orders. Transferred from other mental hospitals. Banstead 1 56 — 19 16 122 Bexley 5 53 1 16 11 81 Cane Hill 2 65 2 25 13 101 Claybury — 43 1 18 18 150 Colney Hatch — 49 — 10 8 82 Hanwell — 118 1 31 14 103 Horton — — — — — — Long Grove — 59 4 27 15 153 Total 8 443 9 146 95 792 28. The decision of the Ministry of Pensions (see Annual Report for 1922, vol. II., p. 14) that, after 30th September, 1923, the Ministry would cease to be Chargeability of ex-service patients. * Figures for 1911-1914 and 1916-1919 are given in the Annual Report for 1921 (vol. II., p. 9). 12 responsible for the maintenance of a number of soldier patients (for whose maintenance they had accepted responsibility during the war and for twelve months afterwards under special provision made in the Royal Warrant) on the ground that the mental disability of these patients was not due to, or aggravated by, war service, has met with considerable opposition from some of the Boards of Guardians upon whom the legal responsibility for maintenance now falls. A few Boards have refused to pay for the maintenance of the patients in question, and this refusal at the end of March, 1924, was the subject of correspondence with the Ministry, to whom it had been suggested that certain cases in which there seemed an element of doubt should be reconsidered with a view to the Government continuing to pay for their maintenance. Alien lunatics. Alien Lunatics. 29. During the year ended 31st December, 1923, 129 alien patients were admitted to London County mental hospitals, chargeable to London parishes or unions, and as 577 were already in residence on 1st January, 1923, the total number under treatment during the year was 706. Of these, 8 were discharged to the care of friends for repatriation, 12 were transferred to other mental hospitals, 46 were discharged as "recovered" or "relieved," and 38 died, leaving 602 in residence on 31st December, 1923. The nationalities of these 602 patients were: Belgian, 14; French, 52; Italian, 52; Spanish, 5; Swiss, 18; Dutch, 13; Norwegian, 3; Swedish, 7; German, 77; Austrian, 24; Hungarian, 7; Czech, 1; Serbian, 1; Roumanian, 6; Bulgarian, 1; Russian and Turkish Jews, 223; Polish, 49; Turkish, 6; Armenian, 3; Syrian, 1; Greek, 4; United States of America, 16; Brazilian, 1; Argentine, 1; South American (unclassified), 1; Chinese, 9; Japanese, 1; Portuguese, 1; Latvian, 2; unknown, 2. Mental After-Care Association. Mental After-Care Association. 30. This Association continues to give useful help in enquiries preliminary to the discharge of patients at certain hospitals and in assistance rendered to patients after their discharge. Sale of work. Permission was given during 1923, as in the previous year, for patients who might wish to do so to co-operate in preparing for a sale of work organised by the Association in aid of its funds. Queen Adelaide fund. Queen Adelaide Fund. 31. Full use of this private fund continues to be made for the relief of deserving patients upon their discharge "recovered" from the mental hospitals. We had hoped that the fund might be available for use for patients leaving the Maudsley hospital, but the trustees of the fund did not see their way to agree to this. The Council has re-appointed Captain Alfred O. Goodrich and Mr. Ernest Sanger to be its representatives on the board of trustees for a further period of four years. Patients' clothing. Clothing. 32. As a result of the deliberations of the special sub-committee (see Annual Report for 1922, vol. II., p. 15), arrangements have been made for women patients' dresses of improved patterns to be cut on wholesale lines, to stock sizes, from material which can then be made up in the mental hospital needlerooms. This should relieve the officer in charge of the needleroom of a great deal of laborious work hitherto involved in cutting-out all the dresses made, and it is hoped will give more opportunity than has hitherto been possible for individuality in trimming and other details, and thus help to do away with the dull uniform effect so characteristic of much of the patients' clothing in the past. The boots and shoes, which are now being made or bought for patients of both sexes are of a much more sightly kind than those generally provided a short time ago. 13 Massage treatment of patients. 33. A trained masseuse has been engaged to give special treatment to patients at Claybury mental hospital for six months as an experiment, on the result of which consideration will be given to the advisability of arranging for massage treatment at all the mental hospitals. Massage. Patients' dietary. 34. Reference was made in the last Annual Report (vol. II., p. 15) to the appointment of a special sub-committee to consider the patients' dietary. The dietary scale in force when the sub-committee was appointed was a per capita "menu" scale, providing for the issue of definite amounts for each meal of the ingredients which were necessary for the preparation of prescribed dishes in accordance with official formulae. Following the sub-committee's report in place of this scale the Council has approved, tentatively, a dietary scale expressed in weekly quantities sufficient for each 100 patients, of the principal orders of food stuffs (e.g., bread, fats, cheese, meat, vegetables, fish, cereals, flour, pulses, dried fruit, tea, sugar, milk, etc.), leaving the precise kind of fat, vegetable, cereal, etc., to be determined at discretion, having regard to the form in which it is proposed the food shall be served. This involves the abolition of stereotyped formulae and enables a considerable variation to be made, at the discretion of the responsible officer, in the menus for all meals. The quantities of the various classes of food prescribed have been calculated with great care, so as to provide an adequate minimum daily caloric value for every patient. Dietary Standard of laundry for patients. 35. Endeavour has been made to improve the standard of laundry work deemed necessary for each patient, so as to bring the conditions at the older mental hospitals, where old equipment, etc., made a high standard difficult, into line with newer institutions. A fixed standard has been prescribed. The achievement of this standard however, has necessitated expenditure of approximately £5,000 for additional plant, alterations to structures, and extra stocks of bed linen, under garments, towels, etc. Standard of laundry. Occupations Officer. 36. Following the recommendation of the Departmental Committee on administration of public mental hospitals that a special officer should be appointed at each institution to act as " occupations officer," with a view to the improvement of the arrangements for the employment of patients, a lady has been engaged in that capacity, part-time, at Horton mental hospital for one year in the first instance as an experiment. She commenced duty on 10th December, 1923. Occupations officer. Second assistant matron. 37. The Council has agreed to the appointment of a second assistant matron hospital trained, at each of the larger mental hospitals. This officer will be specialty responsible for the training of probationer nurses. Second assistant matron. Honorary lady visitor. 38. The experiment first made in 1922 (see Annual Report for 1922, vol. II. p. 16) of appointing a lady to act in an honorary capacity as visitor to the patients at Horton mental hospital, has proved so successful that arrangements have been made for the appointment of one or more such visitors at each of the other mental hospitals. The visitor is able to give valuable assistance as an intermediary between patients and their friends, and to assist in the enquiries which are necessary in some cases when discharge is contemplated, and she can act as a friend to otherwise friendless patients. , Appointment , at each * mental l hospital. [ 14 Administration of public mental hospitals. Enquiry as to administration of mental hospitals. 39. Very careful and detailed consideration was given during 1922 and 1923 to the report (published in August, 1922) of the Departmental Committee appointed to investigate charges contained in a book entitled "The experiences of an asylum doctor" (see Annual Report for 1922, vol. II., p. 16). We reported to the Council on 24th April, 1923, that in general the statements and criticisms in the book could not be held to relate to the London mental hospitals, and discussed the criticisms with regard to the number and training of assistant medical officers, the number of trained hospital nurses and the monotony of diet as to which the Departmental Committee thought there were some grounds as regards mental hospitals generally. Seclusion patients. On one point the Council, on the Committee's recommendation, took action, by asking the Board of Control to consider as to amplifying the definition of "seclusion" of patients in mental hospitals given in the Board's 54th annual report (which is limited to the "enforced isolation of a patient by day") to provide that enforced isolation at any time shall come within the meaning of the term. General rules. General rules. 40. Revised general rules for the management of the mental hospitals, approved by the Council on 31st July, 1923, were approved by the Minister of Health on 5th September, 1923, and are now operative. Structural alterations and miscellaneous information Matters concerning individual mental hospitals. 41. The following paragraphs deal briefly with the more important alterations carried out at the mental hospitals or decided upon during the twelve months under review, with a few other items of information which concern individual hospitals. 42. Banstead. Progress has been made with the scheme for the modification of the large chronic blocks referred to in the Annual Report for 1922 (vol. II., p. 17), and it is anticipated that the work will be commenced during the year 1925-26. 43. Cane Hill. Accommodation in the admission blocks on the male and female sides will be increased by the addition to each of them of a single-room annexe to contain ten beds. Additional verandahs will be provided for these blocks and the airing courts in the female division will be rearranged. The estimated cost, including equipment, is £7,600. 44. Claybury. It has been decided to establish new "admission units," to consist on the male side of wards N1, N2, and Ml (after structural alterations), with Claybury Hall as an admission hospital for suitable rate-aided patients as well as for private patients, and on the female side of wards C1, C2, and B2 (after structural alterations to block C), with a new detached one-storey admission hospital, to accommodate 50 patients, to be built on a site apart from the main building. Two wards in block S are to be allocated for use as accommodation for the less hopeful type of male private patients, supplementing the accommodation now available for private patients at Claybury Hall and improving the possibilities of classification of such patients. The estimated cost, including equipment, is £31,000. 45. Colney Hatch. A special admission hospital villa for 40 male patients will be built on the north side of the main building at an estimated cost, including equipment, of £18,600. Generally. The Maudsley Hospital. 46. Full particulars as to the work carried out at the hospital (which admits voluntary patients only) during the year ended 31st January, 1924, are contained in the first annual report of the medical superintendent, which has been printed for private circulation. 15 47. The number of patients treated during this first year was 1,012, made up Number of as follows patients. Female (including wards children). Male (including wards children). (including Total. children). Total registered out-patients 483 (15) 415 (29) 898 (44) Deduct those re-admitted in O.P. register 2 once 2 once 4 once Number of persons treated as O.P. 481 413 894 Female private rooms. Female (including wards. children). Male (including wards. children). (including Total. children). Total registered in-patients 40 236 (2) 190 (6) 466 (8) Deduct those re-admitted 2 twice 6 once 1 once 11 Transferred F.P. to F.W. register 3 — 3 Nett number of persons treated as in-patients 36 227 189 452 M. F. Total. Persons treated as out-patients only 273 287 560 894 Persons treated first as out-patients and later as in-patients 140 194 334 452 Persons treated as in-patients only 49 69 118 Total persons treated 462 550 1,012 Average number of patients resident throughout year 115 Number in hospital 31.1.24 142 48. King's College Hospital have undertaken the X-ray examination and treatment of patients as and when necessary. The cost of such treatment will not be regarded as included in the fixed charge for maintenance, and will be recovered, means permitting, from the patients or the persons responsible for their maintenance. X-ray examinations. 49. Conferences of the medical stall from all the mental hospitals are held at the hospital once a month for consultation as to diagnosis and treatment, and for the demonstration of rare and interesting conditions. Invitations may be issued by the medical superintendent to past and present students at the courses in psychological medicine held at the hospital and to other medical practitioners. Conferences of medical staff. 50. A further course of lectures in psychological medicine, the seventh held at the hospital, was instituted in January, 1924. Lectures. 51. Application has been made for the recognition of the hospital as a school of the London University, and also as an institution where may be taken the prescribed course on insanity preparatory to the qualifying examinations of the Universities, Oxford, Cambridge and London, and the Examining Board of the Royal Colleges of Physicians and Surgeons. Recognition of hospital by universities, etc. 52.The Council has authorised, as a charge against the accumulated interest on the bequest of £10,000 made by the late Dr. Henry Maudsley, expenditure of £400 for the purchase of apparatus and material necessary for research work, and for grants-in-aid to workers other than members of the Council's staff. Research. 53. Dr. Mapother, the medical superintendent, has accepted, with the Council's consent, the appointment of out-patient physician in psychological medicine and 1 lecturer at the medical school of King's College Hospital. Medical superintendent. West Park mental hospital. 54. The eleventh London County mental hospital, at Epsom, has been named the West Park mental hospital. West Park Mental Hospital. 55. The Council, on 6th November, 1923, appointed Major Norcliffe Roberts, O.B.E., M.D., B.S. (Durham), D.P.M., deputy medical superintendent of Horton mental hospital (at that time acting as medical superintendent of the Ewell Colony during its use as a Ministry of Pensions Hospital), to be the first medical superintendent. Major V. L. Connolly, M.C., M.B., B.Ch. (Belfast), D.P.M., was later appointed deputy medical superintendent and Miss K. A. Longland (assistant matron at Horton mental hospital) was appointed matron. No patients, however, were admitted until after 31st March, 1924. 16 56. The contract with Messrs. T. Bradford and Co., Ltd., for the installation of a laundry plant (see Annual Report for 1922, vol. II., p. 18) has been varied to provide that the contractors will be paid 80 per cent. of the value of all permanent work properly executed and fixed on the site until the amount retained by the Council is equal to 10 per cent. of the amount of the contract price, after which the full value of the further work will be paid to the contractors. 57. Expenditure for the undermentioned additional works at the hospital has been authorised: additional residences for medical staff, £3,520; repair and enlargement of West farm buildings, £13,000; provision of iron fence to enclose farmland, £1,200; provision of greenhouses, potting sheds, and garden staff buildings, £1,500. Lease to Ministry of Pensions. The Ewell Colony. 58. The lease of the Ewell Colony to the Ministry of Pensions for use as a hospital for service pensioners suffering from neurasthenia expired on 31st July, 1923, but was renewed for a term of two years on the same conditions as before, but subject to the additional provision that the Ministry will pay in addition to the rent of £11,000 a year, ten per cent. of the total salaries and wages of the Council's established staff employed at the Colony as a contribution towards the Council's contingent liability to pay superannuation allowances. The Ministry undertook to take all necessary steps to secure an extension beyond 31st December, 1923, of those provisions of the Local Government (Emergency Provisions) Act, 1916, as extended by the Expiring Laws Act, 1922, which safeguard the pension rights of the Council's established asylum officers and servants employed at the Colony during its occupation by the Ministry. These were, in fact, extended by the Expiring Laws Act, 1923, until 31st December, 1924. Medical superintendent. 59. On the promotion of Major Norcliffe Roberts to be medical superintendent of the West Park mental hospital, Dr. L. H. Wootton, a deputy medical superintendent serving at Colney Hatch mental hospital, was seconded to act as medical superintendent of the Ewell Colony. Sale of land. 60. The Council has conveyed to the Urban District Council tor £1330 a plot of land, of rather more than 3 acres, forming part of the Ewell Colony estate, to be used for an extension of a sewage farm, subject to conditions safeguarding the amenities of the Council's property. Readjustment of estates. Horton Estate. 61. About an acre of land hitherto part of The Manor estate has been transferred to the estate of the West Park mental hospital in exchange for about 3½ acres of land which would otherwise form part of that estate. Numbers. Staff. 62. The staff of the mental hospitals department, including the staff at the central offices on 31st March, 1924, numbered 608 officers, 3,313 nurses (male and female), and 1,250 employees of miscellaneous grades. Mental hospitals engineer. 63. The Council decided to retain the services of Mr. W. C. Clifford Smith, O.B.E. (who has passed the usual retiring age of 65), as mental hospitals engineer until 31st October, 1924. Director of the Pathological Laboratory. Maudsley hospital. 64. The Council on 24th April, 1923, appointed Mr. Frederick Lucien Golla, M.B.,B.Ch. (Oxon.), F.R.C.P.(London), to be the pathologist of the London County mental hospitals and director of the pathological laboratory at the Maudsley hospital, in succession to Sir Frederick Mott, K.B.E. Medical superinten- dent of Horton mental hospital. 65. Permission has been given for Lt.-Col. J.R. Lord, C.B.E., medical superintendent of Horton mental hospital, to accept honorary appointment as joint secretary to the National Council for Mental Hygiene. 17 Asylums Officers' Superannuation Act, 1909, and Asylums and Certified Institutions (Officers Pensions) Act., 1918. 66. We continue to deal with matters under these statutes by virtue of powers delegated by the Council. 67. During 1923-24, 52 superannuation allowances were granted to the amount of £4,836 3s. 7d a year. The Minister of Health consented to the addition of six years, under section 2(3) of the 1909 Act, in the computation of one allowance. In eight cases contributions towards pensions granted by the Council were claimed from the authorities of other institutions at which the pensioners had served for at least two years; these contributions, as agreed, amounted to £41 17s. 5d. a year. In two cases, the amount to be contributed by the Council in similar circumstances towards a pension granted by another authority was agreed at £27 6s. l1d. a year. Superannuation allowances. 68. Claims to the number of 156 for repayment of superannuation contributions under section 10(1) of the Asylums Officers' Superannuation Act, 1909, were agreed to. The total sum repaid was £921 5s. 7d. Return of contributions 69. Nine applications for return of contributions could not be agreed to owing to the circumstances in which the services of the applicants had been terminated. 70. Eighty-six applications from female officers and servants, leaving to be married, for repayment of their contributions, as permitted by section 10 (2) of the Act of 1909, were granted. The sums returned amounted to £1,566 5s. 0d. 71. In three cases applications for return of contributions were dealt with under section 5 of the Act of 1909, and the contributions were returned in full to the amount of £103 1s. 2d. 72. The Council granted under section 4 of the Act of 1909 gratuities to the widows of four members of the established staff who had died from illness while in the service and who had either (i.) served for 20 years or more and had reached the age specified in the statute as entitling them to retire on pension, or (ii.) had served for at least 10 years, and in whose case it was medically certified that had they survived their illness they would have remained permanently incapacitated for further asylum duty, who, therefore, had they retired at the date of death, would have been entitled to a pension. The aggregate of these four gratuities was £662 9s. l1d. Gratuities for widows and children. 73. Eleven persons in receipt of pensions under these Acts died during the year. Deaths of pensioners. 74. Written sanction under section 6 of the Act of 1909 was given to six officers and servants to remove to the service of other asylum authorities. Sanction to remove. 75. The Minister of Health, having advised, in reply to a request made (see Annual Report for 1922, vol. II., p. 21) that the basis of computation of proportionate parts to be contributed under section 12 towards a pension granted to an employee whose pensionable service had been rendered under more than two asylum authorities, should no longer be that which the Council had consistently followed (upon advice previously given), the Council's practice has been altered accordingly. Payment of pension by different authorities. 76. The Minister of Health expressed an opinion in August, 1923, based on advice of the Law Officers of the Crown, to the effect that the term "removal" used in section 6 of the 1909 Act refers to a direct removal from the service of one employer to that of another, without a break, and that the words in section 12 "has removed with the written sanction" contemplate a sanction given to the acceptance of another office at or before the time when the original office is resigned. The Council's practice, founded on Counsel's opinion, has been to regard the term "removal" as applying to all cases of subsequent employment even after a break, and to give the sanction to remove mentioned in the proviso to section 6 either before or after subsequent employment has commenced. It is found that the adoption of the Minister's advice leads to anomalous results in cases which are closely Removal. 18 similar, which it is advisable should be treated on consistent lines. Consideration is being given to this with other questions arising out of the administration of the Acts of 1909 and 1918. Income and expenditure. Finance. 77. The income and expenditure on maintenance account on mental hospitals, etc., during the year ended 31st March, 1924, is shown in the following table in comparison with the amounts for the previous eight years— Year ending 31st March. Income. Expenditure. Year ending 31s' March. Income Expenditure. £ £ £ £ 1916 669,174 660,506 1921 1,868,646 1,641,962 1917 662,312 674,237 1922 1,872,482 1,564,770 1918 670,079 736,347 1923 1,508,039 1,381,656 1919 753,767 889,012 1924 1,330,068 1,391,237 1920 1,270,666 1,314,295 Statement of accounts. Cost of maintenance. A detailed statement of the accounts for the year ended 31st March, 1924, is shown with other accounts of the Council in the published Abstract of Accounts (see vol. V.). 78. The charge made by the Council to London boards of guardians at 31st March, 1923, for the maintenance of parish patients in the mental hospitals was 25s. 8d. a head a week. This charge was reduced from 1st July, 1923, to 22s. 9d., at which figure it stood at 31st March, 1924. As the charges for in-county parish patients have exceeded the limit of 14s. a week prescribed by section 283 of the Lunacy Act, 1890, the same charges have been made for patients chargeable to out-county parishes. The charges made for private patients (other than "private list" cases) are dealt with on p. 6. The charges for "private list" cases (i.e., those admitted chargeable to a parish who, having a settlement in or status of irremovability from a London parish, are able to pay the full cost of maintenance, or perhaps a little more as a contribution to capital expenses which are not included in cost of maintenance) have been at the minimum, the charge current for the time being for parish patients and, at the maximum, a charge 4s. 1d. a week in excess of that charge. H. F. Keene, W. Sidney, Chief Officer. Chairman. Appointment of Committee. Meetings. Departmental arrangements. CHAPTER XX. Sixth Report of the London County Council to the Board of Control. Administrative arrangements. 1. The Council's administrative arrangements for the discharge of its duties under the Mental Deficiency Act, 1913, remain as described in previous reports (see Annual Reports for 1915-19, vol. II., p. 29, and 1920, vol. II., p. 17). 2. During 1923 meetings of the Mental Hospitals Committee and of subcommittees wholly concerned with work under the Mental Deficiency Act, have been as follows:—Committee, 11; managing sub-committees of certified institutions for the mentally defective, 39; other sub-committees and Cases Section, 32. Staff. 3. Administrative and executive work continues to be divided between the Mental Hospitals Department and the Public Health Department, in accordance with the scheme detailed in the first annual report (see Annual Report for 1914, vol. II., p. 280). The Comptroller of the Council collects contributions towards the Council's expenses of maintaining defectives in institutions (and in some instances towards the Board of Control's expenses of maintaining defectives in a State institu- 19 tion), and the Solicitor, in certain cases, takes steps to enforce payment of arrears. (For particulars as to collection of contributions, see p. 24.) 4. On 31st December, 1923, the staff authorised for employment in the Mental Hospitals Department entirely upon work connected with the administration of the Mental Deficiency Act was:—1 senior assistant; 1 assistant, first class; 4 assistants, second class (one vacancy, filled by a temporary clerk); 2 assistants, general grade; 2 assistants, minor establishment (one vacancy, filled by a temporary clerk); 2 enquiry officers (non-pensionable). The need for the second of the enquiry officers arose from a considerable increase in the number of cases in which orders to contribute had been obtained. He commenced duty on 25th June, 1923. In the Public Health Department at the same date the staff engaged entirely for work under the Act was 3 women inspectors (2 employed temporarily). Staff employed for central administration. Ascertainment. 5. The Council's duty to ascertain what persons in London are defectives within the meaning of the Act and are subject to be dealt with under the Act has been discharged as fully as possible. Restrictions continue to be imposed by the Board of Control whereby, of the cases ascertained, none but those deemed to be " urgent " as defined by the Board of Control have been dealt with in institutions. 6. The cases of which the Council received information during the year ended 31st December, 1923, were:— Cases ascertained. Source of information. Miscellaneous sources. London Association for the Care of the Mentally Defective. Education authority. Poor-law authorities. Criminal cases. Charged with offences before a court of criminal jurisdiction (Sec. 8). Prisons (Sec. 9). Industrial schools (Sec. 9). Total. 136 92 267 51 72 3 39 660 Supervision. 7. Arrangements for supervision of those for whom this appears to provide adequate protection or for whom no better means of care can be furnished continue to be made through the London Association for the Care of the Mentally Defective. For the financial year ended 31st March, 1924, the Council has paid to the Association £1,200; this amount, however, includes consideration for services rendered by the Association in furnishing reports upon the home circumstances of the relatives of defectives required by the Visitors of certified institutions in which London cases are maintained, to enable the visitors to perform their duties under sec. 11 of the Mental Deficiency Act. Employment of the London Association for the Care of the Mentally Defective. Enquiries made for visitors of institutions, 8. (supervision is arranged by the London Association of all defectives who have been granted leave of absence from institutions of a probationary nature, to homes in London, with a view to ultimate discharge; the payment of £1,200 referred to above covers services rendered in this connection. Supervision of defectives on leave of absence. 9. Voluntary supervision, or after care, continues to be afforded by the Association in suitable cases for defective persons resident in London, after discharge from institutions or guardianship. No pavment is made by the Council for this work. Voluntary supervision or after-care. 10. At 31st December, 1923, the number of cases under statutory supervision in London was 1510 (717 males and 793 females). Provision of occupation centres. 11. In the last Annual Report (vol. II., p. 24,) reference was made to the Council's intention to provide training in "occupation centres" for defectives under Cases supervised 20 Revocation of Article 15 of Provisional Regulations. statutory supervision, who could benefit by attendance at such centres. The immediate difficulty was that Article 15 of the Mental Deficiency Act Provisional Regulations, 1914, narrowed the interpretation of the duty of "supervision" and made it doubtful whether expenditure upon occupation centres was legal. The difficulty was, however, removed by the revocation of the Article by the Minister of Health, on 21st March, 1923. Scheme for use of centres. 12. It having been decided that it would be better, in the first instance at least, for the Council to make use of occupation centres provided by a voluntary agency rather than to attempt to establish and administer centres of its own, a commencement was made in March, 1923, when 62 defectives were approved for attendance at three centres (one established by the Central Association for Mental Welfare, and two by the London Association for the Care of the Mentally Defective). Each centre provided each week five daily sessions of two hours each. By the end of the year three more centres and two groups, each of two centres, had been established by the London Association. The grouped centres were provided to serve in some measure the needs of districts in which defectives are too widely scattered to make it possible for all to attend regularly at one centre; each centre in the group is open for two or three sessions a week and thus a greater number of defectives are able to get the benefit of attendance, though on two or three days a week only. Centres in use. 13. At 31st December, 1923, the centres in use were:— Centre. Address. Sessions a week. Average daily attendance during December, 1923, of defectives under statutory supervision. "Agnes Western" Banner-street, E.C. 5 12 Whitechapel Christchurch Hall, Hanbury-street, E. 5 9 Southwark St. John's Institute, Larcom-street, Walworth 5 8 North Islington Mission Hall, Gifford-street, N. 5 10 Poplar St. Frideswide Hall, Follet Street, E 5 13 Hackney St. Mark's Lecture Hall, Colvestone Crescent, E. 5 10 Battersea (a) Congregational Small Hall, Batterseabridge-road, S.W. 3 5 North Kensington (a) 138, Portobello-road, W. 10 2 6 Brixton (6) Wheatsheaf Hall, South Lambeth-road 3 7 Deptford (6) St. Paul's Institute, High-street 2 9 Total — 89 Payment. The centres marked (a) and (b) are grouped. 14. The Council arranged to pay to the London Association (which undertook responsibility for the management of all the centres, including that provided by the Central Association for Mental Welfare) at the rate of £7 a year for every case recognised for attendance at a centre which made an agreed percentage of possible attendance. This method, however, was not convenient, and later the Council agreed to contribute at the rate of £125 a year for each centre or group of centres approved for use. The errant made in 1923 amounted to £513 16s. 7d. Voluntary cases. 15. The centres are not limited to receive only cases, under statutory supervision, approved by the Council, though it is only in respect of the facilities afforded for such cases that the Council's grant is paid. Cases as to which the Council has no statutory duty may and do attend, and the Association receives a special grant in aid from the Board of Control in respect of this voluntary work 16. The Council's grant to the Association is made subject to the condition. 21 that at least 75 per cent. of the cases upon the roll of each centre are those who have been placed under statutory supervision by the Council. Attendance ordinarily is restricted to cases under 16 years of age, but an extension of age to 18 may be approved in special cases. 17. The training given at the centres consists mainly of simple physical exertises, games, singing, and elementary manual occupations such as building with bricks, raffia basket-making, boot and brass cleaning etc. Occupations. 18. The centres are under the direction of four district committees appointed by the London Association, and each committee includes at least one member of the Mental Hospitals Committee. The centres are inspected from time to time by the Council's officers. Representation of Council on Centre Committees. 20. The use of occupation centres is as yet in an experimental stage, but it can be said that, even with the tentative provision which alone it has been possible to make so far, apparent benefit has resulted to those defectives attending, and attendance has often given relief to distressed parents. Attendance may sometimes defer the necessity for removal to an institution. The principal defect of the present arrangements is that attendances are far from regular, even among the limited Limitations. number tor whom facilities for attendance can be secured. This is partly due to the difficulty of conducting children who live at a distance. The provision of guides might help, and at the end of March, 1924, the possibility of this was under consideration. Guides. Guardianship. 21. On 31st December, 1923, only eight males and seven females were maintained under guardianship. Of these, five males and one female were in village homes in Sussex, placed through the agency of the Guardianship Society of Brighton. Of the remainder, two males and two females were under the guardianship of parents or near relatives; these were exceptional cases in which it was found that care and control could be provided at the defective's own home, if monetary assistance were given, and where the only alternative, apart from institution care, was poor relief. Cases under guardianship. Provision of care in institutions. (a) Accommodation under contract. 22. Of the cases of mental defect maintained by the Council in institutions during 1923, about one half were accommodated under contract, as detailed below : Institution. Males. Females. Institution. Males. Females Metropolitan Asylums Board Certified Institution 325 232 Cumnor Rise Home, Cumnor, Berks 2 National Institutions for Persons Requiring Care and Control:— Helping Hand Home, Upper Holloway 8 Stoke Park Colony, Bristol 47 74 Pontville, Ormskirk, Lanes. 2 — St. Mary's Home, Alton, Hants — 13 PrincessChristian's FarmColony, Hildenborough 1 8 Crathorne, Finchley — 6 Etloe House, Leyton — 23 Dovecot, Knotty Ash, Liverpool — 2 Pield Heath House, Hillingdon — 3 The Home, Everton Terrace, Liverpool 1 St. Francis' School, Buntingford 9 — Durran Hill House, Carlisle — 1 House of Help, Bath — 2 Bigod's Hall, Dunmow 1 — Prudhoe Hall Colony, Prudhoeon-Tyne 1 St. Joseph's Homo, Sudbury, Suffolk 1 Plumstead Institution (Woolwich Guardians) 8 3 Western Counties Institution, Starcross 3 1 Marloes-road Institution (Kensington Guardians) — 28 Girls' Training Homes, Clapton — 9 Walsham How Home, Walthamstow 19 Total 396 437 Accommodation in institutions under contract 22 Charges made for maintenance. 23. The class of patient received and the charges* made for maintenance were:— Institution. Religion. Class of defective received. Charges. By contract. Supplemental payments Maintenance (a week) Burials. Outfits. Maintenance (a week) Burials. Outfits. Metropolitan Asylums Board Certified Institution—Sections at: No restrictions All grades, both sexes (criminal cases not received) Actual cost, viz.:— Reasonable expenses - - - - Darenth, Kent 27/1½ Caterham, Surrey 27/1½ Leavesden, Herts 27/1½ Fountain, Tooting 32/8 Stoke Park Colony Protestant All grades, both sexes (males, only such as can be dealt with by a female staff) High-grade cases:— 5/3 3/6 — 10/6 £3 — Low grade cases:— 14/— £3 — St. Mary's Home Church of England Females over 16, who might have had illegitimate children 14/- - £5 3/6 - - Crathorne Protestant Mothers (feeble-minded or moral imbeciles) and their children (no child retained over 7 years of age) 11/6 £5 £3 5/6 - £3 Etloe House Roman Catholic Feeble-minded females from 16 years of age 11/6 £6 £6 5/6 - — Pield Heath House Roman Catholic Females, feeble-minded and moral imbeciles (tractable cases up to age 16) 11/6 £7 - 5/6 - - St. Francis' School Roman Catholic Educable males 11/6 £7 — 6/- - — Durran Hill House Roman Catholic Feeble-minded females aged 16 and over) (criminals and fallen women not accepted) 11/6 £5 - 5/- - - Bigod's Hall Roman Catholic Males (imbeciles and feeble-minded) up to age of 16 11/6 £5 - 6/- - - St. Joseph's Home Roman Catholic Feeble-minded females aged 16 to 20 11/6 £6 - 3/- - — Western Counties Institution No restriction High-grade cases, both sexes Actual cost plus 2/6 a head a week as "overhead " charge, viz.:— 20/9 £5 - — - — Girls' Training Homes Clapton Protestant Feeble-minded females (trainable) from 8 years upwards 11/6 £6 £5 3/6 - £2 Walsham How Home, Walthamstow Church of England Females, feeble-minded and moral imbeciles 12/- £3 — 5/6 - — Cumnor Rise Home Church of England Feeble-minded females from 14 years (epileptics and fallen women not taken) 12/- £5 £5 4/- - - Helping Hand Home No restriction Feeble-minded females, preferably from 16 years 11/6 £3 £4 and allowances for upkeep 4/- - £4 and allowances for upkeep *Most of the charges specified in the contracts are on a pre-war basis, and are supplemented by additions paid under the authority of the Minister of Health, as shown in the table. 23 Institution. Religion. Class of defective received. Charges. By contract. Supplemental payments. Maintenance (a week). Burials. Outfits. Maintenance (a week) Burials. Outfits. Pontville Roman Catholic Feeble-minded males, between 5 and 16 years 12/- £5 — 5/6 — — Princess Christian's Farm Colony No restriction High grade cases, both sexes 12/6 £4 £5 3/6 £1 /10/- £2 Dovecot, Knotty Ash No restriction High-grade feeble-minded females, from 16 years £34 a year £4 — £26 a year - - The Home, Everton Terrace, Liverpool Protestant Females, feeble-minded and moral imbeciles, over 16 years 15/- £8 £5 1/6 — - House of Help, Bath Church of England Feeble-minded females 12/6 £5/5/- £3 4/- — £2 Prudhoe Hall Colony No restrictions All grades (including epileptics), both sexes 15/- £4 £5 3/8 £1 £1/10/- Plumstead Institution No restrictions All grades (adults), both sexes (Actual cost) Institution. 18/10 Infirmary 49/2 Not to exceed £6 - - - - Marloes-road Institution No restrictions Females, all grades (Actual cost) Institution, 18/1 Infirmary, 36/10 - - - - - 24. Upon the application of the Council, the Board of Control renewed for five years from 3rd January, 1923, their certificate of approval of the use of the Metropolitan Asylums Board's institution for the reception of cases of mental defect. This, however, does not give London the whole benefit of the accommodation provided, winch is available for the reception of cases at the charge of other local authorities. Accommodation provided by the Metropolitan Asylums Board. 25. The Salvation Army having given notice of their intention to close Springfield Lodge certified institution. Camberwell, S.E., on 31st January, 1923, other arrangements were made for the care of the eleven female patients who were being maintained there at the Council's expense. Springfield Lodge. 26. The Managers of the Helping Hand Home, Cathcart Hill, N., approached the Council for assistance in establishing a hostel ancillary to the home, in which selected cases could be housed who might be sent to daily domestic service in the neighbourhood. The Council agreed to make a grant of £75 in return for the reservation of beds, but owing to unforeseen difficulties in securing suitable premises, the hostel has not yet been established. (b) Accommodation provided by the Council. 27. This has continued to be provided at the South Side Home, Streatham Common, S.W. (80 girls and young women), at Brunswick House, Mistley, Essex, (50 lads) and at the Manor, Epsom, where at 31st December, 1923, 357 males and 351 females were resident. The only patients received in these institutions are those London cases for whom the Council has a duty to provide. A statement of expenditure is given in Appendixes I. and II. Helping Hand House; Hostel. 24 Brunswick House; works-hop hut. The Manor, Epsom. 28. A small hut has been erected at Brunswick House for use for woodwork training, band practice, and similar purposes for which there was not suitable accommodation. 29. The difficulties with regard to staff and as to the unsuitability in some respects of the institution buildings for the criminal and intractable type of patient referred to in the last Annual Report (vol. II. p. 28) have continued to hamper the efficiency of The Manor. In spite of these difficulties, however, marked progress has been made, particularly in the school department and in the workshops. In addition to the industries mentioned in the last Annual Report (vol. II. p. 29) printing, bookbinding, spinning and weaving, have been undertaken by patients. The industries are profitable and they have helped to make the patients happy and contented. Boy scouts and girl guides. 30. The scout and guide patrols have helped very considerably to raise the moral tone of the patients enrolled in them (See Annual Report 1922, vol II. p. 2S). One male patient was presented by the Chief Scout with a gilt cross and a certificate in recognition of his bravery and presence of mind in rescuing a child from danger. The scout and guide movements have proved their value at Brunswick House and the South Side Home, as well as at the Manor. Admissions and discharges. 31. 285 patients (141 males and 144 females) were admitted to the Manor during the year ended 31st December, 1923, and in the course of the year 14 males and two females were discharged from further detention. At 31st December, 1923, two males and three females were absent on leave with a view to discharge, and eleven males and two females were absent without leave, haviner escaped. Resident junior assistant medical officer. 32. Mr. R. P. Stewart, M.B., Ch.B., was appointed junior assistant medical officer (resident) at the Manor, and commenced duty on 19th December, 1923. Contributions towards expenses of maintenance of defectives in institutions or under guardianship. Number of cases under contribution and amounts collected. 33. The following statement shows for the year ended 31st December, 1923. how the Council has discharged the duty of making recovery wherever possible of such contributions as are available in relief of the expenses of maintaining defectives in institutions or under guardianship:— (1) Cases under contribution. (2) Sum collectable. (3) Sum collected. (4) Percentage of (3) to (2). (5) Sum written off. £ s. d. £ s. d. £ s. d. 940 6,248 9 2 5,872 9 4 94% 382 17 1 The sum collected included £19 6s., representing contributions for three cases in State institutions collected on behalf of and paid over to the Board of Control. Legal proceeding to enforce payment. 34. Legal proceedings had to be taken during the year for the recovery of payment from persons liable to contribute, with the following result:- (1) In 13 cases. Orders made to pay amounts totalling— (2) In 14 cases. Adjourned on undertaking to pay being given. (3) In 4 cases. Amounts paid at court before proceedings, totalling— Arrears Costs. Arrears. Arrears. Costs. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. 65 6 6 1 19 0 92 7 0 12 16 6 0 9 0 One case adjourned sine die owing to insufficient evidence of means. Statistics of cases dealt with. Statistics. 35. In the absence of any directions by the Board of Control as to the form in which statistics required by No. 28 of the Mental Deficiency Act Provisional Regulations, 1914, shall be submitted, the Council submits the following tables, 25 which continue for the year ended 31st December, 1923, the information tabulated at the end of the last Annual Report:— Sources from which information has been received of cases of alleged mental defect. Period. From 1.4.1914 During Source of information. to 31.12.1923. 1923 only. (i.) (ii.) London Association for the Care of the Mentally Defective 614 92 Local Education Authority 3,135 267 Poor Law Authority 266 51 Police authority (Section 8) 504 72 Transfers from prisons (Section 9) 135 3 Transfers from Industrial schools (Section 9) 289 39 Miscellaneous 1,209 136 Total number of cases of which information was received 6,152 660 Action taken on above cases. Position at 31st December, 1923, with regard to the 6,152 cases referred to in column (i.) of the preceding table— Detained— In institutions provided by the Council 842 In institutions under contract 833 Under guardianship 15 In places of safety awaiting the presentation of a petition for an order 23 Total number of cases detained 1,713 Under statutory supervision 1,510 Still under consideration 179 Removed from active list— Died 323 Discharged from institutional care 186 Removed to a mental hospital under Lunacy Acts 129 Removed to a State institution (violent or dangerous cases) 31 Dealt with through the Poor Law 508 Ascertained not subject for action 1,573 Total 6,152 Cases dealt with in previous table in which action was taken during 1923. Placed in institutions provided by the Council 249 Placed in institutions under contract 116 Placed under guardianship 3 Placed in places of safety until the presentation of a petition for an order 64 Placed under statutory supervision 380 Discharged from institutional care 31 Removed to a mental hospital 9 Removed to a State institution 12 Dealt with through the Poor Law 46 Ascertained not subject for action 245 Died 43 Financial statement. 36. No. 28 of the Regulations provides also for the submission of financial Financial statements for the year ending 31st March. Such a statement (prepared by the statement. Comptroller of the Council) showing the cost to the Council of the administration of the Mental Deficiency Act, 1913, from 1st April, 1923, until 31st March, 1924, forms Appendix I., and particulars of the Council's expenditure on the maintenance of defectives in its own institutions are given in Appendix II. 26 APPENDIX I. Financial statement showing the cost of administration of the Mental Deficiency Act during the year ending 31st March, 1924. £ s. d. £ s. d. £ s. d. Expenditure— (1) Ascertaining numbers, supervising and dealing with defectives— (a) Salaries, etc., of officers 9,957 14 2 (b) Travelling expenses 228 5 10 (c) Costs and charges in legal proceedings 27 19 6 (d) Temporary detention in places of safety, including expenses of conveyance, removal,etc. 987 11 3 (e) Grants to voluntary societies 2,021 6 7 (f) Other expenses (stationery, furniture, office expenses, etc.) 3,261 0 0 16,483 17 4 (2) Institutional treatment— (a) Accommodation and maintenance 51,132 12 5 (b) Conveyance, removal, etc. 155 13 10 (c) Other expenses 21 4 9 51,309 11 0 (3) Guardianship— (a) Maintenance 614 9 5 (b) Conveyance, removal and other expenses 2 18 0 617 7 5 68,410 15 9 (4) Maintained in institutions provided by the local authority— South Side Home, Streatham (a) 5,554 2 1 Brunswick House, Mistley 3,136 3 3 The Manor, Epsom 70,957 1 9 79,647 7 1 148,058 2 10 Income. Contributions towards maintenance of defectives and costs recoverable 6,040 17 5 Charges to staff in Council's institutions for board and lodging, and miscellaneous income— South Side Home (b) 783 15 3 Brunswick House (b) 505 1 0 The Manor (b) 8,555 15 3 9,844 11 6 Grant from Board of Control (c) 66,393 17 0 82,279 5 11 (a) Including debt charges. (b) Including deductions from pay of staff in respect of pensions. (c) Including gratuities in respect of criminal defectives. 27 APPENDIX II. Return of expenditure (and cost a head) during the financial year ended 31st March, 1924, on maintenance of defectives at institutions provided by the Council. Heading. Cost per patient weekly. Brunswick House. South Side Home. The Manor. Number of patients (average) 49.6 78.4 646.6 s. d. s. d. s. d. Salaries and wages— Medical staff 10.9 5.5 1 3.0 Other institution staff 9 6.2 10 8.4 15 0.7 Works and engineering staff — — 1 3.0 Superannuation, insurance and travelling expenses of staff .7 2.7 2.1 10 5.8 11 4.6 17 8.8 Less income from staff for board, lodging, etc. 2 0.4 3 5.7 4 0.1 Net cost of staff 8 5.4 7 10.9 13 8.7 Provisions (including net cost of produce from farm, if any) 4 10.6 6 5.9 6 11.9 Clothing and staff uniforms 1 0.1 1 8.3 2 1.2 Medical requisites and drugs .4 2.1 2.7 Fuel, light and water 10.8 2 1.1 3 8.5 Washing and cleaning materials, etc. 2 2.4 7.6 7.2 Furniture and bedding 1.9 5.3 2 0.8 Removals, burials, etc. 1.0 .2 1.2 Rates, taxes, and insurance 3.2 8.3 1 4.6 Stationery, postage and sundries 1 0.9 2.9 3.9 Miscellaneous 11.2 4.0 1.9 Rent of land and buildings 9.5 — 5 2.6 Debt charges—interest and redemption - 10.4 — Repairs and upkeep of buildings, etc. 4.2 1 4.9 5.4 Additional equipment and special expenditure 9.6 5.2 4.6 21 11.2 23 5.1 37 5.2 Less miscellaneous income (other than for maintenance of patients) 1 7.6 1.7 6.3 Total cost per patient weekly 20 3.6 23 3.4 36 10.9 Brunswick House. South SideHome. The Manor. Totals. Actual figures used in preparing above table— £ s. d. £ s. d. £ s. d. £ s. d. Gross expenditure (a) 3,106 18 9 5,510 15 10 70,062 3 4 78,679 17 11 less income other than contributions towards maintenance of patients (a) 475 16 6 740 9 - 7,660 16 10 8,877 2 4 Net expenditure at institutions 2,631 2 3 4,770 6 10 62,401 6 6 69,802 15 7 (a) The figures are less than those shown in Appendix I., as to meet the requirements of the Board of Control only the net financial result of the farming operations is included for cost purposesand superannuation contributions are deducted from wages. The net expenditure is the same in both tables. PRINTED BY ODIIAMS PRESS, LTD., LONG ACRE, W.C. 2. p 19 LCC 32 London County Council. ANNUAL REPORT OF THE COUNCIL, 1923. Vol. III. PUBLIC HEALTH. (Including the Report for the year 1923 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing.) 725—(O 13992)—76A)—16.9.24)—10976 CONTENTS. Chapter XXIII. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH FOR THE YEAR 1923. Page Introductory Note 5 A.—Vital Statistics. Population—Marriages—Births—Deaths—Infant-Mortality 7 London Life Tables Infectious Diseases— Smallpox 14 Measles—Whooping-Cough—Scarlet F ever—Diphtheria— Diarrhoea and Enteritis 17 Tuberculosis 17 Influenza 21 Cerebro-spinal Fever—Poliomyelitis, Polioencephalitis, and Encephalitis lethargica 30 Plague and Cholera—Anthrax—Typhus 30 Typhoid Fever 31 Cancer 37 Skin Disease due to Wearing Furs 39 Bacteriological Work 40 B .—Administration. Offensive Trades—Lodging Houses—Homeless Persons 42 Venereal Diseases 42 Transmigrants 44 Housing 44 Sanitary Officers 46 Dresser of Fur Skins—Poultry Slaughtering 46 Tuberculosis Mental Deficiency Act, 1913 51 Blind Persons Act 52 Midwives and Lying-in Homes 52 Children Act, 1908 54 Laboratory Work 55 Statistical Tables.—I. Vital Statistics—II. Administrative Work—III. Tuberculosis Dispensaries. Chapter XXIV. REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1923. Page Introductory Note—Medical Inspection and Treatment—Personal Hygiene —Infectious Diseases 60 Results of Medical Inspection 62 Special Enquiries (Minor Ailments) 68 Following-up and Re-inspections 69 Medical Treatment 70 4 Page Treatment of Stammerers 72 School Nursing Staff 73 Nursery Schools 74 Open-Air Education 75 Tuberculosis 81 Children Absent on Account of Ill-health 82 Employment of School Children 84 Physical Exercises 85 Co-operation with Child Welfare Centres 86 Feeding of School Children 86 Personal Hygiene 88 Infectious Diseases 89 Mortality among Children under 15 Years of Age 95 Examination of Candidates 101 Defective Children 102 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 of Inspections 108 Chapter XXV. Public Health—Tuberculosis—Venereal disease—Infant life protection— Lying-in homes—Midwives—Houses let in lodgings—Homeless persons— Lodging houses—Offensive businesses—Milk—Infectious diseases—Appeal Committee—Health administration in London—Diseases of animals 113 Chapter XXVI. Main Drainage 123 Chapter XXVII. Housing 131 Chapter XXVIII. Housing Accounts and Statistics.—Memorandum by the Comptroller of the Council (Mr. C. D. Johnson)—Memorandum by the Valuer (Mr. Frank Hunt, F.S.I.) 140 London County Council. ANNUAL REPORT OF THE COUNCIL, 1923. CHAPTER XXIII. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Sir WILLIAM HAMER) FOR THE YEAR 1923. Part I.—General. Introductory Note. The year 1923 was remarkable for having the lowest death-rate (11.4) ever recorded in London. The infant mortality rate was even more exceptional, as it was only 61 per 1,000 births, a considerable fall from the rate of the preceding year, viz., 75, which was itself a record rate. The comparatively low mortality from influenza, bronchitis and pneumonia, the low rate from measles and the improvement as regards the rates from scarlet fever and diphtheria upon those of 1922, account in large measure for the very low general death-rate of 1923. It may be noted, however, that diarrhoea and enteritis, and cancer, were registered as causes of death in rather larger numbers than in 1922. There was, throughout 1923, great risk of spread of smallpox to London. The number of cases notified in England and Wales had not reached 150 annually during the war years ; in 1919 and again in 1920 it exceeded 200; in 1921 the number was over 300 ; in 1922 it was 967, and in 1923 it was 2,461. Fortunately the mischief caused by the disease in London was kept within very narrow limits (see p. 14). Curiously enough the smallpox introduced into London came not from the Midlands or from other counties, where prevalence of smallpox was more or less established, but from Spain. Another risk which fortunately did not materialise during 1923 was that of spread of epidemic diseases from eastern Europe. Between 1918 and 1922 twelve million cases of typhus and recurrent fever are reported to have occurred in Russia. During the first eleven months of 1923, 221,966 cases of typhus and 230,611 cases of relapsing fever were reported. Cholera was at its highest point in recent years in Russia during 1922. Smallpox in Russia had reached a total of 152,000 cases in 1920, but underwent considerable decline in 1921 and 1922 ; in northern Russia in 1923 there was a rise, but in the Ukraine a fall. Malaria is said to be causing great mortality in Russia at the present time. In the Ukraine alone nearly half a million cases were reported during the first ten months of 1923. The notifications of scarlet fever and diphtheria in London showed noteworthy decline during the year. Typhoid fever fortunately remains at a remarkably low level, moreover, rather more than half the cases notified and subsequently removed to hospitals of the Metropolitan Asylums Board were ultimately found not to be examples of that disease ; some further observations on the very remarkable decline of this disease appear on p. 31. Influenza was beginning to prevail rather extensively throughout western Europe at the close of 1923 and in January and February of 1924. Cases of encephalitis lethargica increased in frequency early in 1924. Poliomyelitis also showed some increase but cerebrospinal fever remained at a low ebb in this country and elsewhere. Further progress was made under the county scheme and under the London and Home Counties' scheme as regards the treatment of tuberculosis and venereal diseases respectively. The annual enumeration of homeless persons made in the early hours of the morning of February, 1923, showed a total of 141 as compared with 112 in 1922. In 1924 the number showed a reduction, despite the amount of unemployment which continued to exist throughout 1923, to a total of 82. 6 7 Considerable advance was made in the provision of new housing accommodation; and careful consideration was given during the year to the code of by-laws regulating health conditions, in houses occupied by more than one family, the drafting of which under the Housing Acts of 1919 and 1923 rests with the Council. Some 20 years ago considerable difficulty was experienced in London in the housing of transmigrants passing through England on their way to lands abroad. In 1919, at the cessation of the war, the unsatisfactory features of this traffic were repeated in an acute form. Steps were taken to minimise the evil until the shipping companies were able to make arrangements in other directions; passengers of this class are not now being brought to London in appreciable numbers. A.—Vital Statistics. The population of London County at the census of 20th June, 1921, was 4,484,523, including members of the armed forces in London but excluding Londoners on active service elsewhere. It is estimated by the Registrar-General that the population with residence in London as at the date of the census was about 4,524,000, allowance being made for persons absent on holiday when the census was taken. The Registrar-General estimates the civil population in the middle of 1923 to have been 4,564,109, and non-civilian 6,000. The births in the period from the middle of 1921 to the middle of 1923 exceeded the deaths by 80,041, and on the basis of the Registrar-General's estimate the balance of movement of population in the two years has resulted in the loss of about 35,000 persons. The estimated mid-year civil populations of the metropolitan boroughs in 1923 are shown in the table on p. 57. Population. The marriages registered in London during 1923 numbered approximately 39,294, or 17.2 per thousand of population, the corresponding figures for last year being 41,611 and 18.4, respectively. From figures recently published it appears that the decrease in the number of marriages in 1922 as compared with 1921 was greatest among women under 21 years of age, being at that age about 10 per cent. The age-distribution of the 1923 marriages is not yet available. The course of the marriage-rate in London since 1840 is shown in the diagram on p. 6. Marriages. The births in London during 1923 numbered 91,662, this being 6,870 less than last year. The birth-rate was 20.1 per thousand of population as compared with 20.9 in 1922 and 22.1 in 1921. The birth-rates for each metropolitan borough and for London as a whole will be found in the table on p. 57 ; and the movement in the London birth-rate since 1840 is shown in the diagram on p. 6. Births. The downward movement of the birth-rate, dating back to the early eighties, is maintained. The decline in the birth-rate and fertility rate in London boroughs in relation to the reduction in infant mortality between the three-year periods 1911-13 and 1921-23 is shown in the appended table. Metropolitan Borough. Birth-rate per 1,000 living. Legitimate births per 100 married women aged 15-45. Infant mortality (Deaths per 1,000 births). 1911-13. 1921-23 Decrease per cent. 1911-13 1921-23. Decrease per cent. 1911-13 1921-23 Decrease per cent. Paddington 21.3 18.9 11.1 17.6 14.3 18.7 109 76 29.8 Kensington 19.2 18.1 5.7 18.0 15.4 14.1 112 87 22.3 Hammersmith 24.0 20.6 14.2 18.5 15.7 15.1 114 74 35.1 Fulham 27.0 20.7 23.4 19.3 15.0 22.3 105 72 31.2 Chelsea 19.1 16.6 13.1 17.2 15.0 12.6 91 67 25.7 Westminster, City of 14.6 13.1 10.7 13.4 11.3 15.7 95 61 35.9 St. Marylebone 19.6 16.2 17.4 16.4 13.2 19.7 97 70 28.4 Hampstead 15.0 14.8 1.1 14.2 12.7 10.1 72 55 24.4 St. Pancras 25.3 21.5 15.2 19.3 16.2 15.9 98 71 27.6 Islington 25.1 22.5 10.5 19.5 17.1 12.5 107 75 30.4 Stoke Newington 21.1 18.8 10.9 17.8 14.9 16.3 85 56 33.7 Hackney 23.8 21.0 12.0 19.8 16.6 15.9 100 66 34.6 Holborn 18.3 14.8 19.2 14.6 12.0 17.6 101 76 25.3 Finsbury 30.1 25.1 16.8 23.6 20.8 11.8 137 78 43.3 8 Metropolitan Borough. Birth-rate per 1,000 living. Legitimate births per 100 married women aged 15—45. Infant mortality (Deaths per 1,000 births). 1911-13. 1921-23. Decrease per cent. 1911-13. 1921-23. Decrease per cent. 1911-13 1921-23 Decrease per cent. London, City of 10.3 9.6 7.1 10.3 9.3 10.3 95 83 13.3 Shoreditch 32.0 28.1 12.2 25.7 22.8 11.4 150 98 34.7 Bethnal Green 31.0 25.0 19.3 25.0 20.5 18.0 122 87 29.2 Stepney 30.5 24.0 21.4 24.5 20.2 17.7 121 78 35.8 Poplar 31.5 26.6 15.5 25.5 21.8 14.6 126 74 41.5 Southwark 30.1 25.3 15.9 22.9 19.6 14.6 122 79 35.1 Bermondsey 31.0 26.5 14.6 25.0 21.8 12.9 134 89 33.7 Lambeth 24.0 21.0 12.4 18.4 15.8 13.9 104 70 32.6 Battersea 25.5 21.4 16.2 19.3 16.4 15.0 107 64 40.5 Wandsworth 21.0 17.2 18.3 16.8 13.6 18.7 96 60 37.2 Camberwell 24.8 21.9 11.6 20.1 17.2 14.1 100 69 30.4 Deptford 27.4 22.6 17.3 20.9 17.1 7.9 117 73 37.1 Greenwich 25.3 21.6 14.6 20.9 17.3 17.3 102 65 36.8 Lewisham 20.7 18.9 8.9 16.6 14.7 11.5 84 52 38.1 Woolwich 23.0 21.2 8.0 17.6 15.7 11.2 84 56 33.3 London County 24.6 21.1 14.5 19.8 16.7 15.8 109 72 33.9 The rates for the period 1921-23 are based, so far as the last year is concerned, upon provisional figures, but the final figures since available do not cause any significant alteration in the rates and percentages given in the table. If the boroughs be grouped according to social condition as shown by the proportion of children of school age scheduled for attendance at elementary schools it is found that the decline in the birth-rate and infant mortality is greatest in those boroughs in which the proportion of children scheduled is highest, thus: Group. Decrease in Birth-rate, per cent. Decrease in Fertility, per cent. Decrease in Infant Mortality, per cent I. 9.8 14.1 23.3 II. 13.3 15.5 30.6 III. 16.5 14.4 36.2 Deaths. The birth-rate and infant mortality rate have been shown in earlier reports to vary very closely with social condition, but the decrease in fertility in the third group is relatively small, and suggests that in this case other considerations must be taken into account. Deaths in the civil population of London during 1923 numbered 51,991, the death-rate being 11.4 per thousand. This is the lowest death-rate ever recorded in London, the previous lowest being 12.5 in 1921. In 1922 the death-rate was 13.5. The distribution of deaths by ages during 1923 is shown in the following table, with corresponding figures for post-war years:— Year. 0— 1— 2— 5— 10— 15— 20— 25— 35— 45— 55— 65 + All ages. 1911-14 11,968 3,546 2,716 1,421 846 1,088 1,299 3,525 5,292 7,142 8,328 18,221 65,392 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 1922 7,089 3,235 2,568 1,240 851 1,126 1,322 2,860 4,242 6,656 8,799 21,233 61,221 1923 5,615 1,373 1,276 860 638 1,016 1,220 2,474 3,737 5,985 8,105 19,692 51,991 On comparing the two years of lowest mortality, 1921 and 1923, it will be seen that the advantage of the latter year is greatest in the first two years of life, this being largely due to the fact that the births in 1920 numbered over 120,000, resulting in a corresponding increase in infant deaths in 1921, while, on the other hand, the deaths in 1923 occurred among survivors of births numbering less than 95,000. The greater number of deaths in the age-group 5 to 15 years in 1921 is accounted for by the epidemic prevalence of scarlet fever and diphtheria in that year. In other periods of life the figures for the two years do not show any noteworthy divergence. 9 The death-rates from all causes for each metropolitan borough and for London as a whole will be found in the table on p. 57 ; and the annual death-rates in London since 1840 in relation to the mean of the rates for the 83 years are shown in the diagram on p. 6. There were 61 deaths per thousand births in 1923 as compared with the previous lowest rate of 75 in 1922 and with 81 in 1921. In the following table the deaths per thousand births from the principal causes of infant mortality are shown for 1923 and preceding periods :— 1911 Cause of Death. to 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1914. Measles 3.40 4.81 1.74 4.92 3.89 0.67 2.02 0.67 3.30 0.96 Whooping-cough 3.63 4.72 3.54 2.51 7.02 0.87 2.89 2.34 3.92 2.23 Influenza 0.27 0.31 0.16 0.27 3.65 1.38 0.46 0.26 1.12 0.20 Tuberculosis 3.40 3.48 2.81 3.88 2.65 1.66 1.52 1.45 1.43 1.21 Bronchitis 6.41 7.60 5.29 6.96 7.02 5.10 5.65 2.89 4.05 2.43 Pneumonia 12.28 16.10 11.69 15.28 16.78 10.25 12.62 11.54 16.00 9.07 Diarrhœa 24.28 20.82 13.89 16.03 13.67 14.75 8.98 18.63 6.26 9.07 Premature birth 18.16 17.60 16.40 17.22 18.47 20.42 15.32 16.17 16.10 14.66 Congenital defects 14.69 15.18 13.86 15.22 14.39 12.70 11.53 11.53 9.30 8.80 All causes 108 112 89 104 108 85 76 81 75 61 Infant mortality. The most noteworthy feature of the infant mortality in 1923 is the low deathrate from diseases of the respiratory system, due to the absence of epidemic influenza and a mild winter. Some increase in deaths from diarrhoea resulted from two short periods of high temperature in the summer. The deaths from premature birth and, more especially, from congenital defects, show remarkable decline. The infant mortality in each metropolitan borough and in London as a whole in 1923 will be found in the table on p. 57 ; and the annual mortality among infanta under one year of age per thousand births in London since 1840 is shown in the diagram facing p. 7. Reference has been made in earlier reports to the remarkable decline in the rate of infant mortality since 1900 in London, and the part which has been played by administrative efforts directed both to the care of the newly born and to the health of expectant and nursing mothers. The influence exerted by elementary education upon this decline has been briefly considered in earlier reports, and is further discussed on p. 60. The effect of restriction of the sale of intoxicants upon infant mortality from overlaying and prematurity has been specially considered by Dr. C. R. Gibson, Medical Officer of North Riding Combined Districts, who in an article in Public Health (May, 1924), suggests that " alcoholic indulgence, or the domestic neglect which it may entail, is one of the leading causes of avoidable infant mortality." He finds in Denmark a correlation of .7 ±.2 between alcohol consumption per head and non-diarrhœal mortality : yet during the war, when the effect of reduced consumption of alcohol is clearly shown in the diminished deaths in adults from alcoholism and cirrhosis in England, there was no corresponding decline in infant mortality. Dr. Gibson makes a point of the fact that during 1915 to 1918 onefourth of the convictions for drunkenness were among women, in place of the usual one-fifth : but some such variation in the sex-ratio of convictions was to be expected at a time when an army of men was being maintained abroad. The decline of infant mortality since 1900 is found not only in London, and England and Wales, but in most European countries. In some—notably those in eastern Europe where specially high infantile mortalities have been recorded—it is a continuation of a decline which commenced many years earlier. On the other hand in the western countries of Europe, with generally much lower rates of infantile mortality, the decrease from 1900 onwards follows a more or less prolonged period of practically unchanged mortality rate. 10 Note on the London Life Tables, with Short Life Tables prepared by Mr. B. E. Spear. London Life Tables. The first extended life-table for London is contained in the Annual Report of the Medical Officer for 1901 (Appendix 1), and relates to the period 1891-1900. The second for the period 1901 to 1910, will be found in the Annual Report for 1912 (vol. III., p. 105). In the ordinary course of things a similar table would have been prepared for the period 1911-1920, but owing to the war the results would not have been comparable with the earlier tables and there are practical difficulties in the construction of the table for this period owing to the absence of necessary data for the war years. Under the circumstances, it was decided to construct short lifetables showing the probability of living through periods of five or ten years of life, and to carry the tables back to the earliest years of death registration, for the purpose of comparison. The latest pre-war table is for the years 1911-1912, while the years taken to represent the post-war experience were 1920 to 1922. The first short life-table constructed for London is contained in the fifth annual report of the Registrar-General and relates to the year 1841. Life-tables based upon only one year's records are not satisfactory owing to the wide range of fluctuation in mortality, especially in the earlier years of last century. The life-table for 1841 gives the expectation of life as 37 years. In the same report life-tables are shown for Liverpool and for Surrey, and in these areas the expectation of life was 26 and 45 years, respectively. Of 100,000 born half would have died in the metropolis before attaining the fortieth year, while in Liverpool half would have died before the tenth year on the basis of the mortality in 1841. There was at that time three years' difference between the expectation of males and females in London, the male expectation being 35 and the female 38 years. For the purpose of comparison it may be mentioned that Halley's life-table, based upon the mortality of Breslau in Silesia, in the years 1687 to 1691, gave an expectation of 33.5 years ; while the Carlisle life-table for England nearly a century later gave a figure of 38.7 years. In a supplement to the 75th annual report of the Registrar-General short lifetables are given for the counties and principal county boroughs of England and Wales based on the mortality in the years 1911 and 1912. The method of calculation used in constructing the tables was devised by Dr. E. C. Snow and is fully described in the report referred to. This method has been adopted for calculating the series of short life-tables for London for successive periods between 1840 and 1922. In the case of the earlier periods it was not possible to adopt Dr. Snow's method entirely, but he has been followed as far as practicable in order to retain comparativity with other tables constructed by his method. One difficulty met with is worthy of mention, namely, that until 1875 the registration of births was not compulsory, and thus an unknown but perhaps relatively small number of births was not recorded. In order to avoid error from this source the probability of living during the first five years of life was derived direct from the mortality at ages 0 to 5 on the basis of the relationship found to exist during decennia subsequent to the introduction of compulsory registration. It was further found that the probability of living during successive five-year periods between the ages 10 and 25 was more accurately obtained from the mortality rates of the five-year age-groups than from Dr. Snow's tables. For the age-group 5 to 10 in the earlier decennia the figures of the English life-table No. 3 (1838 to 1854) contained in the 28th annual report of the Registrar-General (p. lxxiv.) were taken as the basis for the necessary formulae. The mortality-rates at ages and by sexes which have been used for the construction of the nine life-tables for London are shown in the subjoined table:— 11 Males. Period. Age-group. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 + 1841-50 88.0 11.4 5.0 6.8 8.9 11.0 17.7 26.8 47.0 92.0 187.5 330.6 1851-60 83.1 9.7 4.5 6.2 8.3 10.5 16.3 24.7 42.4 85.2 171.9 314.4 1861-70 86.9 9.4 4.2 5.8 8.2 10.9 17.1 25.7 43.8 82.8 169.0 321.4 1871-80 77.9 7.4 3.6 5.0 6.9 10.1 16.6 25.4 43.2 80.1 163.1 304.3 1881-90 73.1 5.9 2.9 4.0 5.4 8.6 15.0 23.9 41.3 78.0 155.9 297.6 1891-00 72.0 5.0 2.5 3.5 4.6 7.4 14.2 23.1 40.7 77.8 154.1 284.1 1901-10 53.5 3.5 2.0 2.9 3.8 5.7 10.9 19.1 34.4 67.6 138.2 285.5 1911-12 44.1 3.4 2.1 2.8 3.5 5.2 10.0 18.3 34.6 67.7 142.8 264.3 1920-22 36.1 3.4 2.0 3.0 3.7 4.4 7.8 14.5 28.8 61.7 137.8 273.3 Females. Period. Age-group. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75- 85 + 1841-50 77.0 10.8 4.9 5.8 6.9 9.7 14.1 20.5 37.7 77.2 166.2 312.8 1851-60 72.9 9.2 4.1 5.4 6.5 8.7 12.8 18.1 33.3 69.6 149.6 288.9 1861-70 76.3 8.8 4.1 5.1 6.2 8.8 12.8 18.5 33.4 67.2 146.5 291.4 1871-80 67.7 6.7 3.4 4.4 5.5 8.0 12.3 18.1 32.9 66.6 141.0 292.7 1881-90 63.3 5.8 2.9 3.6 4.4 6.8 11.4 17.2 30.8 63.4 134.3 264.8 1891-00 62.0 5.2 2.5 2.9 3.5 5.6 10.7 17.1 31.0 63.4 134.6 265.8 1901-10 45.7 3.5 2.0 2.4 2.8 4.2 8.0 13.7 25.5 53.6 117.6 254.9 1911-12 37.6 3.1 2.0 2.4 2.6 3.7 7.1 12.8 23.9 50.6 115.5 242.2 1922-20 29.8 3.3 2.0 2.7 2.9 3.6 5.3 9.6 19.6 45.4 111.4 234.8 There was not much change in the death-rates in the first three decennia, but in 187180 and later periods the mortality has continuously declined, the decrease being greater generally speaking at the younger ages. Taking the rates for the three years 1920-22 as 100, for each age-group and sex, the rates in the ten-year period 18-11-50 were as follows :— Period. 0- 5- 10- 15- 20- 25- 35- 45- 55- 65— 75- 85 + Males. 1920-22 100 100 100 100 100 100 100 100 100 100 100 100 1841-50 244 333 245 225 239 248 226 185 163 149 136 121 Females. 1920-22 100 100 100 100 100 100 100 100 100 100 100 100 1841-50 258 330 238 218 234 265 264 214 193 170 149 133 The decrease in mortality is specially marked at school ages, a fact which is discussed on p. 60. The London of 1841 was more limited in area than in these days, but the density of population was in some parts greater. The contrast in mortality shown in the table is determined not so much by the degree of urbanisation as the extent to which the conditions of urban life have become in course of time subjected to scientific administration. London has an everchanging population and of the number of persons enumerated at ages 45-55 in 1911, 46 per cent. were not born in London, while a calculation from the life-tables shows that only about one-half of the Londoners by birth who on the London experience had survived to the age 45-55, were in 1911 still living in the county. Dr. Greenwood, in a paper read before the Statistical Society in May, 1924, noted that the male death-rates at higher ages in England and Wales compared unfavourably with those of Sweden. He says:—" In 1901-10 an Englishman of 45 living in England had a third greater chance of dying within a year than had a Swede living in Sweden." One of the factors concerned in producing this result is migration. The extent of inflow of males at higher ages from the country into London was considered in the Annual Report for 1920, p. 14, and its prejudicial 12 13 influence on the London death.rates was commented upon. An influx of perhaps greater extent from abroad into this country obtains in the case of males at these higher ages. Civil servants, soldiers, engineers, etc., come home from India, the Colonies, and other parts of the world. The attraction of the hospitals, etc., for those who are the subjects of chronic illness throws a burden more especially unon the large towns and particularly upon London. The expectation of life characterising each of the nine periods for which life. tables were constructed is shown in the following table :— Perioi. Expectation of life (years). Males. Females. 1841.50 34.6 38.3 1851.60 36.4 40.4 1861.70 35.7 39.9 1871.80 380 42.4 1881.90 40.1 44 v 1891.00 41.2 45.4 1901.10 47.2 51.9 1911.12 49.5 54.5 1920.22 53.8 59'1 In the course of 80 years, therefore, the Londoners lifetime has been extended by more than 20 years, males by 19.2 years and femels by 20.8. The death.rate (and birth.rate) in the life.tabie population of London for the various periods is shown in the following table :— Period. Death.rate (and birth.rate) in Life table population. Males. Females. 1841.50 28.9 26.1 1851.60 27.5 24.8 1861.70 280 250 1871.80 26.3 23.6 1881.90 24.9 22.5 1891.00 24.3 220 1901.10 21.2 19.3 1911.12 20.2 18.4 1920.22 18.6 16.9 It will be seen that the true death.rate of the London population has decreased jy 10.3 per 1,000 living among males, i.e., 35"6 per cent., and among females by 9.2 or 35.2 per cent., between 1841.50 and 1920.22. Some of the principal changes which have taken place in the conditions of life in London as shown by the life.tables are illustrated in the diagram on page 12. In the diagram on p. 12 the expectation of life is shown for both sexes in Section 1. The birth.rate and death.rate of the life.table population is the same, since the population is one which, experiencing the death.rate of a given period, is maintained by births equal to the number of deaths. Section 2 of the diagram shows the death. rate (and birth.rate) of the life.table population. In Section 3 of the diagram the fertility.rate, that is, the number of legitimate children born per 100 married women of ages 15 to 45 years, is shown. It will be noted that the fertility decreased fairly regularly throughout, though the fall is accentuated somewhat in the past Wenty years. In part, this decrease is accounted for by the fact that the married women of 1841.50 were younger than those of 1920.22 ; this is not, however, the main factor in the decline, as it is found that of the total decrease in fertility between 1841.50 and 1921, amounting to 29.7 per cent., only about 3.2 per cent, is due to changes in the age constitution of the married women of child.bearing age. In Section 4 is shown the relationship between the population, which would on the basis of the life.table be maintained by the annual births in successive decennia, 10976 b ] 4 compared with the census population in the same period. The difference between the two columns is largely dependent upon the growth of population by immigration. With regard to the figures represented by the last column (relating to the years 1920.22), it should be noted that 1920 was a year in which the number of births was greatly in excess following upon the return to civil life of those on war service ; on the basis of the average for the two years 1921 and 1922, the excess of the actual population would be considerably less, and is indicated in the diagram by an arrowhead shown in the column for the period 1920.22. In Section 5, the relationship between the sexes in the life.table population is compared with that given by the census for successive periods. The excess of females in the actual population is greater throughout, and this is due to the attraction to London of young women, principally for domestic service. It is noteworthy that in the life.table population the excess of females was greatest in the sixties, thereafter there has been a continuous decline not impossibly connected with the increased employment of women in business. The large excess of females in the census population in 1921 is, of course, the result of the war. In Section 6 of the diagram, the death.rate and birth.rate calculated on the enumerated population are contrasted with the life.table figures; the life.tables give the true death.rate of the population, that based on the census population and registered deaths being distorted by changes in the birth.rate, in the course of time, and by the effects of migration. The average death.rate for London in 1920.22 was, on the basis of estimated population and deaths recorded, 12.9 per thousand. If this were the true death.rate Londoners would have an expectation of life equal to 1000/12.9 or 78 years. Actually the expectation, as appears from the life.table for 1920.22 was about 56 years. Smallpox. The year 1923 marks another successful period in dealing with the prevention of smallpox in London, only 11 cases with one death having occurred during the year. There is probably no branch of public health administration which has achieved better results in the prevention of disease during the past 20 years than that which deals with the control of smallpox in London, as the following table which compares the recent figures with those of earlier years will demonstrate :— Quinquennia. Deaths from smallpox. Admissions to M.A.B. hospitals (first hospital opened 1.12.70). Uases of smallpox (i) in London and (ii) in England and Wales. England and Wales. London. London. England and Wales. 1871.75 47,320 9,914 16,455 — — 1876.80 9,226 5,625 16,818 — — 1881.85 10,443 5,486 23,457 — — 1886.90 1,846 42 244 — — 1881.95 2,980 367 4,822 — — 1896.1900 1,078 33 349 — — 1901.05 4,263 1,591 10,516 — — 1906.10 83 2 50 — — 1911.15 59 13 88 86 691 1916.20 77 10 121 80 782 1921 5 0 2 2 336 1922 27 20 72 65* 973 1923 7 1 13 11 2,493 1st quarter of 1924 ? 0 0 0 1,003 •The majority of these occurred in an institution and were infected before the true character of the disease had been revealed. This table shows that, in spite of the fact that smallpox has been steadily gaining ground since 1920 in the rest of the country, London has enjoyed comparative freedom from its ravages, and when the fact of London's special vulnerability is taken into account, the results shown are the more remarkable. The success must be attributed to the close co.operation on the part of the Ministry of Health, the Council, 15 the Metropolitan Asylums Board, the City Corporation, the Port of London Authority, metropolitan borough councils, boards of guardians and sanitary authorities generally in the greater London area. The menace of smallpox is officially realised to the fullest extent, and so far administrative action has been succesrful in stamping out infection before it can obtain a foothold. The medical practitioners appreciate the importance of the subject and are kept aware, as far as possible, of the facilities which exist for securing a consultation in the diagnosis of suspected cases. " To be forewarned is to be forearmed," and this truth has no greater significance than in its application to the control of smallpox. The foregoing observations are well illustrated in the following description of a limited outbreak of smallpox in and around London which commenced in August, 1923. A lady who had just come from Spain fell ill with smallpox in a London hotel, became convalescent, and went about shopping before the true nature of her disease was recognised ; 24 days elapsed between the time when she became infectious and the time when her case was recognised and preventive measures could be initiated. Infection from her attack (which was of the malign type) thus had a long start and in point of fact planted 14 separate foci, 8 in London and 6 in neighbouring out.county districts. The fact that secondary cases arose in only two of these districts is eloquent of the suppressive measures adopted, and reflects credit on all the districts concerned. As a result this outbreak was brought completely to an end in just over two weeks from date when the first case became known. Details are as follows. Attention was first directed to the appearance of smallpox in London on 7th September, 1923, when the medical officer of health of a south London metropolitan borough discovered a case of smallpox. This patient, a girl, was employed as a chambermaid at an hotel in central London, and although more or less delirious when examined, she was able to furnish sufficient information to provide the clue as to the source of infection. During the course of her duties at the hotel she had waited upon a visitor from Spain (a woman, referred to in this report as X), who was ill in bed during the period 13th to 19th August with what was thought, without medical advice, to be influenza with spots, or the result of fish poisoning. It was ascertained that X left the hotel on 19th August, and steps were immediately taken to trace her movements and destination. Later, on 7th September, attention was drawn to two further suspicious cases which were found to be smallpox. In one case the patient had been to Wales on business, but the period elapsing between the date of his return to London and that of the onset of his illness negatived the suggestion that infection might have been contracted during his visit to Wales. The other patient was employed in the vicinity of the hotel where X had stayed. On the following day two additional cases of smallpox were diagnosed in London. One of these patients was employed at the hotel in central London where X had stayed. The other patient had travelled, about a fortnight prior to her illness, to Oxfordshire, where, as far as records showed, no case of smallpox had occurred. On 10th September it was ascertained that X had gone to an address in an out.county suburb. The local medical officer of health, on visiting at that address, discovered an adult, a relative of X, suffering from a severe attack of smallpox, and ascertained that X was out shopping in the west end of London. On her return she was found to be recovering from a mild attack of smallpox. On the same day (10th September) another case of smallpox was discovered in London. The patient was a relative of X and had been in contact with her. Thus between 7th and 10th September, in widely separated districts, 8 cases of smallpox had been discovered, of which 6 were presumably associated directly or indirectly with a common source of infection, namely, X, whose movements from the time of leaving Spain to the time of admission to hospital afford a striking example of the risk of smallpox being introduced into this country from abroad. 10976 B 2 16 X left Valencia for England on 4th August. Smallpox had been more or less pre.' valent in Valencia, and apparently X had been infected about three days before she left Valencia. Arriving at Dover on 7th August she came direct to London, proceeding to an hotel in the vicinity of the railway terminus, where she stayed for two nights. She left this hotel on 9th August for the hotel in central London already referred to. She visited Brighton on 11th August and returned to her London hotel on 13th August, when, as stated above, she kept to her bed until 19th August. She is said to have remained in her own room at the hotel during this period, in which she infected two hotel employees mentioned above. She left the hotel on 19th August for the address at which she was found in the out. county suburb, and was seen on her arrival at that address by a local doctor who diagnosed her complaint as chickenpox. For the next few days she is said to have stayed indoors, but during this period, either on her journey from the central London hotel or subsequently, she infected her relative already referred to, and probably, also, 4 other persons. During the later period of her convalescence, before she was removed to hospital on 10th September, she was going about as usual, visiting, shopping, etc. The shops she visited were ascertained as far as possible, and all precautionary measures in the matter of observation and vaccination of known contacts, including the employees at the shops, were taken. After the removal of X to hospital 10 further cases occurred, 5 of which were notified in London and 5 in extra.metropolitan districts. Three of these persons were infected by the case referred to above, in which a visit to Oxfordshire had been made a fortnight before illness developed. Four other cases were infected or presumed to have been infected, by one of the earliest cases, viz., that of the patient employed in the vicinity of the hotel in which X had stayed. Of the remaining three cases, one was a man, employed by a laundry firm in washing soiled linen from the hotel where X had stayed, and the other two were adults who had occupied at different times the room at the hotel in London occupied a few days previously by X. The medical officers of health of the various metropolitan boroughs and certain contiguous areas around London had the assistance of the Council's experts in diagnosis, Dr. W. McConnel Wanklyn and Dr. J. A. H. Brincker, and took prompt measures to arrest spread of the disease, including the vaccination and observation of contacts. Vaccinations and re.vaccinations by public vaccinators of school children in the schools directly or indirectly connected with the outbreak were also carried out through the medium of the Council's divisional medical officers acting in co.operation with the boards of guardians. Only one child of school age (an unvaccinated boy of 12 years) contracted the disease. Of the 18 cases which occurred, 12 patients whose ages ranged between 23 and 79 years had not been vaccinated since infancy, and of these one died; 5 between the ages of 12 and 50 years were unvaccinated, and of these one died. One patient had been vaccinated nine years previously, and suffered a very mild attack. No other cases of smallpox occurred in London during 1923. It will be of interest, however, to record the occurrence of a case of smallpox in one of the northern suburbs outside the county area, as another instance of the introduction of the disease into this country from Spain. The patient, an Englishman employed at Tortilla, Spain, arrived in London on 7th December, 1923, having travelled via Paris, Calais, and Dover. The nature of his illness was not decided until 11th December, when Dr. Wanklyn was consulted as to the diagnosis at the request of Dr. Tate, County Medical Officer of Middlesex. It was found that the man was suffering from smallpox, his rash having first appeared, as far as could be ascertained, in Paris, on the 6th. Immediate steps were taken in co.operation with Dr. Tate, to follow up the contacts both in and out of London, and fortunately no developments occurred. The occurrence of this case, however, further emphasised the 17 need for constant vigilance in the detection of smallpox introduced from abroad ; and the fact that the infection was promptly suppressed is another instance of the value of the out.county work to the county itself. Information was received from the Port of London Authority of the arrival of two cases of smallpox in the Port, one in March and the other in July. Both patients were members of the crews of the vessels concerned and were removed to the P.S.A. Hospital, Denton, near Gravesend. Particulars of all contacts were communicated to the authorities concerned for observation. In addition to the above, information was received from various ports around the coast, during the course of the year, concerning contacts of cases of smallpox occurring on board vessels arriving in this country and these were followed up. Infectious Diseases The attack.rates and death.rates in London and the constituent boroughs are shown in the table on p. 57. Measles caused 386 deaths in London during 1923, the death.rate being .08 per Measles, thousand as compared with .34 in 1922 and .05 in 1921. Owing to the abnormal birth.rate in 1920 the number of children entering upon the principal age of measles attack was much above the average in 1923. Towards the end of the year it became apparent that a considerable prevalence was at hand, and in the first quarter of 1924 the deaths numbered 907, this being in excess of any total for the winter quarter since 1915. A diagram showing the periods of excessive measles mortality in London and the metropolitan boroughs since 1910 will be found on page 98. There were 432 deaths from whooping.cough in London during 1923, the death. Whooping. rate being 09 per thousand as compared with 25 in 1922. The question of the cough, influence of climatic conditions on the prevalence of whooping.cough is discussed later (see p. 99), where a diagram will be found showing the periods of excessive whooping.cough mortality in London and the metropolitan boroughs since 1910. A further decline in the prevalence in London of scarlet fever occurred in 1923, Scarlet fever, the number of cases notified being 10,047 (52 weeks), as compared with 17,181 in 1922 and 32,703 in 1921. The decline was general throughout London, but a remarkable prevalence of some severity occurred in central Islington during the summer. The area involved was not attacked so severely as the rest of the borough in the preceding summer. The prevalence was maintained throughout the period of the holidays when the schools were closed and school infection cannot, therefore, have played any considerable part in the dissemination of infection. The deaths in 1923 in London numbered 116, the corresponding figure for 1922 being 301. Although on the decline, the diphtheria cases still remain high relatively to Diphtheria, scarlet fever. There were 10,301 cases in 1923 (52 weeks) as against 15,247 in 1922 and 16,293 in 1921. The deaths numbered 616 in 1923 as against 1,145 in 1922. There were 946 deaths among children under two years of age from diarrhoea Diarrhoea and enteritis in London during 1923, this being 10.3 per thousand births. The Enteritis. corresponding rate last year was 7.13, this being the lowest mortality from these causes recorded in London. The deaths from tuberculosis of the respiratory system in London during 1923 Tuberculosis, numbered 4,432, giving a death.rate of .97 per thousand. The corresponding figures for the preceding year were 4,888 and 1.08, respectively. Deaths from other forms of tuberculosis numbered 853, as against 936 in the preceding year. The deaths and death.rates by sexes annually in the past ten years have been as follows :— 18 Deaths.| Approximate death.rates. Year. Males. Femalen. Total. Males. Females. Total. 19l4 3,901 2,430 6,331 1.84 1.01 1.40 1915 4,064 2,651 6,715 1.92 1.11 1.49 1916 3,837 2,527 6,364 1.88 1.05 1.44 1917 4,040 2,728 6,768 201 1.14 1.53 1918 3,946 2,974 6,920 1.99 1.24 1.58 1919 2,945 2,252 5,197 1.47 0.94 118 1920 2,675 2,000 4,675 1.29 0.82 1 04 1921 2,737 2,076 4,813 1.32 0.85 107 1922 2,841 2,047 4,888 1.35 0.84 1.08 1923 2,586 1,846 4,432 1.23 0.75 0.97 The table shows that during the previous three years the mortality had increased. The decrease in 1923 is considerable, and is, in fact, greater than in any year since 1910, if the abnormal figures of the war period be disregarded. The following table shows the age-distribution of the deaths from phthisis in 1923 in relation to 1922 :— Year. Age-group. Total. 0- 5- 10- 15- 20- 25- 35- | 45- 55- 65- 75 + 1922 56 20 90 413 605 959 975 934 568 223 45 4,888 1923 57 24 77 384 529 932 915 832 459 188 35 4,432 Decrease — Increase + + 1 + 4 -13 -29 -76 -27 -60 -102 -109 -35 -10 -456 The decrease is greatest at the principal ages of influenza mortality and it is, no doubt, to some extent to the absence of any epidemic prevalence of influenza in 1923 that the decline in phthisis mortality must be ascribed. The number of notifications of tuberculosis in London during 1923 (52 weeks) was 12,175 as against 11,548 in 1923. Of these 9,791 were pulmonary and 2,384 other forms of tuberculosis. These figures compare with those published in these reports prior to 1921. Further correction of the figures by the exclusion of cases notified as primary but eventually found to have been previously notified, brings the total number of pulmonary cases down to 7,561 and other cases to 2,221, the corresponding figures for last year being 7,561and2,158 Notification of tubercu-losis, Form of tuberculosis notified. Sex. Notifications on Form B. (Primarynotifications of cases discovered through medical inspection in elementary schools.) Notificationson-FormC. (Secondary notifications from institutions receiving cases.) 0. 5- 10 + Total. Poor Law. Other. Pulmonary tuberculosis M 1 11 9 21 1,162 3,359 F. 11 8 19 807 1,857 Other tuberculosis M 2 19 9 30 126 501 F 1 15 15 31 91 443 All forms of tuberculosis M 3 30 18 51 1,288 3,860 F 1 26 23 50 898 2,300 The following is an analysis of the corrected notifications in London durinj (52 weeks):— Form of tuberculosis notified. Sex. Notifications on Form A. (Total of primary notifications received in London boroughs, other than elementary school cases, injra.) 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total Pulmonary tuberculosis M 5 37 99 101 308 494 946 921 742 386 145 4,18. F 8 39 114 131 388 5/0 890 610 350 190 87 3,33 Other tuberculosis M 39 244 280 173 110 79 74 69 33 29 9 1.13 F 25 171 244 168 100 101 99 47 29 20 14 1,02 All forms of tuberculosis M 44 281 379 274 418 573 1,020 990 775 415 154 5,323 F 33 210 358 299 488 634 989 657 379 210 101 4,358 19 In the Annual Report for 1920 reference was made to a paper by L. I. Dublin Environment and C. W. Baker on Tuberculosis Mortality and Racial Susceptibility. Dr. Dublin tubercu.ty (who is statistician to the Metropolitan Life Insurance Co. of New York) a few months ago delivered an interesting address on the " Causes of the Decline of Tuberculosis." He analysed the evidence forthcoming in support of two distinct ways of looking at the question under consideration, as follows:— "The first emphasises the importance of the environmental factors in the causation of tuberculosis and credits the improvement in the death-rate to those human activities which have centred around the amelioration of the environment of the great body of people. The second emphasises the importance of stock and ascribes the decline to secular changes in the germ plasm of nations and of races, which follow from the full interplay of natural forces rather than from the conscious interference of man with nature. The data are so numerous and often so clear.cut that we should have little or no difficulty in determining which of the hypotheses we have outlined has the better of the argument. "Geographical Variation in the Tuberculosis Death-Rate.—The first fact is the great variation in the amount of fatal tuberculosis in various parts of the United States. Tuberculosis is pre-eminently an urban disease. It is, of course, present in rural sections of the country, but to a lesser degree . . . Here, then, are our first facts. Let us try to square them with the two explanations. The environmentalists approach this phenomenon of extreme variation in the tuberculosis death-rate without hesitation. They are familiar with it and have, in fact, based much of their assurance on it. Those who live in the country—the rural population— they say, might be expected to have a lower rate. They are engaged in more healthful occupations ; they live in less congested places ; they live more normal, happier lives; they enjoy a larger and better supply of food and lead altogether a more wholesome existence. Those who live in cities, on the other hand, are in more congested quarters and, therefore, more subject to infection ; they are often engaged in industries which are more distinctly hazardous to general health ; they are on the whole poorer and less well supplied with good food and fresh air. Life is harder and more hazardous in the cities and there are more chances for the natural resistance of the individual to break down. "The geneticists or the constitutionalists, on the other hand, have not made much of the facts of geographical variation, and it is difficult to summarise the views that they hold in explanation of these facts. Obviously, it would be necessary for them to assume that the differences in the death.rates represent differences in the innate stocks, with various degrees of immunity or resistance to tuberculosis in the several parts of the country. They are compelled to posit a hierarchy of constitutional vigors corresponding to the low rates and the high rates. They must assume that the population in the rural areas is constitutionally better selected than that in the cities ; that the population living in Nebraska, for example, is a fitter population than that living in Delaware or in New York ; that the people living in Akron are innately more vigorous than those living in Providence. It must be clear, I think, that on the score of variation of the death-rate, the environmentalists have very much the better of the argument on the first count. "Sex and Age Variations.—But, of course, geographical variation is only one and the first test. Another fact about the tuberculosis death-rate which is almost universal is the marked difference in the death-rate in the two sexes. Tuberculosis mortality is much higher among males than among females . . . How do the two explanations square with this fact ? The environmentalists would say that the boys and girls in our country are pretty much the same as to exposure and as to resistance. The higher rate for females at the ages of adolescence and early adult life they would explain on the assumption that at this period, developmental changes in the organism involve greater hazards than among males. . . . "On the other hand, those who sponsor the theory of the constitutional factor 20 in tuberculosis causation must explain the changing relationships of the death. rates in the two sexes with advancing age. They must assume a difference by inheritance, or by selection, in favour of males at the younger ages and in favour of females at the older ages. There is no evidence for such differential hereditary endowment among brothers and sisters. I should say, however, that they have at no time, to my knowledge, addressed themselves to this problem or attempted to explain the phenomenon. " Racial Variability in the Tuberculosis Death-Rate.—The third outstanding fact in a description of tuberculosis is the marked difference in the rate of mortality which prevails in the various nativity groups composing the population of the country. In a previous study we found that the death rate was lowest among those born in Russia, who, in these two states are for the most part Jews. This interesting fact has been observed again and again not only in the United States, but in other parts of the world where the mortality of Jews has been carefully studied in comparison with that of their neighbours. Tuberculosis does not appear to be as fatal among them as among other races. The disease when it appears is more often of long duration. The rates are also very low among the Italians. "... It is difficult for anyone confronted with these facts to escape the conclusion that an inherited racial immunity is a factor in the development of tuberculosis . . . "On the other hand, there are certain allied facts to be considered which throw additional light on this interesting phenomenon. The rates among the Jews and the Italians are not everywhere uniformly low, but show considerable variation from place to place, reflecting, in fact, the better and worse conditions among which the Jews and Italians of this country live . . . "Variations in Economic Levels.—Another important fact in our discussion is the difference in the tuberculosis death-rate in the various economic strata of the population . . . How shall this set of facts be explained ? The environmentalists rest their case on the hardships of the life of the poor as we have already intimated ; the constitutionalists on the superior endowments and vigour of the selected or 'fit' groups who make up the well-to-do and richer classes of the community as distinguished from the poor. . . . "Occupation in Relation to Tuberculosis.—The incidence of tuberculosis in various occupations also throws light on the nature of the disease, on how it may be caused, and how it may be controlled . . . "... The theory of the geneticists would demand that those who are engaged in various occupations are selected somehow in accordance with their various grades of resistance and inherited ability to withstand tuberculosis. Some occupations undoubtedly attract weaker individuals. On the other hand, the effect of the industrial environment on the life of the worker is very clear-cut, even if often masked by the influences of economic condition, grade of intelligence, and other elements which affect life. The enormously high tuberculosis death-rate of tin miners and of stone cutters is very clearly the result of the injury done to the lung tissue by the material with which they work . . . " Recent changes in the Tuberculosis Death-Rates.—Finally, we shall consider the changes in the tuberculosis death-rate in recent years. As we have seen, the tuberculosis death-rate in the general population of the United States has fallen 50 per cent, in a twenty-year period .... The decline, moreover, has not been uniform in all the groups of the population, but has favoured males more than females, white lives more than coloured lives, and certain definite age periods more particularly than others . . . Certainly as applied to the United States, there is no evidence that the changes that have occurred in the last decades have come about through any improvement in the racial constitution of the people. The eugenists have not lost an opportunity to say that in their opinion no improvement has occurred, and if anything, there has been deterioration. They have pointed to the decline in the 21 birth-rate of the most favoured classes, to the extensive immigration into the country of large numbers of less favoured people, and to the other items that show that the inherent capacity of the population may not have improved. It would seem, therefore, that if the tuberculosis death.rate has declined in the United States, it has not done so because of the improvement of stock during the period under question, but rather in spite of it. "On the other hand, the facts in both parts of the world are not at all inconsistent with the assumption that we are concerned with changes in the environment of the individuals whom we are considering. . . . From every angle, there is good evidence that the population of America is better off. Never before in the history of the country has so favourable a change come over the environment of the people as in the years subsequent to the great war. "May we not, therefore, conclude that the very nature of the disease as expressed in its differential incidence in the various groups of the population and in its capacity to change, is more consistent with the first than with the second of the two explanations ? " . . . . Dr. Dublin does not omit to record the facts that the high rates in California and Colorado " are due in large measure to the immigration of tuberculous persons to those areas " (p. 8); and, again, that the high rates in Denver and San Antonio " reflect the concentration of migrant tuberculosis within their limits." His remarks too, upon the effect upon the immigrant from the rural parts of Ireland of life in crowded American cities are well deserving of note. In the diagram on p. 22 the deaths in four.weekly periods are shown annually influenza, in and since 1890 from diseases of the circulatory system, pneumonia, bronchitis, and influenza, and also the average temperature. There is a close relationship between the winter temperature and the deaths from diseases of the circulatory system, a sharp peak in the mortality curve being associated with a period of winter temperature below the average; but there are it will be noticed occasions when the peak in the mortality curve is greater than can be accounted for by temperature changes, and the cause of this supplementary peak is seen on reference to the contour of influenza mortality, an increase in the number of deaths certified as due to heart disease being invariably found during epidemics of influenza. The effect of periods of cold weather in the winter is also clearly shown in the curves of mortality from pneumonia and bronchitis, and in both there are again found peaks associated with influenza epidemics, independent of any conspicuous temperature changes. In the case of bronchitis, the mortality is much higher in the earlier years shown than in more recent years, even including the year of the great influenza pandemic—.1918: the reason for this appears to be in part, that in the earlier years there were several winters of exceptional severity, and partly that some change in the practice with regard to certification has occurred during the interval of time separating the two series of influenza pandemics. The behaviour of diseases of the influenzal group during 1923 was watched with close attention. The immediately preceding prevalence of " influenza," that of the early weeks of 1922, caused a maximum mortality (551) in the second week of that year. There followed later a very small recorded increase in the deaths, attaining a maximum figure (56) in the 14th week of 1923. It was not, however, until the autumn of the year that it became strikingly apparent " influenza " was again afoot, and the recent prevalence attained a maximum mortality (178) in the 7th week of 1924. It was a few weeks later followed by an increase in the notifications from encephalitis lethargica, which attained a maximum in the 18th week of 1924. Truly, during the last two years at any rate, influenza in one or more of its phases has been endemic in London. The occasion seems a fitting one for a few words of comment on this phenomenon of the endemicity of influenza. Hirsch, in presenting his "Chronological Survey of Epidemics of Influenza, 22 23 according to records existing from the years 1173.1875," commented upon the gross imperfections of this survey, not only so far as past centuries were concerned, but even for years of comparatively recent date; he laments especially the sparsity of material descriptive of the pandemics of 1857.58 and 1874.75, in this country. Some filling in it is true of the more obvious lacunae existing a few centuries back, has been effected ; for example, by annexing the sweating sicknesses of the 15th century ; and later a good deal has been accomplished by including the great dengue prevalences of the 18th and 19th centuries; for, at any rate, the widespread " dengues," occurring in India, the West Indies and other parts of the tropics, at the very identical times when the temperate regions were affected with " influenzas," must be held to belong, epidemiologically speaking, to one and the same disease category. Dr. Shuman of Los Angeles has recently observed (Jour. Amer. Med. Assoc. 1st March, 1924, p. 737) that " in any modern textbook in which dengue is written up, if the reader supplies influenza for dengue the subject matter will not have to be greatly changed." Between July and October, 1923, a considerable prevalence of "dengue" in Calcutta and, indeed, throughout India, coincided in time of prevalence with a recrudescence in London of influenza. A further step can, perhaps, be taken by accepting such a series as the Picardy sweats as belonging to the influenza family; and this inclusion is an important one, for it brings influenza into place among endemic diseases, freeing it from the fetters of a supposedly necessary pandemicity, with which, at one time, it was shackled. A somewhat similar generalisation was, half apologetically, made by Hirsch, when he referred to the " alleged endemicity of influenza in several countries situated within the cold zone "(vol. I. p. 26); and the doctrine, that the embers of pandemic influenza are kept alive in interpandemic periods by " influenza colds," found some favour in this country when, on the occurrence of the 1890 pandemic, it was attempted, by making use of catarrhal prevalences, to bridge over the gulf between the 1890 pandemic and that of 1847.8. The would.be bridge builders, however, received scant support at that time, for the discovery of Pfeiffer's bacillus had then just been made, and hence all schools of opinion were disposed to ignore such details as the missing arches of the bridge, the ruins of which now stare us in the face in the shape of those very outbreaks, of 1857.58 and 1874.75, to which Hirsch himself had pointedly called attention. A great further advance was made by Creighton, when, following up the teaching of Sydenham and Willis, he linked the influenzas of pandemic type with preceding and succeeding "agues." This suggestion has since been confirmed, enlarged, and in recent years successfully welded with the thesis, to which Parsons refers and for which he gives the credit to Bezly Thorne, viz., that influenza is essentially a disease of the nervous system. In Bezly Thome's own words " Influenza is an infectious and febrile affection of the cerebro.spinal nerve centres." In our own day many epidemiologists have fastened upon this hypothesis as their sheet anchor, and have claimed that Creighton's "agues" must be held to cover poliomyelitis, polioencephalitis and cerebrospinal meningitis, and perhaps the whole domain mapped out in the Heine.Medin generalisation ; if they do not include, indeed, something even more comprehensive than this. It is of interest, by the way, to note that a Heine.Medin outbreak occurred last year in Tubingen. (Medical Science, Oct., 1923 p. 27), " The principal feature," it is stated, " of the epidemic was the influenza.like nature of the initial symptoms." . . . "In abortive cases the diagnosis from influenza was impossible." The problem was necessarily again examined from a fresh angle and in a new light when in 1917 and 1918 "encephalitis lethargica" was newly " discovered." In London cerebrospinal meningitis had been made notifiable as long ago as 1907. In 1912 it was decided by the London County Council that the disease poliomyelitis, which produces paralysis in young children, should also be made a notifiable disease, and Sir Shirley Murphy with, as now appears, remarkable foresight, advised that 24 polioencephalitis should be included with it. In the succeeding years some of the cases notified in London under these three heads were found at times to merge somewhat confusingly into one another, and this same phenomenon was occasionally observed, in rural areas also, by medical inspectors of the Local Government Board. In the Spring of 1918 the " new disease," which it is now the fashion to term "encephalitis lethargica," and which had been given this name, in 1917 on the Continent, by Yon Economo of Vienna, came under notice here. It is becoming recognised, nowadays, that any phase which may be assumed by influenza is apt to be described as a " new disease "—men's memories in any case being short, and their eyes being especially blinded at the present time in the dazzling light of so many recent discoveries. On the advent of " encephalitis lethargica," really an old foe with a new name, as Crookshank has clearly shown by study of the records, it was described as an " obscure disease " by the cautious, and as " sleepy sickness," by the man in the street. Some said it was " botulism," some " solanism," but after these hypotheses had been criticised and abandoned, it was found convenient to adopt Von Economo's designation, " encephalitis lethargica," since there was good reason for holding it to be encephalitis, and lethargy was at the time, at any rate, quite a prominent symptom. As Walker Hall of Sheffield has observed, it was " unfortunate so much prominence should have been given to a single symptom, which may in some instances be entirely absent." The " new epidemic disease " was, however, duly declared notifiable, and there followed in 1920, 1921 and 1922 a decline in the familiar poliomyelitis, polioencephalitis, and cerebrospinal meningitis, a well marked prevalence of encephalitis lethargica becoming officially established in London between 1919 and 1921. In discussing "The influenzal group of diseases," in the annual report for 1921 (p. 15), it was stated that " while epidemiology cannot fail to take account of years in which influenza prevails in pandemic phase, note must also be made of years 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 one pandemic and another, i.e. 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." Reference to the Table on p. 30 will show how the various notifiable diseases, referred to above, comported themselves during the years 1913.23 ; cerebrospinal fever predominating in 1915 ; poliomyelitis relatively high in 1913 and 1916 ; encephalitis lethargica high in 1921 and again at the present time in 1924. When "influenza," so called, began markedly to claim attention in the autumn of 1923, pneumonia and bronchitis deaths also increased. In March, encephalitis lethargica, too, became prevalent. " Drowsiness " had been noted by Franklin Parsons as an occasional symptom of influenza in his report on the outbreak of 1889.90. In the encephalitis of 1921 lethargy had been as already remarked an obviously recognisable symptom; but lethargy has since 1891 shown a tendency in many instances to be replaced by, or to alternate with, insomnia. The designation " sleepy sickness," it must be agreed, is unsuitable for a disease of which a prominent symptom may be sleeplessness. The " new disease " was now fairly in the limelight and its vagaries were carefully scrutinised by many pairs of eyes. Walker Hall, one of the two earliest writers upon it in 1921, and the author of the Lumleian Lectures on the disease, before the Royal College of Physicians in 1923, pointed out (Lancet, 29th March, 1924) certain aberrant features presented in recent cases : the intractable insomnia, the "occupation delirium," attacks of dyspnoea, the "abdominal myoclonus," the weakness of eye movement and consequent disturbance of vision." It is from America, however, the land which at once accords to anything novel 25 and surprising a " supreme calcium moment," that there come the latest illuminating glimpses of encephalitis lethargica. Thus, in the Journal of the American Medical Association of March 1st, 1924, there is the statement: " This peculiar malady seems to change its symptoms from year to year. In 1919 and 1920 the predominating symptoms were drowsiness, ophthalmoplegia, pupillary and bladder changes and headaches. In 1921 they were profound toxaemia, cranial nerve palsies, delirium, headaches and neuralgic pains in the limbs." In 1923, at least in Minnesota, there seemed to be an entirely new set of symptoms. " In one group of cases myoclonic twitches of the face, limbs or trunk predominated, and in another group of cases mental confusion with headaches." Again, (March 22nd, 1924, p. 957), there is an account of " Nephritis in Epidemic Encephalitis," by A. E. Bennett, M.D., Philadelphia. He describes the occurrence of nephritis, not infrequently complicating acute cases of epidemic encephalitis in the Philadelphia General Hospital. He points out that the differential diagnosis from myoclonic uraemia is in some cases exceedingly difficult. " The same bacterial cause of the infection in the central nervous system probably produces the kidney lesions. In seeking etiologic factors in the past medical history of chronic nephritides, it is suggested that inquiry be made for past encephalitic disease the same as we question our patients as to antecedent scarlatinal infection." In the same Journal (Oct., 20. 1923) there is an account by Dr. E. L. Hunt of the recent epidemic in New York. He discusses the relationship of the disease with influenza and the question of contagiousness. Dr. Bassoe, in the discussion on Dr. Hunt's paper, suggested that the virus of encephalitis may he dormant for long intervals in the brain or elsewhere. Surely we may recognise here the protean influenza, now not merely in mufti, but changing from one civilian garb to another under our eyes, and demonstrating unmistakably that the more it changes the more it is the same thing. In reporting upon the influenza of 1918 (Appendix to Ann. Rep. for 1918), it was urged, following Creighton, that the Hippocratic method should be applied in examining diseases of the influenzal group; that account should be " taken of gradations, modifications, affinities, being careless of symmetry, of definitions or clear.cut nosological ideas, or the dividing lines of a classification." It is, in fact, the problem of the " idols of the den "examined by Francis Bacon, and referred to by Sir William Jenner, in the opening sentences of his Gulstonian Lectures on the Acute Specific Diseases, when he asks, "Are we to fasten on the differences of things to the neglect of their agreements," or " to perceive the agreements and pass by unheeded the differences " —" to divide where nature has drawn no fine " or " to generalise where nature has bestowed no unity " ? It would at least seem well in dealing with diseases of the influenzal group to rely upon the clue that : " It is by prominences above the plane of the ordinary that reason feels her way, if at all, in her search for the true, and that the proper question in cases such as this is not so much what has occurred, as what has occurred that has never (or as we in our ignorance may suppose has never) occurred before! " Difficulties such as those under consideration are perhaps not readily susceptible of treatment by ordinary statistical methods. As one of the writers, in the classical report of the Ministry of Health, on the Pandemic of Influenza 1918.19, observes (p. 133): " The laws of the fluctuations in sampling the Influenza bag may be very unlike those of the time honoured and static universe of counters," which provides the statistician with his " simple formula." In the case of Influenza the subject of study is a variable, and yet, as already noted, " plus 5a change plus c'est la meme chose," i.e., the same thing, epidemiologically speaking, though perchance not quite the same thing from a mathematical and statistical point of view. The difficulty may be well illustrated by taking one special " pathognomonic symptom "—e.g., sweating. Compare the epidemic of 1485 with modern Influenzas. The former was styled the " sweating sickness." At a recent discussion on Horse Influenza at the Royal Society of Medicine, the question was asked whether it is a fact that in this 26 disease sweating is not a prominent symptom ? A veterinary authority said sweating was not marked as a rule in any disease in horses. Thereupon it was urged that in human influenza sweating might be due to want of washing, drugs, etc. (This, if true of recent influenza, does not readily admit of being substantiated by an appeal to earlier epidemiological literature.) Anyone who has the curiosity to turn up Franklin Parsons' Table of Symptoms in the 1889.90 epidemic will, oddly enough, not find " sweating " there. But in the later report, published in 1893, p. 61, it is noted that " a peculiar pungent odour was remarked as coming from the sweat of influenza cases." Of course, it may be said, when writers on epidemiology speak of sweat in influenza, they have in mind the peculiar pungent odour of influenza sweats. They are not so much thinking of what has occurred, as of " what has occurred that in their experience never occurred before." The peculiar pungent odour, in fact, is again and again encountered in pandemic prevalences. Then in later epidemics infantile paralysis, ophthalmoplegias, retraction of the head, drowsiness, myalgia, polyneuritis, each in its turn, becomes the " characteristic pathognomonic symptom." These, as the epidemiologist knows, are just the phases of influenza, and it is difficult to see how to analyse them by means of " fourfold tables." They cannot be envisaged at all unless the enquirer carefully looks for them, and he must look for some time, for as Sydenham has said, the brief lifetime of any one physician is barely long enough to enable him to follow the cycles observed in epidemic diseases. The great problem of the influenzal group of diseases is the problem of immunity. In the Ministry of Health report it is sought to supply an answer to the question— Is immunity against influenza produced by a previous attack of the disease ? To this question the fourfold table, though with considerable hesitation, replies in the affirmative. But it must be realised that the verdict cannot really be pronounced until the preliminary question, What is influenza ?, has been settled. As the Ministry's report says, " Many of the particulars have been gathered in 14 selected centres of enquiry by untrained or partly trained observers working often under pressure, while even for the expert clinician or epidemiologist to decide, upon the evidence of an uneducated witness, whether he or a member of his family has had an attack of influenza, is a matter of delicacy. Hence we do not suppose that a high standard of accuracy has been reached." The difficulties are really even more fundamental than this. If it be agreed, as most people are agreed nowadays, that influenza is an endemic disease, it must be realised that the question, whether an attack of pandemic influenza protects against another, is one that concerns the succeeding even more than it does the present generation. The latter must look nearer home and forthwith set about studying the phenomena of immunity in the case of the diseases of the influenzal group. This is no light task, for the study of immunity has hitherto been based mainly upon examination of results obtained by inoculating laboratory animals, and there is danger of ignoring the existence of the forest of naturally acquired immunity, owing to the extent to which the wood is hidden by a tangled upgrowth of details relating to artificially acquired immunity. Naturally acquired immunity, notwithstanding all this, merits careful study. The veterinarians have long recognised the enhanced value of an animal that has been " salted " against disease ; just as hospital authorities concerned with smallpox employ vaccinated staffs, and as in the days when typhus was prevalent, it was recognised that a special value was attachable to the doctor or nurse who had undergone attack by the disease. Epidemics of measles or whooping.cough only develop when there are sufficient numbers of susceptible children to enable them to do so, and the precise periodicity of recurrences of these epidemic diseases in certain communities, is mainly determined by the length of the time interval required for the upgrowth of the new generation of susceptibles. In smallpox, as is clearly shown by the figures available from Geneva in the 16th.18th centuries, and from Kilmarnock between 1728 and 1764, from 96 to 99 per cent, of the deaths in pre.vaccination days 27 were those of children under ten years of age. "Smallpox was in such places," says Dr. McVail, "a disease of childhood. . ." In London in 1884, under general vaccination," he adds, " only 34 per cent, of the total smallpox deaths were under 10 years," and " among the vaccinated community of London less than 9 per cent., while among the unvaccinated community 61 per cent., were under 10 years." In epidemic throat maladies (scarlet fever and diphtheria) the influence of natural immunisation is very clearly apparent. Thus, in scarlet fever in London, children under school age suffer markedly in excess in the poorest areas, and persons over school age suffer markedly in excess in the least poor areas. In very poor boroughs the infants of one or two years of age, being more exposed to risk of infection, suffer more than twice as frequently from scarlet fever as those in the less poor boroughs. Having once been attacked, they acquire immunity, and from 6 onwards to 10, " the incidence upon children in the two groups of boroughs becomes practically identical " ; while "after the age of ten the children in the less poor boroughs actually suffer to a greater extent than do those in the poorer boroughs " (Annual Report for 1914, vol. III., p. 128). It was appreciated by J. Netten Radcliffe sixty years ago (Epidem. Trans., 1864.65) that the crowded courts of the towns were the great foci of infection, and he urged that epidemics should be controlled by improving housing conditions, by hospital isolation, disinfection, etc. The severity, at any rate, of the disease has, as the result of this policy, been materially lessened. In diphtheria the position is more complex. In a paper on " Diphtheria in older and newer Bristol" (Epidem. Trans., 1895) Dowson showed that the attack. rate was higher in the suburbs than in the older central part of the town. This phenomenon appeared to be mainly due, as Dowson surmised, to movement of population from the country around into Bristol. The gradual shifting of diphtheria prevalence over a large town like London suggests, moreover, that there is an acquirement of immunity by one part of the town after another (see Diagram opposite p. 48, Ann. Rep., 1918). This process has been shown to be reflected in fluctuations in the numbers of bacillus carriers among the child population; and in New York and elsewhere has been found to be associated with varying percentages of children responding to the Schick test. (See p. 93.) In phthisis the acquirement of immunity by large communities has been recently studied by Col. Geo. F. Bushnell (" A Study in the Epidemiology of Tuberculosis, 1920"). He divides tuberculosis, as exhibited in the various countries of the world, into two types; in the civilised community the disease is widespread but often of chronic course, and the majority of the population become immunised ; in the more remote parts of the world, such for example as Tropical Africa or the Islands of the Pacific, tuberculosis is a comparatively rare disease, the morbidity rates are low, the mortality of those that fall sick is very high. In connection with a chronic disease like phthisis, however, it must be remembered that, as Thomas Young warned us more than 100 years ago, we must have ever in mind the influence of migration upon the death.rates. The case of influenza is in certain respects comparable to that of tuberculosis— a somewhat similar contrast between Europe and the United States, and Africa and the Islands of the Pacific, holds good. But in influenza the manifestations of the disease are more varied even than in tuberculosis. It is only in recent years that the Protean character of influenza has come to be fully appreciated. Probably this is largely accounted for by the fact that influenza is primarily a disease of the cerebrospinal nervous system. It matters less what the precise location of a locus minoris resistentice in the lung chances to be, so far as the clinical picture of the resulting disease is concerned, than does the precise locus, on which the stress of the toxic influence becomes focused, when the spinal cord or the mid.brain chances to be in question. A millimetre's difference in the mid.brain affects the clinical picture more than a millimetre's difference in the lung. Again in tuberculosis the stability of •28 type of tlie materies morbi itself is apparently much more marked than it is in influenza. These two peculiarities of influenza, and more especially the latter, render study of natural immunity in this disease particularly difficult. In attempting to formulate a provisional theory of influenza it is necessary that the following points should be borne in mind :— (i.) Influenza of the pandemic type stands out conspicuously from most other epidemic diseases in respect of the great inequality and diversity of reaction manifested in individual cases of illness ; many cases are fatal, then there are many more of less severity, but a vast percentage of the total number are, fortunately, very mild, or indeed so slight as to pass almost unrecognised. Again, as has again and again been affirmed, the main stress of the disease may fall in one case upon the cerebrospinal, in another upon the gastro.intestinal, and in a third upon the respiratory system. This variability of type, together with the fact that the disease seems to be specially infectious, mainly in the early hours following, or perhaps even in the period shortly preceding, the actual development of symptoms, renders the tracing of case to case infection difficult, and greatly complicates the task of treating by statistical methods phenomena presented in successive epidemics. (ii.) The trailers of influenza exhibit as a rule one main predominant type, gastro.intestinal, cerebrospinal or pulmonary, as the case may be. While pandemic influenza especially attacks persons of young adult or adult age, the trailers seem by preference to affect young children or old persons who have escaped attack during the pandemic. Correspondingly the trailers, and especially those of the trough between two pandemic crests (i.e., those furthest removed from one or another pandemic period), may particularly affect rural areas in civilised countries, and elsewhere outlying thinly populated places and islands quite remote from civilisation. (iii.) During the pandemic phase each individual person has much larger opportunity of infecting other persons than at other times, owing to the fact that the population generally has as a rule outgrown any immunity it formerly possessed, and thus nearly everyone is susceptible to attack. The average time elapsing between contracting the disease and infecting another person is thus at a minimum, and repeated transmission at an early period of the disease, from the infecting individual to another individual, may be in part responsible for the change of type of the disease—its increasing infecting power ; its acquirement of a kind of acclimatisation to the soil in which it is growing, enabling it to flourish more exceedingly and spread more rapidly ; and may favour also exhibition on the part of the host of tolerance of the presence of the infective material and ability to throw off ill effects which might at other times be expected to eventuate. In the report on the prevalences of 1918 (Ann. Rep., 1918), the contrasts between measles and influenza periodicities as exhibited in London were considered with these three points in mind. It was noted that in London measles, the waves, which are of fairly equal size, have a length from crest to crest of one and a half to two years ; that about 180,000 children are attacked during this period, and that the number of susceptibles in the population varies from a maximum of between 200,000 and 300,000 to a minimum of some 50,000 to 80,000. In influenza the epidemics, instead of being of about equal magnitude as in measles, show recurring major waves corresponding to the great pandemic prevalences, and these develop, roughly speaking, about every 15 to 20 years ; and in addition preceding and following each pandemic at intervals of some 1, 2 or 3 years, and showing " like ripples on an ocean swell " there are the trailers, which present, as already noted, clinical characteristics differing conspicuously from those observed in the pandemics. The disparities between the simple measles curve and the complex influenza curve may be largely accounted for apparently by the following facts :— (a) The incubation period is roughly a fortnight in measles, and only from 1 to 3 days in influenza. 29 (b) Measles attacks everybody. Some people appear, at any rate during the greater part of their lives, to be immune from influenza. (c) Measles protects against a subsequent attack. Many people suffer again and again from influenza, and the period of protection afforded by an attack may only last a few months or years. (d) The infecting power exhibited remains confined within comparatively narrow limits in measles. It seems to range under ordinary circumstances in London from a position in which one case on an average infects rather more than one case, to a position in which one case infects rather less than one case; these variations are determined mainly by the varying proportions of susceptible children in the population. (e) In influenza the pandemic mainly spreads at first among those who mix largely with their fellows—in workshops, places of business, etc., on the way to and from work, and in places of assembly. The very young and the aged, who live sequestered lives, are only attacked at a later stage, and, in them, the trailers find a special field for their activities. Thus during a pandemic prevalence in London, the population may be regarded as made up of two sections. In the one—in the workshops, schools, etc., and in trains, buses, trams and places of public assembly—a single case of influenza may on the rising wave of prevalence produce from 5 to 10 or more cases; whereas, in the other section—more or less confined to home life—each newly affected individual rarely infects more than two or three persons, and may, indeed, not infect any at all. (f) There is reason for assuming that the cases occurring early in the influenza pandemic—i.e., on the rising wave—are apt to run a more rapid, and generally speaking a more acute, though not necessarily a more fatal, course than those occurring later. As has been already remarked, the pandemic is both preceded and followed by epidemics of less rapid development, in which the individual cases run a more chronic course, and in these trailers the tendency to special involvement either of the cerebrospinal, gastro.intestinal, or pulmonary system is particularly marked. It is possible, of course, that when infection results from a very early case the symptoms show a clinical picture of differing type from that observed when infection results from a more advanced case. (g) There are two main phases of influenza—the pandemic phase and the trailer phase. In the former the adjustment of the relationship between host and parasite is such as to favour rapid diffusion of the epidemic, rapid implication of one or another system in each individual affected, and rapid course of the illness ; in the latter the relationships favour much more gradual diffusion of the disease, local epidemics tending to affect one or other of the three systems involved in the pandemic, a more delayed recovery and a marked tendency to the development of relapses. These considerations may help to render conceivable a closer approximation in type of the measles and influenza curves, but they by no means completely explain the varying phases of influenza. In forms of life belonging to the protozoa and to the lower fungi alternative methods of spread of an organism may be encountered. In Malaria there are asexual and sexual forms of multiplication. In Anthrax there is propagation by fission or by spore formation. Again, in the " rust " of wheat, propagation is effected by uredospores, teleutospores and secidio. spores ; the first named bringing about the initial rapid spread of the disease early in the year, the two latter forming " latent " or " carrying on " stages, concerned in producing extensions of the disease in subsequent years. It may be that in influenza varying forms of propagation afford explanation of some of the phenomena presented by diseases of the influenza group. Further, by some such hypothesis of alternative forms of multiplication, a clue may be furnished which will explain the way in which encephalitis succeeds influenza, or poliomyelitis replaces cerebrospinal meningitis; here, in a word, may perchance be sought the reason why the varying phases of influenza are encountered. 10976 c 30 The number of cases of cerebrospinal and post-basic meningitis notified during the year 1923 was 70, as compared with 86 for the previous year. The disease has continued to decline progressively since the epidemic year 1915. Of the 70 cases notified, 10 were not regarded as genuine cases ; on the other hand 22 cases were recorded (mainly through the Registrar General's Death Returns) which were not notified under the Public Health (London) Act, 1891. The actual number of cases was therefore 82 of which 63 (76.8 per cent.) proved fatal, as compared with a mortality rate of 82.5 per cent, the previous year. The number of cases of poliomyelitis and polioencephalitis notified during 1923 was 112 as compared with 40 the previous year. As will be observed in the table below the incidence of the disease was higher during the year under review than in any year since 1916. Of the 112 cases notified 5 were not regarded as genuine cases, and one recorded case was not notified, thus making a total of 108 actual cases, of which only 7 were attended by fatal result. During 1923 there were 101 cases of encephalitis lethargica notified. In 18 cases the diagnosis was revised, whilst two cases were not notified, thus reducing the total number of actual cases to 85 ; of which 39 (45.9 per cent.) proved fatal as compared with a fatality rate of 53.6 per cent, in the preceding vear. Poliomyelitis, polioencephalitis and encephalitis lethargica. The following table shows the age incidence of actual cases of cerebrospinal fever, poliomyelitis, polioencephalitis and encephalitis lethargica during 1923. 1 Under 3. 3.5. 5.10. 10. 20. 20. 30. 30. 40. 40. 50. 50.60. Over 60. Total. Cerebrospinal fever 48 8 6 7 6 2 3 1 1 82 Poliomyelitis and polioencephalitis 36 28 17 24 2 1 — — — 108 Encephalitis lethargica 2 2 3 13 20 15 16 11 4 85 The following table shows the yearly incidence (of cases notified) of cerebrospinal fever, poliomyelitis and polioencephalitis since 1913 and of encephalitis lethargica since 1919. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. Cerebrospinal fever 92 73 674 432 430 265 199 164 109 86 70 Poliomyelitis and polioen. 145 93 97 197 53 53 96 65 59 40 112 cephalitis Encephalitis lethargica Not made notifiable till 1st 86 149 243 72 101 January, 1919 Plague and cholera. Anthrax. Typhus fever. No cases of plague or cholera were notified during 1923. Contacts on board vessels arriving in the Port of London were kept under observation. During 1923 only 4 cases of anthrax occurred in London, of which 3 were fatal. In one case the source of infection was not definitely determined, but the patient was employed in the London Docks and was said to have been connected with the shipment of horses. In two other cases the patients were employed at a wharf in handling Russian horsehair. The superintendent of the wharf was advised by the medical officer of health of the borough to take the necessary precautions in dealing with horsehair. The fourth case was that of a child, aged three years, whose father was employed at a wharf in handling Chinese and Japanese hides ; it was understood that Russian horsehair and bristles were also received at this wharf but that the child's father had not handled the material, although he had cleared out a quantity of rubbish at the wharf. This case was somewhat unusual, being an illustration of the possible conveyance of anthrax infection through an intermediary, assuming in the absence of any other ascertainable source that the father carried the infection home to the child. No cases of typhus fever were notified in London during 1923. Cerebrospinal fever. 31 Tyjphoid Fever. There were 331 cases notified as typhoid fever in London in 1923, as compared with 264 in 1922, 328 in 1921 and 387 in 1920. The deaths numbered 42 as against 45 in 1922, 60 in 1921 and 48 in 1920. Of the cases admitted to the Metropolitan Asylums Board hospitals, the diagnosis of typhoid fever was not confirmed in 60.9 per cent. The proportion of unconfirmed cases has shown increase in late years ; it was about one-fourth at the commencement of the present century In 1909 the proportion rose for the first time above one-third (37.9 per cent.). In 1912 and the subsequent years it has generally exceeded 40 per cent, and in 1922 was 45.8 per cent. The years 1909, 1912 and onwards were marked (as noted in these reports) by definite absence of any autumnal prevalence of typhoid fever. They were, moreover, years in which the total number of deaths from typhoid fever, after declining from the higher level of the nineties of the last century, fell still further and dropped below .03 per 1,000 living. In other words since the death rate from "typhoid fever" in London has fallen down to or below .03 per 1,000 living the difficulty as regards diagnosis appears to have become intensified, so that out of some 50 to 100 deaths registered in each of the recent years a considerable percentage (ranging around 50 per cent.) may be presumed not to have really been cases of the disease. In 17 instances two or more than two cases were notified from one house as compared with 14 instances in 1922 and 19 in 1921. There was a group of 5 cases one of which was subsequently decided not to be typhoid ; another group of 5 cases, 3 of these were not London residents and had recently come from Paris ; a group of 4 hospital nurses; a group of 3 members of the staff at another hospital; two groups consisting of 2 cases in a particular house and one in a neighbouring house, a nurse and a patient at a hospital; an instance in which two cases in a sister and a nurse at a hospital were associated with some dozen other persons admitted to the hospital or living in the neighbourhood; and 9 other cases. In at least three of the above groups the infection appears to have been contracted outside London. In two instances fish or cockles, and in one oysters came under suspicion. In the case of the group of a dozen or more cases, including a nurse and a sister at a hospital, and occurring from January.April, 1923, enquiries were made by the borough medical officer, by the house physician at the hospital, and by Dr. Brincker, but it was not found possible finally to decide as to the causation of the outbreak. Special enquiry was made in 1923 as to the bacteriological diagnosis made, if any, and replies were forthcoming in 253 cases ; the presence of B. typhosus was recorded in 93 instances ; 27 were returned as paratyphoid ; 2 as paratyphoid A.; 42 as paratyphoid B. ; 11 as paratyphoid A. and B. ; 35 as typhoid not otherwise described and 57 were returned as not typhoid fever. Information as to probable origin of the disease is given in 173 instances ; in 34 it was believed to have been contracted outside London ; in 59 instances fish or shellfish were held to have been at fault; other foods were suspected in 34 instances: 17 nurses were among the sufferers ; in 9 of these B. typhosus was found, 4 were reported as suffering from paratyphoid B. In the Annual Report for 1922 (vol. III., pp. 19.32), a review of typhoid fever in London during the last 32 years was given and reference was especially made to the part played in the causation of the disease by immature ungutted plaice. At the top of p. 31 reference is made to suggested restrictions as to the marketing of immature fish which were put forward in July 1921 by the Plaice Sub.Committee of the International Council on Fisheries in the North Sea. These suggested restrictions were intended to prevent immature plaice being brought to this country from certain inshore areas (including an area near the mouth of the Elbe) from which, prior to 1909, supplies were from time to time derived. A few years before the war the sale of these immature plaice in London practically ceased and it was not resumed immediately upon the close of the war. During the closing months ol 10976 c 2 32 1921 and in 1922 reports were received that this particular kind of fish was again being sold in London. During August and September last a considerable amount of Danish and Dutch caught fish (the major proportion consisting of plaice) was sold at Billingsgate ; some of the Danish fish was condemned as unfit for food. In the weeks ending Sept. 15th, Oct. 13th, Oct. 20th, and Nov. 3rd, the number of notifications of typhoid fever in London either reached or exceeded ten, a number only equalled on four occasions and not exceeded on any occasion by the average figure for the preceding five years. There was thus an approach to the development of a slight autumnal rise, a feature which had been absent for some years past. The facts were brought to the notice of the Medical Officer of Health of the City and an opportunity was taken of conferring with him on the question. After November 3rd there was a slight fall, though in the week ending December 15th, eleven notifications were again forthcoming ; in the last week of the year the number fell to three. The following review of the behaviour of typhoid fever in the mental hospitals of London during the last 30 years is of interest in connection with the general problem of London typhoid prevalence. In the annual report for 1920 a diagram was exhibited showing prevalence of typhoid fever and dysentery in the London mental hospitals from 1914.1920. The records have recently been further examined as far back as 1890. Water, though often suspected in the early years, seems now in the light of later knowledge to be free from blame. At one hospital (A in the diagram on p. 30 of the 1920 report) typhoid fever has only been reported in four instances since 1890, a remarkably low incidence of the disease ; dysentery on the other hand has been not uncommon in the institution. In B., since the opening in 1898, a few cases of typhoid have occurred in most of the years. In 1912, 21 cases, 6 of which affected female staff, occurred. During the years 1914.1920 typhoid fever was confined to the female side of the institution. In C. (already open in 1890) there was but little typhoid until the outbreaks of 1915, 1916, 1917 and 1918 appeared. In 1919 and 1920, 18 cases occurred, all of them (the whole of the patients and staff having been inoculated) in inoculated persons. Dysentery has been uncommon in this hospital. In D, there has been much dysentery, and typhoid fever has been reported in several years, notably in 1914, 1917 and 1918 and 1921. In E. several cases of typhoid occurred from 1896.1904 and some 19 members of the female staff were affected during those years. Between 1914 and 1920 typhoid was limited to the female side of the institution. Dysentery was of rather common occurrence. In F. typhoid has from time to time occurred from 1875 onwards, and there were 4 cases in 1894, several in 1897 and 1898, and six female attendants were attacked between 1897 and 1899. A few cases developed between 1914 and 1920. Dysentery was prevalent between 1914 and 1918. In G. (opened in 1907) typhoid occurred each year from 1908 onwards, 11 patients and 3 female attendants in 1912; 4 patients and 1 female attendant in 1913; 16 patients in 1914; and 10 patients and 4 female attendants in 1915 ; a further group of nearly 20 cases in 1919. Dysentery was prevalent in 1917 and 1918. In the last three years the total number of cases notified from the mental hospitals has been 41 in 1921, 37 in 1922 and 19 in 1923. The general impression obtained from a review (covering this period of 30 years) of typhoid fever in the mental hospitals, is that it is difficult to differentiate with certainty in many cases between " dysentery " and " typhoid fever." Often prevalences of the one disease seem to coincide with prevalences of the other, in other hospitals or in another section of the same hospital. Female staff have suffered more than males, and the fact that they live in the institutions (to a much greater extent than the males) explains this, whether it be assumed that the infection is conveyed by food or by direct case to case infection from patients. The prevalences of 1917 and 1918, whether of " typhoid fever " or of " dysentery," were clearly associated with war conditions, and probably the shortage of food supplies in those years played some part. typhoid fever in the mental hospitals, 83 It will be seen, therefore, that there were two main periods of " typhoid fever " prevalence— the years 1898.1900 and 1917-1918. The former period corresponds with unusual prevalence of typhoid fever in London generally, the latter period certainly does not. On the whole, on the balance of probabilities it seems likely that the prevalences of 1898.1900, like those in London as a whole, were in part due to infected food (fish); but it is interesting to note the association of the " asylum dysentery " of those years with typhoid fever, an association not apparent in London generally. On the other hand in the later years, 1917 and 1918, the majority of the cases of intestinal disorder in the mental hospitals may have been associated with the scarcity of food due to the submarine menace of those years ; perhaps the influenzas of 1918 and 1919 may also have accounted for some of the coincident gastro.intestinal mischief in mental hospitals. The facts, so far as they are ascertainable after the lapse of years, have been set out in some detail, as the material available from these great institutions seems to be particularly deserving of the closest attention ; the more so as a large amount of pains and trouble have been taken by those concerned to record the results of their enquiries. This review of the history of these diseases in the mental hospitals raises questions of very great interest in connection with study of the epidemiology of both typhoid fever and asylum dysentery generally. In the Annual Report for 1919 there is a diagram (p. 14) which shows three stages in the history of typhoid fever in London. In 1869 the description " typhoid fever " was first recognised for purposes of tabulation by the Registrar.General, and from 1869 to 1884 " typhoid fever " declined from 340 deaths per million to less than half this amount, i.e., to under 150 deaths per milion. Then during the second period, from 1885.1900, the mortality remained almost stationary; in the third period, after 1900, the typhoid death.rate again fell, this time to a minimum of less than 8 deaths per million in 1923. During the first period the death.rate in females fell much more than that in males, and the death.rates at the extremes of life more than those in the middle portion. These changes tend to confirm a suspicion that, in the early days of registration of typhoid fever deaths, much difficulty was experienced in deciding the precise nature of the disease under consideration. Then with the arrest in the fall in the death.rate at all ages from 1885.1900—i.e., in the second period—there seems to have been, so far at any rate as age and sex incidence can be taken as guides on the question, more uniformity of type in the kind of disease coming within the designation " typhoid fever." There were, however, among the cases seen in the M.A.B. hospitals quite a considerable number (20 per cent, to 25 per cent.) found to have been wrongly diagnosed. In the third period there came a time (about 1909) when the ordinary seasonal (autumnal) prevalence of typhoid fever flickered away, and since 1912 it has almost disappeared. The percentage of mistaken diagnoses, represented in the much attenuated lists of notifications of " typhoid fever," has so far increased, that apart from cases infected from abroad there have been, speaking merely from the clinical point of view, very few typical examples of the disease forthcoming. The conclusions to be drawn seem, therefore, to be (i.) That in the first 15 years of typhoid fever registration the mortality returns include a large proportion of deaths not really attributable to typhoid fever. Some of the deaths returned from certain institutions, even some years after 1884, probably come within the same category. (ii.) That from 1885.1900, and in less degree for 9 or 10 years thereafter, typhoid fever, clinically speaking, so far as the large majority of carefully diagnosed cases was concerned, fairly well conformed to type; those affected with it in London throughout the 15 years in question were mainly quite poor persons ; the disease moreover, exhibited a fairly constant age and sex incidence. 34 (iii.) From about 1909 onwards the cases of " typhoid fever " developing in London, apart from persons infected outside London, have in the majority of cases been deemed on further examination not to be typhoid fever. In the light of the foregoing considerations and of the analysis made in last year's annual report of the causation of London typhoid during the last 50 years, attention has been devoted to comparing and contrasting the behaviour of the disease in the County of London with that in other counties in England and Wales, Study of London typhoid, outside and inside the mental hospitals, during the last 30 years suggests that there are, epidemiologically speaking, two kinds of epidemic disease commonly so diagnosed. There is the typhoid caused by eating polluted fish or shellfish, which makes up the bulk of the typhoid in the outside population ; it is unassociated with dysentery, it may occur in explosive outbreaks, it exhibits no tendency to spread from case to case, it shows increase in the autumn, preferentially attacks males and the ages 10—25, and when caused by fish or shellfish other than oysters is mainly limited to persons belonging to Charles Booth's classes C and D. Then, secondly,there is the typhoid of the type sometimes met with in mental hospitals, which is associated with dysentery, does not occur in explosive prevalences, apparently spreads from case to case, shows no marked autumnal increase, preferentially attacks females and not infrequently persons over 25, and has no such marked special incidence upon a particular social class as in the first mentioned type. The fact that there is a distinction between these two typhoids has been rendered particularly apparent during recent years, owing to the almost complete disappearance of the first.named type. Comparison between the typhoid fever of London and that of Ebgland and Wales. In the fight of these considerations pre-conceived notions concerning the reasons determining the contrasts presented by typhoid fever incidence in London and in other parts of this country must be reviewed. First, it may be noted, that the special features observed in the predominant type of typhoid occurring in London can be traced back with complete confidence for 30 or 40 years. It may be that before that time London, like other places, suffered severely from typhoid of the second type, such as may occur nowadays in the tropics, or may be associated with wars and with dysentery, which may affect country districts as much as or even in preference to the towns, may be contagious from case to case and prove to be a disease to which strangers and new arrivals are especially subject, thus giving rise to the view that a kind of acclimatisation occurs. All these features have, of course, been wanting in the main mass of London typhoid of the last 30 years. On the other hand, it must be borne in mind that typhoid fever nowadays is found to be very elusive—witness the Asylums Board's Returns of" wrong diagnosis " —what, then, must have been the difficulties more than 30 years ago ? There is, of course, the possibility that the anomalous features at one time presented by " typhoid " must be attributed to the fact that many different forms of illness were so designated. In this quandary it seemed worth while to focus attention upon the London predominant type of the last thirty-five years, the typhoid which has been found to be associated with consumption of polluted shellfish and fish. If attention be concentrated upon the salient characters observable in this type of typhoid it can be held up as a standard by which to test the typhoid of the rest of England and Wales. Now the London typhoid affected almost exclusively a particular social class. Turning, therefore, to the other counties of England and Wales, question arises whether any similar phenomenon can there be discerned ? Study of the figures, decade by decade, shows very marked excessive incidence of typhoid fever upon mining and industrial areas; in fact upon populations very similar to those which in the past have consumed the kind of shellfish or fish found to be at fault in London. The incidence upon the counties of England and Wales may be examined in detail with the aid of the accompanying maps. In the decade 1871-80, a rate of over 300 per million was attained in four areas— 35 30 the largest of these comprises the coalfield counties of Northumberland, Durham, Lancashire, Yorkshire, Staffordshire, Derbyshire and Nottinghamshire, and overflows southwards into Leicestershire, Rutlandshire and Northamptonshire ; thus already, even fifty years ago, there is the suggestion that this area's influence extends southwards on the way towards London. The second area includes the South Wales coalfield. The third area (Hants with the Isle of Wight) and the fourth (Devon and Cornwall) are areas with no coal, but the former, for three succeeding decades, and the latter, for at least two succeeding decades, maintained a level of typhoid prevalence considerably higher than their neighbours. Considering, in the first instance, these third and fourth areas, their typhoid history differs materially from that of the first and second areas, in the decades 1871.80 to 1901.10, and, indeed, is such as to make it quite clear, in the light of the official reports, that the endemicity of the disease in these third and fourth areas, in the decades in question, must be attributed to shellfish. Turning back again now to the first and second coalfield areas, here, too, shellfish may be in part accountable, but it is probable that even in South Wales there was some superadded cause, and question arises as to whether this area suffered in the same way as the northern area, for it is almost certain that a superadded cause must have operated in that area and that its activities extended towards London if not even further southward. It remains to note, in fact (as regards this decade 1871.80), that from the black deep of the northern coalfield and industrial area, with a typhoid death.rate of over 300 per million, there stretches over England and Wales a shallower surrounding sea of counties with a typhoid death.rate of from 200.299 per million, leaving only three outstanding islands with a rate of less than 200 per million—these islands are constituted by the counties of Herefordshire, Sussex and Dorset. Varying the simile, some point within the northern coalfield area may be looked upon as a focus of added mischief (over and above that attributed to shellfish) in this decade. This influence as it radiates southward clearly loses its strength when it has stretched as far to the west or south as Herefordshire, Dorset and Sussex. The added cause thus seems to operate from the north and east, southwards and westwards. In the decade 1881.90, the deep black areas have become much less dark; three of them have advanced one step (from over 300 to over 200 per million); the fourth, comprising Devon and Cornwall, has advanced two steps (to less than 200 per million). The large northern coalfield area now, moreover, stretches out over Cheshire and Worcestershire, but has lost Westmoreland, Derby and also its three most southerly counties—Northamptonshire, Leicestershire and Rutland. The strength of the influences proceeding, from the focus in the north and east, southwards and westwards is seen still to weaken, as in the preceding decade, on reaching Herefordshire and Dorsetshire ; Sussex has, however, not kept its relative pride of place, but the corresponding position to that which Sussex formerly occupied is now assumed by Bedfordshire. A considerable part of the general improvement manifested throughout the country in this decade is unquestionably due to increasing accuracy of diagnosis—meningitis, appendicitis, pneumonia and the like tending, as time goes on, more and more to be differentiated from typhoid fever. Allowing for all this, comparison can still be made between one part of the country and another as regards typhoid incidence. In the decade 1891.1900 the disturbance emanating from the north and east might be held to take origin in Yorkshire ; North and South Wales in this decade both exhibit the same rate (between 100 and 200 per million). The Herefordshire island stands out with a rate of less than 50 per million; the Dorsetshire island has protruded northwards and greatly extended north.eastward through Wilts and Gloucester, Oxfordshire and Berks, and then Buckinghamshire, to join Bedfordshire, to which the adjoining county of Huntingdonshire is now added. In the decade 1901.10, there is some improvement in the northern area, which is not, however, marked in Durham and Lincolnshire ; Westmoreland, however, has 37 taken an upward step. North Wales improves ; Shropshire joins Herefordshire ; Dorset remains as before, but its north and north-eastward extensions show further development, and even throw down an outlier through Surrey to join Sussex. Hampshire, with the Isle of Wight, still compares badly with the surrounding counties. In the decade 1911.20, further and very marked general improvement is manifested, all the counties save four showing rates of less than 50 per million. Northumberland, after assuming, comparatively speaking, a better relative position, has lapsed, and is joined again with Durham, Yorkshire and Lancashire. Lincolnshire has taken two steps forward and is now on the roll of honour among counties with less than 50 per million deaths from typhoid fever. The location of the place of origin of the added cause already spoken of, in the review of the decade 1871-80, was held, on the showing of the typhoid rates for 1891-1900, to be somewhere in Yorkshire. In the decade 1901-10 Lincolnshire took its place by the side of Yorkshire qua typhoid rates, and then in 1911-20 once more stood aside from it, joining with counties exhibiting less typhoid. This behaviour of Lincolnshire would be explicable, if during the decades 1891.1900 and 1901.10 the area of origin of the superadded cause covered for a time both sides of the estuary of the Humber. The phenomena are, in fact, in accord with the sequence of events described in the Annual Report for 1916, p. 7. There was from about the early nineties occasional resort to, and then gradually lessened use by, the Humber ports (as a source of supply of small plaice) of that part of the A, area which includes the mouth of the Elbe. These events have been seen to correspond in point of time with rise of typhoid prevalence in London in 1891.00 with heightened autumnal prevalences, and with gradual fall (1901-10) followed just after the close of that decade with complete disappearance of autumnal excesses of prevalence. These phenomena are observable, too, in the counties surrounding London and in the northern and some of the midland counties. Moreover, London is known, subsequent to the eighties, to have become increasingly dependent upon the North.Eastern fishing ports for its supply of small plaice. It appears, therefore, that there is here explanation of the parallelism in the behaviour of London and other counties, qua prevalence in general and autumnal prevalence in particular, with occasional supply and later discontinuance of supply of fish from the A3 area—the use commencing in the early nineties, the disuse gradually coming about some years later, and the supply ceasing after 1911. There were 6,346 deaths from cancer in 1923 as compared with 6,044 in the Cancer, previous year. There has been a continuous increase in the mortality since the earliest years of death registration. The rate in London is slightly higher throughout than in England and Wales as a whole, but, as will be seen from the following figures, the difference is small:— Cancer death-rate. Period. London. England and Wales. 1851.60 0.42 0.32 1901.10 0.98 0.90 1911.20 1.21 112 1921 1.33 1.21 1922 1 33 1.23 1923 1.39 1.27 The mortality occurs principally amongst persons of high age and the cancer death-rate in any given population is largely governed by the proportion of aged persons in that population. The progress over long periods is. therefore, most accurately shown by figures relating to age-groups, the sexes being separately considered. In the following table the mortality from cancer in London is shown for each age and sex for the principal age-groups affected, for three-year periods to which each successive census in and since 1851 is central:- 38 Period. Ages. Total of rates. Females. M=100. 25- 35- 45- 55- 65- 75-85 1850-52 Males 0.09 0.21 0.60 1.09 1.86 1 .77 5.62 195 Females 0.21 0.86 1.68 2.44 2.98 2.77 10.94 1860-62 Males 0.09 0.28 0.73 1.45 2.23 1.85 6.63 182 Females 0.20 0.85 1.97 2.74 3.61 2.71 12.08 1870-72 Males 0.08 0.31 0.91 1.86 2.37 2.38 7.91 172 Females 0.23 1.02 2.04 3.42 3.34 3.54 13.59 1880-82 Males 0.10 0.39 1.20 2.55 3.81 3.51 11.56 147 Females 0.19 1.10 2.35 3.74 4.82 4.85 17.05 1890-92 Males 0.14 0.52 1.65 3.60 5.58 5.35 16.84 124 Females 0.23 1.08 2.57 4.31 5.92 6.81 20.92 1900-02 Males 0.11 0.45 1.72 4.34 7.47 8.26 22.35 107 Females 0.19 0.92 2.58 4.68 6.94 8.64 23.95 1910-12 Males 0.13 0.48 2.09 5.27 9.13 10.51 27.61 88 Females 0.17 0.89 2.34 4.62 6.98 9.37 24.37 1920-22 Males 0.12 0.50 2.01 5.70 10.05 12.49 30.87 83 Females 0.17 0.77 2.30 4.52 7.21 10.60 25.57 Rates 1920-22 (1850-52= 100) Males 125 238 335 523 540 706 549 Females 82 90 137 185 242 383 234 The table shows that there has been a much greater increase among males than among females. It may be stated roundly that the mortality for the ages shown has increased among males five-fold since 1851, while among females the present rate is less than two-and-a-half times that of 1851. It will be noticed also that in the past 20 years the female mortality at ages below 65 years has decreased, and that above that age, especially in the age-group 65 to 75, there has been a considerable diminution in the rate of increase. The figures shown in the last column of the table enable an approximate comparison to be made of the total incidence of mortality upon the two sexes, and it will be observed that taking the sum of the male rates shown as 100, that of the females in 1851 was 195, while now it is 83. The proportion of deaths from cancer which occurred in institutions (Poor Law institutions, lunatic asylums, hospitals and nursing homes) is much higher in London than in the rest of England and Wales. The figures for 1911 and 1920 are shown in the following table :— 1911. 1920. Place of Death. London. Rest of England and Wales London. 1920. Males. | Females. Males. Females. Males. Females. Males. Females. Institutions 54 .0 39.8 25.2 16.1 47.8 27.4 19.1 Elsewhere 46.0 | 60.2 74.8 83.9 43. 0 52.2 72.6 80.9 Much speculation has been indulged in as to the cause of cancer. One certain fact, however, seems clear, namely, that cancer frequently follows a chronic or prolonged irritation affecting certain sites in the body. Hereditary pre-disposition to cancer has not at present been proved to be of any practical importance in man, nor has it been shown that increased danger of cancer results from inhabiting houses or districts in which the disease happens to have been more than usually common. It cannot be too strongly urged that the only present hope of mitigating the effects of the disease in individual persons is by recourse to medical treatment at the very earliest suspicion of any abnormal condition which may be the precursor of malignant disease. A memorandum addressed by the Ministry of Health (Circular 426, 14th August, 1923) to all local authorities in England and Wales summarised the present know- 39 ledge with regard to the etiology and incidence of cancer, and set out for the consideration of health authorities some suggestions which might be useful in efforts to deal with the disease. These suggestions included the following:— (i.) Improving the local facilities for clinical consultation and for pathological examinations. (ii.) Improving the local facilities for cancer treatment (operative, or provision of X-ray and radium apparatus) and considering the adequacy of arrangements for this purpose at hospitals, local institutions, etc., which serve the area. (iii.) Improving facilities for transport of patients. (iv.) Arranging locally for post-graduate demonstrations, lectures, or courses on cancer for medical men practising in the area. (v.) Arranging locally for the education of the public by means of public notices, advertisements, broadcast leaflets, lectures, cinemas, etc. With regard to the advice given under (v.) the memorandum pointed out that much caution is obviously needed to avoid over-statement, the making of promises which are not warranted by evidence, or the production of needless and mischievous apprehension of cancer. It is added that it is not contemplated or suggested that there should be established a public cancer service, analogous to the services for tuberculosis or venereal diseases, but that on the other hand public health authorities, etc., should not feel discouraged from individual action within their competence from assisting in securing better facilities for diagnosis or more effective treatment of cancer. London is in a specially advantageous position in comparison with other parts of the country, as well in regard to treatment as to the other suggestions to local authorities referred to above. It has been observed that in many towns and countries a low phthisis mortality is associated with a high cancer death-rate and vice-versa. In London a small negative correlation is found between the crude cancer death-rate and that of phthisis in the metropolitan boroughs, but when the rates, corrected for differences in the age —and sex—constitution of the various populations, are compared there is a small positive correlation: there does not, therefore, appear to be any actual inverse relation shin in the incidence of cancer and phthisis mortality. Publicity was given during the spring of 1923 to a number of cases of skin disease due to the wearing of ladies' furs. The occurrence of such cases was observed by Dr. Veitch Clark, the medical officer of health of Manchester, as early as January 1923. He inquired whether there was any evidence of similar skin conditions in London, and he was informed that no such cases had up to that time come to light In March, however, various notices on the subject appeared in the medical and lay press, and as a result of enquiries made it was found that quite a considerable number of cases of " fur dermatitis " had been dealt with in the general hospitals in London and the provinces. Skin disease due to wearing furs. It was at first popularly believed that the condition was associated with some disease of the animal from which the fur was derived and later it was thought that some compound of arsenic used in the dye, with which the fur was dressed, acted as the irritating agent. A sample from one of the furs implicated however was examined in the Council's chemical laboratory and the report of the chemist was as follows:— A large amount of dye soluble in alcohol was found. The matter soluble in ether was practically all oil. A hydrochloric acid extract yielded no evidence of metals. The ether extract and alcohol extract, both tested on the skin for over 24 hours, caused no irritation. The brown dye extracted had properties similar to phenylene-brown. There was slight evidence of diamines in the acid extract, and it appears probable that the toxic effect on the skin is due to small quantities of volatile dimethyl-paraphenylene-diamine or an allied substance 40 in the newly dyed fur. In course of time this is likely to disappear by volatilization. If this were so the use of the fur would not be followed by any harmful effects. Exposure to bright sunlight should be useful in removing any volatile poison. The furs in question are known generally as " coney beaver," and are produced in various shades of colour. The varieties mainly implicated were found to be those of the lighter shades, the black-coloured furs being apparently harmless. The cause of this may be ascribed to the process of dyeing, and when the furs are completely oxidised by the action of the paraphenylenediamine they become black in colour ; the intermediate processes produce the lighter shades. As far as could be ascertained the dyes came ready made from Germany. The Ministry of Health conferred with the London Fur Traders: Association with a view to obviating the risks entailed in the wearing of the types of fur in question. During the winter season 1923-4, only one complaint of skin disease after wearing a fur has been brought to the notice of the Council's public health department, and it may be assumed that the measures taken to prevent a recurrence of the mischief have been effective. Report of the Bacteriological Laboratory. During 1923, over 6,000 specimens were examined as compared with about 8,500 in 1922, the reduction being almost entirely accounted for by the much smaller number of diphtheria investigations required in consequence of the decline in incidence of the disease from 15,287 cases notified in London in 1922 to 10,301 in 1923. The material for examination is largely represented by cultures from the throat and nose or ear arising from investigations of diphtheria outbreaks in the schools or of contacts among members of the Council's staff ; suspected ringworm hairs from school children, and specimens, mainly cerebro-spinal fluid, sent from various institutions. For this work over 9,500 tubes and plates of various media prepared by the laboratory staff were required. Details of Examinations. (i.) Diphtheria.—3,000 cultures from throat and nose or ear— 252 or 8.4 per cent. morphological diphtheria bacilli found. 129 or 4.3 per cent. suspicious organisms. 2,619 or 87.3 per cent. negative. Included in the above were 13 cultures of discharging ears, which yielded morphological diphtheria bacilli in three cases and suspicious diphtheroid organisms in 10 cases. (ii.) Ringworm.—2,850 hair specimens examined. 1,502 proved negative and 8 suspicious. In 1,333 ringworm fungus was found—81 per cent, being the small spore variety (Microsporon Audouini) and 19 per cent, the large spore (Megalosporon Endothrix). In seven specimens favus fungus (Achorion Schonleinii) was found. (iii.) Conjunctivitis and ophthalmia neonatorum.—40 smears from eye discharges were examined. Gonococci were identified in four or 10 per cent. The majority of the remainder showed the presence of pus cells and various gram positive cocci. (iv.) Cerebro-spinal Fluid.—84 specimens were examined and reported on chemically, cytologically and bacteriologically. 43 were sent from Fulham Infirmary, 32 from St. James' Hospital, Balham, 8 from St. Pancras Infirmary, and one was taken in the course of a consultation visit. The material obtained by lumbar puncture was sent for report and confirmation or otherwise from cases provisionally classed as :— (a) Tuberculous meningitis—29 specimens from 27 cases. The suggested diagnosis was :—(a) Confirmed by laboratory report in 8 by finding 41 tubercle bacilli ; (b) supported in 7 by the marked lymphocytosis and amount of albumin (average -19 per cent. Aufrecht); (c) negatived in 14 (no tubercle bacilli: no lymphocytosis : no excess of albumin). Ultimate diagnosis.—Tuberculous meningitis 14 (11 verified postmortem, 3 post-mortem refused). Other conditions revealed by subsequent course of 13 cases:— Meningeal hæmorrhage, endocarditis, cancer of breast, encephalitis, mastoid disease, cerebral tumour, influenza and meningismus (6 cases). (b) Encephalitis lethargica.—12 specimens. Suggested diagnosis was (a) supported in 6 cases by laboratory report (slight or absent lymphocytosis, albumin average -04 per cent. (Aufrecht), bacteriologically negative); (6) doubtful in 4; (c) negatived in 2 cases (by finding tubercle bacilli, lymphocytosis and excess albumin). Ultimate diagnosis.—Encephalitis (5 cases), cerebral tumour (2 cases), melancholia, tuberculous meningitis(2 cases) , uraemia, neurasthenia. (c) Meningitis (other than tuberculous).—18 specimens from 16 cases. Suggested or doubtful diagnosis was (a) confirmed in 5 cases by laboratory report, viz., influenzal (B. influenzae found), cerebrospinal (meningococcus found), chronic post basis meningitis with hydrocephalus, septic (post mastoid) in 2 cases ; (b) doubtful in 5 cases ; (c) negatived in 8 cases. Ultimate diagnosis,—Meningitis (post-mortem confirmation of laboratory report) in 5 cases, cerebral or meningeal haemorrhage (3 cases), cerebral tumour, mastoid disease, mental deficiency, meningismus (5 cases). (d) Cerebral diseases (21 specimens of 19 cases).—(a) General paralysis and dementia (12); (6) Cerebral meningeal haemorrhage (6); (c) Abcess and mastoid disease (2); (d) Uræmia (1). The suggested diagnosis was (a) supported by laboratory report in 11 cases ; (6) doubtful in 9 cases ; (c) negatived in 1 case. Ultimate diagnosis.—General paralysis and dementia (9 cases), haemorrhage or thrombosis (5 cases), encephalitis, congenital syphilis, chronic alcoholism, abscess and uraemia. (e) Spinal diseases (4 specimens).—Tabes-dorsalis, lateral sclerosis, pressure on nerve roots. Laboratory reports supported diagnosis in only one case, the remaining 3 were doubtful. Ultimate diagnosis.—Tabes, lateral sclerosis, sciatica and pyelitis. (v.) Examination of Milk and Ice Creams. Milk.—Estimation was made of the number of organisms in 10 specimens of fresh milk (6 samples), and dried milk (4 samples). Ice Creams.—24 samples examined in June and July. (a) Bacteriological.—Counts obtained ranging from 108 to 1,722,000 organisms per c.c. Presence of lactose was demonstrated in every sample. (b) Chemical.—None of the common preservatives detected. (c) Microscopical.—Dust particles, sand, carbon, vegetable fibre (linen, cotton and woollen fibres). No indication of cow dung. (vi.) Miscellaneous.— (a) Urine.—9 specimens examined chemically and microscopically, from cases of albuminuria and pyuria among school children. (b) Fœces.—4 specimens from patients at Colney Hatch Mental Hospital were examined for organisms of the dysentery and enteric groups with negative results. (c) Pus.—(1) two specimens from tuberculous abscess—no tubercle bacilli found—one sterile, the other yielded staphylococcus on culture. (2) a case of pyorrhoea which yielded streptococcus. (d) Blood cell counts of two school teachers for evidence of anaemia, one of pernicious type. 42 Consultation Visits.—At the request of medical officers of health or practitioners nine visits to private houses were paid by either Dr. Brincker or Dr. Forbes for assistance in diagnosis. 1. Encephalitis lethargica.—(6 cases) three were verified, the others proved to be cases of cerebral embolism, hysteria and tuberculous meningitis. (Lumbar puncture performed and tubercle bacilli found in cerebrospinal fluid.) 2. Cerebrospinal fever.—(1 case) not confirmed. Case of aniline poisoning, with speedy recovery. 3. Early enteric fever.—(1 case) not confirmed. Case of influenza. 4. Botulism.—(1 case) not confirmed. Acute gastritis due to tinned salmon poisoning complicated by facial paralysis : the patient was removed to King's College Hospital and made complete recovery. Bacteriological examination of pieces of fish failed to show evidence of B. botulinus or other food poisoning organism. Illness possibly due to unrecognisable toxins. B.—Administration. Statistical information available is comprised in Table II. on p. 58, and details of the administration of the General Powers Acts (Tuberculous Milk) and observations on the supervision of slaughterhouses, cowhouses, and offensive trades, will be published later in Chapter XXV. of the Annual Report of the Council, Volume III. Common and seamen's lodging houses. lhe supervision of the 175 common lodging-houses licensed by the Council entailed 9,416 day visits and 386 night visits by the inspectors. The supervision of 36 seamen's lodging-houses licensed under the Merchant Shipping Act, 1894, entailed 1.275 visits by day and 79 by night. Census of homeless persons. A census of homeless persons in London was taken on the night of 23rd February, 1923. The whole of the county was included except the outlying districts which are not usually the resort of such persons. The night was mild with some rain. Only four persons (all women) were found sheltering under arches and staircases. In the streets 126 men and 11 women were found, as compared with 81 men and 23 women on the night of the census in 1922, and 296 men and 76 women at the census taken shortly before the war, in the early part of 1914. In the common lodging-houses 13,891 persons were accommodated, as compared with 13,076 in 1922, and 20,173 in 1914. In the free shelters and labour homes, not licensed, 347 men, 112 women and 14 children were accommodated, as compared with 597 men, 148 women and 13 children in 1922. The number of persons in casual wards on the night in question was 381 men, 17 women and two children, and there were 137 vacant beds. The number of inmates at the date of the last census was 276 men, 11 women and two children, and there were 247 vacant beds. At Rowton Houses 5,042 men were accommodated, the same as in 1922, and there were no vacant, beds. Venereal diseases. The number of new cases of venereal disease dealt with by the hospitals during 1923 was 25,650, of which 7,128 were syphilis, 11,563 gonorrhoea, and 315 soft chancre. Comparing these figures with those of the previous year it will be observed that the total number of new cases dealt with is 1,937 more than in 1922. Year. Syphilis. Gonorrhoea. Soft chancre. Non-venereal. Total. 1922 6,807 10,635 321 5,950 23,713 1923 7,128 11,563 315 6,641 25,650 Increase 321 928 —6 694 1,937 The total attendances were 555,509, and the ratio of attendances to venereal cases is in the proportion of 29 attendances to each new case. This is noteworthy 43 when it is borne in mind that in those countries where venereal diseases are compulsorily notifiable, the ratio of attendances to new cases has never been greater than the figures which are shown for London under the voluntary system adopted in this country. Comparative figures for the seven years the scheme has been in force are shown in the following table:— New cases. Year.Total. Attendances. Venereal. Non-venereal. 1917 13,025 2,360 15,385 120,659 1918 13,679 2,693 16,372 169,485 1919 23,147 5,118 28,265 307,722 1920 24,454 6,592 31,046 464,033 1921 19,368 6,050 25,418 496,209 1922 17,763 5,950 23,713 529,003 1923 19,006 6,644 25.650 555,509 Attention is also drawn to the very large number of non-venereal patients who present themselves for examination. This appears to indicate quite clearly that the general public is appreciating more and more the efforts which have been, and are being, made to spread far and wide a knowledge of the serious nature and grave after effects of the venereal diseases. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the seven years are shown in the following table. Pathological examinations. Year. For treatment centres. For private practitioners. 1917 13,988 3,649 1918 25,973 6,380 1919 51,554 10,464 1920 58,920 14,027 1921 66,134 18,472 1922 74,022 19,836 1923 69,784 24,403 Thp inrreased use made bv medical practitioners of the facilities for the examination of pathological specimens is highly satisfactory. The Committee appointed in 1922 by the Minister of Health (Lord Trevethin as Chairman) to consider and report upon the best medical measures for preventing venereal disease in the civil community having regard to administrative practicability, including cost, issued their report during 1923. The report, which was unanimously signed, stated that success of medical measures for combating venereal disease must largely depend upon the attitude of the community, whose intelligent co-operation can only be secured by widespread education in the matter. The chief recommendations were as follows:— (а) That knowledge as to the nature and consequences of venereal disease should be extended amongst the community. (b) That steps should be taken to diminish conditions conducive to promiscuous intercourse and the spread of disease. (c) That the law should be altered so that properly qualified chemists may sell ad hoc disinfectants and directions for their use, provided these are approved by a competent authority such as the Medical Research Council. (d) That speaking broadly general practitioners require an improvement in medical education in its most advanced aspects to enable them successfully to deal with venereal diseases. (e) That the existing clinics are of great value and the system should in every way be encouraged and improved. Trevethin Committee Report. 44 As regards improving the clinics and the treatment of venereal diseases generally, the following measures were suggested:— (1) The provision of more suitable accommodation. (2) Extension of hours and greater facilities for the intermediate treatment of gonorrhoea. (3) More in-patient beds. (4) More hostels for women. (5) Provision of more homes or hospital beds for children. (6) Provision of trained social workers to be attached to the staff of the clinic. (7) Increased facilities for medical supervision of pregnant women, which entails extending ante-natal clinics. (8) Better instruction of midwives in venereal diseases. The report concludes with the statement that the views and recommendationsrecorded above have been based on the existing medical knowledge as to the prevention and treatment of venereal diseases, and the Committee realise that certain modifications might be called for in the light of important new knowledge, of which there are indications. The majority of the foregoing suggestions are already embodied in the Council's scheme. Housing of transmigrants. In 1919, at the conclusion of the war, the unsatistactory features associated with the housing of transmigrants passing through London, on their way from the continent to America prior to the war, were found to be repeating themselves in an aggravated form. Large numbers—as many as 1,500 on a particular night— were found occupying common lodging-houses, and cheap tenements in the poorer parts of Whitechapel and St. George's in the East. In 1920 an additional place for their accommodation was found in use in St. Pancras. As a result of a conference at the Home Office on 16th June, 1920, the shipping companies undertook to make proper provision for housing these passengers during their stay in this country. In 1921 negotiations were commenced by the companies to acquire a site in Bethnal Green, but at the last moment the proposed arrangements fell through. In the meantime another site had been found at Eastleigh, near Southampton, whither it was decided to convey passengers by water, thus avoiding London. During these negotiations the agent of one of the large shipping companies acquired a large common lodging-house on the eastern boundary of the county, and suitably adapted it. This house, which is of modern construction, had sleeping accommodation for over 500 people. Some 47,000 people passed through the hostel. For the past two years the home has been little used, and it is now closed, the shipping companies having for various reasons ceased to bring their passengers to London. Housing Acts. Details of the progress made with the several represented insanitary areas and the housing schemes undertaken by the Council will be published later in vol. III of the Annual Report of the Council. The table on p. 45 shows the houses in each borough in 1923 ; the number repaired under Section 28 of the Housing Act of 1919 ; certain other particulars as to conditions in 1923 ; and the action taken by the metropolitan borough councils under the provisions of Section 17 of the Housing and Town Planning Act with regard to the making of representations and closing orders—the figures for the years 1911-14, 1915—19, and 1920-23 are included for comparison. 45 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. 1923. 1023. 1923. 1923. 1923. 1911-14 1915-19 1920-23 1911-14 1915-19 1920-23 1911-14 1915-19 1920-23 Battersea 2,7981 2,4938 34 48 8 187 1 13 44 — 13 6 — — Bermondsey 19,177 18,917 12 3 — 68 13 3 111 46 1 67 — — Bethnal Green 19,465 Almost all — 161 — 32 34 10 43 19 5 40 2 4 Camberwell 41,780 4/5 of total — 14 2 — — 8 — — — 1 — 3 Chelsea 10,355 — — — 56 flats 3 — — — — — 9 8 15 Deptford 18,122 Not stated — — — 95 8 — 95 7 — 40 2 — Finsbury 6,788 6,200 — — — 21 17 5 2 17 5 — — 50 Fulham 27,038 20,265 — 3 — 43 1 7 38 1 7 22 — — Greenwich 16,680 Majority — 80 110 193 — — — — 3 26 — — Hackney 34,811 14,085 — 62 4 11 29 37 11 34 — 9 — — Hammersmith 18,481 12,000 — 27 — 37 26 13 6 38 17 — 25 5 Hampstead 12,608 About half — — — 17 17 24 17 17 22 5 — 10 Holborn 3,473 8,571 t'n'mts — — — 63 4 1 6 2 1 46 — — Islington 42,663 27,000 — — — 50 10 3 38 8 3 19 1 1 Kensington 28,416 9,141 4 2 houses, 14 flats 5 cotts., 42 flats 86 9 3 24 9 20 1 — — Lambeth 42,607 31,955 — 116 — 102 38 17 102 — — 129 — 103 Lewisham 35,539 Not stated — 144 — 25 9 — 11 19 15 8 3 - Paddington Not stated Not stated 1 — — 23 17 24 27 10 6 1 — 1 Poplar 23,064 Almost all 1 — 61 68 39 5 68 33 7 2 1 — St. Marylebone 19,039 8,080 — 15 32 32 20 — 32 19 — 9 3 1 St. Pancras 25,216 16,000 — — — 109 53 — 72 56 — — — — Shoreditch 14,000 13,000 — 30 — 12 9 — 12 3 17 11 7 11 Southwark 20,312 20,000 — 80 — 152 4 287 84 — 45 — 32 43 Stepney 31,692 31,692 3 51 136 flats 44 27 2 44 59 — — 6 — Stoke Newington 8,599 3,978 — — — — — — — — — 1 — — Wandsworth 64,637 47,535 — 533 — — 1 — — — — — 7 1 Westminster (City) 27,130 Not stated — — 40 21 7 — 9 6 — 25 39 — Woolwich 26,795 22,593 - 168 38 97 40 20 42 32 10 16 5 2 10976 46 Sanitary officers. The subjoined table shows the number of sanitary officers and health visitors employed by the sanitary authorities in London:— Sanitary area. Sanitary inspectors. Male. Female. Health visitors. | Whole time. Part time. Whole time. Part time. City of London 24 1 — — - Battersea 11 - 2 6 2 Bermondsey 10 — — 8 — Bethnal Green 9 — — 10 - Camberwell 11 2 — 3 - Chelsea 4 — — 1 - Deptford 7 — — 6 1 Finsbury 9 1 — 3 — Fulham 10 1 — 5 — Greenwich 5 1 — 5 1 Hackney 18 2 — 11 — Hammersmith 9 1 — 3 - Hampstead 7 1 — 3 — Holborn 3 — 1 1 1 Islington 18 2 — 7 - Kensington 11 7 — 7 - Lambeth 15 — 2 4 2 Lewisham 9 1 - 8 — Paddington 9 2 — 2 — Poplar 10 1 — 6 — St. Marylebone 11 — 3 3 3 St. Pancras 14 2 4 2 4 Shoreditch 12 — - 5 - Southwark 12 1 — 10 — Stepney 18 — — 11 — Stoke Newington 3 — — 3 — Wandsworth 11 — 2 4 2 Westminster, City of 10 1 — 5 — Woolwich 10 1 2 6 2 London County, 1923 308 28 16 148 18 Dressar of fur skins. At the end of 1923, 42 sets of premises were registered as subject to the by-laws regulating the business of a dresser of fur-skins. Poultry slaughtering During 1923 the Minister of Health confirmed the draft by-laws made under section 19 of the Public Health (London) Act, 1891, regulating the business of a slaughterer of poultry, and detailed inspections of the premises (numbering some 120) which will fall within the province of the bv-laws. are now in progress. Tuberculosis. Under the Council's scheme for the treatment of tuberculosis the total number of beds actually in use on 31st December, 1923, was as follows:— Institutions. Adults. Children. Total. Ex-service. Civilian. Metropolitan Asylums Board 133 796 512 1,441 Voluntary 218 311 195 724 Total 351 1,107 707 2,165 5,123 applications for institutional treatment of adult patients were received, viz:— First applications. Applications for further treatment. Males (Ex-service men) 373 Males (Ex-service men) 748 „ (Civilians) 1,730 „ (Civilians) 381 Females1,561 Females 330 3,664 1,459—Total 5,123 Of these 762 (including 185 examined at County Hall) were not accepted for treatment under the Council's scheme ; 1,460 patients were examined at the County 47 Hall, and their disposal then determined; 1,381 were referred to observation hospitals for admission as a preliminary step to their disposal; 1,637 were accepted for admission direct to institutions without previous observation or examination, and in 68 cases the applications for various reasons were not proceeded with. In 288 of the cases for residential treatment, the patients for various reasons failed to enter observation hospitals or other institutions, and their applications were treated as withdrawn. In 145 other cases treatment was not commenced before the end of the year. As a general principle, the cases passed through the observation beds are patients in whom the diagnosis has not been confirmed by the presence of tubercle bacilli in the sputum; patients with acute symptoms ; and patients with wellmarked disease whose suitability for sanatorium treatment can be determined only after a few weeks' close observation. Cases examined at the County Hall are those in which the diagnosis has been confirmed by the presence of tubercle bacilli in the sputum and which appear, from their reports, to be suitable for sanatorium treatment, and cases of surgical tuberculosis. Cases sent direct to sanatoria are chiefly applicants for further treatment, whose condition and prospects are already known. Action taken with regard to adult patients examined at the County Hall during 1923 Observation hospital. Sanatorium. Home for advanced cases. Not accepted. Total. 253 977 45 185 1,460 During the year 1,741 patients were discharged from observation hospitals nnrl 3,952 from othrt institutions The classification of the 1,741 patients discharged after observation in hospitals : Classification—Group A 363 cases or 24.90% „ B.1 100 „ 6.86% „ B.2 642 44.03% „ B.3 315 „ 21.60% Surgical cases 38 „ 2.61% Total diagnosed as tuberculous 1,458 Diagnosis of tuberculosis not confirmed 283 Total discharged from observation beds 1,741 Action taken with regard to 1,458 cases in which tuberculosis was diagnosed, compared with the figures for 1922 :— Year. 1923. 1922. Discharged home 183 189 Made their own arrangements or refused further treatment 172 169 Transferred to institutions for advanced cases 236 292 Elected to go to infirmaries 36 49 Transferred to surgical hospitals 12 11 Transferred to general hospitals — 3 Transferred to training centres 3 12 Died during observation 42 48 Discharged for misconduct 5 4 Transferred to sanatoria 769 1,427 Totals 1,458 2,204 At the commencement of 1923 the Council had in use 655 beds for children in hospitals and sanatoria, of which 178 were in voluntary institutions and 477 in Metropolitan Asylums Board institutions. The number of cases under treatment on 31st December, 1923, was 707 (195 in voluntary institutions and 512 in Metropolitan Asylums Board institutions). On 1st January, 1923, 340 boys and 315 girls were under treatment and 403 boys and 346 girls were sent away during the year. The total number treated during the year 1923 was, therefore, 1,404, as Tuberculous children. 10976 D 2 48 compared with 1,432 in 1922. In addition, 218 children had the advantage of convalescence through the Invalid Children's Aid Association with the financial assistance of the Council. The scheme of co-operation between the Council and the 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 under the tuberculosis scheme, was continued during 1923. The sum paid to the Association during 1923 was £2,000. During 1923 the Association received 236 applications for convalescent treatment, and 218 children were sent away with the assistance of the Council's grant. The remaining 18 cases were found to be ineligible. In addition to these, 26 children were sent away without help from the Council's grant-in-aid, as the parents were able to pay the full cost of treatment. 37 children were supplied with surgical instruments with the help of the Council's grant-in-aid. As in 1920, 1921, and 1922, the Council arranged with the Association for the children attending the Council's schools for tuberculous children, to go away to the seaside for a fortnight's holiday during the summer of 1923. 202 children were sent to a convalescent home at St. Leonard's-on-Sea, the Council making a grant of £435 towards the cost. In addition to the provision for treatment of tuberculous children in residential institutions, the Council continued the use of five open-air schools specifically for children notified under the Tuberculosis Regulations, 1912, as suffering from tuberculosis of the lungs or of glands with no open wounds. The children are admitted on the certificate of the medical officer of the Council, and preference is given to those returning home after treatment in a sanatorium. The five schools—Camberwell, Elizabethan, Kensal House, Springwell House, and Stormont House—have, together, accommodation for 365 children. During 1923 140 children were admitted to the schools and 149 discharged. Of the latter, 42 were fit for elementary school, 75 were fit for work, 21 were transferred to hospital or sanatorium, 8 moved away, and 3 were discharged for other reasons. At Springwell House the average gain in weight of the children was 3.1 kilograms (1 child only lost, 1 kilogram). At Kensal House the average gain was 2.81 kilograms, while the average gain at the three remaining schools was 3 kilograms (2 children whose weight remained stationary are not included). The medical officer of Stormont House School stated that from a medical standpoint he was in every way satisfied with the progress of the children at the school, and that parents frequently expressed their gratitude for the improvement in their children's health. He referred again to the annual reunion of old pupils, mentioning the fact that, with one exception, all those present were in employment, as evidence that attendance at one of the schools for tuberculous children is not prejudicial to a child's chance of obtaining work. The following observations are quoted from the report of the medical officer of the Elizabethan School:— " The majority of children have improved materially in health and physique, and, as one would expect, the improvement has been more marked in the early cases. A number of the children have marked evidence of lung disease, generally dating from an attack of pneumonia, but the physical signs in these cases have remained almost stationary, and, although their general health has improved materially, it cannot be said that the disease has been arrested. " At the weekly clinics a good deal of attention has been devoted to children who have acquired faulty habits of deportment, breathing and speech, and some of the children appear to have benefited considerably from the advice given. Education and training is much needed to remedy these defects, as they have a bad influence on the children's health and mentality. 49 " Two children whose condition was complicated with commencing scoliosis have been greatly benefited by appropriate treatment, and a number of the children who at one time suffered from adenoids have also received special exercises and advice regarding their breathing " During 1923 Dr. Bardswell has investigated the after histories of adult tuberculous patients in the County of London who received institutional treatment during the year 1918. The results of these enquiries may be summarised as follows:— Enquiry into the careers of 2,987 cases confirms the impressions formed by many experienced observers, as to the usefulness of the sanatorium in the treatment of tuberculosis in its initial stages, and of its ineffectiveness when the disease is wellestablished. Dr. Bardswell's report on after histories of adult tuberculous patients. The cases of pulmonary tuberculosis treated during 1918 were made up of 47 per cent. early cases, 29 per cent. of moderately advanced cases, and 24 per cent. of far advanced cases. Many of the last-named group were in the terminal phases of the disease, for whom temporary alleviation of symptoms was all that could be hoped From the point of view of treatment and recovery, interest centres on the groups of early and moderately advanced cases. The investigation showed that in July, 1923, some four to five years subsequent to their sanatorium treatment, 85 per cent. of the early cases, and 39.9 per cent of the moderately advanced cases were alive and the remaining 15 per cent. of early cases and 60.1 per cent. of moderately advanced cases were dead. The group of far advanced cases, as was anticipated, showed a heavy death-rate, only 4.5 per cent. having survived. The comparable figures for 1914 were—(a) early cases 26 per cent., (b) moderately advanced cases 53 per cent. and (c) far advanced cases 21 per cent. The marked increase of the percentage of early cases dealt with in 1918, as compared with 1914. is encouraging. A higher level of medical skill and attention in 1918 may account for some of the improvement. On the other hand, errors of diagnosis, especially among the ex-service men, almost certainly contribute to the good proportion of early cases. The guiding principle has been to give ex-service men the benefit of any doubt, with the result that many cases of obsolete tuberculosis and of non-pulmonary lung disease have been notified as active tuberculosis. In consequence, some fall in the percentage of early cases may be expected in subsequent years. There appears to be no doubt that the patient's home environment, his housing, work, habits, temperament, and standard of living, determine the consumptive's future to a much greater degree than does his period of sanatorium treatment. Under the conditions to which many, indeed the majority, of London patients return on leaving a sanatorium, well-established tuberculous disease of the lungs is rarely to be cured. Successfully to withstand conditions so unfavourable, tuberculosis must needs be arrested more completely than is possible during a stay of a few months in a sanatorium. A year's continued sanatorium treatment might make more difference. Even then, in many cases, one would expect bad home conditions to be the decisive factor in ultimate failure. The question is often asked : Can nothing more be done to improve the prospects of the case of moderately advanced disease ? Is a mortality of some 70 per cent. within four years to be accepted as inevitable ? The pensioned ex-service man throws some light upon this point. The ex-service man, as compared with the civilian, has enjoyed exceptional advantages. No limit has been put to his institutional treatment. Most of the men have had repeated and prolonged periods of treatment, terminated only at their own request or on the recommendation of medical superintendents of sanatoria. At the same time, financial worries and anxiety about dependents, both during and after treatment, which may be a source of failure in the treatment of the civil population, are eliminated by the receipt of pensions and allowances. The ex-service man, in short, has had a well endowed scheme of alter care. One would expect, therefore, to find that the ex-soldier has done better than 50 the civilian, and this is actually the case. Taking the most instructive class—the moderately advanced cases (B.2)—the records are as follows:— Number of Number Number cases. alive. Percentage. dead. Percentage. Ex-service men 435 221 61% 214 49% Civilian males 191 46 24% 145 76% Civilian females 144 40 28% 104 72% From these records it will be seen that in this group the results of the treatment of the ex-service men are materially better than those for comparable cases among the rest of the population. Age at death of the 1918 cases.—The next table which records the age at death of the 1918 cases, is of some interest. It shows that among the civil population the heaviest mortality occurred at the younger ages among women, namely, from 16 to 30, and at a somewhat later age among men, namely, from 36 to 50. Among the ex-service men, the age of death was relatively low, the greatest number of deaths having occurred at ages 21 to 30:— Age at death. Males. Females. Ex-service men. Totals. 16—20 4l 55 22 l8 21—25 36 82 122 240 26—30 38 69 120 227 31—35 37 30 98 165 36—40 54 14 92 160 41—45 58 13 78 149 46—50 61 8 29 98 51—55 27 3 17 47 56—60 17 2 3 22 61—65 4 2 — 6 66—70 4 — — 4 377 278 581 1,236 The County Medical Officer of Health dealt fully with the subject of mortality from tuberculosis in his annual report for 1922. He has suggested in that report that one of the indirect influences of the war may have been to emphasise the tendency, already manifested several years before the war, towards an increase in the mortality among young adults. This view is confirmed by records given above. The explanation is doubtless to be found in the fact that soon after the war broke out the outward migration of young adults suffering from phthisis practically ceased. With respect to the maintained and indeed increased mortality among women at younger ages in 1921 and 1922, it is suggested in the same report that the " tendency for young girls to exchange ' living-in' as domestic servants for ' living-out' may have operated prejudicially upon their health. The domestic servant, who formerly was well-housed and well-fed and cared for, has now, in many thousands of instances, repaired to the tenement, the picture palace and the factory." One's every-day experience favours this view. Certainly cases of acute pulmonary tuberculosis—the so-called galloping consumption, which runs a rapid and fatal course—are more commonly seen among young adult women than among young adult men. and thpse vouner women are drawn largrly from factorv and allied workers. Dr. Knobel's report on mortality in relation to age and occupation. From figures supplied him by the Registrar-General, Dr. Knobel has studied the question of the mortality from pulmonary tuberculosis of men, in London, for the years 1921 and 1922 in relation to age and occupation. His results are published in " Tubercle " for June, 1924. He points out the wide variation that exists in the mortality rates in different industries and he suggests that there are three main factors at work :— (i.) The number of " weaklings " and " susceptibles " in the industry, (ii.) The character of the work and the conditions under which it is done, (iii.) The general habits of the employees, particularly their tendency to alcoholism. 51 He further suggests that the height of the mortality rates in the early agegroups in an industry will be an indication as to the proportion of weaklings and susceptibles in the industry, and the height of the mortality rates in the later agegroups will provide a measure of the degree to which the occupation, the conditions under which the work is done, or the habits of the employees are responsible for the disease. He has accordingly classified the occupations into four classes according to the height of the mortality rates in two age-groups, 15-25 and 25-65, compared with the mortality rates in these two age-groups of the total occupied, taken as the average. Class 1.—Those occupations in which the death rates from pulmonary tuberculosis are above the average in both age-groups. This class contains makers of bricks, pottery and glass, workers in skins and leather goods, boot and shoe makers, builders and bricklayers, water transport workers, and general labourers. Class 2.—Those occupations in which the death rates for the early age-groups are above, and for the later age-groups are below the average. The main occupations in the class are :—metal workers, makers of foods, drinks, etc., carpenters, painters, railway workers, commercial travellers, insurance agents, clerks, and warehousemen. Class 3.—Those occupations in which the death rates for the early age-groups are below, and for the later age-groups are above the average. This class contains fitters, tailors, workers in wood, messengers, persons employed in entertainments, and personal service, inn-keepers, etc. Class 4.—Those occupations in which the death rates are below the average in both age-groups. The main occupations included in this class are workers in chemicals, precious metals, electrical apparatus, road transport workers, commercial occupations, public administration, and professional occupations. Much more detailed investigation into the various occupations followed in an industry is required before a definite opinion can be formed on the relationship between occupation and pulmonary tuberculosis. Mental Deficiency Act, 1913. On 31st December, 1923, of the 3,223 cases being dealt with at the expense of the Council, there were—In institutions, 1,675 ; under guardianship, 15 ; under supervision, 1,510; in places of safety waiting other action, 23. There remained 2,934 out of the total number 6,157 of cases of alleged mental defect, of which notice has been received since the Act came into operation. These cases include 381 in which no action could be taken; 1,192 ascertained not defective, or not to be London cases ; 508 dealt with through the Poor Law ; 669 removed from the register (died, discharged, or removed to mental hospitals), and 184 still under consideration. During the year 821 cases were examined with the following results :— Type. Male. Female. Total. Idiot 20 8 28 Imbecile 98 90 188 Feeble-minded 238 283 521 Moral imbecile 2 — 2 Not defectivo 45 20 65 Insufficient evidence 6 11 17 Total 409 412 821 In addition to the foregoing, certain cases were examined while still of school age, and are recorded in the section relating to the school medical services. During the year 10 occupation centres have been opened and operate under the Occupation proviso that 75 per cent. of the cases on the roll of each centre shall be cases which have been placed under statutory supervision. Four of the centres are grouped in 52 pairs and work inter-dependently. Visits have been paid to the various centres and favourable reports thereon have been submitted, but it is noted that the work is only in the experimental stage. The curriculum of the centres includes marching and block-building, bead-threading, cross-stitch, raffia-work, and other simple occupations. Where a piano and the necessary assistance is available, there are simple games, musical exercises, and country dances. The parents appear to interest themselves in the work of the centres, and although the attendances of the children are not large, much useful work appears to have been accomplished already. Several mothers have given testimony to the improved deportment and usefulness of the children when at home which has followed their attendance at a centre. Age and cause of death of men tails deficient 8. A point of some interest in connection with the care of defectives is the question of the length of life to be expected. Since the commencement of the Mental Deficiency Act, 1913, it has been noted that of cases dealt with under the Act, 305 have died, and that the deeper the degree of defect the earlier, on the average, has been the date of death. The following figures, however, only represent the average of those who have died during the period, but do not represent the expectation of life of all defectives of the corresponding degree or type. Average age Average age Degree of defect. Sex. at death. Type of defect. at death. Idiot Male 11.6 years. Mongol 10.4 years. Female 11.6 „ Cretin12.5 „ Imbecile Male 12.6 „ Cer. Par. 12.4 „ Female 13.4 „ Epilepsy13.4 „ Feeble-minded Male 20.5 „ Primary Amentia 1.-4 „ Female 21.7 „ (Total of 305 cases.) The feeble-minded generally come to notice somewhat later in life than those more deeply affected in mind, and a number may well have died without attention being drawn to their condition. The causes of death were ascertained in 226 of the cases, and are classified in the following table:— Cause of death. Number dead. Cause of death. Number dead. Diseases of the respiratory organs 79 Paralysis 5 Tuberculosis 55 Meningitis, etc. 23 Epilepsy 23 Miscellaneous 22 Heart disease 11 Fevers 8 Total 226 Blind Persons Act. The Council's scheme for carrying out the provisions of the Blind Persons Act, 1920, set out in previous reports, was continued throughout the year, during which 56 persons over school age were seen. Of these, 38 males and 10 females were found to be capable of benefiting by training, and advice was given as to trades in which the persons should severally be trained, having regard to the prospects of future employment, : 4 males and 4 females were considered t,o be unfit for training. Midwives. Duly certified midwives with London addresses exceed 5,000 in number, of whom 905 gave notice of their intention to practise within the County during the whole or part of the year, an increase of 76 on last year's figures. About 10 per cent. of the midwives with London addresses are in actual independent practice in the County, the remainder acting mostly as monthly or general nurses under medical supervision. Practising midwives, other than those who work entirely in hospitals or infirmaries under medical supervision, are subject to inspection by the Council's officers, with a view to ensuring that a proper standard of efficiency is maintained. This work is carried out by four women medical inspectors, who pay special visits to midwives having cases of a septic nature or persistent high temperature or inflammation of the eyes. Advice is also given by the inspectors on any point of difficulty arising in connection with the work ; 2,549 visits were paid by the inspectors this year, as compared with 2,366 the previous year. 109 infringements of the rules of the Central Midwives Board were reported during the year, of which 74 were slight, and therefore dealt with by means of a verbal caution; 24 cases were of a more serious nature, and were dealt with by a 53 written caution. Of the remaining 11 cases, 8 midwives were seen by the Committee, and 6 of them cautioned ; the other 2 were reported to the Central Midwives Board, as were 3 other midwives who were not so seen. These 5 cases were dealt with as under : 1 was removed from the roll; 1 was cautioned ; in one case sentence was postponed pending the submission of further reports by the Council at the end •of three and six months ; 1 was found guilty of the charges brought, but no further action was taken, and 1 was considered to have been acting as a maternity nurse only. Six midwives were suspended from practice with a view to the prevention of the spread of infection, and in four cases compensation was authorised. One midwife applied for a certificate in support of her application to the Central Midwives Board for the restoration of her name to the Midwives Roll, but the committee decided that this application could not be entertained. The Midwives Act, 1902 (section 1 (2)), makes it an offence for any uncertified woman habitually and for gain to attend women in childbirth except under the direction of a registered medical practitioner. During the year, 20 inquiries were made by the inspectors into such cases, in 11 of which it was decided to take no further action ; 7 were dealt with by a verbal or written action, while of the remaining two cases, one was referred to the Solicitor on two occasions for legal proceedings, and the other committed for trial for an illegal operation. During the year there were 582 still-births reported by midwives in their practice. The figures for previous years were : 1919, 686 ; 1920, 896 ; 1921, 684 ; 1922, 720. Of these infants, 312 were males, and 270 females. Of the 582 still-births, 346 were reported macerated, and 236 not macerated. 360 cases of puerperal fever were reported during the year, as against 311 the previous year. 97 cases proved fatal, as compared with 91 the previous year, a case mortality of nearly 27 per cent. as against 29 per cent. the previous year. In addition the Registrar-General recorded 31 deaths from puerperal sepsis, which were, however, not notified as puerperal fever. The distribution of the notified cases was as follows:— Delivery conducted by Cases. Deaths. (а) Medical practitioners 126 37 (b) Certified midwives 11128 (c) Medical practitioner and certificate 3 1 (d) Hospitals and poor-law institution 87 22 (e) Cases of miscarriage or abortion where no attendant was engaged 33 9 Total 360 97 In certain emergencies specifically enumerated in the Rules of the Central Midwives Board a midwife is required to advise in writing that medical aid be summoned, and must also see that such help is summoned and obtained. The notice is sent to the doctor, and a copy must be forwarded to the local supervising authority. During 1923 as many as 7,040 notices were received, as compared with 6,804 in 1922. Assuming that approximately 42,000 confinements were conducted during the year by midwives in independent practice, it appears that medical aid was required in about 17 per cent. of the cases, as compared with 16 per cent. in the preceding year. Medical aid. Great stress is laid by the Council on the due observance by midwives of the Rules of the Central Midwives Board with regard to inflammation of the eyes. However slight the inflammation may be, it is the duty of the midwife to summon medical aid, and as soon as the notice is received at this office the case is followed up by one of the medical inspectors. Notice is also sent to the borough medical officer, so that the health visitor may continue to keep observation on the child after the midwife has left the case. Most valuable assistance is also given by the Voluntary Nursing Associations in cases where domiciliary treatment is necessary. 54 1,339 notices were received from midwives during the year with regard to medical aid summoned for inflammation of the eyes of infants, as compared with 1,241 in 1922. In addition, 55 other cases occurred in which either medical help was not called in by the midwife or she failed to notify the Council that she had done so. Of these 1,394 cases, 449 proved to be ophthalmia neonatorum, as compared with 547 in 1922 ; 304 other cases that did not occur in the practice of midwives were also notified, making a total for the year of 753 notified cases of this disease. The percentage occurring in the practice of midwives was 59.6, as against 65.3 in 1922. All the cases that occurred in the practice of midwives were investigated by the inspectors, and it was found that 420 were reported as completely cured, while 12 died. In one case blindness resulted in both eyes, and in one case of one eye ; impairment of the vision in both eyes occurred in two cases and of one eye also in two cases, whilst in 11 instances the result could not be ascertained owing to the removal of the patients. In addition, two cases in the practice of midwives were investigated in which there was damage to the eyes, one resulting in total blindness and the other in loss of sight in one eye. These cases, however, were never notified as ophthalmia neonatorum. 64 cases received in-patient hospital treatment at St. Margaret's Hospital. In past years classes have been arranged for the instruction of midwives, and were well attended. As it was found that there had been a falling off in the attendance, it was decided to dispense with such classes during 1923, but it is anticipated thev will be renewed next vear. Lying-in homes. The by-laws made under section 18 of the L.C.C. (General Powers) Act, 1921, are being carried out by the keepers of lying-in homes, and are of assistance to the Council in dealing with any complaint that may be made with regard to the home. Children Act, 1908. The powers of the Council under the Children Act, 1908 (Part 1), with regard to infant life protection are fully indicated in the Annual Report for 1921. The work of inspection is carried out by 14 visitors and two male inspectors. Nurse infants who are being kept under specified unsatisfactory conditions, may under powers given by the Act be removed to a place of safety—i.e., in London to Poor Law institutions. During 1923, 6 nurse infants were removed, as compared with 14 in the previous year. The Act permits the Council to grant whole or partial exemption from inspection in cases where the circumstances appear to warrant such a course, and partial exemption limited to inspection once or twice a year was granted in 3 cases. All the homes in which foster children are kept are visited with a view to ascertaining whether the sanitary condition of the premises is satisfactory. During 1923 1009 reports as compared with 971 during 1922 were made. The premises were found to be satisfactory in 648 cases as compared with 668 the previous year. Sanitary defects were discovered in 143 homes as compared with 141 the previous year while overcrowding was reported in 141 homes as compared with 92 in 1922. Overcrowding and sanitary defects were found in 18 homes as compared with 9 the previous year. In 59 cases no action could be taken owing to the removal of the infant prior to the visit of the inspector. In any case of serious sanitary defect the attention of the borough council was drawn to the defect. A re-arrangement of the accommodation has in some cases enabled an improvement to be effected, but in others this has been impossible and the foster mothers have in such cases been urged either to obtain more suitable accommodation or to return the infant to its parent. As will be obvious the lack of suitable housing accommodation has added to the difficulty of dealing with such cases. The help of the local infant welfare centre is sought in the case of the illness of an infant, and where a foster mother has charge of a weak or ailing infant she is urged to take the infant to the centre and follow the medical advice given there. The visitors are instructed to watch such cases with a view to seeing that the 55 treatment is carried out. Whenever a visitor is doubtful as to the progress of an infant the matter is reported with a view to an inspection being made by one of the Council's medical officers. This practice has worked very satisfactorily and has been of great assistance to the visitors. A nurse infant ceases to be under this part of the Act at the age of seven years, but as the child usually attends school from the age of 5 years it has from that age the additional advantage of supervision by the School medical service. The number of deaths of nurse infants during 1923 was 53, the same as last year, while inquests were held in 11 cases as compared with 9 in 1922. The verdict in 10 cases was death from natural causes, and in the other accidental death ; the child being killed by a motor car. From time to time during the year cases have been brought to notice emphasising the necessity for dealing with the question of adoption and it is anticipated that the matter will be again investigated at an early date. Work of the Chemical Branch. The work of this branch was carried out at four laboratories, viz., the Central Laboratory at County Hall, the Greenwich Generating Station, and the Laboratories at the Northern and Southern Outfalls During the year about 3,500 samples of various articles were submitted by departments of the Council, and examined, in most cases, as to their compliance with specified conditions or general suitability for use. This number includes 173 samples of building materials ; 175 of coals ; 61 of disinfectants ; 175 of foods : 193 of oils ; 78 of paints and colours ; and 115 of petrol (under the Petroleum Acts). Analyses were made in situ of 61 gases used in connection with dry-cleaning and degreasing plant in use in London. In connection with the supervision of dietary of necessitous children in Council Schools, 1,116 samples of milk and 68 complete meals were examined, as well as a number of samples of dried milk. 672 samples of hard and softened water were examined and advice given, in connection with the water-softening plant at County Hall, and about 500 samples of river water were collected at various states of tide and examined in connection with the general investigation of the condition of the river. A series of experiments conducted at the request of the Chief Officer of the London Fire Brigade showed that a mixture of ammonia and air, such as might occur owing to a defect in a refrigerating plant, is explosive when subjected to a high-tension spark discharge. Danger of explosion appears to arise with mixtures not very rich in ammonia when the P.D. across the spark-gap is 20,000 volts or over, but time did not allow of the conditions being fully studied. Central Laboratory. The work of the laboratory at the Greenwich generating station comprises:— (i) The daily examination of samples and materials for controlling the operation of the water-softening plant, the blowing down of boilers, condenser leakage, and the purity of condensed water supplied to the station batteries ; (ii) the sampling, preparation and examination of fuel (coal); (iii) the preparation and examination of fuel ashes, the analysis of flue gases, boiler scales, stores, etc., and investigations connected with corrosion and other troubles incidental to the operation of the station plant. Greenwich Generating Station Laboratory. At the outfalls 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 tides, has been continued in addition to the other work which is carried out in connection with these laboratories. Outfalls. In previous reports reference has been made to experiments conducted in regard to the biological treatment of sewage. It has been found possible, by a variety of methods of treatment, to produce an effluent which, on the scale of the Council's operations, could be admitted to the Thames without producting undesirable Biological treatment of sewage. 56 conditions. So far, the problem of treatment, of the effluent at present discharged from the outfalls, with activated sludge has not been directly attacked, at any rate, for a sufficiently long period to justify any conclusions. On general grounds, and having regard to the experience of the Birmingham Sewage authorities, it would appear that the treatment of effluent, rather than raw sewage, is a most promising method. It would have the advantage that a great part of the impurities would be removed, as at present, in the form of a relatively dry sludge, and would probably enable sufficient treatment with activated sludge to be given in a relatively short residence period in the treatment tanks or channels. Experiments on the keeping properties or stability of the effluent obtained in the " paddle " plant have shown conclusively that, although the full oxidation of all the matters in the original sewage has not been made an aim of treatment, the effluent is unlikely to make any appreciable demand on the self-purificatory powers of the River Thames. This is an important fact, as showing that the prolonged stay in treatment tanks required to produce complete nitrification would be unecessarv. River Wandle. The condition of the River Wandle, to which attention has been called in past years, both in and before it reaches the County of London, has been the subject of investigation and conference between the various bodies concerned. There appears to be general agreement that, in addition to the extensive scheme of the Wandle Valley Drainage Board for improving the character of their effluent, attention should be given to the stream itself throuhout the whole of its course. River Thames. The systematic examination of the River Thames was continued in 1923 at points from Waterloo Bridge to the Edinburgh Lightship, which is in the vicinity of the discharge area for sludge from the Council's outfalls, and for other waste materials. In addition to examination of the water, the survey of the river bottom, which has been in process for some time, was continued throughout the year. The results obtained from the examination of both water and material from the bed showed that, from the Chapman Light at the upper end of Sea Reach onwards to the estuary, the evidence of pollution and deterioration of the river was small and rapidly decreased seaward. In the neighbourhood of actual discharge, no evidence of widespread pollution was at any time found. The year was remarkable for the high temperature reached in June. Having regard to the temperature of the water and the decreased flow of the river at this time provision was made for additional treatment of sewage at the outfalls ; but a general fall of temperature caused improvement in the river water and the treatment was discontinued. CJt TABLE I. COUNTY OF LONDON. Vital statistics for the several metropolitan boroughs and the County of London in the year 1923. (Rates per 1,000 of civil population.) Metropolitan boroughs. (Arranged in topographical order.) Estimated civil population, 1923. Births. Death. Infant mortality (per 1,000 births. Measles Scarlet fever. Diphtheria. Whoop- ing cough. Typhoid fever. Diarrhoea and Enteritis, age 0-2 (per 1,000 births). Phthisis. Pneu inonia. Bronchitis. Cancer. Cases of notifiable infectious disease, la) Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Puerperal fever 'per 1,000 births). Cerebro spinal fever. Acute pneumonia. Western. Paddington 146,200 17.9 11.8 69 .02 .01 .10 .16 .01 8.4 .68 1.04 .79 1.44 2.22 1.52 .09 .37 1.91 .01 2.30 Kensington 178,500 17.5 12.5 70 .10 .01 .08 .13 .01 15.1 .68 1.19 .86 1.56 1.21 1.39 .09 .38 4.81 — .70 Hamm.ersmith 133,600 20.2 11.1 64 .04 .01 .15 .07 .01 9.3 .97 .77 .94 1.29 1.83 1.74 .11 .23 4.81 .02 .62 Fulh.am 161,600 19.3 10.6 65 .15 .04 .12 .09 — 8.3 .93 1.03 .72 1.32 2.89 1.71 .02 .47 10.25 .01 1.33 Chelsea 64,480 15.7 12.5 56 — .02 .16 .08 — 7.9 .90 1.30 .74 1.88 1.71 1.52 .09 .40. 1.97 — .67 Westminster, City of 140,430 12.3 10.7 48 .01 — .04 .04 .01 3.4 .76 .63 .70 1.74 .88 .69 .14 .24 1.71 — .43 Northern. St. Marylebone 105,400 15.7 11.9 69 — .03 .02 .19 .01 9.1 .92 .89 1-04 1.57 1.19 1.24 .16 .49 .60 — .49 Hampstead 87,410 14.2 10.8 44 .02 .01 .09 .05 .02 8.1 .58 .61 .58 1.81 2.13 1.22 .11 .25 4.04 .01 .55 St. Pancras 214,400 20.4 12.1 63 .02 .01 .09 .13 .01 11.4 1.04 1.03 1.04 1.51 2.24 2.41 .09 .43 4.58 .01 1.54 Islington 336,600 21.1 11.7 67 .05 .04 .06 .11 — 14.5 1.01 .98 .78 1.43 3.22 2.65 .05 .27 2.95 .01 .53 Stoke Newington 52,820 18.2 10.8 48 — — .08 .04 .02 5.2 .64 .83 .57 1.93 1.33 1.08 .06 .27 5.21 — .23 Hackney 226,400 19.6 10.7 59 .07 .03 .15 .07 .02 6.8 1.00 1.06 .67 1.40 1 .99 2.35 .08 .33 4.74 .00 .16 Central Holborn 43,376 13.7 12.1 79 .07 .07 .09 .12 — 13.5 1.04 .92 118 1.36 2.47 2.33 .05 .32 5.06 .02 1.11 Finsbury 77,230 23.9 13.2 61 .14 .03 .12 .09 — 16.3 1.22 1.17 1.36 1.50 2.36 4. 04 .03 1.80 7.05 — .83 London, City of (b) 13,772 8.3 11.5 79 .07 - .07 .07 - - 1.09 .72 .65 1.31 2.84 1.31 .22 .36 — — .44 Eastern. . - - - - - - - Shoreditch 106,200 27.0 13.1 83 .21 .06 .12 .09 .01 12.9 1.37 1.53 1.23 1.23 3.72 3.40 .04 .57 2.44 .02 2.32 Bethnal Green 118,700 24.3 11.4 70 .29 .04 .17 .18 12.8 1.36 .98 .94 1.00 2.61 4.10 .04 .66 5.90 .01 160 Stepney 253,850 23.3 11.7 63 .26 .02 .12 .07 — 14.7 1.14 1.36 .90 1.28 2 .03 2.41 .09 .46 2.54 .02 1.39 Poplar 166,400 25.6 11.3 60 .13 .03 .18 .05 .02 8.2 1.01 1.1l 1.10 1.23 1 .74 2.19 .06 .48 3.76 .02 2.77 Southern - - - - - - - - - - - - - - - Southwark 187,464 24.3 13.0 70 .07 .03 .27 .14 .01 12.5 1.29 1.25 1-32 1.29 2.19 4.11 .10 .48 3.73 .02 1.12 Bermondsey 121,700 24.8 12.2 73 .12 .02 .27 .10 .02 16.6 1.22 1.30 .81 1.22 2.70 4.84 .02 .16 1.32 .02 1.03 Lambeth 308,500 20.2 11.6 59 .07 .04 .15 .05 .00 9.3 .97 .96 .82 1.40 2.71 1.89 .03 .36 7.69 .02 .72 Battersea 170,600 20.1 10.8 £0 .14 .04 .20 .09 .01 7.6 .81 .59 .78 1.42 2.52 2.52 .07 .51 2.04 .02 2.01 Wandsworth 336,100 16.3 10.3 54 .03 .01 .08 .09 .00 8.6 .79 .60 .61 1.39 1.72 1.10 .10 .29 2.19 .03 1.28 Camberwell 272,300 20.8 11.1 57 .13 .02 .27 .12 .01 9.0 .97 .90 .76 1.27 1.90 3.17 .05 .30 2.83 — .31 Deptford 114,900 211 11.1 59 .07 .02 .29 .10 .02 7.4 .83 .79 .63 1.22 3.01 3.53 .09 .50 2.47 — .63 Greenwich 102,777 20.6 11.0 62 .03 .02 .11 .15 .06 9.0 1.13 .84 .61 1.29 2.11 2.12 .15 .54 4.72 .05 .68 Lewisham 182,400 18.1 10.2 48 .01 .04 .15 .04 .01 8.8 .75 .67 .73 1.43 2.16 1.58 .02 .27 3.03 .01 .47 Woolwich 140,000 20.0 9.9 43 — .03 .01 .03 3.5 1.23 .46 .66 1.25 2.11 1.06 .10 .29 2.79 .02 1.66 London 4,564,109 20.1 11.4 61 .08 03 .13 .09 01 103 .97 .95 .84 139 2.21 2.26 .07 40 3.84 .01 1.04 (a) Sixteen notifications of smallpox were received, four in Greenwich, three in Battersea, and one each in Paddington, Westminster, Hackney, Finsbury, Camberwell,Lewisham, Hampstead,] Shorediteh, and Bethual Green. The three latter and two of the Battersea cases were, however, subsequently found not to be smallpox. (b) Including Inner and Middle Temples. Tuberculosis Dispensaries—analysis of Returns Jan. — Dec., 1923. 1 2 3 4 5 6 7 8 9 10 11 12 Borough and dispensary. Under observation on 1-1-1923 pending diagnosis. Examined for first time during 1923, including contacts. Number of contacts included in (3). Number included under (2) and (3) suffering from Number included under (2) and (3) found to be nontuberculous. Under observation on 31st December, 1923,pending diagnosis. Total attend ances. Visits to homes by Home consultations. Number referred to affiliated hospital. No. of specimens of sputum examined (a) Pulmonary. (6) Nonpulmonary. Adults. Children. Adults. Children. Adults Children. Adults. Child ren. Adults. Children. Adults. Children. Adults. Children. (a) Tuberculosis officer. (b) Dispensary nurse. Citv of London 1 1 42 19 21 11 13 — — 1 29 18 1 1 649 7 647 18 43 Battersea 52 36 482 411 90 200 150 9 15 37 279 329 85 69 5,436 188 6,942 40 92 1,132 Bermondsey 8 15 484 433 109 271 165 22 14 20 279 377 29 24 5,652 66 4,162 50 81 923 Bethnal Green 11 2 517 334 223 283 125 2 16 35 365 291 9 4 4,932 171 1,535 29 162 756 Camberwell 69 17 999 905 285 546 298 27 42 42 659 839 37 7 10,716 1,103 5,914 50 197 1,925 Chelsea 109 128 248 194 57 53 61 — 1 15 252 273 30 33 2,932 98 2,995 1 — 730 Deptford 9 3 380 381 131 150 100 8 11 23 265 353 11 3 5,491 380 5,079 11 — 665 Finsbury 9 15 275 154 113 110 99 4 12 16 147 137 18 7 3,920 285 2,949 1 12 438 Fulham 9 5 497 513 138 273 132 9 17 71 338 442 12 5 5,549 552 4,603 50 16 1,616 Greenwich 11 9 374 468 224 363 111 19 12 19 243 417 15 15 8,329 176 4,888 26 No hos 235 Hackney (Vic. Pk. Hpl.) 8 — 524 304 239 252 124 3 12 25 369 271 11 3 6,412 211 2,448 25 162 790 (Metro. Hpl.) 10 9 240 143 98 117 79 6 5 10 149 129 13 4 2,643 50 2,472 3 98 430 Hammersmith 7 12 401 189 77 116 133 8 19 17 231 159 12 10 2,705 179 3,347 30 16 543 Hampstead 12 8 243 179 92 107 79 — 9 21 153 158 7 7 1,534 48 2,264 12 75 299 Holborn 15 6 99 59 33 46 36 — 2 9 72 56 3 — 960 13 1,529 — 73 106 Islington (R.N. Hpl.) 7 3 412 309 126 232 140 4 26 14 243 293 3 — 4,001 213 1,312 2 30 394 „ (R. Ch. Hpl.) .. 10 5 375 190 119 130 166 5 12 20 178 155 18 11 6,825 401 2,532 — 12 693 Kensington (Lad. Gr.) „ (Brompton) 58 39 441 364 140 190 115 7 10 35 333 328 38 30 5,124 89 2,943 10 1 786 Lambeth (Cent.) 57 29 437 191 136 108 159 7 4 20 282 162 34 28 4,995 80 2,019 70 70 729 „ (St. Thomas's) 15 2 467 131 92 62 151 3 22 12 301 116 7 — 4,924 — 2,266 — 374 438 Lewisham 5 7 392 271 93 132 173 8 13 22 199 230 9 12 3,198 296 2,873 9 23 201 Paddington (Talbot Rd.) 59 81 409 352 113 98 103 1 6 39 352 375 5 15 5,571 424 2,533 30 34 89 (St. Mary's) 10 4 157 113 53 74 27 1 21 29 104 79 13 8 5,281 120 1,253 4 99 107 Poplar 839 1,011 912 1,054 302 459 150 24 19 15 1,534 2011 25 5 7,325 329 9,074 7 29 1,665 St. Marylebone 11 65 250 148 42 78 84 13 3 22 135 94 4 36 3,155 333 1,263 14 1 367 St. Pancras (Oakley Sq.) 37 19 368 251 100 178 153 10 11 9 180 216 52 33 3,050 124 377 3 — 767 (U.C. Hpl.) 12 5 87 69 20 47 39 3 7 9 45 59 6 3 1,233 8 584 — 47 134 „ (Maiden Rd.) 6 2 82 82 30 45 19 1 3 4 49 67 12 12 703 17 80 — — 124 Shoreditch 23 17 407 309 159 239 142 7 10 15 251 286 18 12 6,390 361 2,682 1 14 716 Southwark 22 8 640 463 211 311 220 31 17 38 388 390 18 4 5,963 32 2,820 7 — 500 Stepney (Green) 38 44 461 528 254 376 125 45 10 12 334 455 21 32 3,511 167 2,275 12 25 521 „ (St. G.-in-the-E.) 13 25 397 439 192 322 115 18 7 21 245 374 16 24 2,481 215 1,477 15 11 407 „ (Whitechapel) 9 5 548 445 295 338 141 16 6 16 380 407 15 10 3,223 194 2,256 2 29 594 Stoke Newington 7 3 110 83 41 58 34 2 6 6 70 73 4 5 1,407 32 778 5 65 215 Wandsworth 12 9 830 510 169 220 292 11 39 33 480 467 30 7 7,111 241 5,348 29 48 1,720 Westminster 4 3 356 173 134 107 203 14 4 17 148 145 2 — 3,133 227 4,717 209 32 360 Woolwich 21 25 655 545 255 270 125 13 7 14 514 521 26 15 7,613 627 3,909 45 — 607 *The scheme (for treatment of tuberculosis) of the Corporation of London includes non-residents employed in the City. The figures shown in this table are for residents only. 59 60 CHAPTER XXIV. REPORT OF THE SCHOOL MEDICAL OFFICER (SIR WILLIAM HAMER) FOR THE YEAR 1923. Introductory Note. Some of the early advocates of elementary education clearly realised that beyond immediately recognisable benefits certain others could be dimly discerned in the background, and time has fully justified anticipations which might at first sight have seemed almost visionary. For example, Wordsworth, when he wrote, in 1814, in " The Excursion," of the " coming of that glorious time " when this imperial realm would " bind herself by statute to secure the rudiments of letters for all her children," expressly had in view the influence to be exerted by national education in the years to come upon difficulties arising from rapid growth of population ; and he clearly appreciated that the whole question of meeting such difficulties was bound up with the problem of imperial expansion. He further declared, with remarkable foresight, that if the national system of education were well founded, there would be no danger of the " prevention of all healthful growth, through material injury," for they whose lot it was to dwell in crowded cities, without fear would five " studious of mutual benefit." Here he would seem to have been hinting at the nineteenth century development of preventive medicine, and perhaps even at the twentieth century evolution of the school medical service. Whether this be so or not, the influence of the schools upon health gradually germinated almost unnoticed by the general public, and it was not until twenty or thirty years ago that it was thrust upon the attention even of those who were in a position favourable for seeing it. The earliest discernible indications were those emerging in connection with prevention of infectious disease and of the spread of verminous conditions. Then, soon after 1900, a curious statistical paradox became strikingly apparent. While the general death rate had fairly steadily and continuously fallen during the preceding forty years, presumably owing largely to greatly improved environmental conditions, a corresponding influence had only begun to affect infant mortality at the beginning of the present century. It was suggested in the Annual Report for 1914 (vol. III., p. 10), that the explanation of this seeming anomaly was to be found, in a lapse of the time needed for the upgrowth of a generation of parents comparing favourably in many respects, and particularly in that of showing a lessened mortality from disease, with preceding generations. In the Annual Report for 1916 (vol. III., p. 4) the case was more accurately stated by ascribing the fall in infant mortality since 1900 mainly to the fact that by that date the majority of mothers had enjoyed the advantages of elementary education. Moreover, the percentage of mothers thus favoured was increasing year by year. The mother may be regarded, indeed, as practically constituting the environment of the infant. Dr. James Wheatley, Medical Officer of Health of Shropshire, in a carefully argued address, read at Portsmouth last summer before the British Medical Association, established beyond all doubt the thesis that the predominating influence in promoting decline in infant mortality has been the Education Act of 1870. If, however, the public elementary schools are to be held largely responsible for this fall, a corresponding movement in death-rates at school ages should also be demonstrable. The figures bear this out. Examination of deaths, at ages, in England and Wales during successive decennial periods (Reg. Genl. Ann. Rep., 1920, p. 9) shows that on the whole the most marked improvement in mortality during the 50 years 1861-1910 has been at ages 5-14—the school ages—the decline being 55 per cent. It should be noted, however, that ages 20-24 show an even more rapid rate of decline in the earlier decennia, presumably largely owing to the influence of migration. Again in 1911-20, the fall has been more marked at 0-4 61 than at the school ages ; doubtless Infant and Child Welfare work may claim some credit for this. It is interesting to compare the school-age figures for London with those for the whole of England and Wales. For a proper appreciation of the lessons to be learnt it is necessary, however, to digress for a moment by referring to a comparison between rural and urban mortality rates made, as long ago as 1857, by Dr. William Farr. He says, " the mortality of the English people is very variable, but generally under favourable conditions does not exceed 17 in 1,000 . . . The deaths of 17 persons in 1,000 may, therefore, be considered in our present imperfect state natural deaths ; and all the deaths above that number may be referred to artificial causes . . . But it may be said that this standard cannot fairly be applied to determine the excessive mortality of large towns, which can never become so healthy as the country. How healthy the towns may become we do not know." Dr. Farr scarcely anticipated that the ideal, supposed in 1857 to be unattainable for large towns, viz., 17, would be far surpassed by a record rate of 11.4 in London last year. Dealing with the London deaths (1838-44) under 5 years of age, Dr. Farr calculated that out of 139,612 deaths, the " excess of deaths in London among children," comparing London with a healthy area, was 58,980. And later, he observed, " The diseases chiefly incidental to children are twice as fatal in the town districts as they are in the country." The Table on pp. 95-96 will enable the figures relating to England and Wales to be compared with those for London for the last six decades. At ages 5-9, in males, London starts, in 1861-70 at a considerable disadvantage, but draws level in 1901-10 and only just loses pride of place in 1911-20. In females London passes England and Wales in 1901-10, but just falls behind again in 1911— 1920. At ages 10-14 less precise conclusions can be drawn and probably migration is an obscuring influence here. In males, London stands in better case in the earlier decades, but gives way to England and Wales in 1891-1900 and 1911-20. At ages 10-14, in females, London leads in each decade with the exception of 1911-20. The higher mortality in London in 1911-20 is partly attributable to epidemic disease (and especially to influenza), and partly to the more correct allocation of transferable deaths which has been made by the Registrar-General since 1911. The striking phenomenon that London, at these school ages in recent decades, either holds a better record, or else runs the rest of the country very close, seems to indicate that there have been special efforts made in London which have, as it were, more than compensated for ill effects associated with the great growth in size of the Metropolis. These influences have presumably in the main been exerted through London's education service and services affiliated thereto, both directly upon the scholars, and in the later decades also indirectly, by reason of the fact that parents, who having themselves been through the schools, have been made more ready to act upon advice and to welcome assistance in regard to health questions generally. Even more noteworthy, however, than the figures relating to the general death-rate at school ages, is the statistical evidence now available with regard to verminous conditions and infectious disease. The results of the delousing work undertaken in London have been set out year by year. Sir George Newman quoted the figures in his last annual report (p. 38) as " typical of those received from the country generally, though the London scheme of cleansing is more complete." Still more striking is the record of seasonal flea prevalence, which has been obtained by examination of London school children during the last twelve years. The chait printed on page 90 shows reduction in the percentage of flea-marked school children from an annual mean of about 28 per cent. in 1913, to 7 per cent. in 1923 ; here is, therefore, precise statistical confirmation of a phenomenon which must have been brought under the notice of many Londoners. The altered death rates from 10976 e 62 the infectious diseases of childhood are also deserving of study and will be further referred to later in this report. Medical Inspection children in the three statutory age groups were examined by the school doctors in elementary schools, and 72,329 of them were found to be suffering from one or more defects. This is a smaller proportion than ever before, since the present standard of examination was instituted, and is a matter for congratulation. 1,395 children in the prescribed age groups were seen in special schools, and 39,331 children not in the age groups were specially examined. In addition the school medical staff inspected 4,923 candidates for scholarship awards and 24,379 children in connection with their specific defects, in special schools. A detailed analysis of results bv Dr. C. J. Thomas is eiven on oases 62 to 67. Medical treatment. The number of children treated under the arrangements made by the Council was 218,794 as compared with 193,854 in 1922. The difference in the two years is almost entirely accounted for by the improved attendance for dental and minor ailment treatment. It may be noted in connection with the examination for visual defect that 90.5 per cent of the children needing spectacles obtained them, the best result vet recorded. Re-inspections. The number of re-inspections was 188,348. The combined results of first and second re-inspections showed that 76.8 per cent. of the children found defective had been dealt with. Personal hygiene. The cleansing scheme was continued during the year and 2,052,904 examinations were made at rota visits by the school nurses. The percentage of verminous conditions found, including those of all degrees, was 18.1, which is lower than in any previous year. The number of scabies cases treated, too, shows a marked diminution- Infectious diseases. Scarlet fever and diphtheria showed marked decline following upon the two years, 1921 and 1922, of high prevalence. The notifications of scarlet fever in 1923 were 10,047 as compared with 17,181 in the preceding year ; those of diphtheria were 10,301 as compared with 15,247. It will be observed that in 1923, as has happened before in London, the notifications of diphtheria actually exceeded those of scarlet fever. Both in 1923 and the two preceding years London suffered disproportionately from diphtheria as compared with the rest of England and Wales. The higher incidence in London was more marked as regards cases than deaths. Influenza was less prevalent than in 1922, but was becoming more common at the close of the year. Measles which had been at a low ebb was also becoming more prevalent in the later weeks of 1923. Measles is a disease the prevalence of which can be appreciably affected by a carefully devised scheme of prevention—some notes are given on p. 94 on the working of such a scheme in three recent outbreaks in London. Charts showing measles, whooping cough, and scarlet fever prevalences are given on pages 98, 99, and 90, and the behaviour of diphtheria since 1891 in London is commented upon on p. 93, where reference is made to the statistics relating to certain other large aggregations of population. The experience of the last 30 years, in fact, shows that the school organisation in London has been largely instrumental in putting a check upon prevalence of epidemics of diseases affecting children of school age. Routine inspection;. Results of medical inspection. Routine inspections were limited to those age-groups prescribed by the Board of Education. 68,916 infants were seen on entry to school, 64,593 children in elementary schools on reaching the age of 8 and 63,818 in their thirteenth year, giving a total of 197,327 children inspected compared with 199,812 in the previous year. They were, in each age-group, pretty evenly divided between boys and girls. As children were no longer seen in the term before they left school, the twelveyear-old children were examined late in the year in order to bring their last 63 examination in school as near their thirteenth birthday as possible. In addition, 1,395 children were seen in the age-groups in special schools. Special exammatIon. In addition to the routine age-group examination, special examinations are provided for children referred by head teachers, care-committee workers, attendance officers, etc., 19,760 boys and 19,571 girls were so examined. Amongst them were reported 1,066 children suffering from mal-nutrition, 2,624 from skin diseases, chiefly scabies, 1,164 with external eye disease, mainly blepharitis and conjunctivitis, 4,590 with defective vision, 654 with squint, 537 with defective hearing, 1,493 with discharging ears, 2,947 with tonsils and adenoids, 2,354 with anaemia, 611 with tuberculosis (definite or suspected), 1,099 with various forms of nerve diseases, and 895 with deformities of different kinds. Acute and serious cases are, of course, seen sometimes at these inspections. Routine inspection in special school. 1,395 children of the eight and twelve-year-old groups were examined in the special schools. These unfortunate waifs are always found to suffer to a greater inspections degree from disease and defects than normal children, such conditions as otorrhœa and external eye disease being specially common. Ailing children, The proportion of children found to be suffering from ailments for which treatment was necessary continues to fall. 72,329 were marked for treatment during the year, being 36.7 per cent, as compared with 37.9 per cent, in 1922, over 39 per cent, in 1920 and 1921, over 42 per cent, in 1919, and 44 per cent, in 1918. Thus a smaller percentage of children was found to require treatment than in any former year, a matter for special satisfaction, as it shows that the school medical service is acting no less as a preventive than as a curative agency. Presence of parents. Parents continue to show an increasing interest in the inspections of their children, and no less than 133,240 actually attended the inspections. For entrants the attendance of parents is over eighty per cent. The contact of school doctor and parent is of the greatest importance as it leads to quicker appreciation of what is required, and affords opportunities for special advice which cannot otherwise be imparted. Even with the elder boys there was an improvement in this respect, though one cannot avoid the reflection, in comparing the attendance of mothers when infants and girls are being inspected with that when elder boys are being seen, that the mothers are absent on the latter occasions through the strongly expressed wish of the boys themselves, who consider they have outgrown apronstrings. Nutrition, The statistical results this year will be carefully scanned as there is an present anxiety lest the long continued unemployment should be reflected in a falling off of the children's condition. Visits to the schools and enquiries of the personnel of the school medical service have given reassurance that there has not been any noticeable falling away, and the figures for nutrition emphasise this. The measures of social amelioration in force clearly do what they were intended to do, and in spite of the adverse economic conditions the condition of the school child in regard to health, nutrition and physique is to-day very much better than it was in the decade which preceded the great war. Among the valuable means of controlling mal-nutrition has been the practice of giving milk or cod-liver oil in school on the recommendation of the school doctor. The percentage of children placed in the under-nourished category was 5.9, a fractional increase on the previous year when the percentage was 5.7. This is to be compared with a percentage of 12.8 in 1913. Cleanliness, The slow but steady improvement in the personal cleanliness of the children is maintained. 88.7 per cent, of the children at all ages were found at medical inspections to have heads completely free from all trace of infestation of vermin compared with 87.6 per cent, in 1922. While 10.5 per cent, were found with nits, only .8 per cent, were found with live vermin. The percentage of elder girls with perfectly clean heads stands now for the first time at over 80, having been raised during the past year from 77.5 to 80.5 per cent. 10976 E 2 64 Thus the arduous work of the school nursing staff is bearing fruit, and the steady and cumulative effect of this hygienic struggle is seen in the fact that in 1913 the percentage of girls with clean heads was only 67.2. Much of the work of the school nurses is educational, and a slow and steady improvement which is lasting and permanent in character is to be preferred to a more rapid improvement due to compulsion, which would prove evanescent when the compelling force was relaxed. It is likely that the full benefit of the work during the past decade will be reaped only when the children dealt with become the fathers and mothers of a new generation. Verminous bodies. While the entrenchments of the head louse are difficult to storm, those of the bodies. body louse are much more vulnerable. Consequently by means of the Council's cleansing schemes the body louse has been virtually driven out of the schools. In 1913 over 2 per cent, of the children in the schools were infested with body lice, in fact, the number with body lice actually exceeded those with live head vermin. In 1923 only 402 children were found with body vermin, that is much less than one child to every two schools and only 0.2 per cent. Teeth. As regards the condition of their teeth the entrant children proved to be rather better than the entrants of 1922. This may very likely be due to the attention to dental conditions now given at some of the Infant Welfare Centres. Condition of Teeth of Entrant Children. 1922. 1923. Sound. Less than 4 decayed. More than 4 decayed. Sound. Less than 4 decayed. More than 4 decayed. Boys 57.4 29.1 13.5 59.3 29.4 11.3 Girls 56.3 30.4 13.3 58.0 30.6 11.4 In the eight-year-old group a very serious amount of decay and oral sepsis is found, and the problem most urgently requiring solution is: why are the milk teeth of these children shed by these processes of suppuration and abscess formation instead of by aseptic absorption ? The grave amount of oral disease in the eight year-old-children appears toaccount for the poorer figures for nutrition which that group invariably yields in comparison with the others. The good work of the Council's dental centres is seen in the progressive improvement of dental conditions in the twelve-year-old group. Although the very remarkable leaps of the two previous years have not been repeated, yet a satisfactory improvement is recorded as shown in the following table :— Dental condition of twelve-year-old children. 1913 1917 1921 1922 1923 Boys 1 500 2 40.0 3 10.0 1 55.2 2 38.6 3 6.2 l 60.3 2 35.7 3 4.0 1 65.3 2 31.5 3 3.2 l 67.7 29.6 3 2.7 Girls 52.4 39.0 8.6 56.4 38.1 5.5 63.5 33.3 3.2 67.5 29.8 2.7 69.4 28.2 2.4. These figures are obtained from the returns of medical inspection. The number of teeth obviously decayed is recorded in every case by the school doctor. The first column contains the percentage of children in whom no decayed teeth are seen, the second column when less than four carious teeth are returned, and the third column where four or more carious teeth are recorded. While not revealing the whole of the dental caries present these are, nevertheless, comparative figures of great value and serve as a measure of the improvement resulting from the school dental treatment. During 1921 and 1922 the remarkable- 65 improvement noticed was due to the fact that children began to leave school who from an early age had come under dental inspection. That the improvement has continued in 1923 is shown both by the figures in the first and the third column, for not only is there a larger proportion both of boys and girls who have teeth which appear sound on inspection, but there is a diminished number oi children with very extensive caries. Between 1913 and 1923 the proportion of twelve-year-old boys with apparently sound teeth has increased from 50 per cent, to 67.7 per cent., while that of those with extensive caries has diminished from 10 per cent, to 2.7 per cent., and a corresponding improvement is shown by the girls. A remarkable feature of the dental tables is that the girls in every year and in every column show a higher degree of resistance to caries than do boys. 21,656 children were found to have some degree of enlargement of tonsils or evidence of adenoid growth. This number represents 11 per cent, of the children in the age-groups compared with 12.8 per cent, in 1922, 16.5 per cent, in 1921, and still higher figures in previous years. It appears, therefore, that the children are growing healthier from this point of view. Oral sepsis due to neglected and decaying teeth is often the precursor of attacks of tonsilitis, and as the greater number (16,533) of the above children have simple enlargement of the tonsils, it may be that the improvement is a secondary effect of the greater attention to dental hygiene and the undoubted gain resulting from treatment of dental decay. Although fewer children were recorded with unhealthy throats a somewhat larger number were referred for treatment, viz., 7,680 or 3.9 per cent., as compared with 3.6 per cent, in the previous year. This is still a considerable reduction upon the proportion referred a few years ago (6.1 per cent, in 1919). It is very generally held that the presence of enlarged tonsils in a child increases the risk of contracting infectious diseases and that removal of the tonsils (and adenoids) diminishes this risk. At the request of Sir James Dundas-Grant some observations were made with a view to testing the truth of this opinion. A large Islington elementary school—The Forster—was taken at which there had been during the year an excessive number of cases of scarlet fever. The number of children on the roll of the school is 1,000. A list of those scholars, 43 in all, who had suffered during the year with scarlet fever was made, and another list of children, numbering 99, who had been reported as having enlarged tonsils and adenoids. Ten names were common to both, i.e., out of 99 children with enlarged tonsils, ten, roughly one in ten, suffered from scarlet fever ; of the remaining 901 children 33 only suffered from scarlet fever, or one in 28. Dr. E. O. Lewis visited the school and elicited the information that nine children of the 99 had been operated upon, and not one of those who had been operated upon suffered from scarlet fever, though in one instance the child had twice been exposed to scarlet fever in the home subsequent to operation. Subtracting the nine children from the 99 it transpires that one in nine children with enlarged and untreated tonsils suffered from scarlet fever as against one in 28 of the others. These figures were very suggestive and show the heavy incidence of infectious disease upon those with already enlarged tonsils, but the number of cases that had been operated upon was too small to warrant any conclusions being drawn. Dr. Lewis therefore took another school (Addison Gardens, Kensington), where there had also recently been an excessive incidence of infectious diseases, both scarlet fever and diphtheria. Every child who had been operated upon for tonsils and adenoids was sought out and the history of infectious disease before and after the operation was obtained. The total number of children present at school during the investigation was 1,367. Of these, 292 children had been operated upon for tonsils and adenoids. The total number of children who had suffered from infectious disease (scarlet fever or diphtheria) was 385. The number of children who suffered from infectious disease after operation was 14. The incidence of infectious disease upon the school population generally Tonsils and adenoids. 66 Ear diseases. was therefore 28 per cent., while upon those who had been operated upon for tonsils and adenoids, this incidence was only 4.8 per cent. There were numerous examples where a child who had been operated upon was intimately exposed to infection subsequently without contracting the disease. The presence of ear disease or defect was noted in 3,366 children (1.7 per cent.), compared with 4,294 children (2.1 per cent.) in the previous year. Of these 2,207 (1.1 per cent.) were referred for treatment. Defect of hearing was recorded in 1,292 children (.7 per cent.), but in only 606 of them was it considered that benefit could be obtained by treatment. The number of children found the previous, year with defect of hearing was 1,572 (.8 per cent.). These figures may be compared with those of 1913, when ear disease was present in 2.4 per cent, of the children examined, while 1.7 per cent, were found with defective hearing. Thus the proportion of children found at routine inspection with defective hearing has during the last ten years been halved. Visual acuity. There was little difference from the previous year in the figures of visual acuity. Those for the eight-year-old children (this is the earliest opportunity the school medical service has of testing the vision of the scholars) were returned as practically identical in the two years, but the older children at the age of twelve showed a slight improvement. 58.7 per cent, of boys and 53.6 per cent, of girls passed the normal test, as compared with 57.1 per cent, and 52.5 per cent, in the previous year, while boys with higher degrees of defect of vision fell from 20.3 to 19.7 per cent., and girls from 22.2 to 21.5 per cent. Some improvement, therefore, continues to take place, although it is due rather to correction of defect by spectacles than to any natural improvement. The superiority of the boys' vision over that of the girls remains striking, but no one will hear of sewing being taught in the morning when the light is good, and much sewing in the winter continues to be done by artificial light. Enlaced glands. Some discussion took place during the year with regard to the nature of enlarged cervical glands. It was felt that it was generally unsatisfactory to record merely the existence of enlarged glands while not indicating the cause, and thereby indicating the steps that should be taken to alleviate the condition of the child. No fewer than 7,729 children (3.9 per cent.) were found to have enlarged cervical glands, and this condition was commoner in boys of the two earlier age-groups than in older boys or in girls. The same high incidence in younger boys was found in the previous year, when no less than 9,331 children (4.7 per cent.) wer3 recorded with enlarged glands of neck. The special age and sex incidence renders it pretty certain that decayed teeth with oral sepsis are the chief determining causes. Dr. E. J. Boome investigated the aetiology of enlarged cervical glands in the children at Cork Street School, Camberwell. There were 996 children in the school, and every case where palpable glands were found in the neck was recorded. They amounted to 114 children of whom 53 were boys and 61 girls. Dividing these into categories in relation to degree of enlargement, in 22 the glands were merely palpable, in 59 they were moderately enlarged, and in 33 they were considerably enlarged, and amongst the latter boys preponderated. (It is clear that Dr. Boome's "considerable enlargement," corresponds to the degree of enlargement usually reported by the school medical staff.) The ostensible causes were as follows:—Dental caries and oral sepsis, 46; unhealthy condition of nose and throat, 32; eczema associated with ear discharge 3; skin disease and verminous condition of the scalp, 18 ; no cause found, 15. Dr. Boome also took careful note of the presence of cervical glands in boys who suffered from debility and were candidates for the Council's Camp School at Bushy. 136 or about one half of the boys were found with glands of the neck palpable or definitely enlarged, in 16 the enlargement was considerable. Here, too, dental decay with oral sepsis was found to be the leading cause, with unhealthy nose and throat conditions second in frequency. 67 The incidence of heart disease is heavier upon girls than boys (in common with other rheumatic manifestations) and falls especially upon the older girls amongst whom 1,130 (3.5 per cent.) were recorded with cardiac defects. Altogether 5,208 children were returned with heart defect, being 2.6 per cent., compared with 2.8 per cent, in 1922, 3.7 per cent, in 1921, and 4.1 per cent, in 1920. There was a considerable fall in the number of children recorded with anaemia, viz., 5,130 or 2.6 per cent., compared with 6,058 (3 per cent.) in 1922, and 4.1 per cent, in 1920. Here, again, girls suffer much more than boys at the twelve-yearold period. Children with lung complaints numbered 6,685 (3.4 per cent.), compared with 7,151 (3.6 per cent.) in the previous year. The incidence is very high upon the entrant infants, many of whom are found to be suffering from bronchitis. Phthisis is very rarely discovered now in the children attending elementary schools examined in the routine age-groups. Only 175 children were found with phthisis, and 142 were found with tuberculous diseases other than phthisis. The teachers are alive to the manifestations of ill-health in children, who are also constantly under the eyes of the members of the care committees and are examined at least once a term by the school nursing sisters. A child who is flagging in health no longer sits in school waiting for a routine examination, but receives medical attention forthwith. The number of children found suffering from nervous disease is not high, being 1,575 in the age-groups, that is less than 1 per cent. There is, therefore, no evidence from the statistical returns that nervous conditions amongst children are on the increase, in fact, there appears to be a slight decline corresponding with the general improvement in health all round. 162 epileptics were noted at routine inspections, but a larger number were brought up at special inspections and naturally most of these children are excluded from school. Similarly while 175 children in the agegroups were found with chorea, 422 not of the age-groups were seen at special inspections. Rickets was reported in 1,975 children (1 per cent.), but the incidence upon entrant boys was noted as 1.6 per cent. Other deformities amounted to 2,542 (1.3 per cent.), being chiefly accounted for by noticeable degrees of spinal curvature found in the older girls (2.4 per cent.). Skin diseases are slightly less prevalent, 2,258 children being noted as suffering, or 1.1 per cent., compared with 1.3 per cent, in 1922, and 1.5 per cent, in 1921. External eye disease was found in 5,237 children, or 2.7 per cent., compared with 2.8 per cent, in the previous year and 3 per cent, in 1921. The analysis of the statistics relating to the 200,000 children examined in the age-groups shows that the steady continuous work of the school medical service continues to bear fruit in improving conditions of health in the London school children. Over a period of years the improvement is very striking. Though slow in some directions the improvement is sure. The greatest advances have been in general cleanliness, and improvement of dental conditions, yet in these directions most still remains to be done. The incidence of various forms of disease upon the different ages and the two sexes shows that there is one set of preventable conditions which falls heaviest upon boys of eight and another set falling heaviest upon girls of twelve. The former set is associated with grave dental decay leading to oral sepsis with enlarged cervical glands and under nourishment, while the latter set constitutes a syndrome in which defective eyesight, anaemia and spinal curvature are the prominent features. Both sets of conditions require further tackling from the standpoint of prevention. Dental hygiene must be prosecuted with energy from the earliest ages, and further efforts must be put forward to secure that girls get the same share of open-air life as boys and more freedom from tasks which not only prevent this, but also involve prolonged stooping and eye-strain under unhygienic conditions. Heart defect and ancemia. Lung complaints Nervous diseases. Deformities. Skin diseases and external eye diseases. Summary of result of routine inspections. 68 Medical inspection at secondary school, etc. The number of pupils inspected in secondary schools was 7,135, namely 3,701 boys and 3,434 girls. As might be expected, the remediable defects are fewer than among scholars in elementary schools. The pupils aged 12 and 15 were all examined in detail, but only special children at other ages. Of twelve year old boys in the secondary schools 74.7 per cent, have sound teeth, and 76.3 per cent, have normal vision, as compared with 67.7 per cent, and 58.7 per cent, respectively in elementary schools. Nose and throat defects are reported in 1.8 per cent., in comparison with 8.2 per cent, in elementary school boys. Of twelve year old girls in the secondary schools, 76.3 per cent, have sound teeth, as compared with 69.4 per cent, in elementary schools, 65.8 per cent, have normal vision, compared with 53.6 per cent., and 6.8 per cent, have nose and throat defects, as compared with 8.8 per cent. The elementary school girls have better teeth, but worse vision than the corresponding boys. But little difference is shown in the returns of fifteen year old pupils from those of twelve year old. The condition of the teeth of the boys aged 15 was rather worse than in the twelve year old group, and the vision of the fifteen year old boys is distinctly worse than that of the twelve year old boys, but is, nevertheless, better than in the girls of the same age. 71.8 per cent, of fifteen year old boys have sound vision, as against 67 per cent, of girls. 233 men students and 1,093 women students were medically examined in the training colleges, and 780 male and 861 female students in trade schools, making a total of 10,102 students seen at the various types of institutions for higher education. Special inquiries. Minor ailments. The arrangements for the treatment of minor ailments are greatly appreciated, the value placed upon them being attested by the very high numbers of children attending. Full detailed analysis and classification of minor ailments at every centre would entail additional cost. In the east end, however, some of the centres have secured for the purpose the services of the Council's whole-time medical inspectors. In two of them, Old Ford and Whitechapel, detailed analyses have been made covering a period of six months during 1923. At the two centres, the number of new cases (children) was 2,433, and of new cases (ailments) 2,566. Diseases of the eyes numbered 498 (19.4 per cent.), of the ear, nose and throat 396 (15.7 per cent.), of the skin 1,173 (45.7 per cent.), accidents 432 (16.7 par cent.), general ailments 31 (1.2 per cent.), and infectious diseases 36 (1.8 per cent.). Analysis of the 498 cases of eye disease gives:—simple conjunctivitis, 298, purulent conjunctivitis 27, blepharitis 75, styes 64, defective vision 21, injury 8, nebulae 2, corneal ulcer 2. nystagmus 1. The 396 cases of ear, nose and throat defect included: otorrhoea 194, wax in ears 64, ear-ache 40, enlarged glands 20, deafness 8, foreign bodies in ear 2, tonsils and adenoids 28, sore throat 10, nasal obstruction 8, tonsilitis 5, deflected septum 4, nasal discharge and rhinitis 1C, ozcena 1, pharyngitis 1, polypus 1. The 1,173 skin complaints comprised impetigo 201, "sores" 585, boils 70, whitlows 58, eczema 35, "dermatitis" 28, chilblains 26, warts 20, pustular rash 17, ringworm (skin) 16, scurfy patches 15, scabies 12, urticaria 12, herpes zoster 10, seborrhcea 7, pustules 7, fissures 6, "heat rash" 5, abscess 5, ringworm (scalp) 4, cellulitis 4, psoriasis 3, alopecia 3, ulcers 3, lupus verrucosus 2, folliculitis 2, corns 2, papular eruption 2, dysidrosis 2, ichthyosis 2, sudamina 2, prurigo 1, lymphangitis 1, granuloma 1, scabs 1, excoriations 1, lichen 1, acne 1. The 432 accidents comprised 129 cuts and wounds, 82 grazes and scratches, 71 burns and scalds, 56 injuries to limb, 32 bruises, 17 sprains, 15 blisters, 10 insect bites, 7 " swellings," 4 dog-bites, 3 splinters, 3 " pinches," 2 injuries to nail, 1 fishbone in throat. 69 31 cases seen at first visit and referred to the proper channel for treatment as not coming under the definition of minor ailments, included dental caries 11, anaemia 5, constipation 3, rheumatism 3, nits 2, bronchial catarrh 2, vomiting 1, debility 1, chorea 1, cough 1, ganglion 1. The 36 cases of infectious diseases sent up as minor ailments comprised 32 cases of mumps and 4 cases of chicken-pox. The above long category of diseases serves to illustrate the multitude of ills that beset the path of the humble dweller in the town. Dr. Chaikin remarks upon the rarity of acute corneal ulcer, which formerly was so common, and ascribes this to improved nutrition. In 391 cases (16.7 per cent.) the children were excluded from school on account of the infectivity of the condition of disease observed. Of the 129 cuts and wounds, 94 occurred in boys and of the 71 burns and scalds 38 occurred in girls, an interesting sidelight on the occupation risks of the two sexes. Following-up and re-inspections. A review of the results of the school medical work over the years 1913-1923 lleads to the conviction that the mountain of disability and suffering which the school medical service at its inception had to face has indeed begun to move. Independent observers in a position to know state that the London child is now a different being. Not only is the improvement marked as a whole, but analysis shows a steady advance year by year at each age and in each sex in a most consistent way. The question inevitably arises whether the rate of improvement is as rapid as it could or should be. That there are conditions that heavily handicap progress is very clear. The improvement which has taken place is largely due to the untiring efforts of voluntary workers who devote themselves unstintingly to the work of alleviation. Amongst the voluntary workers are to be included a great number of the teachers. There are still, however, in London, schools and districts where insufficient help is forthcoming and where the standard of care committee attainment is much below the average. In some cases the vexed question of attendance marks hinders the medical work, and complaints have been received from many quarters on this score. Measures have been taken to remove as far as possible this handicap. The attendance of children at the centres is recorded, and at the end of the year, the total of attendances is credited to each school department. Many teachers complained that requisitions were apportioned on the uncorrected attendance figures, and, therefore, schools most eagerly co-operating were penalised by being allowed smaller quantities of materials. This difficulty was removed during the past year by the agreement of the Council to apportion materials requisitioned by the head teachers on the basis of average roll in place of that of average attendance. Complaints still arise, however, on the score that, if as a result of medical or dental treatment the child remains out of school for several attendances, only the actual attendances at the centre are recorded, and the remainder is a total loss. It is where schools stand near the point upon which they will be regraded on any fall of average attendance that this trouble is most acute. In these schools, too, there is diificulty in obtaining the co-operation of the head teachers in the work of sending children away for convalescence whether to the camp schools or otherwise, and in ascertaining which children would benefit by attending open-air schools. This is a real difficulty, and the cure for it does not appear obvious. The greatest difficulty of all, however, is the ignorance and apathy of some of the parents. Much of the work is educational, it involves the establishment of a higher ideal of hygienic excellence than has hitherto been reached, and means a change of habit and custom amongst a class of the populace notoriously conservative in regard to such matters. There are parents who can be shown only with difficulty the need of attention to early dental defects in their children, and also others who are instinctively hostile to any sort of interference in their affairs. 70 Compulsion unwisely applied would undoubtedly defeat its object and bring about a state of mind inimical to progress. It is inevitable, therefore, tbat progress should be slow, but for that reason it is all the more sure. It can only be by the willing co-operation of the people and their steady growth in knowledge and in wisdom as well as in material prosperity that the desired results can be achieved. The more intelligent parents eagerly avail themselves of the Council's facilities. Dr. James Kerr, whose clinical experience and knowledge of the conditions are unrivalled, has recently remarked upon the surprising improvement in the condition of children who have qualified for scholarships and come before him for medical inspection, and he particularly instanced their dental condition. The statistical figures bear this out in a pronounced and convincing fashion. In 1913 out of 1,635 children examined on qualifying for junior scholarships, no less than 640 required dental treatment before they could pass the medical examination. In 1923, out of 1,560 junior scholars examined, only 111 were referred for dental treatment. The fall here is from 39 per cent, to 7 per cent. These figures fully bear out Dr. Kerr's clinical impressions, and clinch the argument that while amongst the more intelligent of the parents full advantage is being taken of the Council's measures, the task in the future, of the school medical service and indeed of the whole education service, is to spread downwards amongst the population the knowledge of the need for early attention to the defects from which children suffer, and for a more hygienic way of living. The spread of enlightenment and the desire for better things undoubtedly lead to improvement of environmental conditions, and to a higher standard of living generally. 188,348 cases, which had been referred for treatment or placed under special medical observation, were re-inspected during 1923. 89,191 of these were primary re-inspections of children referred for treatment. Of these 54,747 (61.4 per cent.) were discharged or were under treatment and 34,444 were reported as not treated and still requiring it. 55,528 children requiring treatment who had failed to be discharged at their first re-inspection matured for further re-inspection during the year. Of these, 31,637 (57 per cent.) were discharged, or were under treatment. Combining the results of first and second re-inspections, it is found that 76.8 per cent, of the children found defective obtained relief within a year of the primary inspection. This figure is not quite as good as in 1922, when 77.7 per cent, of the children were found satisfactorily dealt with. The failure to obtain treatment is mainly in the dental department, and if the dental defects are deducted from the total it is found that the percentage of children satisfactorily dealt with amounts to 83.0. In a few cases when the parent has persistently refused to obtain treatment, and when the child's condition is in consequence deteriorating, the good offices of the National Society for the Prevention of Cruelty to Children are sought. Note was kept of 398 children referred to the Society in 1923. These comprised 204 cases of defective vision, 140 of dental caries, 22 of eye or ear disease, and 32 of other defects. The Director of the Society reports that the total number of cases of neglect (medical and other) referred by the Council in 1923 was 670. Of these, 323 cases, affecting the welfare of 431 children, were referred to the Society's medical board. Of the 323 medical cases, 193 have been closed, effective action having been taken and the condition of the children alleviated. Medical treatment. At the end of 1923 the treatment scheme included 13 hospitals and 58 centres, in addition to the dental centre at Bushy Park Camp school At these 72 centres 218,794 children, the highest total yet recorded, received treatment during the year for the defects specified: eye, 31,986; ear, nose and throat, 11,936; ringworm, 1,591; minor ailments, 77,949; and teeth, 95,332. After consultation with the British Medical Association the agreements have been amended with the view oi Re-inspections. 71 still further improving the standard of efficiency. There has been some saving of expenditure by the reduction of the maintenance grants first allowed in 1920-21. (a) Minor ailments.—79,380 children received minor ailment treatment, and of these, 77,949, nearly 6,500 more than last year, were treated under the Council's scheme. The number of attendances was 1,413,255. At the cleansing stations, 2,935 cases of scabies and impetigo were treated. The arrangement with the Metropolitan Asylums Board by which children suffering from contagious and chronic external eye diseases are sent direct by the school medical service to the Ophthalmic school at Swanley has continued to work satisfactorily. During the year, 105 children were sent under this arrangement. Fifteen were suffering from trachoma and eleven were re-admitted cases. (b) Visual defect.—31,986 children attended under the Council's arrangements for refraction. Spectacles were prescribed in 23,577 instances, and 21,357 children obtained them; this was a percentage of 90.5, the best result ever observed in London, and 3½ per cent, better than last year. No charge for spectacles falls upon the rates, tJie purchase being arranged by voluntary committees. 82 cases of squint were treated either at the Belgrave Hospital or the Paddington Centre, where special arrangements have been made for this class of ailment, 25 operations were performed at the Belgrave Hospital. (c) Nasal and aural disease.—The total number of cases was 13,098, of whom 11,936 were treated under the Council's scheme. Dr. A. G. Wells undertakes the supervision of the following-up and treatment of children in London suffering from ear, nose and throat diseases. He reports a gratifying extension during the year of the method of ionisation as an additional weapon increasing the effectiveness of the means introduced to deal with children suffering from ear discharge. Dr. Friel, the introducer of this method, continues his ionisation clinics at the Almeric Paget centre in Whitechapel and the Kenleystreet centre, Notting Dale. Another ionisation clinic is in the hands of Dr. Scott at the ionisation treatment centre in Marylebone. Dr. Claremont is using this method at the St. Pancras and at the Highgate New Town centres. Mr. Layton has installed it at the St. George's Dispensary centre, Southwark, and Miss Margaret McMillan at the Deptford centre under Dr. Burney. Dr. Wells holds an inspection centre weekly in each of the five medical divisions at which he sees refractory cases of otorrhcea referred to him by school doctors and medical officers at the treatment centres. Of 981 cases followed up by him, 482 were discharged cured during the year. The percentage so discharged varied in the divisions, viz. : 34 per cent, in the south-western division, 46 per cent, in the southeastern division, 46.6 per cent, in the north-western division, 55 per cent, in the north-eastern division, and 65.3 per cent, in the eastern division. The percentage of children suffering from obstinate chronic ear-discharge that is cured during the year depends appreciably upon the additional facilities available, and Dr. Wells ascribes the comparative failure in the south-western division to the lack in that area of ionisation treatment. He is, however, hopeful that movements afoot to remedy this lack will prove successful in the near future. Of 80 children suffering from pure deafness attending Dr. Wells' inspections, he was able to discharge 54 as cured. The method of ionisation introduced first, so far as the school medical service of the country is concerned, in the London school treatment centres, has attracted very considerable attention. Dr. Friel's methods have been watched by numerous medical officers from other education authorities and several of these have now installed the treatment, which is meeting with much success. The treatment, however, is not a panacea, and the cases to be submitted must be selected with care by an expert in the method. To subject all children suffering from otorrhoea to the treatment would be merely to court failure in certain instances. The treatment of ear diseases ionisation, etc. 72 In view of the general interest in the question, the following detailed analysis by Dr. Wells of the cases treated by Dr. Friel at his two centres, is here given in full. Total. Cured. Lost sight of. Still under treatment. Referred. I. Tympanic conditions :— (a) Tympanic sepsis 71 57 2 12 0 (6) Tympanic sepsis and granulations 21 14 1 5 1 (c) Tympanic sepsis and polypus 16 7 — 9 — (d) Tympanic sepsis and cholesteatoma in typanum 1 - - 1 (e) Tympanic sepsis and caries of malleus 2 1 — — 1 II. Tympanic conditions and eustachian tube, nharvntrea] or nasal conditions 14 10 1 2 1 III. Tympanic conditions and attico-mastoid— (a) Mastoid 42 4 2 18 8 (b) Attic 14 2 — 8 4 (c) Radical operation already 17 3 — 8 6 (d) Operation already—not radical 6 — — 5 1 IV. Tympanic conditions and cause undetermined 4 —— — 4 - V. Tympanic conditions and external otitis 3 2 - 1 — VI. External otitis 3 2 —- 1 - Total 214 102 6 74 32 The arrangement by which the Metropolitan Asylums Board admits to a special institution, on the direct nomination of Dr. Wells, all those children in whom mastoid operation is the only means of cure has been continued. The change by which this work is carried out at the Downs Hospital, Belmont, instead of at the Clevelandstreet Infirmary, in London, has made it difficult to obtain a detailed account of the year's working, but Dr. Wells reports that about 75 per cent, of the children were discharged cured. (d) Dental disease.—236,658 children were inspected by the school dentists, 43,928 more than in the year 1922. 166,454, or 70.3 per cent., were found with defect. 95,332 children were treated at the treatment centres. These figures show a great improvement as compared with the results obtained last year, and indeed are the best yet recorded since dental inspection and treatment were begun. Treatment of stammerers. Tin six central classes for stammering children were continued throughout the year. 266 children (184 boys and 82 girls) passed through the classes, of whom 133 were discharged cured. Only 7 relapses took place amongst the cured, and of these 6 were again discharged without stammer. More and more it becomes recognised that stammering is a pure psychosis. Almost any treatment will cure a number of cases provided it helps to restore selfconfidence in the child and to remove the fear of stammering which is the chief cause. By pursuing a rational mode of treatment on this assumption, in place of the former empiric methods, a greater degree of success is obtainable. Each child requires individual investigation. The children are encouraged to confide in their teacher, and from the relation of their dreams much is learnt. A history of nervous instability either in the child himself or in the family is found in the majority of cases. The larger number start before seven years of age, and in most of these the stammer appears to be a retention of the repetition of sounds which normally accompanies speech development. This repetition is more pronounced among sensitive, highly-strung, children, whose understanding of the spoken word is well in advance of their ability to express themselves in speech. In several cases the stammer synchronises with the first term at school, either at 73 3 or 5 years of age, although in a few it occurs when at 7 years old the child is transferred from the infant department to the boys' school, no doubt a severe ordeal for a nervous child. One parent attributed the stammer to the phonetic method of teaching reading. All cures are provisional, and the number of relapses recorded this year is accounted for by the ability to follow up the cases further, owing to the earlier age of treatment. Two boys relapsed on their voices breaking at puberty. The prognosis in stammering depends upon (a) the teacher; (b) the period between onset and treatment—the sooner after onset a case can be taken in hand the better; (c) the intelligence of the child—intelligent co-operation between teacher and patient is an absolute necessity and the child must be old enough to understand this—in these classes no child is admitted before nine years of age; (d) the physical condition of the child. All physical defects, such as defective vision or teeth, unhealthy condition of nose, throat or ear, must be attended to as soon as possible. Much time can be wasted on a child mentally or physically incapable of receiving full benefit from the course. Where a child is anaemic and generally run down a visit to one of the Council's open-air residential schools greatly facilitates treatment. The School Nursing Staff. The importance of the work of the school nurses and the share of their work in the success of the school medical service is not always appreciated at its full value. A school child may come under the notice of the school doctor only three times, during his school life of nine or eleven years, but every child in London passes under the observation of the school nurse at least once in every school term, that is 27 or 33 times during his school life. This work is, therefore, of prime importance, and, besides ensuring that the general standard of cleanliness and of freedom from chronic infections is safeguarded, also ensures that children, silently suffering from ailments that elude the watchful eyes of the teachers, are detected and brought to the notice of the school doctors or referred directly to the treatment centres. A sidelight on the importance of this work is given in the following account by Dr. Chaikin of work in the East End in regard to the one particular of the discovery of children suffering from ear discharge:— " As is known, the school nurses 'discover' many cases of minor ailments and of other conditions in school children in the course of their rota visits to the schools. This report is intended to show the significance of their 'discovery' of cases of otorrhoea—some not under treatment at all, and others where treatment has been discontinued—during the four years 1920, 1921, 1922 and 1923, in so far as the eastern division is concerned. “The cases were reported to me on Form M.0.303 by the nurses who, at the same time, sent the children to the treatment centres. Furthermore, the cases were passed by me to the district organisers, who took steps to secure their being followed -up. From the serious nature of middle ear disease, and from the numbers reported, the importance of the nurse's work in continually searching out untreated otorrhoea cases cannot be overestimated. The volume of the work is also noticeable when it is borne in mind that it is carried out in the course of other duties. " The following figures relating to otorrhoea cases reported on Form M.0.303, are compiled from records kept by me during the several years :—1920—338; 1921 —403; 1922—251; 1923—420. The total, 1,412 in all, was made up of 542 senior and 345 infant boys, and 318 senior and 207 infant girls, distributed as follows:— Stepney, 525 (0.9 per cent.); Bethnal Green, 520 (2 per cent.); Poplar, 281 (0.8 per cent.); City of London, 86 (3 per cent.). The figures in brackets denote the approximate percentage of the school child population. The following facts may be noted :—(i.) There appears to be an annual fluctuation. It looks as if 1922 had been a healthy year, and 1923 the least healthy. 74 " (ii.) More boys are 'discovered' than girls. This does not mean that otorrhœa is more prevalent among boys than girls. It is easier to see ear discharge in a boy than a girl. Boys may attend treatment centres less regularly. It is possible that parents think less of ear discharge in a boy than a girl. " (iii.) The number of cases ' discovered' in infants departments is very significant if one may assume that cases in infants are more amenable to treatment than those amongst children in senior departments by reason of more recent onset. The average is about 130 a year in infant's departments." Nursery schools. The Rachel McMillan schools in Deptford, with accommodation for 200 children, have had a record attendance during the year, and there is still a large waiting list. A number of children from this school were taken by the teachers to the Averyhill Training College during the summer holidays. The experiment was a great success. Similarly, the Jellicoe and the Notting-hill schools, with their teachers, were transplanted into the country, and Miss Read, who arranges such a holiday yearly for her children at Notting-hill school, says that the mental as well as the physical effect of such a change is incalculable. The McMillan school has already had the effect of materially raising the standard of cleanliness in the district. The number of children requiring daily bathing has dwindled considerably, while several are not bathed at school at all. This is particularly noticeable here where the numbers are large. The Jellicoe school for the same reason has found it possible to substitute for their large immersion bath a bath of the kitchen sink type, similar to that used for small children in the McMillan school. The Jellicoe school has had the bath placed on a lower stand so that the children can wash their hands in small portable basins placed in the bath, thus economising in fixtures for water supply and waste. With the extra space secured by this arrangement it has been possible to arrange for the cooking to be done on the premises instead of at the Infant Welfare Centre next door. The schools fortunately have been singularly free from epidemics during the year, but the Council's recent decision that payment of grant be made on an average attendance instead of a percentage basis has had the not unforeseen effect of closing schools, where attendance is pulled down by epidemics or illness, until a larger attendance can be secured. This is contrary to the conception of the nursery school as a means whereby epidemic diseases can be controlled, and where absence is an indication for a visit from teacher or nurse for the purpose of ascertaining whether the child is being properly looked after, and of taking steps accordingly. These children are more liable to illness than older children, whose resistance is higher, and supervision in illness has so far been a feature of the nursery school, where a child is never absent for more than two days without enquiries being made. The number of children from 3 to 5 years of age attending the infants' departments of elementary schools is over 50,000, and it might be well to consider the points of difference in the provision made for these children and those in the nursery schools. One finds nursery schools in various types of buildings. Four are in private houses adapted for the purpose, one in a garage and courtyard, and the McMillan schools are composed of wooden shelters erected on open-air principles. All give good results, but as far as the main building is concerned, for summer and winter use few can compare with the newer type of elementary school, with French windows opening into a sunny playground, a large airy hall, and well warmed cloakrooms where wet clothes and boots can be dried. The fundamental difference lies in the fact that the amenities of the nursery school approach more nearly the amenities of a middle class home. The nursery school recognises that personal attention to the physical requirements of the child is at least as important as attention to his Dr. Hogarth's report on Nursery Schools. (i.) Building. (ii.) Physical requirements. 75 mental requirements. The children's conveniences are either in the school or are approached by a covered and sheltered way. In the elementary schools generally the only conveniences not necessitating a journey across the playground are those for teachers; boys' urinals have no overhead shelter. In the nursery school hot water is available, and a child can be bathed if necessary. The need for a daily rest for small children is officially recognised, and the necessary equipment, such as beds and blankets, is provided. (iii.) Rest. Every child has a cup of milk in the morning. A mid-day meal is provided for all children except at the Goldsmith Training College Nursery School, where a mid-day meal is provided only for necessitous children or those whose parents prefer them to have the meal in school. (Most of these children are well known to the College, many of them having attended the College Infant Welfare Centre.) (iv.) Food. I he number of children per head of start is smaller in the nursery schools, but the outstanding feature in the staffing of these schools is that the teachers employed, whether certificated or not, have had special training in the care and management of this group of children, whose requirements differ so greatly from those of older children. Although this special training is not yet available in London at the Council's training colleges for teachers, the Rachel McMillan Training Centre, the Goldsmiths' Training College, and the Gyp3y-hill Training College, all in London, have nursery schools attached to them. (v.) Staffing. Open air education. One of the problems of children's care, particularly in towns, is how to procure for many of the children a sufficiency of open air and sunlight. This is a particularly urgent problem in London, with its unprecedented aggregation of population. Individual children react in varying degree to the deprivation of fresh air and sunlight. There are marked racial differences. Italians, Jews and Welshmen thrive and prosper under town conditions, where the blond northerner languishes. Nothing is more striking to a visitor to an open-air school or convalescent home than the abnormal preponderance of children of the fair type. Added to this deficiency of fresh air and sunlight is the deficiency of fresh food, fruit, green vegetables, and pure untreated milk. Recent research into the causes of deficiency disease in childhood has emphasised the inter-relationship of sunlight and the mysterious vitamine constituents of the dietary in their prevention. Town pallor in the school population of London is recognised as a precursor of tuberculosis. Perhaps the most fascinating page in the history of children's care in London is that dealing with the various practical measures which have been adopted to deal with the school child who begins to flag and becomes listless, to grow pale and thin and to pine. "You must send him away at once for a month into the country, mother," is continually on the lips of the hospital physician, advice which it is too often out of the power of the mother, unaided, to follow. Many years before the advent of the school medical service, the Children's Country Holiday Fund sent innumerable London children to the country for a summer holiday for a fortnight, and the school organisation was always placed fully at their service for the prosecution of this good work. When war conditions depleted their resources and limited the number of children to be sent, the authorities of the Fund sought the help of the school medical service in choosing those children particularly in need of a holiday from the point of view of health. Year by year, too, the services of the school nurses have been put at the disposal of the Fund to ensure that the children going away shall be free from verminous infestation and contagious disease. The Invalid Children's Aid Association has done and continues to do invaluable work in sending to convalescent homes London children who require long periods of country life to restore them to health, but these are chiefly children who have 76 suffered from acute illness and are under the care of hospital physicians or tuberculosis officers, although a certain number of children in whom the school care committees are interested are also sent away by them. A large number of other societies, including the Ragged Schools Union, have also assisted in this form of activity on behalf of the ailing London child. Between the child requiring a fortnight's country holiday in the summer and the child requiring a prolonged convalescence for profound debility, however, there remained a number of children who were able to attend school and suffered from no definite disease, and yet showed in a varying degree those symptoms which have been labelled as pre-tuberculous. For these children there was long no provision. Shrewsbury house open air school. In 1907, an experiment in open-air education for the benefit of one type of these children was commenced by the Council at Bostall Woods. This school was transferred in 1908 to Shrewsbury House, Plumstead, where a successful open-air school has ever since been held. The report upon this school for 1923 points out that the feature of the weather was the abnormal deficiency in sunshine save for the period 1st to 28th July, when during school hours there were 71 hours 17 minutes sunshine. The school was open on 256 days, rain fell on 156 of these, and rest was possible in the open air on 153 days. Fires in classrooms were necessary on only 33 days. The average attendance continues to be high considering the delicate type of child and the difficulty of access to the school. The average number on the roll was 115, the average attendance 102, and the percentage 88.7. The children when once acclimatised prefer open-air school to ordinary school. The school doctor visited the school once a fortnight. Every child was medically examined at least once a term, many of them were examined much oftener. 25 children left the school during the year, of these 16 were admitted for anæmia, debility, and malnutrition, and all were improved. Three were admitted for quiescent phthisis, one for tuberculosis of the skin, and two for gland tuberculosis; all these were improved. Two children suffered from chronic bronchitis and one from rheumatism; these three children alone were not cured, but the two with bronchitis were much improved in general condition. The rheumatic child was considered unsuitable for open-air school conditions. The average length of stay of these 25 children was 26 months. 19 left the school on account of age. and seven returned to the elementary school. Of the 120 children still in attendance at the end of the year, 107 were recorded as improved in health, and 13 not improved. Seventy of these children were of the pre-tuberculous type, and all were improved but two ; 28 suffered from arrested tubercle and all these were improved but one. Of six cases of chronic bronchitis, none is as yet improved; of seven cases of recurrent bronchial catarrh, six were improved; of three cases of asthma, two were not improved; of two cases of chorea, one improved and one did not; one case of phlyctenular conjunctivitis was much improved; and so were three cases of simple enlargement of the cervical glands. Although the cases of chronic bronchitis have not improved as far as this malady (which is intractable) is concerned, their general condition has greatly benefited. The average gain in weight during the year of the children was 3.32 kilogrammes (7⅓ lbs.) in eleven months, compared with the average gain of elementary school children of the same age distribution of 2.8 kilogrammes. Twenty-five of the children left London during the summer holidays to go to the sea-side or the country. Taking the improvement in weight of those who did not get a change as 1, the increase of those who went away was found to be 1.9. The dietary is satisfactory as to quantity and suitable as to food value. Butter, fruit and green vegetables are regularly included. Appetites vary from good to enormous, and a poor one is hard to find. 77 In 1908 also two other open-air schools were opened in London at Birley House (Forest Hill) and Montpelier House, Upper Holloway. That at Birley House has been successfully carried on ever since, but the site at Montpelier House was unfortunately lost, and north London has remained without open-air school facilities. Other openair schools. In 1920, a site was obtained at Stowey House, Clapham Common, and this has developed into the largest of the Council's open-air day schools. Stowey House. Sir Henry Gauvain, the Council's consulting specialist for tuberculous children, drew attention to the remarkable results which are obtained by sunhght treatment of debilitated children. It is found, as shown by Rollier in Switzerland, that merely by exposing the skin to the sun's rays, a very great improvement in appetite, metabolism and general health, takes place over and above that produced by ordinary open-air treatment. Heliotherapy Sir Henry has demonstrated that the sun has this special power during the summer months even in England. He was anxious that the treatment should be tried for debilitated children in London, and having visited Stowey House, was of opinion that it was quite possible with easily arranged modifications of the organisation to carry out the treatment there. Permission for this to be done was given and the head teacher of the school threw himself with ardour into the experiment. Thirty-five most suitable lads were chosen by the school doctor from the upper school. The head teacher explained the scheme to the parents, and asked each parent who desired his boy to undergo the course to provide a special costume of a loose shirt, very short serge shorts, short socks and shoes. These were readily forthcoming, and the class waited rather anxiously for the sun to appear. Unfortunately the season was most perverse, and it was not until the middle of June that the treatment could be commenced. The first week the lads worked in light shirts, short pants, socks and shoes. The second week shirts were discarded for certain lessons, the periods of exposure gradually being increased, and so on up to the summer holidays. As a result of a few weeks' treatment the children appeared more alert, more energetic, and particularly happy. On the return from the holidays, acclimatisation was more quickly effected, and the bodies, as is essential, were browned without signs of redness. The summer vacation, unfortunately, seriously limits the time during which the cure can be carried on, and also breaks up the period with loss of continuity of treatment. The 1923 summer was also deplorable in the lack of sunny weather, but the results were sufficiently promising to make it highly desirable for the experiment to be continued next summer. Bow road open-air schcoL A fourth open-air school was established at Bow-road in 1922, partially meeting the needs of an immense congested area. The number on the roll was 134 (86 boys and 48 girls), and present average attendance is about 100. The buildings consist of adapted Army huts, which are not ideal for the purpose of an open-air school. On that account lessons, rest and meals are taken outside in the open air on all possible occasions, This is an advantage. However ideal an open-air classroom may be, it is not so ideal as the open air itself. Lessons have been in the classroom on 11.5 per cent, only of total meetings. Rain is the only reason for retiring in this way to shelter. Meals have been taken indoors on 25 per cent, and rest on 35 per cent, of total occasions. The desks are collapsible and such that, if a sudden shower comes on, the boys and girls just fold them up and take them at once indoors. Details of 20 children who had been excluded from or were very irregular in their attendance at their ordinary schools are as follows, the percentage of attendance at the open-air school of these children being 83.5 :— 78 N ame. Age. Attendance history at previous school. Percentage of attendance at open-air school. Name. Age. Attendance history at previous school. Percentage of attendance at open-air school. Fred S. 14 Practically no attendance 92 Harriet F. 13 Absent about 2 years 97 John W. 11 do. 85 Winifred M. 11 do. 83 returned to Doris M. 15 do. 74 elementary Miriam E. 11 do. 50 returned to elementary school fit Lily G. 13 do. school fit 74 Chas D. 12 do. 91 Queenie G. 14 do 76 Margt. S. 9 do. 98 Elsie B. 13 Absent about 4 years 89 Peter B. 9 do. 96 Sarah W. 14 do. 91 Agnes C. 15 Absent about 78 Will C. 13 do. 88 3 years Arthur K. 13 do. 95 Violet G. 10 Absent about 3 years 86 Ida H. 12 do. 55 Fred. W. 14 Irregular 100 Total average attendances at open-air school 83.5 No ill-effects were observable through the school being first opened in midwinter. A frequent cause of anxiety among the parents is the question of travelling. Fortunately the children are travelling both morning and evening against the heavy business traffic. They are divided into travel sections, each section being in charge of a prefect. Four sections travel by tram car, a fifth section by omnibus, and a small section by train. The prefects report each morning as to the incidents of the previous evening journey. Three meals a day are provided at the school. One difficulty is caused by the presence of a large number of Jewish children so that two separate canteens are necessary. Delicate children are faddy about their food, and have been spoilt by the anxieties of their parents. Porridge and milk will be taken after two or three days' persuasion, but great difficulty is (or was) found in getting the children to eat fresh vegetables. It is remarkable that children who are debilitated frequently refuse the very articles of diet that are essential. The condition of some pre-tuberculous children is directly due to the want of firmness or resource on the part of parents in regard to the dietary. Often debilitated children are spoilt children. And the more they are debilitated, the more they are spoilt. A vicious circle is thus established with disastrous results. The problem of fresh vegetables has been practically solved by grating them and administering them in stews. Fom the date of the school opening until October, 1923, 38 children returned to elementary school fit, 19 children left over age, some of whom were fit, and 19 left through removals and other causes. The average increase in weight over 12 months was 3.3 kilogrammes in boys, and 3.36 in girls. The boys have increased on an average 1 kilogramme and the girls half a kilogramme more than the average child in elementary schools. Clothing is no great difficulty. Parents seem to be able to provide layers and layers of body clothing. Some children are much overclothed. About 20 per cent, of the children, however, come badly shod, but help has been forthcoming from the Mayor of Poplar's fund. The curriculum is admirably adapted to meet the conditions of the children and their environment. Singing and dancing are prominent features. The great improvement in the carriage of the girls is due to the systematic course in dancing given. The teaching and practice of hygiene is a definite part of the school instruction. The Council's booklet on "The Health of School Children" forms the basis of the lessons, while washing, teeth-cleaning, etc., form the practice. The reports on the Shooter's-hill and Bow-road open-air schools inspire the hope that it may be possible to proceed further with the Council's program for the establishment of open-air schools in other parts. It is hoped that a further 79 air school will shortly be opened in South London, and redoubled efforts are being made to overcome the difficulties in North London. The great obstacle to the latter is that London is built upon up to its limits and far beyond, in this direction, and the only chance is to acquire some mansion with extensive grounds which in the present condition of house shortage is well nigh impossible. It is a thousand pities that a tiny portion of each of the larger parks cannot be devoted to this purpose. During school hours the parks are comparatively speaking, unfrequented, the use of a small portion for the restoration of health of the debilitated child would be practically unnoticeable, and would in no measure detract from their amenities. It appears deplorable that such opportunities should be wasted. No sites likely to be secured in London will compare in results with those that would be obtained bv open-air schools in the large narks and open spaces. In view 01 the difficulty experienced in getting sufficient open-air school accommodation many teachers for some years have attempted to secure open-air education for isolated classes of children in the playground of the school or in some instances in adjacent parks or open spaces. Four such classes in exceptionally favourable positions are held throughout the year. 89 other open-air classes were held during the summer only. 21 of them were for delicate children selected by the school doctor, while 70 were for ordinary classes held in the open-air instead of within the school walls. Special reports on the 21 classes for delicate children were received. Many of the children were clearly benefited, but the results naturally were not so good all round as those obtained at the open-air schools where adequate facilities for rest and feeding are present. Open-air classes. The reports are generally more enthusiastic in regard to classes held in the parks than to those held in the playgrounds, but even in the latter good work was done and teachers should be encouraged to carry on open-air work wherever the conditions allow. After the war many thought that it would be advisable for the Council to acquire some of the military camps for educational purposes. A number of camps were inspected, but in the end the only suitable camp found was that at Bushy Park. The equipment was presented to the Council by the Canadian Red Cross Society, and Upper Lodge, with the land adjoining, has since been graciously placed by the King at the Council's disposal. The function of the school is to preserve town children who begin to flag from sinking into a state of chronic anaemia or debility. It is expressly brought into being to deal with the child whose doctor says : "Now mother, the thing to do is to get him into the country for a month." This is quite a different type from that for which the day open-air school is established. Convalescent camp schools. Bushy. The school has achieved a notable success. Not only do the boys improve in health, they have their teeth thoroughly seen to during their stay, are taught the rudiments of hygiene both by precept and practice, and receive as well a moral uplift from the excellent tone maintained. Boys gain in weight in some cases as much as seven or nine pounds during their stay. Defects of posture and carriage and incipient deformities are skilfully and methodically dealt with by intensive remedial exercises. Not only does each boy learn and practice a hygienic mode of living, but at the end of his stay each boy carries away with him a definite set of instructions suited to his needs. One boy was sent to the school by the Care Committee specially in the hope that he would reach the physical standard required by the Post Office. This he achieved, making a growth of over an inch in height, which enabled him to pass the test. Daring the year, 781 boys received individual treatment for physical defects during their stay, and 94 per cent, were visibly improved. The benefits of the school are widespread, catering, as it does, for over 3,000 boys a year. Girls are not so fortunate. However, a most successful institution is run by the Council at Wanstead House, Margate, where three hundred girls of the same Wanstead house, Margate. 80 type as the Bushy boy are treated annually, each girl staying at the school six weeks. More provision of the kind is needed, and it is hoped shortly to increase the accommodation at Barham House, St. Leonards, as well as to utilise a new institution near Bournemouth for girls. This school at St. Leonards receives camp school parties selected on medical grounds, from the crowded district of Hoxton. Dr. Lewis, the divisional medical officer in North-east London, writes: "There is no doubt that the camp school has been and is of great benefit to the locality (Hoxton)." Note must be taken finally of the School Journey Association. Primarily for educational purposes, classes of children are taken for periods averaging a fortnight by the teachers to the country during school term. Incidentally, the children obtain benefit to their health by these journeys. The aid of the school medical staff is freely given in connection with these journeys, and the freedom from attacks of infectious disease, and from conveyance of contagious conditions generally experienced, is due to the careful examination and preparation of the children. During 1923 it was found possible to deal with the majority of applications, for the medical examination of children immediately before setting out. 187 parties were inspected before departure. It was necessary to exclude on medical grounds many children proposed to be included. These comprised a few children who were contacts with cases of infectious disease, those suffering fron tonsilitis and contagious conditions, a few cases of otorrhcea, and a few who were in such an unsatisfactory state of health that the teachers could not be advised to take the responsibility of their inclusion. Several children suffering from pediculosis and other parasitic conditions were dealt with at the Council's centres, and thus made fit for inclusion. Some apprehension was felt owing to the prevalence of infectious diseases, notably scarlet fever and diphtheria, lest some of the journeys should be spoilt by serious cases of this kind. Owing, however, to the care taken in the selection less trouble in this respect was experienced than in any former year. Some accidents and cases of illness occurred, but these were unavoidable. One child from Walnut Tree Walk school fell ill with an acute attack of appendicitis, for which an operation wa? necessary; one child from Holland-street broke an arm; and a boy from the Michael Faraday school contracted an acute attack of rheumatism after exposure to wet conditions. Sixty-one parties were re-inspected by the school doctors at or soon after return. All the doctors remark upon the great improvement shown generally in health as a result of the journeys, especially as evinced by the disappearance of anaemia and restoration of the tone of the heart muscle. As examples the following may be cited:— Dr. Cresswell Burrows says that 43 girls from Wapping were presented to him before going to Barham House, St. Leonards. Three were found tobe unfit on account of contagious conditions. Of the 40 who travelled, 28 showed some anaemia, 6 under-nutrition, and 9 disorderly action of the heart with defective muscle tone. 39 girls were seen on return, all the conditions of anaemia were cured except in one case, general improvement was noted in each case of malnutrition, five of the nine cases of functional heart trouble were cured, while others showed improvement; one case in particular with cardiac murmurs before the journey was found completely cleared up on return. "There is no doubt as to the great benefit each girl derived from the month's stay by the sea." Dr. Nairn Dobbie reports on seeing a party of boys at Lawn-lane school after their return. "The difference seen in these sun-browned and bright boys from the. pale rather tired and listless lads of three weeks ago is a great argument for the good done by the school journeys, more especial' y amongst children culled from a poor neighbourhood." Barham house. School Journeys. 81 Tuberculosis. One of the most important objectives in connection with tuberculosis is undoubtedly the earliest possible detection of the disease ; for this systematic examination and supervision of child contacts if essential. To effect this the closest co-operation between the school and the tuberculosis dispensary is required ; and as experience of the scheme in operation by means of form M.0.33 showed certain directions in which improvement could be made, the following modifications of the scheme were drawn up. Tuberculosis. Form M.O. 333 will replace M.O. 33 ; the tuberculosis officer refers on M.O.333:— A.—All " unsatisfactory children," whether contacts or not, who, after observation at the dispensary, are considered to be probably non-tuberculous, but who require supervision. Brief medical particulars of each case are entered on the card. B.—-All contacts who on first examination are apparently healthy, and also, as far as possible, all other contacts that he has been unable to examine. The name, date of birth, address, and school attended, are entered on the card, and each case classified by the tuberculosis officer under one of the following headings. The card is then sent to the divisional medical officer. Class 1. An " unsatisfactory " child, whether contact or not. Class 2. An apparently healthy contact; or Class 3. A contact that has not been examined. Procedure in the dispensary. Class 1 are (a) examined by the school medical officer quarterly, and referred back to the dispensary if at any time, in his opinion, the child should be regarded as probably tuberculous. (b) weighed approximately monthly, and the weight recorded on the chart. Class 2 are (a) examined once a year ; (6) weighed quarterly. Class 3 are examined as soon after reference as possible, classified by the school medical officer, and dealt with as Class 1 or Class 2, as the case may be. Once a year a conference is mutually arranged between the divisional medical officer and the tuberculosis officer, at which records of all cases referred under the scheme are reviewed, and the cases re-classified or discharged from further observation Procedure in the school. Dr. F. C. Lewis submits the following report of the first year under the amended scheme in the north-eastern division. " I have met the tuberculosis officers working in this division, and with them have reviewed the cases which have come under notice. The following table provides an analysis of the results. The first column shows the total numbers referred to me, the second column relates to the children who now appear to need no further supervision, and the numbers of those who would apparently benefit by retention in the scheme appear in column three :— Dispensary. Total. Discharged. Retained. Metropolitan Hospital 85 67 18 Royal Chest Hospital 399 306 93* Victoria Park Hospital 48 28 20† Royal Northern Hospital 76 66 10 608 467 141 * Including 21 for re-examination by tuberculosis officer. † Including 2 for re-examination by tuberculosis officer. In the eastern division, Dr. Chaikin reports during the same time that 1,137 school children were kept under observation of whom, 195 were discharged, the remainder still being under observation. 297 were Class 1, 736 Class 2, and 104 Class 3. Twenty children of Class 1 were excluded from school. 82 Children absent from school on account of illness. A special census is made in November each year of children out of school for chronic illness. The results for the past four years are given in the appended table. While the total numbers reported each year do not greatly differ, the percentage of children suffering from tuberculosis tends to decline, while that relating to rheumatism tends to increase. The number of children stated to be suffering from chronic nervous disorders increased during 1923. Of the 2,726 children, 1,170 were boys and 1,556 girls. In boys, the percentage absent from rheumatism was 19.4, and from tuberculosis 20.1; in girls, on the other hand, the percentage suffering from rheumatic disorders was 27.3, and from tuberculosis 14.6, showing very remarkably the excessive incidence of rheumatic diseases upon girls compared with boys. Children absent from school three months owing to illness reported in November— 1920, 1921, 1922, 1923. Children. Percentage of total. Complaint. 1920. 1921. 1922. 1923. 1920. 1921. 1922. 1923 Rheumatism, heart and chorea 537 659 682 652 21.12 21.61 23.5 23.92 Nervous disorders 219 238 245 274 8.21 7.8 8.44 10.05 Tuberculosis (pulmonary and other) 595 613 502 462 22.33 20.1 17.3 16.95 Anaemia and debility 155 219 212 184 5.82 7.18 7.31 6.75 Ringworm 125 231 200 145 4-69 7.57 6.89 5.32 Skin complaints (other than ringworm) 102 77 52 66 383 2.52 1.79 2.42 Eye complaints 167 150 144 112 6.27 4.91 4.96 4.11 Infectious disease — — 80 67 — — 2.76 2.46 Other diseases 765 862 785 764 28.7 28.27 27.05 28.02 All diseases 2,665 3,049 2,902 2,726 — — — — The greatest number absent is at age 6, next to this at age 13. The least number is at age 10. At age 12, the proportion of the whole is 12 per cent, in girls and only 7.6 per cent, in boys. Chorea. The records show an increase in the number of cases of the disease designated chorea. In 1920, the proportion of the out-of-school children suffering from chorea was only 7.4 per cent; in 1921 it was 8.19, in 1922 it reached 9.2, and in 1923 it was 9. In seeking an explanation, it is necessary to bear in mind that chorea is no longer the clear-cut clinical entity it was formerly supposed to be. Although some still maintain that chorea is almost invariably a rheumatic manifestation, others are now insisting that it is primarily a nervous disease. In 1923, the total number of out-of-school cases was 2,725, and 230 of these were certified as choreics. This figure does not reflect adequately the loss of education due to chorea, as these children remain out of school for longer periods than those suffering from most other complaints. Seventy per cent, of the chorea cases were girls. Up to the age of ten there is great disparity between the numbers of choreic girls and boys. In fact, amongst the nine-year old cases, the boys were in a slight majority. After the age of ten, the girls were greatly in the majority ; and amongst the thirteen-year-old cases there were 41 girls and only 2 boys. The age distribution is specially interesting. With one exception, the number of cases increases continuously up to the age of thirteen. Below the age of ten, the choreic children formed 6.69 per cent, of the out-of-school cases, whereas between the ages of ten and thirteen the percentage is 11.3, and amongst the thirteen-yearold children 13.3 per cent, of the whole group of out-of-school cases suffer from chorea. So many children leave the school in their fourteenth year that it is impossible at present to estimate the incidence of chorea at ages above thirteen. It is evident from the figures that what is certified as chorea is a disease that increases in frequency up to the age of adolescence and the increase is considerably accelerated during the pre-puberty ages and especially amongst girls. 83 This is not the age-distribution that might be expected if chorea were primarily of rheumatic origin, unless it be argued that the nervous sequelae of rheumatism delayed their appearance for some years after the other signs. It is generally agreed that in about 80 per cent, of rheumatic cases there is a history beginning between the ages of four and nine. There are other features of these "out-of-school" statistics which suggest that the relationship between rheumatism and chorea has been somewhat exaggerated in the past. For example, there is not an equivalent increase in the numbers of rheumatism cases. The proportions of out-of-school cases stated to be suffering from rheumatism during the last four years were 4.09, 4.82, 5.2 and 4.33 per cent, respectively. Then, again, the incidence of heart disease amongst the cases certified as choreic is low. In one group of 230 chorea cases 26 only (11 per cent.) were notified as having cardiac disease. The data may be somewhat incomplete on this point, but all cases with serious heart-lesions would come under notice through one channel or another. Previous investigators have published results indicating that widely varying proportions—between fifteen and seventy per cent—of chorea cases had cardiac disease. The low incidence of heart disease in the group of choreic children is all the more significant because it coincided with a steady increase in the numbers of children suffering from heart disease. In the last four years the percentage of out-of-school cases with heart disease was 8.67, 8.69, 8.13 and 10.6 respectively. (It is of interest to note that not a single case was noted in which chorea was stated to be a sequel to scarlet fever.) The general features of the statistics support the conclusion suggested by the clinical examination of several cases, namely that there is an increasing tendency to certify as chorea conditions of purely neurogenic character. The substantial increase of the number of girls of thirteen said to be suffering from chorea is another proof that what hitherto was regarded as simply adolescent instability is now called chorea. One explanation of this tendency is that during these last few years this adolescent nervous instability is decidedly more pronounced than it used to be, with the result that doctors regard the condition as akin to the more serious disease, viz., chorea. That there is of late an increase of nervous trouble amongst children is shown by further analysis of the figures. Those stated to be absent owing to nervous trouble formed the following proportions of all the cases in the years 1920-23, 8.21, 7.8, 8.44, and 10.05 per cent, respectively. The sudden increase last year may be merely a spurious variation, but before adopting this view it should be borne in mind that many of the cases of chorea would be more appropriately classified as nervous diseases ; and that this woifld raise the proportion of nervous disease to such an extent as to make it extremely improbable that the variation is merely accidental. When seeking an explanation of this increase of adolescent narvous instability, it is natural and so easy just to say: " The war again." It was suggested that the numbers of mentally defective amongst war-babies would show a decided increase above the normal rate ; but there is no evidence of this. The effects of war conditions upon the nervous condition of the children are, however, more substantial, and the explanation cannot be so lightly discarded as in many other present-day problems. The mental injuries that a child of eight or younger received during the air-raids would be expected to add to the mental conflicts and other features of mental maladjustment of the adolescent. This explanation is well in line with the more recent psychological results of the study of the adolescent. Still more obvious is the result of the severe prevalence of influenza in 1918 and 1919 and the trailing outbreaks which have succeeded that prevalence. Investigations showed that scarcely a child in school failed to suffer during the prevalence. The virus of influenza has a predilection for attacking the nervous system, and many cases labelled chorea are undoubtedly the aftermath of influenza and of the associated encephalitis lethargica. 84 The distribution of chorea in London so far as it can be gauged by the percentages of total causes of absence for the various districts exhibits considerable variation. Lambeth 14.4 per cent. Wandsworth 8.6 per cent. Chelsea 6.2 per cent. Camberwell 8.9 „ Greenwich 80 „ Hackney 60 „ Poplar 8.6 „ Islington 7 .3 „ St. Pancras 5.6 „ City and Stepney 8.6 „ Paddington 6.6 ,, Southwark 5 .0 „ The number of tubercular cases amongst children has decreased steadily in the last four years. The percentages of out-of-school cases notified as tubercular during the years 1920-23 were 22.33, 20.1, 17.3 and 16.95 respectively. The steady decrease is undoubtedly due to more efficient supervision, the thoroughness of which is shown by the following figures. In all, 421 children out-of-school were certified as tubercular; 251 of these were in convalescent homes, 96 attended the various metropolitan hospitals, 31 attended dispensaries, 27 were treated by private doctors, 12 were in infirmaries and 4 were on holiday in the country. There were only 20 cases, in the whole of London, which did not seem to be under constant medical supervision. A detailed analysis of the data shows that the numbers of boys and girls afflicted are about equal (227 boys and 214 girls). There is a definite preponderance of surgical cases amongst the boys and of medical cases amongst the girls. The figures also suggest that the onset of the disease seems to be decidedly earlier in surgical than in medical cases. Employment of School Children. Under the Council s Employment By-laws no child liable to attend school can be employed out of school hours unless a certificate of fitness has been obtained from the school medical officer. The following summary gives the number of children seen under the By-laws during the past year in each division. Division. Children examined. Certificates granted. Certificates issued cri condition that treatment is obtained. Rejections. Application withdrawn fcr various reasons. Certificate revoked. E 169 155 10 4 — — N.E. 378 360 13 4 1 — N.W. 845 686 56 26 77 — S.E. 678 659 15 3 — 1 S.W. 658 655 1 2 — — Total 2,728 2,515 95 39 78 1 Of the 2,728 children only 66 were girls. Seventy per cent, were to be engaged in the delivery of newspapers. In 1.4 per cent, the school doctors refused certificates on account of the general ill-health of the child or the physical unsuitability of the child for the employment proposed. The rejections included two cases of tuberculosis, 13 of heart disease and rheumatic affections and 10 of general debility. The proportion of children for whom conditional certificates were granted was 3.2 per cent. The conditions mainly imposed were that necessary medical treatment of defects should be carried out including dental attention, and correction of visual defect and treatment of minor ailments, but in some instances a shorter period of work than the by-laws permit and restrictions upon the lifting or carrying of heavy weights were imposed. These children and others in whom the doctors had doubts were kept under continuous medical observation. In about five per cent, of the children employed, continuous medical observation was considered necessary. In only one instance was a license revoked in consequence of deterioration of health; this was in the case of a boy engaged in newspaper delivery who developed trouble in the knee joint. So far as medical observation can discover, the introduction of the by-laws has cured the evils which formerly undoubtedly arose through the employment of 85 children in wage-earning capacity out of school hours. Only children physically fit are allowed to be employed, and the restrictions in hours and in character of the work have made it very unlikely that harm can accrue to any child except in very rare instances. Physical Exercises. The reports of the organisers of physical education in the Education Officer's department show that advances are rapidly being made. There is no doubt that a considerable share in the improvement of the health, physique and stamina of the London school child, which is recognised on all sides, is to be ascribed to the intelligent practice of physical education. Major Gem refers to the large increase in the number of boys' departments which have adopted the team system and the efficiency tests which add both to the zest and effectiveness of physical education. Miss Simmons and Miss Graham point out the growth of a broader conception and freer handling of the girls which have brought about an increased interest and an improved tone. Special classes for children selected by the school doctor are held in about 25 girls' and junior mixed departments. The organisers say "wonderful results have been obtained in a short time in some very poor localities. We feel this side of the work should be extended, but the classes require a considerable amount of attention from us and depletion of staff has made it difficult for head mistresses to spare a teacher daily for a small section of girls drawn from several classes. In some cases the head mistresses, realising the benefit that the daily lesson has been to the few children in the remedial class, have dropped the remedial class and instituted a daily lesson throughout the school." A typical medical report on these special classes, which all who have paid attention to them have recognised to be of surprising value, is given in the following account of the special exercise class at Smallwood Road (girls department), 1923, by Dr. C. E. Thornton :— " This class is made up of girls (8 years old and upwards) suffering from varying degrees of spinal curvatures, chiefly of the statical type. From the annexed tables it will be seen that kyphosis is the commonest deformity: it is also the easiest to rectify: scoliosis is much more resisting to treatment. General debility seems to be the chief predisposing factor, most of the girls being anaemic and of poor muscular development. Defective vision and adenoids were in no greater proportion than they are found generally in school children. Apart from the improvement obtained with regard to the specific deformity, all the children showed a definite and in some cases surprising improvement in their general health after a month or so of the exercises. "It is to be regretted that remedial exercise classes are not more frequent in the senior departments. This class is the only one which has come under my observation although in all the schools I inspect I find a number of children who would undoubtedly benefit by such a special course of exercise." Kyphosis. Scoliosis. Kypho-Scoliosis. Flat feet. Number. Discharged. Number. Discharged. Number. Discharged. Number. Discharged. Cured. Improved. Cured. Improved. Cured. Improved. Cured. Improved. 17 9 3 9 1 2 3 - 1 2 - — The chief organised game for girls is net-ball. London is divided into sixteen districts and the champion team of each district competes for the all-London cup which was presented in June 1923 by Lady Astor. Colls Road girls' department, Peckham, was the first winner of the cup. As a net-ball course can be marked out in most play grounds it is universally available and the recent time restriction bv the Board of Education will not affect Organised games 86 the game, which is as ideally suited to the physical characteristics of young girls as football is to those of boys. Swimming is taken by the majority of schools. About 11,000 girls were taught to swim in 1923. Co-operation with Child Welfare Centres. Wherever possible co-operation is established between the school medical service and the maternity and child welfare centres. At several centres the same premises are used for the two purposes, and the use of the Council's dental equipment has been allowed for the treatment of mothers and infants attending the infant welfare centres. A scheme is also in operation whereby the record cards of the children who have attended the maternity centres are passed on to the Council and distributed to the schools for the information of the school doctors. Negotiations are at present in progress with the National League for Health, Maternity and Child Welfare with a view to simplifying the card used and to increasing the number of maternity centres taking part in the scheme. School Feeding. More and more the assistance of the school medical service is sought in carrying out the Council's duties in regard to the school feeding of necessitous children. All children given school meals are not seen by the school doctor. It is only when deprivation of food has had time to produce physical signs that the assistance of the doctor is required and in London this is not waited for in the normal case. On the other hand many children are placed upon the feeding list as a result of the medical inspection when signs and symptoms are discovered which make careful enquiry into home circumstances desirable. The assistance of the medical department is often sought in doubtful cases where children are taken off the feeding list, the school doctor being requested to keep such children under observation so that if any sign of deprivation occur the child may at once be returned to school feeding. All menus are submitted to the school medical officer for approval. Necessitous children can always obtain sufficient starchy foods at home, and school feeding resolves itself into supplementing the protein portion of the daily diet. Hence the London rule that every school meal for a necessitous child shall contain at least 25 grammes of protein. Formerly school meals were prepared centrally by the Alexandra Trust and distributed in special containers. Although economical, this plan was not the best because it was found impossible under it to preserve vegetables in a palatable condition. The present arrangement by which the meals are prepared locally and mainly at the domestic economy centres is better, and the value of the meals is considerably enhanced. The following memorandum has been issued for the guidance of those concerned:— Schedule of quantities and general instructions for School Meals. (i.) Meat meals.—3 oz. with bone, 2½ oz. without bone. Potatoes ⅓ lb. Root or green vegetables 2 oz. (One of the puddings set out below.) (ii.) Meat puddings or pies.—2½ oz. meat without bone. 2 oz. flour, ⅔oz. suet, dripping or lard. Potatoes ⅓lb. Root or green vegetables 2 oz. (iii.) Soup meals.—Soup, 2 oz. peas or lentils, ½ oz. rice, tapioca and barley mixed together.½ pint stock, seasoning, ¼oz. dripping. Potatoes ⅓ lb. Suet pudding must be always served as a second course with soup. 1¼ oz. flour, £ oz oatmeal, oz. fat, ⅔oz. dried fruit, syrup or jam, or 1 oz. fresh fruit and ¼ oz. sugar. (iv.) Fish meals.—¼ Ib. fish. ½lb. potatoes. 2 oz. vegetables. (One of the ptiddings set out below.) Pudding for inclusion in meals i. and iv. 87 (a) Boiled suet pudding.—2 oz. flour, ⅔oz. suet, ½oz. dried fruit, syrup or jam or 1 oz. fresh fruit and £ oz. sugar. (b)Baked pastry.—2 oz. flour, ⅔oz. dripping, ½oz. jam or 1 oz. fresh fruit and ¼ oz. sugar. (c) Milk pudding.—⅓ pint of pudding per child. The pudding should contain the following proportions:—2 oz. cereal, viz.: rice, tapioca, or barley, ½ pint milk, ½ pint water, 2 oz. sugar, 1 oz. suet chopped very finely. (d) Batter pudding.—1 oz. flour, ¼ egg, ¼ gill milk, ¼ gill water, salt, 1 oz. syrup, sugar or jam or fresh fruit and ¼ oz. sugar. (e) Orange pudding.—1 orange cut into slices, ½oz. sugar, ½gill milk custard. (When this pudding is served a dumpling or a piece of Yorkshire pudding must be served with the first course.) (f)Any other pudding of equal food value may be served. General rules:—Meat must be served three or four times a week. Soup must be served only once a week. Fish may be served once a week in lieu of meat. Cheese pie or pudding may be served occasionally instead of soup. Haricot beans may be served once or twice a week instead of green vegetables. Fresh fruit should be used in the making of puddings and pies whenever it is cheap. Potatoes baked in dripping should be served at least once a week. The meals should be varied as much as possible. Another most valuable means of dealing with the under-nourished child is the provision of milk and cod-liver oil in school. These are given only on the advice of the medical officers and the children concerned are kept under medical supervision, their weights being carefully taken and consideration being given to their nutritional state at regular intervals. Too great value cannot be attached to this most important sphere of activity. The number of milk meals for the week ended 24th January, 1924, was 19,824 (free or part payment), and 45,911 (full payment), total 65,735, while 2,726 (free or part payment) and 5,891 (full payment) doses of cod-liver oil were also given. Nor does this represent the total amount of milk and cod-liver oil supplied, as many head teachers are running milk-clubs and making independent arrangements with dairies. Some milk meals obtained for non-necessitous children from the official contractor are included in the returns, others are not, and meals obtained from dairies outside the contract are rarely returned, so that the statistics are incomplete. Although milk meals are largely recommended by the school doctor, the size of the list of children receiving milk meals at particular schools depends to a great extent upon the opinion of the head teachers and the care committees as to the utility and desirableness of giving milk in school. The number of children seen at routine medical inspection who, prima facie, require milk in school on medical grounds is small. The size of the milk list depends almost entirely on the zeal and enthusiasm of the teachers and care committee workers in seeking out suitable children and bringing them before the doctor as special cases for consideration. When restrictions were imposed by the Board of Education (circular No. 1261, 17th May, 1922), it was felt that more care and consideration must be given to the question of the ill-nourished child and that it would be advantageous if the milk cases were studied more carefully from the nutritional point of view, to ascertain whether the mere giving of milk was sufficient in every case of malnutrition and to make certain that children in one district no longer in need of milk should not be receiving it to the exclusion of children in other districts who required it urgently. As a result the doctors found many children obtaining free milk whose physical condition no longer warranted it on purely medical grounds. One of the difficulties arises from the fact that it has been customary to place children on the dinner list when necessitous irrespective of their physical condition, but in general only on the milk list when their physical condition or their health demanded it upon medical grounds. Some care committees desire to place children 88 on the milk list for preventive reasons, just as upon the dinner list. In these cases some differences are bound to arise between the standard wished to be adopted by the care committees and that adopted simply on the physical condition of the children. The position was, however, safeguarded by the provision under which children removed from the milk list are subsequently kept under observation for a sufficient period of time. The amount of time and care given by many head teachers in poor schools in supervising the service of milk meals and administering the cod-liver oil meals deserves the fullest recognition. Supervision Milk supplied to the children has been systematically examined throughout the of dietaries. year. The total number of samples analysed was 1,116. Of these 116 (10.4 per cent.) were unsatisfactory, 3.5 per cent. containing added water and 6.9 per cent, showing a deficiency of fat. The maximum addition of water in any one sample was 20 per cent. whilst the greatest abstration of fat was 26 per cent. In connection with the provision of meals 68 meals were examined in the Council's central laboratory and in a number of cases attention was drawn to the need that existed for an increase in the protein or the calorific value. The Teaching of Hygiene. At a conference between the school medical officer and the Council's educational inspectorate to discuss the annual report of the Chief Medical Officer of the Board of Education the question of the teaching of hygiene was discussed. As a result a memorandum* was framed in consultation by the two departments and issued to all head teachers of senior departments of public elementary schools in London for use in connection with the work of its schools. Personal Hygiene. The total number of examinations made at rota visits during the year by the district school nurses was 2,052,904; verminous conditions were present in 371,790 instances, or 18.1 per cent., as compared with 18.7 per cent., in 1922 and 20.5 per cent in 1921. The results of the work for several years 1912-1923 under the cleansing scheme are shown in the following table:— Year. Examinations at rota visits. Venrinous conditions noted at rota visits. Per cent. Verminous children referred to stations. Subsequently cleansed byparents. Verminous children cleansed at stations. Scabies cases bathed at stations. 1912 — —_ — 23,573 10,179 10,340 1913 — — — 29,903 15,241 14,662 — 1914 1,053,218 286,664 27.2 28,361 14,392 13,969 589 1915 2,444,885 689,428 28.1 28,033 14,677 13,386 1,059 1916 2,399,280 612,659 25.5 24,705 11,314 13,391 3,213 1917 2,130,186 528,658 24.8 19,503 8,506 11,000 6,940 1918 1,921,762 465,608 24.2 13,237 4,912 8,325 9,624 1919 2,031,735 459,396 22.6 33,222 15,929 17,292 8,371 1920 1,944,105 368,732 18.9 43,764 16,355 27,409 9,675 1921 2,113,463 435,282 20.5 65,084 22,489 42,595 5,863 1922 2,158,100 405,335 18.7 73,800 26.031 47,769 3,944 1923 2,052,604i 371,790 18.1 79,702 26,469 53,233 2,935 In addition to the figures set out above the numbers of children dealt with at the head cleansing centres during 1921, 1922 and 1923 were 13,586, 24,637 and 24,516 respectively. * Copies may be obtained from the Public Health Department, The County Hall. S.E. 1. 89 The reduction in the percentage of children found unclean corresponds closely with the findings of the school doctors at routine medical inspections. It is the practice of the school nurses in London to include not only children found harbouring pediculi and their ova, but also children who are found flea-bitten; also, as the children are seen more than three times a year by the school nurses and it is probable that especially dirty schools receive more attention, it is clear that the above figures are not to be compared with those of other authorities where differing methods and standards may exist. It is satisfactory to report a continued decrease in the number of children suffering from scabies. This decrease has permitted an extended use of the cleansing facilities for dealing with the verminous child. The Council has agreements with 18 of the sanitary authorities for the use of their cleansing stations and with voluntary committees for the use of seven centres where head cleansings only are effected. These centres with the Council's own nine stations make a total of 34 centres which are available for the cleansing of school children throughout London. Out of 79,702 children whose verminous condition was brought to the notice of the parents 35,516 attended voluntarily at the cleansing stations, but in 21,951 cases it was necessary to serve statutory notices after a further examination. Following upon these statutory notices, 6,115 children attended the stations voluntarily, but of the remainder 11,602 were found verminous after a still further examination and were compulsorily taken by the nurses for cleansing. Among the children who were compulsorily cleansed 770 were subsequently found to have relapsed and prosecutions under section 87 of the Education Act were instituted in 659 cases. As in previous years the borough medical officers were informed concerning children dealt with under the Council's cleansing scheme in order that the home conditions might be remedied under the Acts of 1904 and 1922. During 1923 reports were received in regard to 3,589 homes visited; out of this number disinfestation or destruction of bedding or disinfestation of homes was carried out in 1,088 instances. In 1922 the corresponding figures were 5,005 homes visited, action taken in 1,228 cases; 4,882 homes were visited and action was taken in 1,792 cases in 1921. Apart from the question of verminous conditions, arrangements have been made in Camberwell and Kensington for classes of school children to be taken to the public washing baths during school hours. The number of baths arranged for during 1923 was 3,991 in Camberwell and 5,151 in Kensington. In addition certain borough councils are now providing cheap tickets, the use of which is limited to school children attending the baths, generally before 6 p.m. Infectious Diseases. The decline in the incidence of scarlet fever which followed the major wave of Scarlet fever prevalence in 1920-21 continued during 1923, 4,824 cases having been reported as occurring among London school children, as compared with 8,026 (1922), 17,030 (1921), and 11,860 (1920) respectively. The disease persisted more or less actively in certain centres, notably in Islington, Fulham and Stepney to the nor!h, and in Camberwell, Lewisham, Lambeth and Wandsworth to the south of the river. The outbreak in Islington is worthy of passing comment inasmuch as the area affected in Holloway was comparatively restricted, and the outbreak commenced in August and continued throughout the autumn. This outbreak naturally affected the schools in the neighbourhood and one school (the "Forster") was specially involved. This school, as well as others, was visited from time to time, by the Council's medical staff and the reports indicated that the outbreak was not a school infection, but was maintained by the conditions of life in the larger tenement houses in the neighbourhood. 90 91 The number of schools specially affected and visited by the Council's medical officers during the year was 137, entailing 224 departmental investigations at the schools concerned. The number of children inspected at these investigations was 26,440 (12,283 boys and 14,157 girls). In previous reports this relationship has been exhibited in diagrammatic form. Relationship between flea A chart giving the figures up-to-date appears on the preceding page. The length of prevalence the base of each shaded area represents the interval of time between the maximum and scarlet point of flea prevalence and the maximum point of scarlet fever prevalence in each 'ever. year. With only three exceptions, viz., in the years 1909, 1922 and 1923, the maximum point on the flea curve precedes by some weeks (from 1 to 10) the maximum point on the scarlet fever curve. The three years, which have been described as exceptional, are not really exceptional though technically so classed. Thus in 1909 there was a mild outbreak in June, preceding the normal autumnal prevalence, and this quite unusual occurrence cannot be regarded as having any relationship with the development of the ordinary seasonal wave of scarlet fever, which followed a few weeks after the maximum of the flea curve (as shown on the diagram.) Again, in both 1922 and 1923 the autumnal rises in the flea curve were barely apparent, and the autumnal rises in the scarlet fever curves were only very slightly marked ; under such circumstances compliance with the general rule that the first named maxima should precede by a few weeks the two latter maxima was not to be anticipated. In the Annual Report for 1917 (p. 37) ten lines of argument were outlined in favour of the thesis that scarlet fever is transmitted by the flea; the first of these was to the effect that "There is a very close correspondence in form between the last nine seasonal curves of scarlet fever and of flea prevalence, and the autumnal maximum of the latter has invariably antedated that of the former, the antedating being by periods of from 1 to 8 or more weeks." The extended experience of the years subsequent to 1917 broadly confirms the argument put forward seven years ago. A criticism of the flea hypothesis of causation of scarlet fever, which has emerged since 1920, has been to the effect that in 1920 and 1921 considerable autumnal prevalences of scarlet fever were recorded, despite generally speaking a downward trend exhibited in the curves showing prevalence of fleas. In the Annual Reports for 1921 (Vol. III., pp. 44-7) and 1922 (Vol. III., pp. 80) it was pointed out that other factors besides the extent of flea prevalence were of course concerned ; for example, accumulation of susceptible children, and in this connection variations in the birth rate have influence; and again meteorological conditions need to be reckoned with, for dry years favour scarlet fever prevalence; moreover, the question of influence exerted by extent of hospital isolation must not be lost sight of. The annexed chart brings out very clearly the remarkable diminution, which has occurred since the records were first started, in the extent of flea prevalence among London children. This diminution, taken in conjunction with the almost equally remarkable reduction in prevalence of other vermin (lice and bugs), shows that very remarkable improvement as regards verminous conditions has been effected in the last 15 or 20 years. The number of cases of diphtheria in the schools was 3,985 as compared with Diphtheria. 5,641 (1922), 6,661 (1921) and 5,681 (1920). The distribution of the disease conformed generally to that of scarlet fever, the north-eastern and eastern, with the southeastern and south-western districts (immediately south of the river in both cases) being mainly affected. During the year 164 investigations were conducted by assistant medical officers in 102 schools, and 16,856 children (8,520 boys and 8,336 girls) were inspected. The bacteriological examinations made in the department in connection with diphtheria numbered 3,000 of which 252 showed the presence of diphtheria bacilli, whilst 129 raised some suspicion and were referred for further examination. The remainder were negative. 92 93 A diagram is given on page 92 showing the mortality from diphtheria and Death rates in London and certain croup in England and Wales, London and New York City, annually, for the years 1859-1923. Croup was more frequently returned as a cause of death in the earlier other years both in England and in New York. Up to about 1885 deaths certified as due localities, to croup in England exceeded those from diphtheria, but thereafter diphtheria is in excess, and in the past 15 years the deaths certified as due to croup are relatively insignificant. Similar changes in the relative mortality ascribed to diphtheria and croup are observed in American cities. In regard to the New York diphtheria and croup mortality shown in the diagram, it is observed, in the report from which the figures are taken, that in the earlier years registration of deaths was incomplete and that diphtheria deaths include angina, quinsy, and inflammation or ulceration of the throat or tonsils; attention is also drawn to the confusion in the earlier years between scarlet fever and diphtheria. In England and Wales these latter diseases were not separated by the Registrar General until 1859. It is remarkable that the mortality from diphtheria and croup in New York in the earlier years was much above that from scarlet fever : thus in the decennium 1871-80 the diphtheria death-rate was about twice that from scarlet fever: in the same period the London figure for scarlet fever was just twice that for diphtheria and croup. Subsequently the figures for the two cities have converged, and the rates for the decennium 1911-20 show a mortality in both from diphtheria and croup about four times that from scarlet fever. The late Sir Shirley Murphy in his Annual Report for 1898 (p. 31) drew attention to the fact that the case mortality of scarlet fever had declined very nearly as much as that of diphtheria in the period during which antitoxic treatment of diphtheria was generally adopted; from which he concluded that there was a possibility that some part of the reduction in diphtheria might be due to natural causes. The relationship shown by the diagram between the London and New York incidence of diphtheria in the last three years is interesting in view of the work done in the latter city, more especially in the Boroughs of Manhattan and Brooklyn, by Drs. Park and Zingher in the prophylactic treatment of diphtheria. The number of children dealt with during recent years might be regarded as large enough to influence the mortality, but the difference in the trend of the curves for New York and London is not sufficient to warrant any final conclusion. In considering the marked prevalence of diphtheria in London, in 1921 and 1922, now happily decidedly on the decline, it is worthy of recall that many years ago Sir Arthur Newsholme found that years of high diphtheria mortality were associated with periods of dry weather; and it is perhaps not without significance that the abnormal drought of 1921 was most severe in the south-eastern area of England. The cases of measles numbered 13,784 as compared with 34,385 (1922), 8,317 Measles. (1921) and 28,888 (1920). Towards the end of November measles commenced to show clear indications of a rise in prevalence. The number of cases reported steadily mounted week by week and by the time the children had resumed school after the Christmas holidays it was clear that an epidemic was in progress. The special scheme of visitation by the school nurses with a view to co-operating with the teaching staff, the school attendance authorities and the borough medical officers. described in the Annual Report for 1919 (Vol. III., p. 85), was at once put into operation. In the Annual Report for 1920 (Vol. III., p. 90) the result of the scheme was given. In addition to speeding up of notifications generally, it was shown that a number of children actually suffering from measles was detected as a result of the daily visits of the nurses to the affected schools. Measles became prevalent in the spring of 1922 and the outbreak which commenced in November 1923 is now (April, 1924) declining. 10976 G 94 The following table shows the working of the scheme in these three outbreaks. 1920. April-May. (6 weeks). 1922. February-April. (10 weeks). 1924. January-March. (9 weeks). (1) Schools visited by nurse 233 186 506 (2) Sessions devoted to work 673 346 1,358 (3) Cases of definite measles discovered in attendance at school by nurses, excluded and reported direct to Borough Medical Officers 59 20 105 (4) Suspicious cases discovered in school and excluded by nurses 541 331 1,215 (5) Suspicious cases referred to in (4) which subsequently proved to be measles 139 125 320 (6) Doubtful absentees reported to school attendance authorities for immediate visitation 4,296 4,176 11,198 (7) Number of absentees referred to under (6) and proved to be measles 776 1,187 1,868 It will be seen from the table that although the present outbreak is not yet (April, 1924) at an end, it has already in comparison with the others cast a greater burden of work upon the school medical service. Much of the increase, however, is of course due to perfected organisation; for experience gained in the outbreaks of 1920 and 1922 has resulted in a much larger number of visits to the schools being made by the nurses and in a corresponding increase in the extent of limitation of spread of the epidemic. During the nine weeks for which figures are available 11,198 doubtful absentees were reported to the attendance authorities for immediate visitation; of these, 1,868 proved to be suffering from measles. No less than 425 children were found in school by the nurses to have measles or were excluded on suspicion and turned out later to be cases of measles. In the chart on page 92 the course of the three outbreaks is shown as seen from the point of view of school notifications. The 1920 outbreak began in February, rose to a maximum in March, commenced to fall about the Easter holidays, showed a small rise after the holidays, and finally trailed off in July. The 1922 outbreak was almost identical in character with that of 1920. It also began in February, reached its maximum, however, in the Easter holidays, showed a rather larger recrudescence after the holidays and again trailed away in the summer term. The outbreak in 1923-24, however, shows considerable differences; commencing in November it did not reach its highest level until the end of January and remained at the height of 2,000 cases a week throughout February and March to April. From this diagram also, it appears that the present attack is bigger in bulk than either of the two former outbreaks. It has been much slower in reaching its maximum and the top of the wave has been flattened out. The change of type is the result of two opposing forces. In the first place the intervals between the last three waves have been distinctly prolonged; and secondly, in the present outbreak more especially, the hindrance to the progress of measles which has resulted from the strenuous efforts made to obtain early knowledge and early and more efficient treatment for the children suffering from measles have greatly reduced the mortality from the disease. whooping The number of cases of whooping cough reported among school children during cough. 1923 was 7,304 as compared with 10,340 (1922), 9,584 (1921), 8,779 (1920) 3,397 (1919) and 11,671 (1918). The school nurses paid special visits to 37 schools affected with the object of advising the head teachers as to the means of prevention and control. 10976 G 2 95 In 1923 ringworm continued to decline, 2,322 fresh cases having been discovered Ringworm and reported during the year as compared with 2,766 (1922), 3,473 (1921) and 3,983 and Favus. (1920). At the end of 1923 over 705 of the known cases remained uncured, as compared with 818 and 999 at the end of 1922 and 1921 respectively. The proportion of cases cured by X-ray treatment at the Council's centres was 69 per cent.; in 1922 the percentage was 65 and in 1921 was 60. During the twelve months 2,842 hair specimens were examined in the Council's laboratory, of which 1,332 (including re-examinations) proved to contain ringworm fungus. Only two fresh cases of favus were discovered during the year. In the course of a prevalence around London of smallpox imported from Spain Smallpox, during the autumn of the year, and comprising some 18 cases, one school child, viz., an unvaccinated boy of 12 years attending a Greenwich school, contracted the disease. Appropriate measures were taken to prevent spread of the disease and no other children became infected. Vaccinations of school children with the consent of the parents were carried out by public vaccinators in five schools in the affected areas, (two in Camberwell, one in Greenwich, one in Battersea and one in Hackney); 599 children were vaccinated by these arrangements (327 primary vaccinations and 272 re-vaccinations). Chickenpox was more than usually prevalent during 1923, 13,849 cases having Chickenpox. been reported as occurring among children attending the Council's schools, as compared with 8,213 in 1922 and 9.811 in 1921. School nurses specially visited 205 schools for the purpose of excluding suspicious cases and of advising head teachers generally as to the symptoms and means of prevention. The number of schools visited each term was as follows:—Spring term 41, summer term 109, and autumn and winter terms 55 schools. The number of cases of mumps reported among school children was 7,916 as Mumps. compared with 4,207 in 1922 and 13,317 in 1921. Although the disease was not so prevalent as in 1921, the east end of London was badly affected, particularly Poplar and the Isle of Dogs where the disease persisted for some time. School nurses visited 125 schools to enquire into the prevalence of mumps and to advise head teachers as to measures of control. There was a very noticeable increase in the prevalence of ophthalmia in the Ophthalmia. London schools during 1923, 1,881 cases having been reported compared with 801 in 1922 and 466 in 1921. The prevalence was most marked in Shoreditch and the east end, especially the former, where special measures had to be taken to combat the disease. The outbreak was suppressed after persistent visitation of the homes and schools by the nurses and by prompt treatment and supervision of returning cases. Residential The health of the children in the Council's residential schools was satisfactory and industhroughout the year and the infectious illness records at these schools do not call trial schools. for special comment; the few cases of infection which occurred were isolated and there was no spread. Mortality among Children under 15 Years of Age. The following tables show for England and Wales and for London the mortality among children under 15 years of age in five-year age periods, in eight successive decennia. England and Wales. Decennium. Males. Females. Mean. 0— 5- 10- 0— 5- 10- 0- 5— 10— 1841-50 71.2 9.2 5.1 6.1 8.9 5.4 66.1 9.0 5.2 1851-60 72.4 8.5 4.9 62.7 8.4 5.1 67.5 8.4 5.0 1861-70 73.5 8.2 4.5 63.7 7.8 4.5 68.7 8.0 4.5 1871-80 68.4 6.7 3.7 58.3 6.2 3.7 63.3 6.4 3.7 1881-90 61.6 5.3 3.0 51.9 5.3 3.1 56.7 5.3 3.0 1891-1900 62.7 4.3 2.4 52.8 4.4 2.6 57.7 4.3 2.5 1901-10 50.0 3.5 2.1 41.9 3.6 2.2 45.9 3.5 2.1 1911-20 37.5 3.5 2.2 31.2 3.5 2.3 34.3 3.5 2.2 96 London. Decennium. Males. Females. Mean. 0— 5. 10— 0— 5— 10. 0— 5— 10- 1841-50 88.0 11.4 5.0 77.0 10.8 4.9 82.5 11.1 4.9 1851-60 83.1 9.7 4.5 72.9 9.2 4.1 78.0 9.4 4.3 1861-70 86.9 9.4 4.2 76.3 8.8 4.1 81.6 9.1 4.1 1871-80 77.9 7.4 3.6 67.7 6.7 3.4 72.8 7.0 3.5 1881-90 73.1 5.9 2.9 63.3 5.8 2.9 68.2 5.8 2.9 1891-1900 72 .0 5.0 2.5 62.0 5.2 2.5 67.0 5.1 2.5 1901-10 53.5 3.5 2.0 45.7 3.5 2.0 49.6 3.5 2.0 1911-20 39.3 3.7 2.3 33.0 3.6 2.4 36.2 3.6 2.3 London (England and Wales = 100). Decennium. Males. Females. Mean. 0— 5. 10— 0— 5— 10- 0- 5— 10- 1841-50 124 124 98 126 121 91 125 122 94 1851-60 115 114 92 116 110 80 115 112 86 1861-70 118 115 93 120 113 91 119 114 92 1871-80 114 110 97 116 108 92 115 109 94 1881-90 119 111 97 122 109 94 120 110 95 1891-1900 115 116 104 117 118 96 116 117 100 1901-10 107 100 95 109 97 91 108 98 93 1911-20 105 106 105 106 103 104 105 104 104 It will be noted that while the London rates for ages under 10 years are generally in excess of those for England and Wales, this excess has gradually declined, and in the past twenty years there is little difference between the two sets of figures. From the third table, showing the London rates, England and Wales being taken as 100, it will be seen that the excess in the London mortality is generally greater at age 0-5 and 5-10, but that at age 10-15 the London rate is generally below the figure for England and Wales. It might perhaps be urged that the more adverse environment of the London children in the earlier decennia, when England and Wales was less urbanised, resulted in the elimination of weaklings, so that the surviving population, on attaining the age of 10 years, was healthier than the generally more favourably circumstanced population of England and Wales as a whole. This is consistent with Dr. E. C. Snow's conclusion that "natural selection, in the form of a selected death rate, is strongly operative in man in the early years of life." (The Intensity of Natural Selection in Man. Drapers' Company Research Memorial, 1911.) The age of lowest mortality falls within the age group 10-15 years. Figures relating to the three years 1920-1922 show a minimum rate at 13 years of age, the death-rate at that age being less than one-sixth of that for all ages. The principal causes of death at school age are the common infectious diseases (especially diphtheria), tuberculosis, diseases of the heart and respiratory diseases. In the following table the mortality per million living from the principal causes of death of London children from five to fifteen years of age is compared with that for England and Wales as a whole in the two decennial periods 1901-10 and 1911-20:— Cause of death. 1901-10. 1911-20. England and Wales. London. England and Wales. London. Typhoid fever 65 42 22 13 Measles 94 101 116 115 Scarlet fever 172 142 88 76 Whooping-cough 39 49 32 39 Diphtheria 325 248 309 302 Influenza 28 23 203 178 Tuberculosis 628 664 600 673 Rheumatic fever 78 94 72 82 Meningitis 128 91 109 91 Cause of death. 1901-10. 1911-20. England and Wales. London. England and Wales. London. Heart disease 197 299 122 173 Respiratory disease 315 295 352 319 Diarrhoea and enteritis 45 37 42 30 Appendicitis 76 120 93 101 Nephritis 55 52 55 46 Violence:—Vehicles 44 78 81 155 Other 181 158 172 160 97 It will be seen that in the 20 years the London mortality from the common infectious diseases is below that for England and Wales as regards typhoid fever, scarlet fever and diphtheria, but that whooping cough is more fatal in London, The tuberculosis death rate is only slightly higher in London than in England and Wales, but there is a marked excess in the London mortality from heart disease. In the county boroughs of England and Wales the frequency with which heart disease is returned as the cause of death at school age is about twice that of the rural districts. A higher proportion of deaths from this cause appears, therefore, to be normally associated with urban conditions. Greater accuracy of diagnosis in large towns may, however, play some part in the difference observed. With regard to diseases of the respiratory system, it is remarkable that London, with its fogs and dust, should have a lower mortality rate than England and Wales as a whole. It will be noted that the deaths caused by vehicles have nearly doubled in the 20 years covered by the figures. The increase is attributable to the introduction of mechanical traction. The deaths in London among children aged 5-15 caused by vehicles and horses in 1923 numbered 107 as compared with 123 in 1922 and 91 in 1921. The diphtheria attack-rate in London during 1923 was 2.3 per thousand of population; in 1922 the rate was 3.4 and in 1921 it was 3.6, while for the ten years 1911-20 the average was 2.0. Notwithstanding the marked decline in the London prevalence of diphtheria in 1923 upon that of the immediately preceding years, the attack-rate was still considerably greater than the corresponding rate in the rest of England and Wales (0.9 per 1,000 living). Of the total number of cases of diphtheria notified in 1923, numbering 10,301 (52 weeks), 4,699 or 46 per cent, were among children aged 5-15 years, of whom 224 or 4.8 per cent. died. The corresponding percentages for 1922 were 4.8 per cent, and 5.7 per cent, respectively. The scarlet fever attack-rate in London during 1923 was 2.2 per thousand of population as compared with 3.8 in 1922. In the rest of England and Wales the corresponding figures were 2.2 and 2.7 respectively. Of the total of 10,047 cases of scarlet fever notified in 1923 (52 weeks), 5,597 (56 per cent.) were of ages 5-15, of whom 86 (1.5 per cent.) died. The corresponding percentages for 1922 were 60 and 0.8 per cent, respectively. Whooping-cough and measles were not prevalent in 1923, and the deaths at ages 5-15 were only 9 and 11 respectively. Two diagrams ha ve been prepared to show the progress of the measles and whooping-cough mortality in London and the various metropolitan boroughs during the last 13 years (see pp. 98-99). The black columns indicate that the mortality was above the average, each column being proportional in height to the mortality in a given quarter, the average for that quarter in the whole period being taken as 100. For instance, in Hackney the measles mortality in the first quarter of 1915 was equal to 131 as compared with the average of the first quarters taken as 100, while in the last quarter of 1914 it was, in terms of the average for the fourth quarteis, 761. The diagram shows clearly the marked decline in mortality which has occurred since 98 99 100 1918 in both diseases, although the decline will be seen to be greater for measles than for whooping-cough. The figures upon which the diagram is based have been approximately corrected for the decrease in births caused by the war, but for reasons referred to later the correction is only partial. In the past five or six years arrangements have been made in most metropolitan boroughs for assistance in the home nursing of children attacked by measles or whooping-cough, and the arrangements made for admission of a proportion of the cases to hospitals of the Metropolitan Asylums Board have also been more extensively made use of. The segregation of a large number of cases in MA.B. hospitals, and the attendance on other cases of trained nurses, must have tended both to reduce the mortality in the cases dealt with and to diminish the spread of infection. It may be added that in 1916-18 measles, but not whooping-cough, was made compulsorily notifiable throughout London. The spread of measles and whooping cough is very largely governed by the density of susceptible children. On this subject, so far as measles is concerned, reference may be made to the discussion in the Annual Report for 1919 (Vol, III., p. 88). The fluctuations in birth-rate during and after the war caused corresponding variations in the density of the child population of London, and in preparing the diagram the deaths after 1914 have been increased or decreased proportionately to allow as far as practicable for the effect of the fluctuating births. It will, however, be understood that the correction thus made does not fully eliminate the effect of the fluctuations. For example, if in a row of 100 houses it be assumed that infection spreads from a house to the next house but not to the next but one, then, if there is a susceptible child in every house, one case will lead to all houses being invaded, but if there is a susceptible child in every other house no spread of infection would occur. In the latter case, while the susceptible population is only halved, the spread is reduced to nil. The increase in the number of births from 70,976 in 1918 to 120, 529 in 1920 is sufficiently great to have an effect on the range of infection, and for this factor no correction can practically be made. The excess of births during 1920 and the remarkably low prevalence of measles last year result in there being at the present time a large number of susceptible children, and it is to this circumstance that the prolonged prevalence at the present time is due. The actual figures of mortality for the first quarter of 1924 were not available in time for inclusion in the diagram but the total deaths will be not far short of the total for the corresponding quarter of 1915. With regard to the diagram showing whooping-cough prevalence, the chief point to be noted is the great weight of attack upon the year 1918, following upon a year of low prevalence. The whooping-cough occurred shortly before the JuneJuly prevalence of influenza and some months before the great October-November influenza epidemic. There may have been occasional confusion between the two diseases, especially in the middle of the year. There is, it will be seen from the diagram no corresponding feature in measles. There appears to be some relationship between the type of winter weather and the incidence of whooping-cough, the effect of a prolonged period of cold weather in the winter being in some years to decrease the immediate incidence of whooping-cough, and in all years to increase the prevalence in the following winter. Since 1899 there have been several instances of prolonged cold weather in the autumn and winter quarters; thus, in the winter of 1890-91 the weekly temperature was below freezing point for six consecutive weeks. In 1892-3, just at the turn of the year, the average temperature was below freezing point for two weeks, and again in 1895 in the fifth to seventh weeks, the average temperature in the sixth week of this year being as low as 22.4° Fahr. Thereafter there were no similar periods of continued low temperature until 1917, in the fourth to sixth weeks of which year the average was below freezing-point. 101 In 1919, in the fifth to seventh weeks, the temperature was also just below freezing-point. From the Annual Report for 1921 (vol III., p. 44), where a diagram is given showing the weekly mortality from whooping-cough since 1890, it will be seen that the years which standout from all others as years of high mortality are 1892,1896 and 1918, while 1894 and 1920 are also conspicuous. These are the years which, as stated above, have followed winters in which there were periods of more or lees prolonged cold weather. The year of greatest mortality from whooping-cough in London was 1882, when the deaths numbered 4,647. The winter of the year preceding was memorable for its exceptional severity. It does not appear consistently that a severe winter has a moderating effect upon current prevalence of whooping-cough: increase at any rate in the mortality from whooping-cough in the year following a severe winter is more consistently found, and the question as to the reason for this association is deserving of examination. In a study of the prevalence of whooping-cough in Amsterdam by Dr. B. H. Sajet and J. V. Gerderen, it is remarked that the attack rate upon the first-born (or only child) is lower than that recorded for the second and third children. The favourable condition for the first-born or only child apparently becomes more pronounced with rise in the social scale. It was found that the death-rate among non-Jewish children was about three-and-a-half times that recorded for Jewish children, the comparison being made for both poorer and better quarters of Amsterdam. Children of poorer social class were found to be attacked earlier. and the better class later; thus while among the former less than 10 per cent, were attacked over 5 years of age among the latter the attack rate was 35 per cent. Examination of Candidates. Including some who attended for their first examination in the previous year, the number of candidates submitting themselves for examination during the year was 5,546. The total number of examinations was 6,566. The candidates may be classified as (a) candidates for entrance to the permanent service; (b) candidates for the award of scholarships. The total number of candidates examined was 623 (227 males and 396 females), Candidates but of these candidates 11 attended for their first examination in the previous year. for permanent service. There were however 715 examinations (257 males and 458 females); in 112 cases (38 males and 74 females) a second or third examination was necessary. Of the number thus referred, remedial treatment was satisfactorily obtained in 99 cases; 2 were rejected; 3 withdrew their applications; and 8 were still under consideration at the end of the year. The total number of rejections was 17. The reasons for rejection were: vision 6; heart 1; miscellaneous 10. The scholarships and awards granted by the Council fall into three divisions, Candidates each of which requires different treatment in so far as the medical examination for the award of of candidates is concerned, (a) County scholarships enabling candidates to proceed schorlarships. to institutions of university rank; (b) Technical scholarships enabling candidates to receive instruction in trades, and special scholarships; (c) Awards enabling candidates to prepare for the teaching profession. The total number of candidates examined was 4,923; these include 8 who attended for their first examination in the previous year. There were, however, 5,851 examinations, the excess being due to the fact that in 911 cases a second or third examination was necessary; 851 obtained satisfactory treatment and were on re-examination certified as fit. 121 candidates were found to be unfit; of these 3 were rejected for two defects each; 105 were rejected as the result of their first examination and 16 as the result of subsequent examinations. The reasons 102 for rejection were: defective vision 59; unsatisfactory personal hygiene 1; defective teeth 3; unsatisfactory general health 26; unsatisfactory condition of heart 9; miscellaneous 26. Some were rejected for more than one defect. Cases There are also referred to the public health department special cases of specially referred. employees in the education service absent owing to personal illness ; questions in regard to students in institutions for higher education whose health is considered such as to render exceptional attention advisable; cases of teachers returning to duty after extended leave of absence (a) owing to personal illness; (b) for educational purposes; (c) to married women under No. E 22 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 dealt with was 3,154, as compared with 2,934 in 1923, an increase of 220 or 7.5 per cent. The major part of these cases consisted of teachers, 483 being men, and 1,352 being women. The increase is partly attributable to the arrangements made during the latter part of the previous year, whereby London teachers about to proceed overseas under the interchange scheme were to be subject to medical examination. 37 were seen during the year, two of whom were found to be physically unsuitable for the venture. Physical All applicants for admission to the Council's course of physical instruction, education of instituted in 1920 in order to train teachers to carry out the provisions of the teachers. Education Act, 1918, relative to the physical education of school children, were examined. 300 examinations were conducted, and over 16.6 per cent., actually 50 candidates, were found to be unfit to undergo the prescribed course for the reasons specified, viz., heart 4; general conditions 27; war wounds 1; miscellaneous 18. Some of the candidates were seen on two or more occasions. In previous reports attention has been drawn to the effect of age upon the health of the teaching staff. During the year under review the cases of teachers attending for examination with a view to taking a course of physical education have been classified in three age groups, viz., age 20 to 30; age 30 to 40; above 40. In the first group 8 per cent, of the cases were rejected; in the second and third groups the rejections were 13 per cent, and 36.5 per cent, respectively. Accidents The arrangements made in 1922 whereby medical aid and advice could be and sudden given in the event of cases of accident or sudden illness at the County Hall were illness at County Hall. continued in 1923, and aid was rendered and advice given in 214 cases. Generally, the cases were of a minor character, such as faintness, bruises owing to falls, sprains, foreign bodies in the eyes and poisoned wounds, although there were a few cases of haemorrhage, also of serious burns. Defective Children. The total number of examinations conducted under the Education Act during the year was 24,379—an increase of 1,251 on 1922. Admission 4,944 admission examinations were held as compared with 4,843 in 1922. 1,623 examinations children (892 boys and 731 girls) were deemed suitable to attend elementary schools; 59 (27 boys and 32 girls) schools for the blind, 270 (111 boys and 159 girls) schools for myopes, 91 (40 boys and 51 girls) Swanley, 922 (452 boys and 470 girls) P.D. Schools; 1,034 (598 boys and 436 girls) M.D. Schools; 5 (2 boys and 3 girls) open air schools; 83 (40 boys and 43 girls) schools for the hard of hearing; 97 (33 boys and 64 girls) schools for the deaf; 26 (11 boys and 15 girls) were epileptic; 481 (209 boys and 272 girls) invalided from school attendance; 104 (43 boys and 61 girls) imbeciles, and 14 (8 boys and 6 girls) were idiots. 103 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 56 38 94 Cerebral paralysis 5 4 9 Various paralyses 28 20 48 Tuberculosis of bones and joints 105 96 201 Congenital deformities 9 13 22 Other deformities 48 21 69 Heart disease— Congenital 31 26 57 Acquired valvular 106 179 285 Acquired non-valvular 9 14 23 Other diseases 55 59 114 Total 452 470 922 The special schools were visited at least once a quarter and every child present was seen at least once during the year, the total examinations amounting to 18,547; in addition, 784 special examinations were made of children already on the rolls of special schools in connection with applications for non-enforcement of attendance at special schools, etc., etc. As a result of the visits and re-examinations, tho following re-classification took place:—256 returned on improvement to elementary schools; 17 to schools for the deaf and hard of hearing; 17 to schools for the blind and partially blind; 17 from schools for the physically defective to schools for the mentally defective; 5 from schools for the mentally defective to schools for the physically defective; 46 were excluded as imbecile, 86 were invalided on medical grounds ; and 479, over 14 years of age, were excluded as no longer certifiable. Examinations were also conducted in 104 cases with a view to ascertaining their fitness for education in industrial or reformatory schools. After careers of children formerly attending special mentally defective schools.* Male. Female. Total. (1)Number of children born in or subsequent to 1905, who have left special (mentally defective) schools and who have been on the books of the Association 1,057 8841*1,941 (2)Number who—. (а) have since died 12 3 (b) who are known to be incapable by reason of mental or physical defect of undertaking employment 50 53 103 (c) are in attendance at an institution for further education 2 1 3 (d) are in other institutions 17 13 30 (e) were notified and placed under "supervision" 12 4 10 (3) Number employed in— (a) Industrial or manual occupations (i.e., factory work, any trade or part of a trade) 269 225 494 (b) Agricultural or rural occupations 3 — 3 (c) Domestic occupations (i.e., servants sleeping in or out, lift boys and those "helping at home") 13 235 248 (d) Commercial (i.e., shop assistants or selling behind a counter), fessional (or army and navy), clerical (office boys or girls) 32 7 39 (e) Blind alley or other precarious occupations (i.e., van-boys, newsboys, errand boys or girls, selling from a barrow) 161 19 180 (f) Judged to be employable but out of work owing to industrial crisis 255 157 412 (g) Not seen either at home or employment centre, and position not known 215 136 351 *Data furnished by the London Association for the Care of the Mentally Defective, †(Particulars in regard to cases over 18 years of age have not been supplied by the London Association.) 104 Mental ages of children deemed suitable for M.D. special schools. Dr. Shrubsall has analysed the mental ages of children examined and deemed capable of deriving benefit from instruction in a Special (M.D.) School:— Chronological age Mental age. Total. Mean mental age. Annual gain. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 7 12 103 145 53 2 315 4-8 — 8 2 59 232 344 78 2 — — — — 717 5-6 0-8 9 — 6 60 269 259 34 — — — — 628 6-4 0-8 10 — 2 22 46 135 78 4 — — — 287 7 0 0-6 11 — — 4 21 44 59 12 1 — — 141 7-4 0-4 12 — — 4 6 29 34 14 3 — — 90 7-6 0-2 13 — — 1 5 18 30 20 2 — — 76 7-9 0-3 14 — — — — 24 51 88 54 — — 217 8-8 0-9 15 — — — — 5 75 149 79 — — 308 90 0-2 Totals 14 170 468 744 594 363 287 139 — — 2,779 6-7 — Mean chronological age 71 7-5 8-0 8-6 9'8 121 14-2 14-5 100 — Non-verbal Dr. Williams and Dr. Boome have conducted an investigation into some non- mental verbal tests of mental efficiency to ascertain whether some simple and ready methodefficiency. could be devised to limit the stress laid on purely verbal ability in the current standardised tests. There are certain children, e.g., young uneducated deaf, to whom verbal tests are definitely inapplicable. Some highly-nervous children if at once confronted with a question which demands an answer—even one so simple as: " What is a fork ? "—seem unable to make the slightest utterance, whereas after they have gained confidence, by being successful with a task which makes no demand on speech, they responded to the ordinary Binet Simon series. For this purpose three tests have been tried with the assistance of the head and assistant teachers of several schools. Male. Female. Total. (4) Number whose careers have not been traced or who have left the neighbourhood 20 15 35 (5) No action possible 7 17 24 1,057 884 1,941 1,146 (31 blind, 148 deaf, 967 crippled) cases were notified to the After-Care Association for blind, deaf, and crippled children, who have furnished the following information in regard thereto:— Placed by Placed by Number employed in— Association, other means. Totals (1) (a) Industrial or normal occupations 334 242 576 (6) Agricultural or rural occupations — — — (c) Domestic occupations 4 29 33 (d) Commercial occupations 12 41 53 (e) Blind-alley occupations 8 68 76 (/) Miscellaneous 2 5 7 360 385 745 (2) (a) Who have since died 13 (6) Are known to be incapable by reason of mental or physical defect of undertaking employment 88 (c) Are in attendance at an institution for further education and training 48 (3) Who have left London or cannot be traced 8 (4) Whose applications have been withdrawn and who refused openings 69 (5) Not yet placed 175 1,146 105 Colour Disc Matching.—This consists of a sheet of thick cardboard with four sunken circular spaces coloured red, blue, green and yellow, with 4 discs similarly coloured which will readily fit into these spaces:— The test may be given verbally or by example, e.g., for the deaf. Verbally, the child was told "to put these little things in their proper places." In the case of the deaf all the coloured discs were put in their appropriate places and taken out again, then signs made to the child to do likewise. No importance was attached to the speed at which it was done, but it was found that, if there was going to be success at all, the time taken was 10 seconds with normal children. Results showed that of 14 normal infants between 3 and 4 years of age with verbal instructions, 9 responded correctly at once, 2 were correct at a second attempt and 3 failed completely even when the test was demonstrated to them in addition. Of 18 mentally defective children with a mental age of 5 and upwards, all were successful and the time taken was never more than 13 seconds. Young imbeciles with a mental age of 2 years or less failed completely even after prolonged trials. The conclusions are that the test should standardise about the age of 3 years, should certainly be done in 15 seconds and is readily applicable to almost all types of children. The missing object test.—This consists of 6 pictures of simple every-day occurrences:— (1) Dog chasing a cat. (4) Girl feeding chickens. (2) Girl bowling a hoop. (5) Two children playing ball. (3) Boy flying a kite. (6) Child blowing bubbles. The objects italicised were cut out, so that a circular hole remains in each picture and there were six separate discs representing the omitted objects. Six additional discs representing objects inappropriate to all and any of the pictures were also prepared. The directions given were: "Look at these pictures, they are not complete, put in what is missing." No time limit was given and it was not intended as a speed test. In fact, the children were cautioned to do it carefully. In practice, however, it was found that three minutes was ample time if there was going to be success at all. For the deaf and others to whom verbal instruction is impossible the child is shown one picture wrongly completed and then corrected. Signs are then made to the child to continue. Forty-eight normal children from 6 to 7 years of age, obtained an average of 5.75 correct in 1.6 minutes. From this it may be seen that the vast majority of these children were absolutely successful. Testing many children of higher ages, it was found that there rarely was a failure. It may be taken then as established that the test is a very fair one for the ordinary child of 6 years and the rare exceptions may be attributed to attempts at excessive speed. As to the lower limit, 6 children of 4 years old failed utterly. Of twenty 5-6 year olds, 8 were completely successful, 12 were partially successful, while there were no absolute failures. Of 20 mentally defective children taken haphazard, with mental ages of 5 to 9, there were 6 successful, all of whom reached the 7 year level in the Binet scale. 106 There were 14 failures, 8 had a mental age of 6 or less, one had a mental age of 7, 4 had a mental age of 8 and one of 9 years. It had been noted that these elder children were peculiar, unstable, and making but little progress. Trials were made of 8 imbeciles at an occupation centre, of whom five failed completely, one was a partial success and two succeeded. These two latter had beeu independently noted as being rather above the average. One special case is of particular interest, a boy of 14 years who, with verbal tests could not reach the 3 year old level, promptly carried out this test. On further examination he was found to have so much practical ability as to suggest that his defect was largely an auditory aphasia. Thus it appears that the test standardises about 6 years of age, is readily and easily applicable, and is independent of verbal ability. The Animal Family Test.—The materials consisted of 24 cards forming 8 families of 3 members each. The families picked were those of the rabbit, horse, zebra, dog, elephant, donkey, cat and bear. The cards were arranged in a standardised order of 4 rows with 6 in each, the arrangement of the cards being such that no two members of the same family appeared together in the series. The child is told that there are eight families of animals, each with " Mum, Dad, and Baby," is requested to collect them as quickly as possible and told to put them aside. Three trials were given. The results with normal infants were:— 4-year olds. 5-year olds. 1st trial, 1 success, 6 failures. 1st trial, 5 successes, 10 failures. 2nd „ 2 successes, 5 „ 2nd „ 9 „ 6 „ 3rd „ 2 „ 5 „ 3rd „ 12 „ 3 ,, A six year old boy, who had been previously noted as a suspected mentally defective, and a 7 year old boy, who had been actually recommended for the Statutory M.D. examination, both failed hopelessly. It would seem that as 80 per cent, of the 5 year olds succeeded with 3 trials, it would be a fair test for that age. With a number of mentally defective children, the results of children with a mental age of 5 years in the first, second, and third trials were respectively as follows:—1 success, 2 failures; 2 successes, 1 failure; 3 successes, no failure. Of children with a mental age of 6 years, there were no successes and 6 failures in the first trial; 2 successes and 4 failures in the second trial, and 2 successes and 4 failures in the third trial. It may be added that 3 of these children had a very low intelligence quotient. Children with a mental age of 7 years were all successful in the first trial; and of children with a mental age of 8 years and upwards there were 6 successes and 3 failures in the first trial, 8 successes and 1 failure in the second, and all were successful in the third. With the mentally defective children the results are not quite so consistent, but on the whole they conform to those obtained by normal children. Although it may be considered a fair test for a child with a mental age of 5 to 6 years, and may be of use in special cases, it is too cumbersome for any general routine work. Encephalitis During the past five years there have been many cases of epidemic encephalitis, lethargica. in connection with which two types of after-effects have been evident. One group of children has exhibited progressive physical weakness, paralysis, and lack of muscular control, often ending in death. Others have shown very definite conduct changes, the duration of which it is impossible to forecast at present. In some instances they have been noted over a period as long as five years. Part of this conduct change and lack of control is specifically due to the effects of the inflammation of the brain, but, on the top of these, further conduct changes of a functional character are implanted as a result of the difficulties the patients find in attuning themselves to the minor irritations of their environment. Some of the children have recovered sufficiently to remain in an ordinary school; others have had to be boarded out so as to relieve them and their parents from mutual irritation; a certain number have been placed in industrial schools; some in special schools, 107 and a few in mental hospitals; but all suffer from much the same mental and physical conditions, the form of disposal being largely a matter of chance. Should this disease continue to be prevalent, as unfortunately appears likely, the question of making special provision for the education and control of the sufferers of school age will ultimately need careful consideration, since, if left alone, they are dangerous to themselves, and no slight menance to the community. Fifty cases have been specially investigated by Dr. Shrubsall in regard to the incidence of mental after-effects with the following results:— Year of onset of acute illness. Age of onset. Age. No. Age. No. 1910 1 1920 21 -1 1 7 3 1916 1 1921 6 1 2 8 4 1917 Nil 1922 4 2 3 9 2 1918 10 1923 2 3 1 10 5 1919 5 — 4 2 11 7 Total 50 5 5 12 5 6 9 13 1 Of the cases, twenty-five showed no definite physical signs other than some irritability of the nervous system shown by increased knee jerks, etc., fourteen had slight physical disability not amounting to crippling, six suffered from physical disabilities resulting in definite crippling, five were more or less helpless and deteriorating, and one child was blind from double optic atrophy. It was possible to estimate the mental condition in forty-seven out of the fifty cases, the intelligence quotients being :— Quotient .3 .4 .5 .6 .7 .8 .9 and over No. 1 Nil 2 4 13 11 16 Their educational attainments range from the infants' grades to Standard VII, the bulk of the children being between Standards I and IV. The majority of the children showed signs of emotional disturbances, sixteen were described as restless, spoilt or spiteful, nine were noted as sleepy and apathetic, in six pilfering was a marked feature, while in six they were out of control. One suffered from screaming fits, and another was described as very childish. Six only were noted as emotionally normal, while in five the physical defects were the predominant feature in the syndrome. 286 children were referred for special examination as suffering from deafness. Deaf children. These cases were seen by the Council's consulting aural surgeon, with the children, following results:— Fit for elementary school 14 ,, „ „ (front row) 57 „ hard of hearing centre 83 „ deaf school (normal) 98 „ „ (defective) 1 „ mentally defective centre 6 „ physically defective centre 2 Invalided 12 Advice given 10 Imbecile or idiot 3 286 In the cases found suitable for special education, the cause of deafness has been classified as under:— Boys. Girls. Total. Congenital 16 25 41 Acquired 62 66 128 Doubtful 5 4 9 83 95 178 108 The acquired cases were due to the following causes:— Boys. Girls. Total. Meningitis (various forms) 5 6 11 Infectious fevers 17 26 43 Congenital syphilis 1 5 6 Pneumonia (suppuration) 1 1 2 Primary ear diseases (catarrh, suppuration or results thereof) 36 28 64 Injuries 2 0 2 62 66 128 Residential There are 4 residential (industrial) schools, 6 residential schools (2 for blind, schools. 2 for deaf, 1 for defective deaf and 1 for mentally defective children), with a total accommodation for 820 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 874 boys were admitted to Pentonville Road Place of Detention, and 300 girls and infants to Penton Road. TABLE I. Medical Inspections. (a) ROUTINE INSPECTIONS. (6) OTHER INSPECTIONS. Boys. Girls. Total. Boys. Girls. Total. (1) Entrants 34,958 33,958 68,916 Number of special inspections (a) 19,760 19,571 39,331 (2) Intermediate 32,213 32,380 64,593 (b) 33,958 33,517 67,475 (3) Leavers 31,852 31,966 63,818 Number of re-inspections — — 146,260 Elementarv schools— 1 Total 99,023 98,301 197,327 Special Schools 774 621 1,395 Total — — 253,066 (a) Special cases where individual notes are made. (b) Cases seen where individual notes are not made (infectious disease contacts, etc.). TABLE II. (a) Defects found by Medical Inspection in 1923. ELEMENTARY AND SPECIAL SCHOOLS. Defect or disease. Routine inspections. Special inspections. Defects. Defects. Requiring treatment. Requiring observation only. Requiring treatment. Requiring observation only. Malnutrition 323 689 572 494 Uncleanliness—Head Nil — — — Body Nil — — — Skin— Ringworm—Head 35 — 161 26 Body 71 1 43 6 Scabies 89 1 1,126 5 Impetigo 432 11 587 21 Other disease (non-tubercular) 983 199 564 85 Eye— Blepharitis 852 102 378 19 Conjunctivitis 405 32 574 36 Keratitis 11 4 27 14 Corneal opacities 12 14 13 4 Corneal ulcers 20 8 79 20 109 Defect or disease. Routine inspections Special inspections. Defects. Defects. Requiring treatment. Requiring observation only. Requiring treatment. Requiring observation only. Eye—(continued.) Defective vision (excluding squint) 12,782 6,264 4,046 544 Squint 1,400 541 593 61 Other conditions 198 56 91 15 Ear— Defective hearing 617 283 454 83 Otitis media 1,749 507 1,388 105 Other ear diseases 496 86 217 34 Nose and throat— Enlarged tonsils 4,689 4,663 1,422 354 Adenoids 1,180 572 518 74 Enlarged tonsils and adenoids 1,861 860 522 57 Other conditions 1,129 505 689 295 Enlarged cervical glands (non-tubercular) 283 1,487 285 286 Defective speech 87 222 110 49 Teeth, dental diseases 47,800 905 4,028 120 Heart and circulation— Heart disease—Organic 8 251 82 51 Functional 11 675 34 56 Not stated 217 2,994 372 1,036 Anaemia 1,293 927 1,914 440 Lungs— Bronchitis 1,504 1,417 684 251 Other non-tubercular* 224 761 255 376 Tuberculosis— Pulmonary—Definite 55 15 79 27 Suspected — 58 115 171 Non-pulmonary—-Glands 22 16 78 22 Spine — 1 9 4 Hip 5 10 16 7 Bones and joints 3 10 18 18 Skin 13 5 5 2 Other forms. 11 16 25 15 Nervous— Epilepsy 45 117 218 124 Chorea 77 98 288 134 Other conditions 111 239 158 177 Deformities— Rickets 97 74 71 24 Spinal curvature 488 476 236 73 Other forms 318 131 350 141 Other conditions 2,818 1,690 5,039 1,504 • Probably some of these are cases of suspected phthisis. (b) Children found at routine medical inspection to require treatment (excluding uncleanliness). Age group. 1. Number of Children. Percentage of defective children. 4. Inspected. 2. Found to require treatment. 3. Entrants 68,916 24,409 35.4 Intermediates 64,593 25,949 40.2 Leavers 63,818 21,971 34.4 Total—-Elementary schools 197,327 72,329 36.7 Special schools 1,395 563 40.4 10976 h 110 TABLE III. Exceptional Children in London in 1923. Blind (including partially blind)— Boys. Girls. Total. (i.) Suitable for training in a school or class for the totally blind Attending Certified Schools or Classes for the Blind 164 144 308 Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution 4 5 9 (ii.) Suitable for training in a school or class for the partially blind Attending Certified Schools or Classes for the partially Blind 386 473 859 Attending Public Elementary Schools 30 45 75 At other Institutions — —. .— At no School or Institution 3 4 7 Deaf (including deaf and dumb and partially deaf)— (i.) Suitable for training in a school or class for the totally deaf or deaf and dumb Attending Certified Schools or Classes for the Deaf 383 320 703 Attending Public Elementary Schools — — — At other Institutions — — — At no School or Institution 7 13 20 (ii.) Suitable for training in a school or class for the partially deaf Attending Certified Schools or Classes for the partially deaf 62 68 130 Attending Public Elementary Schools 2 — 2 At other Institutions — — — At no School or Institution 4 2 6 Mentally defective. Feeble-minded (cases not notifiable to the Local Control Authorities) Attending Certified Schools for Mentally Defective Children 4,016 3,089 7,105 Attending Public Elementary Schools 12 11 23 *At other Institutions 216 161 377 At no School or Institution 83 85 168 Notified to the Local Control Authority during the year Feeble-minded 48 62 100 Imbeciles 69 75 144 Idiots 11 9 20 Epileptics. Suffering from epilepsy Attending Certified Special Schools for Epileptics 41 32 73 In Institutions other than Certified Special Schools 34 41 75 Attending Public Elementary Schools— Ordinary 313 331 644 Special 87 73 160 At no School or Institution 129 145 274 Physically defective. Active pulmonary and glandular tuberculosis At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 14 14 28 At Certified Residential Open-air Schools — — — At Certified Day Open-air Schools 215 194 409 At Public Elementary Schools 87 78 165 *At other Institutions 164 149 313 At no School or Institution 99 118 217 Delicate children (e..g, pre- or latent tuberculosis, malnutrition, debility, anaemia,etc.) At Certified Residentail Open-air Schools 3,390 646 4,036 At Certified Day Open-air Schools 355 250 605 At Public Elementary Schools 4,722 4,341 9,063 *At other Institutions 149 73 222 At no School or Institution 164 220 384 Active non-pulmonary tuberculosis At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 55 36 91 At Public Elementary Schools 84 78 162 *At other Institutions 331 236 567 At no School or Institution 136 109 245 • Some of these cases may not have come to the notice of the School Medical Officer, but have been dealt with throughout by the Guardians. Ill Physically defective —continued. Boys. Girls. Total. Crippled children At Certified Hospital Schools 89 46 135 (other than those At Certified Residential Cripple Schools ... 27 5 32 with active tubercu- At Certified Day Cripple Schools 2,204 2,048 4,252 lous disease), e.g., At Public Elementary Schools 1,596 2,010 3,606 children suffering *At other Institutions 182 158 340 from paralysis, etc., At no School or Institution 178 247 425 and including those with severe heart disease * Some of these cases may not have como to the notice of the School Medical Officer, but have been dealt with throughout by the Guardians. TABLE IV. Defects treated during 1923. TREATMENT TABLE. Group I. Minor Ailments (excluding uncleanliness, for which see Group V). Disease or defect. Defects treated or under treatment. Under Council scheme. Otherwise. Total. Skin. Ringworm—Head 1,591* 804 2,395 Ringworm—Body > > 77,949 2,935 1,431 82,315 Scahies j" 2,935 Impetigo Other skin disease Eye disease. (External and other, but excluding cases falling in Group II). Ear disease. Cases in which operative treatment (e.g., mastoid operations, etc.) is given should be excluded and particulars given in the body of the Report. Miscellaneous. (e.g., minor injuries, bruises, sores, chilblains, etc.). 82,475 2,235 84,710 • 1,41G by X-Ray. Group II. Defective Vision and Squint. (Excluding eye defects treated as Minor Ailments, Group I.) Defects dealt with. Defect or disease. Under Coun- otherwise. Total. oil's scheme. Otherwise. Total. Errors of Refraction (including Squint, but operations for 29,986 1,573 Squint are recorded separately in the body of the Report). Other defect or disease of the eyes (excluding those in 2,000 Group L). (estimated) Number of children for whom glasses were prescribed (under Council's scheme), 23,577. Total number of children who obtained or received glasses (under Council's scheme), 21,357. 10976 H 2 112 Group III. Treatment of Defects of Nose and Throat. Number of defects. Received operative treatment. Received other forms of treatment. Total number treated. Under Council's scheme. Private practitioner or hospital. Total. 6,494 *1,162 7,656 5,442 13,098 *169 private doctor, 993 hospital. Form of treatment not specified. Group IV. Dental Defects. (1) Number of children who were:— (ui) Inspected by the Dentist Age Group No Record Total 236,658. (b) Found to require treatment, 166,454 (70.34 per cent.). (c) Actually treated, 95,332. (d) Re-treated as the result of periodical examination, 20,578. (2) Half-days devoted to—Inspection, 2,130 Treatment, 14,070—Total 16,200. (3) Attendances by children for treatment, 152,536. (4) Fillings—Permanent teeth, 59,082 Temporary „ 23,431—-Total 82,513. (5) Extractions—Permanent teeth, 40,659 Temporary „ 277,182—Total 317,841. (6) Administrations of general anaesthetics for extractions, 44,345. (7) Other operations—Permanent teeth 19,227 Temporary ,, ' Group V. Uncleanliness. (а) Average number of visits per school made during the year by the School Nurses, 6. (b) Examinations of children in the schools by school nurses, 2,052,904. (c) Instances of uncleanliness, 371,790. (d) Children cleansed under Council's arrangements 92,909. (e) Cases in which legal proceedings were taken:— (i.) Under the Children Act, 1908—659. (ii.) Under School Attendance By-laws—Nil. 113 Tuberculosis —History. 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, revised in October, 1922.* 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. The scheme specifies (clause 40) the working arrangements into which the Council is prepared to enter with the authorities of other county areas with regard to certain cases in which questions may arise as to the county authority which should be responsible for the provision and continuance of any course of residential treatment. Further details are given in the Annual Report for 1922 (vol. III., p. 100). The following table shows the provision for residential treatment under the 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. 1920 932 1 1,167 2,099 306 704 1,010 1921 1,215 1,050 2,265 225 669 894 1922 1,024 906 1,930 250 655 905 1923 975 749 1,724 285 707 992 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. 1920 2,320 3,045 5,365 712 618 1,330 1921 3,356 2,544 5,900 727 430 1,157 1922 3,121 1,289 4,410 835 285 1,120 1923 2,298 1,304 3,602 822 351 1,173 The above figures 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 1923 was 102. At the end of 1923 there were 170 cases (145 adults and 25 children) under consideration for residential treatment. Details of treatment are given above (see pp. 46/.) Care committees. In accordance with circular No. 308 (8th May, 1922) of the Ministry of Health, schemes have been submitted by the metropolitan borough councils for the establishment of permanent tuberculosis care committees composed of representatives of local authorities, boards of guardians, insurance committees and charitable and social work organisations in the district. Such committees are now in operation in nearly all the metropolitan boroughs. The functions of the care committees are generally to look after the welfare and interests of patients, to render such advice and assistance as circumstances dictate, with a view to enabling a family to adjust its circumstances to the new conditions and to derive the fullest advantage from the medical treatment prescribed; and further, to co-ordinate voluntary effort for the provision of certain kinds of assistance that may be needed in particular cases, e.g., additional food, change of air, clothing, etc. A subsidiary but important function of the care committees is to undertake, on behalf of the Council, the assessment of charges made in proper cases in respect of residential treatment afforded to children and adults. * Scheme for the treatment of tuberculosis in London. No. 2183. Price 4d. † Figures for 1914-19 are given in the Annual Report for 1921 (vol. III., p. 62). 114 A circular was addressed by the Council to the borough councils giving detailed information as to work which, it was suggested, care committees might usefully perform. Arising out of a proposal approved at a conference referred to below, that financial assistance should be provided for care committees, the attention of the borough councils was drawn to the voluntary organisations from which assistance could be obtained. The Council felt that when the care committees had developed their work and tested the Council's suggestions it would be found that existing means for securing assistance would substantially satisfy the needs. Approved expenditure incurred by borough councils in respect of office and clerical expenses in connection with the care committees ranks for the Government grant and the Council's grant towards the cost of the dispensary service. Tuberculosis dispensaries. The dispensary service was the subject of a special survey in 1920.* A further survey was made in the autumn of 1921. A conference was held in February and March, 1923, between representatives of the Council and of the metropolitan borough councils in connection with the tuberculosis dispensary service. As a result the Council called the attention of the London Panel Committee and the British Medical Association to the desirability of securing earlier notification of cases of tuberculosis. The Council also urged the borough councils concerned to secure closer co-operation between their public health departments and the dispensary in accordance with Ministry of Health Circular, No. 149. In order to secure greater co-ordination of the work, borough councils were also urged to arrange for tuberculosis officers to be appointed visiting consulting physicians for tuberculosis at poor law infirmaries in their areas. A circular was issued to tuberculosis officers giving information as to the arrangements under which they are enabled to visit hospitals and sanatoria in order to keep themselves posted as to the condition of patients from their areas. With the approval of the Minister of Health, the Council has approved of arrangements being made for the post-graduate instruction of tuberculosis officers, and the borough councils have been invited to submit proposals. There are now 21 municipal dispensaries, one voluntary dispensary—largely aided by a borough council—and 9 dispensaries—also aided by the borough councils and the City Corporation—at hospitals. Two borough councils have provided branch dispensaries. The medical officers (or tuberculous officers) of dispensaries, including the City of London, number 39, of whom nine 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 to 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 1923 the numbers of new cases examined at the dispensaries were :— 8,245 adults (insured), 7,015 adults (uninsured), and 11,751 children. The provision of dental treatment in connection with dispensary treatment Dental treatment. * Tuberculosis in London. Report of the Public Health Committee. 1st July, 1920. No. 2035. Price 6d. The development of the dispensary system was described in the Annual Report for 1920 (vol. III., p. 110). 115 Physically defective children. is regarded as an essential part of the tuberculosis dispensary service. At the end of 1923, proposals submitted by eighteen borough councils had been approved. Arising out of reports by Major R. C. Elmslie on the schools for physically defective children and by Sir Henry Gauvain on surgical cases of tuberculosis sent by the Council to various institutions, the Council considered the general question of the treatment and care of physically defective children.* The powers of public authorities in connection with the health and education services were considered, as well as the developments and action taken in the matters under review as regards tuberculous diseases and non-tuberculous diseases and conditions. The Minister of Health was approached with a view to determining the best steps to be taken to secure early and efficient diagnosis and treatment of poliomyelitis, and of securing increased facilities for treatment of the resulting infantile paralysis. Venereal disease. Details are given in the Annual Report for 1921 (vol. III., p. 63) of the joint scheme by the Council and authorities near London for the diagnosis and treatment of venereal diseases. Arrangements have been made for free treatment and diagnosis for in-patients and out-patients at 29 hospitals and for the reception of patients for treatment at seven hostels. Special provision 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 from venereal disease, and approved practitioners may obtain, free of cost, salvarsan or its substitutes. The cost of diagnosis and treatment at hospitals and hostels is divided between the Council and the participating authorities according to the user of the facilities available. The Council makes direct payments to hospitals for salvarsan or its substitutes supplied to medical practitioners in London. Details of cases treated in this and preceding years are given above (see pp. 42-3). Publicity arrangements. 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, 1924, were determined by the Council on 27th March, 1923. Since 1st April, 1922 the Council has itself undertaken certain publicity work which could most usefully be directed through official channels. Rescue and preventive work. Arising out of proposals of the National Council of Social Service, a central council representing public authorities and voluntary agencies concerned in rescue and preventive work in London has been formed for the co-ordination of rescue and preventive work among women and girls in London. The Council has four representatives on the Central Council. 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 1923,2,392 foster-mothers and 2,926 nurse-infants were notified. Power is given to remove to a place of safety an infant in the charge of a fostermother 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 * Physically Defective Children. Joint report made to the Council by the Education. Committee and the Public Health Committee, December, 1923. No. 2274. Price 6d. 116 partially or wholly premises which are so conducted as to render ordinary inspection unnecessary. unnecessary. Some particulars of the Council's work are as follows :— Year. Infants removed from foster mothers. Exemptions. Deaths. Infringements discovered. Cautions. Prosecutions. Convictions. 1921 20 3 42 302 285 26 26 1922 14 3 52 279 266 13 13 1923 6 3* 53 303 292 11 10 On 1st March, 1921, the Council authorised officers of the Greenwich Metropolitan Borough Council to act as infant fife protection visitors under the Act for a period of one year extending to 30th June, 1922, and on 25th July, 1922, on the application of the borough council, continued this arrangement until 30th June, 1923. The authority, which was subject to agreed terms and conditions and to review at the end of the period, was discontinued as from 31st December, 1923. 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 proposals † to the Minister of Health, but no definite action has yet been taken by him thereon. Lying-in homes. The Council s powers and duties with regard to the registration and inspection of lying-in homes are described in the Annual Report for 1922 (vol. III., p. 104). At the end of 1923, 277 premises were on the register, 50 were added during the year, one registration was cancelled, and 44 entries were removed (owing to discontinuance of user, removal, etc.), leaving a net total of 282 on the register at the end of the year. Eleven premises carried on by registered medical practitioners were exempted during the year. Under the powers conferred by Part IV. of the London County Council (General Powers) Act, 1921, the Council on 1st March, 1921, delegated to the Greenwich Metropolitan Borough Council its powers of inspection of lying-in homes in that borough. This delegation—at first for one year and thereafter for certain periods—was discontinued as from 31st December, 1923. 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 in London. 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 an 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. Owing to the difficulty of assessing the sums to be recovered, the Council, in 1921, adopted a scale of assessments graduated according to net income, after allowing a deduction in respect of each maintainable child or other dependant. From 1st April, 1923, to 31st March, 1924, the Council's expenditure under this head was about £4,100, of which about £1,100 was recovered. Further details of the Council's work are given above (see p. 52). 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 1923 was £429. Notifications by midwives of intention to practise during the year numbered * Partial. † See Annual Report for 1920 (vol. III., p. 113). 117 864 ; of intention to practise for specific periods less than a year, 23 ; and of having acted in specific cases, 18. There were 360 cases of puerperal fever and 753 of ophthalmia neonatorum. Ten inquests were held on women, and 83 on children. Five prima facie cases of negligence or misconduct were reported to the Central Midwives Board. In one of these the Board was of opinion that the midwife had acted as a maternity nurse and not as a midwife ; in one case the Board found that the charges were proved and the midwife was cautioned as to a strict and prompt observance of the rules of the Board ; in one case the Board removed the name of the midwife from the roll; in one case the Board postponed sentence and asked for periodical reports on the midwife's conduct and methods of practice ; and in the remaining case the charge was admitted but the Board took no action thereon. Action was taken against an uncertified woman for using the title " fully qualified midwife." An undertaking to discontinue the use of this description was given on her behalf and she was fined £1 and costs. She failed however to fulfil the undertaking and upon subsequent conviction was fined £5 and costs. Use of nitric acid. Two cases occurred in which strong nitric acid had been put into the eyes of newly born infants in mistake for a weak solution of nitrate of silver, resulting in one case in total blindness of one eye and in the other in very grave impairment of sight. The Council decided on 20th November, 1923, to inform the Central Midwives Board that, in its opinion, the use of nitric acid by practising midwives should be prohibited. The prohibition of this acid would not prejudicially affect the position of midwives as the purpose which it serves could be attained by other and equally simple means. Houses divided into separate tenements. 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. In view of the suggestions of the Minister of Health and of representations made by various interested parties, the by-laws were considerably revised, but in the early part of 1923 it was not found practicable to settle the by-laws without knowledge of the position which would arise on the expiration of the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. The Rent and Mortgage Interest Restrictions Act, 1923, prolonged, with certain exceptions, the duration of the Act of 1920 until 24th June, 1925. Moreover, under section 14 of the Housing, etc., Act, 1923, by-laws made by the Council in pursuance of section 26 of the Housing, Town Planning, etc., Act, 1919, may provide that the by-laws shall, either generally or as respects any particular metropolitan borough or any part thereof, have effect subject to such modifications, limitations or exceptions as may be specified in the by-laws. The section provides, also, that as soon as any by-laws made by the Council come into force, all by-laws made by metropolitan borough councils under section 94 of the Public Health (London) Act, 1891, shall cease to have effect, but that a borough council shall have power, after the Council has made by-laws, to make by-laws under the said section 94 with respect to any houses or parts of houses in its area let in lodgings or occupied by members of more than one family to which the by-laws made by the Council do not apply. The section extends the purposes for which by-laws may be made by the Council in order to include the taking of precautions in the case of any infectious disease. Revised by-laws were accordingly prepared on the basis of the powers conferred by the above-mentioned Acts, but on 18th December, 1923, the Council decided, in view of objections raised, to give further consideration to the text of the by-laws. Census of homeless persons. 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 lodginghouses, and the provision existing for the accommodation of persons of the poorest class. The censuses were taken on a winter night, and the total number of homeless persons found in the streets, on staircases and under arches were : February, 1915, 118 Common lodginghouses. 178; 1916,44; 1917,28; 1918,9; 1919,8; 1920,51; 1921,56; 1922,112; and 1923, 141. Further details are given above (see p. 42). Particulars with regard to common lodging-houses licensed by the Council are as follows :— Year. Houses licensed. Lodgers authorised. j Prosecutions. Convictions. Penalties and costs. Cases of infectious disease. 1921.. 181 18,503 1 1 £3 18s. 1 1922.. 178 17,948 1 1 £3 2 1923.. 175 17,700 5 5 £19 10s. 2 Seamen's lodging- houses. Particulars of seamen's lodging-houses licensed by the Council are as follows :— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious disease. 1921 51 1,287 13 11 £130 10s. 6d. 1 1922 44 1,170 1 1 — 1 1923 36 1,089 4 4 £40 1 Offensive businesses. In accordance with the powers conferred upon the Council by Part V. of the London County Council (General Powers) Act, 1907, the Council has made and renewed agreements with certain metropolitan borough councils for the cleansing of verminous inmates of licensed common lodging-houses and their clothing. The following table gives particulars of licensed slaughterhouses, knackers' yards and registered offensive businesses for 1921-23 :— Year. Slaughterhouses. Knackers' yards. Offensive businesses. 1921 158 4 60 1922 153 4 60 1923 147 4 101 During 1923 sanction was given to the enlargement of the business of a fellmonger and to the establishment anew of the business of a fat melter. Two applications for the establishment anew of the business of a dresser of fur-skins were received, one of which was granted and the other refused. 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 has since made by-laws for regulating the conduct of the businesses in question, and these by-laws have been confirmed by the Minister of Health. Under section 9 of the London County Council (General Powers) Act, 1908, the Council on 17th June, 1913, made by-laws with respect to the businesses of (i.) a vendor of fried fish and a fish curer, and (ii.) a rag and bone dealer. The former were confirmed by the late Local Government Board and the Home Secretary early in 1914, but the Board suggested that the latter should be modified especially as regards the construction of premises used for the business. Owing to the war, consideration of the question was adjourned until 1920, when the views of the trade associations interested were invited. As a result some of the proposed by-laws were amended, and the Council on 19th June, 1923, agreed to the by-laws as revised. In September, 1923, they were confirmed by the Minister of Health and the Home Secretary. During 1923 the Council considered the amendment of its by-laws for regulating the conduct of the business of a slaughterer of cattle by the incorporation, from the model by-laws issued by the Minister of Health, of a clause requiring the use of mechanically operated instruments for slaughter of animals. The Council on 6th March, 1923, made a by-law in these terms, and it was confirmed by the Minister of 119 Cowhouses. Health on 7th December, 1923, with a modification of the proviso relating to the slaughter of animals for the food of Jews. The numbers of cowhouses licensed by the Council are as follows 1915, 154 ; 1919, 116 ; 1920, 107 ; 1921, 101; 1922, 100 ; 1923, 98. 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 1923, 2,340 samples from milk consigned to London railway termini from 34 counties were submitted for bacteriological examination. Of these samples, 96, or 4.1 per cent., yielded tubercle baccilli as against 2.6 per cent. in 1922, 3.48 per cent. in 1921, 5.9 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 91 farms and examined 2,927 cows. It was found that 68 cows, i.e., 2.3 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 408 farms, and inspected 11,848 cows ; all the animals examined at these re-visits were found to be in a satisfactory condition with the exception of 59 which appeared to be tuberculous. In each instance the owner undertook to have the animal removed. At the request of the City Corporation a farm was inspected the milk from which had been found to be infected with tuberculosis; 60 cows were examined, but no evidence of disease could be detected. It was ascertained, however, that one cow suspected to be suffering from tuberculosis had been slaughtered prior to the inspector's visit. Three similar requests were received from the Holborn Metropolitan Borough Council. Four farms were visited and 276 cows examined but no evidence of disease could be detected. At one farm, however, a cow had been slaughtered, and at another two cows had been removed prior to the inspector's visit on the ground of suspected tuberculosis. In addition 104 farms were re-visited and 2,774 cows inspected. The animals were found to be in a satisfactory condition except 16, and the usual arrangements were made with the farmer for the disposal of the animals affected. Milk supply and storage. During 1923 four inspections were made of the cows in London cowsheds, and the total number of examinations made was 7,370. No case of generalised tuberculosis was detected, but in 125 cases other unhealthy conditions were found. The Milk and Dairies (Amendment) Act, 1922, (i.) postpones until 1st September, 1925, the operation of the Milk and Dairies (Consolidation) Act, 1915, except in so far as it repeals the Milk and Dairies Act, 1914, and the Milk and Dairies Acts Postponement Act, 1915, (ii.) empowers local authorities (in London, the City Corporation and the metropolitan borough councils) to refuse to register or to remove from the register the name of any retailers of milk when such a course appears necessary in the interests of the public health, (iii.) prohibits the sale or offer for sale of any milk as " certified," " Grade A," " Pasteurised " or under any other designation except under and in accordance with a licence granted by the Minister of Health or with his authority under the provisions of an order made by him under the Act, (iv.) prohibits the addition to milk for sale of colouring matter or water or any dried or condensed milk or any fluid reconstituted therefrom, or any skimmed milk or separated milk, (v.) makes it an offence for anyone knowingly to sell the milk from a cow suffering from tuberculosis of the udder, (vi.) authorises the Minister of Health to make orders for the prevention of danger arising to public health from the importation of milk for sale for human consumption. In addition, the Act contains several other provisions in regard to the administration and enforcement thereof. With regard to (iii.), the Minister of Health made the Milk (Special Designations) Order, 1923, which revoked previous orders prescribing the terms and conditions upon which the licences in question might be granted. Under the order the Council 120 is authorised to grant licences to producers to sell Grade A milk, and if the producer of such milk delivers the same to the consumer direct, to issue also a distributor's licence. The order provided that if the Minister of Health was satisfied that a county council was unwilling or did not propose to grant the licences, the Minister might authorise the district council (in London, the metropolitan borough councils) to do so. In view of existing legislation, the Council considered that there would be, in effect, dual jurisdiction in London in matters concerning the supply and distribution of milk, and in these circumstances and in view of the very small demand for producers' licences fo sell Grade A milk, the Council on 31st July, 1923, decided not to exercise the power conferred by the order. Epidemic, endemic and infectious diseases. In connection with the prevention of the spread of infectious diseases, and with a view of securing prompt recognition of cases of smallpox at the earliest possible moment, the Council in 1922 issued notices calling the attention of all medical practitioners, and the authorities of all hospitals and public medical institutions in London to the facilities provided by the Council in connection with the diagnosis of smallpox. Eleven cases of smallpox occurred in London during 1923, of which one proved fatal. No decision has been come to by the Minister of Health upon the Council's representations (see Annual Report for 1922, vol. III., pp. 107-8) to the effect that it should be empowered in times of epidemic to close for short intervals places of public entertainment in which the ventilation is determined by the Council to be unsatisfactory, or to take such action as may appear to be expedient in order to prevent the spread of infectious disease among persons frequenting such premises.. By-laws as to drains, etc. The drainage by-laws made by the Council in 1900 under section 202 of the Metropolis Management Act, 1855, restricted the materials of soil and ventilating pipes within buildings to drawn lead only. From time to time representations have been made with a view to the relaxation of this requirement, and after careful consideration the Council on 23rd October, 1923, made amending by-laws allowing such pipes to be constructed of heavy cast-iron as well as of drawn lead. The amending by-laws have been submitted to the Minister of Health for approval. Appeal Committee. The Appeal Committee are the statutory appeal committee under the Metropolis Management Act, 1855, section 212. The Committee also hear and decide all appeals made to the Council under any other Act of Parliament (except appeals undersection 20 (5) of the Public Health (London) Act, 1891, against decisions of the Public Health Committee). No appeals were heard during the year 1923. Health administration in London. Details are given in the Annual Report for 1921 (vol. III., p. 67) of the Council's action with regard to the organisation of health administration in London. In accordance with the decision of the Council on 29th November, 1921, and 16th January, 1922, evidence relating to public health services was given before the Royal Commission on London Government on the lines of the report submitted to the Council on 19th December, 1919, by the Special Committee on Health Administration in London* (see Annual Report, 1921, vol. 1., pp. 34-36 ; and 1922, vol. 1., pp. 46-52). The report of the Royal Commission was issued in March, 1923 (see vol. I., pp. 46-7). Diseases of animals. 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, parasitic mange and foot and mouth disease, diseases which are communicable to man. The Acts are supplemented by Orders issued by the Minister of Agriculture and Fisheries. During 1923 the incidence of the principal animal diseases so far as London is concerned was as follows :—Glanders, including farcy, nil; swine fever, two outbreaks, one affecting 44 animals ; anthrax, nil; parasitic mange, 128 outbreaks involving 226 animals, and foot and mouth disease, one outbreak affecting 20 animals. * Report of the Special Committee on Health Administration in London. No. 2000. Price 3d. 121 Glanders or Farcy. 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 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. 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. The Order was 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 1923 there were two infringements of the Importation of Dogs Orders, penalties and costs amounting to £2 being imposed. Swine fever. Swine fever has been very prevalent throughout Great Britain during the past few years. Two outbreaks were dealt with in London during the year. During 1923 under the Regulation of Movement of Swine Order 19,405 swine were examined at feeders' premises. There was one infringement of the Order, which was dealt with by means of a written caution. There was one infringement of the Swine Fever Order of 1908. A conviction was obtained, the defendant being required to pay £1 1s. costs. 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. Rabies. The Council is convinced that the most efficacious measures for 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, 20,398 dogs were seized by the police during 1923 and 13,900 were destroyed. Parasitic mange. On the outbreak of the war, the Order 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 1923, however, the returns of cases in London showed an increase but it is a satisfactory feature that fewer animals were affected in each outbreak than in the previous year. The following figures relate to 1923 :—outbreaks, 128 ; horses affected, 226 ; infringements, 20 ; written cautions sent, 9 ; convictions, 11 ; penalties and costs, £99 17s. For the purposes of comparison, the number of outbreaks in 1922 was 96, affecting 164 horses. Sheep scab. During 1923 the Minister of Agriculture and Fisheries made an Order known as the Sheep Scab Order of 1923. This Order (i) requires sheep owners to take such steps from time to time as are reasonably practicable to secure that their sheep are free from scab, and (ii.) entirely alters the legal position of the sheep owner as regards the disease. Under previous Orders sheep scab might be present among a flock without the owner incurring any penalty, provided that he reported the existence of the disease and carried out the prescribed general treatment. These requirements are still in force but, in addition, after 1st July, 1924, the owner of sheep affected with the complaint will be liable to a penalty up to £20 or, if more than four animals are affected, to a fine not exceeding £5 for each animal, unless he can show that he has habitually taken adequate measures to cure and prevent the disease in his flocks. All necessary steps were taken to bring the requirements of the Order to the notice of the persons concerned. 122 Foot and mouth disease. In consequence of the serious outbreak of foot and mouth disease in the early part of 1922, the Minister of Agriculture and Fisheries in March, 1922, appointed a Departmental Committee to inquire into the origin and circumstances of the outbreak, and into the policy and procedure pursued in dealing with the disease, and to report whether any alteration of the methods of administrative control hitherto adopted, or any amendment of the existing law was necessary or desirable. The Committee reported in December, 1922. From 24th January to 1st October, 1922, the number of outbreaks of the disease reached 1,125, it spread to 44 counties in England, Scotland and Wales, and involved the slaughter of 23,606 cattle, 21,710 sheep, 9,540 pigs and 48 goats at a cost for compensation of £790,244. The report also dealt with the introduction of infection, the means by which infection might be spread, the initial outbreaks of the disease in January, 1922, the distribution of the disease from the first infected place, the infection of markets in this country, the causes of the development of the outbreak, the policy pursued in connection therewith, the procedure adopted at infected places, the movement restrictions imposed in connection with the disease, the general precautions adopted for preventing its spread and the organisation and administration for dealing with outbreaks. The comptroller of the Council placed before the Departmental Committee the Council's view that the arrangements for meeting the cost of dealing with outbreaks of animal diseases, whereby part of the cost incurred by the Government is charged upon local authorities through the Local Taxation Account, were inequitable. It was contended that, as the service is a national one and local authorities have no control over the expenditure such expenditure should be borne by national funds. The Departmental Committee agreed with this view. It is understood that their recommendations are receiving the attention of the Minister of Agriculture and Fisheries. Outbreaks in Essex and Surrey. In consequence of the existence of foot and mouth disease in Plaistow, Essex and Morden, Surrey, the Minister of Agriculture and Fisheries made orders on 23rd April, 1923, and 26th October, 1923, respectively, prohibiting the movement of animals within an area having a radius of about 15 miles from those places. The areas in each case included the whole of London. Provision was made in the orders for the movement of animals to a slaughterhouse in the prohibited area from premises outside that area, for immediate slaughter, under licence from the local authority of the area of destination. To ensure that this provision was complied with, it was essential to follow up all animals imported into London to see that slaughter was effected. The orders were subsequently revoked and modified orders substituted therefor. Under the new orders London formed part of a controlled area into and within which movement of animals was permitted under a licence granted by an inspector of a local authority. The new orders permitted the holding in the controlled area of a market for fat animals intended for immediate slaughter provided it was licensed by the local authority. In consequence of the outbreak, the Metropolitan Cattle Market at Islington had been suspended and an application made by the City Corporation, as the owners of the market, for authority to hold such a market as usual was acceded to. All requisite steps were also taken to bring the terms of the orders to the notice of persons concerned. Outbreak in London. On 14th November, 1923, an outbreak occurred in London and 20 out of 94 pigs were found to be affected. As the owner had had no fresh stock on his premises for a period of four months, the origin of the disease is obscure. Animals in Transit. To ensure that the requirements of the Animals (Transit and General) Order, 1912, and the Exportation and Transit of Horses, etc., Order of 1921, 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 1923 numbered 2,164, the animals examined being— horses 2,942, cattle 38,341, sheep 41,398, swine 6,653, making a total of 89,334. 123 Inspection of poultry, There were 19 infringements, 16 written cautions and 3 convictions, with penalties and costs amounting to £29 12s. During 1923 representations were made to the Minister of Agriculture and Fisheries by the Poultry Advisory Committee and the National Poultry Council as to the danger of the spread of infection among poultry at markets and auctions and suggesting that veterinary inspectors should extend their examination of stock at markets and marts so as to include poultry. The existing powers of the Minister in respect of poultry are limited to those contained in the Poultry Act, 1911, which enables the Minister to make Orders (i.) for protecting poultry from unnecessary suffering in connection with their exposure for sale and their disposal after sale, and (ii.) for requiring the cleansing and disinfecting of receptacles or vehicles. The Minister asked for the views of the Council as to (i.) the desirableness of obtaining statutory powers for the purpose mentioned, and (ii.) the practicability of enforcing such requirements. The Council, on 23rd October, 1923, expressed the opinion that it was desirable that live poultry at wholesale markets and other such places should be subject to compulsory veterinary inspection. CHAPTER XXVI. MAIN DRAINAGE. The district drained by the Council's main drainage system has an area of nearly Drainage 149 square miles with a population (in 1921) of 5,333,387. This includes an area of area and statistics. nearly 32 square miles, with a population of 850,138, outside London. The quantities of sewage, etc., dealt with during 1923 were as follows :— Sewage treated— Million gallons. Northern outfall 54,805.6 ,, ,, (daily average) 150.2 Southern outfall 31,362.9 ,, ,, (daily average) 85.9 Sludge sent to sea— Tons. Northern outfall 1,450,000 ,, ,, (daily average) 3,973 Southern outfall 823,100 ,, ,, (daily average) 2,255 The sludge vessels made 2,217 trips and travelled altogether 244,778 nautical 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. 120). 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 necessary at certain places. 124 Sewage treatment. The experiments in connection with the biological treatment of sewage on the activated sludge basis have continued during the year with the new tanks which have been equipped with different types of appliances for agitating the sewage. Three processes are now in operation, namely (i.) the diffusion of air through the sewage by means of porous tiles fitted in the bottom of the tank; (ii.) the agitation of the sewage by paddle wheels which constantly expose fresh layers of the sewage to the air; and (iii.) the spraying of the sewage into the air through a nozzle. Experiments are being continued but it would be premature to attempt at present to make a final decision on the merits of the three methods. Owing to the condition of the Thames during the summer, due principally to the small flow of water over Teddington weir, the use of chemicals for precipitating solids at the main drainage outfalls was resumed. Treatment had lasted for less than two months when the condition of the river improved, and it was possible to discontinue the use of chemicals. The cost, including expenditure on preliminary work, chemicals and labour, amounted to approximately £2,(XX). Northern outfall. The Council on 19th December, 1922, approved expenditure of £14,000 in respect of the installation of two new boilers of the water tube pattern at the Northern outfall in place of the boilers in the eastern boiler house which were worn out after more than 33 years' service. During 1923 tenders were accepted for the boilers and accessory plant as follows:—Stirling Boiler Company, Limited, for boilers, £8,834 ; John Mowlem and Company, Limited, for foundations, etc., £2,298 : Wilson and Perrett, Limited, for water softening and oil extracting plant, £794 5s.; Dilworth and Carr, Limited, for piping, £1,156 ; Leeds Engineering and Hydraulic Company, Limited, for hydraulic ash-hoist, £254. A soft water tank of re-inforced concrete was constructed by the Council's jobbing works contractors (John Mowlem and Company, Limited), the price tendered being £543. The overhead sludge tanks were found to need considerable repair, and the Council on 14th February, 1923, accepted the tender, amounting to £3,434 of Messrs. Flavell and Churchill for the work. Further repairs to the pier, which have proceeded continuously since 1913, have been carried out during the year at a cost of about £1,000. This work was executed by direct employment of labour as was also the work of repairing the railways at the outfall, at an estimated cost of £450. Repairs to the river banks were carried out by the jobbing works contractors at a cost of about £2,500. Repairs to the pipes and valves controlling the supply of water from the river to the ponds and condensers were authorised at a cost not exceeding £1,800. 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 1923 amounted to £1,500 for work to be executed by direct employment of labour, and for the purchase of valves and other parts from Clayton, Goodfellow and Company, Limited, at a cost of £486 10s. Sludge vessels. The roads and paving at the outfall have been repaired at a cost of £430 1s. 8d., and a new sludge loading pump has been installed at a cost of £263 12s. 4d. The fleet of vessels for conveying sludge from the outfalls to the Black Deep was built up between 1887 and 1895 when six vessels were obtained, each of a carrying capacity of about 1,000 tons. These arrangements were not altered until the present year. The new sludge vessel, the s.s. Henry Ward, built by William Beardmore and Company, Limited, was completed at a cost of £42,914, and placed in commission on 28th September, 1923. She has a carrying capacity of 1,500 tons and is manned by a crew of the same size as the older and smaller vessels. The question of dealing with the older vessels has received careful consideration. The s.s. Bazalgette was re-conditioned during the year 1921 at a cost of £55,207, and such re-conditioning may give her a further life of 15 years. Extensive repairs were carried out to the hull of the s.s. Barking and it was intended to complete her 125 conditioning and to instal new machinery, and the other four vessels would also, in due course, require extensive repairs to keep them in commission. In the circumstances it was felt that it would be more economical to obtain new vessels of the same type as the Henry Ward which proved very satisfactory in working. The s.s. Barrow, Belvedere and Bazalgette were overhauled during the year at a total cost of £1,864. Outfall intercepting and main sewers. A proposal for utilising the top of the northern outfall sewer embankment as a thoroughfare between Old Ford and Barking was put forward by the Poplar Metropolitan Borough Council. The embankment is not suitable for vehicular traffic, but the portion in West Ham has been laid out as a promenade and fenced by the Corporation. Westward of Stratford High-street no such use is made of the embankment, nor is it practicable to construct a thoroughfare between Stratford High-street and Old Ford in view of the obstacle offered by the main line of the London and North Eastern Railway, Great Eastern section, which is on the same level as the top of the embankment. It would, however, be possible to shorten the route between those places by making use of the embankment between Old Ford and Marsh Gate-lane, and permission has been given to the borough council to form a footway between these points. Repairs, etc., have been carried out during the year to intercepting and main sewers as follows:— Feet £ Heathwall Sewer 646 481 Effra Branch Sewer 2,135 3,582 Falcon Brook Sewer 1,034 783 Marcia-road Sewer 1,052 1,700 Fleet Sewer (twin culverts) 950 10,950 Ranelagh Sewer 900 3,950 Wick-lane Sewer 823 1,925 Pennington-street Sewer 527 2,775 Hackney Brook Sewer 342 625 Northern Outfall Sewer, Bridges — 5,700 It will be observed that the cost of sewers repairs varies within wide limits, consequent upon their varying sizes and the extent of the work necessary to put them into good condition. The storm water outlet from the RatclifE-highway sewer discharges into the Thames under the property of the Free Trade Wharf Company, Limited, and arrangements have been made to construct a new outlet which will pass mainly under King Edward VII. Memorial Park at Shadwell. The estimated cost of the new outlet is £2,500 of which the Company will pay two-thirds. The Company will be permitted to build over the small portion of the new outlet under its property, subject to the Council's interests being fully protected. Abbey Mills pumping station. The reservoirs at Abbey Mills pumping station have been repaired at a cost of about £350. North Woolwich pumping station and rising mains. The total cost of the enlargement of North Woolwich pumping station and of the construction of the new 24-inch rising main from the pumping station to the northern outfall has amounted approximately to £27,000, including the cost of machinery, and £45,000 respectively. In consequence of the use of the new main it was possible to relieve the strain on the existing pipes and heavy expenditure on repairs has been obviated. The construction of the new 24-inch main rendered it possible to undertake the replacement of the two original 14-inch mains which were worn out. This work was included in the list of main drainage works for the provision of employment in respect of which the Council on 16th and 30th October, 1923, approved estimates of expenditure. A tender, amounting to £15,375, submitted by Mr. Howard Farrow for laying the new mains, was accepted. Repairs were authorised to the settling 10976 1 126 Flood works. pond of the station at an estimated cost of £500 and a new centrifugal pump was obtained at a cost of £195. North eastern storm relief sewer. 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. (See Annual Report for 1920, vol. III., p. 121.) Part of this, a storm-relief sewer from Kelvin-road, Highbury, to the Thames at Shadwell, 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 Bethnalgreen-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 under contract No. 1, begun in May, 1921, involves the construction of a brick sewer, about 2½ miles long, circular in section, varying from 8 to 9 feet in diameter. 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 1½ miles long, 11 feet 4 inches in diameter, and is being constructed from the Shadwell end, its outlet into the Thames being through the river wall fronting the new King Edward Memorial Park at Shadwell. At the end of 1923 the driving of the tunnels had been practically completed, and the lining and subsidiary works are proceeding. To provide additional employment the Council in 1921, accelerated 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 the improvement of the river Graveney, the Wandle Valley sewer, the Charlton storm reliefsewer, and flood relief works at Hammersmith. Unemployment continued during 1922 and for its relief further portions of the 1919 scheme were undertaken. These comprise the enlargement of the Isle of Dogs and Abbey Mills pumping stations, and the construction of the south-western storm relief sewer. In 1923, further works included in the scheme were put in hand, comprising the construction of storm relief sewers in Lewisham and Woolwich and the installation of additional machinery at Shad Thames pumping station. H.M. Government, through the Unemployment Grants Committee, agreed to make a grant towards the cost. Details of all these schemes are given below. River Graveney. The improvement of the river Graveney consisted in the formation of 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. The estimated cost of the work, including provision for land, compensation and supervision was £230,000. A contract for the work was let to Messrs. John Price and Son. Work under the contract was begun in June, 1921, and completed in January, 1923, at a cost amounting to approximately £167,000. Wandle Valley sewer. The Wandle Valley sewer is designed both as a soil sewer and a storm-water sewer. Sewage 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 2⅓ miles in length, and, if necessary, can be extended to the Thames. The cost will be about £170,000. A contract for the work was let to W. G. Tarrant, Ltd., and a start was made in December, 1921. At the end of 1923 the work was very nearly completed. Charlton storm relief sewer. The Charlton storm relief sewer is designed to afford relief to the southern highlevel sewer. It connects with the high-level sewer at Charlton and is 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. The cost, including the cost of property and incidentals, will be about £160,000. For the construction of the sewer itself the tender amounting to £128,452, upon a fixed price basis of S. Pearson and Son (contracting department), Limited, was accepted by the Council in January, 1922, and work was begun in the following month. At the end of 1923 the work was very nearly completed. 127 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 Western pumping station, and in times of storm also at Lots-road pumping station. 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 estimate for the whole work, including the acquisition of the property, etc., was £360,000. A contract was let to Messrs. Kinnear Moodie and Co., for the construction of a sewer for the sum of £145,220 upon a fixed price basis. Work was begun in December, 1921, and completed in June, 1923, at a cost of £137,440. The tender of Gwynne's Engineering Company, Ltd., amounting to £59,370 for five sets of engines and pumps was accepted on 17th February, 1922. Permission was given for the Company to sublet the main and auxiliary engines to the Premier Gas Engine Company, Ltd. The order to commence work was given on 3rd May, 1922, and at the end of the year work to the value of about £12,000 had been completed. The motive power for the engines is gas and special arrangements for supply were made with the Brentford Gas Company. The mains near the station were insufficient to supply the station and a new main is being laid in respect of which the Council has agreed to pay £4,000. It has also been necessary to lay a special main for the supply of water for cooling purposes and this work is being carried out by the Metropolitan Water Board at the Council's expense. Tenders were also received for the erection of the proposed pumping station at Hammersmith, and that submitted by Leslie and Company, Ltd., and amounting to £56,290 was accepted on 1st March, 1922. At the end of 1923 the erection of the buildings had been substantially completed. The tender, amounting to £1,750, submitted by Clayton, Goodfellow and Company, Limited, for the supply of penstocks and operating gear was accepted. Nos. 42, 44 and 46, Chancellors-road which were affected by the works have been purchased and, as far as may be required, they will be utilised as quarters for the staff employed at the station. Abbey Mills pumping station enlargement. The enlargement of Abbey Mills pumping station involves alterations in the Worthington engine house at the station, the installation of new pumping plant there, and the provision of additional boilers in one of the boiler houses and of supplementary plant. The total estimated cost is £60,000. Boilers have been supplied by Clayton, Son and Company, Limited, and fitted at a cost of £8,872, and the tender amounting to £19,750, of Gwynne's Engineering Company, Ltd., for the supply of machinery was accepted on 20th December, 1922. During 1923, tenders were accepted as follows:—Holdsworth and Sons, Limited, £3,237 for the supply of three Lancashire boilers; Mr. F. R. Hipperson, £13,815 for the construction of foundations for the new machinery; E. Green and Son, Limited, £1,827 for a fuel economiser and Meldrums, Limited, £2,220 for mechanical stoking plant. Isle of Hogs pumping station enlargement. In addition to the work done at Abbey mills pumping station in connection with the drainage of the low-lying areas in Poplar and the Isle of Dogs, storm water is pumped direct into the Thames at the Isle of Dogs pumping station and the flood relief scheme submitted to the Council in 1919 provides for the enlargement of this pumping station and the substitution of gas for steam power. The Premier Gas Engine Company whose tender for gas engines was accepted before the outbreak of war submitted an amended offer calculated upon post-war conditions to complete the work upon the basis of a new contract price of £9,829, of which £545 would be provisional. The Company's offer was accepted on 24th November, 1922, and on 10976 1 2 128 7th December, 1922, the Council accepted the tender, amounting to £29,405, of W. Pattinson and Sons, Ltd., for the building work involved in the enlargement of the station. The Council on 24th December, 1923, accepted the tender of the Lilleshall Co., Ltd., amounting to £3,118, for the supply of two 30-inch centrifugal pumps, etc. Quarters will be provided for certain of the staff, and houses adjoining the station have been acquired for the purpose. The total estimated cost of the enlargement is £73,000. Southwestern storm relief sewer. The south-western storm relief sewer has been designed to assist in the drainage of areas in Clapham, Streatham, Brixton, West Norwood and Dulwich. The scheme anticipated the construction in the first place of a sewer which would tap the Effra sewer at Effra-road, Brixton, and the Balham sewer, the southern high-level sewer and the southern high-level sewer extension near Clapham-road station, and would also be connected with certain local sewers. The new sewer will discharge into the Thames at Nine Elms. The estimated cost including incidental expenses is £315,000. If required at a later date the sewer can be extended southward to relieve the Effra Branch sewer at West Norwood. The length of sewer from ESra-road to Nine Elms is 2⅜ miles, and in order to expedite the work for the purpose of affording additional employment the work was made the subject of two contracts of unequal value, approximately 25 per cent. and 75 per cent. For the construction of the smaller portion between Effra-road and Clapham-road, the Council on 23rd November, 1922, accepted the tender, amounting to £52,454, of Mitchell Brothers, Sons and Company, Limited, and work was begun in December, 1922. The time specified in the contract for the completion of the work was nine months, and up to the end of December, 1923, work to the value of about £46,450 had been completed. The Council on 1st March, 1923, accepted the tender, amounting to £210,939, of the Unit Construction Company, Limited, for the construction of the sewer from Clapham-road to the Thames. Work upon this section was begun in March, 1923, and up to the end of December, 1923, the value of finished work was approximately £18,500. Storm relief sewers in Lewisham and Woolwich. The scheme for the relief of floodings provided for the construction of storm relief sewers in Lewisham and Woolwich to relieve the area drained by the southern high-level sewer No. 2, including the whole or part of Penge, Beckenham, Catford, Lee, Eltham, Kidbrooke, Greenwich and Woolwich. The latter sewer is about 10 miles long, and intercepts the flows of several important sewers. Since 1919, when the scheme was submitted, extensive building operations have taken place in the area, including the Council's operations at Bellingham and Downham (see p. 135) and those of the Woolwich Metropolitan Borough Council at Eltham. Large areas in these districts are still undeveloped and it is probable that further building will take place in the near future. The works proposed comprise two sewers, namely, the Lewisham branch sewer and the Eltham sewer. The former will run from Bell-green, Lower Sydenham, to a junction with the southern highlevel sewer No. 2 near Court Hill-road, Lewisham, and a branch sewer will be constructed from Catford station. The total length will be about 3 miles. The new Eltham sewer will run from the junction of the Council's existing Eltham sewer and the local sewer in Eltham-road, near Eltham-green, to the southern high-level sewer No. 2 at Charlton, near the junction of the latter with the Charlton storm relief sewer, a distance of approximately 1½ miles. The works will be put in hand immediately for the provision of additional employment and they have been approved for the purpose of State aid by the Unemployment Grants Committee. The estimated cost of the sewers, including expenditure not provided for in the contracts, amounts to £299,500 for the Lewisham branch sewer and to £256,000 for the Eltham sewer. Shad Thames pumping station. Shad Thames pumping station was opened in 1909 to relieve the low-lying areas in Southwark, Bermondsey and Deptford, which previously were almost 129 entirely dependent upon Deptford pumping station. The new station was designed to accommodate six pumping sets, but as a first instalment three only were put in and they served for several years. Further floodings occurred in this area and the flood relief scheme of 1919 included proposals for completing the equipment of this station. The Council on 4th December, 1923, approved an estimate of expenditure of £22,000 for this work which will be undertaken as soon as possible. Beverley Brook. For several years past complaint nas been made of floodings in Barnes during times of heavy rainfall from the overflowing of Beverley-brook. The total length of the brook and its tributaries is about 30 miles, and it drains an area of about 14,500 acres, only about 1,820 of which are in London. The Metropolis Management Act, 1855, vested in the Metropolitan Board of Works the lower portion of the brook, with a length of about 4 miles, including l¼ miles through Crown lands (Richmond-park). The use made of the brook for the discharge of storm water from London is comparatively small. In 1913 certain of the out-county authorities who were most affected were approached with a view of contributing towards a relief scheme from which they would benefit, but with the exception of the Barnes Urban District Council all declined. The negotiations with the latter, interrupted by the war, have been brought to a conclusion, subject to ratification by Parliament which the Council on 6th November, 1923, decided to seek. The principal item of the arrangement is the construction of a culvert, not less that 8 feet in diameter, to draw off storm water from the brook at a point near Priest's-bridge, Upper Richmondroad and to discharge it into the Thames by the most direct route. The approximate estimate of the cost of this work is £39,500, towards which the District Council will contribute one-fifth or £8,000, whichever is less. Sewer in Streathamhill and Brixton-hill. To relieve floodings in certain areas in the south-west district of London the south-western storm relief sewer (see above) is now in course ot construction. This sewer cannot by itself relieve floodings which occur in parts of Streatham and Brixton as the local sewer which runs down Streatham-hill and Brixton-hill is of insufficient capacity to convey the quantity of water which falls during heavy storms. The local sewer in question is under the control of the Wandsworth and the Lambeth Metropolitan Borough Councils so far as it lies in the areas under their respective control. The borough councils urged that the Council should take over this sewer and carry out such works thereto as might be necessary to relieve floodings along its length. Alternatively they suggested an alteration in the proposed route of the south-western storm relief sewer so as to obviate the necessity for the execution of works to the local sewer. The Council was unable to accede to either of these suggestions which, although they might relieve the two boroughs of expense would entail greater expenditure on the general community. After negotiation the borough councils agreed that the Council should undertake the construction of a new sewer, 4 feet in diameter, in Streatham-hill and Brixton-hill to connect with the south-western storm relief sewer at the joint expense of the borough councils in the proportion of two-thirds to Wandsworth and one-third to Lambeth. After completion the new sewer will be vested in the Council. The proposed works will leave the present local sewer in Water-lane as a connecting link between two of the Council's sewers and it is therefore proposed that the Water-lane sewer shall be taken over by the Council as a main sewer. There remains the present local sewer in Streatham-hill and Brixton-hill and this will continue to be maintained by the borough councils. The estimated cost of the new sewer, including expenditure not provided for in the contract, amounts to £57,500 and the work has been included in the list of works approved by the Unemployment Grants Committee for the purpose of State aid and steps are being taken to put the work in hand as soon as preliminary arrangements are completed. Out-county drainage. The annual contribution by the West Ham Corporation in respect of the drainage of the borough into the Council's system was fixed by an arbitrator in 1904 at 2¼d. in the £ on the assessable value of the borough (excluding Government property). 130 This contribution fell far below the cost of the service rendered and the Council therefore obtained authority in its General Powers Acts, 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. Negotiations took place between the Council and the Corporation with a view to a settlement, and ultimately the Council on 17th July, 1923, decided to apply to the Minister for an order under section 34 of the Act fixing, by consent, as from and including 1st January, 1922, the Corporation's payment, such payment being the London main drainage rate less ¾d. in the £ and being calculated upon the rateable value of the borough (including Government property). Local sewers. Section 69 of the Metropolis Management Act, 1855, provides that no local sewer shall be made without the approval of the Council. During 1923, the construction or reconstruction of 80.261 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 1923 the Council gave its consent in 19 such cases. In consenting to the erection of buildings over sewers the Council imposes conditions to safeguard its interests in the sewer or sewers concerned. Sometimes a charge has been made either annually or by payment of a lump sum, but doubts having arisen as to the extent to which the Council is entitled to attach particular conditions to its consent the Council on 6th November, 1923, decided to seek legislation in order to remove these doubts. Staff. The Council on 27th March, 1923, fixed the staff in the chief engineer's department employed at main drainage stations, etc., and in the Thames floods prevention service. The total number of officers and employees on the fixed staff is 926 and two watchmen who each work one day a week on relief. In view of the possible reduction in the number of vessels the permanent staff for the sludge vessels is limited to four complete crews. Any vessel above the number of four will be manned by officers and men either transferred or employed temporarily. The complement of officers and crew for each vessel is 24. The staff is in three categories namely (i.) officers and employees whose salaries and wages are not based on trade rates or decisions of Industrial Councils, (ii.) officers and employees with wages based on the rates in various trades and (iii.) manual workers. The first category includes the superintendents and other executive officers, clerical assistants and a few employees whom it is not possible to classify elsewhere. With the exception of the superintendent of the sludge vessels whose salary is on a post-war basis and therefore inclusive, the salaries and wages of these officers and employees are subject to variations in accordance with the Council's general scheme of temporary additions to salaries and wages. The second category includes mechanics in various trades and their unskilled helpers whose rates of pay are based upon trade or other agreements, subject in certain instances to additional payments in view of the nature of the work upon which they are employed ; the three men employed in the Thames floods prevention service whose rates of pay are adjusted from time to time in accordance with any variations in pay granted to river workers ; and the officers and crews of the sludge vessels whose rates of pay are reconsidered in the event of any alteration taking place in the rates of pay of officers and men employed on vessels of similar tonnage in the coasting trade. The third category includes the group of workmen who come within the purview of the Joint Industrial Council for Local Authorities' Non- 131 Trading Services (Manual Workers). Formerly these employees came under three district or provincial councils, the findings of the London District Council operating only at main drainage stations within the County of London, while the southern outfall which is in Erith, came within the jurisdiction of the Provincial Council for the Southern Home Counties Division and Abbey mills pumping station, which is in West Ham, came within the jurisdiction of the Provincial Council for Essex, Hertfordshire and Middlesex, which ceased to function in 1921. In the last mentioned case the arrangements made by the late Provincial Council were maintained voluntarily. The National Joint Industrial Council decided that the Southern outfall and Abbey-mills pumping station should be included in the jurisdiction of the London District Council, the Southern outfall with effect as and from 6th September, 1923, and Abbey-mills pumping station with effect as and from 2nd November, 1923. Workmen receiving more than the rate for their grade retain the additional amounts, but their successors will receive the rates specified for the respective grades. New rates for officers and crews on weekly vessels on ordinary Board of Trade Articles were made by the National Maritime Board to operate as from 16th April, 1923. The new rates were 10s. a week lower than the previous rates for officers and 6s. 6d. a week lower for the various ratings in the crews. The Board was asked to make similar reductions in the wages of the officers and crews of the sludge vessels. The men were dealt with by the Thames District Maritime Board which reduced their rates by 6s. 6d. a week for three months as from 10th May, 1923, to enable the Council to consider the recommendation of the Board that the Council should follow the National Maritime Board's decisions and procedure. The Council on 31st July, 1923, agreed to accept the rulings of the Board upon differences of opinion between it and the crews relative to their rates and conditions of service, provided that such matters as in the Council's opinion are matters of discipline shall be dealt with by the Council without reference to the Board. As regards the officers, the Board suggested that as it controlled no machinery which could deal with a local problem of this nature, the matter should be dealt with by direct negotiation between the Council and the officers. It was subsequently agreed that the rates of pay of the officers, except masters, should, as from and including 5th July, 1923, and until further order, be 5s. a week more than the rates fixed by the National Maritime Board for similar ranks in the coasting trade. As regards masters for whom the Board has not fixed rates the Council decided to reduce their rates of pay by 5s. a week as from and including 5th July, 1923, and to make such rates subject to adjustment from time to time in accordance with any variation in the rate of pay of first mates. Powers and duties of the Council. CHAPTER XXVII. HOUSING. The powers of the Council in relation to the housing of the working classes are derived from the Housing Acts, 1890 to 1923. Apart from administrative duties, the main divisions of the work are (i.) the provision of new dwellings to meet the need for additional accommodation, and (ii.) the improvement or reconstruction of unhealthy areas, including the provision of dwellings for rehousing persons of the working classes displaced. Stateassisted 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 (see Annual Report for 1920, vol. III., p. 124) for the provision of workingclass dwellings to meet the needs of London and for the improvement of housing 132 conditions therein. Under the Act any financial loss on the scheme as well as losses on schemes undertaken by metropolitan borough councils, so far as they exceed the produce of a penny rate, are borne by the National Exchequer. Owing to financial stringency, the house-building programme was considerably curtailed by the Minister, and eventually the number of houses to be built by the Council, apart from dwellings for rehousing in connection with clearance schemes, was reduced from 29,000 to 8,814. Of these, 7,433 had been completed by the end of 1923. Although the Government did not continue to undertake the unlimited liability previously involved, it soon became convinced that some form of State assistance was necessary. Not long after the curtailment of the Council's scheme there was a general fall in wages and cost of materials, the combined effect being to reduce building prices within more reasonable limits. This was naturally followed by a revival of house building by private enterprise, but the houses were almost entirely intended for sale and were destined in the main for middle class occupation. The Government therefore decided to assist local authorities to build houses, and at the same time to encourage the provision of small houses by private enterprise by the contribution of a fixed sum per house. The State's liability was thus limited, any loss beyond the amount of its contribution being borne by the local authority. In fixing the State's contribution it was intended that the loss upon a scheme undertaken by a local authority should, as far as possible, be borne equally by the State and the local authority, but the loss seems to have been under-estimated and in most cases the larger share falls upon the local authorities. The Government's proposals were embodied in the Housing, etc., Act, 1923. Primarily the Act aims at encouraging the building of houses by private enterprise, and before municipal effort can qualify for the State grant the Minister of Health must be satisfied that the needs of the district can more appropriately be met by the local authority itself. The State contribution is a sum of £6 a house for 20 years payable annually to the local authority. Such houses must be completed before 1st October, 1925, but this period may be extended to 1st June, 1926. The local authority, for the purpose of encouraging the provision of houses by private enterprise, may grant assistance by either lump sum payments or annual grants, supplementing the State contribution to such extent as it may deem desirable with the approval of the Minister. The object of the Act is to assist in the construction of houses mostly in demand for occupation by the working classes, and, except in special cases to be determined by the Minister, houses must be either (a) a two-storied house with a minimum of 620 and a maximum of 950 superficial feet, or (6) a structurally separate and selfcontained flat or a one-storied house with a minimum of 550 and a maximum of 880 superficial feet. Each house or flat must be provided with a fixed bath. The Council, on 31st July, 1923, approved a scheme for the administration of the subsidy provisions of the Act. Under this scheme a purchaser of an approved new house for his own occupation (including any person employing a builder to erect a house in which he intends to reside), provided that he satisfies the Council, after due consideration of his financial resources, as to the need for a grant, is eligible to receive from the Council a grant equivalent to £6 a year for 20 years, or a lump sum of £75, subject to the Council's approval of the price to be paid. The present situation calls for the production of houses which may be rented for occupation, and the Council has decided to make money grants as follows in respect of approved houses and flats erected and maintained for letting for residential purposes at inclusive weekly rents fixed by comparison with the rents of existing houses in the same neighbourhood :— (a) For a house with not more than two bedrooms, with or without a parlour, a grant of £9 a year for 20 years. (b) For a house with more than two bedrooms, a grant of £8 a year for 20 years. 133 As an incentive to the production of houses in large numbers, an addition of 5 per cent. is made to the grant in respect of each house in excess of 100 provided by one agency making it £9 9s. or £8 8s., as the case may be, and a further addition of 5 per cent. making it £9 18s. or £8 16s., in all, is made in respect of each house over 300 so provided. Up to 31st December, 1923, the Council had approved proposals submitted by private builders for the erection of 495 houses to qualify for subsidy on completion. The State contribution in respect of a house provided by a metropolitan borough council is supplemented by the Council to the extent of one-half of the annual loss over and above the amount of such contribution up to a sum not exceeding £3 a year for 20 years. Where sites are available on the Council's estates, the Council is prepared to lease to builders plots of lands with sewers and roads constructed at an agreed ground rent so fixed as to give the lessee credit for the subsidy for which the house to be erected may be eligible. The Act enables a local authority to grant certain relief from rates in houses converted into two or more self-contained flats, but, in view of the complications in the application of this provision to London, the Council has decided to take no action thereon. During 1923 the Council decided, with the approval of the Minister, to erect upwards of 4,000 houses on its own estates to qualify for the State grant under the Act. Particulars are given later. Unhealthy areas. The Act empowers the Minister to contribute towards the expenses incurred by local authorities in carrying out improvement schemes under Parts I. and II. of the Housing Act of 1890, such contributions being limited to one half of the estimated average annual loss. A figure of £200,000 a year for the whole country has been mentioned by the Minister as the amount which might be contributed by the State, and of this sum it is proposed to allocate £50,000 to London. A comprehensive programme of slum clearance is being prepared by the Council and several schemes have been made, some of which have been confirmed by the Minister. Particulars are given later (see pp. 136-8). White Hart lane estate. Details of the Council's housing operations during the year are as follows :— The development of about 56 acres of the White Hart-lane estate under the State assisted (1919) scheme was completed during the year. The 710 houses and flats on this section, which were built by Messrs. Fred and T. Thorne under a contract on a cost plus participating profit basis, comprise 143 of five rooms, 279 of four rooms, 248 of three rooms, and 40 of two rooms. The Council has prepared a scheme for the development of a small vacant site of about 1 acre on the west side of the new arterial road through the estate. The erection of 17 four-roomed houses to qualify for the State subsidy under the Act of 1923 is proposed and the total expenditure, including cost of buildings, roads, sewers and land is estimated at £10,118. A scheme for the erection of nine shops with flats over on the Lordship-lane frontage is also being prepared. A site in Lordship-lane has been let on building lease for the erection of a shop. Roehampton estate. Roehampton estate was acquired in 1919, and an area of about 93 acres has been allocated for the erection of working-class dwellings. The roads and sewers on the whole estate have been constructed and the development of the first section has been completed by the erection of 624 houses. A contract for 168 houses on the second section is being carried out and 36 of the houses had been completed at the end of 1923. This contract has been taken over by the Unit Construction Company, Ltd., who have undertaken to carry out the work at the prices contained in the original contract. The Minister of Health has approved the erection of 375 additional houses to complete the development of the estate under the Assisted (1919) scheme, and tenders for the major portion of the work were invited during the year. The Minister was not, however, prepared to allow the Council to accept any of the tenders received and the work has been postponed for the present. 134 The weekly net rents for the 168 houses on the second section have been fixed as follows : Three rooms, scullery and bathroom, l1s. 6d. and 12s.; four rooms, scullery and bathroom, non-parlour type, 12s. 6d. and 13s., parlour type, 13s. 6d. The site of Dover House with adjacent land, comprising in all about 39½ acres, was let during the year to Wm. Willett, Limited, on building lease, at a rent of £2,040 a year. The Company, having demolished the mansion and outbuildings, proposes to erect one-story buildings known as the " Willett country flat." An elementary school has been erected on the estate and a site of about 9 acres has been allocated as a playing field in connection with the education service. Becontree. At Becontree 2,891 houses have been completed on a section known as the Ilford (No. 1) section, comprising 440 acres. With the approval of the Minister of Health another section, known as the Dagenham (No. 2) section in the south-eastern corner of the estate, comprising 59 acres, is being developed by the erection of 1,002 houses, the whole of the work being charged to the Assisted Scheme under the Act of 1919. During the year 134 houses on this section were completed. The Minister has approved the erection of 1,000 additional houses on the Dagenham section and 1,000 houses on land adjacent to the Ilford (No. 1) section to rank for subsidy under the Housing, etc., Act, 1923. These sections are known as the Dagenham (No. 3) and the Valence (No. 4) sections, and work on the former was commenced towards the end of 1923. Capital estimates amounting to £1,000,000 for the development of these two sections were approved by the Council on 31st July and 13th November, 1923. Rents on the Dagenham (No. 2) section have been based on those fixed for the Ilford (No. 1) section. To meet the need for economy, the new houses are being constructed of a modified type, with fewer amenities than those on the Ilford section, and the rents are consequently lower. The weekly net rents subject to suitable variations on account of position or other special amenities, are as follows : Houses— Five rooms, scullery and bath, 12s. 6d. ; four rooms (parlour type), scullery and bath, l1s. 6d.; four rooms (non-parlour type), scullery and bath, 10s. 6d.; three rooms, scullery and bath, 9s. 6d.: Flats—Three rooms, scullery and bath (first floor), 9s. ; three rooms, scullery and bath (ground floor), 8s. 6d. ; two rooms, scullery and bath (first floor), 8s.; two rooms, scullery and bath (ground floor), 7s. 6d. On 19th June, 1923, the Council decided to enter into an agreement with the Gas Light and Coke Company for the supply of gas for fighting, cooking and heating on this section, the company laying the mains and service pipes, carcassing the houses and providing all necessary fittings in consideration of a payment of £5 17s. 6d. for each dwelling. Ripple-road along the southern boundary of the estate, which is part of the main arterial road to Southend, has been widened to 80 feet and the Council has surrendered about 10½ acres of land for the purpose. During the year the Council agreed to surrender some strips of land about 4 acres in extent and such rights as it might possess in other strips comprising some 2½ acres for the widening of Longbridge-road in the urban districts of Ilford and Barking Town, the local authorities undertaking to bear any tenants' compensation and the cost of fencing. As part of the arrangement the Council was permitted to incorporate in its building sites some land lying between the line of the hedge bordering the original road and the boundary line of the new road. Land measuring about 800 square yards has also been surrendered on similar terms for the widening of Goodmayes-lane. During 1923 the Council sold two sites for the erection of churches (Wesleyan Methodist and Roman Catholic) and another site on the Ilford section to the Essex County Council for an elementary school. Other sites have been let on building leases for 99 years for the erection of shops and on 12th June, 1923, the Council accepted the tender amounting to £3,300 of Hammond and Miles, Limited, for the erection of five shops on the Ilford section. Arrangements are being made for the erection of further shops for letting. A site of about 2½ acres on the Ilford section 135 has been let on building lease for the erection of a social club and hall; land has been let for a temporary post office; and an arrangement has been entered into with the Postmaster-General for the placing of a number of telephone kiosks on the estate. On 12th June, 1923, H.M. the King accompanied by H.M. the Queen visited the estate. Their Majesties inspected the Ilford section and viewed several of the houses and subsequently visited the undeveloped portion of the estate. In commemoration of the visit their Majesties each planted a tree in the garden at the corner of Bushgrove-road and Groveway. The licences in respect of four beerhouses have been retained and the Council has decided that the ultimate system of control should be based on management by a company or association whose servants would not have any pecuniary interest in encouraging the sale of alcoholic liquors, but that provision should be made for the general entertainment and refreshment of the population. One of the houses is in a dilapidated condition and endeavours are being made to lease a site on the estate for the erection of a new refreshment house to which the licence in respect of the old house might be transferred. Bellingham. The development of Bellingham (176½ acres) was completed during the year, the whole of the work having been carried out by Sir Robert McAlpine and Sons, under a contract on a cost plus participating profit basis. The accommodation consists of 402 houses of five rooms, 1,211 of four rooms, 188 of three rooms, 156 three-roomed flats and 132 two-roomed flats, making a total of 2,089 lettings. Each house and flat in addition to the accommodation mentioned, has a scullery and a bathroom. About 52 acres have been reserved for the erection of other than workingclass dwellings. On 6th June, 1923, the Council sanctioned expenditure of £427 10s. towards the cost of the making up Brookhowse-road, while on 31st July, 1923, the Council agreed to contribute one-fourth, not exceeding £250, of the cost of constructing a foot-bridge to take the place of the level crossing over the Mid-Kent branch of the Southern Railway. During 1923 the Council leased to the Church of England authorities and the London Congregational Union respectively two plots of land adjoining the sites sold to them for the erection of churches. A tenancy of a piece of land was also granted to the Tenants' Association for use as a lawn tennis ground, the Council preparing the ground at a cost not exceeding £100. Several additional sites on the estate were let during the year on building lease for 99 years for the erection of shops. Downham. The Council has acquired under compulsory powers about 470 acres of land at Grove-park, Lewisham, for development for housing purposes. It was always intended to acquire additional land for rounding off the site and for giving access to main roads, and on 16th October, 1923, the Council made a new order for the compulsory purchase of about 66½ acres. In order to secure a satisfactory scheme of development, it is necessary for the Council to have powers over this land. The name of Downham which has been selected for the estate commemorates the title of the late Lord Downham, a former chairman of the Council, who, as President of the Local Government Board, initiated the Government's post-war housing policy. It is proposed in the first instance to develop about 183 acres at the southwestern or Bromley-road end of the estate, and the Minister of Health has approved of the erection of 2,000 houses to rank for the State subsidy under the Housing, etc., Act, 1923. On 31st July, 1923, the Council approved a capital estimate of £300,000 in respect of the work. Provision will be made for schools, shops, public buildings, etc. In order to qualify for the subsidy the houses must be finished before 1st October, 1925, and the Council came to the conclusion that the only practicable course to ensure the provision of the requisite number of houses within the time limit was to entrust the whole work of development to one large firm of contractors possessing 186 adequate powers of organisation and the necessary resources, as it was only by so doing that the financial and time-saving advantages accruing from railway connections across the estate could be fully secured. Towards the end of 1923 alternative tenders for the work were invited by advertisement, the tender in the one case to be on a firm price basis and in the other on the basis of cost price with a varying fee or commission. The tenders were due to be received early in 1924. Tabardstreet, etc. scheme. The Tabard-street and Grotto-place, Southwark, and Crosby-row, Bermondsey, 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 Tabardstreet area for not fewer than 2,580 persons. The reconstructed area is known as the Tabard Garden estate. Chaucer, Becket, Geoffrey and Harbledown Houses with accommodation for 1,650 persons were completed between 1916 and 1922 ; Rochester House, containing 42 tenements with accommodation for 260 persons in May, 1923; and Huberd House, containing 38 tenements with accommodation for 214 persons in October, 1923. Tenders for the erection of Tabard House to contain 42 tenements with accommodation for 256 persons were invited towards the end of 1923. Three shops with flats over and four workshops are to be erected on land adjoining Chaucer House, the work being undertaken early in 1924. The Southwark Metropolitan Borough Council has undertaken, at an estimated cost of £1,920, to complete the widening of Pardoner-street and to construct another short length of the new road named Manciple-street, the work, however, to be paid for on the basis of actual cost. Six perambulator or bicycle sheds to be let at 6d. a week each have been constructed in the courtyard of Huberd House at an estimated cost of £70. The weekly net rents for accommodation in Rochester House and Huberd House, have been fixed as follows : Two rooms, 10s. 6d. and l1s.; three rooms, 13s. to 14s. 6d. ; four rooms, 15s. 6d. and 16s. ; five rooms, 18s., with slight variations on account of position or other special amenities. The centre of the estate will be laid out as a public garden, about 5 acres in extent, but much of the site is still covered with houses of which it is difficult to obtain possession on account of the shortage of accommodation. A portion has been made available as a temporary playground for children and arrangements are being made for the permanent lay-out of the first section comprising about 1 acre. Brady street scheme. On 1st February, 1922, the Minister of Health confirmed with certain modifications the scheme made by the Council under Part II. of the Housing Act, 1890, for dealing with the Brady-street area, Bethnal Green (7 acres) at an estimated cost of £101,000, excluding the cost of new dwellings. About 1,875 persons of the working classes will be displaced and the confirming order requires the provision of accommodation for 1,600 persons on the cleared site and for 265 persons elsewhere. A site at Goldsmith's-row, Shoreditch, has been appropriated for the purpose and a block of dwellings known as Whiston House, containing 12 tenements with accommodation for 90 persons erected thereon. An exchange of lands was agreed with Mann, Crossman and Paulin, Ltd., by which an outlying part of the area adjoining their premises was to be retained by or transferred to them, and they undertook to provide at Walthamstow accommodation for at least 175 persons, which is the number of those to be displaced from that part. Plans were submitted to the Council and approved in October, 1923, for 36 cottages, comprising 10 with two bedrooms, living room and parlour and 26 with one additional bedroom, and the building work was commenced before the end of the year. The reconstructed arc. will be known as the Collingwood estate, and the first block of dwellings therein known as Bullen House, containing 45 tenements with accommodation for 274 persons, was completed in September, 1923. The net rents are : Two-roomed flats, 9s. and 9s. 6d.; three-roomed flats, *See Annual .Reports for 1915-19 (vol. III., p. 116), and 1920 (vol. III., p. 128). 137 l1s. and l1s. 6d. ; four-roomed flats, 13s. and 13s. 6d., with slight variations on account of position or amenities. Electric light has been installed by the Bethnal Green Metropolitan Borough Council in the tenements and on the staircases, and a gas installation for cooking and heating has been supplied by the gas company in consideration of a payment by the Council of £3 a tenement. The site for the second block of dwellings (Pellew House) to accommodate 274 persons has been cleared and tenders for the erection of the building were about to be invited at the end of 1923. Ware-street scheme. The scheme for dealing with the Ware-street area, Hoxton (9¼ acres), under Part 1. of the Housing Act, 1890, was confirmed with modifications by the Minister of Health on 20th June, 1922. The cost of acquisition and clearance is estimated at £93,500. About 2,648 persons of the working classes will be displaced and accommodation has to be provided for that number, of which not fewer than 2,160 are to be accommodated within the area. The site of the first block of dwellings, to be known as Archer House, with accommodation for 228 persons, is being acquired. The provision of 72 three-storey cottage flats as rehousing accommodation for 378 persons on the White Hart-lane estate was approved by the Minister of Health, and on 31st July, 1923, the Council accepted the tender of £30,690 by Messrs. Rowley Bros. for the erection of the buildings. Accommodation for 120 persons will still remain to be provided outside the area and this may be met by the allocation of another site on the White Hart-lane estate. For the Ware-street area when reconstructed the name Whitmore estate has been selected. Hickman's Folly scheme. On 23rd May, 1923, the Minister of Health confirmed, subject to modifications, the scheme made by the Council under Part I. of the Housing Act of 1890 for dealing with the Hickman's Folly area of about 6 acres, comprising 226 dwelling houses in addition to some business premises. About 1,645 persons of the working classes will be displaced, and the order requires the provision of accommodation for 1,660 persons, of whom not fewer than 1,000 are to be accommodated in the area. The cost, excluding the cost of erecting the new dwellings, is estimated at £93,500. Negotiations are proceeding for the acquisition of the property, and proposals for the lav-out of the area and the provision of new dwellings are being considered. Bell-lane and Ellen-street scheme. On 8th November, 1923, the Minister of Health confirmed, with modifications, the scheme made by the Council under Part I. of the Housing Act of 1890 for dealing with the Bell-lane area, Spitalfields (4 acres), and the Ellen-street area, St. Georgein-the-East (1½ acres). The scheme provides that dwellings for the accommodation of 1,705 persons of the working classes shall be provided, of whom not fewer than 600 shall be accommodated in the Bell-lane area, and the remainder elsewhere. Questions arising out of the confirming order are being considered. Prusom- street scheme. On 27th February, 1923, the Council made a scheme under Part I. of the Housing Act of 1890, for dealing with the Prusom-street area in Wapping. The area, which is about 10¼ acres in extent, comprises 326 dwelling houses, occupied by about 2,704 persons of the working classes. It also includes various buildings used as workshops and stables, the Congregational chapel fronting Old Gravel-lane and the large building known as the casual wards in Raymond-street. The sites of certain properties already demolished also come within the area. Speaking generally, the streets are narrow and the houses old and badly arranged, with dampness apparent in most of them. The Council is satisfied that the condition of the area generally is such that nothing short of clearance and reconstruction can afford an effective remedy for the evils existing. Owing to the surroundings, as well as the shape and extent of the cleared sites, a large part of the northern end of the area is not considered suitable for the provision of housing accommodation, and the scheme, if confirmed, would permit of this being disposed of for commercial purposes. On the bulk of the remainder of the area it is proposed to provide accommodation for 2,030 persons. The remaining 674 persons will be provided for elsewhere, pre- 138 ferably on the Council's estates at Becontree or in the south-eastern district, which are accessible by means of the underground railways. The estimated gross capital cost of the scheme, exclusive of the cost of the new dwellings, is £70,000, but, after taking credit for the surplus lands available for disposal, together with the value of the sites proposed to be utilised for housing purposes, the capital cost is reduced to £24,000. Application was made to the Minister of Health for confirmation of the scheme, and a local inquiry was held on 27th November, 1923. The Minister's decision is now awaited, and, in order that no time may be lost in carrying the scheme into effect as and when confirmed, plans for the first block of new dwellings are being prepared. George'sroad and Brand-street scheme. An official representation, under Part I. of the Housing Act of 1890, having been made with reference to two unhealthy areas known as the George's-road and Brand-street areas, Holloway, the Council, being of opinion that the evils existing in the areas could only be effectively remedied by means of an improvement scheme under the Act, decided, on 27th November, 1923, to make such a scheme, and to submit it to the Minister of Health for confirmation. The George's-road area, of about 2 acres, comprises two groups of houses, 113 in number, and containing a population of about 754. The Brand-street area, which adjoins the Northern Polytechnic Institute, slightly exceeds one acre in extent, and comprises 75 small houses with a population of about 412 persons. Some of it will probably be absorbed for educational purposes. Altogether, 1,166 persons of the working classes will be displaced, and it is proposed to provide accommodation for an equal number of persons of whom about 900 will be accommodated on the cleared areas. In order to provide a suitable site for the erection of the dwellings on the George's-road area, it will be necessary to close James-street, and to acquire a small factory at the end of the street. The estimated cost of acquisition and clearance amounts to £34,500 gross, exclusive of the cost of erecting the new dwellings. As St. Mary's recreation ground, maintained by the Islington Metropolitan Borough Council, is only about a quarter of a mile distant, the proposed lay-out does not make any provision for recreation space other than that which will be provided by the courtyards of the dwellings. The scheme involves the displacement of a number of costermongers, and it is proposed, therefore, to provide a site upon which sheds for the storage of barrows can be erected, if required. East-hill estate. In order to facilitate the clearance of unhealthy areas in London, under Part I. or Part II. of the Housing Act of 1890, the Council considers it imperative that advantage should be taken of opportunities for acquiring sites for the erection of tenement dwellings which can be regarded as part of the rehousing accommodation to be provided under approved schemes. By this means the clearance and reconstruction of condemned areas can be considerably expedited to the public benefit Some difficulty is experienced in finding sites which can be secured at a satisfactory price for housing development, but during 1923 the attention of the Council was directed to the St. Peter's Hospital site, otherwise known as the Fishmongers' Almshouses, in East-hill, Wandsworth, which was for sale. The area of the site is 8 acres, and dwellings with accommodation for over 3,200 persons can be provided on the site. The site has a frontage of about 420 feet to East-hill and has a depth of about 1,000 feet towards the Southern Railway (South Western section). It is within easy distance of Clapham Junction and Wandsworth Town stations and East-hill is a tramway and omnibus route. Wandsworth Common is only about 130 yards distant. The Council considered that the site was eminently suitable for housing purposes, and the Council decided accordingly on 10th July, 1923, to acquire it at a cost not exceeding £20,500. The scheme will fall within the financial arrangement contemplated in section 1 (3) of the Housing, etc., Act, 1923, whereby the State contributes one-half of the estimated average annual loss arising out of the scheme, such sum being met out of the annual sum of at least £50,000 a year 139 marked for London in respect of schemes under Part I. or Part II. of the Housing Act, 1890. (See p. 133). The preparation of plans and other preliminary work in connection with the construction of roads and sewers and the erection of dwellings is being proceeded with, the Council having on 24th July, 1923, voted a sum of £4,000 for the purpose. The site when developed will be known as the East-hill estate. Bents. During 1923 the Council reviewed the general question of the rents charged for its dwellings whether provided in fulfilment of re-housing obligations or otherwise before or after the war. The Council's dwellings compared not unfavourably in the matter of rent with accommodation provided by other agencies, and it did not appear to the Council that the net rents as a whole should be revised at that time. The Council thought it right, however, to make an exception in the case of Becontree on account of the unfinished state of its development and the consequent effect on the value of the amenities, and on 31st July, 1923, decided that an abatement of 1s. should be made in the weekly net rent of each 6-roomed house and an abatement of 6d. a week in that of each of the remaining houses on the Ilford (No. 1) section of the estate. This alteration represents a reduction of £3,954 a year in the total net rent receivable. Selection of tenants. In view of the acute housing shortage the Council, on 26th June, 1923, decided that, until further order, preference in the letting of accommodation on its several estates should be given to British subjects, and also for the present as a general rule to confine the registration of applicants for houses to persons residing in London. Electric light. During 1923 the Council entered into an arrangement with the St. Pancras Metropolitan Borough Council to instal electricity in the dwellings on the Churchway estate, free of cost to the Council, and the Council also agreed to the installation of electric light in houses on the Totterdown Fields estate, Tooting, where desired by the tenants, subject to the payment of an additional rent proportionate to the expenditure involved. Workmen's trains, etc. The Council's action in the earlier years with regard to workmen's trains at cheap fares was dealt with in the Annual Report for 1920 (vol. I., p. 77). During 1923 the Council considered what steps it should take to secure that the standard rates and charges to be fixed by the Railway Rates Tribunal should provide for substantial reductions in the present workmen's and third-class fares. In view of the importance of cheap travelling facilities as a factor in the solution of the housing problem, the Council, as a housing authority, is concerned in securing for the working classes the lowest rates which the railway companies can reasonably be asked to afford. On this principle, the Council decided on 6th February, 1923, to make the strongest possible representations to the Rates Tribunal. As a result of the Council's action the Tribunal found in favour of standard schedules of charges for both season and workmen's tickets. Forms of schedules submitted by the companies were considered by the Tribunal on 29th-31st May, 1923. As regards workmen's fares, the companies proposed to divide each of the first four miles of the journey into thirds and, in cases in which the single journey exceeded four miles, to charge for the first four miles at some fixed figure and a flat rate for each additional half-mile or part thereof. On behalf of the Council objection was taken to the whole of the form of schedule and a suggestion was put forward for the division of the mileage into zones and for the work men's fare between two points to be fixed on some percentage of the ordinary third class single fare, the percentages to decrease with increase of mileage. As regards season tickets, the companies' form of schedule provided for 1st, 2nd and 3rd class tickets being issued for periods of one, three, six and twelve months, the charge to be determined later for each mile, fractions of under half a mile to be dropped and a fraction of half a mile or over to be charged as one mile. Generally the Council did not disapprove of this form of schedule. The Tribunal was attracted by the Council's argument as to helping the solution of the housing difficulty and intimated that it would therefore alter the companies' 140 schedule for distances beyond four miles to provide for a zoning of mileage. As regards distances up to four miles the Tribunal approved the form but pointed out that it was not bound to give different monetary values to each break of a third of a mile. The general effect is to leave the schedule in such a form as to enable the Tribunal to consider the Council's suggestions when the companies' proposals as to the amounts of the standard fares are submitted. CHAPTER XXVIII. ACCOUNTS AND STATISTICS. Memorandum by the Comptroller of the Council (Mr. C. D. Johnson) relating to the Housing Accounts for the Year 1923-24. These accounts are prepared in advance of the Annual Accounts of the Council for the year ending 31st March, 1924. In order that they may be ready for presentation to the Council by the time appointed, 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 1923 (Clearance of unhealthy areas and rehousing under Parts I. and II., and housing under Part III. of the Act of 1890), and of rehousing under various Street Improvement, etc., Acts. They are divided into three main sections, distinguishing primarily between the schemes carried out by the Council prior to the Act of 1919, which are designated Non-assisted Schemes, and the Assisted Schemes under the Acts of 1919 and 1923, respectively. Each section is further sub-divided between clearance schemes and dwellings. The "Clearance Schemes "sub-sections of the accounts cover only the acquisition and clearance of unhealthy areas. The "Working-class dwellings" sub-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 sites 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 sites. The difference in treatment is necessary in order to set out clearly the financial results of the Council's management of the dwellings as such, i.e., apart from other considerations, dwelling under Parts I. and II. of the Act and under Improvement Acts representing compulsory provision for rehousing on sites which may be unsuitable from a commercial point of view, whereas the Council's action under Part III. (until the passing of the 1919 Act) was voluntary. A.—Non-Assisted Schemes. This section comprises the accounts of schemes carried out by the Council without financial assistance from the State. With one exception (Calverley House, provided to rehouse persons displaced from property acquired by Education Committee for a school site), the whole of the non-assisted dwellings were erected prior to the enactment of the Housing, Town Planning, etc., Act, 1919. The section includes all schemes, whether for a clearance of unhealthy areas or for the erection of dwellings and, as regards the latter, whether they have been erected under the provisions of the Housing Acts, or to provide the rehousing accommodation required by Acts authorising street improvements and other works. 141 Clearance schemes.—In the year 1923-24, the deficiency on clearance schemes, mainly debt charges on the capital cost of acquiring and clearing the sites, establishment charges, and items in connection with surplus property, is £46,687 8s. 7d., and this sum has been charged to the Special County Kate Account. Working-class dwellings.—The results of the year s working compared with those of the previous year are as follows :— Dwellings—- 1923-24. 1922-23. Housing of the Working Classes Act. 1890— £ s. d. £ s. d. Parts I. and II. Surplus 20,292 11 2 Surplus 13,972 16 7 Part III Surplus 18,592 6 7 Surplus 13,787 3 9 Total—Housing Act Surplus 38,884 17 9 Surplus 27,760 - 4 Improvements Acts Surplus 13,505 11 2 Surplus 9,015 13 8 Total—Non-assisted Schemes Surplus 52,390 8 11 Surplus 36,775 14 - The surplus (£38,884 17s. 9d.) for 1923-24 on the dwellings erected under the Housing Act, together with the corresponding surplus for the year 1922-23 (£27,760 0s. 4d.), which was held in reserve, together amount to £66,644 18s. 1d. Of this sum £3,655 10s. 11d. is applied to meet the deficiency for the year 1923-24 in respect of dwellings in course of erection under the Assisted (1923) Scheme, the balance (£62,989 7s. 2d.) being carried forward as a reserve towards meeting the deficiencies which will arise on future housing operations of the Council under the Act of 1923. The net surplus for the year on dwellings erected under Improvements, etc., Acts is £13,505 l1s. 2d., of which £13,475 12s. 8d. is due to the General County Account and £29 18s. 6d. to the Tramways Account (rehousing in connection with Greenwich Power Station). The total net financial result on "non-assisted" dwellings and estates taken as a whole from April, 1894 (the date of the opening of the first block), to 31st March, 1924, is a surplus of £106,984 5s. l1d. £1,197 6s. 8d. has been contributed from Tramways Account in respect of certain rehousing obligations in connection with the Greenwich Power Station, £41,536 14s. 6d. has been transferred in relief of rates, £3,655 10s. l1d. has been applied in meeting deficiencies on the Assisted (1923), Scheme, and £62,989 7s. 2d. is held in reserve, as stated above. B.—Assisted Scheme—Housing, Etc., Act, 1919. 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 deficiency (as approved by the Minister of Health) on the Housing (Assisted Scheme) Account in excess of the produce of a penny rate is met out of moneys voted by Parliament. The results for the year 1923-24, compared with those for the previous year, are as follows:— 1923-24. 1922-23. £ s. d. £ s. d. 1. Clearance schemes Deficiency 4,358 19 6 Deficiency 2,758 3 4 2. Working-class dwellings Deficiency 408,057 12 2 Deficiency 402,355 9 7 3. Housing schemes of metropolitan borough councils (including central offices charges) Deficiency 254,546 1 3 Deficiency 240,914 1 10 4. Local bonds (for housing) Deficiency 34,448 17 11 Deficiency 42,488 6 10 Total deficiency 701,411 10 10 688,516 1 7 10976 K 142 The total deficiency is provided for as follows: Chargeable to Special County Account— £ s. d. £ s. d. Produce of a special county rate of one penny in the £ £175,365 14 6 Less—Adjustment in respect of year 1920-21 etc. [infra) 7,551 14 7 167,813 19 11 173,992 — _ Exchequer subsidy:— Loss on Assisted (1919) Scheme in excess of the produce of a penny rate (subject to approval of Ministry of Health) 526,045 16 4 Add—Adjustment (supra) 7,551 14 7 533,597 10 11 514,524 1 7 701,411 10 10 688,516 1 7 The liability of the Ministry under the Act of 1919 is limited to the " loss " as defined in the regulations and as approved by the Minister. Should any part of the deficiency not be approved, the difference becomes an additional charge on the county rate. The adjustment shown above arises chiefly from the fact that the debt charges brought to account in 1920-21, based on estimates, were revised when precise information was available as to the actual amount of the 1920 issue of Stock and Bonds to be appropriated for this account. The resulting credit, although appearing in the accounts of a later year, belonged to 1920-21, in which year the loss, being less than the amount of a penny rate, fell entirely on the Council. The Ministry have agreed that, in the circumstances, the Council alone is entitled to the benefit of the credit, and the adjustment is made accordingly. As regards the largest head of deficiency (working-class dwellings), it will be seen from the detailed statement that a considerable part of the deficiency (£88,328 17s. 7d.) 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, and, in the end, the total capital expenditure on land and development is entirely absorbed in the cost of the dwellings. 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 thus show the financial results of the assisted scheme for the County of London as a whole. A sum of £254,546 1s. 3d. is provisionally included to cover the borough councils' losses for the year 1923-24 as compared with £240,914 1s. l0d. for the year 1922-23. The amount is subject to revision, but the county rate wall not be affected by any variation because the Council's liability on the assisted scheme as a whole is limited to the amount of a penny rate. Local Bonds (for housing).—The issue of these Bonds ceased on 30th July, 1921, the total amount raised to that date being £3,955,605. Deducting £106,373 6s. 2d. for expenses of issue, the net amount raised was £3,849,231 13s. lOd. £3,847,868 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 143 the same as that payable by the Council on the face value of the Bonds, viz., 6 per cent., and the instalments in repayment of the expenses of issue and the annual cost of management, etc., fall wholly on the assisted scheme account. In addition, the Assisted Scheme bears the large (and growing) deficiency of interest due to the investment of amounts repaid by borough councils not producing as much as the 6 per cent. payable on the Bonds. C.—Assisted Scheme—Housing, Etc., Act, 1923. This section covers the expenditure and income arising from (a) clearance schemes and the consequent rehousing, any deficiency being subject to State subsidy of 50 per cent., and (6) various schemes and operations for providing additional housing accommodation, under the conditions prescribed in the Act. In addition to the accounts relating to dwellings erected by the Council itself under the provisions as to subsidy of the Act of 1923, the section covers also the assistance given by the Council to metropolitan borough councils in the form of grant, and to private enterprise, either by grant or in the form of loans and guarantees under section 5 of the Act. Although considerable commitments have been entered into by the Council at 31st March, 1924, the accounts this year show little more than preliminary expenses, the net deficiency under all heads being £7,107 18s. 7d., as follows Schemes undertaken by the Council- £ s. d Clearance Bchemcs Deficiency 1,785 16 9 Working-class dwellings- Part I Deficiency 623 10 — Part III Deficiency 2,409 6 9 3,655 10 11 Schemes undertaken by private enterprise— Debt charges (interest accrued) on capital grants, and sundry expenses Deficiency 916 12 7 Loans under Section 5 of the Act—Expenses (net) Deficiency 126 8 4 7,107 18 7 This is provided as follows :— Exchequer subsidy— 50 per cent. of deficiency on clearance schemes and dwellings for rehousing persons displaced (£2,409 6s. 9d.) 1,204 13 5 Balance falling on the Council £ s. d. Dwellings (Part III)—Met out of surplus on nonassisted dwellings 3,655 10 11 [Note.—a grant at the rate of £6 a house will be receivable when the dwelling, are completed, and only the balance of loss will then fall on the Council.] Chargeable to Special County Rate Account 2,247 14 3 5,903 5 2 Total deficiency 7,107 18 7 Net Deficiency, 1923-24—How Met. The financial results for the year under the several sections and sub-sections may be epitomised as follows:— £ s. d. £ s. d. Total expenditure 1,669,513 — 9 Total income 966,696 11 8 Net deficiency 702,816 9 1 10976 k* 144 This is borne as follows— Exchequer subsidy— £ s. d. £ 8. d. Assisted scheme, Act of 1919 533,597 10 11 Assisted scheme, Act of 1923 1,204 13 5 534,802 4 4 Special County Rate Account— Non-assisted (pre-war) clearance schemes 46,687 8 7 Assisted scheme, Act of 1919 167,813 19 11 Assisted scheme, Act of 1923 .. 2,247 11 3 216,749 2 9 751,551 7 1 Less—Surplus on non-assisted (pre-war) housing schemes— £ s. d. Carried to General County Account 13,475 12 8 Carried to Tramways Account 29 18 6 Reserved to meet deficiencies on operations under Act of 1923 38,884 17 9 .Deduct—Amount applied to meet deficiency in 1923-24 3,655 10 11 35,229 6 10 48,734 18 - 702,816 9 1 The net amount actually charged on rate accounts for the year is thus £216,749 2s. 9d. less £13,475 12s. 8d., or £203,273 10s. 1d. Repairs and Renewals Funds. The purpose of these funds is to equalise the annual charges for repairs and to provide a surplus in the early years to meet the cost of the more extensive works which may be anticipated in subsequent years. The annual transfers to the fund from the revenue account of the non-assisted schemes are based on definite estimates of the dates and intervals at which particular kinds of repairs and renewals will fall to be undertaken. As regards dwellings erected under the Assisted (1919) Scheme, the charge to the revenue account has been limited by the Minister of Health to an amount equal to 15 per cent, on the rental. The regulation on the point is due for review in 1925. Meanwhile, representations have been made to the Minister as to the inadequacy of the allowance. Capital Expenditure and Debt. The total capital expenditure in respect of housing up to 31st March, 1924, amounts to £15,499,566 6s. 11d., as follows— Non-assisted schemes. Assisted (1919) schemes. Assisted (1923) schemes. £ s. d. £ s. d. £ s. d. Clearance schemes 2,734,733 13 11 12,464 8 9 640 12 10 Erection of dwellings 3,031,138 6 6 9,543,432 15 8 165,211 9 3 Grants to builders and others, and loans under Section 5 of the Act of 1923 — — 11,945 _ 5,765,872 - 5 9,555,897 4 5 177,797 2 1 Net debt outstanding 3,432,235 6 2 (a)10,701,538 1 4 177,729 2 - (a) Including £1,316,290 11s. 8d. balance outstanding of deferred charges (expenses of issue, including discount) in respect of Local Bonds for Housing and London County Stocks and Bonds. With the exception of the Non-Assisted Clearance Schemes, the debt in respect of which is provided for on the instalment system, provision for redemption is made on the cumulative annuity system. This system has always been followed for the Council's dwellings, and it is the one prescribed for subsidy purposes (Assisted Schemes) by the Ministry of Health. 145 Housing Estates—Memorandum by the Valuer (Mr. Frank Hunt, C.V.O.). Extension of Council's Housing Activities. As has been the case in each year since the war the volume of work connected with the administration of the Council's dwellings has during 1923-24 shown a continuous increase. This is the natural consequence of the extension of the Council's housing activities caused by the housing legislation passed in recent years. At the end of March, 1923, 7,189 dwellings had been erected under the provisions of the Housing, Town Planning, etc., Act, 1919, and during the year ended 31st March, 1924, 857 additional dwellings were provided, making a total of 8,046 postwar dwellings. Schemes under which nearly 6,000 additional dwellings will be provided at Becontree, Roehampton, Downham (Grove Park), East-hill-estate, Wandsworth, the White Hart-lane estate, the Collingwood estate, Bethnal-green, and the Tabard-garden estate, Southwark, had also been approved. The pre-war dwellings numbered 9,985, so that the actual number of dwellings in charge at the end of the year was 18,031, or nearly double the number before the war. The management of these dwellings, entailing, as it does, in addition to the normal work of management such as the collection of rents and the execution of repairs, the handling of a great number of applications for tenancies, the investigation of the circumstances of the applicants, the rationing of accommodation according to the applicants' needs, and the numerous other questions inevitably arising in connection with the management of new estates developed to meet special needs, has been out of all proportion to that associated with the management of an equal number of pre-war dwellings. There has also been a great amount of preliminary work in connection with the development of projected new estates. Demand for accommodation. There has been no abatement of the great demand for accommodation on the Council's estates. Apart from the large number of applications which had previously been received, 10,151 applications were received during 1920-21, and 10,036 during 1921-22, although, in the main, it had been found necessary to close the waiting lists as early as 1920. During 1923-24, 4,350 applicants were registered for certain types of cottages, although it had been necessary, except in the case of Becontree, to close the waiting lists, and a great many applicants had to be informed that their applications could not be entertained. Moreover, as in previous years, a very large number of persons made inquiries, both written and oral, 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. It is undoubtedly the case also that many persons refrain from making inquiries owing to its being well known that the Council cannot, in present circumstances, meet the requirements of the numerous applicants already registered. It is indicative of the situation that the number of persons who called at the central office during the year to apply for houses was over 32,000, an average of 113 a day, while over 31,000 inquiries, an average of 111 a day, were made by letter as to the possibility of obtaining living accommodation on the Council's estates. In the case of Downham, which is in the early stage of development, the names of no fewer than 5,470 prospective applicants had been recorded at the end of the year, and numerous other enquiries as to the possibility of obtaining accommodation on this estate are still being received. Experience has shown, however, that a considerable proportion—approximately a sixth—do not avail themselves of accommodation when it is offered to them; of these about half are unable to pay the rents required, while others have obtained accommodation elsewhere. During the year it was decided, having regard to the large number of applications from persons residing in London, that, except in very special cases, all applications from persons residing outside London, should be held in abeyance. The difficulty of obtaining suitable accommodation is most acute in the cases of persons about to be married, newly-married couples, and persons with families 146 so small as to render them ineligible for accommodation in dwellings other than those of the smallest types. Method of allotting accommodation. Before the war it was the general practice of the Council, upon the receipt of satisfactory references, to accept tenants in the order in which their applications were received. Preference was only 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 London. These preferences still hold good. Since the war the Council has, from time to time, given temporarily further preferences, other circumstances being equal, to persons who gave up their homes in order to join H.M. Forces, or to undertake work of national importance, to firemen required to vacate quarters at fire-stations, and to certain other small classes of people. In order to make the full use of all available accommodation the Council has found it necessary to adopt the following general principles:—(i.) Applicants are to be allotted dwellings not larger than are deemed to be sufficient to meet the reasonable needs of their families, taking into consideration the sex and ages of the children and the bedroom accommodation required ; (ii.) no person residing alone is to be accepted as a tenant; and (iii.) not more than two rooms are to be allotted to a married couple without children or two single women living together. In some cases the circumstances of the applicants, owing to ill-health, overcrowding, the insanitary state of their homes or to other conditions have been such that it has been decided to grant special preference in exceptionally hard cases of this kind. It has been necessary during the year to decline to entertain some applications on the ground that the income of the applicants was inadequate to enable them to pay the rents, although these are less than remunerative and entail heavy expenditure out of public funds. Under the tenancy agreements sub-letting is not allowed, and tenants are not allowed to take lodgers. New dwellings provided daring the year. Of the 857 additional dwellings provided during the year, 596 are situated at Becontree, 64 on the White Hart-lane estate, 72 at Roehampton, 80 on the Tabardgarden estate, and 45 on the Collingwood estate, which is being erected to rehouse persons displaced by the Brady-street clearance scheme. The tenements on the Tabard-garden estate and the Collingwood estate are of the block dwelling type, while all the others are of the cottage or cottage-flat type. On the basis of two persons a room the post-war dwellings occupied at the end of March, 1924, provided accommodation for 61,742 persons. Total accom- modation provided. The pre-war dwellings comprise 6,543 tenements in block dwellings, 3,148 cottages and 294 cottage-flats, providing accommodation for 57,007 persons on the basis of two persons a room. There are also the three lodging-houses (Bruce House, Carrington House, and Parker-street House), with cubicles providing accommodation for 1,878 persons. The pre-war accommodation thus provided was for 58,885 persons. Adding to this figure the accommodation in the post-war dwellings, the Council's dwellings and lodging-houses provided, at the end of March, 1924, accommodation, calculated on the basis of two persons a room, for 120,627 persons. The actual population on that date was approximately 76,000 persons, which is greater than the population of Bath, almost as great as that of Ipswich, and practically the same as that of the metropolitan borough of Finsbury. Rehousing. Owing to war conditions the Council did not during the years 1915-20 carry out any displacements consequent upon street improvement, clearance or education schemes. During the years 1920-23, however, the Council rehoused 521 persons, the majority of whom had been displaced under the Tabard-street clearance scheme, and the remainder under the Brady-street, Bethnal-green, clearance scheme. During 1923-24, 589 persons were rehoused, of whom some had been displaced by the Tabard-street scheme, some by the Brady-street scheme, and some by the Warestreet, Shoreditch, scheme. Of these 589 persons 164 were accommodated on the 147 Tabard-garden estate, 163 on the Collingwood estate, and the remainder on other estates. The total number rehoused up to 31st March, 1924, was 2,866. Transfers. During the year 916 tenants were transferred to other tenements on the Council's estates. These transfers are sometimes to a different estate, owing to the tenant having changed his place of work, and sometimes to a larger or smaller tenement 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. Removaland empties. During the year 882 tenants left, of whom 101 were given notice to quit, either for non-payment of rent, unsatisfactory conduct or some other cause. The remaining 781 gave notice and left to suit their own convenience. Enumeration of tenants and overcrowding The annual enumeration of tenants was taken in March, 1924, and, as in previous years, the enumeration returns were carefully examined in order to detect overcrowding. For this purpose 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 age of five and ten being regarded as half an adult. This year the number of tenements on the pre-war estates not complying with this standard was 270 out of a total of 9,985, while 17 dwellings out of a total of 8,046 on the post-war estates were found to be overcrowded. 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 bylaws made under the Public Health Acts. The overcrowding will be remedied as opportunities occur by transfers to larger tenements. Rent Restrictions Acta. 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 over a complete financial year, is about £66,500. These permitted increases have not been made in respect of property acquired by the Council forming part of slum clearance areas. The periodical revision of rents consequent upon alterations in the rates involves a great amount of work, the calculations affecting about 16,500 tenements with varying rents and rateable values and situated in the areas of nearly thirty different local rating authorities. Outbreaks of fire. There were 37 outbreaks of fire at the estates during the year, the cost of reinstatement being about £110. Vital statistics. The health conditions on all the estates continue to be highly satisfactory, the death-rates on the estates in typical metropolitan boroughs being markedly lower than the borough death-rates. Financial results. Details are given in the memorandum by the comptroller of the Council at the beginning of this chapter of the financial results of the Council's housing schemes up to 31st March, 1924, but it may be apposite to repeat here some of the more important figures. Dealing first with the Non-assisted Schemes, the aggregate capital expenditure on dwellings provided to 31st March, 1924, was £3,031,138. The gross rental (including rates and taxes) for the year was £352,028. From this amount should be deducted the losses arising out of empties and rent irrecoverable. The financial result of the year's working, after providing for interest and sinking fund charges on the capital expenditure, was a surplus of £52,390, as compared with 148 a surplus for the preceding year of £36,776. The interest and sinking fund charges amounted to £115,942, or 32.93 per cent. of the gross rental. Other outgoings amounted to £185,293, or 52.63 per cent. of the gross rental, including £83,073 (23.59 per cent. of the gross rental) for rates and taxes. The balance of the Acquisition of Lands Fund, the difference between totals of debt charges on cash and stock bases and the interest on cash balances have been taken into account in arriving at these results. As regards the 8,046 dwellings erected under the Assisted Schemes, and in occupation during the year, the financial result, after providing for interest and sinking fund charges, was a deficiency of £318,130. This deficiency will be included in the amount recoverable from H.M. Government. The interest and sinking fund charges amounted to £551,226, and the expenditure on other outgoings accounted for (excluding rates and taxes) was £49,538. The amount paid in respect of rates, taxes, etc., was £77,251. Rent irrecoverable. Some tenants left during the year without paying arrears of rent, but the amount thus irrecoverable amounted only to £592, or about .09 per cent. of the total rent. Of the amount irrecoverable £131 or .037 per cent. of the gross rental arose on NonAssisted Schemes, while £461 or .16 per cent., of the gross rental arose on the Assisted Schemes. Empties. The loss by empties during the year was £2,160, or .34 per cent. of the rent as compared with 51 per cent. in 1922-23. This loss was, as usual, mainly due to Carrington House not being fully occupied by lodgers, £1,932 of the total loss being in respect of Carrington House. Excluding this the loss was only £228. Apart from Carrington House these empties were caused almost entirely by dwellings having to be cleaned and repaired in connection with change of tenancy. Repairs. The necessary repairs to the dwellings are carried out by direct employment of labour. The amount so spent in 1913-4 was £23,934. In 1920-21, this expenditure had risen to £68,572, this increase being due to the higher wages, to the heavy rise in the prices of materials, and to the necessity of overtaking the arrears of painting and other work suspended during the war. During 1923-24 the expenditure on Non-Assisted Schemes amounted to £37,560, and to £15,825 on Assisted Schemes. It will be seen that there was relatively a substantial decrease in the expenditure under this head during the year, this being attributable partly to the fall in wages and the cost of materials and partly to arrears of work, caused by the war, having been overtaken in the preceding few years.