Lcc 34. London County Council. ANNUAL REPORT OF THE COUNCIL, 1925. Vol. III. PUBLIC HEALTH. (Including the Reports for the year 1925 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing.) 726—(0.11216)—13.12.26—13651 CONTENTS. Chapter I. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH FOR THE YEAR 1925. Page Introductory Note 5 Vital Statistics— Population—Marriages—Births—Deaths—Infant Mortality 12 Mortality in London 1841-1925 15 Infectious Diseases— Smallpox 24 Measles—Whooping-cough—Scarlet Fever and Diphtheria 28 Diarrhoea and Enteritis—Cancer 28 Anthrax—Plague and Cholera—Typhus—Cerebro-Spinal Fever— Poliomyelitis—Polioencephalitis—Encephalitislethargica 29 Influenza 32 Typhoid Fever 37 Bacteriological Work 42 Special investigations 49 Tuberculosis 55 Administration— Common and Seamen's Lodging Houses—Homeless Persons—Housing Acts 56 Tuberculosis 58 Venereal Diseases 69 Midwives' Act and Children Act 71 Mental Deficiency Act, 1913 74 Laboratory Work 75 Statistical Tables.—I. Vital Statistics—II. Administrative Work—III. Tuberculosis Dispensaries 77 Chapter II. REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR 1925. Page Introductory Note—Medical Inspection and Treatment—Personal Hygiene —Infectious Diseases 80 Staff—School Buildings 82 Results of Medical Inspection 83 Infectious Diseases among School Children 91 Ringworm104 Encephalitis Lethargica 106 Following-up and Reinspections 113 Results of Dental Inspection 114 Children absent from School for Long Periods 116 4 Medical Treatment 117 Manifestation of Rheumatism in Childhood 123 Open-air Education 128 Physical Training 136 School Meals 138 Personal Hgyiene 139 Defective Children 144 Examination of Pupils at Secondary Schools 152 Juvenile Employment—Theatrical Children 153 Special Enquiries and Research 154 Vocational Guidance—Backward Children—Albuminuria—Canal Boat Children. Examination of Candidates 163 Statistical Tables.—I. Inspections—II. Defects—III. Exceptional Children—IV. Treatment of Minor Ailments, Visual Defects, Defects of Nose and Throat, Dental Defects, Uncleanliness.. Chapter III. Public Health.—Tuberculosis—Venereal Diseases—Infant Life Protection —Lying-in-Homes—Midwives—Houses let in Lodgings—Homeless Persons—Lodging Houses—Offensive Businesses—Milk—London Health Services—Diseases of Animals—Smoke Nuisance 170 Chapter IV. Main Drainage 181 Chapter V. Housing 187 Chapter VI. Housing Accounts and Statistics.—Memoranda by the Comptroller of the Council and the Valuer 201 (5) London County Council. ANNUAL REPORT OF THE COUNCIL, 1925. CHAPTER I. REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH (Dr. F. N. K. MENZIES) PREPARED IN COLLABORATION WITH SIR WILLIAM HAMER, WHO WAS MEDICAL OFFICER UNTIL THE END OF 1925. This annual report, the thirty-fourth of the series to which it belongs, com pletes the second chapter of the official record of the work of the Public Health Department. The occasion prompts casting a backward glance over the ground traversed, and presenting a review of London's health record during the existence of the Council, studied in the light of changes in mortality from certain specified causes during that period. Dr. James Niven prepared three years ago, on his retirement from the post of Medical Officer of Health of Manchester, "Observations on the History of Public Health Effort" in that city. The period of time covered dated nominally from 1868, the year in which the first medical officer of health of Manchester, Mr. John Leigh, was appointed, but for the most part the " Observations " relate to the years of Dr. Niven's own official life (1894-1923). The first medical officer of the County of London (the late Sir Shirley Murphy) was appointed in 1890 and an account of public health effort in London, since that date fairly corresponds in time with the years of Dr. Niven's survey. The close similarity of experience in the two administrative areas is remarkable, though such differences as are exhibited (now in favour of the one and now of the other area) are very instructive. Dr. Niven held that "by far the most important influence which has governed the improvement of the public health in Manchester, apart from economic conditions, has been the removal of organic filth, whether without or within the habitations of the people"; and that "probably the next in importance has been the control of infectious disease." He further referred to housing, parks, the physical care and training of children, the provision of public baths and washhouses, and the supply of pure water and food of good quality; finally, he says, " the part played by education has been far from small." Broadly, this summary may be accepted as applying also to London, though in the working out of the desired reforms the methods adopted (owing of course to the differing environmental circumstances of the two areas) have been in some respects wholly dissimilar. Manchester, quite early, had secured an unexceptionable water supply, London has had to put the finishing touches to that problem very largely in the course of the last three decades, and has done the work on quite different lines from those of Manchester. On the other hand, in London, already in 1890, "dry disposal" and even cesspools, had almost become things of the past, while Manchester was for some years after that date still grappling with the difficulties of middens, privies and the pail system. Most striking of all have been the differences in the distribution of administrative duties between various authorities in the two areas, and yet the results aimed at, and in large measure attained in both, during the last 35 years, present fairly close resemblances. In London, on Shirley Murphy's appointment in 1890, the working of the new Housing of the Working Classes Act of that year, and the shaping of the Public Health London Act, 1891 (that was to be), were the two great problems to be faced. 6 The former involved obtaining detailed information concerning insanitary areas in London needing reconstruction, a work which has never ceased to make demands on the energies of the Council's Public Health Department from that day to this; the great Boundary Street scheme was already in 1890 under way and this was followed in succeeding years by a large number of further improvement schemes. The Public Health London Act (1891) brought with it new powers of bye-law making, of licensing, and (specially important, as now appears in retrospect) of acting in default of sanitary authorities. These duties occupied very fully the time of the then small staff of the newly created department. The overcrowding and insanitary conditions existing in London in the " nineties " were steadily exposed to view in a number of sanitary surveys of certain of the administrative areas under the control (at that period) of Vestries and District Boards. These reports led straightway to much needed strengthening of local sanitary staffs; indeed, between 1889 and the end of the century the number of sanitary inspectors in London was more than doubled. The surveys referred to showed, moreover, the clamant need for amendment of administration relating to houses occupied by members of more than one family ; the problems here presented were, however, so great that a comprehensive settlement of them is only now, at length, in sight. The Council had approved, in 1894, a code of bye-laws regulating house-drainage and disposal of offensive refuse generally ; under these carefully thought out new powers sanitary authorities were enabled with comparatively little difficulty to institute, at quite an early date, a thorough overhauling of house-drainage ; while, accumulations of manure, etc., and innumerable collections and tips of house-refuse, were, after the institution of proceedings in a number of instances, practically banished from the county area before the end of the nineteenth century, to the lasting benefit of the health of the modern Londoner. In 1894, too, a new Building Act was passed which contained far-sighted provisions, aimed at preventing the erection of insanitary houses and blocks of dwellings ; these sections have operated most beneficially in regulating the new housing provision of the last 30 years. Offensive trades, slaughterhouses, cowsheds and dairies came under the Council's close scrutiny, and, as the result of control, by licensing or by new byelaws and regulations, many unsatisfactory premises ceased to exist, and London has since enjoyed almost complete freedom from the particular kinds of mischief which it was thus sought to remedy. During these early years there was a threat of cholera and a considerable prevalence of smallpox. The Council was, largely on account of the extent to which it was found that this latter disease was spread by vagrants, entrusted, in 1894, under a Provisional Order of the Secretary of State, with the inspection of, and later (under the General Powers Act of 1902) became the annual licensing authority for common lodging houses. Up to that time the "doss houses" of London were largely frequented by persons "known to the Police" and needing their supervision ; on the change of control the premises were found to present many conditions urgently needing improvement from a health and, indeed, from other points of view. Houses accommodating single men, single women and "doubles " commonly existed side by side with one another; there was overcrowding, the standard of cubic space being then only 250 cubic feet, and beds and bedding were, as a rule, in the absence of facilities for cleansing, verminous. The removal of bugs from woodwork and bedsteads, and of fleas, bugs and lice from bedding and clothing seemed at first an impossible task ; but steady work— aided by keepers and deputies of "the doss houses " and later (on the inclusion of Salvation Army shelters as "common lodging houses ") by the officers of "the Army," and further, with the help of special disinfecting appliances (and particularly of the painter's blow lamp and the disinfecting apparatus of the health authorities)—in the course of a few 7 years practically disposed of these difficulties, so far as the London common lodging houses and Salvation Army shelters were concerned. The problem of bugs, in the poorest tenement houses and cottages, still remains finally to be disposed of, by steady use by Borough Councils of the powers conferred by the County Council's new code of bye-laws. In the early days the lodgers in the shelters were accommodated in bunks, either laid on the floor or arranged in tiers known as "double deckers." Some contained as many as six beds and were three stories high, the top beds being reached by a ladder. They were supplied with American cloth mattresses and coverings but not with sheets, and lodgers often slept in their clothes, or if they undressed wrapped themselves in newspapers for warmth. Many special provisions relating to food supplies (ice-cream, fried-fish shops, places where food is stored, etc.), to water supplies on upper floors of tenement houses, and to vermin, were obtained by the Council in its successive General Powers Acts; and numbers of reports by the Medical Officer and his assistants on dust destructors, cemeteries, houses let in lodgings, anthrax, disinfection, mortuaries, mineral waters, watercress beds, milk outbreaks and milk examination, and on cholera, plague, smallpox, typhoid fever, scarlet fever, diphtheria, influenza, cerebrospinal fever, tuberculosis, venereal diseases, etc., etc., were issued by the Council. The house-fly problem was studied and solved, not by fly-papers, but by removal of the breeding grounds of the fly. An American hygienist visiting London some 15 years ago observed that he had seen most of the cities in the States and in Europe but knew none so free from the house-fly nuisance as London. Fleas and lice have given ground more slowly, but are steadily being put to rojit. The extensive use made by Borough Councils of their powers of disinfecting premises, clothing and bedding, and the greatly increased facilities for hospital treatment of infectious disease (with consequential cleansing and disinfestation of the patients) afforded by the Metropolitan Asylums Board, have no doubt contributed materially to reduction of prevalence of body vermin. Already, in 1901, the Council, in view of possible introduction of disease from abroad by seamen, had, using the powers conferred by Section 214 of the Merchant Shipping Act, 1894, made bye-laws regulating Seamen's Lodging Houses, and these were approved by the Board of Trade. In 1909 powers of licensing the houses annually were also obtained, and under these powers not only was London safeguarded against exotic diseases, such as plague and cholera, but the seamen were protected by the steps taken to prevent verminous conditions, gambling, opium smoking and immorality. Of late years strenuous efforts have been made by the Council, as Education Authority, to push the fight against verminous conditions to a finish, by securing complete cleanliness of the rising generation; to this end much more extended use of the Public Baths of London by school children has been encouraged as an educational measure ; this campaign has been greatly helped by school teachers, and has been much appreciated by the children and their parents ; it has moreover, led to largely increased voluntary use of these baths. Provision has, further, been made by the Council for coping with the slighter cases of infestation of children's heads, at special cleansing stations. It is, perhaps, in connection with personal hygiene, now generally recognised as forming such an important part of preventive medicine, that the influence of education upon health has been most conspicuously apparent. Reference was made in these annual reports shortly before the war to an enquiry instituted by Sir Robert Blair, with the help of a number of head teachers, into the changed conditions (within their experience) exhibited by the children in the schools. Any observer who is old enough to recall the appearance of the poorer London children half a century ago, when the London School Board was only just beginning to make its influence felt; in the days of unregulated child labour, of boy bootblacks and child crossing sweepers ; the days of " ragged schools," when bare feet were the rule, and frostbite, ophthalmia, running ears, enlarged glands resulting 8 from skin infestation, malnutrition and deformities were only too common ; and particularly any medical observer, familiar with the vermin infested rooms of his midwifery experiences in the slums of London, or with the sight of the skins of children in out-patient departments, many of which were peppered with hundreds of flea marks : such an one, if he will stand and look at the scholars trooping into school nowadays will realise that the main cause of improved sickness and mortality statistics among the child population in the London of to-day is to be found in the heightened sense of parental responsibility, aroused in a generation of parents who have themselves passed through the schools. It is something like half a century since elementary education became compulsory and universal in this country. Like the air we breathe, it is now regarded —or disregarded—as so much a part of our environment that its manifold reactions on all the affairs of life pass almost unnoticed and unrecorded. In common with every other aspect of social progress, that of public health has benefited also, both by the indirect and by the direct effects of the great education service. The indirect effects are those produced by the substitution of a reading and discriminating for an illiterate and ignorant public. Although intelligence has not necessarily been increased, knowledge has grown and spread. A public opinion has been created which stands behind the efforts of the sanitarian, without which his would still be a voice crying in the wilderness. A single example of the overwhelming importance of the indirect effects of the education system is seen in the remarkable fall of infant mortality and the saving of child life, which came about as a younger generation, after passing through the primary schools, became in due course the parents of a new generation. Thus the indirect results of the education system are truly incalculable. The direct effects of the education service on the health of the child and adolescent are, of course, plain for all to see. Thirty years ago school places had been found for all children of school age ; the habit of school attendance was almost completely acquired, although " truant schools " still formed part of the system ; there was a sufficiency, in London at any rate, of trained teachers to staff the schools ; and a reasonably efficient elementary education was imparted to the children. These were great results to have been attained in 25 years. But up to this point little or no regard was paid specifically to physical conditions. There were no school nurses, no school doctors, no school dentists, no system of special schools, no proper physical education, no children's baths, no school hygiene, no school feeding. There was scarcely an indication of that movement towards physical care of the school child which has been such a predominant feature in the later history of the education system. The position in the last five years of the nineteenth century in regard to the physical care of school children in London was as follows:—The School Board for London had in 1890 appointed a part time medical officer (Sir William R. Smith); Mrs. Humphrey Ward had established a "cripple " school in Tavistock Place on a voluntary basis, and the striking results of this experiment had interested the School Board, with the result that special schools for defective children were being established. The Act providing for the education of blind and deaf children had already been passed in 1893, but in 1899 the Defective and Epileptic Children (Education) Act gave the School Board the power to deal with these children, and regularised the position of special schools. Dr. Shuttleworth and Dr. Dickinson Berry had been appointed as part time medical officers to assist in the certification of special school children. The establishment of health courses in the evening schools had made the appointment of doctors as lecturers possible and Sir John Collie was engaged as advisor on these subjects. During the early years of the present century, however, the need for more general extension of children's care was beginning to be apparent. Eminent 9 authorities had pointed out the prevalence of myopia in school children, and the School Board for London appointed in February, 1902, eight part-time oculists to supervise the examination of the vision of school children. Dr. James Kerr was in this year (1902) appointed whole-time medical officer in place of Sir William R. Smith, and three part-time assistant medical officers were also appointed. At this date, also, there was appointed one school nurse (Miss Lockington), whose duty it was to deal with ringworm, which had long been causing much loss of school attendance. Under Dr. Kerr's direction all these threads, which formed the beginnings of children's care, were gathered into one skein, and an active school medical department came into existence. Meanwhile a series of important committees and commissions were enquiring into the state of the health of children, and the publication of their reports and the evidence given before them, coming one after another like the peals of a thunderous organ, immediately bore fruit in facilitating the work of the school medical department and later led to legal enactments ensuring the permanency and orderly growth of the work. The Inter-departmental Committee on Employment of School Children reported in 1902 and the Royal Commission on Physical Training in Scotland in 1903, the Inter-departmental Committee on Physical Deterioration in 1904 and the Committee on Medical Inspection and Feeding of Children attending Public Elementary Schools, in 1905. The Balfour Act (for London) passed in 1903, forms a great landmark,as it placed the education work under the London County Council, and prepared the way for the fusion of the school medical department with the public health department. It also for the first time made a comprehensive review of the condition of all school children possible by bringing the non-provided schools under the direction of the Education Committee. In 1907 the McKenna Act made the medical inspection of children compulsory and gave the power to the education authority to provide medical treatment. This led to great addition to the work under Dr. Kerr and a large increase in the staff of school doctors and nurses. Meanwhile there had been extension of the special schools, and special classes for myopic children and children hard of hearing had been established. Investigations upon measles, scarlet fever and diphtheria in the schools had enabled the department to frame a code of rules for the control of these and other infectious diseases and, with the growth of the school nursing service, cleansing schemes were commenced in every school. The large amount of defect among school children revealed by medical inspection led to special arrangements with the voluntary hospitals for their treatment, and, where these failed, to the establishment of special school treatment centres. The growing work of children's care, embracing not only the following up of defective children, but the administration of the Feeding of School Children Act (1906) and the Choice of Employment Act (1910) led to the establishment of the voluntary school care committee system of London, of which Miss T. M. Morton became the principal organiser. A further step in evolution took place in 1912, when the school medical work was placed under the direction of the medical officer of the County; the medical treatment of school children hitherto administered by the Education Officer was also transferred to his direction. Dr. Kerr acted as Research Medical Officer, and later Miss Morton became also an officer (part-time) of the public health department. In this way the whole of the medical inspection, following up and treatment was consolidated under one direction and the work was completely co-ordinated with the other medical work of the Council. This gave opportunities for further advance. The School Medical Service was organised in five divisions (each under a divisional medical officer) and the staff of school doctors and nurses was largely strengthened. From 1912 to the present time there has been a remarkable increase 10 in the provision for medical treatment, an increase which is still going on. In January, 1910, arrangements were made with seven hospitals for the treatment of 12,700 children, in 1912 there were in addition three ad hoc " treatment centres;" there are now (in 1925) 73 hospitals and treatment centres in the scheme, providing for the treatment of 254,000 ailments of children annually, including 120,000 children dentally treated. It is impossible here to recount all the various activities which have been undertaken during this time for the improvement of the health of the children, in growth of provision for physical exercises and games, school camps, open-air education, convalescent treatment, and the great increase in sight-saving classes, of which there were 5 in 1914 and 26 in 1925. The result of all these manifold activities for the benefit of the school child is shown in improved physique and health. Some forms of uncleanliness, such as body vermin, have practically disappeared, others are very greatly reduced. The condition of the children's teeth on leaving school has greatly improved, and is still improving. It is recorded in the minutes for 1898 of the School Board for London that 80 per cent of pupil teachers were found, on medical examination, to require dental treatment. In 1925 the percentage of scholarship holders found to require dental treatment was 7 per cent. The interest taken by the parents in the medical and dental inspections of their children is very great. Over 80 per cent, attend at one inspection or other of the school child. The bringing into consultation, of the parent with the doctor and the dentist, on this immense scale has a huge propaganda value for public health. Turning now to Dr. Niven's second special influence for good, the control of infectious disease. Here, while attaching great value (and of course London experience is emphatically with him) to efficient disinfection and to hospital isolation, he laid stress also on the importance of "a good system of investigation of disease." Shirley Murphy would undoubtedly have endorsed this and he, in fact, established a tradition in accordance therewith from the very outset. The medical and inspectorial staff of the public health department (as Dr. Niven testifies was the case in Manchester also) entered with zest into, and was carefully trained for, this most essential work. Again and again "the chief " would insist upon proving all things, exploring all the possibilities, at whatever cost of time and trouble. The well equipped enquirer of to-day, with many novel means of investigation at his disposal, is sometimes tempted, perchance, to jump to conclusions ; if not, indeed, to regard as somewhat old fashioned the dull routine of methodically testing all observations and hypotheses regarding causation of disease by study, not only of the phenomena presented by actual sufferers, but also of those yielded by a " control population." This "control work " was, ab initio, always rigorously insisted upon and loyally and unwearyingly carried out; thus, over and over again, it was found in practice possible to avoid too ready acceptance, or unwarranted use, of what the event might show to be an inappropriate method of administrative procedure. Furthermore, it was recognised throughout that the essential condition of success in London (where jurisdictions perhaps have been even more divided than in Manchester) was to be sought in the closest possible co-operation with the staffs of the borough councils, with those of the hospitals of the Metropolitan Asylums Board, of voluntary hospitals, of poor law institutions, and last, but not least, with the general practitioner. Both Shirley Murphy and Niven, despite their extreme caution, were ever alert to make use of any extension of knowledge utilisable for preventing spread of epidemic disease. From the beginning they were alive to the danger of "mild" and "overlooked " cases. Shirley Murphy studied with keen interest, in the early years of this century, Koch's campaign against typhoid fever in south-west Germany, and the experiments made in this country and abroad in connection with isolation of healthy carriers of diphtheria and typhoid bacilli. He realised, however, from the 11 first, the difficulties arising in connection with the procedures advocated, and as experience accumulated he was led, fifteen or more years ago, to the conclusion that in the light of existing knowledge, segregation of healthy carriers could not be systematically applied in a large community; as he said, if it came to segregation of healthy persons at all, it must be" segregation of the sound"; for the reason that the numbers of healthy carriers, of one or another germ under suspicion (rightly or wrongly) of being a potential source of danger, have proved to be so unexpectedly large. He was, of course (as was Niven also) a firm believer in the aerial convect ion of smallpox, and one of his earliest pieces of research work, as medical officer of health, was to organise the collection, in precise detail, of all the facts relating to cases admitted to the smallpox hospital (as it then was) in North Islington; this enquiry had a happy ending, however (particularly for one of the investigators, who lived within the quarter mile circle drawn from that hospital as centre), when the building was converted to other uses and smallpox hospitals were thus finally banished from the County of London altogether. Shirley Murphy, later, greatly strengthened London's defences against smallpox by securing the services of a consultant for diagnostic purposes, and this officer's experience was gradually made available also in a number of areas adjoining the County of London. Dr. Niven's comprehensive and detailed observations on the influences exerted by the various measures taken to control the several zymotic diseases in Manchester are full of interest, especially for those concerned with like problems affecting the London population. Dr. Niven was inclined (p. 29) to look with some favour on the view that dissemination of scarlet fever may stand in association with prevalence of fleas; he held that " it would be unwise to relinquish the assistance which the hospital affords in keeping scarlet fever down, unless for some important and temporary object " (such as an epidemic of plague, cholera, or an overwhelming outbreak of smallpox). He queried whether it is possible " to deal with dangerous forms of scarlet fever as, for practical purposes, conditioned by the adjuvant microorganisms, to be prevented through them, or cured through them." Dr. Niven weighed with great care the evidence as to causation of enteric fever, and wrote that, in 1905, " new facts emerged, or appeared more strongly than before, to point to shellfish as a decided source of infection " ; moreover, he told of action taken by the Manchester Markets Committee to " ensure purity in the mussels." He said " it is to these measures, I don't doubt, that we owe much of the reduction in enteric fever from 1914 onwards, possibly also in 1911 and 1912." He was thus convinced that estuarially polluted food was a prominent factor in typhoid causation, and after much time and thought devoted to the " carrier hypothesis," he "-rote, " I cannot believe that " carrier " cases play an important part in the spread of enteric fever." He concluded his account of work done in preventing infectious disease with a full consideration of diphtheria, diarrhoea and influenza and with a detailed history of the Manchester Venereal Diseases scheme and the Tuberculosis scheme. As regards tuberculosis especially Dr. Niven, it will be remembered, must be credited with a lion's share of pioneer work, from the time of his early championship of notification to that of securing the well-known " Manchester Milk Clauses." So much has been achieved as regards control of the once far too familiar zymotic diseases that there is a disposition displayed by those who never knew them, in their habit as they lived half a century ago, to declare that disinfection of premises and isolation of sick persons can now be looked upon as having had their day; some very advanced thinkers, indeed, propose to substitute, for the " oldfashioned methods." discouragement of such " dangerous practices " as kissing and shaking hands, and even insist that almost exclusive attention must nowadays be concentrated upon " well persons," whom they hold to be the source of most of the troubles arising in connection with infectious disease at the present day. In the 12 hope of throwing some light (inter alia) on this perverse and pessimistic point of view a chart has been prepared, with the help of Mr. B. E. Spear (p. 18), showing year by year for the London population the fluctuations in the number of deaths from particular accredited causes. When due allowance has been made for disturbing influences, and especially for the altering age-constitution of the population, it transpires that certain apparent increases of mortality—those from cancer, pneumonia and influenza—are mainly if not entirely attributable, on the one hand to change of fashion in nomenclature, or on the other to greater accuracy of diagnosis. Their importance is in any case seen to be dwarfed into small proportions in comparison with the marvellous decreases observed. The conspicuous decline in phthisis is, undoubtedly, in part due to better housing and feeding and in part to migration of population, though this latter factor became much less extensively operative some 15 or 20 years ago. The most remarkable contour, of course, is that for zymotic diseases, which bears eloquent testimony to the value of the public health effort of the last 40 or 50 years, which has brought about the practical extinction or conspicuous decline in prevalence of the chief zymotics. The contours, however, which, perhaps, present features most deserving of special study at the moment are those of bronchitis and of diseases of the brain and nervous system, in both of which, despite the increase in the populations at risk, there is an unexpectedly pronounced decline; altered age-constitution has doubtless operated here, and there has probably, too, been some transference to other categories (to pneumonia and heart disease in the case of bronchitis ; and to influenza and other headings, from both bronchitis and diseases of the brain and nervous system); but these explanations are not adequate to account for an outstanding and as yet unexplained decline under the two last named headings. In so far as the extreme ages (old age and infancy) are concerned, it is doubtless the greatly increased care for the very old and very young (one of the conspicuous developments of modern civilisation) which must be held to be largely accountable ; but it may be suspected also that some of the improvement at all ages under the headings referred to must be ascribed to decided falling away in the maleficent influence of those close allies "alcoholism " and "venereal disease," both of which, while making but little parade at any time in registered causes of deaths, have notoriously had their power for evil greatly curtailed in the last half and particularly in the last quarter of a century. It comes as a special surprise, however, in an age which is reputed to be one of "nerve strain," "brain fag" and "overpressure," and in which much has recently been heard about the " epidemic diseases of the central nervous system," to find that diseases of the nervous system make so little impression upon records of mortality nowadays, as compared with the far away "sixties " and "seventies." In face of the vast improvements brought about as regards mortality statistics in the period which has been reviewed, no share in which can possibly be ascribed to restrictions upon liberty of "well persons," such as are now being advocated by the extremists, the conclusion is obvious that some evidence of the utility and practicability of the proposed new methods will have to be forthcoming before they can meet with general approval. Population. Vital Statistics. The population of the County of London 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 at the date of the census was about 4,524,000, allowance being made in this estimate for persons absent on holiday when the census was taken. The Registrar-General estimates the total population in the middle of 1925 to have been 4,612.000, including 10,000 non-civilians. The 13 13651 R 14 estimated mid-year populations of the metropolitan boroughs in 1925 are shown in the table on page 77. Marriages. Marriages registered in London during 1925 numbered approximately 39,641 or 17.2 per thousand of the population, this rate being the same as in the preceding year. Births. The births in London during 1925 numbered 82,401, this being 2,746 less than last year. The birth-rate was 17.9 per thousand of the population as compared with 18.6 in 1924 and 20.1 in 1923. The birth-rate for each metropolitan borough and for London as a whole will be found in the table on page 77. The London birth-rate since 1840 is shown in the diagram on page 13. The Registrar-General's estimate of the population of London in 1925 allows an increase of 88,000 in the County population in the four years since the last census. During this period the births have exceeded the deaths by about 138,000, so that there has been a loss by the balance of the excess of emigration over immigration of about 50,000 persons. Death The deaths in the civil population of London during 1925 numbered 54,591, giving a death-rate of 11.9 per thousand as compared with 12.2 in 1924 and 11.4 in 1923. The distribution of the deaths by ages in 1925 is shown in the following table with corresponding figures for the preceding two years, and the annual average for the years 1911-14 and 1919-22:— Year. 0- 1— 2— 5— 1- 15— 20— 25— 35— 45— 55— 65 + All ages. 1911-14 ll,968 3,546 2,716 1,421 846 1,088 1,299 3,525 5,292 7,142 8,328 18,221 65,392 1919-22 7,836 2,131 1,919 1,376 853 1,175 1,318 3,103 4,238 6,414 8,265 19,828 58,456 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 1924 5,904 2,164 1,863 817 709 1,015 1,225 2,514 3,770 6,265 8,582 21,059 55,887 1925 5,599 1,427 1,371 816 647 1,091 1,235 2,531 3,618 6,034 8,500 21,722 54,591 The year of lowest death-rate in London was 1923 when, as will be seen, the deaths numbered 2,600 less than in 1925. The excess in 1925 is greatest at the higher ages and is chiefly attributable to the relatively greater incidence of influenza and diseases of the respiratory system. In 52 registration weeks of 1925 there were 606 deaths in London caused by vehicles and horses, 157 being children under 15 years of age. The corresponding figures for 1924 (53 weeks) were 593 and 166. The death-rates from all causes and from certain specified diseases for each metropolitan borough and for London as a whole will be found in the table on page 77. The annual death-rates in London since 1840 in relation to the mean of the rates for the last 85 years are shown in the diagram on page 13. Infant mortality There were 68 deaths under 1 year of age per thousand births in 1925 as compared with 69 in 1924 and 61 in 1923. In the following table the deaths under one year of age per thousand births, from the principal causes of infant mortality, are shown for 1925 and preceding years. Cause of Death. 1911 to 1914. 1915 to 1918. 1919 to 1922. 1921. 1922. 1923. 1924. 1925. Measles 3.40 3.84 1.64 0.57 3.30 0.96 3.37 0..87 Whooping-cough 3.63 4.45 2.50 2.34 3.92 2.23 2.30 4.58 Influenza 0.27 1.10 0.81 0.26 1.12 0.20 0.62 0.38 Tuberculosis 3.40 3.20 1.52 1.45 1.13 1.21 1.20 1.48 Bronchitis 6.41 6.72 4.42 2.89 4.05 2.43 3.62 3.02 Pneumonia 12.28 14.96 12.60 11.54 16.00 9.07 14.13 12.27 Diarrhcea 24.28 16.10 12.16 18.63 6.26 9.07 7.89 9.72 Premature birth 18.16 17.42 17.00 16.17 16.10 14.66 15.89 14.31 Congenital defects 14.69 14.66 11.26 11.53 9.30 8.80 7.96 8.70 All causes 108 103 79 81 75 61 69 68 15 Mortality in London from certain causes 1841-1925. The changes which have occurred in the course of the last eighty-five years in the London mortality from certain diseases or groups of diseases, are broadly shown in the diagram on page 18. It must be borne clearly in mind that the contours there given are not based upon the death-rates per thousand living but upon the actual deaths registered in each year. Some of the contours shown relate to groups of diseases and causes of death, and the groups are not in some instances identical with those constituting groups similarly designated in the Registrar-General's annual reports. All except the first three contours are drawn to the same scale. The all-causes deaths are shown on a scale one-fifth, the zymotic and bronchitis deaths on a scale two-fifths of that of the remaining curves. The heading "Zymotic Diseases" includes the principal infectious diseases, smallpox, cholera, typhus and other fevers, diarrhcea, measles, whooping cough, and also croup, gastritis and gastro-enteritis; but influenza is not included in this group, being shown by a dotted line above the zymotic disease contour and also separately. In the earlier years venereal diseases, pyaemia and puerperal fever were included among zymotic diseases in the Registrar-General's reports, but these have here been excluded throughout. The group of diseases of the heart and circulatory system does not include apoplexy. Diseases of the brain and nervous system comprise tubercular and simple meningitis, insanity, paralysis and diseases of the ears and eyes, but the group does not include apoplexy, epilepsy, or convulsions, deaths from the last named being shown in a separate curve. The group of urinary diseases is the same as that of the Registrar-General. Diseases of the digestive system are shown for ages above five years, in order to avoid the disturbing effect upon the figures resulting from the practice, which obtained in the nineties, of using the terms gastritis and gastro-enteritis for deaths, which in earlier years would have been ascribed to diarrhcea simply and thus have been included in the zymotic group of diseases. Senile dementia was not classed with old age from 1881 to 1910, being in this period allocated to insanity, but the number of deaths from this cause is relatively small and insufficient to affect appreciably the contour shown in the diagram. In regard to the classification of causes of death, it may be of interest to recall that the Act requiring the registration of births, deaths and marriages in England was passed in 1837. A classified list of diseases was at that time drawn up by the Presidents of the Royal College of Physicians and the Royal College of Surgeons, and the Master of the Society of Apothecaries,, and circulated to members of the medical profession. This list was adopted in practice by the Registrar-General and in 1845 it was circulated to all registrars of births and deaths in England for their guidance in the registration of deaths. The classification of causes of death adopted by the Registrar-General was based upon this list, and this classification remained in force with some few alterations until 1881, when it was revised, some of the medical terms used having become obsolete, and other changes being rendered necessary by increased knowledge of the causation of disease. After 1881 the classification of causes of death was revised from time to time until 1911, when the Internationl list of Causes of Death was adopted, involving considerable changes in the classification then in use in England. This list is subject to revision every ten years. It may be added that, in addition to the changes brought about by the introduction of this list, in 1911, the deaths registered in any district were allocated to the usual place of residence of the deceased, so that the general register office became a clearing house, as well as a registration office for deaths throughout the country. It is necessary in considering the contours to have in view the changes which have taken place in the population of the London registration area since 1840. The population in 1841 of registration London, as then constituted, was 1,875,493. 13651 b 2 16 Additions were, however, made to the. area in 1844 and 1846, and these added about 73,000 to the population, but apart from such additions the population increased between 1841 and 1851 by more than 400,000. In each of the two following decennia the rate of increase was about the same, but between 1871 and 1881 the rate of growth was more rapid, the addition in this period being 562,223. Thereafter, the rate of inter-censal growth began to diminish, being about 400,000 between 1881 and 1891, 300,000 from 1891 to 1901, while in the ten years 1901 to 1911 (for the first time in the period covered by the diagram), there was an inter-censal decrease, amounting to about 15,000. Broadly speaking, it may be said that the population in London increased steadily from 1841 to 1901 and has since remained practically stationary. The population has grown by immigration, and by excess of births over deaths, and both factors have a disturbing effect upon age-constitution. Immigration involves the addition to the London population of young adults of both sexes; these throughout the period are in excess of what would be found in a community growing only by natural increase, that is, by excess of births over deaths. The changes in the birth-rate are apparent from the diagram on page 13. The rapid decline of the rate in recent years has resulted in a marked diminution of the child population relatively to the total population of the County. There were, in 1851, rather less than 300,000 children under five years of age in London and, in each successive census, the number increased until in 1891 it exceeded 500,000. Thereafter, it declined with the declining birth-rate and, at the last census (1921), the number was 376,055. It follows from these changes in the population that diseases which are mainly fatal among children will, apart from any change of incidence or fatality, show an increase in number up to 1891 and, thereafter a decrease, greatly accentuated since 1911. This circumstance must be borne in mind in considering the contours in the diagram, especially that relating to convulsions, the deaths from which are almost entirely limited to the first two years of life and also, though to a less extent, to diseases of the brain and nervous system, this latter group including simple and tubercular meningitis which are both more largely incident upon the early years of life. The population in 1841 over 65 years of age numbered less than 70,000, but there was a continuous increase throughout the 80 years to 1921, when this agegroup numbered nearly 260,000. This increase is principally due to increase in the birth-rate during the first half of the last century, though the excess of immigration over emigration has also played some part. It is worthy of note here that the short life-tables for London referred to in the annual report of the Medical Officer of Health for 1923, page 10, show that of the 371,776 persons aged 5 to 15 living in London in 1841, there would have survived in 1911, 44,921 persons, whose ages then were 75 to 85. The actual number of persons at this age enumerated in the census was 52,352, the excess over the expected number representing, approximately, increase due to the excess of immigration over emigration in the intervening years. It will necessarily follow from the continuous increase in the population at high ages that diseases which are mainly fatal in later life will show an increased number of deaths, while the death-rate per thousand of the population at risk may actually not have increased or may even have decreased. In the case of bronchitis, which is largely incident upon persons over 55 years of age, it will be seen that there is a fall in the deaths in the past 30 years, notwithstanding the increase in the population at risk. Deaths from diseases of the heart and circulatory system, however, show a continued increase and actually the rate of increase is, in some periods, greater than the rate of increase of the population. At the ages chiefly involved, the increase in deaths from heart diseases is, however, dependent upon other circumstances than either increase of population at risk or increase in the incidence of diseases of the heart; more exact certification 17 of the cause of death has undoubtedly had something to do with the increase shown. As an instance of the effect which changes in regard to certification may have, it may be mentioned that arterio-sclerosis has only in recent years figured on death certificates to any conspicuous extent; this does not mean that the disease is more frequently met with nowadays, but rather that the term has been adopted by the medical profession to a larger extent in recent years in preference to less definite terms on the death certificates. The following figures suggest that the heading arterio-sclerosis has, in many instances, replaced "old age" as the certified cause of death:— Certified cause of death. Deaths among persons over 65 years of age. 1911. 1916. 1920. Arterio-sclerosis 372 842 1,028 Old age 3.163 2,920 2,262 It is of course impracticable to make any correction for changes of this kind, depending as they do not upon any change in the method of classification, or in the incidence of disease, but upon changing fashion of certification, and such changes render it difficult to trace, with any certainty, the course of any particular disease over long periods of time, during which alterations of nomenclature, or certification in greater detail of the causes leading to death, have resulted in changes, the extent of which must be a matter of surmise. The course of mortality, certified as due to old-age, is shown in a contour on the diagram and, from what is observed above in regard to the increase, of the population at risk, it would be expected that the old age mortality would show a continued increase, pari passu, with the increase of the population, this cause of death being almost entirely limited to ages above 65. Actually, however, it will be seen that the curve does not show any remarkable increase and, in fact, during recent years, that is, the years when arterio-sclerosis has come into fashion in certification, there has been a decrease. The other diseases or groups of diseases shown in the diagram, which in addition to old age and heart •diseases mainly affect persons of high age, are cancer and diseases of the urinary system to which further reference is made below. Zymotic diseases. The most remarkable of the curves is that showing the mortality from zymotic diseases. During the 20 years 1841-1860 one-fourth of the deaths registered were returned as due to one or other of the group of diseases classed as zymotic, the outstanding proportion of the deaths being due to cholera (1849 and 1854), infectious fevers and smallpox. Later cholera and typhus disappeared and, though less rapidly, the smallpox mortality declined. The following table compares tne age-incidence of deaths from the principal diseases of the zymotic group in 1851-60, 1881—90 and 1911-20. The figures shown are the percentages (of such deaths) of deaths fron all causes. Period. Deaths from zymotic diseases per cent, of deaths from all causes. 0—15. 15—65. 65 + All ages. 1851-60 3.50 11-5 6.5 22.0 1881-90 29.3 4.1 1.9 15.4 1911-20 30.1 1.2 0.9 9.3 It will be seen that at ages below fifteen years the decrease in mortality from zymotic diseases, notwithstanding the practical disappearance of smallpox, cholera and typhus, has not kept pace in recent years with the decline in the mortality from all causes at these ages. The proportions of deaths from the principal diseases 18 19 comprised in the zymotic group at ages below five years in the three decennia are as follows:— Disease. 1851 —60. 1881 —90. 1911 —20. Deaths 0—5. Per cent. of all causes. Deaths 0—5. Per cent, of all causes. Deaths 0—5. Per cent, of all causes. Smallpox 4,252 1.66 1,200 0.35 6 0.00 Measles 12,741 4.98 23,685 6.96 14,455 9.08 Scarlet fever 17,290 6.76 8,887 2.61 1,069 0.67 Diphtheria 6,848 2.01 4,511 2.83 Whooping-cough 21,510 8.41 26,673 7.84 8,008 5.03 Typhus, Typhoid fever, etc. 4,641 1.81 826 0.24 27 0.02 Diarrhæal diseases 24,480 9.57 29,813 8.76 23,201 14.58 Total 84,914 33.2 97,932 28.77 51,277 32.21 All causes 255,844 — 340,368 — 159,175 — The diseases which have increased in importance relatively to all causes are, it will be seen, measles, diphtheria and diarrhœal diseases. With regard to the latter, it should be observed that the period 1911-20 includes a year of exceptionally high summer temperature (i.e., 1911, when there were 5,313 deaths from diarrhœa among infants under two years of age) while the average for the nine other years in the decennium was 1,880; on the other hand, the ten years 1881-90 were chararacterised generally by summers of normal temperature. Bronchitis. Pneumonia. Influenza. Owing to exigency of space it has unfortunately been necessary to show the contour for bronchitis mortality on a different scale from that of "all causes." Were the two contours shown on the same scale the middle part of the bronchitis contour would be thrown up, and its similarity to that for all causes thus be shown to be closer than the diagram suggests. There is evidence of confusion of bronchitis and asthma in the early years, especially from 1841-46, but otherwise it does not seem probable that the movement of the mortality generally thereafter in the earlier period (i.e., up to the end of the "eighties") is to be attributed in the main either to alterations in nomenclature or improved certification. The rapid increase during the first half of the period covered by the diagram is greater than would be accounted for by increase in population at high ages, for it will be seen on reference to the supplement to the Registrar-General's Annual Report, No. 75, Part III., page 210, that, after full correction for changes in age-and-sex constitution of the population, the mortality in England and Wales from bronchitis still remains higher in the "seventies" and "eighties " than before or since. The possibility is not lost sight of that there may have been transfers of deaths from other groups of diseases to the heading "bronchitis," but diseases of the heart and urinary system, both commonly associated with bronchitis, were also on the increase during the years of increasing bronchitis mortality. While in general the course of the mortality from bronchitis is similar to that from all causes, on comparing the contours of the two curves it will be noticed that during the "nineties " the bronchitis mortality tends to fall more than that of all causes. This, however, was the period when influenza pandemics were prevalent and a glance at the contours showing the mortality from influenza and pneumonia at this time makes it clear that with the sudden rise observed under these headings, there occurred simultaneously a reduction in the deaths attributed to bronchitis. Allowing, however, for the depletion to some extent of the bronchitis mortality resulting from influenza pandemics and also for the fact that bronchitis is mainly a disease of old age, the decline in deaths from this cause from the " nineties " onwards is more marked than that from all causes. The bronchitis mortality would undoubtedly have begun to decline earlier but for a series of severe winters experienced between 1886 and 1896. That these years were unfavourable to persons 20 of high age (and to infants) is shown by the diagram given on page 4 in the Annual Report of the Medical Officer of Health for 1917, which relates to all causes except diarrhcea. diarrhcea. In the following table the extent to which the temperature in the winter quarters of successive five-yearly periods, from 1871 onwards, fell below normal is shown, and it is clearly apparent that the winters of 1886-90 and 1891-95 were altogether exceptional:— Period. Number of winter quarters with average temperature below normal. Aggregate of degrees below normal in the winter quarters referred to in the preceding column. 1871—75 2 — 11 1876—80 3 — 3-6 1881—85 1 — 2-7 1886—90 5 —12-5 1891—95 3 — 9-7 1896—00 1 — 0-8 1901—05 2 — 2-7 1906—10 2 — 21 1911—15 None. — Phthisis. The deaths from phthisis, it will be seen in the diagram, reached a maximum about the "seventies," but a clearer idea of the movement of phthisis mortality will be obtained on reference to the diagram given in the Annual Report of the medical officer of Health for 1914, opposite page 28. The figures upon which this diagram is based have been corrected for differences in the age-constitution of the population. It will be noticed that the movement of the female mortality rate is more regular than that of male. The mortality of both sexes began to decline about the middle of "the sixties" and the decrease has been continuous since then up to the close of the last century and extending also even to the close of the first decade of the present century. During the War, as will be seen on reference to recent reports of the medical officer of health, there was a considerable increase in the death-rate, especially among young adults. On comparing the contours in the diagram of bronchitis and phthisis mortality, it will be seen that the variations above noted are observed in both contours. Since the two diseases are very often concurrent, some transfer from one to the other might be expected to have occurred in the course of so long a period, but there does not seem to be any reason for thinking (from the generally similar trend of the two curves) that any considerable changes in allocation of deaths as between one disease and the other have occurred in the whole period under review. It is of interest to note in regard to the bronchitis contour that in a study of the trend of pneumonia mortality in Massachusetts by Drs. Eugene R. Kelley and Angeline D. Hamblen (Public Health Reports of United States Public Health Service, volume 40, No. 32—August, 1925) it is shown that the bronchitis mortality in Massachusetts increased from "the seventies" to "the nineties" and thereafter continuously decreased, showing, therefore, much the same progression as that observed in London. Diseases of the heart and circulatory system. The group of diseases of the heart and circulatory system comprises a number of specified diseases, of which the most important is valvular disease of the heart including endocarditis. The deaths classed to this heading have greatly increased since 1881, when these deaths were first separately stated. No other specified disease in the heart group shows anything like the same extent of increase. There is reason for thinking that the increase is very largely, if not entirely, due to improved diagnosis and certification. The mortality from heart diseases falls largely upon ages over 65 years, and the population at this age in the decennium 1891-1900 was nearly double that in 1851-1860. On comparing the deaths above 65 years in these two decennia, it is found that while deaths from diseases of the nervous, respiratory and digestive systems have increased more or less proportionately to the increase in population, 21 deaths from diseases of the circulatory and urinary systems show greater increase than would be accounted for by the increase in population, while deaths attributed to old age remain practically stationary. The figures suggest that with progressive improvement in diagnosis and certification there has been an increasing transfer from the indefinite heading "old age" to the more definite headings "heart disease" and " nephritis." Returning to the question of the increase in valvular disease and endocarditis, it is found that the large proportion of deaths attributed to heart disease, but not allocated to any of the specified headings comprising the heart group, has decreased continually since 1880, and it is thus evident that there has been a transfer of deaths from these undefined heart diseases to the definite heading of valvular disease and endocarditis. Further confirmation of this view is found in the fact that the increase in valvular disease is greatest at ages over 65 years ; for it will be appreciated that the diagnosis, in deaths from this cause occurring at ages below 65 years, when complications are less frequent, is more definite than at high ages when, owing to general functional decay, valvular disease is apt to be associated with diseases of the respiratory or nervous systems. With regard to cancer, on reference to the annual report or tne medical officer for 1923 (page 38) it will be seen that when the changes in the age-constitution of the population have been allowed for, as far as practicable, the cancer mortality per thousand living still shows increase, although among females the rate of increase has recently fallen, while at ages below 65 years the mortality has actually decreased. The view is still defensible that the increase in the mortality from cancer is very largely, at any rate, accounted for by increase in the population at high ages upon which the maximum mortality falls and by the great improvement in accuracy of certification. More than 30 years ago this hypothesis was maintained by Mr. George King, F.I.A., and Dr. (now Sir) Arthur Newsholme, in a paper read before the Royal Society (proceedings of the Royal Society, volume 54). At that time the amount of reliable statistical records of the incidence of cancer was limited. Since then, however. Dr. T. H. C. Stevenson has made detailed analysis of the records of cancer mortality in England and Wales and discussions bearing upon the question of the movement of the mortality rate in recent years will be found in the annual reports of the Registrar-General, notably those for 1911 (page lxxvi), 1913 (page Ivii), 1917 (page lxx) and 1922 (page 74). It should be borne in mind that cancer includes all malignant growths, growths which differ histologically as well as in age-incidence. The deaths from cancer cannot, therefore, be taken as exactly comparable in different districts and at different times. Cancer Diseases of the urinary system. The diseases of the urinary system consist principally of acute and chronic nephritis, and it will be seen from the Supplement to the Registrar-General's 75th Annual Report, Part III., p. ccxi. that, when full correction has been made for differences in the age- and sex-constitution of the population of England and Wales, the death-rate from these causes has increased continuously since 1841-50, though at ages below forty-five years some decrease has occurred since the "nineties." Diseases of brain and nervous system. The course of mortality from diseases of the brain and nervous system is probably not accurately represented by the curve given in the diagram. Many changes have occurred both in nomenclature and classification of the diseases contained in the group so that it cannot be said with any degree of certainty that the deaths comprised in this group in the early years precisely correspond as to cause with those of more recent years. In the "list of causes of death," drawn up in 1837, cephalitis and hydrocephalus were both included in the group of brain diseases; subsequently, in 1847, hydrocephalus, which was mostly tubercular meningitis, was transferred to the group of tubercular diseases. The term "cephalitis" gave place in 1881 to the heading "inflammation of the brain "and this was replaced in 1901 by " meningitis (not tubercular)". As, however, in the early years cephalitis 22 and hydrocephalus were not specifically divided into tubercular and non-tubercular brain disease it was necessary to include both in this group throughout the period. Other causes of death of importance comprised in the group are paralysis and insanity. Dealing first with simple and tubercular meningitis, both are mainly fatal among children under five years of age and the course of mortality from these and other orain diseases at these ages is found to be very similar to that from convulsions, there being some tendency to increase up to the "eighties," owing to the increase of the population under five years of age, while subsequently, partly as a result or reduction in the births and partly owing to diminution in the incidence of meningitis, both simple and tubercular, the curve shows a sharp decline. A comparison of the movement of the mortality from diseases of the brain and nervous system at ages under five years with that of deaths over five years of age shows that, in the first 30 years of the period covered by the diagram, during which an increase occurred in the deaths over five years of age, there was practically no change in the deaths under five years. In subsequent years the figures for the two age groups are similar until about 15 years ago, when the deaths under five years of age began to fall more rapidly. With regard to paralysis and insanity, these two headings were retained unaltered in the List of Causes of Death from 1841 to 1880, but in 1881 radical changes were made so far as the different diseases which were comprised under these two headings are concerned. Thus, general paralysis of the insane becomes classed with insanity, while diseases included under the heading of " paralysis " were distributed to various stated causes of death. The group includes diseases, the syphilitic origin of which was not at the time recognised, which form a considerable portion of the deaths among the insane. There can be little doubt that progressive improvement in the certification of deaths among inmates of asylums occurred in the course of the period from 1841 to 1925. The Lunacy Commissioners were appointed in 1847 and gave place to the Board of Control in 1914. In 1844 only about 20 per cent. of insane persons were accommodated in County asylums; in 1869 about 43 per cent. were so provided for, while in 1924 there were nearly 80 per cent. thus accommodated. The development in municipal provision for the insane has undoubtedly been accompanied by improved certification of deaths, and this in conjunction with the changes in methods of classification referred to above makes it a matter of doubt as to how far the curve for brain and nervous diseases in the diagram can be regarded as representing the actual changes in the incidence of these diseases. It may be added that from 1841 to 1857 delirium tremens was included among diseases of the nervous system, and the deaths from this cause are not included in the figures upon which the diagram is based. The number of deaths attributed to delirium tremens and intemperance varied little from 1841 to 1880, and as the population during this period increased considerably, the death-rates per thousand living had actually declined. There was, however, no decrease in the amount of alcohol consumed per head of population, and it is, therefore, doubtful how far reliance can be placed upon the mortality rates as an index of the effects of alcoholic excess upon mortality. From 1881 the heading "delirium tremens and intemperance " was replaced by "alcoholism," and from thence onwards to 1901 there was a rapid increase in the number of deaths under this new heading, the deaths being more than trebled in the twenty years. There is, during this period, no corresponding increase, either in the proceedings for drunkenness or in the amount of alcoholic liquor consumed per head of the population and the increased mortality classed to alcoholism must rather be due to better certification than to any considerable increase in deaths from this cause. Among the diseases directly associated with alcoholism, cirrhosis of the liver takes a prominent place (see Annual Report of the Registrar-General, 1911, page 23 xliii.,and similar tables in later reports). Cirrhosis of the liver was not separately stated as a cause of death until 1881, and although the number of deaths so certified increased in the course of the next 20 years the increase was small, and in fact, negligible in comparison with that noted under the heading of alcoholism in the same period. From about the end of "the nineties" the deaths registered as due to alcoholism declined rapidly and, as a decrease is also apparent in the deaths from cirrhosis, it is clear that the reduced consumption of alcohol has been the cause since then of the reduction in mortality from alcoholic excess. It has been shown that there is a want of correlation between the recorded deaths from alcoholism and the extent of alcoholic excess as shewn by the consumption of alcohol per head of the population ; and it is the general opinion that the deaths recorded as due to venereal disease afford no real indication either of the extent of venereal affections or of the variations in their prevalence since 1840. The deaths directly attributed to venereal disease show decrease since about 1900, and there is strong reason for believing that there has been a notable decline in the mortality caused directly or indirectly by venereal disease. It will be readily understood that while a decrease in the incidence of venereal disease and in diseases resulting from alcoholic excess might not immediately affect the deaths registered as due to syphilis and alcoholism, it would have a material influence upon the deaths in later life from diseases known to result from these causes. Some part of the decrease shown to have occurred in the mortality from diseases of the nervous system and from bronchitis may perhaps be looked for here. There has, it will be observed, been but little change in the number of deaths from diseases of the digestive system, notwithstanding the increase in the population at risk. The deaths recorded in this group have undoubtedly been reduced as the result of improved diagnosis and certification, for it includes several headings, such as ascites, teething, stricture of the intestines, etc., which are of an indefinite character. Not much, therefore, can be concluded from the curve, but it is of interest to note that, although the use of preservatives in food has been assigned as the cause of certain diseases of the stomach and intestines, there is little evidence of any increase in diseases of the digestive system as a whole in recent years. Ill-defined and nonspecified causes of death. A curve showing the mortality from ill-defined and non-specified causes of death is included in the diagram on page 18. The group consists largely of deaths among infants from ill-defined causes associated with premature birth, and the movement of the mortality recorded in this group is, therefore, governed more by changes in the birth-rate than by improved diagnosis and certification; this will be clear from the close similarity of this contour to that of convulsions. All causes. On reference to the diagram on page 18, it will be seen that during the twenty years, 1841-1860, the death-rate from all causes in London showed no tendency to decline. Thereafter there was a steady decrease, the rate of decline being accentuated in the last twenty years. On comparing the course of the London mortality with that of European countries generally since 1840, much the same movement in the mortality is found to have occurred, as is shown by a French Government publication, " Statistique Internationale du Mouvement de la Population, 19011910" (volume 2, page 119). In this volume a diagram is shown of decennial mortality in the principal European countries and, while broadly speaking, there was not much change in the decennial mortality rates from 1841-1850 to 1871-80, some countries showing increase and some decrease, after 1871-1880 there was no exception to the rapid decline of the death-rate, though the decrease was small in Ireland. Generally speaking the amount of the decrease is greatest in the countries which had the highest rate in the "seventies." It is of course not practicable to deal here in detail with all the changes which have played a part in reducing the deaths from all causes in London since 1840, and from what has been said in regard to the similarity of the general movement 24 of the European death-rate to that of London it will be readily understood that too much importance may easily be assigned to purely local factors. With regard, however, to the zymotic diseases, epidemics of cholera and fever led to improvement of the water supply and methods of sewage disposal. In regard to smallpox, the more effective enforcement of vaccination by the appointment of public vaccination officers in 1871 must be associated with the downward trend of smallpox mortality from about that time. In the early " seventies'' food prices and food supplies became stabilised, and attention was directed to the housing conditions of the poor, many clearance schemes being initiated under the Artisans and Labourers'General Dwellings Act, 1875, and numerous tenement dwellings being provided by private bodies. In 1870 the Elementary Education Act was passed, and there can be little doubt that a great deal of the fall in mortality which dates from about the end of the "eighties," is to be associated with education. Among the factors which have had much to do with improvement in the diagnosis and certification of deaths, reference must be made to the greatly increased proportion of deaths occurring in institutions. The percentage of such deaths in successive ten-year intervals since 1840 are shown in the following table :— Year. Percentage. Year. Percentage. Year. Percentage. 1841 14.5 1871 18.3 1901 33.4 1851 15.5 1881 20.9 1911 41.3 1861 15.8 1891 25.6 1921 49.2 Smallpox. Infectious Diseases. The attack-rates and death-rates of the principal infectious diseases in London and the constituent boroughs are shown in the table on page 77. During 1925, 15 cases of smallpox were notified as occurring within the administrative county of London, of which five were found not to be suffering from smallpox on revision of diagnosis. Another case was discovered in London but was referable to the Port of London authority. Of the 10 confirmed cases in London, 8 occurred in the metropolitan borough of Bethnal Green, and one of these (a hemorrhagic case) proved fatal—a female of 57 years who had not been vaccinated since childhood. The other two cases, which were both non-fatal, occurred in Lambeth and were apparently unassociated with the outbreak in Bethnal Green, although they were discovered about the same time. The character of the symptoms in both these patients indicated the mild type of smallpox which has been prevalent in the midlands and the north for the past few years. The Port of London case was that of a sailor who disembarked from his ship in the Port and was later in the same day diagnosed in a doctor's surgery in Stepney to be suffering from smallpox. Fuller particulars of the 11 cases to which reference has been made are given below. Comment was made in last year's annual report upon the continued prevalence of smallpox of a mild character in the provinces and upon the remarkable fact that hitherto London has escaped involvement in this epidemic. Of all the cities in the United Kingdom, London is probably the most vulnerable to attack, whether by the mild type of smallpox from the provinces or by the severer kind from the Mediterranean and the East, firstly because of the large number of visitors it receives yearly from the country or overseas, and secondly because, as a Port, it is in daily touch, through sea-borne commercial traffic, with all parts of the world. On this account it is all the more noteworthy that, apart from local and isolated outbreaks which occur from time to time, this vast metropolitan area remains, in spite of its susceptibility and great proportion of unvaccinated inhabitants, comparatively free from the disease. The following table which is quoted from the 25 report of the Chief Medical Officer of the Ministry of Health for the year 1924, and brought up to date, emphasises the foregoing remarks. Year. England and Wales (including London). London. Cases. Deaths. Cases. Deaths. 1911 289 23 72 9 1912 121 9 4 1 1913 113 10 3 — 1914 65 4 2 — 1915 93 13 11 3 1916 159 18 1 — 1917 7 3 — — 1918 63 2 35 — 1919 311 28 24 6 1920 280 30 18 4 1921 336 5 2 1922 973 27 65 20 1923 2,504 7 11 1 1924 3,797 8 4 — 1925 5,354 ? 10 1 1926 (first quarter) 3,408 ? — — The Council has, throughout the year, continued to place at the disposal of medical officers of health and general medical practitioners within the Administrative County, as well as in certain of the Home Counties and extra-metropolitan areas, the services of its expert medical staff in the diagnosis of suspected cases, and has actively co-operated with sanitary authorities both inside and outside the County in taking all possible preventive action. In this connection it may be mentioned that all known contacts of cases occurring in London and persons known to have been exposed to smallpox in the provinces or abroad and who came to London, were kept under surveillance. A brief account of the cases of smallpox discovered in London during 1925 is appended. The outbreak in Bethnal Green. A series of eight cases of smallpox occurred in the borough of Bethnal Green between the 23rd April and the 22nd July, 1925. Six of the patients were adults, whose ages ranged between 30 and 57 years, only one of whom had been vaccinated since infancy, i.e., in the Army during the war. There was one fatal case, a woman aged 57 years, who had not been vaccinated since infancy. The remaining two cases were unvaccinated children aged 2 and 4 years respectively. The type of illness was stated to be of the N. African strain. The first patient fell ill on the 16th April. He was a shipping clerk, "H.L." aged 30 years, and was employed in the City of London. He did not consult a doctor until two days after the onset of illness and it was not until the 20th April that a rash appeared. Dr. J. A. H. Brincker was called in consultation to give an opinion on the 23rd April and he pronounced the case to be one of smallpox in a comparatively mild form. The patient had, about a fortnight before his illness, visited a warehouse at Tilbury Docks to obtain samples of cotton and woollen rags for his firm. The bales of rags from which the samples were taken were conveyed from India by the S.S. " City of Naples," which left Rangoon on the 22nd January. A member of the crew was landed from this vessel on the 2nd February, at Negapatam suffering from smallpox, and it is possible that he was either infected in the course of loading the bales or that he infected them after his illness developed. The bales were dispatched from Tilbury before it was known that the shipping clerk had contracted smallpox, but they were eventually traced and disinfected before any distribution of the rags had taken place. During the week-end 2nd-3rd May, four other members of the shipping clerk's family, his wife, aged 31 (vaccinated in infancy), and three unvaccinated children, 26 aged 10(m.), 4(f.), 2 (f.), years respectively, were notified and removed to S. Wharf. The boy, aged 10 years, was subsequently found not to be suffering from smallpox; in the case of the female child of 2 years the rash was confluent. All the members of the family were vaccinated after the removal of "H.L.", but as he had been suffering for some days before the nature of his illness was discovered, the vaccination was of no avail, except perhaps in the case of the boy, aged 10 years, whose escape may have been due to his not having been infected at all, or to the fact that he was infected at a later date and in time for vaccination to overtake the process of incubation. On the 11th May, " A. W. W.", a male aged 47 years, a disinfector employed by the Bethnal Green borough council, developed a rash and consulted a private doctor, who notified the case as one of scarlet fever the following day. His movements had been uncontrolled for at least 24 hours after the appearance of the rash. The patient was removed to the Eastern Fever Hospital, where the Medical Superintendent suspected smallpox and had the man removed on the 13th May to S. Wharf, where the diagnosis of smallpox was confirmed. The members of the disinfector's family refused vaccination, with the exception of his wife, but fortunately they escaped attack. No further cases occurred until the 23rd June, i.e., six weeks later, when "E. H.," a female aged 57 years, who had not been vaccinated since childhood, developed an attack of hæmorrhagic smallpox. She was seen by Dr. W. McConnel Wanklyn, who confirmed the diagnosis. The patient died in hospital the next day. She was employed as a charwoman at various addresses in S. Hackney and was last at work on the 17th June, two days after she fell ill, the rash having appeared on or about the 18th June. She had been attended by two local doctors and had been seen by Dr. Oates, the medical officer of health of Bethnal Green, who called in Dr. Wanklyn. The source of infection was obscure, but the chain of events pointed to some undisclosed case or cases (presumably associated with the disinfector already referred to) having been responsible for her infection. The outbreak came to an end with the occurrence of two further cases living next door to the last mentioned patient, viz., a man and his wife, aged 57 and 59 years respectively, neither of whom had been vaccinated since infancy. All possible precautions were taken by Dr. G. E. Oates, the medical officer of health, including house to house visitations, circularisation of medical practitioners, vaccination of contacts where consent could be obtained, immediate removal to hospital, disinfection, etc., and it is gratifying to record that the disease did not spread further. As an illustration of the difficulties encountered in the matter of vaccination it may be mentioned that at Olga Street L.C.C. School, which was situated in the heart of the affected area, out of 1,370 children on the roll, 799 had never been vaccinated, and a further 116 had not been vaccinated within the last 10 years. Arrangements were made for a public vaccinator to visit the school, but in only 27 cases was the consent of the parents to the vaccination of their children obtained. This school was kept under close supervision throughout by the school medical officer, and fortunately no case of smallpox occurred among the pupils. Finally it may be mentioned that the Bethnal Green borough council made chickenpox a notifiable disease for two months from the 13th July, 1925. Cases of "provincial" smallpox in Lambeth.—A case of smallpox of the milder type, which has been occurring for some years past in the midland and northern counties, was discovered in Lambeth about the time when the secondary cases in Bethnal Green occurred, and it was at first thought that the patient may have been infected from that area. Enquiries contra-indicated this, firstly because no possible connection could be traced, and secondly the type of disease was different as already stated. The patient, E.J., an unvaccinated girl of 17 years, a resident in the borough of Lambeth, was removed to S. Wharf on the certificate of Dr. 27 Priestley, medical officer of health, on the 4th May. She had developed the disease a week before she came under medical observation and had been freely moving about, going to cinemas, etc. She was employed by a firm in Aldersgate Street, E.C., as a paper folder, and attended work for about 4 days after the rash first appeared. All the employees were vaccinated, with but few exceptions in which consent was withheld. All the known contacts were kept under close observation and only one additional case occurred, namely, the father of the girl, aged 66 years, unvaccinated since infancy. He was not revaccinated when his daughter was discovered to be suffering from smallpox as he was already sickening when the public vaccinator called. His rash appeared on the night of the 8-9 May, and he was removed to hospital on the latter date. No further cases occurred. Port of London case.—On the 29th January, the S.S. Hadrian, a coasting vessel plying between Newcastle-on-Tyne and London, arrived in the Free Trade Dock, Shadwell. One of the ship's firemen, W. B., aged 27 years (unvaccinated since infancy), left the ship and went to a doctor's surgery in High Street, Shadwell, where he was found to have smallpox, the diagnosis being confirmed by Dr. D. L. Thomas, medical officer of health of Stepney. He was at once removed to hospital. Dr. Willoughby, medical officer of health of the Port Sanitary Authority, found that another member of the ship's crew had just recovered from a mild attack of smallpox ; this patient had been working on board throughout the attack. The remainder of the crew were vaccinated and all the necessary precautions were taken. The passengers had already disembarked, and, as the ship was a coasting vessel, their names and addresses were not taken. Further investigations showed that there had been an outbreak of " influenzal colds " among the crew on board the ship on her previous journey and the patients had been left at Newcastle. The history suggests that these earlier cases of illness may have been mild smallpox of the type prevalent in Durham and the north generally. No further developments occurred in London, but this occurrence once again indicates the possibility of introduction into London of the particular kind of variolous infection now prevalent in the provinces. Miscellaneous cases affecting London.—It will be of interest to record the following cases which, though non-residents of London, represented potential danger to the metropolis. (i.) A girl, "E.W.," aged 15 years, came from Nuneaton to stay at an address in Fulham during the period 21-28 December, 1924. On the 3rd January, 1925, the medical officer of health of Fulham ascertained that during the period of her stay in London, her brother and four of her coworkers were notified to be suffering from smallpox. On her return to Nuneaton, the girl herself was examined and was deemed to have suffered from a mild attack of the disease. Enquiries showed that whilst she was in Fulham she had a few spots on her face which cleared up under ointment treatment. All the necessary precautions were taken, including supervision and vaccination of contacts, and although her movements were in no way restricted, whilst in London, no further developments arose. (ii.) On the 30th May, 1925, Dr. Hyslop Thompson, medical officer of health of Hertfordshire, reported the occurrence of a case of smallpox in Radlett. The patient, an adult male, who had been vaccinated in 1910, and again in 1919 with negative result, returned from a visit to Switzerland on the 14th May and the rash appeared on the 28th May. The case was of a mild type, and it is probable that he contracted the infection in Switzerland, or more possibly during his journey home. There was a large number of contacts, many of whom travelled daily to and from their businesses in London. All the direct contacts were vaccinated or revaccinated and no further cases occurred. 28 Measles. In addition to the above-mentioned cases, large numbers of possible smallpox contacts proceeding to London, from ships arriving in this country from abroad on which cases of smallpox had occurred, were reported by port sanitary authorities, from time to time, and these were kept under observation by the medical officers of health of the boroughs concerned. Special attention was also devoted to common and seamen's lodging-houses, in this connection, by the Council's inspectors. Measles caused 345 deaths in London during 1925, the death-rate being -07 per thousand as compared with .29 in 1924 and .08 in 1923. Measles is generally prevalent in London every other year and was prevalent in 1924 so that an epidemic became due in 1926. Signs of this epidemic were already evident in the autumn of 1925 (and in the last quarter of 1925 and the first quarter of 1926) the deaths numbered 921, as compared with 1,130 in the corresponding quarters of 1923-24. The administrative steps taken to lessen the spread and reduce the mortality from measles in recent years are discussed in page 102 of this report to which reference should be made. Whoopingcough. There were 869 deaths from whooping-cough in London during 1925, the deathrate being .19 per thousand as compared with .11 in 1924. Figures showing the course of mortality from whooping-cough in recent years are shown on page 100 of this report. Scarlet Fever and Diphtheria. The scarlet fever attack-rate in London during 1925 was 2.7 per thousand living as compared with 2.5 in 1924. In the rest of England and Wales the corresponding figures were 2.3 and 2.1 respectively. Of a total of 12,215 cases of scarlet fever notified in 1925 (52 weeks) 6,758 or 55 per cent. were between 5 and 15 years of age, deaths at this age period numbering 32 or 0.5 per cent. of the cases. The corresponding percentages for 1924 were 53 and 0.5 respectively. The total number of cases of scarlet fever notified in 1925 shows an increase upon the number notified in 1924 and suggests that the trough of a wave which reached its maximum in the year 1921 has now been passed and, assuming a repetition of the 7 year period which has been the rule since 1907, a further rise in the number of cases may be expected in 1926. The diphtheria attack-rate in London during 1925 was 2.7 per thousand living as against 2.3 in the two preceding years and 2.0 for the 10 years 1911-1920. The London attack-rate is considerably higher than that for the rest of England and Wales, which was 1.0 per thousand living in 1925. Of the total cases notified in 1925, numbering 12,472 (52 weeks), 6,041 or 48 per cent. were among children aged 5 to 15 years, while the deaths were 178, giving a case-mortality for this age-period of 2.9 per cent. The corresponding figures for 1924 were 43 per cent. and 3.9 per cent. respectively. Diarrhœa and Enteritis. Diarrhoea and enteritis caused 889 deaths among children under 2 years of age in London during 1925, this being 10.79 per thousand births. The corresponding rate in 1924 was 8.73. Cancer. There were 6,628 deaths from cancer in 1925 as compared with 6,483 in 1924, the death-rate per thousand living being 1.44 as against 1.42 in 1924, 1.39 in 1923 and 1.21 in ten years 1911-1920. A further report on Cancer of the Breast, with special reference to its associated antecedent conditions, by Dr. Janet Lane-Claypon, has been issued by the Ministry of Health (Eeports on Public Health and Medical Subjects No. 32). Dr. Lane-Claypon obtained records relating to some 508 cases of breast cancer among women and of 509 women of similar social and civil condition not suffering or having suffered from cancer. A comparison of the two series of records confirms the observation that cancer of the breast is more frequent among the unmarried, and further shows that among married women the incidence is greater among those who have not suckled their children or are childless. Among antecedent conditions most frequently associated with breast cancer is injury of the breast. 29 In No. 99 of the Special Report series of the Medical Research Council, Dr. Matthew Young and Mr. W. T. Russell discuss the incidence of Cancer in relation to various trades and professions. Anthrax. During 1925, seven cases of anthrax occurred in London, of which two died. The infection was attributable in five instances to the handling of foreign hides and, in one case, to wool derived from the East. The remaining case was ascribed to the use of an infected shaving brush. Plague and Cholera. No cases of plague or cholera occurred in London during 1925. Typhus fever No cases of typhus fever occurred in London during the year. Cerebrospinal fever. Of the 95 cases notified during 1925, 23 were not regarded as genuine cases ; on the other hand 21 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 therefore was 93, of which 76 (82 per cent.) proved fatal, as compared with a mortality of 79 per cent. the previous year. Poliomyelitis, and polioencephalitis. During 1925, 55 cases of this disease were notified, and of these 7 were not regarded as genuine cases. There were 7 deaths. Reference was made in last year's annual report to the arrangements made for the London County Council and the Metropolitan Asylums Board to co-operate in securing treatment of London children suffering from poliomyelitis. Full provision is now made at Queen Mary's Hospital, Carshalton, for the treatment not only of cases entering upon the second stage of the disease (deemed for this purpose to be three months after onset), but also of those requiring correctional operations for resulting deformities. At present, 50 beds are placed at the disposal of the Council. The usual procedure is for cases to be submitted to the Council through the medical officers of health of the metropolitan borough councils. Cases considered suitable are referred to the Metropolitan Asylums Board, who allot a bed at Carshalton. The cost of treatment is borne by the Metropolitan Asylums Board, but certain cases are assessed and the amount collected as contributions, less a small charge for the expenses incurred in collection, is handed over to the Board to help to defray the cost of treatment. This arrangement has been in force since September, 1924. Up to 31st December, 1925, 40 cases had been sent to Carshalton for treatment. Encephalitis le hargica. A comprehensive report on encephalitis lethargica is contained on page 106 of the report of the school medical officer for the year under review, so that, apart from presenting the following statistical information concerning notified cases during 1925, it is not proposed to add here any further remarks on the subject. The number of cases of the disease notified during 1925 was 304, representing a considerable reduction upon the figures for the previous year, viz., 605. In 54 cases the diagnosis was revised, thus reducing the number to 250, of which 102 (40 per cent.) proved fatal, as compared with a fatality rate of 22 per cent. in 1924 and 45.9 per cent. in 1923. It will thus be apparent that the mortality rate is subject to considerable variation. Every case is closely followed up and it has been arranged with the medical officers of health of the metropolitan boroughs not only to furnish the Council with detailed particulars on a special card of all cases in the acute stage, but also to follow up cases among persons of non-school ages at least every six months for the purpose of obtaining progress reports; the subsequent domiciliary enquiries into cases occurring among children attending the Council's schools are undertaken by the school care committees. In this way a considerable amount of valuable information is accumulated. The following tables will be of interest as showing (1) the age incidence of actual cases and (2) the yearly prevalence of the three kindred diseases, cerebro-spinal fever, poliomyelitis (including polioencephalitis) and encephalitis lethargica. 13651 c 30 Table of age incidence (actual cases). Age periods. Under 3. 3-5. 5-10. 1020. 2030. 3040. 4050. 50-60. Over 60. Total. Cerebro-spinal fever 57 9 7 13 2 — 1 3 1 93 Poliomyelitis and polioencephalitis 18 9 6 10 3 — 2 — — 48 Encephalitis lethargica 8 8 17 | 48 51 29 39 28 22 250 Table of yearly prevalence (notified cases). Year. 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. 1925. Cerebro-spinal fever 92 73 674 432 430 265 199 164 109 86 70 97 95 Poliomyelitis and polioencephalitis 145 93 97 197 53 53 96 65 59 40 112 116 55 Encephalitis lethareica Not notifable until 1st January, 1919. 86 149 243 72 101 605 304 Consultation risits During 1925, at the request of borough medical officers of health and general practitioners, 18 visits were paid in the metropolitan area to assist in the diagnosisof suspected cases of notifiable disease, e.g., particularly encephalitis lethargica, and less often, cerebrospinal meningitis and poliomyelitis. Five visits were paid in the borough of Paddington, three in Westminster and Hampstead, two in Islington and one in each of the boroughs of Lambeth, Woolwich, Stepney, Hackney and Ealing. Of the eighteen patients visited at their homes, 13 were regarded provisionally as suffering from encephalitis, 10 in the acute stage and 3 in the later stages; of the disease. Two were thought to be possible cases of cerebrospinal meningitis, and two tuberculous or other form of meningitis. Poliomyelitis and septicaemia. following tonsillectomy were temporarily diagnosed in the remaining two cases. The ages of the patients ranged from 15 months to 69 years. Encephalitis lethargica (Acute stage.)—In seven out of 10 cases, the consultation opinion supported the provisional diagnosis of encephalitis and notification was. advised. Lumbar puncture was performed in two cases and yielded practically normal cerebrospinal fluid. Diagnosis was confirmed by subsequent events resulting in apparent recovery in two and death in three cases. Of the two not so confirmed, one patient was ultimately decided to be suffering from mental disorder not attributable to encephalitis, and the other died two months later from cerebral haemorrhage, a previous attack of which was probably responsible for the original condition diagnosed as encephalitis. Diagnosis of encephalitis confirmed. 1. Male, aged 30 (professional football player). Symptoms.—Sleeplessness (4 nights). Internal squint and diplopia. Nystagmus. Slight disorientation. Tremor of hands. Temperature 99.2. (two weeks). Result.—Slow recovery. Attempt to resume employment but proved unfit. 2. Female, aged 53. Symptoms.—Pain in head. Lethargy. Nausea. Transient diplopia. Clonic muscular spasms. Temporary defective speech. Result.— Partial recovery, but mental instability. 3. Female, aged 60. Symptoms.—Headache. Increasing lethargy. Inability to speak or show response. Result.—Death three months after onset. 4. Female, aged 65. Symptoms.—Inability to walk. Insomnia. Temporary squint and diplopia. Loss of memory, lethargy and coma. Result.—Death two weeks after onset. 5. Male, aged 53. Symptoms.—Headache. Insomnia. Later gradual and increasing lethargy. Clonic muscular spasms. Lumbar puncture—normal cerebrospinal fluid. Result.—Death one month after onset. 31 Diagnosis of Encephalitis not confirmed. 1. Female, aged 62. Symptoms.—Feverish attack for three days. Temperature 101. Pain in back and arm. Drowsiness 10 days. Result.—After removal to hospital—diagnosis of mental disorder, delusions and history of suicidal tendency. 2. Female, aged 55. Symptoms.—Sudden " Fit."—unconscious, vomiting, convergent squint and diplopia. Insomnia. Later—drowsiness. Result.—Complete recovery in hospital. Diagnosis.—Cerebral arteriosclerosis. High blood pressure causing cerebral haemorrhage. Later—returned home. Death occurred two months afterwards from sudden apoplexy. In three cases the clinical features did not suggest encephalitis and the diagnosis was amended and subsequently confirmed as follows:— 1. Male, aged 8.—Original diagnosis—Tuberculous meningitis or encephalitis. Symptoms.—Headache and pain in left eye. Temperature 102. Drowsiness. Painful swelling of left orbit. Amended diagnosis.—Orbital cellulitis as the result of blow. Progress.—Complete recovery. 2. Male, aged 32. Original diagnosis.—Encephalitis lethargica(?) Symptoms.— Sudden faintness and loss of consciousness. Fall on head, giddiness, headache, vomiting. Amended diagnosis.—Cerebral concussion. Progress.—Prompt relief following lumbar puncture and withdrawal of 30 c.c. blood-tinged but normal cerebro-spinal fluid. Rapid recovery. 3. Female, aged 45.—Original diagnosis.—Encephalitis (?). Symptoms.—Headache, slight ptosis. Amended diagnosis.—Migraine. Progress.—Cerebral haemorrhage, slow improvement. Of three cases originally diagnosed as presenting postencephalitic sequelae one only could be regarded as probably attributable to an attack of encephalitis, and one possibly so. 1. Male, aged 15 months. Symptoms.—Initial attack. Internal squint and drowsiness at 4 months. Later, convulsive attacks and vomiting. Sequel.— Arrested mental development. 2. Female, aged 19. Symptoms.—Two months' inability to concentrate on her work. Severe headaches, emotional, hiccup. Diagnosis.—Evidence in favour of initial encephalitis uncertain ; neurasthenia. 3. Male, aged 11. Sytnptoms.—Raised temperature. Diplopia and slight squint. Diagnosis.—No evidence of encephalitis. Defective vision requiring correction by glasses. Cases provisionally diagnosed as possible but doubtful cerebrospinal fever or other form of meningitis or poliomyelitis. 1. Female, aged 69. Symptoms.—Headache, drowsiness, pains in limbs, petechial eruption on trunk and legs, raised temperature. Diagnosis.—No evidence of meningitis, probably rheumatic purpura. Result.—In hospital—acute lymphatic leucaemia, determined by blood examination. Death four days later. 2. Male, aged 4. Symptoms.—Raised temperature, pain in back of neck, slight squint and twitching of eyelids. Erythema. Diagnosis.—No evidence of meningitis or encephalitis, probably influenza. Result.—Rapid recovery—Influenza. 3. Female, aged 13 months. Symptoms.—Raised temperature, drowsy, irritable, squint. Diagnosis.—No evidence of meningitis or poliomyelitis. Condition due to teething, and gastric disturbance. Result.—Rapid recovery—Teething and Constipation. 4. Female, aged 7.—Symptoms.—Following tonsillectomy raised temperature to 104 and 105. Diagnosis.—No evidence of meningitis. Septicaemia. Result.— On removal to hospital gradual recovery from septicaemia. 5. Female, aged 3.—Symptoms.—Diarrhoea, sore throat and pains in leg. Raised temperature, (?) poliomyelitis. Diagnosis.—No evidence of poliomyelitis, probably Influenza. Result.—Rapid recovery. Influenza. 13651 C 2 32 In all of the five cases the evidence at consultation was not in favour of any notifiable condition as at first apprehended, and the opinions then expressed, with one exception, were borne out by the subsequent course of events. Influenza. The total number of deaths attributed directly to influenza in 1925 was 1,082. Influenza was prevalent during the winter months of the year and the mortality reached a maximum in the sixth week, the deaths in that week numbering 92. Influenza was also somewhat prevalent towards the end of the year when, during several successive weeks, an abnormally low temperature was recorded. The influenzal group of diseases.—During 1925, encephalitis lethargica (see Table on p. 30) was less prevalent than in 1924, while cerebrospinal fever and poliomyelitis showed no exceptional activity. During the year the Watsonian lectures, on " The epidemic diseases of the central nervous system," were delivered by Dr. A. K. Chalmers, before the Royal Faculty of Physicians and Surgeons of Glasgow. Dr. Chalmers began by remarking concerning the group of diseases in question—" I have been influenced by a desire to ascertain whether any common picture could be formed of their origin and method of spread, rather than by any hope that I can add to the clinical knowledge of their several forms." In a word, he studied the group from the epidemiological rather than from the purely clinical point of view; regarding the subject under examination as a mass phenomenon; as he himself expresses it, in one of his final paragraphs, "It is the history of the symptoms as they develop rather than the impression which they create at any given observation which counts in their recognition." Sir William Jenner, when he set about a corresponding attempt to classify the continued fevers proceeded mainly on clinical lines. He begins, it is true, by an allusion to the beautiful emblem, that of Plato's "den," which warns us that " though men live, indeed, in the view of the heavens, yet our minds are confined in the caverns of our bodies." He elected deliberately, however, in his study of the continued fevers to proceed in the main clinically, and on an understanding that he would "neither divide, where Nature has drawn no line, nor generalise where Nature has bestowed no unity." In reporting upon "influenza" in London in 1918 in the Annual Report for that year, it was felt to be essential, on the other hand, to adopt the epidemiological point of view, and following Creighton, take account of "gradations, modifications, affinities being careless of symmetry, of definitions or clean cut nosological ideas, or the dividing lines of a classification." It has, it is true, undoubtedly been more usual of late years to attach paramount importance to the purely clinical point of view, or at any rate to give epidemiology only a second place, as in the formula " when the object is to ascertain the nature of an illness, clinical and epidemiological similarities between it and other diseases are of less value than differences." Emphasis upon such a formula is, clearly, however, more justifiable in enquiring as to the nature of individual illnesses than in studying an epidemic, particularly if this should chance to be one of so protean a character as an epidemic of influenza. Dr. Chalmers, as an epidemiologist, does not hesitate; he considers "the setting in which the new diseases occurred"; he says, "all of them have been associated in a way sometimes suggesting a causal relationship between them he cites the pioneer work of the late Dr. Wallace Anderson, of Dennistoun, in tracing relationship between sporadic cases of cerebrospinal fever right away back in the early "nineties" and the later epidemic cases of 1906-08, and says that Dr. Anderson correctly interpreted the position in regarding the disease as having been present in Glasgow, at least, all through the "nineties" decade; he further considers the "phases of the epidemic period"; he asks "under what nosological disguise does the sporadic case lurk in the intervals "; and he suspects that it is in the guise of "tuberculous meningitis"; he refers to Dr. Matthew Hay's report on the Aberdeen 33 outbreak of 1916, almost contemporaneous with the famous New York outbreak of "poliomyelitis" ; and, finally, he attacks the problem of the two types of affection of the nervous system, "polioencephalitis" and "lethargic encephalitis," occurring in 1918-19, these two designations being at first, as he notes, " used as probably interchangeable terms." The recrudescences of "encephalitis lethargica" of 1920 and of 1923-24 were, he finds, associated with "well marked irritative symptoms, which were usually slight or absent in the cases occurring in the years when the cases were fewer." "The only result of this was that the clinical picture tended to become confused, and meningitis, pneumonia, insanity, acute chorea, cerebral haemorrhage or abscess, and influenza, among others, are among the names which might ultimately obscure the presence of encephalitis lethargica or be mistaken for it." The similarity of experience, in these epidemics of the central nervous system, as studied epidemiologically in Glasgow and in London, certainly seems to confirm the advice given by Sydenham, " If any one ask how he is to fish out the species of a particular fever let him choose for his field of observation some large and populous place." In the outbreaks of 1920 and 1923 in Glasgow, as in some parts of America and elsewhere, it is noted there was a "substitution of symptoms of cerebral irritation for somnolence or lethargy in the initial stages"; this, however, as already stated last year, was not a very marked feature in London, and analysis of the commoner symptoms in more recent prevalences confirms this impression. Dr. Chalmers studied the question of "cases following or associated with other illnesses," a subject enquired into also in London, both in connection with cerebrospinal fever and encephalitis lethargica. A map is given by Dr. Chalmers showing topographical distribution of cases of encephalitis lethargica in Glasgow. Dr. Shrubsail has for some years past been engaged in studying the topographical distribution of heart cases among children in the special schools of London, and has found evidence of a tendency to concentrate in the river valleys. (See p. 126.) With a view to comparison between the grouping of these cases and that of encephalitis lethargica, the London cases of both diseases are shown in the map on p. 125. The lesson to be learnt from these studies of Dr. Chalmers is that "if we are to accept the succession of detached outbreaks, as linked up with each other through a chain of sporadic cases, the field of enquiry cannot well be limited to epidemic periods alone. Nor can it, with much hope of advance, be limited to the few clinical types, which, by reason of their gravity, compel attention." Dr. Chalmers is, indeed, justified in claiming recognition of those "gradations, modifications, affinities," which Creighton insisted upon in studying epidemic diseases. It is the method of Hippocrates and Sydenham; and it is one which complies with the demand of Heraclitus, that men should seek the sciences not in their own narrow worlds but in the wide one. The deaths from influenza in the autumn and winter of 1925-26 were as follows:— Week No. Deaths. Week No. Deaths. Week No. Deaths. 1925. 1926. 1926. 45 8 1 24 11 19 46 10 2 16 12 27 47 16 3 11 13 48 48 22 4 14 14 74 49 22 5 10 15 59 50 26 6 16 16 35 51 14 7 12 17 28 52 27 8 20 18 23 9 12 19 15 10 15 34 The following note relating to the periodicity of influenza prevalences prepared, by Mr. Spear of the public health department, a year ago, is of interest, inasmuch as the week in which the maximum influenza mortality was to be expected in 1926 is indicated by Mr. Spear as being the 11th week, which, as will be seen from the above table, is within three weeks of the actual time of maximum. There appears to be a law governing the interval separating successive influenza "waves," and a fairly accurate forecast can, as Mr. Spear shows, be made of the time likely to elapse between an epidemic and its successor. Note by Mr. B. E. Spear on Periodicity in Influenza. On summing the weekly mortality in London in the past 36 years it is found that the greatest number of deaths occurs about the 9th or 10th week of the year, while the minimum mortality is reached about the 35th or 36th week. This latter period seems to be in the nature of a limit up to and from which influenza " waves " surge and rebound. For instance, in the remarkable epidemics of 1918 the first reached its climax in the 28th week. It was followed by the great epidemic of the autumn of that year with a maximum mortality about the 44th week. The first epidemic it will be noticed reached its climax about 8 weeks before the period associated with the minimum seasonal mortality, while the corresponding phase in the succeeding epidemic was reached 8 weeks after that period. This balancing about the 35th or 36th week of the year appears to be characteristic of influenza prevalences and may, therefore, be made to serve as a means of forecasting approximately the time when a prevalence may be expected. Since 1889 there have been 39 prevalences or epidemics of influenza in London and of these the method would have failed to forecast 3, while it foreshadowed a prevalence in 1896 of which the maximum cannot be located in the small figures of London deaths, though in Copenhagen, where influenza is notifiable, cases reached the maximum about the time expected. In addition there were in 1900 two influenza prevalences within 14 weeks of one another, and here the forecast falls midway between the two. The second of these two prevalences was a relatively small one and is not shown at all in the Copenhagen figures of cases. The remaining prevalences follow the rule of balanced incidences about the 35th week approximately, and in 21 instances the error does not exceed 4 weeks. (See tables on pages 36 and 37.) The diagram on page 35 illustrates the balancing of the epidemics. The contours show the influenza mortality in 4-weekly periods in the years indicated. The vertical line passes through the 4-weekly period which contains the 35th week of each contour, and it will be seen that the epidemics tend to balance about this line. On reference to the table on page 37 it will be seen that the error in the forecast based on the second epidemic of 1916 was greater than in any other year except 1920, being 11 weeks later than expected. The epidemic due at the end of 1891 was 7 weeks too late, while the two epidemics of 1916 balanced exactly. In the Copenhagen section of the diagram, which is based upon cases instead of deaths, the vertical line is advanced two weeks, as the maximum cases during a prevalence is attained earlier than the maximum dea'hs. It may be thought that an error of 6 weeks in a forecast of this kind is considerable, but it must be borne in mind that the only way in which the prevalence can be timed from past mortality returns is by the week of maximum deaths, and while in some epidemics the maximum is sharply defined, there are others in which a nearly level mortality is maintained for two months or even longer, and in these instances it is difficult to locate the week in which the prevalence attained a maximum. Further, the balance of the epidemics about the late summers of each year suggests that some climatic condition is associated with the prevalence and in that case no rigid observance of set times can be expected. 35 36 Since influenza is prevalent normally during the winter months it might be thought that the assumption that an epidemic will recur in a year's time from any given prevalence would be as accurate as that given by the above method, but while such a forecast would serve well in the case of epidemics falling about the 9th week of the year, it would be hopelessly at fault in the case of epidemics several months later. Thus in the 7 instances where an epidemic has occurred after the 13th week and before the 35th week, the forecast would be nearly 15 weeks too late on the average, while the average error on the hypothesis of balanced incidence for the same instances would be less than two weeks. It may be asked, why the 35th week ? In regard to this it should be borne in mind that while it might be expected that the maximum temperature would be recorded at the time of the summer solstice, actually the maximum lags considerably upon this time. The lag, therefore, of 9 or 10 weeks, in the case of epidemics which take several weeks to develop, is not inconsistent with dependence upon seasonal conditions. Dr. Brownlee (Lancet, 8 Nov., 1919. Also Min. of Health, Influenza Report 1920, p. 575) has published a periodogram analysis of influenza mortality. In a discussion in the Lancet* of the results reached by him, it was pointed out that in certain epidemics the amplitude of the "wave" as measured by the mortality was so great as to over-shadow and practically to eliminate smaller prevalences and thus the periodogram shows a periodicity where none existed. The results obtained, on an assumption of Dr. Brownlee's 33 weeks' periodicity and by the suggested method of balanced incidences, are compared in the following table, in which are shown the errors in forecast of influenza prevalences in the years 1890-1924 inclusive, (I.) on hypothesis of balanced incidence about the 35th week of the year, and (II.) on hypothesis of periodicity of 33 weeks. Method of forecast. Forecast too early by Forecast correct to within 4 weeks. Forecast too late by 14 weeks or more. 5—13 weeks. 5—13 weeks. 14 weeks or more. I — 6 20 6 1 II 2 6 8 9 8 It may be of interest to note that the last prevalence of influenza in London reached a maximum in the 6th week of the year (1925). This is 29 weeks before the 35th week and, therefore, the next prevalence should occur 29 weeks thereafter or about the 11th week of next year (1926). An "interloper" may arrive about the end of this year, but in London there have not been more than 3 such interloping epidemics in the past 36 years. In conclusion, although it appears from the London figures that forecasts as long ahead as two years can be made, the number of such instances is too small to justify any reliance upon them. These may, therefore, be dismissed and emphasis rather laid upon so much of the hypothesis as appears to be fully established, as well by the London and Copenhagen records as by others which have been examined, namely,— "When an epidemic of influenza reaches a maximum mortality in the half-year between the 9th and 35th weeks (i.) it will recur in the succeeding half-year, (ii.) the two epidemics will, as to the time relation of their mortality maxima, tend to balance about the commencement of the 35th week of the year. The table on page 37 shows that there are several instances in which the hypothesis fails, but with the reservation which thus attaches to any particular forecast it may be noted that a prevalence of influenza is indicated about the end of 1926. * The periodicity of Influenza. B. E. Spear, F.S.S., " The Lancet," 23th March, 1920. 37 Registration year (52 or 53* weeks). Week of influenza prevalence with maximum mortality. Interval from middle of week of maximum mortality. Expected interval to next maximum. Difference be tween actual and expected interval.† Registration year. (52 or 53* weeks). Week of influenza prevalence with maximum mortality Interval from middle of week of maximum mortality. Expected interval to next maximum. Duterence between actual and expected interval.† To commence ment of 35th week of year (weeks). To week of next maximum mortality (weeks) To commence ment of 35th week of year (weeks). To week of next maximum mortality (weeks). Column (3) 2. ('olunn (4)(5). Column (3) x o Column (4) — (5). (1) (2) (3) (4) (5) (6) (1) (2) (3) (4) (5) (6) 1890 3rd 31½ 69 63 + 6 1909 12th 22½ 46 45 + 1 1891* 20th 14½ 36 29 + 7 1910 6th 28½ 54 57 - 3 1892 3rd 31½ 63 63 0 1910 (48th) — — — — 1893 14th 20½ 36 41 - 5 1911 8th 26½ 52 53 - 1 1894 50th 36½ 64 73 - 9 1912 8th 26½ 56 53 + 3 1894 No prevalence — — — — 1913* 12th 22½ 46 45 + 1 1914 5th 29½ 55 59 - 4 1895 10th 24½ ? — — 1915 8th 26½ 61 53 + 8 1896* ? ? ? — 1916 17th 17½ 35 35 0 1897 16th 18½ 41 37 + 4 1916 52nd 34½ 80 69 + 11 1898 5th 29½ 58 59 - 1 1917 No prevalence – – – – 1899 11th 23½ 43 47 - 4 1900 2nd 32½ 60 65 - 5 1918* 28th 6½ 16 13 + 3 1901 10th 24½ 50 49 + 1 1918 44th 43½ 73 87 - 14 1902* 8th 26½ 48 53 - 5 1919 (9th) – – — — 1903 3rd 31½ 59 63 - 4 1920 12th 22½ 53 45 + 8 1904 10th 24½ 49 49 0 1921 13th 21½ 41 43 – 2 1904 (50th) — — — — 1922 2nd 32½ 64 65 - 1 1905 7 th 27½ 61 55 + 6 1923 14th 20½ 45 41 + 4 1906 16th 18½ 37 37 0 1924* 7th 27½ 52 55 - 3 1907 1st 33½ 60 67 - 7 1925 6th 28½ 60 57 + 3 1908* 9th 25 ½ 56 51 + 5 1926 14th 20½ ? 41 ? † Plus=Forecast too early) Minus=Forecast too late) by the number of weeks shown in column 6. Typhoid, Fever. There were 395 cases of typhoid fever notified in London in 1925 (52 weeks) as compared with 410 in 1924 (53 weeks). The deaths in the calendar year numbered 49 as against 53 in 1924. Of the cases admitted to the Metropolitan Asylums Board hospitals the diagnosis of typhoid fever (including continued fever) was not confirmed in 31.2 per cent., the corresponding percentage for 1924 being 25.7. In 24 instances two or more than two cases were notified from one house, as compared with 27 in 1924. Four of these 24 groups of cases were associated with an outbreak in the Croydon area attributed to infected food, there being one instance of 7 cases in one house, one of 5 cases and two of 4 cases. In the remaining 20 groups there were four instances of 3 cases in one house, one of these being in the area of an outbreak in Streatham attributed to infected milk. In 181 cases information was obtained in 1925 as to the results of bacteriological diagnoses. diagnoses. The following is an analysis of the returns, the corresponding figures for the two preceding years being also shown for the purpose of comparison:— Bacteriological diagnosis. 1925. 1924. 1923. Typhoid B. typhosus 29 61 48 84 93 123 " Typhoid " 32 36 30 Paratyphoid A 1 126 2 62 2 82 B 71 31 42 A and B 2 3 11 Undefined 52 26 27 Total number of cases in which information was received 181 141 196 Cases returned as both typhoid and paratyphoid, and therefore included twice in abovo statement 6 5 9 38 Of the six cases returned as both typhoid and paratyphoid in 1925, two were paratyphoid B, two A and B, and two were paratyphoid not further defined. The corresponding details for the five cases in 1924 were three paratyphoid B, one A and B and one paratyphoid not further defined, and for the nine cases in 1923, two paratyphoid A, four B, and three A and B. Notes on the epidemiology of typhoid fever. The great decline in this disease observed during the last 25 years, has aroused the keenest interest, and varied explanations have been given of the phenomenon. From a purely bacteriological point of view, it may perchance be noted that there is now available a new means of diagnosis (Widal reaction; isolation of the bacillus from blood culture, etc.), and the point has even been stressed that this method has been increasingly employed since about the time wen the decline of typhoid fever in civilised communities became specially accentuated; again, it is said, preventive ininoculation and control of bacillus carriers have been extensively practised during recent years. From the epidemiological point of view, on the other hand, it is naturally argued that 20 years prior to the time in question, steady effort was made, particularly in this country and in Germany, to improve water supplies; and at least 10 years before that same date, a strenuous campaign was inaugurated here to prevent consumption of polluted shellfish. These two lines of action were, moreover, actively followed, after intervals of (roughly speaking) some 10 years in other countries, notably in the United States. It is a very striking fact that after corresponding intervals (from the dates of commencement of gradual, and then of rapid decline, here in England), first a gradual, and then a rapid decline of typhoid fever were observed in the countries referred to, and notably was this the case in North America. In the Journal of the American Medical Association (January 24th, 1925), comment was made on these phenomena, it being stated that " For some years health officers in Great Britain—where elimination of drinking water infection antedated by some years that in the United States—have been led to attach great importance to shellfish infection as a factor in their own present-day typhoid." The writer pointed out that" In London, in 1923, out of 173 typhoid cases, in which information was obtained as to possible origin, fish or shellfish were held to have been at fault in 59 instances, or more than one-third of the total." It might have been added that, in another third, the disease was definitely found to have been notified in error. In the London annual report for 1921, attention was called to a most important "Investigation of the pollution of tidal waters of Maryland and Virginia, with special reference to shellfish bearing areas," by Hugh S. Cumming, which had appeared some years previously. This report (Government Printing Office, Washington, March, 1916) was, it was remarked, a fitting sequel to Dr. Bulstrode's study of a similar problem in this country in 1896. In the London annual report for 1924, attention was further called to the occurrence of two considerable shellfish outbreaks in New York and Chicago during that year, and in this connection, the comments of the American Journal (above referred to) were mentioned as being of special interest. The American writer held the view that "sources of infection, formerly submerged in a great wave of water-borne and milk-borne disease, can now be seen rising as hidden reefs above the surface." Experience in London, it was observed, suggested an alternative way of regarding the problem, considered from the historical point of view; namely, that possibly some of the supposed waterborne and milk-borne epidemics of the last century were really shellfish-borne ; and such a consideration, if found to be valid, undoubtedly prompts exercise of special caution as regards too ready acceptance of the water and milk origin of typhoid fever at the present time. These suggestions led to a particularly interesting rejoinder (Journal of the American Medical Association, 6th March, 1926). The attempt "to interpret the 39 typhoid trend in other localities on the basis of London experience" is first deprecated, and, the writer then continues, "An unbiassed observer will be prepared to accept the view that winkles, oysters and fried ungutted plaice are"—or, rather, it should read have been in the past—" a relatively common cause of typhoid in London, but cannot admit that carrier infection, milk-borne infection and similar factors are entirely inoperative, or even materially less operative than they are elsewhere." The answer to this friendly criticism is first, that the thought, so far as America was concerned, was, of course, prompted by study of the Washington report of 1916, which, it was realised supported the conclusions of Bulstrode's report of 1896, of his later report of 1911, and of various papers and researches in this country following thereon; and second, that historical and geographical pathology is the very life-blood of epidemiology and hence typhoid causation can only be adequately studied by comparing and contrasting experiences gained at various times and in different parts of the world. It is a never to be forgotten fact that, as noted elsewhere (Public Health, 1921, p. 57), "A President of the Society of Engineers, fifty years ago, was able to trace all cases of typhoid fever, coming under his notice in London, to faulty drains; the next succeeding generation concentrated its attention upon contaminated wells; their successors suspected river water supplies and polluted milk ... in Belfast, cockles have undoubtedly been paramount; in Germany, the appeal has consistently been made, since the early years of the present century, to healthy carriers ; in the armies in the Great War, protective inoculation was deemed to overshadow everything, and in South Africa, in the Spanish American War and elsewhere, flies have been regarded as very important"; and now there must certainly be added shellfish in America, as well as here; while even ice-cream, watercress, and quite lately, cream-buns and many other articles of food have been thought of as possible vehicles of infection. Clearly, much is to be learnt, here and now, by study of the behaviour of typhoid fever in other times and in other parts of the world, and American experience is far too intriguing for the idea ever to be entertained that workers in London can afford to refrain from study of "the typhoid trend in other localities, on the basis of London experience." The problem presented by "residual typhoid "is, indeed, one of very great difficulty, and demands most careful examination; for it is obvious that the preventive measures now advocated by the bacteriologist, owing to the comparatively recent date of their introduction on any appreciable scale, cannot have caused the huge decline of typhoid fever observed in the last quarter of a century; it is the more necessary, therefore, while scrutinising most thoroughly every possible suggested means of preventing disease, to avoid losing a sense of proportion; it is idle to ignore moreover the probability that mischiefs, which are known to have operated widely, in this country, even up to 25 years ago, may still from time to time be found even nowadays to be potent for harm on occasion. In London, typhoid fever, from 1912 to 1924 (with small exceptions referred to in the annual report for 1924), practically ceased to exhibit the once familiar autumnal increase; it also failed to show the special incidence upon poor populations so strikingly manifested from the time when the disease was first made notifiable—i.e., from 1890, until a few years before the War. The number of notified cases, in which the diagnosis was not confirmed on removal to hospital, has been in recent years even larger than heretofore; but a still appreciable percentage (though a small actual number, of the cases occurring in the last few years, has continued to be attributable to causes recognised at least 25 years ago as responsible for typhoid fever. The sex-incidence of the disease, it should be added, at ages 20-45, has notably altered, and, naturally there has been a tendency to ascribe this to the protective inoculation (mainly of males) practised during the war ; but, as has been pointed out, the gross figures as regards sex-incidence, lend no material support to this view. The 40 incidence was about equal on males and females at these ages in the years just before the War; in 1917 and 1918 (at the time when the greatest number of men were abroad) the "males attacked per 100 females "fell to 46 and 49 respectively; the percentages of males then gradually rose in fair correspondence with the additions to the males (owing to return of survivors) to 53, 60, 70 and 70 in the four succeeding years. In the small numbers attacked during the last two years this percentage has shown a decline but, while this is a curious phenomenon demanding further study, it is difficult to associate it with protective inoculation. The last two years have brought, in England and Wales, (as well as in London) a small increase in notified cases, and localised outbreaks of typhoid or paratyphoid fever have occurred. It is noteworthy that in certain of these outbreaks, contaminated foodstuffs, deemed to have been infected by bacillus carriers, have been held to be at fault. It is particularly instructive, in this connection, to find from a recent issue of the American Journal already referred to (December 12th, 1925), that "in many parts of Europe, the 1924 typhoid rate was notably higher than that for 1923," and in a still later issue (March 27th, 1926, pp. 948 and 955) to note that there has been observable in the large cities of the United States, in 1925, a "substantial and widespread increase in typhoid." There does not, it is stated, "appear to have been any extensive prevalence of water-borne disease, and barring the oyster infection early in the year, no particular multiplication of sources of infection seems to have occurred. It is tempting to relate excessive typhoid prevalence over a wide territory to some general factor, such as weather conditions, but it will be necessary to collect more data before this aspect of the problem can be profitably approached. In the meantime, the annual fluctuations brought out in these summaries will suggest to epidemiologists various lines of enquiry." It is difficult to resist this invitation to speculate on a "typhoid trend," which has produced somewhat similar statistical results in both hemispheres. Two guesses as to possible world-wide operative causes, which may have exercised some influence, may perhaps be hazarded. First, there is an undoubted tendency, nowadays, todiagnose typhoid fever, or paratyphoid fever, largely on Widal reactions ; and often even at that, on reactions observed in (what used to be considered) comparatively low dilutions. Secondly, here in England, at any rate, there seems to be a tendency of late years, to overlook the existence of localised prevalences of gastro-intestinal influenza ; and it would be interesting to learn if, in any outbreaks of this last-named disease which may have chanced to be recognised, Widal reactions were found in dilutions as high as say 1 in 40 or 1 in 50 ; bearing in mind, of course, the fact that it used to be understood that normally a serum may react in such a low dilution without necessarily justifying a diagnosis of typhoid or paratyphoid fever. In the days before agglutination reactions, it was not uncommon for the question to be raised prima facie, as to whether a typhoid prevalence might be due to milk, but for it to be agreed subsequently, in the light of careful statistical enquiries thereupon instituted, that a milk thesis was not by itself adequate to explain the whole of the exceptional incidence of the disease. Outbreaks in which difficulties of this sort arose are referred to in a paper published in 1911 (Trans. Hoy. Soc. Med., Epidem. Sect., pp. 110, 116 and 145), and an interesting case of the kind is one which occurred in 1898, and which is discussed very fully in the Annual Report for 1924 of the Medical Officer of the County of Lanark (pp. 477 et seq.). Furthermore, in this same connection, an important recent paper" On the prevalence of typhoid carriers in a general population " (Journal of the A.M.A., 3rd October, 1925, p. 1036) may be referred to. It was found, by the writers of this paper (Welch, Dehler and Havens, 76th Session of the American Medical Association, 1925) that, by use of the most approved methods, from 3 to 10 per cent, of 1,076 dairy employees examined (the higher percentage being found in a locality where there had been a high typhoid-rate a few years previously) were healthy 41 carriers of either typhoid or paratyphoid bacilli. Should such a result prove to be of common occurrence, it is obvious that the discovery of a healthy bacillus carrier (upon examination of, say, one or two dozen dairy employees) must be regarded merely as a result to be expected just as a matter of chance, and one to which no special significance, from the point of view of causation of typhoid, can be ascribed. Autumnal incidence of typhoid fever. These considerations have led to further examination of the question of seasonal A incidence of typhoid fever, in London and in the country generally, during recent years, and a chart showing the records for the last three years is exhibited on p. 35. This chart and an earlier one (p. 21 of the Annual Report of the Medical Officer for 1922) show the almost entire absence of any autumnal prevalence of typhoid fever in London between 1911 and 1924. In the latter year, the autumnal increase (in cases notified) was due to an outbreak of typhoid fever in Bethnal Green during September, October and November (see Annual Report of the Medical Officer of Health, 1924, p. 35). In 1925, there was again an increase in the prevalence of typhoid in London in the latter half of the year, and in this case, the increase resulted from three separate prevalences, one (of paratyphoid) centred in Croydon involving in all 75 cases, of which 30 occurred within the County of London in the extreme south of Lambeth and Lewisham; the second (also of paratyphoid) occurred in the Lee Green area of Lewisham, where some 17 cases occurred at irregular intervals over a period of two months; and the third was a sharp localised typhoid fever prevalence in Streatham in October, the number of cases of illness reported being 32. The first of these outbreaks was reported upon by Dr. II. P. Newsholme, medical officer of health of Croydon, who ascribed it to various articles of food (supplied by a firm of confectioners) which were held to have been infected by a man whose blood agglutinated the Bacillus paratyphosus B; the second outbreak was of altogether obscure origin; the third was one of true typhoid fever and was believed to be due to milk infected by a carrier of the Bacillus typhosus. The autumnal prevalences of typhoid have been more marked in England and Wales in the last three years than in London (Chart p. 35). There was a welldefined autumnal increase in 1923 and 1925. In 1924 a remarkable departure from the normal seasonal incidence was observed, for while the autumnal rise is apparent, there is imposed upon the normal contour of seasonal incidence a considerable prevalence in the months of May, June and July, the number of cases in the latter part of June and early July being so great as to exceed the height of the autumnal prevalence in October. Analysis of the figures shows that the abnormal early summer prevalences were mainly attributable to outbreaks in three localities, namely in the West Riding of Yorkshire in May, and in Luton and in Dover in June and July; but even when allowance is made for these localised outbreaks, the incidence in these three months remains considerably above the normal for this time of year. Some of the prevalences outside London, as in the county itself, were outbreaks of typhoid, some of paratyphoid fever; in a few of them the possibility of a diagnosis of gastro-intestinal influenza was considered, but was held to be ruled out on discovery of a bacillus carrier. Reference has been made from time to time in these reports to the sale in London of small ungutted plaice derived from the "fish nurseries " of the so-called A3 area, i.e., that part of the shallows of the North Sea which adjoins the German and Danish coasts. In the annual report for 1922 (pp. 24-29) and in last year's report (p. 34), the efforts, made by the fish trade some twenty or more years ago, to obtain legislation protecting the plaice fisheries of the North Sea from injury, were alluded to and attention was called to the then recently published "Report on Sea Fisheries, 1919-23" of the Ministry of Agriculture and Fisheries (pp. 67-73). The outcome of its findings was to emphasise the need of taking steps to protect the " small plaice nursery grounds." The Plaice Fisheries Sub-Committee had recommended 42 (July, 1921) prohibition of fishing, by steam trawlers and motor vessels of more than 50 h.p., in certain of the shallow areas in question, and limitation of use of other parts of the nursery grounds to April, May and June. The Sub-Committee's recommendations were approved in September, 1922, by the International Council, and steps were, thereupon, taken to endeavour to secure the sympathetic support of the industry in carrying out the restrictions. On November 2nd, 1925, a letter was sent from the Ministry of Agriculture and Fisheries to associations and federations of the industry, inviting them to consider "by what means protection may be given to the plaice fisheries," and stating that it had been decided to discuss "at an International Conference, which it had been suggested might be held in the course of the winter, the practicability of an international arrangement for the conservation of the North Sea plaice fisheries." In the meantime, it is to be observed that the statistics for certain recent years show a decided increase in the figures for "small plaice," as compared with "large plaice" and "medium plaice," harvested from the North Sea. Report from the Bacteriological Laboratory by Dr. Graham Forbes. During 1925 a total of no fewer than 10,710 bacteriological and microscopical examinations were made in the investigation of infectious, contagious and other forms of disease. For the carrying out of all the various bacteriological examinations made during the year over 10,500 tubes and close on 100 plates of different culture media were prepared by the laboratory staff. The media used included over 9,500 tubes of blood serum for diphtheria culture work alone, and over 1,000 tubes of agar, gelatin, blood agar, tryptagar broth, various sugars, litmus milk, etc., required for other investigations. Diphtheria investigations.—Special visits were made to 405 different departments in 214 schools, and 43,017 children were inspected. From those selected for throat and nose swabbing, a total of 7,910 serum cultures were bacteriologically examined as compared with 6,606 during 1921, a year of unusually severe diphtheria prevalence. Out of the 7,910 examinations, 7,012 or 88.6 per cent. proved negative, 609 or 7.7 per cent. showed the presence of diphtheria bacilli, and in 289 or 3.7 per cent. suspicious organisms were found. These totals are inclusive of re-examinations, and were derived from 390 children carrying diphtheria bacilli, and 213 with suspicious organisms. Virulence tests.—The virulence test by means of animal inoculation was applied in the case of the more chronic persistent carriers. In 92 cases the diphtheria bacillus was isolated in pure culture and sent to the Clinical Research Association for the necessary animal tests. In 68, or 74 per cent., the cultures were reported virulent, and in 24 or 26 per cent., avirulent. These results show a higher proportion of virulent carriers than is usually found, even in time of epidemic, e.g., in the years 1921 and 1922, when out of a total of over 400 isolated cultures, gratuitously tested by the Wellcome Research Laboratories, 66 per cent. proved virulent and 33 per cent. avirulent, whereas in non-epidemic periods the proportions have been found exactly reversed. Examination of the cerebrospinal fluid as an aid to clinical diagnosis.—During 1925, 114 specimens of fluid, obtained by lumbar puncture from 105 cases, were sent for examination to the laboratory by the medical superintendents of poor law hospitals—as compared with 106 specimens from 100 cases dealt with in 1924. Though primarily undertaken to assist in the diagnosis of cerebro-spinal fever, encephalitis lethargica, polio-encephalitis and poliomyelitis, examination of the cerebro-spinal fluid plays an important part in the differential diagnosis also of other conditions, which simulate and need to be distinguished from the strictly notifiable nervous diseases. Thus the ultimate findings in the 105 cases in which [43 examination of the fluid was called for, were in favour of encephalitis lethargica in 15, tuberculous meningitis in 21, other forms of meningitis in 11; and assisted diagnosis of disease of the mastoid bone or accessory nasal sinuses in 5, gross cerebral lesions such as abscess and tumor in 7, disorders of the cerebral circulation (haemorrhage congestion and thrombosis, etc.), in 11, cerebral degeneration in 6, neurosyphilis of the brain and spinal cord in 14, disordered mental states in 5,meningismus and other conditions in which the brain was unaffected in 10 cases. Encephalitis Lethargica.—Nineteen specimens of cerebro-spinal fluid from fifteen cases were examined. The cases included 7 males and 8 females, whose ages ranged from 14/12 years to 53 years. As is usually found in the majority of cases of encephalitis the fluid was practically normal in composition, thus in ten cases it was clear, transparent and colourless, with total protein content under •02 per cent., free from excess of globulin, dextrose in normal trace of .7 per cent., or occasionally slightly increased in amount, and the cell count was under 5 per c.m.m. In four specimens there was turbidity or slight opalescence, with fine clot formation, or flocculi of fibrin and cells in two, and a cell count ranging from 5 to 10 up to 22,90 and 226 per c.m.m., and consisting almost entirely of lymphocytes. In the two specimens with high cell counts and fibrin formation there was also an excess of globulin—and protein amounting to .07 and .2 per cent.; whereas the 19 specimens showed a range of total protein varying from .005 to .2 per cent. with an average of .037 per cent., as compared with the normal .01-.02. In five specimens traces of blood were present, usually visible only on centrifugation, the films from the blood-cell-deposit showing little, if any, increase in the number of lymphocytes. As a result of examination of the fluid it was possible in all cases to support the diagnosis of encephalitis or post-encephalitis which had been put forward on clinical grounds, whereas in 6 cases the alternative, or only diagnosis made, of tuberculous meningitis was clearly contra-indicated in favour of encephalitis. This was ultimately confirmed by the subsequent course of 15 cases, which resulted in recovery in five, death in four (one complicated by diabetes) and the development of post-encephalitic sequelae, such as altered mental states and Parkinsonian symptoms, in six. Owing to the varied clinical manifestations of encephalitis lethargica, its differentiation from other cerebral conditions is often a matter of very considerable difficulty. It is common to find that during prevalence of the disease, cases of cerebral tumour, abscess, haemorrhage, meningitis and disordered mental states have been mistaken for encephalitis and notified as such. It is, therefore, unfortunate that as a rule the changes in the composition of the fluid are too slight to give material help in diagnosis. Even in tuberculous meningitis, unless tubercle bacilli have been definitely found, doubt may arise, especially in children, as to whether the changes shown by the fluid are due to meningitis or to unusual constituents resulting from encephalitis, e.g., turbidity or opalescence, excess of protein, lymphocyte increase in the cell content, and the presence of fine threads of fibrinous or occasionally colloid material clot, without tubercle bacilli being found (v. two cases of encephalitis mentioned above and two cases of tuberculous meningitis referred to later). Somewhat similar abnormalities in appearance and composition of the cerebrospinal fluid in certain cases of encephalitis have been described in a paper read before the Pathological Society of Great Britain in January, 1925, by G. S. Williamson, who attributed the changes to the inflammatory process involving the ependyma, or lining membrane of the ventricles, and causing a catarrhal ependymitis. Tuberculous meningitis.—Twenty-three specimens of fluid from 21 cases of this variety of meningitis were examined, 11 females and 10 males, aged 2-25. 21 specimens were sent from 19 patients at St. James' Hospital and one each from Fulham and St. Pancras Hospitals. The appearance was clear and colourless in 11, light straw-coloured in 1, slightly turbid in 6, and blood was present in variable 44 traces in 5. With the exception of two all yielded the characteristic fine clot or threads of fibrin. Cytology.—Cell counts were made in 4, yielding an average of 87 per c.m.m. and ranging from 68 to 130. In the remainder a marked or definite lymphocytosis was present. Bacteriology.—Tubercle bacilli were found in films from the teased clot or cell deposit in twelve, were regarded as doubtful in two and not found in 9 specimens. Chemistry.—The total protein content showed a range of .025 to .7 per cent., with an average of .22 per cent. Globulin was present in marked excess in 21, slight excess in 1, and not in excess in 1. Dextrose was found present in slight traces in 16, and absent in 7 specimens. As a result of examination of the fluid the clinical diagnosis of tuberculous meningitis was supported with certainty in twelve, and strong probability in six cases, to be subsequently confirmed by post-mortem examination in the 18 cases. In eight cases the clinical diagnosis was given alternatively, as encephalitis in six, cerebral tumour in one and cerebral syphilis in one. But in six of the eight, including the two last-mentioned diagnoses, after examination of the fluid, it was possible to eliminate the suggested alternatives in favour of tuberculous meningitis, postmortem later affording confirmatory proof. Examples of difficulties in diagnosis.—In two cases the presence of a lymphocytosis and increased protein content and the failure to find tubercle bacilli, were regarded as supporting the possibility of encephalitis, but this was not confirmed post-mortem, for both proved to be cases of tuberculous meningitis. On the other hand in two other cases, not included in the above category, the primary diagnosis of tuberculous meningitis, in spite of the failure to find tubercle bacilli in the fluid, seemed justified by the increase in lymphocytes and protein content. Yet subsequent events showed this to be incorrect, the patient recovering in one case, and post-mortem examination in the other revealed a non-tuberculous post-basal meningitis. In a further case, also suggested as tuberculous meningitis, the diagnosis was definitely contraindicated by the practically normal fluid and the clinical features in favour of cerebral tumour or abscess, later confirmed by the autopsy showing multiple cerebral abscesses secondary to bronchiectasis. Meningitis other than tuberculous.—Fourteen specimens of fluid from 11 cases of meningitis due to other organisms than the tubercle bacillus were examined. The characters of the fluid in each case were distinctive of a form of meningitis, which to the naked eye, from the marked turbidity, was obviously not tuberculous, and which on further examination showed a heavier protein content, 1 to 9 per cent., marked excess of globulin, absence of dextrose and heavy cell deposits, either in the form of pus, or polymorphonuclear excess with dense coagulum. Bacteriologically the cases fell into the following groups:— (1) Meningococcal=(cerebro-spinal, post-basic) meningitis.—Five cases in which the meningococcus was recognised in film preparation from the cell deposit, but owing to the rapidity with which it dies on exposure to cold, the organism was successfully cultivated only in one case. Two cases recovered, three proved fatal. (2) Influenzal meningitis.—Two cases, both fatal. B. influenzae (Pfeiffer) was obtained in pure culture on blood agar and identified in film preparations from the cell deposit in each case. (3) Streptococcal meningitis.—A hemolytic streptococcus was grown in pure culture, and found in films from the cell deposit of two cases—both fatal, one occurring as an uncommon sequela five weeks after scarlet fever, the other following middle-ear disease. 45 (4) Pneumococcal meningitis.—The pneumococcus was obtained in film preparation and pure culture from the fluid of two cases, both fatal, one due to pneumococcal septicaemia, the other to extension from disease of the middle ear. It is worthy of note that out of a total of 32 investigated cases of all forms of generalised meningitis, the meningococcus organism was held responsible for five, or 15 per cent.; the other forms being tuberculous in 66 per cent., streptococcal, pneumococcal, influenzal in 6 per cent. each. Diseases of the middle ear and accessory nasal sinuses.—Of the 11 cases of meningitis under the previous heading, nine may be regarded as attributable to a blood infection by the particular organism concerned ; the other two, occurred as secondary extensions from the middle ear, one being due to streptococcus, the other to the pneumococcus. Valuable information as to the involvement of the meninges in conditions requiring urgent operative measures, may, therefore, be provided by examination of the cerebro-spinal fluid, e.g., middle-ear disease and inflammatory conditions of the accessory nasal sinuses. Besides the two cases just mentioned, fluid was also examined from four others ; in two cases of middle-ear disease, involving the mastoid bone, the fluid was found normal showing no evidence of meningitis, one made recovery after operation, the other proved fatal from operative shock, and post-mortem examination of the brain showed no evidence of meningitis. In one case the fluid gave definite evidence of meningitis, by the excess of protein present and heavy deposit of inflammatory cells. Death occurred, meningitis being found post-mortem, due to extension of inflammation from the sphenoidal sinus. On the other hand a localised meningitis, as in a case which proved fatal from extension of inflammation from the frontal sinus, may show little change in the cerebro-spinal fluid, owing to the restricted area infected becoming shut off from the rest of the cranial cavity. Grross cerebral lesions.—(1) Cerebral Abscess—(Four cases). The cerebro-spinal fluid may show little or no change in composition, but the following case of abscess secondary to inflammation of the frontal sinus proved an exception. The fluid on lumbar puncture yielded a heavy deposit of pus showing a few gram-positive cocci in film preparations but yielding no growth in cultivation. Purulent meningitis was, therefore, diagnosed. Post-mortem examination, however, showed that an abscess in the frontal lobe had ruptured into the lateral ventricle, thus accounting for the presence of pus in the cerebro-spinal fluid. In a second case, diagnosed clinically as tuberculous meningitis, the excess of polymorphonuclear cells, low protein content, and absence of tubercle bacilli were not suggestive of meningitis, but taken in conjunction with the clinical features, headache, vomiting and optic neuritis, were more in favour of cerebral tumour or abscess. Post-mortem showed multiple cerebral abscesses secondary to pulmonary bronchiectasis. In two other cases the composition of the fluid was found to be within the normal limits and gave no clue to their diagnosis. Post-mortem examinations revealed, in one, a cerebellar abscess secondary to chronic middle ear disease, in the other, abscess of the temporo-sphenoidal lobe attributable to puerperal infection. (2) Cerebral tumour.—Three cases, in which the alternative diagnosis of tuberculous meningitis was clearly contra-indicated by the negative characters of the fluid in each case. In two, the absence of any change in the fluid, taken in conjunction with the clinical features, suggested the possibility of encephalitis lethargica, but post-mortem examination showed in each case a gliomatous tumour involving the occipital lobe. In the third case, a normal cell content but excess of protein were regarded as in favour of cerebral tumour, taken together with a history of persistent headache and disordered vision. Post-mortem proved this amended diagnosis to be correct, deposits of cerebral growth secondary to carcinoma of the bronchus being found. 13651 D 46 It is probable that the position of a cerebral tumour or abscess may affect the characters of the fluid. If superficial and involving the cortex, thereby causing pressure on the cerebral or meningeal vessels, the growth is likely to cause escape of blood plasma or even blood cells into the meninges, and so an increase in the amount of intra-cranial fluid as well as of its protein content, with little alteration in the total number of cells. When, however, the tumour is deep-seated, not exercising pressure on the superficial membranes, nor involving the lateral ventricles, there is less likelihood of change in composition of the fluid. Very seldom are cells derived from the neoplasm to be recognised as such in the centrifugation deposit. Vascular Lesions due to changes affecting the cerebral vessels and blood supply.— Included in this category were four cases of paralysis, in which the provisional diagnosis was respectively uraemia, meningitis or cerebral irritation and encephalitis lethargica. The fluid showed little departure from the normal, except slight increase in the protein content and traces of blood in two cases without yellow discolouration of the supernatant fluid after centrifugation of the blood cell deposit. Traces of blood may or may not occur in cases of recent haemorrhage with yellow discolouration or xanthochromia of the cerebro-spinal fluid, but the latter condition when present is more indicative of old haemorrhage or compression of the cord by tumour. Uraemia was contra-indicated by the fact that urea was not found in more than the normal trace (.04 per cent.) It was, therefore, possible to exclude the suggested diagnoses, with the exception of encephalitis, which as already mentioned has so often to be taken into consideration in the differentiation of other forms of cerebral disease and is well known as a cause of hemiplegia. From the subsequent course of each of the four cases they were ultimately diagnosed as follows:— (1) Puerperal hemiplegia (Moxon's)—probably due to arterial thrombosis, in a woman aged 38, accompanied by epileptiform fits at the onset, with later paralysis of the right arm and leg. Subsequently the patient was discharged after 3 months, relieved. (2) Cerebral haemorrhage due to the toxaemia of pregnancy in a woman aged 17, marked by convulsive attacks affecting the left side and proving fatal 6 weeks after the onset. (3) Recurrent haemorrhages into the internal capsule in a man aet. 61, due to cerebral arteriosclerosis, proving suddenly fatal from a fresh haemorrhage. (4) Cerebral softening of the basal ganglia due to arterial thrombosis, which proved fatal in less than a fortnight after the onset in a woman aged 47. Circulatory disturbance whether due to chronic inflammatory changes (usually syphilitic endarteritis) or to degenerative thickening of the arteries (cerebral arteriosclerosis) may give rise not only to cerebral haemorrhage and thrombosis with softening, but also to changes in the mental state of a patient without the occurrence of paralytic symptoms. In two examples of paralysis due to cerebral haemorrhage followed by dementia, as well as in a case of simple dementia without paralysis attributable to cerebral arteriosclerosis, the cerebrospinal fluid showed little change from the normal, but the negative results of the Wassermann and colloidal-benzoin reactions contraindicated syphilis as a cause. This indeed is the extent of the information which the cerebrospinal fluid can be relied upon to yield in such cases of simple cerebral arteriosclerosis uncomplicated by syphilitic endarteritis. Moreover, the forms of mental confusion and changes in character attributable to either of these conditions may in certain cases be difficult to distinguish from similar states occurring as the result of encephalitis, nor will the cerebrospinal fluid provide a clue except evidence for or against syphilis by means of the special reaction tests. 47 In cerebral concussion and congestion, with or without blood effusion, the withdrawal of fluid by lumbar puncture invariably gives relief. Examination of the fluid may show nothing abnormal except in the event of actual haemorrhage, of which the presence of blood or blood serum in the fluid may be indicative, but not invariably so. The fluid from three cases of concussion, two of which occurred as the result of falls on the head during epileptic seizures, showed traces of blood visible only on centrifugation. In the third of the three cases there was doubt as to the diagnosis, encephalitis lethargica being in question owing to the marked drowsiness and headache. However, lumbar puncture released a considerable amount of fluid slightly blood-stained and under raised pressure, which gave prompt relief to the symptoms. From the subsequent rapid recovery of the patient, together with the history of sudden giddiness resulting in a fall on the head, it was concluded that the symptoms were attributable only to concussion. As an example of cerebral congestion may be mentioned a case in which the diagnosis of tuberculous meningitis was corrected as the result of examination of the cerebro-spinal fluid. The presence of serum and blood cells, but no excess of lymphocytes and no tubercle bacilli, indicated only cerebral congestion. This was borne out at post-mortem examination, the condition being found due to ulcerative endocarditis, although there was no evidence of cerebral embolism. Other cerebral conditions or disordered mental states, simulating encephalitis or its sequelæ, in which the fluid was found to be normal in composition, included:— post-influenzal depression, dementia præecox, psychosis of puberty and epilepsy (two cases). In the absence of a past history of epileptic attacks the diagnosis of the lethargy due to the post-epileptic state may be difficult to distinguish from the drowsiness of encephalitis. The problem is all the more puzzling when encephalitis supervenes in a chronic epileptic, and vice versa, when, as occasionally occurs, epilepsy develops as a post-encephalitic condition. The epileptic complication, whether one of association with encephalitis, or directly resulting therefrom, or requiring differentiation of two separate causes of a lethargic state, has hitherto received scanty attention in the literature of the subject. Cerebral degeneration or atrophy in early life calls for separate classification and provided two examples only. 1. Cerebral diplegia in a child of five, who had suffered from loss of power of the right side of the body for some months and epileptiform fits. There was no clear history of encephalitis lethargica but the clinical condition in hospital suggested either meningitis or encephalitis as accounting for the lethargic state. The cerebrospinal fluid was quite abnormal in appearance, of a milky opacity, yielding no clot but considerable deposit of amorphous cell debris and degenerate cells in units and clusters and a cell count of 25 per c.m.m. Protein content -025 per cent., globulin in slight excess. Dextrose, definite trace. Whilst not in favour of meningitis, the changes in composition of the fluid were regarded as not inconsistent with those occurring in some cases of encephalitis and described as catarrhal ependymitis or inflammation of the membrane lining the cerebral ventricles, but such changes may also be found in cerebral atrophy, to which group the case was eventually decided to belong. 2. Chronic internal hydrocephalus.—This condition is most often attributable to a past attack of post-basic or meningococcal meningitis in early infancy, by the inflammatory process blocking the foramen of Majendie in the roof of the fourth ventricle, thus creating obstruction to the outflow of fluid from the ventricles of the brain and causing their subsequent distension. Occlusion of the foramen may also occur as a developmental defect, causing simple congenital hydrocephalus. The fluid withdrawn in considerable quantity from a child aged 7 months, was faintly blood-tinged, and in addition to the blood corpuscles, film preparations from the 13651 d 2 48 centrifugation deposit showed scanty lymphocytes and large endothelial cells. No organisms were formed. Protein=.025 per cent. No globulin; dextrose, a slight trace. Chemical analysis yielded urea .05 per cent., sodium chloride .7 per cent. (i.e., normal amounts). Phosphates (as calcium phosphate *196 per cent, or as (P206) .089 per cent.) were ten times the normal amount. Excess of phosphates has also been recorded in cases of simple congenital hydrocephalus amounting to three or four times the normal quantity .013-.02 per cent. Neurosyphilis of the Brain and Spinal Cord.—1. General paralysis provided 11 cases (8 males and 3 females, ages 36 to 49 years) in which examination of the cerebrospinal fluid confirmed the diagnosis. All the specimens were clear and colourless with the exception of two which exhibited slight turbidity. The cell content was in each case above normal, but showed a range of from 10 to 138 cells per c.m.m. with an average of 41. Lymphocytes were the greatly prevailing type of cell with occasionally large endothelial cells. Protein as measured by Aufrecht's albuminometer showed a range of from .01—.1 per cent., or an average of .05 per cent., i.e., definitely in excess of the normal .02. Globulin was in every case in excess. Dextrose was as a rule above the normal .7 per cent. The Wassermann and colloidal benzoin reactions gave positive results confirmatory of neurosyphilis. 2. Tabes dorsalis (locomotor ataxy).—In three cases the diagnosis was confirmed by the fluid showing changes similar to those above recorded in the closely allied condition of G.P.I. Three other cases, in which the fluid did not confirm the suggested diagnosis of tabes, proved eventually to be peripheral neuritis, syphilitic pachymeningitis of the cauda equina, and melancholia associated with arteriosclerosis. In four additional cases, suggested as either G.P.I. or attributable to neurosyphilis, the specific nature of the disease was not confirmed. The conditions were subsequently diagnosed as dementia and obsessional insanity due to chronic alcoholism in two, in which the fluids showed nothing abnormal. Alzheimer's disease was suggested as a possible diagnosis of the third case. This condition has been attributed to a presenile form of cerebral arteriosclerosis characterised by slow dementia with focal symptoms, aphasia and apraxia, and in addition to the changes in the blood vessels, is associated with a proliferation of the neurofibrils (diffuse gliomatosis). The fluid showed no change in composition and the negative special reaction tests contra-indicated neurosyphilis. Postencephalitis was also put forward as an alternative diagnosis. This case, in a man aged 47, supplied a history dating back to 1917, beginning with an attack of cerebral thrombosis causing right hemiplegia, followed by recovery. In 1924 a further lesion occurred resulting in paralysis of the right side of the face, with tremor and fits and much mental confusion. From this condition there has been but little improvement since, and gradual mental deterioration has become manifest, necessitating removal to an asylum. The fourth case attributed to syphilis of the mid-brain presented tremor, wasting and weakness of the hands and forearms. The fluid, however, gave no confirmation of neurosyphilis, the patient was subsequently discharged, with his condition relieved, under the diagnosis of syphilitic mesencephalitis. 3. Syphilitic meningitis.—The fluid from a single case of this somewhat rare condition afforded no clue to the diagnosis, which was only revealed by post-mortem examination, when in addition to the meningitis, gummata were found involving the right frontal lobe. The patient, a girl aged 17, during her stay in hospital provided no suggestive family history nor did her clinical condition yield any evidence pointing to congenital or acquired syphilis. The temperature was up to 100°F. at first and later normal. The blood Wassermann reaction was negative 10 days after admission. Her symptoms were drowsiness, headache and vomiting. The cerebrospinal fluid 49 was clear and colourless with a cell count of 7 or 8 per c.m.m. and centrifugation yielded scanty number of blood corpuscles and lymphocytes and a very few polymorph cells. Total protein of .04 per cent., globulin not in excess. Dextrose slightly in excess of the normal. Clinical diagnosis suggested either encephalitis lethargica or tuberculous meningitis. The latter was clearly contra-indicated by the practically normal cerebrospinal fluid, except for a slight increase in protein. Unfortunately tests were not applied for the Wassermann or colloidal benzoin reactions, but the fact that there was no increase of globulin makes it probable that the reactions would have proved negative. Moreover, the Wassermann reaction in the blood had been found negative. The conclusions arrived at as the result of the examination of the fluid were, therefore, in favour of encephalitis as the more probable of the two suggested diagnoses, but with the added alternative of cerebral tumour, which post-mortem examination subsequently proved to be as nearly correct as was possible. However, as ophthalmoscopic examination revealed no abnormal changes in the fundus oculi pointing to cerebral tumour, the case was decided to be one of encephalitis lethargica and notified as such. Following lumbar puncture there was considerable improvement in mental alertness, with disappearance of headache and vomiting for over a month, when a relapse occurred; drowsiness again supervened with gradual loss of consciousness and death took place 6 weeks after admission. The post-mortem discovery of meningitis and gummatous tumours in the right frontal lobe was quite unexpected, but the syphilitic nature of the tumours was verified by microscopic examination. Meningismus, a term applied to conditions simulating meningitis, in which the fluid is found to be normal in composition, occurring in infancy or early childhood, the symptoms being due to reflex disturbance attributable to the toxic effect of an acute febrile attack, e.g., in pneumonia; also associated with teething or gastric disorder. Examples were provided by five cases of broncho-pneumonia, acetonæmia, vomiting and diarrhoea, constipation and teething, in children aged six months to 5 years, in whom the original diagnosis of meningitis was disproved by the completely normal fluid and by the subsequent course of events. Other cases in which lumbar puncture was performed for diagnostic purposes and yielded normal fluid were five cases in which the cerebral conditions suspected were cerebral abscess, meningitis, uraemia, cerebral haemorrhage, and cerebral tumour or meningitis; the final diagnoses reached in these five cases were nephritis, enteric fever, nephritis, carcinoma of stomach and chronic nephritis respectively. Special investigations. In addition to the routine laboratory examinations, certain special investigations were conducted:— (1) A bacteriological examination was made by Dr. Forbes of samples of the pulverised material from the refuse dump at Ebury Bridge, a reference to which appears on page 75. (2) Dr. Nairn Dobbie also carried out a series of tests on the dust-allaying properties of a special oil used on the surface of school flooring. His observations were directed to ascertaining by bacteriological methods, as an approximate index of the relative number of dust particles, the number of organisms deposited when agar and gelatin culture plates were exposed to the air for certain periods in rooms where floors had been treated or not with the oil preparation. The plates were then incubated and counts made of the resulting colonies which had grown. In two selected schools six experiments were carried out, comprising 24 separate tests, 12 being in a treated room, 12 in a non-treated, and under such varying atmospheric 50 conditions as when the children were sitting still in class, after stamping their feet to raise the dust and after the cleaners had swept the floor of the two rooms. The bacterial counts showed without exception that considerably fewer colonies, and therefore fewer dust particles, were deposited on the plates exposed to the air of the room, the floor of which had been treated with the dust-allaying oil than on the plates exposed in the untreated room. (3) By Dr. Forbes on the role of the streptococcus in relation to throat infection and the transmission of Puerperal Fever and Scarlet Fever. The infecting organism associated with the majority of cases of puerperal fever has for long been recognised as a streptococcus, usually the variety known as S. pyogenes. The etiology of scarlet fever, however, has for many years past been the subject of much discussion and still active investigation. Even as long ago as 1884 Loeffler had observed the abundance of hæmolytic streptococci in the throats of severe scarlet fever cases. Klein, in 1886, attributed an outbreak of the disease in London to streptococcal infection of the milk from a Hendon dairy farm, supplied by cows suffering from ulcerated udders. He succeeded in isolating a streptococcus which he named S. scarlatinæ, both from the infected milk and from the blood of eleven scarlet fever patients, consumers of the milk. Kurth later drew attention to a streptococcus in the scarlatinal throat which he called S. conglomeratus. This was followed by further work from Klein, who with Gordon claimed that this streptococcus, pathogenic to mice, was always to be found in the scarlatinal throat and not in the normal throat. Gordon, in postmortem examinations of fatal scarlet fever, isolated at one time S. scarlatinæ, at another S. pyogenes and occasionally a double infection by both strains. He also published in the L.G.B. Reports for 1903-4 an account of the grouping of streptococci as the result of their behaviour in a series of fermentation and cultural tests: and again in the L.G.B. reports (1910-11) on streptococci in scarlet fever. On similar lines in 1906 appeared an exhaustive report by Andrewes and Horder (Lancet, September 15th, 1906, page 708 et seq.) on " The Study of streptococci pathogenic to man," in which considerable attention was devoted to the relationship of certain strains with both scarlet fever and puerperal fever. At that time, as regards a specific organism in scarlet fever, the results of cultural tests were held to be too conflicting for very definite conclusions, but the evidence went to show that if any particular streptococcus was concerned, it would probably be one of the hæmolytic types named " anginosus " as the more likely causative agent, and also "pyogenes " as an important though secondary factor ; both having been consistently found in culture from the throats of scarlet fever cases— " anginosus " in 20 and " pyogenes " in 11, out of 33 cases investigated. An account is also given by Andrewes and Horder of a remarkable chain of infection linking together cases of puerperal and scarlet fever. Nurse B at a maternity hospital, in attendance on a woman A, developed tonsilitis and three days later scarlet fever. The patient A then developed puerperal fever and yielded streptococcus pyogenes in culture from her blood on the sixth day after confinement. She was transferred to the Great Northern Hospital and died three days later, but the nurse (C) who had been attending her there developed scarlet fever, and streptoccus anginosus was isolated from her tonsils. At the maternity hospital Nurse B was replaced by Nurse D, who attended A for a day or two before her removal to the Great Northern Hospital and remained well, but attended a confinement case E in the district, which proved fatal from septicaemia on the fifth day after confinement. Nurse B's room at the maternity hospital was disinfected and then scrubbed by a charwoman F, who, two or three days later, developed scarlet fever and subsequently infected her two children with scarlet fever. 51 Nurse B (scarlet fever) Charwoman F (scarlet fever) G H (scarlet fever) Patient A (puerperal fever) Nurse D (not ill) Nurse C (scarlet fever) Patient E (puerperal fever). Such a sequence of events would seem to show a close connection between scarlet fever and the streptococcal septicaemia which characterises puerperal fever, suggesting a common streptococcal origin. The joint authors of the report suggested that scarlet fever might be due— (1) Primarily to streptococcal infection, although evidence was not sufficiently complete to indicate one specific variety of streptococcus. (2) To a specific streptococcus (as designated by Klein, Gordon and Kurth) within the limits of the streptococcus anginosus group. (3) To some non-streptococcal cause which was ultra-microscopic. Since this date much work has been carried out in recent years on the etiology of scarlet fever, which has gone very far to prove that a hæmolytic streptococcus is intimately associated with, if not causative of, the disease (see particularly M. H. Gordon's work on the serological grouping of hæmolytic streptococci, in which he distinguished the scarlatinal streptococcus as Type IIIv., B.M.J., April 30,1921). In earlier researches Moser in 1902 in Autria, and Savchenko and Grabitewsky in 1905 and 1907 in Russia, took a leading part in the production of an immunising serum, and their pioneer work was taken up later by the German workers, Schultz and Charlton, and in America by George and Gladys Dick, and Dochez. However, as Andrewes and Horder had pointed out in 1906, until scarlet fever had been produced in human beings by infection with a pure culture of streptococcus, no crucial proof had been furnished as to its etiological relationship with scarlet fever. It remained for the Dicks, following up the work of Savchenko and Grabitewsky in tracing this causal relationship, to establish the necessary proof in 1923 by the successful inoculation of volunteers with a pure streptococcus culture obtained from a case of scarlet fever. They further introduced the special test now well recognised by their name, in which an individual's susceptibility to scarlet fever could be ascertained by intradermic injection of .2 c.c. of the diluted toxic filtrate obtained from a broth culture of the scarlatinal streptococcus. The test, when resulting in a reddened area, signified a positive reaction, i.e., susceptibility from lack of natural protective substance in the blood, in precisely the same manner as the behaviour of the Schick test for diphtheria. Schultze and Charlton in 1918 had described a diagnostic reaction, the blanching of the scarlatinal rash, caused over a circumscribed area by a .2 c.c. injection, of the diluted serum of a scarlatinal convalescent, or as later used, of scarlatinal antistreptococcus horse serum, into the brightest part of the rash. Dochez in 1924 isolated a streptococcal strain and from it by special method/ prepared the serum known by his name, now in use for the treatment of scarlet fevei as is also a similar serum prepared by the Dicks. The past three years have been productive of an increasing number of observations on the application of the Dick test and Schultz-Charlton diagnostic reaction, not only in America and this country, but in many other parts of the world. 52 In this country, among those responsible for much of the recent work may be mentioned Drs. E. H. R. Harries of the Birmingham City Hospital, R. A. O'Brien and C. C. Okell in London, as well as workers at the Metropolitan Asylums Board hospitals. The work has lately been extended to include the question of artificial active immunisation, achieved by inoculation in graded doses of the standardised scarlatinal toxin—on the lines on which similar immunisation against diphtheria has been employed for the past seven years in New York. In Aberdeen, in particular, prophylactic inoculation against both diphtheria and scarlet fever has been authorised by the authorities for the past six months, and is being carried out under the supervision of the medical officer of health, Dr. Parlane Kinloch, aided by the special research work of Dr. Smith, the City bacteriologist. There is now considerable accumulation of evidence in support of the diagnostic value of the Dick test and Schultz-Charlton reaction, but still further experience has yet to prove their ultimate reliability and the efficacy of prophylactic inoculation against scarlet fever, as well as of the specific treatment of the disease by means of scarlatinal antistreptococcal serum, which is being made use of with promising results. Bearing on the possible relationship between the conveyance of a specific streptococcus in the throats of carriers and the causation of infection in both puerperal and scarlet fever, mention may here be made of certain investigations which were attempted in the Council's laboratory. 1. Puerperal fever.—Request was made for investigation in connection with the occurrence of cases of puerperal fever and the suggested association with streptococcal carriers. Cultures were taken from the tonsils and nasal mucosa of eight maternity nurses to ascertain the types of bacterial flora present with particular reference to the haemolytic group of streptococci. Of the eight examined, three yielded a haemolytic streptococcus which proved on fermentation sugar tests not to ferment mannite. Of the three positives, one had been associated with two or more cases of puerperal fever. From results so limited in scope it was obvious that no definite criteria could be drawn, especially in view of the fact that hitherto by serological tests the existence of an independent group of streptococci has not been definitely established in connection with puerperal fever, although suggested by Gordon's results as due to strep. pyogenes. (Type I). Moreover haemolytic streptococci are estimated to be found in the throats of about 10 per cent. of normal individuals. A. F. Lash and Bertha Raplan have recently published (J. A. M. A., April 17th, 1926, p. 1197) the results of observations on streptococcus hæmolyticus in its relation to puerperal fever. Its serological and toxic characters are represented as specific in regard to puerperal infection. But, as the investigation is limited to this condition only and does not include corresponding neutralising and agglutinating tests with other streptococcal strains, e.g., scarlatinal and erysipelas, their toxins and sera, the work must be regarded as incomplete and any claim to specificity as not yet proven. Although it is a matter of considerable doubt whether suspension from maternity duty would be strictly justified in the case of any nurse found to be carrying an organism not uncommonly present in a proportion of any group of individuals, yet the possible risk of conveyance of infection from nurse to patient is one which obviously calls for very careful consideration and cannot be lightly ignored. 2. Scarlet fever.—The occurrence of scarlet fever and a simultaneous prevalence of sore throats in one of the departments at Harper Street School (Southwark), provided an opportunity for bacteriological investigation with a view to ascertaining the incidence of streptococcal throat infection among recent absentees. In the one department there had been eight cases of scarlet fever, and sore throat had been responsible for no fewer than 80 absentees. The proportion of sore throat to scarlet 53 fever cases was by no means evenly distributed throughout the department, some class rooms free from scarlet fever having had almost as many cases of sore throat as the class room with most scarlet fever cases. In this room a selection was made of children who had recently been absent for sore throat, as well as of those showing enlarged tonsils or marked redness of the fauces. Throat swabbings were planted on serum and subcultured on blood agar from eleven of the selected children, and from eight of them or 72 per cent, a hsemolytic streptococcus was isolated. To four of the strains a limited number of fermentation tests were applied and showed that in each case mannite was not fermented. Although the proportion of cases among the selected children yielding a hæmolytic streptococcus was relatively high and therefore suggestive, the scope of this single investigation was obviously too limited to admit of any real conclusions, and notably in the absence of the necessary serological tests, in addition to control culture tests as applied to children in other class rooms free from scarlet fever but affected by sore throats, as well as in rooms free from both. As already stated hæmolytic streptococci have been recognised as normally present in the throats of about 10 per cent. of ordinary individuals. Their significance as indicative of risk of transferring infection whether in the form of scarlet fever, puerperal fever, or (very doubtfully), in a few instances of some non-specific cases of pemphigus, is as yet far from being understood. If there is any correlation existing between the incidence of scarlet fever, prevalence of sore throat and the carrier state in the normal throat, it is perhaps not unreasonable to surmise a possible relationship between the strains of hæmolytic streptococci occurring in the three conditions respectively; which further suggests the interaction of the " seed " and the " soil " in the extent of immunity response evoked by the one from the other; in the insusceptible individual productive of a harmless saprophytic state, in another, more susceptible, of a strictly local lesion e.g., tonsilitis or pharyngitis, and, in the non-immune, of true scarlet fever. The degree of immunity may, however, not be the only factor governing the issue ; but a more decisive unknown third factor or virus, in addition to the known streptococcal seed and susceptible soil, may be required to play the determining part in producing an attack of scarlet fever. In a recent paper by O'Brien and Okell (Public Health, May 1926, p. 246) on the Dick Test, the existence of many points requiring explanation and further study is emphasised, such, for instance, as to whether all scarlet fever toxaemias are due to the same toxin, whether there are different toxins in true scarlet fever, or, in other words, immunologically different types of the disease. They also refer to the suggestions, made by Rundle, that there are two or more types of scarlet fever, and by Park as to a possible wide antigenic (i.e., anti-body producing) overlap between the different streptococci, e.g., ordinary scarlet fever toxin containing antigenic or toxin components a, b, c, d, and others containing a, b, c, e and so forth. Certain observations lately made by Dr. G. H. Eagles at the Lister Institute are suggestive of the existence of some common affinity, in that the toxins derived from hsemolytic streptococci, e.g., those obtained from scarlatinal throats, convalescents, puerperal fever, erysipelas and pyogenes infections may, when injected intracutaneously, produce positive " Dick " tests. Similar positive results were obtained by Sir Frederick Andrewes with the filtrate of a hsemolytic streptococcus from lymphangitis of the arm, when inoculated into a known positive Dick reactor, and negative results when applied to a known negative reactor. Moreover Eagles found that separate sera, obtained as the result of animal inoculation with scarlatinal, erysipelas, and puerperal fever hsemolytic streptococci, neutralised not only their corresponding toxins, but, severally, scarlatinal serum neutralised erysipelas toxin, and vice versa, erysipelas serum, scarlatinal toxin; and that in 40 to 50 per cent. of cases of puerperal fever the streptococcal toxin 54 was partially neutralised by either scarlatinal or erysipelas serum ; and vice versa in the same proportion of cases puerperal streptococcal serum neutralised the scarlatinal and erysipelas toxins. Directly concerned with the question of the relationship of throat infection to scarlet fever is a paper (by F. A. Stevens and A. R. Dochez of New York) (J. A. M.A. April 10th, 1926, p. 1110) which describes an epidemic of hæmolytic streptococcus infection among the nursing staff and patients at a certain hospital giving rise for several months to cases of scarlet fever and of sore throat without rash. The authors quote the evidence of several writers 50 to 60 years ago to show that scarlet fever had long been suspected to occur unaccompanied by any rash. As the result of their observations they consider that there is sufficient justification for this belief; further, they found that the type of throat infection concerned might affect individuals who gave negative skin reactions to scarlatinal-toxin and were, therefore, presumably insusceptible to true scarlet fever. Their investigations included the isolation of hæmolytic streptococci from the throats of the contacts suffering from pharyngitis, as well as of the cases of scarlet fever, and the testing of the strains with the sera from types of the two groups respectively, as regards agglutination and absorption and the neutralisation of toxin. The scarlatinal sera agglutinated five out of 17 of the pharyngitis strains of hæmolytic streptococci and neutralised their toxins; thus showing that the toxin production of the pharyngitis streptococci and agglutinating properties of the scarlatinal sera were in some cases closely parallel. An important observation arising from their work confirmed that of Rosenow, namely, that the skin reaction following intracutaneous inoculation of scarlatinal toxin was an index of antitoxic immunity, but not of immunity of the throat to streptococcal infection, as shown by the fact already mentioned that cases of scarlatinal angina actually occurred in individuals giving a negative skin reaction. They refer to the wide distribution of streptococcus scarlatinæ, from the observations of Dr. Anna Williams, who reported the presence of scarlatinal-toxin-producing strains in osteomyelitis, endocarditis and in chronically inflamed tonsils, without any of the usual manifestations of scarlet fever. It was not surprising, therefore, that five of the strains of streptococci obtained in cultures from the cases of acute pharyngitis, occurring in the epidemic of scarlatina and angina, showed both the agglutinative and toxin-producing properties of streptococcus scarlatinae. Reference has already been made to the doubtful reliability of the cutaneous reaction as a specific index of scarlatinal susceptibility (v. p. 52). This has also been observed by Gerbasi of Naples (Pediatria Naples, February 1st, 1926. p. 119), who found that injection of toxins from hæmolytic streptococci, derived from other sources than scarlet fever, produced in children reactions similar to those with the Dick toxin, and therefore possibly destroying or reducing the value of the specificity of the scarlet fever streptococcus and the Dick reaction. Stevens and Dochez are also inclined to share this view and utter a word of caution against drawing too strict an analogy between scarlet fever and diphtheria. Whereas in diphtheria the infecting organism is essentially a toxin-producer and the Schick test is apparently an accurate index of susceptibility to diphtheria infection, in scarlet fever the streptococcus scarlatinæ is both a toxin producer, and, by dissemination through the circulation, is productive of secondary bacterial infection. Therefore, although the Dick test may be regarded as an index of antitoxic immunity, they hold that it is no index of bacterial (streptococcal) immunity. This dual combination of the bacterial and toxic factors may possibly serve to explain the varying individual susceptibility mentioned on p. 53; giving rise, in one individual, to simple acute pharyngitis or angina without any rash due to bacterial susceptibility, but a sufficient antitoxic immunity,—yet causing in another, true scarlet fever from lack of both antitoxic and antibacterial immunity. 55 As the result of work of the most recent date, and as foreshadowed 20 years ago by the observations of Andrewes and Horder, it would appear that members of the hæmolytic streptococcal group, especially those associated with scarlet fever and puerperal fever, are in all probability more or less closely related one to the other by a common factor, possibly an antigenic similarity, e.g., in the capability of different strains to absorb agglutinin for a particular strain (e.g., scarlatinal) from the corresponding (scarlatinal) serum. What, however, is the precise nature of this affinity, or whether there exists a specific differentiation for individual strains as indicated by Gordon's serological grouping into separate types, and dependent on the degree of personal immunity, remains for future research to demonstrate. Other investigations. Ringworm.—A total of 2,642 specimens of hair was examined as compared with 2,694 in 1924. Of these 1,567 were returned as negative and 12 as suspicious. The 1,063 positive specimens showing the presence of fungus were sub-divided as follows:—844 small spore, 195 large spore ringworm, and 24 favus. Conjunctivitis.—Films from the eye discharges of 28 infants were examined for evidence of gonococcal ophthalmia. The gonococcus was recognised in four, doubtful in two, and not identified in the remaining twenty-two cases, in which various gram-positive cocci or bacilli only were seen. Miscellaneous specimens sent for examination included (1) sputum, two specimens ; tubercle bacilli found in one. (2) Urine—four specimens for chemical and microscopical examination. (3) Fluid from pemphigus blisters in the case of two infants yielded negative results. (4) Throat and nose swabs from three infants showed no diphtheria bacilli. Blood examinations.—Two cases. (1) Complete count yielded typical picture of pernicious anaemia in an assistant teacher. (2) Blood films proved negative for malarial parasites in a school nurse. Tuberculosis. The deaths from tuberculosis of the respiratory system in London during 1925 numbered 4,361, giving a death-rate of 0.95 per thousand, corresponding figures for 1924 being 4,486 and 0.98 respectively. Deaths from other forms of tuberculosis numbered 796 as against 834 in the preceding year, the death-rate being 0.17 per thousand of the population. The deaths and death-rate from tuberculosis of the respiratory system by sexes in recent years have been as follows:— Year. Deaths. Death-rates. Males. Females. Total. Males. Females. Total. 1919 2,945 2,252 5,197 1.47 0.94 1.18 1920 2,675 2,000 4,675 1.29 0.82 1.04 1921 2,737 2,076 4,813 1.32 0.85 1.07 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 1924 2,629 1,857 4,486 1.24 0.75 0.98 1925 2,571 1,790 4,361 1.21 0.72 0.95 Notification of tuberculosis. The number of notifications of tuberculosis received in London boroughs during 1925 (52 weeks), after correction of the figures by the exclusion of cases notified as primary but eventually found to have been previously notified, was 9,661 as compared with 9,613 in 1924 (53 weeks). The cases of pulmonary tuberculosis numbered 7,554 and other cases 2,107, the corresponding figures for last year being 7,406 and 2,207. The following is an analysis of the notifications in London during 1925 (52 weeks). 56 Form of tuberculosis notified. Sex. Notifications on Form A. (Total of primary notifications received in London than elementary school cases, injra.) boroughs, other 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total. Pulmonary tuberculosis M. 9 40 91 109 351 539 943 934 762 397 121 4,296 F. 2 34 82 120 436 589 871 544 321 170 66 3,235 Other tuberculosis M. 36 214 295 161 107 61 78 51 36 22 9 1,070 F. 26 184 189 144 127 94 99 60 29 15 12 979 All forms of tuberculosis M. 45 254 386 270 458 600 1,021 985 798 419 130 5,366 F. 28 218 271 264 563 683 970 604 350 185 78 4.214 Form of tuberculosis notified. Sex. Notifications on Form B. (Primary notifications of cases discovered through medical inspection in elementary schools.) Notifications on Form C. (Secondary notifications from institutions receiving cases.) 0- 5- 10 + Total. Poor Law. Other. Pulmonary tuberculosis M. 1 4 10 15 1,077 3,507 F. — 4 4 8 758 2,086 Other tuberculosis M. 1 15 12 28 129 541 F. 1 10 19 30 84 551 All forms of tuberculosis M. 2 19 22 43 1,206 4,048 F. 1 14 23 38 842 2,637 In addition to the primary cases notified on forms A and B shown in the above tables, a number of cases came to the knowledge of Medical Officers of Health otherwise than by notification. These figures include cases not notified before death:— Form of tuberculosis notified. Sex. New cases of tuberculosis coming to knowledge otherwise than by notification on forms A and B. 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total. Pulmonary tuberculosis ... M. 8 10 7 5 16 35 99 71 83 68 30 432 F. 6 10 5 5 26 29 73 44 22 29 21 270 Other tuberculosis M. 25 59 20 16 12 10 11 11 — 10 2 176 F. 30 34 20 17 11 15 12 9 9 6 7 170 All forms of tuberculosis ... M. 33 69 27 21 28 45 110 82 83 78 32 608 F. 36 44 25 22 37 44 85 53 31 35 28 440 Under the Public Health (Tuberculosis) Regulations, 1924, the Medical Officers of Health are required to prepare, from the register of notified cases of tuberculosis, a quarterly return showing the number of cases on the register at the commencement and at the end of the quarter, and the number added to and removed from registers during the same period. The returns under this order received from the several metropolitan boroughs, show that at the end of 1925 there were 39,551 cases of pulmonary tuberculosis (22,600 males and 16,951 females) on the Registers of the Metropolitan Boroughs and 15,074 cases of other forms of tuberculosis (7,936 males and 7,138 females). Administration. Common and seamen's lodginghouses. The supervision of the 168 common lodging houses licensed by the Council under the L.C.C. (General Powers) Act, 1902, entailed 9,700 day visits and 373 night visits by the inspectors. The supervision of 33 seamen's lodging houses licensed under the Merchant Shipping Act, 1894, entailed 865 visits by day and 81 by night. Census of homeless persons. A census of homeless persons in London was taken on the night of Friday the 20th February, 1925. The area covered extended over the whole of the county, except the outlying portions which are not usually the resort of such persons. The 57 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. 1925. 1925. 1925. 1925. 1925. 1911-14 1915-19 1920-25 1911-14 1915-19 1920-25 1911-14 1915-19 1920-25 Battersea 27,848 24,956 5 20 18 187 1 14 44 — 14 6 — 10 Bermondsey 19,246 18,986 5 10 6 68 13 3 111 46 1 67 — — Bethnal Green 19,397 Almost all — 48 tenements — 32 34 15 43 19 10 40 2 4 Camberwell 42,476 27,874 — — 8 — — — 1 — 3 Chelsea 11,528 2,496 — 56 — 3 — 1 — 3 9 8 21 Deptford 18,123 16,310 — 1 — 95 8 — 95 7 — 40 2 — Finsbury 11,000 6,500 — — — 21 17 5 2 17 5 60 Fulham 27,040 20,265 — — 36 flats 43 1 14 38 1 14 22 — 7 Greenwich 16,845 Majority — 147 125 193 1 — 3 26 — —• Hackney 35,145 14,272 — 87 30 11 29 49 11 34 — 9 — — Hammersmith 18,620 12,000 150 50 — 37 26 16 6 38 20 — 25 10 Hampstead 12,557 Not stated — — — 17 17 24 17 17 22 5 — 15 Holborn 3,473 8,571 t'n'mte — 37 tenements — 63 4 1 6 2 1 46 — — Islington 45,000 28,000 — — 435 50 10 3 38 8 3 19 1 1 Kensington 30,044 9,184 — 36 flats, 4 cotts. 36 flats, 4 cotts. 86 9 5 24 9 22 1 — — Lambeth 42,607 31,955 — 108 96 102 38 17 102 — — 129 — 103 Lewisham 39,220 Not stated — 457 25 9 2 11 19 17 8 3 —* Paddington 17,000 9,100 — — — 23 17 27 27 10 9 1 — 1 Poplar 23,248 23,000 1 81 56 68 39 16 68 33 23 2 1 4 St. Marylebone 16,294 8,131 — 32 flats 20 flats 32 20 — 32 19 — 9 3 1 St. Pancras 25,216 16,000 — — — 109 53 — 72 56 — — — — Shoreditch 14,000 13,000 — 59 30 12 9 — 12 3 17 11 7 11 Southwark 20,474 14,000 — 42 — 152 4 419 84 — 64 — 32 43 Stepney 31,708 31,708 4 — — 44 27 2 44 59 — 6 — Stoke Newington 8,605 3,078 — — — — — — 1 — — Wandsworth 67,764 — — 741 — — 1 1 3 — 7 20 Westminster (City) 27,352 11,376 — — 25 21 7 9 6 — 25 39 4 Woolwich 27,333 22,954 — 186 74 97 40 34 42 32 22 16 5 5 58 night was clear and fine. Only 5 persons (all females) were found sheltering under arches, or on staircases. In the streets 76 males and 37 females were found, as compared with 61 males and 17 females in 1924, and 296 males and 76 females in 1914, on the occasion of previous censuses. In the common lodging houses 14,425 persons were accommodated as compared with 14,165 in 1924, and 20,173 in 1914 before the war. In the free shelters and labour homes not licensed, 448 males, 118 females and 23 children were accommodated as compared with 481 males, 118 females and 13 children in 1924. The number of persons in casual wards on the night in question was 503 (492 males, 9 females and 2 children), the largest number recorded at any census since 1913. At London Rowton Houses 5,054 men were accommodated, and there were no vacant beds. Housing Acts. Details as to progress made with the several represented insanitary areas and the housing schemes undertaken by the Council will be seen on reference to Chapter XXV. The table on page 7 shows the houses in each borough in 1925; the number repaired under Section 3 of the Housing Act of 1925; certain other particulars as to conditions in 1925; and also gives the details of action taken by the metropolitan borough councils under the provisions of the existing Housing Acts of 1925 with regard to the making of representations and closing orders during the vears 1911-14, 1915-19, and 1920-25. Poultry slaughtering Detailed inspections of the premises (which are estimated to number over 100), subject to the byelaws regulating the business of a slaughterer of poultry, are now in progress. The Council's Tuberculosis Scheme. Tuberculosis. Dispensary treatment of adults and children. It may be said that the movement for organised provision for the treatment of tuberculosis in London commenced about 1909, when a dispensary was established by a voluntary Committee to serve the boroughs of Kensington and Paddington. From this Committee evolved the Central Fund for the Prevention of Tuberculosis, which was established in 1911 and in course of time provided eleven dispensaries in various parts of London. Concurrently, other voluntary agencies established dispensaries in two other boroughs. Compulsory "notification" of the disease developed from 1st January, 1909, when the Tuberculosis Regulations of 1908 made compulsory notification, to medical officers of sanitary authorities, of cases of pulmonary tuberculosis occurring amongst inmates of poor law institutions or amongst persons under the care of district medical officers. This was followed in March, 1911, by a further order extending compulsory notification to inmates and out-patients of hospitals. Finally, by the Public Health (Tuberculosis) Regulations, 1912, compulsory notification, to the Borough Medical Officer of Health of all cases in which tuberculosis in any form is diagnosed, was imposed on the medical profession and the local sanitary authorities were required to take precautionary action against the spreading of infection. A considerable step forward was taken by the passing of the National Insurance Act, 1911. This Act included provision, with State assistance, for dealing with the sickness of the industrial classes, and special powers in respect of the treatment of tuberculosis were conferred both upon Insurance Committees set up under the Act and upon existing local authorities. In consideration of facilities for treatment being extended, by county councils and county borough councils, including metropolitan boroughs, to all classes of the community, the Government undertook to pay 50 per cent. of the net cost of treatment provided for the ininsured population, including dependants of insured persons, under schemes approved by the Minister of Health. In London, the outcome of the Act of 1911 and of this decision was the approval by the Minister of Health of the Tuberculosis Scheme of the Council which was adopted in May, 1914. This scheme largely followed the lines of the report of the Interdepartmental Committee on 59 Tuberculosis. Provision was made for dealing with the problem in two main divisions, viz., (a) a dispensary service for each metropolitan Borough, around which was linked, on the one hand the public health service of the borough and on the other all the various voluntary agencies in the area for helping sufferers, co-ordinated by a representative care committee system; and (b) provision of residential accommodation. The scheme provided for incorporating existing voluntary accommodation including general and special hospitals in London and sanatoria, and for avoiding overlapping with work already done both by voluntary agencies and public authorities (e.g., Poor Law), both in respect of out-patient and residential treatment, and it was emphasised that the purpose of the Council was to supplement and not to supersede existing agencies and accommodation for dealing with the problem. As the duty of providing for the domiciliary treatment of insured persons under the National Insurance Act was made the function of the Insurance Committee, the arrangements for utilising the dispensary service in London in that connection were left to the London Insurance Committee, upon whom also devolved the responsibility until the passing of the National Insurance Act, 1920, of providing residential treatment for insured tuberculous persons, but optional powers were conferred upon county councils enabling them to supplement insurance funds in the event of the money available under the National Insurance Acts being insufficient for the requirements. The original tuberculosis scheme for London, in its main principles continues in operation, but in October, 1922, it was revised principally in the direction of meeting the changes which were necessary, owing to the withdrawal of " sanatorium benefit " from the benefits of insured persons under the National Insurance Acts, and modifications in machinery and method which experience had indicated to be desirable. The eleven voluntary dispensaries established by the Central Fund, and the dispensaries started by voluntary local committees in Poplar and St. Pancras, were all ultimately embodied in the schemes of the borough councils in whose areas they were situated, and, in addition, 8 dispensaries were specially established within hospitals. Borough dispensaries had also been provided in seven boroughs. From time to time fresh schemes were submitted for the Council's approval until in 1919 all the borough councils had approved schemes. The total number of dispensaries is 33 and there are branch dispensaries in 2 boroughs. Although every borough then had its approved scheme, the development had proceeded almost entirely under abnormal conditions due to the war. An investigation into the work of the dispensaries which was conducted in 1919 revealed serious defects. It was found that the dispensaries were cognisant of a relatively small proportion of the total cases of tuberculosis in their area and that insufficient time and attention were devoted to the examination of contacts and to home visiting. Thus the first essential condition of efficient work, viz., that the tuberculosis officer should have knowledge of all the tuberculous patients, suspects and contacts in his district, remained unfulfilled. The small proportion of tuberculous patients known by the tuberculosis officers was accounted for to a considerable extent by the lack of co-operation in some areas between the tuberculosis dispensary and the department of the medical officer of health. Some medical officers of health interpreted the Public Health (Tuberculosis) Regulation, 1912 (Article XI.), in the sense that it precluded them from making use of the services of the tuberculosis dispensary in matters concerning notified cases (not dispensary patients) or from notifying the dispensary of such cases. The tuberculosis officer's ignorance of the " notified " cases extended automatically to the contacts. Further difficulty, which operated even in districts where the tuberculosis officer was in touch with the medical officer of health, arose from the fact that many cases of tuberculosis were not notified immediately the disease became definite, many cases even remaining unnotified until the patient's death. Another serious weakness in the dispensary system was the apparent failure to realise the 60 importance of the early diagnosis of doubtful cases. The Council's tuberculosis scheme of 1914 stipulated that dispensary schemes must include provision, either in the dispensary or at a hospital working in connection with the dispensary for the diagnosis not only of ordinary cases but also of incipient, anomalous and difficult cases, and that the dispensary should be linked up with a hospital to which special cases should be referred for consultation or treatment, residential or otherwise. In practice few cases of doubtful diagnosis were referred by tuberculosis officers to the consulting centres at hospitals, and as regards diagnosis at the dispensaries it was found that generally speaking there was a lack of intensive study of doubtful cases, which were often kept in attendance for observation for long periods. The congestion arising from the accumulation of these observation cases, resulted in these cases ceasing to be observed, and there was no time for physical examination of even a tithe of them. Tuberculosis officers frequently gave medicine for trifling symptoms or in some cases even for no medical reason in order to ensure the further attendance of patients. The arrangements for treatment at the dispensaries also revealed serious defects. Patients were provided with medicine whether needed or not, with the result that the drug bills were unnecessarily heavy, and patients were encouraged to rely more on medicine and less on advice on such essential matters as personal and home hygiene and diet. Another matter in which there was an obvious need for improvement was the question of co-operation between the dispensary and other agencies. Sufficient use was not made by the dispensary of the information available through the periodical examination in the elementary schools of children on the dispensary registers, and there was room for more effective co-operation with general practitioners. One of the most conspicuous defects in the dispensary organisation was the lack of attention paid to what is termed " aftercare," in which is included such questions as the suitable employment of tuberculous patients. Closely connected with all these matters was the question of the adequacy of the dispensary staff. It was found that there was a considerable variation in the amount of time devoted by tuberculosis officers to their duties. Allowing for the fact that defective organisation was responsible for a certain amount of wasted time, it was apparent that if the dispensary work was to be put on a satisfactory basis it would be necessary to increase the number of assistant tuberculosis officers and tuberculosis health visitors, and to relieve the tuberculosis officers of the clerical work. Since 1919 there has been a steady improvement in the organisation and working of the dispensaries. Co-operation between the dispensaries and the public health departments has been secmed by the appointment of the tuberculosis officers by the borough councils as assistants to the medical officers of health. Considerable attention has been given to the failure to notify cases of tuberculosis, and though there has been some improvement, there is still an unduly high proportion of cases that remain unnotified, many of them even until the patient's death. Statistics furnished by a number of boroughs show the following average percentage of the number of cases dying unnotified or dying within three months of notification. 1920. 49 per cent. 1921. 53 per cent. 1923. 44 per cent. 1924. 44 per cent. Greater attention has been given in the dispensary to the question of early diagnosis and the consequent reduction in the number of cases remaining undiagnosed for long periods has enabled the tuberculosis officers to give more time to their legitimate functions. It has also resulted in a marked reduction in the use of drugs. Arrangements have been made at the dispensaries for evening sessions to be held for employed patients and special sessions are held for school children. To a 61 considerable extent the practice has been adopted of seeing patients by appointment. A system has been inaugurated by which information is interchanged between the tuberculosis officers and the school doctors as regards the progress of school children whose names are on the dispensary register. Special provision has been made in the dispensaries for the tuberculosis officers to be relieved of clerical work. Tuberculosis care committees. Another important development has taken place in the establishment of tuberculosis care committees in nearly all the boroughs. In June, 1915, the Council adopted a model scheme for the appointment by borough councils of tuberculosis care committees, the membership of which is to be representative of all the agencies in the borough, official and voluntary, engaged in dealing with patients suffering from tuberculosis. As the borough councils were unable in 1915 to appoint these committees, owing to war conditions, the Council organised and appointed interim committees until such time as the borough councils were able to take over the work. The number of interim tuberculosis care committees appointed by the Council was 30. In 1922 the Ministry of Health addressed a circular to metropolitan borough councils expressing the opinion that the time was opportune for the establishment of permanent committees. As a result schemes were submitted by most of the borough councils. At the present time all the borough councils with four exceptions have permanent committees working under schemes approved by the Council and the Ministry of Health. In two boroughs (Islington and Bethnal Green) the interim committees continue to function. In Lambeth the care work is discharged by an officer of the borough council of the almoner type for the municipal ad hoc dispensary, and by the lady almoner's department of St. Thomas's Hospital in connection with the branch dispensary established at that hospital; and in Bermondsey the arrangements for carrying on the work still remain in abeyance. In 13 boroughs the secretarial work is discharged by paid secretaries, and in 10 boroughs by hon. secretaries. In the borough of Paddington the medical officer of health acts as secretary. The care committees include among their members representatives of all agencies, public and charitable, operating in their areas and this facilitates co-operation in social work and avoidance of duplication of visiting and of effort. In many cases the occurrence of tuberculosis in a family seriously disturbs the economic balance, and it is the primary aim of a care committee to give such advice and assistance as circumstances dictate to enable the family to tide over the most difficult period, to maintain or, if lost, to regain, economic independence and to enable the patient to derive the fullest possible advantage from the medical treatment prescribed. The widely varying circumstances of the homes from which tuberculous patients come, make it impossible to give an exhaustive account of the problems with which the committees have to deal. The following are some of the matters which frequently engage the attention of the committees:— (а) The provision of extra nourishment for the family. (b) The provision of extra room or extra bed accommodation. (c) The provision of an open-air shelter for erection in the patient's garden. (d) The removal of the patient to friends or relatives in the country, or the relief of the family by the boarding out of the children and the finding of suitable work for the patient or other members of the family. (e) The care of the children and of the home during the absence of the mother and housewife. (f) While avoiding anything in the nature of a sanitary inspection, which is carried out by officers of the borough council, the care committee bring to the notice of the public health authority any obvious defects, sanitary or otherwise, requiring investigation. 13651 E 62 The care committee give advice and assistance to the patient and other members of the family with regard to the care of the family generally, in order to permit patient to accept, with a contented mind, the residential treatment advised. In the cases of patients undergoing residential treatment (in hospital, sanatorium or infirmary), the home is kept under such regular supervision as may appear necessary in order to determine the success of any efforts that have been made towards improvement and in order to be fully informed of any change of circumstances and of any conditions that may influence a decision as to extension of treatment or otherwise. Attention is paid while the patient is away to the suitability of the arrangements for the reception of the patient on discharge, including the removal of the home to a more suitable location, if necessary and practicable, and the endeavour is made to secure suitable work for the patient, or if necessary some modification of the conditions of his former employment. Knowledge of conditions at home often enables a visitor to intervene and dissuade patients from taking a premature discharge, or parents from removing their children from institutions while under treatment. In the case of children and adults who are approved by the County Council for treatment in residential institutions under the Council's scheme, the care committee undertakes the assessment and collection of contributions in accordance with the arrangements specified by the Council, the amount of the assessment being subject to approval by the public health committee of the Council. Residential treatment. In the matter of residential accommodation the Council directed its efforts towards meeting the known deficiency of beds and the increasing demand which was expected to result from the activities of the dispensary service in the discovery of cases in the early stages when the most satisfactory results are derived from sanatorium treatment. The duty of providing for insured persons was the function of the London Insurance Committee and they made direct arrangements with the authorities of residential institutions, including the Metropolitan Asylums Board, for the use of beds. The direct responsibility undertaken by the Council in the first instance was, therefore, limited to uninsured adults and children. Although the scheme did not exclude provision for the treatment of advanced cases, action was deferred pending further investigation, having regard to the fact that a considerable proportion of such cases were treated in poor law infirmaries. From the first the Council sought and obtained the co-operation of the hospitals, both general and special, and of the Metropolitan Asylums Board, although, during the war, the assistance available at the hospitals was limited by the heavy demands made upon accommodation and staff, in dealing with wounded soldiers and in military service of the normal staffs. The Metropolitan Asylums Board immediately adapted two of its institutions, viz., Downs Sanatorium, Surrey, (which was originally a school for children suffering from ringworm, etc.), and part of the Northern Hospital. Winchmore Hill, (a fever hospital) for sanatorium cases. The Board also arranged for part of the accommodation for children at Queen Mary's Hospital, Carshalton, to be allotted to the Council's cases. It was difficult, in 1914, to estimate with any degree of confidence the requirements. The accommodation authorised under the original scheme of May, 1914, was 160 hospital beds and 240 sanatorium beds for adults and 150 beds for children in voluntary institutions, together with 100 beds for adults and 100 beds for children in Metropolitan Asylums Board institutions, on the understanding that the beds would be required gradually, the maximum being reached by March, 1915. The outbreak of the war prevented extensions involving building operations, and it became necessary to limit the numbers to the accommodation already available, viz., 100 beds provided by the Metropolitan Asylums Board and 100 beds in voluntary institutions for uninsured adults, and 150 beds provided by the Metropolitan Asylums 63 Board and 231 in voluntary institutions for children, until the termination of the war This involved selection of the most favourable cases, but the Metropolitan Asylums Board were able to adapt St. George's Home, Chelsea, for advanced cases (women) and to receive a proportion of such cases (women) at the Northern Hospital, Winchmore Hill, and Downs Sanatorium (men), the latter being largely insured persons. The problem of the advanced case has presented considerable difficulty, both from the preventative and treatment points of view. Before the advent of county councils and borough councils practically the only institutions available were the poor law infirmaries. The fact that 50 per cent. of the Council's expenditure on the treatment of tuberculosis is met by Exchequer grant, which is not available in relief of poor law expenditure, has resulted in continual pressure upon the Council to provide accommodation for these cases. It has been emphasised throughout that the institutions should be near enough to the homes of the patients to enable relatives to visit and even to permit of patients from time to time being allowed to visit their homes. Infirmaries are generally local and some of them have quite suitable accommodation. It has always been felt that the extensive provision of new accommodation would involve waste of this accommodation and that a large class of chronic cases more or less destitute and likely to live for indefinite periods should be accommodated in these institutions. Some advocates have urged the provision of small " homes " of 20 to 30 beds where certain unavoidable features of large institutions which become irksome can be relaxed. Investigation has indicated that such institutions, apart from other unfavourable considerations, are comparatively very costly and it has been necessary to meet the demands by the provision of large institutions. This has been done by the Metropolitan Asylums Board, who, in addition to St. George's Home and Winchmore Hill Hospital, placed Colindale Hospital, Hendon, containing about 325 beds, at the disposal of the Council and has now adapted Grove Park Hospital, Lee, for the accommodation of 320 patients. There is, however, a number of small institutions both in London and in various parts of the country to which specially selected cases are sent. The duty of deciding suitability for residential treatment has always rested upon the medical officer of health of the Council, but throughout he has had the advantage of various aids, other than the original medical reports, in arriving at his decisions. It was recognised that varying standards would operate amongst medical men, and the Council was able to obtain the co-operation of leading consultants who were formed into an advisory board. This board drew up a medical classification describing the types of case which may roughly be divided into "early," " moderately advanced " and " advanced," and this classification, with slight modification, has been used by the Ministry of Health in their circular 37t dated September, 1925, to local authorities, laying down regulations as to uniform records and statistical returns throughout the country. Notwithstanding this guidance it was felt that personal examination of a number of cases would be necessary, and the Council arranged a rota of consultants to examine patients at the County Hall and the disposal of the patients was determined on their reports. This arrangement in practice was found to be unsatisfactory, and a later development was the setting aside of a definite number of beds in hospitals in London, principally Brompton Hospital, and the City of London Chest Hospital. Victoria Park, for the " observation " for short periods of cases which the medical officer of health of the Council was unable to accept for residential treatment on the information given in the medical reports. Experience showed the advisability of a middle course. The requirement that all cases which could not be determined on clinical reports should be admitted to hospital led to congestion and delay in treatment, and provision was made for the examination of a proportion of doubtful cases at County Hall by a clinical medical 13651 E 2 64 officer on the staff of the public health department. Stricter classification of the cases was adopted and distinction was made between those in which several examinations of sputum had given negative results, and the cases in which examinations of sputum had demonstrated the presence of tubercle bacilli. The arrangement for the admission of the former class into " observation " beds has been continued, while modification has been made in the method of dealing with the " positive " sputum cases in which, from the clinical records submitted with the application, the prospect of permanent benefit from sanatorium treatment appears to be doubtful. Arrangements were made for the examination of such cases by a clinical medical officer on the staff of the Council. This modification was made in 1921. The value of revised methods of selection may be seen in the following tables. The first table gives the results of the observation of 158 ex-service and civilian insured cases which were under observation in Brompton and City of London Chest Hospital, Victoria Park, during 1920. No. of cases observed. Tuberculous. Not tuberculous. Cases accepted as tuberculous by Ministry of Pensions but queried by tuberculosis officers 73 11 62 Cases accepted by Ministry of Pensions and by tuberculosis officers as tuberculous, but passed through observation beds 21 3 18 Civilians recommended by tuberculosis officers for admission to observation beds 48 18 30 Civilian cases diagnosed by tuberculosis officers as tuberculous, but passed through observation beds 16 2 14 158 34 124 It will be noticed that 124 (or over 78 per cent.) of the 158 cases were reported as not suffering from tuberculosis. Of the 34 cases diagnosed as tuberculous, 10 were considered to be " arrested " cases not requiring active treatment; only 24 (or 15 per cent.) of the 158 cases being recommended for treatment. The subsequent results of observation in hospital are shown in the following table:— Classification of patients referred to observation hospitals:— 1921. 1922. 1923. 1924. 1925. No. of patients passed through observation beds 2,863 2,494 1,741 1,365 1,334 Classification—Grade A. 478 416 363 283 374 B.l 331 249 100 74 66 B.2 1,093 999 642 515 465 B.3 515 438 315 204 169 Surgical 12 102 38 51 31 No of cases in which diagnosis was not confirmed 434 290 283 238 229 Adult patients examined at the County Hall, and disposal thereof since 1922:— 1922. 1923. 1924. 1925. No. examined at County Hall 653 1,460 924 197 Sent to— Observation hospital 188 253 93 26 Sanatorium 393 977 729 142 Home for advanced cases 64 45 49 9 Not accepted 8 185 53 20 65 The more stable staff of dispensaries since the war and the increasing experience of tuberculosis officers has resulted in a marked reduction of cases which, while they cannot be accepted on clinical reports, can be determined on one physical examination by a clinical expert at the County Hall, and the doubtful cases now are largely of a kind which require intensive observation in hospital to determine disposal. With the passage of time and experience of working " sanatorium benefit " under the National Insurance Acts, the London Insurance Committee found increasing difficulty in meeting the needs of insured persons within the financial resources placed at their disposal under the Acts. County councils throughout the country were empowered to undertake treatment of insured persons on behalf of insurance committees on certain financial terms or to make good the financial deficiencies of insurance committees. The London Insurance Committee appealed to the Council for assistance in 1919, and an interim arrangement was agreed to by the two bodies which continued down to May, 1921, when under the National Health Insurance Act, 1920, residential treatment for tuberculosis ceased to be one of the benefits conferred upon insured persons under the National Insurance Acts and insured persons were placed in the same position in this matter as the uninsured population. As the Council had already acted upon its powers of providing for the uninsured population it added to its responsibility the provision necessary for dealing with the largely increased numbers of sufferers for whom accommodation was required in consequence of this amendment of the Insurance Acts. In the following year the work was made compulsory on all county councils. The development of the work is indicated in the following table which shows the number of cases treated each year since early in 1914. It should here be mentioned that in 1917 the Council, at the request of the late Local Government Board (now Ministry of Health), undertook the preferential treatment of men invalided from the Army owing to tuberculosis, but this work was later transferred to the London Insurance Committee, and ultimately again to the Council, when the London Insurance Committee ceased to deal with treatment of tuberculosis as an insurance benefit, other than as an ordinary medical benefit in line with other ailments. The Ministry of Pensions, through the Ministry of Health, have reimbursed first the London Insurance Committee and subsequently the Council for the full cost of the treatment of ex-service cases. The figures for ex-service men are given separately in the table. Table shewing development of provision of residential treatment under the Council's Tuberculosis Scheme (1914-1925 inclusive). Year. No. of admissions during year. Adults. No. of beils occupied at end of year. Adults. Uninsured. Insured. Ex-service men. Total. CHILdren. Uninsur-d. Insured. Ex-servicemen. Total. Children. 1914 47 3,593* — 3,640 121 33 689* - 722 90 1015 322 2,603* — 2,925 374 126 428* — 554 241 1910 492 2,215* — 2,707 551 133 348* — 481 320 1917 594 2,297* — 2,891 573 162 364* — 526 375 1918 667 2,257 1,426 4,350 738 133 392 291 816 376 1919 690 2,204 2,727 5,621 833 170 568 570 1,308 557 1920 932 2,320 3,045 6,297 1,167 306 712 618 1,638 704 1921 1,215 3,356 2,544 7,115 1,050 225 727 430 1.382 669 1922 1,024 3,121 1,289 5,434 906 250 835 285 1,370 655 1923 975 2,298 1,304 4,577 749 285 822 351 1,458 707 1924 1,041 2,670 1,037 4,748 915 302 1,045 265 1,612 746 1925 1,192 2,706 836 4.534 921 357 1,074 237 1,668 792 * Includes ex-service men. A feature of residential treatment which has its influence both upon the accommodation required and the ultimate results of treatment is the length of stay in the 66 sanatorium. Prolonged residence obviously results in more beds being required and premature discharge increases the liability to relapse. The experience during the war period was a tendency to short periods of treatment. There were several factors to account for this. Those outstanding may be summarised as follows:— (1) the failure to appreciate the need for treatment when the patients ceased to feel ill. (2) the ease with which employment was obtainable. (3) the number of cases known as " educational" cases, i.e., patients in whom permanent arrest could not be expected, but whose lives could be prolonged by training for short periods under institutional conditions as to how to look after themselves, and (4) the fact that "sanatorium" treatment when provided under the National Insurance Acts was regarded as a " right," which resulted in a considerable demand for beds in excess of the number obtainable within the financial limits imposed upon the London Insurance Committee. This was met by limitation of period of treatment. The constant direction of effort to bring under sanatorium treatment the " early " cases where permanent benefit may be expected, the increased appreciation on the part of patients of the importance of remaining under treatment so long as the medical superintendents consider it necessary, and the policy of the Council of allowing treatment until the maximum benefit is derived, have all tended to increase the period of treatment. It is now desirable to turn to the results of treatment. In the earlier years of the working of the scheme, as indicated in the observations made above as to the dispensary service, and as to the procedure in respect of the selection of cases, a large proportion of the cases recommended for treatment were not sanatorium cases in the strict sense. Moreover, the great demand for labour under war conditions had the effect of keeping back from treatment favourable cases until completely incapacitated from work, and patients frequently discharged themselves prematurely against medical advice in their anxiety to return to profitable employment. The after histories of patients treated by the Council in 1914 and 1915 were traced to the end of 1919, and a similar course was followed by the London Insurance Committee. The results in both investigations indicated a high proportion of deaths as shown in the tables on page 67. These results were confirmed by investigations in various parts of the country and considerable discussion followed as to whether " sanatorium " treatment is an effective means of treating pulmonary tuberculosis. In the annual report for 1920 there is a statement on this matter (p. 37) to the effect that the examination of the figures in detail shows clearly that there has been considerable misconception of the meaning of the term " sanatorium treatmeut," not only by the general public but also by medical men, and further that in more than 50 per cent. of the cases sent to sanatoria the disease was too advanced for sanatorium treatment to be of permanent benefit to the patients. It has not been considered to be of value to work out the results of treatment in respect of patients treated between 1916-20, as at best no improvement could be expected, owing to the continuance of the methods of recommendation and selection in operation during the war period till at least the middle of 1920, and to the disturbed conditions both in the medical profession and the general life of the community which persisted for some years after the war. The improved methods for searching out and examining contacts and the arrangements for more rigid selection of cases for sanatorium treatment, including the provision for examination of selected cases at County Hall and the systematic use of " observation " beds described earlier in this report, were expected to improve the results. 67 The following tables give the results of the original investigations by the Council and London Insurance Committee concerning patients treated in 1914-1915 and the comparable figures for subsequent similar investigations. After history of the Council's Patients who received residential treatment during part of 1914 and during 1915, and of insured persons recommended for sanatorium benefit in 1914. Number of cases. Numbers known alter tour years to be Alive. Dead. 1. Council's patients— (a) Adults (uninsured)—- For diagnosis 5 3 (60%) 2 (40%) Early cases 59 27 (45.8%) 32 (54.2%) Moderately advanced cases 97 33 (34%) 64 (66%) Far advanced cases 23 4 (17.4%) 19 (82.6%) (b) Children (pulmonary)— 4 (16.7%) Diagnosis doubtful 24 20 (83.3%) Early cases 81 78 (96 2%) 3 (3.8%) Moderately advanced cases 48 36 (75%) 12 (25%) Far advanced cases 10 4 (40%) 6 (60%) {c) Children (non-pulmonarv)— Hip 16 12 (75%) 4 (25%) Spine 2 1 (50%) 1 (50%) Other bones 4 3 (75%) 1 (25%) Glands 14 12 (85.7%) 2 (14.3%) 2. Insurance Committee patients— Adults (insured)— Early cases 552 386 (70%) 166 (30%) Moderately advanced cases 1,417 361 (25.4%) 1,066 (74.6%) Far advanced 619 20 (3.2%) 599 (96.8%) Of 306 uninsured adults treated 122 (39.9 per cent.) were not traced, and of 288 children treated 89 had passed out of supervision. Of 3,224 insured adults recommended for sanatorium benefit 636 (19.9 per cent.) were not traced. The figures for insured and iminsured adults are not comparable as insured persons of both sexes work under the stress of industrial conditions, whilst uninsured persons, principally women, are not engaged in ordinary industrial life. Moreover, of the 3,244 insured persons recommended for sanatorium benefit only 1,515 received residential treatment. After history of the patients treated in 1918. Number of cases enquired into, 2,987. Of these 47 per cent, were early cases, 29 per cent. moderately advanced, and 24 per cent. far advanced cases. After 5 years. Early cases 85% alive 15% dead Moderately advanced cases 39.9% alive 60.1% dead Far advanced cases 4.5% alive 95.5% dead There was a marked increase in the percentage of early cases dealt with in 1918 as compared with the figures for 1914. This was accounted for partly by a higher level of medical skill and attention and partly by the number of discharged soldiers who had exceptional advantages in being able to undergo treatment for longer periods free from financial worries and anxieties about dependants. Cases dealt with in 1925. 5,869 applications for institutional treatment of adult patients were received during the year 1925, viz.:— First applications. Applications for further treatment. Males (Ex-service men) 381 Males (Ex-service men) ... 598 „ (Civilians) . 1,929 „ (Civilians) 605 Females . 1,829 Females 527 4,139 1,730—Total 5,869 68 Of these 514 were not accepted for treatment under the Council's scheme ; 197 patients were examined at the County Hall, and their disposal then determined ; 1,313 were referred to observation hospitals for admission as a preliminary step to their disposal; 3,766 were accepted for admission direct to institutions on the reports of the medical officers recommending the cases, and in 79 cases the applications for various reasons were not proceeded with. In 369 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 182 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 aremainly those in which the diagnosis has been confirmed by the presence of tubercle bacilli in the sputum and in respect of which there appears, on examination of the reports, to be doubt as to the suitability of the patients 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 1925 :— Observation hospital. Sanatorium. Home for advanced cases. Not accented. Total. 26 142 9 10 197 During the year 1,334 patients were discharged from observation hospitals and 4,878 from other institutions. The classification of the 1,334 patients discharged after observation in hospitals : Classification—Group A 374 cases or 34.82% of total pulmonary cases. „ B1 66 „ 6.15% B2 465 „ 43.30% „ B3 169 „ 15.73% Total pulmonary cases 1,074 Surgical cases 31 Total diagnosed as tuberculous 1,105 In the remaining 229 cases the diagnosis of tuberculosis was not confirmed. Action taken with regard to 1,105 cases in which tuberculosis was diagnosed, compared with the figures for 1924 :— Year. 1925. 1924. Discharged home 2 71 Made their own arrangements or refused further treatment 117 136 Transferred to institutions for advanced cases 66 157 Elected to go to infirmaries 37 14 Transferred to surgical hospitals 4 13 Transferred to general hospitals - 5 Transferred to training centres - 2 Died during observation 69 48 Discharged for misconduct 3 2 Transferred to sanatoria 807 679 Totals 1,105 1,127 At the commencement of 1925 the Council had in use the following number of beds:— Adults. Discharged soldiers. Civilians. Total adults. Children. Total children. Voluntary Institutions 150 481 1,623 191 744 Metropolitan Asylums Board Institutions 115 877 553 69 The number of cases under treatment on 31st December, 1925, was:— Adults. Discharged soldiers. Civilians. Total adults. Children. Total children Voluntary Institutions 154 560 1,668 182 792 Metropolitan Asylums Board Institutions 83 871 610 4934 adults and 917 children were sent away during the year. The total number treated during the year 1925 was 6,557 adults and 1,661 as compared with 6,198 adults and 1,622 children in 1924. In addition, 270 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 clothing, outfits and surgical appliances for children who had received treatment under the tuberculosis scheme, was continued during 1925. The sum paid to the Association during 1925 was £2,000. During 1925 the Association received 432 applications for assistance, and 270 children were sent away with the assistance of the Council's grant. 20 applications were for boots and clothing, and 16 cases were found to be ineligible. 63 children were supplied with surgical instruments with the help of the Council's grant-in-aid. In addition to these, 13 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. Since 1920 the Council has 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. In 1925, children to the number of 221 were sent to a convalescent home at St. Leonards-on-Sea, the Council making a grant of £480 towards the cost. Open-air schools. 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 1925 there were 157 children admitted to the schools and 153 discharged. Of the latter, 42 were fit for elementary school, 74 were fit for work, 17 were transferred to hospital or sanatorium, 8 moved away, and 11 were discharged for other reasons. One child died from tubercular meningitis. The Medical Officer of the Elizabethan School mentions that three children suffering from tuberculous glands of the neck have received artificial sunlight treatment at the clinics at Humanity House, Westminster, and that in each case considerable benefit was derived from the treatment. A number of children from the Stormont House School also received light treatment at Victoria Park Hospital, and the medical officer of the school reports that a few of these appear to have benefited. The Medical Officer of Springwell House School refers to the small amount of infectious disease during the year. It is worthy of note that the records of the school show that there has not been a case of measles since 1919. Venereal diseases. The number of new cases of venereal disease dealt with by the hospitals under the London and Home Counties Scheme during 1925 was 17,502, of which 5,902 were syphilis, 11,321 gonorrhæ, and 279 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 779 less than in 1924. 70 Year. Syphilis. Gonorrhoea. Soft chancre. Non-venereal. Total. 1924 6,626 11,350 305 7,292 25,573 1925 5,902 11,321 279 8,680 26,182 Increase + or decrease — — 724 -29 -26 + 1,388 + 609 The distribution of new cases of venereal disease between the sexes is shown in the following table, the figures for the preceding years being given for comparison. It will be seen that in the case of syphilis the figures for 1925 are the lowest recorded since the scheme first came into operation. Year. New cases. Total venereal cases. Syphilis. Soft chancre. Gonorrhoea. M. F. M. F. M. F. M. F. 1917 4,427 3,351 199 11 3,830 1,207 8,456 4,569 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1919 6,394 3.391 463 18 10,441 2,440 17,298 5,849 1920 6,988 3,579 766 25 10,669 2,427 18,423 6,031 1921 5,088 3,100 458 13 8,573 2,136 14,119 5,249 1922 4,207 2,600 309 12 8,233 2,402 12,749 5,014 1923 4,497 2,631 311 4 9,043 2,520 13,851 5,155 1924 4,174 2,452 301 4 8,565 2,785 13,040 5,241 1925 3,556 2,346 268 11 8,464 2,857 12,288 5,214 Importance is attached to the necessity of securing the regular attendance of patients at the clinics, more especially in the case of gonorrhoea, and efforts to secure the requisite provision of facilities for intermediate treatment at times other than during the hours of the clinic are meeting with considerable success. A number of patients still fail to complete the full course of treatment considered necessary before final discharge, due in no small measure to the false impression that a cure has been effected on the disappearance of outward signs of the disease. The need for improving conditions likely to cause patients to discontinue attendance at the clinics or to transfer from one clinic to another continues to receive careful attention. Ratio of attendances. The total attendances were 646,131, and the ratio of attendances to venereal cases is in the proportion of 36 attendances to each new case. This figure shows a considerable advance over that for previous years and is noteworthy 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. country. Comparative figures for the nine years the scheme has been in force are shown in the following table :— Year. New cases. Total. Attendances. In-patient days. Venereal. Non-venereal. 1917 13,025 2,360 15,385 120,659 63,923 1918 13,679 2,693 16,372 169,485 66,095 1919 23,147 5,118 28,265 307,722 73,211 1920 24,454 6,592 31,046 464,033 81,612 1921 19,368 6,050 25.418 496,209 79,692 1922 17,763 5,950 23,713 529,003 112,564 1923 19,006 6,644 25,650 555,509 106,662 1924 18,281 7,292 25,573 589,002 102,456 1925 17,502 8,680 26,182 646.131 102,454 71 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. Pathology and bacteriology. Another point worthy of note is the total number of examinations made of pathological specimens. Comparative figures for the nine 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 1924 79,005 24,797 1925 106,064 26,346 The increased use made by medical practitioners of the facilities for the examination of pathological specimens is highly satisfactory. Under the Scheme, medical practitioners who fulfil certain conditions, are entitled to free supplies of the approved arseno-benzol preparations for the treatment of their private patients. The number of medical practitioners availing themselves of this service is now 423, as compared with 108 at the end of 1917, the first vear of the operation of the Scheme. Hostel accommodation The necessity was recognised from the outset for accommodation where young women and children under treatment could be lodged during the period of infectivity. Certain hostels managed by or independently of hospitals, have received grants in aid for this purpose, and experience has proved the value of these hostels for the more efficient treatment of certain cases and for preventing the spread of disease. During the year 1925, the number of patients dealt with at these institutions from the areas in the scheme was 263, the aggregate number of days in residence being 22,968. Midwives Act and Children Act. Midwives. Duly certified midwives with London addresses exceed 5,000 in number, of whom 901 gave notice of their intention to practise within the County during the whole or part of the year, a decrease of 5 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: 2,384 visits were paid by the inspectors this year, as compared with 2,294 the previous year. Infringements of rules of U.M.B. 84 infringements of the rules of the Central Midwives Board were reported during the year, of which 44 were slight, and therefore dealt with by means of a verbal caution; 23 cases were of a more serious nature, and were dealt with by a written caution. As to the remaining 17 cases, 14 midwives were seen by the Committee, and cautioned by them, the other 3 being reported to the Central Midwives Board. In the 3 cases reported to the Board, 2 midwives were struck off the Roll; in the other case the Board adjourned the case owing to the absence of an essential witness. 13 midwives were suspended from practice with a view to the prevention of the spread of infection, and in 6 cases compensation was authorised. One midwife 72 applied for a certificate in support of her application to the Central Midwives Board for the restoration of her name to the Midwives Roll. 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 15 inquiries were made by the inspectors into such cases, in 7 of which it was decided to take no further action; 7 were dealt with by a verbal or written caution, and the case of one woman was referred to the Middlesex Countv Council. Still births. During the year there were 510 still-births reported by midwives in their practice. The figures for previous years were: 1920, 896; 1921, 684; 1922, 720; 1923, 582; 1924, 594. Of the 510 still-births 286 were males, and 219 females, and 5 not stated; furthermore, 254 were reported macerated; and 236 not macerated, and 20 not stated. Puerperal fever, 316 cases of puerperal fever were reported during the year, as against 300 the previous year. 78 cases proved fatal, as compared with 70 the previous year, a case mortality of about 25 per cent. as against over 23 per cent. the previous year. In addition the Registrar-General recorded 26 deaths from puerperal sepsis, which were, however, not notified as puerperal fever. The distribution of the notified cases was as follows:— Delivery conducted Ky Cases. Deaths. (а) Medical practitioners 109 24 (b) Certified midwives 86 17 (c) Medical practitioner and certified midwife 10 4 (d) Hospitals and poor-law institutions 66 19 (e) Medical students 14 2 (f)Cases of miscarriage or abortion where no attendant was engaged 27 7 (g) Uncertified women 4 3 Total 316 76 Medical aid. 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 1925 as many as 7,034 notices were received, as compared with 6,961 in 1924. Assuming that approximately 41,000 confinements were conducted during the year by midwives in independent practice, it appears that medical aid was required in about 17.1 per cent. of the cases, about the same percentage as in the preceding year. Ophthalmia neonatorum. 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. 1,284 notices were received from midwives during the year with regard to medical aid summoned for inflammation of the eyes of infants, as compared with 1,266 in 1924. In addition, 65 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 1,349 cases, 422 proved to be ophthalmia neonatorum, as compared with 431 in 1924; 281 other cases that did not occur in the practice of midwives were also notified, making a total for the year of 703 notified cases of this disease. The percentage occurring in the practice of midwives was 60.0, as against 61.0 in 1924. All the cases that occurred in the practice of midwives were investigated by the inspectors, and it was found that 398 were reported as completely cured, while 73 14 died. Impairment of the vision in both eyes occurred in 1 case and of one eye only in 3 cases, whilst in 6 instances the result could not be ascertained owing to the removal of the patients. 65 cases received in-patient hospital treatment at St. Margaret's Hospital. There were 131 cases of pemphigus reported during the year. In past years classes have been arranged for the instruction of midwives, and were well attended. In 1924 and 1925 classes both for general midwifery subjects and only ante-natal work were held. Lying-in homes. In pursuance of Section 18 of the London County Council General Powers Act of 1921 the Council has made by-laws prescribing the registers to be kept and the entries to be made therein. Receipts must also be given for payments made and such receipts must contain certain particulars. Any death of a patient or child must be notified to the Council within 24 hours. These by-laws 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. The number of beds available in London for maternity cases is estimated to be as under:— Registered Lying-in-homes 830 Municipal Maternity Homes 148 Special Hospitals 452 General 225 Poor Law Institutions 540 2,195 beds. It is estimated that the total number of cases that can be received per annum is about 37,000 or 43 per cent. of the total births. The number of lying-in homes registered in London since 1916 is as under:— 1916 183 1921 258 1917 222 1922 277 1918 272 1923 277 1919 258 1924 275 1920 258 1925 277 Of these:— (а) 133 were maintained by certified midwives. (b) 144 were maintained by persons not midwives. (c) 99 were mixed homes. (d) 9 claimed exemption in 1925. (e) 9 have been cancelled since 1915. (f) 312 were cancelled voluntarily. (g) 11 were refused registration. The work of registration and inspection is carried out by 4 assistant medical officers as part of their duties under the Midwives Acts. The sanitary inspection is carried out by sanitary officers of the department; thus no special staff has been allocated exclusively to the work. Several other local authorities have obtained similar powers to the London County Council owing to the tendency, when London alone had powers, for homes of an undesirable character to be moved from London into adjoining counties to avoid inspection. Since 1915 the undesirable home has gradually disappeared in London, while the standard of efficiency in other homes has improved, particularly in the case of those used by persons of small means. 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 1925, 3 nurse infants were removed, as compared with 7 in the previous year. The Act permits the Council to grant whole or partial exemption Children Act, 1908. 74 from inspection in cases where the circumstances appear to warrant such a course No request for exemption was received during the year. 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 1925, 947 reports, as compared with 992 during 1924, were made. The premises were found to be satisfactory in 498 cases as compared with 617 the previous year. Sanitary defects were discovered in 242 homes as compared with 157 the previous year, while overcrowding was reported in 141 homes as compared with 128 in 1924. Overcrowding and sanitary defects were found in 16 homes as compared with 37 the previous year. In 50 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 rearrangement 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 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 1925 was 38, as compared with 26 last year, while inquests were held in 16 cases, as compared with 8 in 1924. The verdict inl4 cases was death from natural causes, and in the two others accidental death. In last vear's report reference was again made to the question of adoption of infants. During that year three bills dealing with this matter were introduced in Parliament. A committee was also appointed by the Home Secretary to examine the problem of child adoption from the point of view of possible legislation, and at the request of that committee evidence was submitted on behalf of the Council. During 1925 the Committee issued reports of its findings and a draft Bill to give effect to them. Mental Deficiency Act. 1913. On 31st December, 1925, of the 3,935 cases being dealt with at the expense of the Council, there were 2,138 in institutions, 28 under guardianship, 1754 under statutory supervision, 15 in places of safety waiting other action. During the year 722 cases were examined with the following results:— Idiot. Imbecile. Feeble minded. Moral Imbecile. Not Defective. Insufficient Evidence. Total. Male 11 108 216 1 20 5 361 Female 15 87 217 — 39 3 361 Total 26 195 433 1 59 8 722 Occupation centres. In addition to the foregoing, certain cases were examined while still of school age and are recorded on a later page. The Occupation Centres opened in the year 1923 were continued throughout the year. The majority of the Centres Vere visited by the Council's certifying officers, who found that the improvement in the children's behaviour, appearance, 75 habits and cleanliness was very marked, and that the benefits the centres afford appeared to be greatly appreciated by many of the parents. The Council has continued the provision made for the employment of guides where necessary, in order to convoy the children to and from the centres. Blind Persons Act. The Council s scheme tor carrying out the provisions of the Blind Persons Act, 1920, set out in previous reports, was continued throughout the year, during which 84 persons over school age were seen. Of these, 48 males and 26 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. 7 males and 3 females were considered to be unfit for training under the provisions of the Act. Work of the Chemical Branch. Central Laboratory. The work of this branch was carried out at four laboratories—viz., the central laboratory at County Hall, the Greenwich generating station, and laboratories at the northern and southern outfalls. During the year nearly 5,000 samples of various kinds were examined. Most or these were submitted by other departments of the Council for examination as to their compliance with specified requirements or their suitability for various purposes. In many cases special methods of examination, physical or chemical, have been devised to test the suitability of the material submitted. The samples examined included 259 samples of building materials, 60 of coals, 21 of disinfectants, 724 of foods, 18 of cattle feeding stuffs, 29 of drugs, 201 of oils, 143 of paints, colours and varnishes and 119 of petroleum (under the Petroleum Acts). Analyses were made in situ of 8 gases in connection with dry-cleaning and degreasing plant in use in London. In connection with the heating and hot-water supply of County Hall, 47 flue gases and 633 samples of unsoftened and softened water were examined and advice given. Analyses were made of 527 samples of water from the River Thames and of 103 other waters, whilst 96 samples of rain water containing matters deposited from the air were examined. A considerable amount of work of an advisory character, frequently involving much investigation, has been carried out in connection with such matters as revision of specification for materials, tests of fire-resisting materials and failure of materials in use. Specifications have been drawn up for paints used for protective purposes, and means of testing have been devised which, it is hoped, will enable materials of the desired properties to be obtained as a result of open tender. Steps have also been taken with a view to securing uniformity and simplification of specifications for lubricating oils. Woolwich Ferry, conveyance of dangerous goods. The conditions under which goods that, for various reasons, may be classed as dangerous, should be carried on the ferry boats at Woolwich, have been investigated and suggestions made for an amendment of the bye-laws to suit present conditions. Bathing lakes, open-air swimming baths and paddling ponds. The special chemical work referred to in the report for last year in connection with the bathing lakes, open-air swimming baths and paddling ponds, has been continued, and the experiments with a system of filtration have been kept under observation. It is hoped to report at the end of the ensuing bathing season on the results of these experiments. Collection of house refuse An experiment of great interest is being conducted at the Ebury bridge depot of the Westminster City Council. House refuse, after the removal of tinned iron cannisters, bottles and other large matters is comminuted by suitable machinery and then stacked in a heap which is allowed to reach very large dimensions. The changes occurring in this heap have been the subject of continued chemical and biological observation, and it is proposed to continue these investigations on the same heap so long as it is available, and report the results of the observations in the next annual report. 76 Greenwich Power Station Laboratory. The work of the laboratory at the Greenwich power station comprises:—(i.) The daily examination of samples of water and materials with a view to the control of the water-softening plant, the blowing-down of boilers, the detection of condenser leakage, and advice on such matters as the purity of condensed water supplied to the station batteries; (ii.) the sampling, preparation and examination of samples of fuel (coal) used both at the power station and at other works of the Council, such as the main drainage outfalls and pumping stations; the preparation and examination of samples of fuel ashes, etc.; and (iii.) investigations connected with corrosion of metals and other matters affecting the operation of the station plant. Outfalls. At the outfall laboratories systematic daily examinations of the sewage reaching the outfalls and the resulting effluent and sludge, as well as of the water of the river Thames at both high and low tides, and other analyses in connection with the working of the outfalls have been continued. Much attention has also been given to chemical work relating to fuel economy and systematic examinations of fuel, feed-water, etc., are now made on lines similar to the work at Greenwich power station. In addition much experimental work needed to throw light on matters connected with the river, or sewage treatment, has been undertaken at these laboratories. Biological treatment of sewage. The experimental treatment of large volumes of sewage, and, later, of large volumes of effluent by mechanical agitation has been continued with uniformly satisfactory results. Further points in connection with this mode of treatment need elucidation and are being investigated. It has been found that the treatment and reactivation sections of the combined plant are capable of treating 300,000 gallons of effluent a day. The insufliciency of the present settling tanks so far appears to be the limiting factor. River Lee. This river was visited and chemical examinations made of the water in July and again in October. On both occasions it was found to be, from Tottenham lock downwards, in a very unsatisfactory state. It is clear that this condition is likely to continue until the effluents brought down by the intercepting ditch which receives the Pymmes brook and other streams, are improved and the lesser pollution from the small brooks, discharging through or near the old Tottenham sewage works, is stopped. The natural river below Lea bridge, where it passes by Hackney marsh and forms the County boundary was in a dirty condition in October. The rapid flow of this shallow stream causes it to be in part self-cleansing but there is much room for improvement. River Thames. The systematic examination of the river Thames was continued in 1925, 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 waste matters discharged by other bodies. Provision has been made for additional treatment of sewage at the outfalls, and in view of the condition of the river it became necessary to use iron salts at both outfalls for about a month beginning on 4th August. 77 TABLE I. COUNTY OF LONDON. Vital statistics for the several metropolitan boroughs and the County of London in the year 1925. (Rates per 1,000 of civil population.) Metropolitan boroughs. (Arranged in topographical order.) Estimated civil population, 1925. Births. Deaths. Infant mortal- ity (per 1,000 births). Measles Scarlet fever. Diphtheria. Whoop- ing cough. Typhoid fever. Diarrhoea and Enteritis, age 0-2 per 1,000 births). Phthisis. Pneumonia. Bronchitis. Cancer. Cases of notifiable infectious disease, (a) Scarlet fever. Diphtheria. Typhoid fever. Erysipelas. Puerperal fever 'per 1,000 births). Cerebro spinal fever. Acute pneumonia. Western. Paddington 147,100 15.9 12.2 72 .07 .01 .07 .09 .02 9.4 .65 109 .78 1.58 1.81 2.30 .12 .44 6.43 .03 2.41 Kensington 179,400 15.8 13.2 79 .09 .01 .06 .10 .02 10.5 .75 1.22 1.11 1.76 1.49 1.66 .16 .29 1.76 .06 .78 Hammersmith 134,500 17.5 12.0 65 .05 .02 .09 .24 .02 10.6 .92 1.08 .71 1.61 217 1.55 .07 .35 6.40 .01 105 Fulham 163,700 17.2 10.7 75 .01 .02 .06 .22 — 14.2 .97 .92 .78 1.25 2.41 1.66 .06 .45 7.49 .02 1.94 Chelsea 64,820 14.4 13.7 68 .05 .11 .11 .02 12.8 .83 113 .88 2.02 1 33 2.66 .06 .50 3.22 — 1.66 Westminster, City of 139,600 10.7 12.4 69 .01 .12 .11 .03 8.5 .85 .97 .76 1.76 1.47 2.07 .12 .32 3.28 .01 .42 Northern. St. Marylebone 106,100 14.1 11.9 64 — .02 .07 .21 .02 17.4 .78 1.23 .81 1.60 1.64 1.25 .18 .36 4 02 •02 •67 Hampstead 88,040 12.2 10.5 55 .02 .01 .02 .05 — 6.5 .59 .66 .55 1.61 2 03 1.80 .14 .25 .93 .02 .82 St. Pancras 215,900 18.0 12.7 72 .01 .15 .33 .01 12.9 .91 105 1.23 1.54 302 3.26 .08 .54 5.94 .03 1.42 Islington 339,200 19.3 12.3 63 .07 .02 .06 .19 .01 10.4 1.10 1.29 .84 1.62 3.37 2.70 .03 .32 3.52 .01 .40 Stoke Newington 53,190 15.4 11.9 67 — — .08 .11 .02 8.5 .92 .90 .79 1.37 1.30 1.40 — .19 3.67 — .28 Hackney 228,300 17.9 11.5 65 .08 .02 .13 .15 .01 11.7 .88 .94 .74 1.32 2.31 2.90 .03 .25 318 .02 .15 Central. Holborn 43,315 12.2 12.5 63 .02 .05 .21 .02 11.4 1.04 .95 1.27 1.52 211 1.90 .14 .35 3.81 .02 1.27 Finsbury 77,560 22.4 13.5 60 .14 .08 .19 .04 13.8 1.42 112 1.52 1.48 3.67 3.27 .09 .94 6.91 .03 1.05 London, City of (b) 13,629 7.4 11.9 59 .07 .07 .15 19.8 .59 117 .81 .88 1.77 1.40 — .59 9.93 — .74 Eastern. Shoreditch 107,300 24.5 13.2 88 .32 .05 .14 .28 .01 15.6 119 1.37 1.38 113 4.53 411 .02 .66 4.96 .02 2.68 Bethnal Green 119,800 22.0 11.9 81 .12 .03 .14 .53 .01 21.3 103 109 .80 1.27 2.78 416 .10 .77 2.67 .03 1.76 Stepney 255,370 20.8 12.2 76 .11 .02 .09 .27 — 21.5 1.26 1.33 .84 1.24 2.34 2.54 .11 .52 2.82 .01 .87 Poplar 168,500 22.7 11.7 76 .17 .04 .36 — 13.6 .93 1.55 .98 115 2.80 218 .01 .46 3.93 .04 3.78 Southern. Southwark 189,000 21.3 13.2 78 .14 04 16 28 12.4 1.08 1.34 1.11 1.40 3.93 4.80 .03 .64 2.75 .03 1.39 Bermondsey 123,000 22.6 12.8 76 .17 .02 .24 .22 — 6.1 117 1.59 .98 1.47 2.91 4.36 .04 .29 3.25 .02 .97 Lambeth 311,100 17.8 12.4 64 .02 .03 .18 .16 .02 8.3 100 .99 101 1.53 3.35 2.67 .08 .43 4.88 .01 .81 Battersea 172,100 18.5 10.5 58 .02 .05 .06 .12 .01 5.0 .91 .62 .86 1.37 3.22 2.66 .05 .39 1.89 .01 1.70 Wandsworth 340,900 14.3 10.5 54 .00 .03 .08 .11 01 5.5 .75 .56 .72 136 2.33 2.23 .17 .35 1.85 .03 1.33 Camber well 275,400 17.7 11.1 64 .08 .05 .15 .15 6.4 .99 108 .84 1.28 3.26 3.36 .05 .43 2.06 .01 .49 Deptford 115,900 18.8 12.1 63 .27 .03 .20 .15 — 5.5 .90 .98 1.06 1.42 2.47 5.03 .03 .55 7.38 .02 1.31 Greenwich 102,936 18.7 11.4 70 .19 .04 .14 .17 .01 9.8 1.05 .77 1.00 1.23 2.96 4.23 .08 .50 4.64 .03 .94 Lewisham 185,600 15.7 10.4 56 .02 .01 .09 .10 .01 6.9 .64 .72 .83 1.50 2.04 1.32 .24 .30 3.79 .01 .69 Woolwich 140,740 17.8 10.8 55 .06 .03 .09 .12 .03 2.7 1.14 .69 .78 1.37 2.47 2.09 .11 .31 3.50 .03 1.94 London 4,602,000 17.9 11.9 68 07 .02 .11 .19 01 10.8 .95 104 .90 1.44 266 272 09 .42 383 .02 118 (a) Thirteen notifications of smallpox were received, eleven in Bethnal Green and two in Lambeth. Of the Bethnal Green cases one proved fatal, and in three instances the diagnosis of smallpox was not confirmed. (6) Including Inner and Middle Temples. 13651 P 78 TABLE II. COUNTY OF LONDON. Statistics of the administrative work carried out during the year 1925. Cowsheds. Slaughterhouses. Offensive Trades. Smoke nuisances. Underground rooms. Overcrowding. Houses let in lodgings. Common lodging houses. Cleansing of persons and rooms. Water supplj Milkshops. Ice cream premises. Other food places. Sanitary Authority. No. licensed. No. of inspections. No. licensed. No. of inspections. No. licensed. No. of inspections. Observations. Complaints. Notices. No. illegally occupied. No. closed or otherwise remedied. Instances found. No. remedied. No. on register. No. of inspections. Prosecutions. Houses licensed. Authorised lodgers. Adults. Children. Premises or rooms. Tenement houses extra supply. No. on register. No. of inspections, j No. on register. No. of inspections. No. of places. No. of inspections. City of London — — 7 * — — 121 15 — — — 1 1 124 393 — 1 455 12 927 — — 340 348 63 68 927 373 Battersea 1 6 2 319 3 4 86 7 4 — 17 6 85 46 — 3 201 261 4,724 3,243 33 147 818 201 336 258 2,003 Bermondsey — — — — 13 32 54 1 1 1 — — — 223 446 — 3 1,197 78 — 2,179 49 213 831 145 145 594 2 993 Bethnal Green 11 119 3 318 9 89 16 9 3 — — — — 207 661 — 6 395 7 — 1,443 48 245 725 194 243 204 370 Camberwell 1 5 2 280 9 29 114 13 13 5 — 70 42 297 228 — 5 438 62 3,38' 380 — 450 1,462 338 681 313 646 Chelsea — — 3 71 — — 12 5 — 1 1 3 3 — — — 2 172 10 966 407 1 75 122 40 42 90 155 Deptford — — 2 109 6 3O 62 17 5 — — ? 13 289 578 — 4 1,089 — 2,049 1,887 — 163 421 169 309 52 77 Finsbury — — 2 113 2 22 30 7 5 2 2 12 12 835 4,698 — 2 470 10 — 98 1 149 175 S6 122 269 374 Fulham — — 2 61 — — 160 10 2 1 1 137 38 — — 2 87 5 4 3,833 103 109 116 216 173 346 1,025 Greenwich 2 7 5 36 2 3 35 1 3 — — 12 3 247 222 — 2 90 8 727 200 15 119 147 126 129 181 1,504 Hackney 7 8 17 416 19 6 8 834 34 31 1 1 97 13 473 1,549 — 4 313 77 3,357 637 1 372 1,509 257 560 621 1,321 Hammersmith — 7 447 3 21 25 18 14 4 3 37 19 2,479 9 — 1 292 90 2,587 63 12 86 2,022 169 235 852 6,778 Hampstead — — 2 28 — — 7 5 1 17 9 9 8 — — — — — 4 1,142 31 51 87 211 68 141 483 1,216 Holborn — — 1 2 — — 604 7 7 3 3 4 4 577 1,050 6 14 1,093 124 — 94 5 129 141 81 264 384 2,884 Islington 4 31 13 730 17 48 114 51 17 4 4 19 19 1 011 2,371 — 23 793 23 4,841 3,835 50 568 1,262 238 223 662 19,826 Kensington — — 5 345 1 47 427 19 2 46 39 75 54 3 614 7,926 131 8 407 109 4,332 1,727 364 125 401 171 239 871 2,332 Lambeth 3 9 11 200 4 48 222 87 111 7 7 46 46 372 4,464 — 4 415 — — 442 101 470 2,820 165 495 11 132 Lewisham 6 55 8 418 — — 21 7 7 1 1 113 20 3 30 — — — — — 87 — 150 349 — — Not Not stated stated Paddington 1 15 3 93 1 40 152 7 1 4 2 11 3 1,406 5,773 27 3 165 9 3 206 — 102 349 140 224 402 1,606 Poplar 10 34 8 58 7 2 24 102 25 — — 10 1,453 ? — 6 499 69 1,648 372 — 128 544 146 247 380 2,042 St. Marylebone 1 20 3 51 3 63 693 2 2 6 6 4 4 1,079 13,564 — 5 763 3,978 2,513 734 23 143 360 118 210 366 1,254 St. Pancras 2 39 5 149 1 46 280 28 12 — — 23 18 2,365 1,894 12 2 78 1,130 5,878 1,655 44 213 832 328 394 ? 5,444 Shoreditch 2 19 2 21 5 83 45 1 1 2 2 58 39 307 1,625 6 4 281 — — 573 3 264 1,683 135 306 228 856 Southwark — — 5 39 2 9 3 2 — — 29 29 572 260 — 20 1,993 1,066 3,624 16,936 15 337 2,091 130 130 - 522 2,160 Stepney 23 61 1 1 96 41 217 32 26 4 4 57 42 2,645 3,887 2 26 3,662 420 — 1,090 1 437 1,401 285 498 529 1,321 Stoke Newington 1 1 4 52 1 1 73 10 — — — 4 4 — — — — 1 881 133 — 62 32 26 31 256 627 Wandsworth 1 2 8 270 9 107 66 32 30 38 15 120 24 294 841 — 2 94 180 1 376 252 525 336 487 1,084 5 793 Westminster 1 2 — — — — 1,999 103 23 12 11 43 17 1,103 4,317 — 4 1,530 117 928 36 55 492 537 139 108 3,095 2,969 Woolwich 9 114 8 35 — — 16 2 — — — 391 16 325 775 — 13 404 29 2,441 162 4 88 558 221 751 288 1,678 Note.—In the columns above a dash signifies a nil return. Common lodging houses, licensed number, 169 ; lodgers, 17,385; visits—day, 9,700, night, 373; prosecutions, 3; penalties and cos's, £8 19s. 6d. Seamen's lodging houses, licensed number, 33; Bermondsey, 5; Poplar, 7; Stepney, 21; lodgers, 1,092. \ Visits—day, 865; night, 81; prosecutions, 7; penalties and costs, £41 8s. Prosecutions—Smoke Nuisauces : Bermondsey, 1; Bethnal Green, 1; Poplar, 2; Hackney, 1. * Continuous supervision during slaughtering. Water Supply : Bethnal Green, 1; Paddington, 1: Kensington, 12; St. Pancras, 1; St. Marylebone 1. Overcrowding: Hampstead, 2; Shoreditch, 1; Paddington, 1; Fulham, 11; Kensington, 10; Battersea, 1; Holborn, 2 Milkshops: St. Pancras 2; Oity, 2. Ice Cream Premises: Islington, 4. Offensive Trades: Wandsworth, 1. 79 Table III. Tuberculosis Dispensaries—Analysis of Returns Jan.-Dec., 1925. 1 Borough and dispensary. 2 Under observation on 1-1-1925 pending diagnosis. 3 Examined for first time during 1925, including contacts. 4 Number of contacts included in (3). 5 Number included under (2) and (3) suffering from 6 Number included under (2) and (3) found to be nontuberculous. 7 Under observation on 31st December. 1925. pending diagnosis or ceased attendance bef re comp etion of d agnosis. 8 Total attendances. 9 Visits to homes by 10 Home consul tations. 11 Number referred to affiliated hospital. 12 No. of specimens of sputum examined (a) Pulmonary. (i) Nonpulmonary. Adults. Children. Adults. Children. Adults. Children. Adults. Child ren. Adults. Children. Adults. Children. Adults. Children. (a) Tuberculosis officer. (b) Dispen sa0ry nurse. †City of London 4 3 41 18 16 14 20 2 2 1 22 17 1 1 565 2 506 3 27 48 Battersea 151 91 456 337 80 153 162 12 11 37 224 275 210 104 5,177 195 5,670 28 91 1,422 Bermondsey 13 12 423 495 105 328 148 11 15 34 256 453 17 9 9,463 58 4,695 38 196 1,151 Bethnal Green 8 3 454 234 143 157 119 4 15 18 293 206 35 9 4,494 158 1,791 39 145 680 Camberwell 29 4 826 729 223 504 263 13 31 39 454 672 107 9 9,326 1,317 9,296 63 278 1,475 Chelsea 37 46 208 149 51 39 58 — 1 157 182 29 13 3,002 54 2,818 — 520 Deptford 19 10 375 258 73 80 118 8 7 20 214 218 55 22 5,790 262 4,139 62 913 Finsbury 11 10 286 156 137 124 112 2 5 11 170 143 10 10 4,003 265 3,137 1 25 474 Fulham 16 17 543 516 151 258 168 19 7 47 344 446 40 21 5,361 560 5,421 45 65 1,707 Greenwich 6 14 476 405 244 286 124 15 13 26 335 371 10 7 6,806 153 4,473 21 176 Hackney (Vic. Pk. Hpl.) 8 3 425 253 149 189 120 4 11 17 268 223 34 12 5,572 153 2,225 29 164 696 (Metro. Hpl.) 3 3 255 134 97 101 79 3 5 14 164 117 10 3 2,603 107 2,283 27 80 489 Hammersmith 13 12 390 215 83 110 145 10 16 18 217 187 25 12 3,462 155 4,205 26 29 557 Hampstead 5 6 191 108 63 65 68 4 6 5 119 95 3 10 1,359 40 2,085 13 10 224 Holborn — — 135 62 35 53 75 — 4 4 53 58 3 746 55 987 11 38 106 Islington (R.N. Hpl.) 4 2 385 161 111 107 151 1 13 16 216 146 9 3,423 174 2,002 8 47 291 (R. Ch. Hpl.) 19 10 421 235 132 163 175 2 12 14 239 222 14 7 6,176 377 2,744 1 44 770 Kensington 16 16 440 367 173 223 100 2 10 24 308 335 38 22 3,804 75 2,186 20 511 Lambeth (Cent.) 36 17 494 196 127 90 206 16 15 21 249 156 60 20 5,353 199 2,022 95 77 839 ,, (St. Thomas's) 7 — 545 280 100 100 167 4 12 12 362 261 11 3 4,882 296 2,265 219 685 474 Lewisham 2 4 399 227 99 126 156 6 27 16 212 207 6 2 3,170 399 2,349 12 11 103 Paddington (Talbot Rd.) 7 9 370 334 140 173 105 5 7 87 238 230 27 21 6.271 479 1,944 21 36 162 „ (St. Mary's) 6 8 162 82 52 43 41 1 10 17 116 68 1 4 4.842 136 1.490 4 103 157 Poplar 12 10 681 654 182 259 156 16 7 11 507 618 23 19 6,191 326 9,178 5 26 1,911 St. Marylebone 10 28 231 129 39 70 82 6 5 8 117 84 37 59 3,772 194 1,378 15 17 350 St. Pancras (Oakley Sq.) 56 37 391 309 55 169 201 2 17 71 127 241 102 32 4,010 167 3,406 10 951 * „ (U.C. Hpl.) — — 27 7 4 4 13 — 1 — 8 7 5 — 190 5 115 — 7 39 * „ (Maiden Rd.) 13 17 14 32 4 24 5 1 — 7 32 15 16 245 7 126 — _ 59 Shoreditch 29 8 379 231 167 171 116 — 4 11 267 219 21 9 5,718 258 2,984 — 31 687 Southwark 37 30 542 345 145 234 185 17 20 29 328 280 46 49 5,692 31 4,343 4 61 790 Stepney (Green) 19 20 409 323 242 . 241 102 29 5 6 290 282 31 26 2,828 134 2,643 11 13 462 „ (St. G.-in-the-E.) 15 21 298 345 148 247 79 8 5 14 195 317 34 27 2,695 72 1,535 19 15 436 „ (Whilechapel) 6 17 610 390 363 298 144 11 4 14 462 363 6 19 3,782 170 2,226 2 32 798 Stoke Newington 1 2 115 68 31 45 39 3 5 5 67 59 5 3 1,378 59 823 10 38 269 Wandsworth 23 8 829 452 164 206 292 9 26 26 492 413 42 12 6,544 321 5,153 93 34 1,711 Westminster — — 260 135 86 64 152 15 10 24 97 96 1 2,637 87 5,636 90 16 443 Woolwich 14 7 739 610 253 288 170 19 8 14 530 571 45 13 6,631 471 3,928 39 - 380 Totals 655 505 14225 9981 4467 5806 4616 280 372 731 8,724 8,870 1,168 605 157963 7,971 114207 1 084 2,441 23,231 .†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. * Quarter ended 31st March, 1925. 13651 F 2 80 CHAPTER II. REPORT OF THE SCHOOL MEDICAL OFFICER (Dr. F. N. K. MENZIES) FOR THE YEAR 1925. PREPARED IN COLLABORATION WITH SIR WILLIAM HAMER, WHOSE TERM OF OFFICE AS SCHOOL MEDICAL OFFICER TERMINATED AT THE END OF THAT YEAR. Introductory Note. In recent school annual reports note has been made of the influence, now clearly emerging to view, of the Education Act of 1870, upon health. Dr. J. F. J. Sykes, the late Medical Officer of Health of St. Pancras, was one of the first to focus attention upon a curious phenomenon presented by infant mortality, which after being almost stationary for many years, prior to the end of the last century, suddenly began to show decline, and has continued to do so almost uninterruptedly to the present day. Nine years ago, in the London school report for 1916 (Ann. Rep., Vol. III., p. 4) this fall was ascribed to the fact that at the commencement of the twentieth century the majority of parents had passed through the elementary schools. Dr. James Wheatley, Medical Officer of Health of Shropshire, in the summer of 1923, in an address before the British Medical Association at Portsmouth, showed beyond all question that the predominating influence in promoting this decline in infant mortality had been the Act of 1870, and he urged that "general education had operated mainly by developing the sense of responsibility of parents in the health and lives of their children." In the London school report of 1923 (pp. 95 and 96), it was indicated that there was a corresponding movement in death rates at school ages. Again, last year, reference was made to a very interesting paper by Dr. Gibson (Public Health, Vol. XXXVII., May, 1924), who quoted the statement of Richard Browne (a seventeenth-century writer) to the effect that "Infection, negligence and ignorance "are the great causes of "accidents of old age," and then applied it to other ages, to infancy, and to the age 45-54. Dr. Gibson laid stress, inter alia, upon the influence of increased sobriety. It has been pointed out that here in London (Ann. Rep., 1917, p. 4) the most marked correspondence, presented by mortality rates at ages, in the last 25 years, is at the extremes— infancy and old age; and that "no theory purporting to account for the behaviour of the mortality at the youngest ages can be complete which fails to explain the correspondence shown to exist at the other extreme of life." The statistics certainly justify the quotation placed at the head of Dr. Gibson's paper and they support the contention that ''education by removing negligence and ignorance has materially influenced mortality at the ages of comparative helplessness—childhood and advanced age." At the same time it must of course be agreed that "increased sobriety has beyond all doubt exercised considerable influence"; this is unquestionably one of the operative influences through which education has worked for good. Thirty-seven years ago it was stated by the author of "English Sanitary Institutions" that "over great territories of social evil, adjacent to the field of our merely medical work, we seem to see on all sides, just as in our own province, the common pervasion of one deep want—the want of riper national education." The writer urged that for the prevention of Crime it was of vital importance to" recognise the stage where crime is first mentally conceived, substitute moral influences for influences which tend to make the will criminal; to prevent Drunkenness, he held it necessary "to develop the reasonable minds, to which drunkenness shall have neither charm nor excuse"; for the true prevention of Pauperism, he deemed indispensable "the interior forces of personal character, the faculties of activity and self control, the thrift power of labour and frugality." Of course for many a year the motto could only be "We work in hope," but now for more than half a century 81 the deep want of national education has been increasingly supplied. "There must be no impatience of results," said William James, "They are sure to float up of their own accord from a long enough daily work at a given matter." And they are floating up. The gleaming ideal of the pioneers is gradually being realised; there stands revealed one of the ''truths that wake to nerish never." The three years' programme. The omens are auspicious and should encourage all those engaged in carrying out the further advance, which is embodied in the three years' programme of the Council's resolution of July 22nd, 1924. From 1st April, 1925, seven important developments in connection with the school medical service were contemplated. The examination of children leaving school was reinstituted under this programme in the second and third terms of 1925, and thus it became possible once more to give that assistance in the vocational guidance of the children, which is so valued by all care committee workers; many interesting facts elicited at these medical examinations are detailed by Dr. Thomas on p. 90. Further, on p. 118, the extension of the treatment of teeth and of minor ailments (the second item on the programme) is referred to. The third item, the inauguration of two new centres for the inpatient treatment of tonsils and adenoids is being carried into effect, centres in Hackney Wick and Peckham being now almost ready for work. The steps taken as regards new provision for ear disease, involving the establishment of six special ionisation centres at which Dr. Wells and his two assistants see the children, and the new procedure, which it is proposed to inaugurate, are described on p. 119. References to the three remaining items on the programme—further provision for remedial exercises, further provision for open-air education and further special medical services—are made on pp. 136 and 128. Medical Inspection. During the year, 197,702 children in the three statutory age groups, and 41,011 children approaching the age of 14 years were examined by the school doctors in London elementary schools, and 102,533 were found to require treatment. 1,652 children in the age groups in special schools were examined and 42,882 children not in the age groups were brought forward for special examination. An additional 33,475 children were inspected in connection with school journeys, open-air classes, etc. Further, the school medical staff examined 7,019 candidates for scholarships or for permanent positions in the school service, and 26,054 cases in connection with their specific defects in special schools. A detailed analysis by Dr. C. J. Thomas of the results of inspection is given on pp. 83-91. Medical treatment. The number of ailments treated under the Council's scheme was 254,000, a marked increase upon any other previous year. The largest increase was in the dental departments, where 112,964 children were treated as compared with 99,045 in 1924. Re-inspections. The number of reinspections was 159,388. The combined results of first and second reinspections showed that 75.5 per cent. of the children found defective had been dealt with. Personal hygiene. 1,937,588 examinations were made at rota visits by the school nurses. The percentage of verminous conditions found was 16.6. The number of scabies cases continues to decline, 2,077 being treated as compared with 2,155 in 1924. Infectious diseases. The prevalence last year of encephalitis lethargica was decidedly less marked than in 1924. On pp. 112 and 118 reference is made to the treatment, at Winchmore Hill, of children suffering from the sequelae of encephalitis, now being undertaken by the Metropolitan Asylums Board. Diphtheria notifications show no diminution as compared with last year, though the deaths are definitely less numerous than those occurring in 1924, and that year showed slight improvement upon the mortality of 1923. The results of preventive inoculation, which is being practised on a large scale in America, are being followed with close attention, and the behaviour of the disease in New York City and State is illustrated on p. 97. Measles was again becoming prevalent in London at the close 82 of 1925. On pp. 99-100 the course of recent outbreaks of this disease is described, and comment is made upon the noteworthy decline in the death-rate since 1918, a result which is not entirely explained by the fluctuations in the birth-rate in recent years, and is unquestionably in part due to the special measures taken to prevent spread of measles and lessen mortality among the sufferers. In this connection the Metropolitan Asylums Board has been able considerably to extend the provision made for institutional treatment, owing to the lessened prevalence of scarlet fever and diphtheria since 1920-21. Staff. The staff engaged in the work of the London School Medical Service includes, in addition to the School Medical Officer, who is also the Medical Officer of Health, one Senior Medical Officer giving his whole time to the work, one Senior Medical Officer supervising the work of special schools in addition to the general work of mental deficiency, one Principal Assistant Medical Officer for infectious diseases, one Principal Assistant Medical Officer for supervision of aural diseases with two assistant aurists part time, five Divisional Medical Officers supervising the work in the five divisions into which London is divided for school medical purposes, one Divisional Medical Officer dealing with infectious diseases, two divisional Medical Officers dealing with special schools in addition to the general work of mental deficiency, 25 Assistant Medical Officers (full time), 59 Assistant Medical Officers (part time, each for three sessions a week on yearly engagements), and part time temporary medical assistants on special authorities giving 111 sessions a week. There are in addition, one Principal Assistant Medical Officer (part time) for secondary schools, and four part time Consulting Medical Officers for aural, ophthalmic, orthopaedic and dental matters. School Buildings. Under the three years' programme a sum of £282,000 was included in the estimates for the year 1925-6 for building new schools and modernising old schools. In addition, a sum of £36,000 was allowed in respect of minor structural improvements such as the division and rearrangement of classrooms, provision of practical workrooms and other improvements. A further sum was included for modernising gas lighting, improving the heating of schools and executing miscellaneous small works. The medical staff report upon defects of lighting and heating, etc., which are observed by them at their visits to the schools for medical inspection purposes and when necessary the Education Officer is informed, in order that the proposals made shall receive consideration. Specific complaints are also referred to the Medical Officer for investigation and report to committee before the decision is made to include work in the year's programme. The Medical Officer is also asked from time to time to decide upon the urgency of proposals. All plans for new schools are considered in an early stage at a conference at the County Hall, at which a representative of the Medical Officer attends, and schemes for remodelling and rebuilding schools are considered at local conferences on the site, at which the Divisional Medical Officer is present. Medical inspection rooms are included in all new buildings and wherever possible in all cases of remodelling. Attention has been given during the year to school furniture, especial regard having been paid to the furnishing of rooms for children under five years of age. The best method of providing for sleep has been explored, and a new type of chair has been introduced to take the place of the existing chairs with circular backs. The new type provides for a straight back and for legs which slightly spread and thereby increase the stability. Attention has also been paid to the methods of cleansing of schools. 83 Results of Medical Inspection. The number of children in the statutory age groups inspected in elementary schools during 1925, was 197,702, being 4,817 more than in the previous year. These included 82,209 entrant infants, 49,871 eight-year-old and 65,622 twelve-yearold children. The difference in the magnitude of the groups reflects the alterations in the birth-rate immediately before, during, and just subsequent to the War. 1,652 additional children were seen in their age groups at mentally defective, deaf and myopic special schools. Owing to the operation of the three-year programme under which the inspection of all children in the term before they leave school has been resumed since April 1st, 1925, a further 41,011 children in the elementary schools, were spected during the year. There has, therefore, been a very large increase in the primary medical work in the schools which has affected inevitably the ancillary work arising out of medical inspection. This in itself represents a considerable growth during the year in the arrangements made for the medical care and oversight of the school population. 42,882 children were specially medically examined in detail (outside the age groups) who were presented to the doctors by care committee workers, school nurses, head teachers and attendance officers, either because there were indications of failing health or because they were absent from school. An additional 33,475 children were inspected in connection with school journeys, open-air classes, camp schools and so forth. Furthermore 159,388 reinspections were made of children who had been noted as ailing at previous inspections. 102,533 children examined in the age groups were referred for treatment for various kinds of ailment. These included dental conditions. The percentage referred for treatment was 42.9 compared with 38.5 per cent. in 1924. The increase is due to the larger proportion of children referred for treatment for enlarged tonsils and adenoid growths. The physical condition of entrant children. The examination of the entrant infants is a very important, probably the most important, part of the routine work in the schools. This examination partakes of the nature both of a routine and of a special examination. For the first time in their lives a large number of these little children come under medical observation. At the other age groups the children have been daily under careful observation by educated people, have been seen frequently by the school nurses, and those with obvious signs of disease or defect, mental or physical, have been brought as special cases before the school doctor. Partially blind children have been sent to myopic schools, deaf and partially deaf children to deaf and hard of hearing schools. epileptics to colonies, mentally and physically defective children to special schools, tuberculous children to the dispensaries and open-air schools and so on. In the older age groups, therefore, we are dealing with a selected population in which abnormal children have been screened out and numbers of ailing children treated. The entrant children, however, have enjoyed little of this preparatory work and nothing that can be compared with the constant care and supervision given to the school child. It is not surprising, therefore, that a comparatively large incidence of disease and defect is found amongst them. Fortunately, the parents attend very well in the case of the entrant child, and this gives the school doctor a great opportunity at the outset, not only to point out and discuss with the mother the health and condition of the child but to give such advice as will materially influence the child's upbringing. Nutrition of entrant infants. During the past few years the maternity and child welfare centres have been at work as the agencies which supervise the health of the child in the pre-school period. It will be useful, therefore, to compare the results of the examinations of the entrants to school over a period of years in order to ascertain how far there has been a change in the condition of the health of the pre-school child, and in what directions the 84 changes, if any, have taken place. A series of tables has, therefore, been prepared giving the results of the inspection of entrants in the years 1913, 1915, 1920 and 1925. Good. Boys. Average. Poor. Good. Girls. Average. Poor. 1. 2. 3. 1. 2. 3. 1913 30.6 58.5 11.9 32.7 57.6 9.7 1915 32.1 62.4 5.5 32.3 62.5 5.2 1920 26.1 67.5 6.4 26.6 67.5 5.9 1925 21.4 72.9 5.7 22.4 72.6 50 The percentages in this table show the great drop in the number of children poorly nourished which took place during the war when unemployment practically ceased to exist. In 1920 there was apparent a tendency to increase in the number poorly nourished, but in 1925 the number of entrants found to be poorly nourished is not greater than in 1915, and it may be claimed that in spite of unemployment, the measures that have been taken to prevent distress have been conspicuously successful so far as the figures of nutrition of entrant infants can testify. The table further shows that there has been an equalising influence at work, and the central column containing the average child has increased at the expense of the first column. Cleanliness of entrant infants. The tendency of the times is thus well illustrated, inequalities at the one end of the scale are being reduced, while the incidence of distress at the other end is being held in check or even lessened. Boys. Girls. Clean. Head Nits. Vermin. Clean. Body Dirty. Vermin. Clean. Head Nits. Vermin. Clean. Body Dirty. Vermin 1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2. 3. 1913 86.8 12.5 0.7 77.6 20.6 1.8 73.9 24.8 1.8 76.9 21.3 1.8 1915 90.0 9.7 0.3 82.0 17.2 0.8 76.2 22.4 1.4 81.1 18.0 0.9 1920 93.8 5.9 0.3 90.9 8.7 0.4 82.2 16.5 1.3 90.6 9.0 0.4 1925 95.0 4.7 0.3 96.1 3.8 0.1 88.9 9.9 1.2 95.9 4.0 0.1 The intensive campaign against bodily uncleanliness and verminous infestation, which the school medical service has waged, has had its effect not only upon the school children themselves but upon the homes, as is shown by these mostsatisfactory figures. In 1913, 24.8 per cent. of entrant girls had nits in the hair, by 1925 this has been reduced progressively to 9.9 per cent. been reduced progressively to 9.9 per cent. Body vermin in 1913 were found in one in 50 of all entrant children, in 1925 they are found in only one in a thousand. Bovs. Girls. Sound. Slight caries. Severe caries. Sound. Slight caries. Severe caries. 1. 2. 3. 1. 2. 3. 1915 47.6 38.2 14.2 47.1 39.1 13.8 1920 53.2 32.7 141 52.7 33.6 13.7 1925 54.3 31.4 14.3 53.4 32.9 13.7 Condition of teeth of entrant infants as shown by medical inspection. Figures for teeth in 1913 based upon the same classification are unfortunately not available. In the ten years 1915 to 1925 there has been a definite increase of 6 or 7 per cent. in the number of entrants found on medical inspection to have sound teeth. This may well be due to more hygienic care and feeding on the part of some of the parents, owing to the influence of the maternity and child welfare centres, and to the propaganda work of the school dentists who address the mothers at school dental inspections. On the other hand there appears to be no reduction of the percentage of children with very bad condition of the teeth, as shown in the third column. 14 per cent. of the entrant infants continue to arrive at school with extensive dental caries (four or more teeth obviously decayed) a condition accompanied in many cases by oral sepsis leading to much general ill health. 85 The percentages of those examined referred for treatment amongst entrant infants for certain ailments were as follows:— Boys. Girls. 1913. 1915. 1920. 1925. 1913. 1915. 1920. 1925. Skin 1.0 1.1 1.7 10 .9 .9 1.1 .8 Nose and throat 8.9 70 80 9.7 7.9 6.2 7.4 8.9 Eyes 2.7 2.6 2.7 2.3 2.7 2.7 2.6 2.2 Ears 1.7 1.7 1.7 1.4 1.8 1.8 1.8 1.6 Lungs 2 0 1.8 2.4 1.8 2.0 1.7 2.2 1.7 Deformities and rickets .7 .5 .4 .4 .7 .2 .3 .3 With the exception of ailments of the nose and throat (chiefly enlarged tonsils and adenoids) which tend to increase, there is some evidence in the above table of a slight improvement generally in the health of the entrant infants, particularly in those conditions which depend upon improved care and personal hygiene. Analysis of the results of the medical inspection of the three statutory age groups. Defects found.—86,925 children in the statutory age groups were found with defects needing treatment. This represents 43.9 per cent. of the children inspected, a larger proportion by 5.4 per cent, than in 1924. The apparent increase is due to the larger numbers of entrant infants who came under review in comparison with the other age groups. The entrant infants, in spite of the fact that very few are referred for visual defects, always give a higher proportion of children requiring treatment than the other age groups, owing to the fact that they for the first time come under the continuous care and observation, which, school attendance provides for the whole population at school age, in a way impossible to achieve for any other section of the population. 47 per cent. of entrant infants, 45 per cent. of eight-year old children and 40 per cent. of twelve-year old children were recorded with ailments requiring attention; these, however, include dental caries, a malady which is so widely diffused amongst children of all ages. Nutrition. 12,518 children in the age groups were found to be under nourished. This is 6.3 per cent. of the number inspected, compared with 6.2 per cent. in 1924, 5.9 per cent. in 1923 and 5.7 per cent. in 1922. In 1913 the percentage of children under nourished was 12.8. At the present time remedial agencies exist that were undreamt-of in 1913, and, as the figures show, even the period of prolonged unemployment has produced surprisingly little effect upon the nutrition of the children. In any survey of the condition of children in any class of school a certain proportion will be found to be under nourished quite apart from the question of adequate and proper supplies of food. There are many children coming from good homes who receive every care and attention and the best of feeding who in comparison with the average child must be regarded as under nourished. They are frequently children of the "nervous" type who are abnormally active, both mentally and physically, and their metabolism is continually keyed up to a high pitch. As the result not a vestige of fat is stored in the body and they present a lean and hungry appearance, contrasting very sharply with the chubby contours of the average child. No amount of additional nutriment will make the slightest difference to this type of child. Their proper management consists of wise and gentle restraint (for they are almost always "difficult" children) insistence upon early bed time and avoidance of all sources of undue excitement. They, therefore, profit greatly by a period of country life where the constant and varied nervous stimuli of the town are replaced by an equable and restful environment. Cleanliness. One of the most striking and gratifying manifestations of the beneficent results of the work of the school medical service in improving the health and condition of the children is the great and progressive increase in personal cleanliness. In 1913 only 67.2 per cent. of the older girls in London elementary schools were found without traces of verminous infestation of the hair. In 1916 and 1917 86 this percentage had been raised to 70, in 1920 the figure reached 75, by 1923 it had climbed to 80, in 1924 to 82.5 and in 1925 progress has been maintained at such a rate that the high water level of 85.2 was reached. What this means in improvement in morale and the feeling of personal respect, which it should be the aim of any national system of education to foster, it is impossible to calculate. There is no doubt that the arduous work of the school nurses has been greatly helped by the revolution in fashion which has taken place. It is, indeed, interesting to find that at times Dame Fashion would almost appear to have taken counsel with the Lady Hygeia. Formerly in many ways the vagaries of feminine modes struck deeply at the roots of health and sapped the vitality, especially of girls and young women. They dictated the compression of vital organs, the constriction of the circulating organs, and the limitation of freedom of movement. The result was seen in malformations and diseases very prevalent in the population. The disappearance from the dress of girls of constricting devices, such as corsets and garters, has had a very great effect in improving both physique and health. The disease of chlorosis or green sickness, " a malady most incident to maids," has practically disappeared with the corset, although within the memory of the present generation it was rife. Long skirts trailing in the mire are a mere memory. And now the growing custom of cutting short the hair of girls may perhaps even enable some poet of a later age to refer without misgiving to the "tangles of Neaera's hair." Other forms of uncleanliness and notably the parasites of the underclothing had already practically disappeared, the boys with their frequently cropped heads had already become free from the louse, but the girls with their long hair so difficult to manage and so easy to infect, have remained until now an outstanding difficulty. Dental decay. Over one hundred thousand school children are now being treated annually under the Council's arrangements in London for dental caries. A large number, in addition, as the outcome of medical and dental inspection and following up, are being treated by private agencies and hospitals. The result of this activity is shown in a progressive improvement in the condition of the teeth of children leaving school. Not only is actual treatment carried out on a scale impossible a few years back, but the instruction in dental hygiene given in schools and centres is having its effect in better attention generally to oral hygiene. Condition of teeth of 12-year old children. The table printed below shows in biennial periods the findings of the school doctors in regard to the condition of the teeth of twelve-year old children since 1913; and shows that a great improvement has been effected, especially in reduction of the more serious cases of dental decay in the older children:— 1913. 1915. 1917. 1919. 1 2 3 1 2 3 1 2 3 1 o 3 Boys 50 40 10 531 39.7 7.2 55.2 38.6 6.2 55.1 39.7 5.2 Girls 52.4 39 8.6 55.5 37.8 6.7 56.4 381 5.5 56.5 391 4.4 1921. 1923. 1925. 1 2 3 1 2 3 1 2 3 Boys i 60.3 35.7 40 67.7 29.6 2.7 69.2 28.0 2.8 Girls 63.5 33.3 3.2 69.4 28.2 2.4 70.2 27.5 2.3 1 represents teeth apparently sound, 2 represents caries present but not extensive, 3 represents considerable caries (4 or more teeth decayed) with oral sepsis. Tonsils and adenoids. 12,876 children in the statutory age groups were referred for treatment for enlarged tonsils or adenoid growths as compared with 8,944 in 1924, an increase from 4.6 per cent. to 6.5 per cent. This large increase requires some examination and discussion. In the first place it is necessary to consider the effect of unequal incidence of these diseases upon the three age groups. The figures and percentages for the two years are as follows:— 87 Children referred for treatment for enlarged tonsils and adenoid growths Entrants. 8-year old. 12-year old. No. Per cent. No. Per cent. No. Per cent. 1924 3,946 6.1 2,992 4.8 2,006 3.1 1925 7,197 8.8 3,053 6.3 2,626 4.0 It is seen that the incidence of tonsils and adenoids is much higher upon the younger children and the excess of 17,000 entrant infants (in 1925 over 1924) alone accounts for over 1,000 additional children referred for treatment. But this alteration in the age distribution of the children only explains one-fourth of the total increase which has occurred. The percentage columns show that at each age group larger proportions of the children inspected have been referred for treatment. Many more children inspected are recorded with enlarged tonsils and adenoid growths than are advised to have treatment, the greater proportion are dealt with in an expectant fashion, being kept under observation while the effect of hygienic advice to the parents is ascertained. The number of children found to have tonsils and adenoids and the proportions of these referred for treatment are shown in the following table for the two years:— Entrants. 8-vear old. 12-year old. Tonsils and adenoids. Per cent, referred for treatment. Tonsils and adenoids. Per cent, referred for treatment. Tonsils and adenoids. Per cent, referred for treatment. 1924 10,504 37 7,442 40 5,423 37 1925 16,366 44 6,786 45 6,069 43 Not only were larger numbers of children recorded with unhealthy throats during the year, therefore, but a larger proportion at each age was referred for treatment. There are only two explanations possible. Either there must have been an increase in the prevalence and the severity of cases of tonsils or adenoids or there must have been an alteration of average standard on the part of the individual medical officers inspecting the children. Whether a child, with some degree of tonsillar enlargement and obstruction to nasal breathing from adenoid growths, shall be referred for operative treatment or not, depends upon the individual experience of the examining doctor, and there is necessarily a rather wide margin for individual difference in this respect. Owing to the change over, which has taken place in the London school medical service, from the whole time to the part time principle, there has recently been a large infusion of new blood into the service, and the newly-appointed part time doctors are on the whole younger and perhaps more disposed to favour active interference with conditions of disease, while the older and more experienced officers are more likely to assume a waiting attitude in regard to the border-line case. Then, in such a case, the attitude of the parent is to be borne in mind. Three or four years ago a prejudice against operation was artificially fostered, unhappily with temporary success, many parents becoming reluctant to give their consent. That prejudice has now disappeared and parents are more willing. As in many border-line cases the decision, either to refer for treatment or to wait, will be the result of a discussion with the mother, this circumstance alone may account for some increase in the numbers referred. On the other hand, there are definite reasons for thinking that there has been an actual increase during the past two years in the incidence of enlarged tonsils and adenoids. The weather conditions have been such as to foster repeated attacks of catarrh, and reports from residential schools and other quarters generally indicate a somewhat higher prevalence of unhealthy throat conditions. As will be seen presently there has been a concomitant though slighter increase in other diseases closely associated with the presence of enlarged tonsils and adenoids. The increase in the number of "cases noted, apart from those referred for treatment," also points in that direction. 88 The probability is that both factors have played their part and that, while conditions have been favourable to the development of an increased amount of throat disease, there has also been a change in attitude leading to the adoption of more active measures in dealing with them. Ear diseases. Otorrhoea (or running ears) was found in 2,853 children during routine inspection, or 1.44 per cent. This is a slight increase upon the proportion found in 1924—viz., 1.32 per cent. As ear discharge is commonly produced by unhealthy throat conditions, owing to the spread of catarrh along the Eustachian tube to the middle ear, the increased incidence is to be ascribed to the greater prevalence of unhealthy throat conditions during the year. Defect of hearing was reported in 1,168 children. The proportion (0.59 per cent.) was identical with that present in the year 1924. Otorrhcea after scarlet fever. The arrangement made with the Metropolitan Asylums Board, in the case of three of their isolation hospitals, for the notification to the Council of all children who suffer from aural symptoms during scarlet fever has been continued. Such children have been specially kept under observation in school by the medical staff in order that any recurrence of the disease may not escape detection in its early stages. During 1925, 130 cases were reported of children actually attending London schools, of whom 11 were found to suffer from further attacks of otorrhcea. Of this latter number 5 cases were subsequently reported to be cleared up. Enlarged glands of the neck. Enlarged glands of the neck were noted in 9,398 children (4.75 per cent.) lhis was an increase over 1924, when the percentage was 4.23, while in 1923 it was 3.9. The simultaneous increases in these conditions which accompany unhealthy throat conditions make it evident that there has been a real increase in the latter, due, as was suggested last year, to the effect of climatic conditions and the prevalence of infectious complaints. Visual defects. 53.1 per cent. of 8.year.old boys and 54.9 per cent. of 8-year-old girls failed to pass the test for normal vision with both eyes tested separately. In the 12-year-old group 42 per cent. of boys and 45.9 per cent. of girls failed. These figures correspond very closely with those of the previous year, the only exception being in the case of 8-year-old girls whose vision is better this year. The proportion of children with more serious defect (V=6/12 or worse) was as follows: 8-year-old boys 18 per cent., girls 18.9 per cent.; 12-year-old boys 20.2 per cent. girls 21 per cent. Last year the 12-year-old boys were returned as 20.1 per cent. with more serious defect, and girls as 21.6 per cent. The movement whereby the excessive defect upon girls in comparison with boys is being reduced is, therefore, still in progress. In 1913, boys of 12 showed 22.7 per cent. with vision defect and girls 25.7 per cent., an excess of 3 per cent. on the girls. In 1920, boys of 12 showed 20.7 per cent. and girls 22.1 per cent., an excess of 1.4 on girls. In the present year the figures above show that not only is there somewhat less vision defect found in both sexes, but the excess in girls is reduced to 0.8 per cent. The Council's regulations now prohibit the teaching of needlework by artificial light except in cases in which the school medical officer is satisfied that the artificial light is sufficient for the teaching of needlework without involving risk of injury to the children's eyesight. Further, when on any occasion it is necessary to use artificial light during the time when instruction, according to the time table, should be given in needlework, arrangements are made for an alternative lesson to be given. In order to avoid the necessity for departing too frequently from the time table, head teachers are required to make provision, where practicable, for instruction in needlework to be given before 3 p.m. on any given day. 89 The London Central Spectacles Committee drew attention to the dangers of girls sewing in poor light and the Elementary Education Committee in December, 1925, directed that special attention should be drawn to the above regulation and that the conditions should be borne in mind when time tables are approved. The attention drawn in last year's report to the excessive incidence of visual defect amongst the older Jewish boys has resulted in definite action being taken. The names of pupils attending the Fairclough and Dempsey-street Myope schools were supplied to the Jewish Health Organisation of Great Britain, who submitted recommendations to the Talmud Torah Trust. At the request of the latter body four ophthalmic surgeons were nominated to supervise the arrangements to be made. These officers will see that the requirements of the health authorities are agreed to, and that children with poor eyesight are relieved from strain; further, recommendations have been made for the complete hygienic oversight of the Talmud Torahs. Heart defect.and anromia. Special consideration is given elsewhere in the report to the question of the 1 rheumatic child. Here, only those heart defects found amongst the apparently 1 normal children, who are examined in the age groups, are dealt with. Of these 5,364 were recorded as suffering from heart defects, either functional or organic. It is not an easy thing in a noisy school for the inspector to make a definite diagnosis between functional and organic disease. Moreover, the distinctions between the two conditions have become more blurred with the advance of knowledge, and it is recognised that many conditions which used to be regarded as " functional" are indeed true organic defects, although the heart muscle rather than the valvular appendages is chiefly involved. The percentage of heart defect found this year is 2.71, a slight improvement upon 1924, when the percentage was 2.79. At the age 8, heart defect falls equally upon the two sexes (boys 2.8 per cent., girls 2.9 per cent.). At the age 12, there is a very definite excess upon girls (boys 2.6 per cent., girls 3.8 per cent.). This excess is recorded year after year and shows that there is some influence acting upon girls between the years of 8 and 12 which does not act upon boys. Greater confinement to the house and the performance of household work on the part of girls has been put forward as the explanation, and it may well be the true one, as there is no doubt that girls have to take a large share in the daily domestic work of the house, as they approach the school-leaving age, which the boys generally manage to escape. Similarly, it will be seen that deformities of the spine and feet are more common in girls of this age than in their brothers, and almost certainly for the same reason. Anaemia was recorded in 5,438 children or 2.75 per cent., a slight improvement upon 1924, when 2.99 per cent. of children were found with anaemia. It is found that in years of little sunshine there is more anaemia amongst the children than in sunny years. How far artificial sunshine could take the place of natural sunshine cannot as yet be said, but all indications show that sunshine has a very potent effect upon health and the more advantage that is taken of natural sunshine when it is nresent the better. Lung disease. 7,713 children were recorded as having lung symptoms other than tuberculosis; this is 3.9 per cent. of those inspected in the routine examinations. The percentage in the previous year was 3.37. The increase, however, is mainly owing to altered age incidence, as the bulk of non-tuberculous lung trouble found amongst elementary school children consists in rickety bronchitis from which entrant infants so often suffer. Six per cent. of entrant infants are found with some symptoms of bronchitis as against 3.4 per cent. of 8-year-old children and 1.7 per cent. of 12-year-olds. At each age boys suffer slightly more often than girls. Only about one in a thousand children in the elementary schools is detected at Tuberculosis. 90 the routine inspection with pulmonary tuberculosis, and a similar percentage with other forms of tuberculosis. The exact figures being 161 with pulmonary and 133 with other forms. Tuberculosis is more frequently detected at special inspections. Nervous diseases. Nervous diseases are also chiefly found at special inspections. In the age groups epilepsy was noted in 130 children, including 53 entrant infants. Chorea in 187 children chiefly of the older ages, and paralysis in 178 children, including 92 entrants. "Other" nervous diseases were detected in 1,122 children, including 478 entrants. Deformities. Rickets was found in 1,320 children, a considerable drop from the numbers in 1924 (1,786) and in 1923 (1,975). 816 cases were amongst the entrant infants, 553 (1.3 per cent.) were infant boys and 263 (0.6 per cent.) were infant girls. Spinal deformities were noted in 1,144 children mainly in the 12-year-old group and especially the girls of that group. 254 12-year-old boys (0.8 per cent.) and 440 girls (1.4 per cent.) were noted with spinal trouble. Other deformities were noted in 1,462 children. Special inspections. Very important is the provision for the inspection of ailing children coming under the notice of teachers, care committee workers, school nurses or attendance officers. 42,882 children not in the age groups were thus presented for detailed examination; 1,077 were found suffering from malnutrition (2.5 per cent. as compared with 0.7 per cent. in the age groups), 2,068 from skin diseases (4.8 per cent. compared with 1.1 per cent. in the age groups), 1,820 with external eye disease (4.2 per cent. compared with 2.5 per cent. in the age groups), 2,128 from ear disease (4.9 per cent. compared with 2.6 per cent. in the age groups), 1,526 from heart trouble (3.6 per cent. compared with 2.7 per cent. in the age groups) and 1,445 with non. tuberculous lung trouble (3.4 per cent. compared with 3.5 per cent. in the age groups), 553 children were found at special inspections to be suffering from tuberculous disease actual or suspected (1.3 per cent. compared with 0.1 per cent. in the age groups). These figures show that the oversight of the children in the schools is such that cases of failing health are quickly noticed and brought to the medical officer, and they serve to explain the small numbers of children in the age groups found to be suffering from tuberculosis or gross illness. This is of course as it should be, for it would be intolerable if children remained in school suffering for two or three years between one statutory medical inspection and the next. The health of the child leaving school. During the second and third terms of the year an inspection was made of all children due to leave school in the term following this medical examination. This inspection is made with special reference to vocational guidance. The restoration of this fourth age group to the inspection scheme gives an opportunity again to deduce the full value of the care given to the healthy development of the child in school and the results of the intensive following-up, which is customary in the last two years of school life, are apparent. 20,451 boys and 20,560 girls were inspected. In nutrition they proved markedly superior to any of the other age groups; 5.1 per cent. of the boys and 4.3 per cent. of the girls being recorded as poorly nourished as against 6 per cent. in the total of children inspected, and 25.8 per cent. of the boys and 29.5 per cent. of the girls above the average in nourishment as compared with 21.1 per cent. in the total of all age groups. The cleanliness of the girls was still better than that of the 12-year-old girls, 87.5 per cent. being returned as satisfactory, as against 85.2 in the latter. The great stride made in this respect in the last few years is illustrated by the fact that in 1921, when the 14-year-old group was last inspected, the percentage of girls with satisfactory cleanliness was only 77.7 per cent., so that there has been a betterment of 10 per cent. in the four years. On the other hand, there is no improvement in the condition of the teeth at 14 years as compared with that at 12 years, 28,435 children having left school with sound teeth, or 69.3 per cent., the same proportion as at 12 years. The vision of the leavers is markedly superior to that of any other age group, 62 per cent. of the boys and 57.9 per cent. of the girls passing the test as against 51.8 per cent. of children in the 8-year-old and 12-year-old groups combined. 91 With the exception of a slight increase in spinal deformity in girls (1.6 per cent. as compared with 1.4 per cent. at 12) and a slight increase in hard-of-hearing boys (0.8 per cent. compared with 0.7 per cent. at 12) the health of the leaving children is superior at all points to that at any other age. There is much less disease of ear, nose and throat, less skin disease, less eye disease, and less disease of heart, lungs and nervous system. The improved condition of the leaving child is a great tribute to the total effect of care and training given during the period of school life. Although much has been done to improve the condition of the children's teeth and provision has been made through the Council's scheme alone, leaving out the increase in facilities generally, for the treatment of 120,000 children annually, or about one in five of all children in average attendance, it is the great prevalence of dental decay which still, remains the unsolved difficulty. It is doubtful whether provision of dental treatment, however full and wide it may become, will or can ever solve this problem. It is the causes and the conditions which produce this almost universal defect which require to be discovered. Prevention and not dentistry is the sovereign remedy. The investigation in residential schools organised by the Government Dental Decay Committee in the hope of solving the riddle will be watched with close attention, but results can hardly be expected until a generation of school life has been lived through. Meanwhile the best course to adopt is to prosecute a constant struggle by the means of modern dentistry in order to confine the ravages of dental decay within limits. The control of infectious diseases among school children. The experience of the school medical service in London has demonstrated that the control of infectious diseases occurring among children attending school is best secured by a system of immediate exclusion from school of individual scholars, who are themselves suffering or suspected to be suffering from illness of an infectious or contagious character, and of children living in infected houses; the prompt notification by head teachers of such exclusions to the School Medical Officer and the Medical Officer of Health of the Borough concerned ; and the investigation by medical officers of school outbreaks as they arise. As a guide to immediate action in the matter of excluding individual children from school, head teachers are provided with a comprehensive handbook setting out the periods of exclusion required and the general principles or rules to be observed when cases of infectious disease occur in the school. School closure as a means of preventing the spread of infection has for long been abandoned in London, on the ground that such action deprives the school authority of the essential knowledge of fresh cases as they arise, and of the facilities for examining other children with a view to ascertaining the existence of suspected or unrecognised cases which play so important a role in the spread of disease : further, it is held that in large urban communities school attendance is one of the less important factors in the dissemination of infection, and that the promiscuous intercourse and scramble of play in the homes and streets, as well as the presence of unrecognised cases at crowded assemblies, such as cinemas and other places of amusement, etc., provide the chief opportunities for infection. Consequently, no schools have been closed in London in connection with infectious illness for many years past; on the other hand, every year large numbers of schools and many thousands of pupils are specially inspected during local outbreaks affecting school children, with a view to discovering the sources of infection and excluding children whose attendance might be a danger to others. The number of special medical inspections and visits to schools in connection with the prevention of infectious illness during 1925 is set out in the following pages. Other contributory means of prevention are general attention to the hygiene and sanitary conditions of the schools. Occasionally, it may become desirable to disinfect a school during an extensive outbreak, but, generally speaking, 92 routine disinfection of schools is considered to be valueless, and therefore a waste of public money. In the Memorandum on "Closure of and Exclusion from School" issued jointly by the Ministry of Health and the Board of Education, which is referred to below, the following statement appears:—"There is little doubt that infection in schools is spread to a much greater extent by infectious persons than by infected things. . . This statement forms the general basis of preventive work in the London schools. Memorandum on closure of and exclusion from school. This Memorandum, which was issued in 1925 to local education and sanitary authorities under the joint auspices of the Ministry of Health and Board of Education, is a revised edition of the Memorandum published under the same title in 1909. It deals with the principles governing the closure of schools and the exclusion of individual children therefrom on grounds of infectious illness, and enunciates in detail the methods by which such principles should be carried out in practice, including isolation and quarantine periods, etc. Broadly speaking, it corresponds with the practice adopted in London, as was the case with the earlier publication. The Memorandum contains slight divergencies from the previous issue, special reference being made to the question of school closure, concerning which an alteration in policy is adopted. In an introductory note the following paragraph appears:— (1) If there is one general principle more than another upon which this Memorandum lays stress, it is that if during epidemics of infectious disease, the power to exclude individual children from School be used to the best advantage, it is only in special and quite exceptional circumstances that it will be necessary to close a School in the interests of public health. This principle was laid down asone of the fundamental ideas underlying the previous edition of this Memorandum, and the experience of the last 15 years has only gone to strengthen it. Prior to the issue of this Memorandum, Local Education Authorities were empowered under Article 45 (6) of the Board of Education's Code of Begulations to close schools on the ground that school attendance was seriously lowered by reason of the prevalence of infectious illness. The Board's regulation (Article 45 (b)) has now been amended to secure that school closure shall not in future be allowed for grant purposes on such grounds alone, and provides that schools can only be closed for purely medical reasons. Apart from this modification regarding school closure, exclusion periods for certain diseases were amended, as follows:— Scarlet Fever.—The period of exclusion of home contacts to be 7 days, instead of 14 days, as formerly. Measles.—Children suffering from measles to be excluded for 3 weeks instead of 4 weeks. The conditions of exclusion of contacts remain unaltered. German Measles.—Sufferers to be excluded for one week instead of two weeks. No alteration in the period of exclusion of contacts. Instructions based upon these revised quarantine rules have been incorporated in the Council's Handbook of Infectious Diseases and have been issued for the guidance of teachers in London schools. General review of incidence of infectious illness and of the visitation of schools. The following table shows the number of actual cases of infectious and contagious illnesses reported by head teachers as occurring among school children during the year under review compared with figures for the preceding four years :— Disease. Diphtheria. Scarlet fever. Measles and German measles. Whooping cough. Chicken pox. Mumps. Scabies. Ophthalmia. Kingworm. 1921 6,661 17,030 8,317 9,584 9,811 13,317 2,998 466 3,081 1922 5,641 8,026 34,385 10,340 8,213 4,207 1,570 801 2,488 1923 3,985 4,824 13,784 7,304 13,849 7,916 1,110 1,881 1,935 1924 3,696 5,093 35,946 8,404 11,826 15,424 920 1,101 1,558 1925 5,033 5,717 24,521* 12,795 17,583 9,161 711 882 1,364 * Prevalence of German measles. 93 It will be noted from the above table that there was a considerable increase in diphtheria, whooping-cough and chicken-pox, and a slight rise in the number of cases of scarlet fever; on the other hand, mumps, which had been very prevalent in 1924, materially declined, and it will be observed that the two parasitic diseases, scabies and ringworm, which formerly played such havoc in the general school attendance, and still persist in individual cases where appropriate treatment is not applied, have markedly diminished in prevalence during the past few years. This reduction may be ascribed to the unremitting attention devoted to their eradication; i.e., in the case of scabies, by treatment at the cleansing stations and the disinfestation of homes, and, as regards ringworm, by the application of X-rav treatment. The number of schools which were visited by medical officers during the year, and the number of departmental visits on the occurrence of local outbreaks of scarlet fever and diphtheria are shown in the subjoined table:— Diphtheria and Scarlet Fever in London, 1925. Division. Spring term. Summer term. Autumn and winter terms. Total (depts.). Total (schools). No. of children inspected. N.W. Diph. 23 19 40 82 45 7,798 S.F 10 16 42 68 41 6,712 Total number of visits 33 35 82 150 86 14,510 N.E. Diph. 15 7 27 49 33 4,479 S.F 9 22 40 71 36 8,783 Total number of visits 22 29 67 120 69 13,262 E. Diph. 13 6 11 30 22 3,643 S.F. 4 8 21 33 21 4,610 Total number of visits 17 14 32 63 43 8,253 S.E Diph 40 25 73 138 58 13,970 S.F. 11 22 50 83 47 8,731 Total number of visits 51 47 123 221 105 22,701 S.W. Diph 20 27 59 106 56 13,127 S.F. 19 26 58 103 61 17,238 Total number of visits 39 53 117 209 117 30,365 Grand Totals. Diph. 111 84 210 405 214 43,017 S.F. 53 94 211 358 206 46,074 Number of visits 164 178 421 763 420 89,091 In addition to the inspections for scarlet fever and diphtheria referred to in the above table, the medical staff also conducted special enquiries at a number of schools owing to the prevalence of miscellaneous infections, e.g., skin ailments, sore throats, eye diseases, influenza, etc. 13651 G 94 During the year 27 special investigations were made by the Council's public health inspectors in cases where the condition of schools or of their environment were alleged to have been responsible for rendering children more susceptible to infectious illness. The services of the school nursing staff were utilised for investigating and giving advice to teachers during the prevalence of minor infectious ailments and in this connection 343 schools were visited from time to time (chicken-pox, 179 schools; whooping-cough, 52; mumps, 99; impetigo, 4; influenza, 9). School nurses were also employed on a certain number of occasions in supplementing and following up the enquiries of the medical staff during special outbreaks of scarlet fever and diphtheria. In each instance the school was visited daily, or as often as possible, the children inspected, absentees examined on their return, and, in the case of diphtheria, swabs taken where required. In recent months the nurses have been visiting schools and taking all necessary action in connection with the prevalence of measles. Diphtheria. The numbers of cases of diphtheria notified from the schools during the past four quinquennia are as follow:— Quinquennia. 1906-10. 1911-15. 1916-20. 1921-25. Number of cases of diphtheria in Council's schools 12,601 14,653 18,515 25,016 This steady rise in the prevalence of diphtheria is deserving of special study, especially having regard to the increased precautions which are taken in the schools in recent years as regards the investigation of school outbreaks and the bacteriological examination of children in affected classes. The notification figures are undoubtedly swollen by the inclusion of purely bacteriological cases, though to what extent it is difficult to say, as no differentiation is made in the notification returns between clinical and bacteriological cases. It is, however, noteworthy that scarlet fever, the diagnosis of which does not rest upon bacteriological findings, has declined more rapidly since the epidemic years 1920-22, than has diphtheria. The fact that the inclusion of bacteriological cases tends to augment the notification figures is supported by information published by the Metropolitan Asylums Board in its annual reports. The following table shows the number of admissions of cases of diphtheria and scarlet fever to the Board's fever hospitals in the three years, 1922-4, and the number in which the diagnosis of diphtheria was based on purely bacteriological grounds or in which there was no evidence of diphtheria beyond that of the admission certificate. Figures showing the number of cases of mistaken diagnosis are also shown. It will be observed that the percentage of non-clinical or mistaken cases of diphtheria is particularly high, especially in comparison with scarlet fever. ##]Year. 2. Total admissions to 1 M.A.B. hospitals. 3. No. of bacteriological and negative* cases. 4. No. of cases of mistaken diagnosis. 5. Percentage ot cols. 3 and 4 to total admissions. 1922— S.F. 15,279 1,075 7.0 per cent. Diph. 1923— 11,737 l,015 2,021 25.9 „ S.F. 8,370 —. 1,150 13.7 per cent. Diph. 7,522 838 1,985 37.5 1924— S.F. 9,715 1,282 13.2 percent. Diph. 7,569 619 2,261 38.0 * Negative cases are those in which there was no evidence of diphtheria beyond that of the admission certificate (these cases are not included in col. 4). 95 There is the further argument to be adduced, that whilst the general incidence of diphtheria among persons of all ages has been maintained at a high level the mortality has steadily declined during the past three years. Whilst making due allowance for the improvement in the treatment of diphtheria in recent years, by the more comprehensive and speedier use of antitoxin, the inference to be drawn from this table is either that the disease has been of a considerably milder type during the past three years or that there has been a greater tendency to notify cases as diphtheria on slenderer clinical evidence or on purely bacteriological grounds; or it may be that the lower case-mortality may be explained by a combination of both these reasons. The geographical distribution of the disease in 1925 roughly coincided with that of 1924. The districts principally affected were those south of, and in close proximity to, the Thames—viz., Southwark, Bermondsey, Camberwell, Deptford, Wandsworth, and in the later part of the year, Battersea. On the north of the river, Islington, St. Pancras and Hackney were specially involved in the prevalence throughout the year, whilst in the autumn a localised outbreak of persistent character occurred in a part of Westminster. In the east end of London, mainly in Stepney, and to a less extent Bethnal Green, the disease maintained a fairly high level of prevalence, though these districts were not so badly attacked as those south of the river, nor were school children so markedly affected. The western boroughs were relatively little affected. During 1925, 214 schools were visited by the Council's medical officers for the purpose of investigating the occurrence of diphtheria among the pupils, entailing 405 visits to separate departments and the examination of some 43,000 children. The number of bacteriological examinations conducted during the course of the year in connection with visits to schools and otherwise amounted to 7,910, of which 609 revealed the presence of diphtheria bacilli and 289 of organisms of a doubtful character. These figures, however, include re-examinations, the actual number of children found to be carrying diphtheria bacilli being 390, whilst 213 were suspicious; 169 children were removed to hospital as a result of these bacteriological examinations and the remainder were re-swabbed from time to time until negative results were obtained. In May, 1925, the Education Committee, as a result of the advice contained in the " Memorandum on Closure of and Exclusion from School," referred to on a previous page, authorised virulence tests in a limited number of cases of diphtheria carriers. These tests have been restricted mainly to the chronic carriers and special cases, and out of 92 specimens 68 were found to be virulent and 24 avirulent; the children included among the last-mentioned twenty-four cases were allowed to resume school attendance. The question of dealing with the virulent "carrier" is a difficult one. If there are any clinical signs of diphtheria there will be no hesitation in notifying the case and removing the child to hospital. On the other hand there are many cases in which there are insufficient clinical grounds on which a notification can be based, and a certain number in which an abnormality of the throat or nose, though not symptomatic of diphtheria, may constitute a condition favourable for the diphtheria bacillus. The main object in such cases is to employ such remedial treatment, whether operative or otherwise, as will tend to remove the bacilli, and enquiry is being pursued as to the best means of attaining this end. The services of school nurses are being utilised more and more in connection with outbreaks of infectious illness. They have been of considerable assistance in the reswabbing of diphtheria carriers and their employment on this work has not only been of service in keeping the children concerned under close observation and securing appropriate medical treatment where necessary, but in reducing the intervals between their re-examinations has minimised the period of absence from school in a large number of cases. 13651 g 2 96 This speeding-up of the return to school of diphtheria carriers since the school nurses were first employed on this work in 1924 is shown in the following table :— Period of absence from school. 1920. 1924. 1925. Carrier cases. Approx. per cent. Carrier cases. Approx. per cent. Carrier cases. Approx. per cent. Up to 4 weeks 324 66 233 80 330 81 4—8 weeks 111 22 44 15 60 15 8—12 weeks 27 5 10 3 10 2 Over 12 weeks 31 6 2 1 9 2 In view of the persistence of diphtheria in London within recent years, the application of the Schick test and active immunisation carried out in certain parts of America and Great Britain are being watched with close interest. Reference to the work which is being done on active immunisation against diphtheria has been made from time to time in the annual reports and elsewhere. The Council, on the 11th March, 1924, resolved that the Public Health and Education Committees should consider and report whether or not the treatment carried out by the department of health in New York City for rendering children immune from diphtheria should be adopted in the London schools. An exhaustive review of the subject was submitted to the Public Health Committee, who reported to the Council on the 13th October, 1925, that inquiries were being conducted by the Ministry of Health with regard to the immunisation of staffs at fever hospitals and in connection with maternity and child welfare work, and that in their opinion these lines of investigation should be thoroughly explored before further consideration is given to the immunisation of children of school age. The Council concurred in the views of the Public Health Committee and decided (13th October, 1925) that the time was not ripe for the introduction of the Schick test into the Council's scheme of medical treatment of school children. The diagram on page 97 shows the mortality rates from diphtheria in London, New York City and New York State (excluding New York City), and it will be seen that, broadly speaking, the trend of mortality differs little in the three areas. Scarlet fever. During 1925, 5,717 cases of scarlet fever were reported among children attending the Council's schools as compared with 5,093 (1924), 4,824 (1923), 8,026 (1922), 17,030 (1921), 11,860 (1920). Since the epidemic of 1920-22, the prevalence of scarlet fever has rapidly declined and the annual returns of cases during the past three years were considerably lower than the yearly average (6,744 cases) for the fourteen years 1906-1919, which preceded the 1920-22 epidemic, whereas in the case of diphtheria the figures for the same years—viz., 5,033 (1925), 3,696 (1924) and 3,985 (1923), were much higher than the annual average (2,846 cases) for the same pre-epidemic period. The following tabular statement illustrates the difference in the behaviour of scarlet fever and diphtheria before, during and after the epidemic referred to. Number of cases of diphtheria and scarlet fever reported from the schools:— Disease. Average number of cases annually (1906-1919). No. of cases occurring in each year of epidemic period. Average number of cases annually (1923-1925). 1920. 1921. 1922. Scarlet fever Diphtheria 6,744 2,846 11,860 5,841 17,030 6,661 8,026 5,641 5,211 4,238 The autumnal rise of scarlet fever in 1925 commenced about the middle of September and reached its height in the third week of October. The geographical distribution of the disease approximately coincided with that of diphtheria, the areas chiefly concerned being those south of and bordering upon the river, whilst in the 97 98 north, Islington and to a less extent, St. Pancras and Hackney were involved ; the disease was also mildly prevalent in the East-end. As in the case of diphtheria, the western districts, with the exception of Fulham, were not specially affected. The number of schools visited by the Council's medical officers for the purpose of investigating the occurrence of scarlet fever among the pupils was 204, entailing 358 departmental investigations and the inspection of some 46,000 children. Measles. Method of ascertainment of cases.—The means adopted for ascertaining the existence of measles, involving the question of compulsory notification of the disease, has been made the subject of reports from time to time. Compulsory notification has frequently been imposed in different parts of the country by local orders, and has generally been abandoned because the advantages gained have not been commensurate with the cost involved. In 1915 measles and German measles were made compulsorily notifiable throughout England and Wales by the late Local Government Board, the notification being limited to the first case in a household. The Order was, however, rescinded in 1919, and a memorandum was issued by the Ministry of Health pointing out the ineffectiveness of the Order and indicating the more practical measures which should be adopted by local authorities in combating the disease. In London the chief means of obtaining knowledge of cases of measles is secured through the school organisation. Although, in certain metropolitan borougha, measles is still compulsorily notifiable, the weight of opinion inclines to the view that the combined efforts of the head teachers and school attendance officers, supplemented in times of special prevalence by the assistance of school nurses, provide the best and most practicable means of securing knowledge of cases as they occur. The information thus obtained is immediately forwarded to the school medical officer and to the medical officer of health of the borough concerned, in order that the latter officer may provide nursing assistance, where necessary, and select cases for removal to hospital. Further details of the procedure are later referred to under the heading of "Administrative measures." Incidence.—In view of the fact that measles is not compulsorily notifiable, the exact total number of cases of measles occurring in the general population is not known, although limited statistics for measles and German measles are obtainable for the years 1916-1919, when compulsory notification was in force. These figures, however, only furnish a rough guide, as in a large number of cases no medical advice is sought, and, furthermore, only the first case in a household was notified. The total incidence of measles at the pre-school ages and in the population generally may be estimated at nearly three times the number of cases occurring among school children. The undermentioned table shows the number of cases of measles reported by head teachers of the schools during the past 20 years. Similar figures in respect of scarlet fever and diphtheria are shown for purposes of comparison:— Year. No. of cases reported among elementary school children. Year. No. of cases reported among elementary school children. Measles and German measles. Scarlet fever. Diphtheria. Measles and German measles. Scarlet fever. Diphtheria. 1906 18,899 8,371 2,549 1916 19,317 3,551 3,480 1907 26,179 12,307 3,170 1917 27,828 2,522 2,919 1908 19,385 10,291 2,809 1918 25,800 2,772 2,910 1909 20,145 7,716 2,212 1919 13,260 5,574 3,365 1910 25,677 4,700 1,861 1920 28,888 11,860 5,841 1911 31,905 4,640 2,572 1921 8,317 17,030 6,661 1912 19,809 5,060 2,571 1922 34,385 8,026 5,641 1913 15,142 7,969 2,663 1923 13,787 4,824 3,985 1914 18,585 11,337 3,391 1924 35,946 5,093 3,696 1915 31,313 7,600 3,366 1925 24,521 5,717 5,033 Total 459,088 146,960 70,695 99 German measles was prevalent during the late spring and summer of 1925, and continued to occur throughout the remainder of the year ; on this account the measles figues for 1925 included in the above table, are higher than would ordinarily have been anticipated. The biennial epidemic of true measles commenced about the end of October, about the time it was due, or perhaps a little earlier, and from that time onward the number of cases reported from the schools progressively rose each week, until the peak of the curve was reached in the week ended 13th February, 1926, when a total number of 3,456 cases was reported by head teachers in the London schools. The school notifications of measles each month from October to March, were as follows :— 1925. 1926. Total. Oct. (4 weeks). Nov. (4 weeks). Dec. (3½weeks). Jan. (3 weeks). Feb. (4 weeks). Mar. (4 weeks). No. of cases of measles reported from Council's schools 1,504 3,302 4,977 8,101* 12,111 8,032 38,027 * Including Christmas holiday cases. In the diagram on page 101 contours are given showing the progress of measles epidemics in recent years based upon the cases reported among children attending the Council's schools. The climax of the epidemics both in 1920 and 1922 was reached about the 12th week in the year ; the 1924 and 1926 epidemics are shown to have commenced appreciably earlier and the climax was reached in both some three or four weeks earlier than in the two preceding epidemics. The marked decrease in cases in the 10th and 11th weeks of 1926 suggest the early termination of this epidemic. Mortality and Complications.—In view of the fact that measles has never been wholly notifiable, the Order of 1915, mentioned above, having only referred to first cases in a household, there are no figures on which to base the case-mortality from measles in London. In Aberdeen, however, measles was notifiable for the 20 years 1883-1902, and the mortality figures show that under one year of age the percentage case mortality was 13.9, from one to two years 10.0, two to three years 3.4, three to four years 1-6, and four to five years 0.9, the rates gradually diminishing to vanishing point from these ages onward. These figures show that the burden of mortality fell mainly on children under two years of age, and the mortality returns of the Registrar General still show that the great majority of deaths occur among very young children. The deaths from measles during the 1925-6 epidemic from the beginning of November, 1925, up to the end of March, 1926, are as follows November. December. January. Week ending— 7 th. 14th. 21st. 28th. 5th. 12th. 19th. 26th. 2nd. 9th. 16th. 23rd. 30th. No. of deaths (all ages) 8 15 15 28 26 21 31 37 44 35 58 63 60 February. March. Total. Week ending— 6th. 13th. 20th. 27th. 6th. 13th. 20th. 27th. No. of deaths (all ages) 39 49 61 47 40 60 56 49 842 The most common complications to which death is due during an attack of measles are bronchitis and pneumonia, diarrhoea and convulsions. Measles is especially fatal in rickety children. In many non-fatal cases measles may be the forerunner of such ailments as chronic bronchitis, pleurisy, tuberculosis and other lung disorders, as well as affections of the eyes and ears, conditions which cause prolonged disablement where they do not produce death. 100 The success which has been achieved in recent years in reducing mortality due to measles is a gratifying feature of London public health administration. The following table illustrates the progressive decline in the number of deaths among persons of all ages during the three quinquennia, 1911-15, 1916-20 and 1921-25 It will be observed that, whilst the quinquennial incidence of cases remains fairly constant among school children, and presumably for the whole population, there has been a very marked and progressive reduction in the total number of deaths. For purposes of comparison, similar data with regard to whooping cough are shown:— Quinquennium. Measles. Whooping cough. No. of cases among school children. No. of deaths (all persons). No. of cases (school children). No. of deaths (all persons). 1911—15 116,754 9,596 7 4,872 1916—20 115,093 5,830 39,926 4,010 1921—25 116,956 3,859 48,427 3,479 Inasmuch as measles is mainly fatal among children under five years of age (the deaths at this age being about 95 per cent. of the total deaths for all ages in London), a rate calculated per thousand of population is unsatisfactory for periods in which considerable variations occur in the birth-rate. In order, therefore, to obtain a more accurate picture of the movement of the measles death-rate in recent years, it is necessary to eliminate the disturbing effect of the rapid changes in the birth-rate caused by the war. This can best be done by stating the deaths occurring in each successive year of life up to the fifth year among children born in the same year; thus the deaths of children aged 0-1 years in 1918 mainly occurred among children born in the preceding year ; deaths at ages 1-2 years in 1919 belong to the same births, and so on to deaths at ages 4-5 in 1922. These deaths, added together, give the deaths under five years of age belonging to the births in 1917, and a deathrate per thousand born is thus obtained. An adjustment has been made to allow for the fact that the deaths mostly occur in the first half of each year. The resulting rates for the past ten years are given in the following table, the corresponding rates for whooping-cough being also shown for the purpose of comparison (see also the diagram on p. 101). Year of birth. Deaths per 1,000 hom, up to 5th year of ace. Measles. Whooping cough. 1911 1.33 .83 1912 1.36 .77 1913 1.51 .89 1914 1.28 .91 1915 1.43 .86 1916 1.36 1.01 1917 .67 .95 1918 .86 .60 1919 .70 .70 1920 .89 .77 1911-15 1.38 .85 1916-20 .90 .80 On comparing the figures relating to children born in 1911-15 with those for children born in 1916-20, it will be seen that almost all the decrease in measles mortality is accounted for by the drop in and since 1917, while in whooping-cough the mortality during the two periods has not shown nearly so marked a change. 101 102 Administrative measures.—Various methods have been attempted from time to time to arrest outbreaks in London schools, such as closure of affected classrooms, exclusion of "unprotected" children, etc., with little measure of success. The chief difficulty, as previously stated, is the extreme infectiousness of the disease for some days before the rash appears, and this renders hopeless any attempt to control the disease by comprehensive measures of isolation. Much can be done, however, in the way of prevention of complications and reduction in mortality, by energetic local action in the direction of home nursing and treatment of sufferers, combined with the removal to hospital of the more serious cases, especially those living under unhealthy conditions. The need for utilising to the fullest possible extent the administrative powers and machinery, both central and local, for securing the fuller control of measles, led to concerted action by the Council and the metropolitan borough councils five years ago, when a conference was held (25th February, 1921), between representatives of the Council and the metropolitan borough councils, with a view to ascertaining what practical steps could be taken to secure the fuller control of the disease. The Council's existing scheme of dealing with measles had actually been in operation before the conference was held, and there was a general measure of agreement with the scheme, which involves the fullest utilisation by the borough councils, on the one hand, of their powers under the Public Health (London) Act, 1891, and the Maternity and Child Welfare Act, 1918, for giving all possible assistance in the matter of providing nursing and medical treatment, in co-operation with the Central Council for district nursing and local voluntary nursing associations; and by the Council, on the other hand, in providing all possible facilities of its school organisation, involving the co-operation of head teachers, school attendance staff and school nurses in bringing cases of measles to light and reporting them to the medical officer of health of the borough concerned. It is sufficient to say that the procedure has been applied in successive epidemics in recent years, and that there has been a concurrent decline in mortality from the disease, as will be noted in the table on page 100 and in the diagram on page 101. There is no doubt that greater care in the nursing of patients supplemented by extended hospital accommodation, combined with propaganda in the schools and homes, must inevitably have an ameliorative effect upon the mortality returns. During the five months ended 31st March, 1926, whilst the epidemic was in progress, the measles scheme was put into operation in 761 schools. Apart from these measures head teachers take various precautions in the schools when measles occurs, including the distribution of warning cards to children who have not previously had measles. Hospital Accommodation.—The accommodation provided by the Metropolitan Asylums Board for the treatment of cases of measles, although limited, is utilised to the fullest extent. Since 1912 the Metropolitan Asylums Board have been authorised to admit non-pauper cases of measles, but it is only intended that the more serious cases, and those living in overcrowded and insanitary homes where proper nursing is not possible, shall be so accommodated. The selection of cases for hospital treatment is left to the medical officer of health of the borough. As showing the increased accommodation provided by the Board for such cases in recent years, it may be mentioned that in 1920, when measles was epidemic 234 cases were admitted to the Board's hospitals during the three months when the disease was most prevalent; in 1924, another epidemic year, the number of admissions in three months reached a total of 2,981. During the last epidemic, 2,556 cases of measles were admitted to the Board's hospitals between 1st November, 1925, and 27th March, 1926. The following figures relating to London as a whole show the number of deaths 103 which have occurred in Poor Law institutions since the order of the Local Government Board came into force:— Year. Measles: place of death. M.A.B. hospitals. Poor Law institutions. Elsewhere. Total. M.A.B. and Poor Law. Number. Per cent. of total. 1911 438 216 1,923 2,577 654 25.4 1912 414 103 1,311 1,828 517 28.3 1913 428 – – 1,547 – 1914 70 426 880 1,376 496 36.0 1915 132 485 1,669 2,286 617 27.0 1916 97 94 631 822 191 23.2 1917 348 – – 2,019 – – 1918 187 424 1,038 1,649 611 37.1 1919 49 78 226 353 127 36.0 1920 63 371 582 1,016 434 42.7 1921 31 66 147 244 97 39.8 1922 141 631 791 1,563 772 49.4 1923 114 104 168 386 218 56.5 1924 451 334 545 1,330 785 59.0 The corresponding figures for whooping-cough are as follows:— Year. Whooping cough: place of death. M.A.B. hospitals. Poor Law institution. Elsewhere. Total. M.A.B. and Poor Law. N umber of deaths. Per cent. of total. 1911 144 63 834 1,041 207 19.9 1912 146 36 803 985 182 18.5 1913 137 — — 793 — — 1914 87 196 638 921 283 30.7 1915 14 239 905 1,158 253 21.8 1916 71 135 596 802 206 25.7 1917 50 — — 566 — — 1918 55 593 1,039 1,687 648 38.4 1919 15 47 150 212 62 29.2 1920 12 268 491 771 280 36.3 1921 8 207 331 546 215 39.4 1922 14 490 624 1,128 504 44.7 1923 76 125 231 432 201 46.5 1924 97 159 261 517 256 49.5 It will be seen that the percentage of measles deaths in Poor Law institutions and M.A.B. hospitals has more than doubled between 1915 and 1924, and that in the latter year three-fifths of the total deaths in London occurred in institutions for the poor, showing how close a relationship there is between fatal measles and poverty, and how considerable an effort had been made to secure hospital treatment for poor children. Of the administrative steps, briefly reviewed, there can be little doubt that the most effective in the reduction of mortality from measles has been the attention to and nursing of sick children in hospitals or in their homes. Greater attention has been given to this disease than to whooping-cough, the latter having already decreased considerably before the war. Owing to the war, conditions were very adverse in the poor quarters of London and the mortality from measles in particular was excessive in these areas in the winter of 1917 (before the food supply was brought under control) and it is probable that, but for these adverse conditions, the reduction in the measles mortality would have occurred earlier. With the rationing of food and the decline of the birth-rate, conditions altered for the better, both for the children and the mothers, and it is to this two-fold improvement, associated with the administrative steps described, that the remarkable drop in measles mortality must be attributed. 104 Whooping cough. Whooping cough was prevalent during 1925, particularly in the earlier months of the year. The total number of cases reported as occurring among school children was 12,795, as compared with 8,404 in 1924, 7,304 (1923), 10,340 (1922) and 9,584 (1921). As in the case of measles, borough councils are empowered, under the Maternity and Child Welfare Act (1918), to provide nursing assistance, where necessary, for cases of whooping cough. Ringworm and favus. The progressive decline in the incidence of scalp ringworm (tinea tonsurans) among school children, which has been so noteworthy during the last few years, was maintained in 1925, as will be observed in the subjoined table. This success in the campaign against ringworm is due to the skilled detection of new cases by the school nurses, and to the increasing use of the X-ray form of treatment, which now cures nearly 75 per cent. of the cases. Year. Fresh cases. Cured cases. Cases outstanding at the end of the year. 1911 6,214 5,872 2,458 1912 5,311 5,131 2,204 1913 5,573 5,257 2,277 1914 4,449 4,904 1,638 1915 3,747 3,928 1,334 1916 3,115 3,081 1,232 1917 2,814 2,964 992 1918 2,639 2,555 979 1919 3,447 3,103 1,259 1920 3,983 3,856 1,332 1921 3,473 3,765 999 1922 2,766 2,918 818 1923 2,322 2,395 705 1924 1,724 1,924 482 1925 1,518 1,611 373 The decline in the number of cases of ringworm in recent years has been accompanied by a reduction of the average length of absence of the affected children. The combination of these two factors has led to a very considerable gain in school attendance. Whereas in 1911 the average length of absence was 6 months, in 1921 the period had been reduced to 5 months, and in 1924 to 19 weeks. As an illustration of the amount of saving of loss of school attendance due to the prevention of ringworm, and the consequential gain, both educationally and financially, it will be of interest to record that in 1921 the loss in school attendance amounted to approximately 650,000 sessions on account of ringworm, whereas in 1924 the attendances lost for the same cause were only 337,130. The children cured by X-ray in 1924 were able to return to school, on the average, in 9.7 weeks after the treatment commenced, whereas the children treated by ointments, lotions, etc., were absent from school for an average period of 26 weeks. Efforts are being made, by more frequent and thorough observation of the process of epilation of the scalp following application of the rays, to expedite still further the return to school of children whose parents agree to this form of treatment, which, if universally applied, would practically extirpate ringworm altogether. As a contrast to these cases cured by methods of radio-therapy, it will be of interest to record that at the time when the calculation of absences due to ringworm was carried out in 1925, there were 33 children under treatment by ointments, etc., who had been absent from school for more than 12 months. Of these, 20 had been absent from 52 to 78 weeks, 5 from 78 to 104 weeks, 3 from 2 to 3 years, 1 for 5 years, and 4, who had been re-infected from time to time, had been absent for 62 weeks, 72 weeks, 2 years and 4 years, respectively. Of these 33 cases, 10 were ultimately cured by X-rays, with the parents' belated consent, and in the remaining 23 parental consent could not be obtained. During 1925, 2,640 specimens of hair stumps were examined in the Council's 105 laboratory, and of these 1,039 contained ringworm fungus and 24 proved to be favus. 17 fresh cases of favus were discovered during the year, and 7 cases reported in 1924 remained uncured at the beginning of 1925. Of these 24 cases 11 were cured, 1 left school, and 12 remained under treatment at the end of the year. Chickenpox. The rising incidence of chicken-pox during the past two or three years became more marked in 1925, 17,583 cases having been reported as occurring among school children as compared with 11,826 in 1924, 13,849 (1923), 8,213 (1922), and 9,811 (1921). The school nurses specially visited 179 schools where outbreaks had occurred, with a view to giving advice to the teachers. There appears to be no marked seasonal influence in the prevalence of chickenpox, although in the year under review the highest incidence was associated with the summer months. Mumps. There was a decline in the prevalence of mumps during the year. 9,161 cases having been reported as compared with 15,424 in 1924, whilst 7,916 were reported in 1923, and 4,207 in 1922. The school nurses visited 99 affected schools for the purpose of advising head teachers. Ophthalmia. After a period of prevalence in 1923 and to a less extent in 1924, the incidence of ophthalmia reached a more normal level in 1925, 882 cases having been reported as compared with 1,101 in 1924, 1,881 (1923), 801 (1922) and 466 (1921). If every case of ophthalmia were promptly excluded from school, treated in the early stages of the disease, and preventive precautions taken in the home, incidence would be limited to sporadic cases. The assistant medical officers and school nurses are diligent in detecting the ailment among school children and efficient treatment is secured for the cases as they arise. Residential schools and places of detention. The health of the children generally at the Council's residential schools and places of detention was, on the whole, very satisfactory as regards the incidence of infectious illness. There were a few slight outbreaks, but these were quickly suppressed. For example, at Homerton Deaf School, Penn, Bucks, 4 cases of scarlet fever occurred at comparatively long intervals. The first case was reported on the 14th September. A month later an assistant teacher developed the complaint, and this case was followed, after a further interval of one month, by two additional cases among the children. No internal source of infection could be discovered within the school, and as a succession of cases of scarlet fever had occurred in the surrounding countryside the outbreak was attributed to extra-school infection. The King's Canadian Camp School came under observation owing to the occurrence of a case of diphtheria. The patient was a newly-admitted boy who ran away to his home and was discovered the following day to be suffering from diphtheria. All the other members of the party, who were admitted at the same time, were swabbed, with the result that 4 were found to be carrying diphtheria bacilli, and were removed to hospital. None of these showed any clinical symptoms and no further cases were reported. At Barham Home Open-Air School, St. Leonards-on-Sea, two cases of mild scarlet fever were reported in September. Both cases were promptly removed to the Borough Sanatorium, and every precaution was taken to prevent further cases arising. No developments arose. Upton House Industrial School was affected by a slight outbreak of ringworm, which was limited to 4 cases. The medical officer of the school suggested that, as a routine measure, the hair of the boys at the school should always be kept short, and his proposal was adopted. At Elm Court School for Elder Blind Girls, a case of typhoid fever occurred, particulars of which it may be of interest to record. The child was examined at the school by a senior medical officer of the Council on 23rd September and was notified to be suffering from typhoid fever. The child was removed to the SouthEastem Fever Hospital, where the diagnosis was confirmed. Enquiries were at 106 once instituted at the child's home in Fulham with a view to ascertaining the source of infection, as the date of the commencement of her illness indicated that she was infected about the end of the Summer holidays. The Medical Officer of Health of Fulham ascertained that the child had eaten mussels a day or two before she returned to school. The mussels had been collected at a sea-coast town in Devonshire by a friend of the family and conveyed to London. Five persons partook of the mussels, and, of these, the girl alone was attacked with illness. There was no suggestion that conditions at the school were responsible for her illness and it was assumed that the mussels were the source of infection. PentonviUe Place of Detention was invaded by diphtheria on two separate occasions, but the precautions taken prevented the disease from spreading. Two cases of the disease were reported on 30th June, and as a result of the bacteriological examination of the remainder of the children, 4 were found to be harbouring diphtheria bacilli, and were at once removed to hospital. On the second occasion a boy was found by the medical officer to have a sore throat and was isolated. A swab from his throat yielded diphtheria bacilli and he was removed to hospital. Following his removal, 21 other boys were swabbed and two found to be diphtheria carriers, although neither had any clinical symptoms. They were removed to hospital as a precautionary measure. Another case occurred on 20th October, and bacteriological examinations of the remainder revealed the presence of another carrier who was forthwith removed. An investigation of the sanitary condition of the place of detention revealed certain defects in the drains and fitments which were at once promptly remedied. As a result of these outbreaks, the Education (Special Services Sub-) Committee gave instructions that in future all new admissions to the two places of detention (Ponton-road and Pentonville) should be bacteriologically examined before being allowed to mix with the others. This has since been consistently carried out. Between October 23rd, 1925, and March 8th, 1926, 258 new admissions to Pentonville Place of Detention were bacteriologically examined, of which two were found to be carrying germs of diphtheria. At Ponton-road Place of Detention 83 new admissions were similarly examined in the same period, but all with negative result. Encephalitis Lethargica. Encephalitis has caused widespread anxiety on account of the apparently sudden appearance of a new disorder, characterised not only by a high death-rate in the initial attack, but also showing in many cases relapses and sequelae of a grave and pathetic nature. In some patients the original disease seemed never to clear up, whilst, in others, after an interval of apparent health, there were relapses into conditions resembling the shaking palsy of old age, or to partial paralysis and states of muscular twitchings and tremor, or character changes and considerable mental disorder. The after-effects seemed to be more marked in the younger sufferers who, if they survived the initial attack, but did not completely recover, seemed doomed, as has been described in popular language, to a condition either of premature senility or of "possession by a devil." The disorder is perhaps not quite so new as was at first thought, nor the outlook quite so hopeless. While from the administrative side it must be realised that " epidemic encephalitis " is only one of a series of diseases affecting the nervous system in a somewhat similar manner, it certainly produces the most spectacular after-effects. The name " encephalitis," however, demands a moment's consideration. Encephalitis means inflammation of the brain, the first part of the word coming from the Greek encephalos, meaning brain, while itis is from the Greek word meaning inflammation. This is mentioned because kindred diseases, affecting other parts of the nervous system, have names constructed in a similar manner—e.g., myelitis, from the Greek word myelos, meaning marrow, the name give to the spinal cord, a root which is used in the word 107 poliomyelitis, the disease which produces the flaccid paralysis of the extremities, commonly known as "infantile paralysis." The prefix folio stands for grey, the inflammation in this disease attacking a horn of the crescent of the grey mass of nerve cells making up the centre of the spinal cord. As will be shown later, some of the symptoms of these diseases are due to the general action of the poison or toxin of the disease and the fever which accompanies their production, and others depend entirely on the part of the nervous system which chances to be affected. The term "lethargica" was added on account of the stupor which is a feature in many cases, so much so that in popular language the condition is often called "sleepy sickness." This popular name has led to considerable public confusion between "encephalitis lethargica" and the tropical African disease "sleeping sickness" or "negro lethargy," which is an entirely different illness due to infection by an animal organism introduced into the blood by the bite of the tsetse fly. The two diseases, however, have this in common—that the lethargy is in either case due to the morbid processes affecting the same part of the brain stem, thus illustrating the point made previously, that certain symptoms are due to the site of the inflammation quite apart from the cause of the inflammation. The exact causal agent in encephalitis lethargica is as yet unknown, although it can be shown that the disease can be transmitted from one animal to another and is possibly conveyed by the nasal secretions. Recent history of encephalitis lethargica. The first cases of an obscure nervous disorder, not recognised as belonging to any of the ordinary categories, occurred behind the French lines on the Yerdun front in 1915-16, and were studied in various military neurological clinics, but attracted little attention. Later in 1916-17, cases occurred in Vienna, presenting the now well-known features of stupor and diplopia (double vision), and from that time onward attention began to be paid to the supposed new disease. In Great Britain cases were noted at the end of 1917, in which the most constant symptom was a rapid onset of languor or drowsiness, with moderate fever, often muscular tremors, a dropping of the eyelids, termed ptosis, and a weakness of the muscles of the face, giving rise to a mask-like expression. Death occurred in a large number of the cases from a progressive paralysis of the muscles concerned in swallowing and breathing, so that the patients were literally drowned in their own secretions. In those who recovered, the duration of the illness varied from a few days to six weeks or longer. As similar symptoms had been noted in certain cases of poisoning by infected food, the condition was at first suspected to be due to a particular variety of food poisoning known as botulism. Considerable attention was directed to this so-called new disorder. Researches were instigated and memoranda prepared by the medical officers of the then Local Government Board. In London, the Council circulated an explanatory memorandum of the Local Government Board, and placed the services of medical officers of the public health department at the disposal of practitioners for the purpose of consultation. The whole subject was fully reported upon to the Public Health Committee, and reports thereon will be found in the annual reports of the county medical officer of health. It was soon found that the disease could not be due to food poisoning, and for a time it was thought to be a cerebral form of acute poliomyelitis, though later it was regarded as a separate disease. Since 1918, practically all parts of the world have been affected. For a time, however, attention was largely diverted from its consideration, owing to the world-wide outbreak of influenza which started in the early summer of 1918. The prevalence of encephalitis still continues, though perhaps the recent cases have been rather less severe than in earlier years. General description. The disease attacks both sexes equally and affects all ages, though there are proportionally rather more cases in the earlier decades of life. The earlier stages of the disease may last for a few days or extend to a fortnight. During this period there is general lassitude, headache, occasional vomiting or diarrhcea, with soreness 108 or dryness of the throat, followed in most cases by double vision and somnolence. In the acute stage there is marked weakness, fever, stupor, often alternating with nocturnal delirium, difficulties in speech and spasmodic twitchings of the limbs and face. In some cases there are no localising symptoms, in others there are squints, double vision, difficulties in accommodation of the eyes, facial paralysis, and paralysis of the tongue and gullet. Death is due to paralysis of the nervous respiratory centres. Severe cases lie in bed with complete lack of expression and, though irritable when aroused, quickly relapse. Stupor may last only a day or so, or may persist for weeks. Some cases show only muscular spasms or fine twitchings, of the abdominal muscles. In 1922-24 rather more cases showed brain affections with epileptiform fits, maniacal outbursts or insomnia. There are a certain number of mild or abortive cases, and experience has shown that some can pass entirely unrecognised until the onset of certain sequelae of the disease. Naturally many of the milder cases have been called "influenza," while in others the disease has either occurred simultaneously with, or has so closely resembled scarlet fever or diphtheria, as to have originally been diagnosed as such. Some cases with prolonged depression and stuporous conditions have at first been thought to be typhoid fever, while rarely, a case with marked respiratory disturbance, has been thought to be acute tuberculosis. Incidence and mortality. Encephalitis lethargica has been a notifiable disease since the beginning of 1919, but it is evident that only a proportion of the cases have been recognised in the early or acute stage. In London the numbers notified are as follows:— Year. Total notified cases. Number of these of school age (3-14). Year. Total notified cases. Number of these of school age (3-14). 1919 86 15 1923 101 17 1920 149 41 1924 610 173 1921 243 59 1925 305 47 1922 72 17 Total 1,566 369 Full information is not available as to all these cases, and it is probable that there were at least as many more cases that were unrecognised. The figures as to age incidence show that persons of any age may be attacked, but that the heaviest rate is between 10 and 30. In London between 1919 and 1925 the numbers notified, as to which the information of age and onset was available, were:— Ages 5 6-10. 10-20. 20-30. 30-40. 40-50. 50-60. Over 60. Notified cases 81 120 365 232 196 186 138 86 The case-mortality rates quoted have ranged from 15 per cent. to 53 per cent., that in London for notified cases to the end of 1924 being 30.2 per cent. In 1925 the rate for verified cases was 45.3 per cent. The following table shows the distribution of actually confirmed cases, and the number of deaths in the different age groups, occurring within the scope of the analysis —i.e., from January to September, 1925. Ages. —5. 5—15. 15—25. 25—35. 35—45. 45—55. Over 55. Total. Cases 15 31 43 17 26 26 21 179 Deaths 5 14 14 4 11 16 17 81 No special racial incidence has been noted, while all social classes of the community have been affected. The disease has been, on the whole, distinctly more prevalent in the colder months of the year, the curve of incidence rising in the autumn and falling in the spring. This feature has been noted not only in London, but throughout the British Isles, Western Europe and North America. 109 Relation of the inoidence to that of other diseases. Other epidemic diseases affecting the nervous system have been prevalent during this century, especially poliomyelitis and cerebro-spinal fever. The case incidence of the latter, which was very high in the years 1915 to 1917, has fallen materially since that date, so much so as to raise some doubt as to whether certain cases which might in the former years have been called cerebro-spinal fever, may not have latterly been termed encephalitis lethargica. The outbreak of these diseases has borne a distinct relation in point of time to that of influenza. Some forms of influenza have given rise to nervous symptoms of a similar character, though milder in degree and of shorter duration than those noted in epidemic encephalitis. For example, somnolence and later irritability were commonly observed in 1924, while double vision occurred occasionally. The infectivity of encephalitis is apparently of a very low order if attention be paid to cases only showing nervous symptoms. It is, however, possible that the infection may be conveyed by those in whom the disease takes some other form, or by the apparently healthy. Some indeed hold that epidemic encephalitis is only one of the protean forms of influenza, but this view, though strongly supported and, on the whole, gainins in favour, has not as vet received anv official acceptance. Sequelae. The peculiar complications associated with the disease may arise in the course of the original illness and persist afterwards, or they may supervene after the acute attack has passed off. recurring even as long as two years afterwards. The more serious sequelae may follow an apparently very mild or even an unrecognised attack. These sequelae depend on the localisation of the secondary changes which follow the original inflammation, and may be classed under two main headings, motor and mental. The motor changes may be stiffness or paralysis of certain muscle groups, respiratory changes and spasms, tremors or jerky movements of muscles of the limbs, diaphragm or larynx, halting movements, or the condition known as "Parkinsonism," which is practically identical with senile shaking palsy. The mental symptoms vary with the age of the individual at the date of onset of the acute illness. In young children, the mental growth may be checked and any grade of idiocy, imbecility or feebleness of mind may result. Increased irritability alternating with mental hebetude is usual, while there may be maniacal outbursts, loss of self-control or a complete change of character, the previously wellbehaved child taking to lying or theft. Hysterical outbursts are quite common. The effects of the encephalitis are to increase the irritability and diminish the powers of self control, the form of the resulting behaviour depending, in the main, on the previous experience and original mental make-up of the individual. The most difficult cases are those in which both parents and children have a markedly nervous disposition and act as mutual irritants one to another. The extent to which sequelae occur is not definitely known, owing to the number of mild cases which attract little attention, but out of some 800 cases of those who survived the initial illness that have come under observation, about half of whom had not originally been notified, 137 are known to have suffered from some sequelae. More definite information is available as to the cases affected in the early months of 1925, though the length of time since the onset is insufficient to permit of a final conclusion as to their prospects. An analysis of 222 cases out of 305, which were notified during 1925, showed that 45 later proved not to have suffered from encephalitis but from some other ailment. Of the 179 genuine cases, 81 died, or 45.3 per cent. The highest mortality occurred in the age group over 55 years—i.e., of the 21 cases, 17 died, or 81 per cent. The lowest mortality was in the age group 25-35 years—viz., of the 17 cases, 4 were fatal—23.5 per cent. These cannot be regarded as the final figures, however, as death sometimes ensues one, two, three, four or more years after the onset. Relapses are also not 13651 h 110 infrequent—e.g., in one particular instance (cases analysed in 1925) the onset occurred in May of 1924, and in November of the same year the patient was reported by the Medical Officer of Health to have completely recovered ; in December of the following year (1925) the patient suffered a renewed attack with fatal result—i.e., eighteen months after the original attack. Other instances of relapses could be cited. Of the 98 surviving cases, 32 were reported at the time of inquiry (which was made from between 6-12 months after the date of notification) to have recovered with few or no after-effects. The possibility of relapses has, however, to be borne in mind. Of the remaining 66 patients who exhibited one or other of the characteristic sequelae, 42 suffered mental changes of varying kind, 33 were affected by some alteration of their sleep rhythm and 42 developed physical infirmities of various kinds, of which 6 presented a condition of "Parkinsonism" (one under 15 years of age and 5 over 15 years), one of them coupled with " paralysis agitans." The following analysis will be of interest as showing the after-effects of the disease in the different age groups:— Age groups. 1 5-15. 15-25. 25-35. 35-45. j 45-55. Over 55. Total. No. of cases developing sequelae 5 9 19 11 11 8 3 66 Sleep rhythm affected 2 4 9 7 3 6 2 33 Mental changes 3 8 10 7 6 6 2 42 A.—M.D. or imbecile 1 — 2 — — — — 3 B.—Retardation, memory affected, etc. — 2 5 4 3 1 2 17 C.—Emotional, depressed, eccentric, apathetic, spiteful, irritable, etc. 1 6 8 5 6 5 1 32 D.—More serious conduct changes 2 1 – – – – – 3 Physical changes (including nervous conditions, such as tremors, etc.). 1 6 11 8 9 3 3 41 The table indicates that older persons were affected by mental changes to the same extent as children (though possibly not quite in the same degree). Out of 66 cases, 33 were under 25 years of age, and 33 over 25 years, and mental sequelae were exhibited in exactly 21 cases in each group, whilst on the physical side there was a slight preponderance among the older persons. It will be of interest, in considering the after-effects of the disease, to refer to the table on p. 110 of the Annual Report of the School Medical Officer for 1924, in which the mental and physical sequelae in 193 cases are classified. It may be noticed that, although in a few instances the intellect has been seriously impaired and, in others, there has been disturbance of conduct, a certain number, even though showing after effects, have been able to continue at work or at school with satisfactory progress, and that in one instance, at any rate, a sufferer has been able to gain a scholarship. The most distressing feature of epidemic encephalitis is the tendency to relapse, or for the onset of sequelae to occur after an interval of apparent health. The most characteristic and peculiar of these is the condition termed "Parkinsonism," in which the sufferer has a slow speech, unsteady gait, a tendency to stagger back on initiating or stopping movements of progression, a mask-like unemotional face, tremors of the limbs and the like, the whole resembling the senile condition. This sequela seems peculiar to epidemic encephalitis, but many of its other after-effects are to be found in other disorders, some of a mildly infectious nature, which affect the nervous system, the whole picture depending on the part of the system affected, a point which is referred to under the next heading. Some of the features are due to the irritation or paralysis of function of the nerve cells, owing to poisons Relation of some of the symptoms find sequelæ of epidemic encephalitis to those of other disorders in children. 1ll circulating in the blood, others are due to organic changes resulting from the inflammation. How poisons or toxins can produce the effects can be illustrated by the action of a simple poison, alcohol. Alcohol in excessive doses produces a loss of control, a tendency to restlessness and talkativeness, in which gradually the thoughts expressed become confused and the speech thick, while the loss of control of the muscles of the face may be shown by dribbling. The gait becomes staggering and movements inaccurate, and there is also double vision. Drowsiness or even stupor may follow, but after a sleep the individual recovers, though next day there is often headache, lassitude and unusual irritability. After the toxic doses of alcohol have been frequently repeated there may be organic changes shown by fine tremors, slight incoordinations of movements, pains and tenderness in the limbs, or even wrist or footdrop. Mentally, there is a defect of memory of an irregular type and especially applying to recent events. Facts become merged with phantasies, the patient gets slightly disoriented and may develop hallucinations or delusions. While the toxic effects pass off rapidly if the dose is not repeated, the organic changes once established remain permanently. In other forms of encephalitis the poison is not so quickly eliminated, and the organic changes are more readily set up, but the essential features are of the same nature. Fortunately, so far as children are concerned, alcohol is a toxin which has, practically speaking, ceased to be supplied, though it remains a potent agent for the mental and physical ill-health of those of riper years. But certain diseases act through toxins in a somewhat similar way, especially those of rheumatism, diphtheria and certain vague chronic infections. The cerebral form of rheumatism, known as chorea, produces twitchings and tremors of the same kind as does epidemic encephalitis, and leads to irritability, mental hebetude, character changes and even maniacal outbursts which differ only in degree from those of the more recently recognised disorder. Diphtheria is frequently followed by various paralyses and also more rarely by other symptoms, such as tremors and irritability. Chorea, indeed, may be regarded as a true encephalitis, though due to rheumatism. When the history of the onset is vague it is often impossible to be quite sure whether a given child, showing twitchings with character changes and other symptoms, owes its condition to one or the other of these primary disorders. Group of disorders affecting the central nervous system and the need for after care. On referring to past records, in the light of recent experience it would seem that a condition of encephalitis may arise from a variety of infections such as give rise, not only to the epidemic forms under review, but also to such diseases as poliomyelitis, cerebro-spinal meningitis, scarlet fever, diphtheria, "influenza," rheumatism, etc. The severity and after-effects of the encephalitis vary with the nature of the infection. In an extreme case, such as in rabies, the result is always fatal. In mild "influenzal" cases there are no sequelae at all. Just as local physical rest is necessary in the early stages of paralysis, so is mental rest essential when the brain has been involved. The most important factor from the standpoint of mentality is the state of irritation and lack of concentration exhibited by the patient after the initial illness. At this stage, sufferers, especially children, seem to have lost all power of weighing up a situation, and react at once in an indiscriminating manner either to one extreme or the other. Older persons express themselves as unable to withstand minor worries, or to overlook events which they formerly took as a matter of course. During this phase, considerateness is necessary, but measures for control must be uniform and consistent. No mental conflict would arise were the results of misconduct as inevitable as those which would follow such an act, for example, as the touching of a hot object. The difficulty is that this phase is frequently overlooked, especially by parents, so that the children discover that by rebellious conduct they can gain the desired objects. Once this discovery is made the convalescing child, like a normal infant, takes full advantage of its opportunities. Parents often pet and chide a child 13651 H 2 112 alternately for precisely the same behaviour, and consequently, on a basis of increased irritability there is built up a superstructure of neurosis, the child unconsciously resenting the difference in treatment. These results follow many of the infections, but are much more serious and more marked in the severer condition of encephalitis lethargica. It would appear that convalescent treatment away from the irritation of clashing personalities in home life is needed in all types of illness affecting, to a greater or less extent, the central nervous system. The duration and nature of such treatment should be proportionate or appropriate to the severity of the attack. Special institutional treatment. Provision has been made at the Metropolitan Asylums Board's Northern Hospital, Winchmore Hill, for 100 children up to the age of 15 years developing mental and moral sequelae consequent upon an attack of encephalitis lethargica. This accommodation has been set aside for the purpose of observing to what extent amelioration of the after-effects can be effected by close observation and treatment of the sufferers, and in this respect the scheme must be regarded as experimental. The institution was opened for the reception of cases in November, 1925, and at the time of writing (26-3-26) 105 children have been admitted at one time or another and 8 have been discharged for various reasons. The children are only admitted on the application of the Council or Boards of Guardians, and the following table shows the age and sex distribution of cases sent in by the two authorities. Age and sex. 0—. 5—. 10-15. Total. M. F. M. F. M. F. M. F. Sent by Council 1 1 15 7 32 30 48 38 Sent by Guardians — — 3 3 10 3 13 6 Of the children discharged, three were sent home at the request of the parents, two were certified as having sufficiently improved to warrant discharge, and two were sent home as being incapable of control, of whom one died shortly after her discharge. The institution is divided into four pavilions, each capable of providing for 25 children, with two dormitories in each pavilion. The dining and living rooms are spacious and airy. The hospital is situated on high ground, there is adequate playing ground accommodation, and the general conditions at the institution are eminently favourable to the convalescence of debilitated children. Appropriate treatment is given, and the necessary attention devoted to education and training as far as it can be done. Reading and writing, etc., drawing, painting, basket and raffia work are taught. The medical officer in charge made a classification of the first 50 cases dealt with at the institution, from which it appears that the frequency of the following recognised post-encephalitic symptoms was as follows, some children being included under more than one group. 1. Quiet and well-behaved 12 cases. 5. Paralytic and badly behaved.. 7 cases. 2. Mischievous and quarrelsome 18 „ 6. Dull and stupid 10 „ 3. Vicious and spiteful 9 „ 7. Severe Parkinsonian .. 5 ,, 4. Paralytic and well-behaved 1 case. 8. Slight Parkinsonian 9 „ At first there were definite indications, in the majority of cases, of a marked improvement both in respect of sleep and conduct. This was no doubt accounted for, in part, by the change of environment. The improvement, however, was not uniformly sustained, and it was found that the cases displaying serious disturbances of behaviour alternate between exacerbations of temper or viciousness, and periods of docility or better conduct. The period of observation of the cases, up to the present, is too short to allow of any definite conclusions as to the prospects in most cases. It is clear, however, that there are two types which present special difficulty —namely, the mentally deranged and violent cases, and those showing Parkinson symptoms. 113 There appears to be little hope of eventually dealing with the more violent cases outside a mental hospital or certified institution, although even there they appear to be giving trouble. Following up. Parents are invariably notified of the approaching medical inspection of their children, and the majority of them accept the invitation to be present. At the inspection with the doctor are the school nurse and the representative of the school care committee. It is the duty of the school care committee to follow up the cases with a view to ascertaining the parents' wishes and means in regard to obtaining treatment and to applying for vouchers for treatment centres or hospitals when these are required. As in the normal case the parent is present, arrangements are made in the majority of instances on the spot. If the care committee representative is for any reason absent, particulars are written by the doctor on the special following-up card for her guidance, and acting upon these she interviews the parent at the next opportunity. In cases where the parent is not present, an advice card is issued by the school doctor stating the nature of the defect. This card gives directions and advice in regard to the measures to be taken by the parent to obtain treatment. It is often delivered in person by the school nurse at the home. If no action is taken the care committee representative interviews the parent with a view to helping and persuading her. Repeated visits are in many cases necessary. If a parent is neglectful, a special officer in the attendance branch takes over the case, and in a small proportion of urgent cases, where all else fails, the case is reported to the National Society for the Prevention of Cruelty to Children for prosecution. The results of following up by the school care committees are reviewed at the doctor's re-inspections. In the ordinary case the doctor reviews all the children, referred for treatment during one particular term, at the beginning of the next term but one. Thus, children referred for observation or treatment in the spring term are reviewed at the beginning of the Michaelmas term. All cases not completed and still unsatisfactory are marked for a second re-inspection. During 1925, of elementary school children previously referred for treatment, 111,561 cases were submitted for a first re-inspection and 55,166 cases that had not been discharged on a first re-inspection were reviewed a second time. Of the 111,561, 47,778 (42.8 per cent.) were discharged as satisfactory and 9,892 (8.9 per cent.) were reported improved but recommended to be kept under observation. At the second re-inspection 57.3 per cent. of the cases seen were found to have been cured, or to have improved and no longer to require treatment. By combining the results of the first and second re-inspections it appears that 75.5 per cent. of the cases originally noted for treatment are found ultimately to have been treated or discharged as satisfactory. This percentage is the same as that for 1924. Of the cases treated, 76.5 per cent. were dealt with under the Council's scheme; 7.6 per cent. were patients of private doctors, and 15.9 per cent were seen at hospitals and institutions not under the Council's scheme. It was pointed out last year that there was more difficulty in getting dental cases treated than other ailments. There has been distinct improvement in this respect during 1925. At first re-inspection 43.7 per cent. of the dental cases were discharged, as against 42.4 per cent. in 1924. At second re-inspection the percentages were 42.4 in 1925 and 39.5 in 1924. The combined result shows that 70 per cent. of the dental cases arising from medical inspection were satisfactorily dealt with in 1925 compared with 68.2 per cent. in 1924. If dental cases be excluded from the total, the final result shows that 80.3 per cent. of the cases requiring treatment are eventually satisfactorily dealt with. 114 First reinspections of cases previously referred for treatment. Second reinspections of cases not previously discharged. Re-inspections in 1925. Class of ailment and number seen. Treated by doctor. Treated under Council's scheme. Treated at hospitals not in Council's scheme. Not treated, but recovered. Not treated. Improved. For observation Not treated. Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 19,556 .. 108 52 5,281 2,307 507 313 1,243 2,479 7,266 (0.5) (0.3) (27.0) (11.8) (2.6) (1.6) (6.4) (12.7) (37.1) Minor ailments 289 68 2,675 1,023 437 315 2,393 994 2,199 10,393 (2.8) (0.7) (25.7) (9.8) (4.2) (3.0) (23.0) (9.6) (21.2) Nose and throat, 105 20 3,503 259 850 124 1,494 1,726 6,847 14,928 (0.7) (0.1) (23.5) (1.7) (5.7) (0.8) (10.0) (11.6) (45.9) Teeth, 52,868 1,476 532 16,826 872 691 171 4,106 877 27,317 (2.8) (1.0) (31.8) (1.6) (1.3) (0.3) (7.8) (1.7) (51.7) Other ailments, 379 174 304 241 1,589 1,557 3,522 3,816 2,234 13,816 (2.7) (.13) (2.2) (1.7) (11.5) (11.3) (25.5) (27.6) (16.2) Total, 111,561 .. 2,357 846 28,589 4,702 4,074 2,480 12,758 9,892 45,863 (2.1) (0.8) (25.6) (4.2) (3.7) (2.2) (11.4) (8.9) (41.1) Class of ailment and number seen. Treated by doctor. Treated under Council's scheme. Treated at hospitals not in Council's scheme. Not treated, but recovered. Not treated. Improved. For observation Not treated- Still needing treatment. Cured. Not cured. Cured. Not cured. Cured. Not cured. Refraction, 11,182 .. 60 32 2,440 1,209 276 172 948 1 ,665 4,380 (0.5) (0.3) (21.8) (10.8) (2.5) (1.5) (8.5) (14.9) (39.2) .Minor ailments, 61 35 843 495 159 172 968 502 1,155 4,390 (1.4) (0.8) (19.2) (11.3) (3.6) (3.9) (22.1) (11.4) (26.3) Nose and throat, 46 13 1,519 108 417 58 1,184 815 3,000 7,750 (0.6) (0.2) (19.6) (1.4) (5.4) (0.7) (15.3) (10.5) (46.3) Teeth, 24,938 819 239 6,301 344 434 110 3,016 399 13,276 (3.3) (1.0) (25.3) (1.4) (1.7) (0.4) (12.1) (1.6) (53.2) Other ailments 83 76 107 127 616 777 2,047 1,926 1,147 6,906 (1.2) (1.1) (1.6) (1.8) (8.9) (11.3) (29.6) (27.9) (16.6) Total, 55,166 1,069 395 11,210 2,283 1,902 1,289 8,163 5,307 23.548 (2.0) (0.7) (20.3) (4.1) (3.5) (2.3) (14.8) (9.6) (42.7) Results of Dental Inspections. The teeth of the children are inspected by the school doctors and the inspecting dentists. The school doctors see the children in the course of statutory examinations —viz., on entering school; at the ages of 8 and 12; and also on approaching the age of 14. The dentists inspect the teeth of the children of the other ages. Overlapping as between dentists and doctors is thus avoided. Medical inspections.—At the medical inspections the school doctors examine 25 children in a session, and about 30 per cent. of the children are referred for dental treatment. These examinations are conducted from a medical rather than a dental point of view, and the cases largely consist of those in whom the dental condition is affecting general health. The representative of the school care committee is present at these examinations, and the care committees are able to follow up these cases with a large measure of success. The children are re-inspected in due course by the doctor, and the results of re-inspections are tabulated and reported annually to the Council and to the Board of Education. Dental inspections.—The inspecting dentists see about 125 children in a session, and about 70 per cent. are found to require treatment. These include a large number of slight cases where decay is just commencing and can only be detected by a specialist using special appliances. Owing to the large number of cases and the importance of not burdening the dentists with clerical labour, it has not been found possible to 115 tabulate the results of dental inspections in the thorough manner in which the results of medical inspection are ascertained, and it should be pointed out that many of the defects are so slight that there is great difficulty in persuading the mother that anything at all needs doing. Results.—The results of the first and second re-inspections of the school doctors during 1925 showed that 70 per cent. of the children found at the primary medical inspections to require dental treatment eventually obtain the necessary attention. Similar figures do not exist in regard to the dentists' examinations, and it would be impossible to obtain them without an exceedingly large amount of clerical work, which it is impossible for the school care committees and the dental, organising and clerical staff to give. At the request of the Sub-Committee, a special inquiry was made in Finsbury some months ago, and it appears that of the children referred for dental treatment by doctors and dentists in that district, about 50 per cent. were, in fact, dealt with. Hitherto, all efforts have been concentrated upon getting as many of the children treated as possible, rather than upon obtaining statistics. I hat very substantial progress is being made is shown by the following figures :— Year. No. of children inspected by dentist. No. found by dentist, to require treatment. Percentage found to require treatment,. No. treated at the Council's centres. (1) (2) (3) (4) (5) 1915 69,516 56,864 81.79 44,875 1916 81,794 66,624 81.5 49,844 1917 89,962 71,447 79.4 56,913 1918 106,586 83,068 77.9 68,445 1919 144,456 112,227 77. 79,216 1920 154,347 115,619 75. 89,456 1921 151,395 111,250 73.5 94,177 1922 192,730 137,487 72.5 84,848 1923 236,658 166,454 70.3 93,332 1924 256,542 178,802 69.67 99,045 1925 262,482 182,524 69.54 112,964 It will be observed that in 1915 the dentists found that 81.79 of the children examined needed treatment and that this percentage has been reduced to 69.54 in 1925. It should be explained that the numbers given in column (5) include cases which attended as a result of the school doctors' inspections as well as those referred by the school dentists. On the other hand, in addition to the children who attend at the Council's centres, a number receive treatment from private dentists and institutions not included in the Council's arrangements. For all practical purposes the position statistically in regard to dental work can be deduced from the comparison of the number of children found at inspections to be in need of treatment during the year with the number actually treated at the Council's centres, together with an estimate (based on the results of medical inspections) of the number of children treated by private dentists and hospitals outside the scheme. Number referred for treatment. Number treated. (a) At medical inspections 69,778 (1) At Council's centres 112,964 (6) At dental inspections 182,524 (2) By private dentists and at institutions not included in Council's arrangements (estimated) 15,000 252,302 Less number referred by both doctor and dentist 13,051 - 239,251 i.e., 53 per cent. 127,964 Conversion of inspection sessions into treatment sessions.—In 1923 the Council agreed to a scheme by which the dental inspections should be largely increased in 116 numbers. By this scheme all the schools in London were placed on a dental rota and dental inspection of the children is carried out by the school dentists annually for all age groups of children except those due for examination during the year by the school doctors. Circumstances have prevented the consequent increase of treatment provision at the rate that was then expected. Between 1921 and 1925 the dental inspections have increased from 151,395 to 262,482—that is, 73 per cent. Provision for dental treatment under the Council's scheme in the same time has been increased from 94,177 to 112,964 cases—that is, 20 per cent. The result has been that although more dental work has been done, the percentage of those treated to those found needing treatment has fallen. This, however, is entirely due to the increased inspections carried out, and is not a real reduction. In fact, there has been a steady increase in the number of children treated. Owing to necessarily slow growth of dental provision, due to the financial situation, the present position is that many of the dental centres are congested with patients, bookings are made long ahead, and the dental inspections not being adjusted to treatment requirements, in many centres the congestion is progressive, and the work is greatly hampered. Formerly it was possible partly to hold up inspections at a particular centre which was congested until arrears of treatment were overtaken, inspection sessions being converted into treatment sessions at need. Under the rigid application of the present scheme, this was not possible: freedom of action in this matter is now restored so that inspection sessions may be converted into treatment sessions when found necessary. Many more children will thus be treated, while the general result, so far as inspection is concerned, will be that, temporarily, in some schools the children will be inspected at 15 to 18 monthly intervals, instead of at intervals of one year. Children absent from School for long periods. The attendance officers supply each month a list of the children in their districts who have been absent from school for a period of three months and upwards. Inquiry is made into the adequacy of the treatment the cases are receiving and from time to time special examinations are made to ensure that every effort is being made to secure proper treatment or to ascertain whether special education is advisable. During the month of November, 2,398 children were on the list, several suffering from two or more complaints. The following table gives details for the last four years. It will be seen that the rheumatic group of cases accounts for one fourth of the chronic invalidity amongst school children and rheumatism is by far the most important single cause for prolonged illness in children. The age distribution of these cases shows that prolonged absence from school occurs most frequently at age 5-6 largely due to the after effects of measles and scarlet fever, and again at age 12-13 when the incidence of heart disease, rheumatism and chorea is heavier. At ages 10-14 more than twice as many girls as boys are absent from these causes. There is also a large preponderance of older girls absent from anaemia and pulmonary tuberculosis though boys suffer more often from other forms of tuberculosis. X-ray treatment of ringworm renders long absence from this cause less common than in previous years. There were 85 absences in November, 1924, and 81 in 1925, compared with 234 in 1913 and 178 in 1914. Not only are there fewer cases but the period of absence is so much shorter that few of the cases remain out of school as long as three months. 117 Complaint. Children. Percentage of total.[.###] 1922 1023. 1924. 1925. 1922. 1923. 1924. 1925. Rheumatism, heart and chorea 682 652 672 614 23.5 23.92 25.02 24.71 Nervous disorders 245 274 288 268 8.44 10.05 10.72 10.78 Tuberculosis (pulmonary and other) 502 462 399 322 17.3 16.95 14.86 12.96 Anaemia and debility 212 184 201 196 7.31 6.75 7.48 7.89 Ringworm 200 145 85 81 6.89 5.32 3.16 3.26 Skin complaints (other than ringworm) 52 66 76 72 1.79 2.42 2.83 2.9 Eye complaints 144 112 135 103 4.96 4.11 5.03 4.14 Infectious diseases 80 67 *98 *92 2.76 2.46 3.65 3.7 Other diseases 785 764 732 737 27.05 28.02 27.25 29.66 All diseases (total No. of cases) 2,902 2.726 2,686 2,485 * Including 37 cases of encephalitis lethargica. Total No. of children out of school — 2,683 2,608 2,398 Medical Treatment. The Education (Administrative Provisions) Act of 1908, imposed upon local education authorities the duty of providing for the medical inspection of school children, and gave an optional power, since made compulsory, of making arrangements for the treatment of certain specified ailments. The augmented inspection work was begun in March, 1909. and it was soon found that the existing arrangements for treatment were quite inadequate. The hospitals were overburdened with child patients, and it became evident that the facilities for treatment must be materially increased. In January, 1910, the Council made arrangements with seven hospitals for the treatment of some 12,700 children. All the responsibility for treatment was undertaken by the hospital authorities. No arrangements were made for following up the cases, and the only information concerning children who had ceased attendance before treatment was completed was received as an accompaniment of the claim for payment, and was much too late to be of service. In February, 1911, arrangements were made at the London Hospital for an assistant organiser of children's care work to attend the hospital to regulate the attendance of the children and to supply information to the care committee. The experiment was so successful that it was extended to cover all the treatment arrangements of the Council. Owing to the difficulty of making complete arrangements with the larger hospitals in London, due mainly to the fact that their organisations were not adapted to cope with the immense mass of childhood's ailments with which they were overwhelmed, further means of dealing with the matter were sought. Fortunately, at this point, with the co-operation of local committees of medical practitioners, it was possible to inaugurate a system of treatment centres. The first was opened in July, 1910, at Hampstead on the premises of the Kilburn Provident Medical Institute, followed by a second at Norwood in September of the same year, and a third in Wandsworth in January, 1911. In 1912 the medical treatment scheme was reorganised and cast into its present form—that is to say, that whilst full use is made of the hospitals as far as their resources will permit, the main bulk of treatment is carried out at school treatment centres controlled by voluntary committees, much to the advantage of children living in areas remote from hospitals. Attendances for treatment are regulated by the Council's organisers of children's care work. Records of the cases treated are kept at the centres. The care organisation follows up the cases to see that treatment is completed. In short no means is neglected to secure the effective treatment of every child needing it, and that there shall be no failure to obtain treatment by reason of the absence of facilities or by ignorance on the part of parents or guardians. The passing of the Education Act, 1918, somewhat altered the conception of the duties of the local authority with regard to treatment. The earlier Act, already referred to, gave an optional power to make arrangements for the medical treatment 118 of elementary school children. Section 2 (1) (b) of the Education Act, 1918, made this optional power a duty as regards elementary school children, and Section 18 extended the optional power to include the provision of facilities for treatment in respect of children attending any school or educational institution whether aided or not by the local authority. These requirements were later incorporated in the consolidating Education Act of 1921. The London County Council has made arrangements for the medical and dental treatment of scholarship holders at secondary and trade schools, and has extended the facilities to fee-paving pupils subject to the actual cost of treatment being recovered. The average cost of treatment during the current year was : Adenoids and enlarged tonsils 10s. 10d., minor ailments 7s. 7d., dental treatment 7s., and X-ray treatment of ringworm 25s. 7d. The charge made to parents of elementary school children and scholarship holders is 2s. for each major ailment, and 1s. for continuous treatment of a minor ailment after the completion of a fortnight's free treatment. Necessitous children are treated free. A development of the medical treatment scheme not foreseen at its inception is the use of the dental centres by schools for mothers and infant welfare centres. Although the Council is in no way responsible for the work done in this way the associated use of the centre is of material benefit to all concerned in the larger issues of the public health service. A further development on somewhat more advanced lines is the provision of in-patient treatment for children requiring surgical aid for enlarged tonsils and adenoids. There are at present two such centres, situated in Highgate and Woolwich respectively. Two others are to be opened shortly. In the early part of 1921. arrangements were made with the Metropolitan Asylums Board whereby the Board kindly offered, free of cost to the Council, treatment at the Board's residential school situated at White Oak, Swanley, for prolonged periods of children suffering from infective ophthalmia. The children are lodged in separate cottages under a house mother, they are well fed, clothed and educated, in addition to receiving skilled medical attention for their particular ailment. The children return looking fit and well, and many parents have expressed their gratitudeat having their children returned to them so much improved. The parents or guardians are assessed according to their means to pay a weekly charge for maintenance, but the maximum charge as at present fixed is only 8s. 9d. per week. During 1925 the provision for treatment was extended to cases of interstitial keratitis. Since 1921, 718 children, including 257 cases of trachoma, have been sent to White Oak, and the arrangement was found to be specially useful in 1924, when there was a somewhat extensive outbreak of trachoma in the east end of London. Similar arrangements have been made with the Metropolitan Asylums Board for mastoid operations at Downs Children's Hospital, and more recently for the treatment of cases of encephalitis lethargica at Winchmore Hill. As already mentioned, there were in January, 1910, only 7 hospitals providing for 12,700 children. In January, 1913, there were 12 hospitals and 17 treatment centres providing for 73,000 children. Throughout the difficulties of the war period the scheme still extended its ramifications until in January, 1919, there were 11 hospitals and 43 centres providing for more than 160,000 children. At the end of 1925, there were 13 hospitals and 60 centres in addition to the dental centre at Bushy Camp School. The provision made for the several ailments and the numbers treated during the year (the latter shown in brackets) were, eyes, 34,630 (36,356); ear, nose and throat, 13,250 (15,066); ringworm, 1,752 (1,167); minor ailments, 65,890 (88,447); dental ailments, ] 15,830 (112,964). Total 231,352 (254,000). It will be observed that the numbers treated exceed the numbers under agreement except as regards ringworm and teeth. It is to be expected with the present method of treatment that there should be a rapid decline in ringworm. As regards minor ailments, it will be seen that the numbers treated are 34 per cent. in excess of the numbers under agreement. 119 The treatment of dental defect presents more difficulty owing to the large number of failures to keep appointments for operative treatment. This is the result in many cases of parental prejudice, and makes it necessary to arrange appointments for a number of cases rather in excess of the number treated. In the following statement the ailments are dealt with separately in the ordersuggested by the Board of Education. (a) Minor ailments.—88,447 children received minor ailment treatment, an increase of 8,118 on the number for 1924. The arrangements with the Metropolitan Asylums Board for the treatment of contagious ophthalmia have been extended to cover cases of interstitial keratitis, and 116 children were sent to White Oak during the year. This number included 26 cases of trachoma, a pleasingly small number if compared with 1924 when 216 cases of trachoma were sent. (b) Visual defects.—36,356 children were dealt with under the Council's scheme for refraction. Spectacles were prescribed in 25,555 cases, and in 22.957 cases (89.8 per cent.) were obtained. (c) Nasal and Aural defects.—The total number of cases treated was 16,699, of which 15,066 were treated under the Council's scheme. There has been a steady increase in the cases treated under this heading for some years past. Probably this is due, not to increase in defect but to the special measures taken to seek out suffering children and to secure treatment. The scheme which came into operation in April, 1925, is undoubtedly responsible for a large part of the increase. Scheme for the treatment of discharging ears. The new scheme introduced on April 1st this year under the Council's three-year programme for the better supervision of children suffering from discharging ears included the appointment of two assistant aurists for five sessions a week and the establishment of six special ionisation centres, one in each division except the northwest division, where two were established to meet the difficulty of transit. In each division three sessions are held in each week by Dr. Wells and the two assistant aurists. The centres deal with children referred by the treatment centre doctors, school doctors, school nurses, care committees and teachers. These are examined by the aurists and dealt with according to the condition found in each case. Some are referred back to the treatment centre most easily accessible for the child, for conservative treatment recommended by the aurist. Other cases are treated at the special centres by ionisation, while appropriate cases are referred to the Downs Hospital for mastoid operation. The latter cases, after discharge from hospital, attend the " after care clinic " at Kentish Town, which is an institution of the Metropolitan Asylums Board. Children requiring operation for tonsils and adenoids are referred by the aurists to the centre with which the Council has arrangements. An organiser and two nurses are in attendance and with the aurists form the staff at each of the ionisation clinics. The nurses under the direction of the aurists undertake the ionisation, while the organiser is responsible for the following up and is the link between the special centre and the various treatment centres in the division. The following are the statistics relating to the work done under the new scheme from 1st April to 31st December, 1925 :— Suppurating ears — Patients. Ears. Total number of attendances 6,292 7,639 „ ,, ,, cases 1.475 1,818 ,, „ ., „ lapsed 81 97 ,, „ discharged first attendance (these are in addition to above) 165 — Total number of cases discharged cured 645 788 ,, „ still under treatment on 31st December, 1925 706 924 120 This represents a net result of 45-7 per cent, of ears cured of the completed cases. Purely deaf children — Patients. Ears. Total number of attendances 551 1,012 „ „ „ cases 177 326 „ „ „ cases completely cured 41 74 Patients. Ears. Total number of cases improved 9 17 „ „ „ „ unrelieved 22 35 „ „ „ „ under treatment on 31st December, 1925 96 182 This represents as a net result of the completed cases 22.7 per cent. cured, 5.2 per cent. improved, 10.7 per cent. unrel eve 1. The following table represents a complete analysis of all the lonisation work done at the ionisation centres from 1st April to 31st December, 1925 Causes of suppuration. Total cases. Cured. Lapsed. Sent to hospital. Still under treatment. Acute Supp. Otitis media. 1 — — — 1 Chronic Supp. Otitis media due to I. Tympanic conditions solely— (a) Tympanic sepsis. 475 298 9 — 168 (6) T.S.—granulations 136 75 2 2 57 (c) T.S.—polypi 22 7 1 1 13 (d) T.S.—caries 7 1 — 2 4 (e) T.S.—other conditions 10 3 — — 7 II. Tympanic conditions combined with— (a) Tonsils and adenoids 21 17 — 1 3 (6) Nasal conditions 29 23 — — 6 (e) Oral conditions — — — — — III. Tympanic conditions combined with— (a) Attic disease 163 33 7 25 98 (6) Mastoid disease (no operation) 156 11 4 70 71 (c) Mastoid (operation already) 39 14 5 1 19 IV. Tympanic conditions combined with— (a) External otitis 2 — — — 2 (6) Stricture of meatus 1 1 — — — External otitis 7 1 1 — 5 Cause undetermined — — — — — Totals 1.069 484 29 102 454 It will be seen that 1,069 ears were ionised, and of these 29 lapsed ; 102 were sent to hospital for mastoid operation; 484 were cured and 454 were still under treatment at the end of the year. This represents, as a net result, of the completed cases, 46-5 per cent, cured. The percentage of cures is smaller than might be obtained by a more strict selection of cases. The reasons for this are as follows :— Firstly, the cases which have been referred to the aurists for treatment, and in particular by the treatment centre doctors, have been, in the main, advanced cases of disease. They represent to a very large extent the worst cases under treatment at the centres. Secondly, instead of making a strict selection of the cases, and only ionising those which appeared to be suitable cases, it has been the practice to go far beyond this, even beyond what may be termed border line cases; and an endeavour has been made to convert a large number of unsuitable cases into suitable ones, sometimes with success but often without. This has naturally rendered the percentage of successes rather low. If regard to high statistical results had been the first consideration, this could have been attained by dealing only, by ionisation, with those cases which were from the outset suitable. 121 The interests of the children, however, were pre-eminently the first consideration, and every possible means was resorted to before submitting them to treatment by mastoid operation. It will be seen, therefore, that 46.5 per cent. cured cases does not give the true assessment in value that must be placed upon ionisation. If the percentage were stated with reference to "all cases," it would be much higher, but would then, of course, include many early cases which would clear up promptly. It has been decided that a better arrangement would be to work through all cases attending the treatment centres in turn. In this way all the cases, not merely the worst cases at any particular centre, will be dealt with and early cases cleared up, with advantage to the children, and further, the ultimate effect will be to tend towards the elimination of "late" cases of ear discharge in children, which is one of the most important objects to achieve. This arrangement is to be put into operation during the year 1926. The details of the work done at the after-care clinic, Kentish Town, including the mastoid operations done at the Downs Hospital, are as follows:— Total number of ionisations 1,408 ,, ,, ,, dressings 939 Patients. Ears. Number of eases treated at after care clinic 224 269 After mastoid operation. Patients. Ears. Number discharged from Downs Hospital 172 207 „ t reated here and discharged cured 83 93 „ still under treatment 31st December 60 82 „ treated at L.C.C. clinics, etc. 9 10 ,, discharged Downs Hospital dry 16 18 „ sent to Downs Hospital for further operation 2 2 „ lapsed 2 2 In addition a certain number of cases were treated at the after-care clinic which had no operation, viz.:— Patients. Ears. Number of cases treated 77 90 „ discharged cured 72 84 „ still under treatment 5 6 (d) Dental defects.—58 part time inspecting dentists were engaged in examining the teeth of children in the schools, and 2,240 sessions were devoted to this work. 262,482 children were inspected and of these 182,524 (6954 per cent.) were found to require treatment. 112,964 children were treated at the Council's centres, or 13,919 more than in the preceding year. Dental report by Mr. C. Edward Wallis. Since 1910, when the first dental centre was opened in Blackfriars. no less than 56 dental centres have been established. It will be convenient to summarise the experience gained under the following headings:— 1. Propaganda. 2. Staff. 3. Co-ordination of work. 4. Supervision of work. 5. Output of work. 6. Payment for treatment. Propaganda.—It is abundantly clear that it is useless to open a dental clinic without a preliminary and continuous course of dental propaganda directed to the parents, school teachers, and voluntary and other workers engaged in "followingup," and accordingly every effort is made to obtain intelligent and instructed co-operation whereby the parents can be made to see the advantages to health and school progress dependent upon healthy mouths and teeth. With this aim in view lantern lectures on dental hygiene are given to parents, elder children, and care committee members wherever found necessary. One of the common hindrances to school dental treatment is the apathy and want of interest of the parents, and there is constant effort to remove this, with the 122 object not only of allaying opposition, but of creating an actual demand for a healthy mouth as a natural accompaniment of a healthy body as an aid to efficient school progress. Staff.—It is sometimes thought that anyone with a dental diploma is thereby suitable for a dental clinic appointment, and one of the lessons learned is the fallacy of any such idea. The success of a dental clinic depends almost entirely upon the suitable selection of the dental surgeon and nurse. However skilful a dentist may be, unless he can command the confidence and even regard of the children and parents, he cannot secure the best results. Occasionally the substitution of one dentist for another has made a change in the output and popularity of a clinic. It follows, therefore, that the utmost care must be exercised in their selection. It is found in London that, on the whole, part-time dentists are more satisfactory than whole time ones except in a few rare cases in which older men have given up general dental practice for school dental work. Again it is absolutely essential that a school dentist, besides having a pleasant manner, should have the gift of explaining treatment to parents in simple intelligible language without the use of technical terms. Much parental opposition may be overcome by a proper and considerate explanation of the treatment required. A point not always evident is that clinic dental surgeons have to supervise the work of their clinics, and it is, therefore, specially necessary that dentists of experience and common sense should be appointed to these highly responsible posts, and not the newly qualified and inexperienced. As regards anaesthetists in dental centres it is absolutely essential that every anaesthetist so employed shall have special experience in giving nitrous oxide and ethyl chloride for dental operations upon children, and it is by no means easy to obtain persons gifted in this respect. It is also important that the dental surgeon and dental anaesthetist should work closely en rapport, as it is essential that whatever may be required may be completed while the child is in a state of complete anaesthesia. This mutual co-operation obviously precludes a frequent and even a yearly change of anaesthetists, and so valuable is a really good dental anaesthetist that his services should be retained for as long as possible. Co-ordination and supervision of work.—Experience of these clinics soon showed that co-ordination and supervision of the work by an experienced dental surgeon was essential. Further, a uniform and uncomplicated method of recording work done was found to be necessary in order that complaints of malpractice and so forth might be investigated and dealt with at once. The charts in use in the London dental centres are made as simple and self-explanatory as possible, and at the same time there is avoidance of undue clerical work at the expense of necessary dental treatment. Output of work.—It is often asked what output should be expected of a dental surgeon, and after consultation with the senior, most experienced and conscientious members of the dental staff, it is generally agreed as a broad statement that one stopping per child per annum is the minimum to be expected, though in a few centres the quantum approaches an average of three to four stoppings per child. It is of interest to know that this larger output is derived from the older and more experienced, who have developed the art of working quickly and efficiently in accordance with the sessional time available. Payment for treatment.—The question is often raised as to whether the charges made for dental treatment act as a deterrent and prevent parents from obtaining what is required for their children. Much inquiry has been made in regard to this, whereby an interesting fact has emerged, namely that parents who pay at their first visit, almost invariably make their children attend until the treatment is completed, a most valuable: result, and much better than when a mother lets her child attend once and then fails to re-attend for the completion of the treatment. 123 Classes for stammerers. During 1925, 276 children passed through the stammering centres; of these, 70 were discharged cured, 43 were discharged provisionally cured, as they did not stammer in the clinic. It was recognised, however, that under special stress, e.g., moving to a higher class, it was possible that the stammer might reappear temporarily. From past experience of those provisionally cured, it is found that these recurrences are increasingly small. The important point being that confidence having been established in the class, it becomes necessary to put this new-found confidence to the test of the every-day world, rather than they should become dependent on the atmosphere of the clinic alone. All children discharged are followed up for the three following terms and reports obtained as to their condition. During the year 14 of these children were noted as having relapsed and were re-admitted to the clinic for a further course of treatment. Of these 9 were discharged as cured during the year, 4 were still attending at the end of the year and one child had left school. Much depends upon the after-care of children who have been discharged cured from the classes. Sympathy and encouragement in the environment both at school and at home are necessary to ensure permanent results. How much this is so is seen from the fact that at the Jews' Free School relapses after discharge have been almost unknown. At the Jews' Free School centre, the children are selected from this school only. The results are extremely gratifying, and show the importance of the help and sympathy of the headmaster and the care committee. One case of cleft palate with very defective articulation was treated at this school, after the stammering children had been dismissed from the class, with very beneficial results. Further investigations have been carried out with regard to the family histories of the stammering children. It is interesting to note that taking 109 consecutive cases, 20 were first-born children, and in 16 cases there was a family history of lefthandedness, although the sufferer may not have been left-handed. Manifestations of Rheumatism in Childhood. While no age is exempt from the incidence of rheumatism there is a special liability to attack in the case of children of school age. In addition to the greater incidence, it is important to note that the manifestations of rheumatism during the school period of life assume a special character. The rheumatic infection is especially liable at this age to involve the heart, leaving permanent disease of this organ. Dr. Carey Coombs, of Bristol, estimates that about two-thirds of the rheumatic heart cases in Bristol begin between the ages of 5 and 15. At the school age also the rheumatic infection is very liable to affect the central nervous system, and chorea, or St. Vitus' dance, is a rheumatic symptom which is practically limited to school children. There are two special features connected with rheumatism in children which it is important to emphasise—(1) Instead of the onset taking the form of an acute illness, it often commences insidiously as a general falling off in health, accompanied by pallor, but with no active complaint other than occasional sore throat and what are vaguely described as " growing pains." In such cases there is a special danger of involvement of the heart. Many of these cases are often not suspected or diagnosed until they come under inspection by the doctor at school. (2) Rheumatism differs from most of the acute infectious fevers in that one attack confers no immunity upon the patient. On the contrary, recurrence of the disease is very frequent, and the liability to attack is greatly raised in those who have already suffered. There is great danger in recurrent attacks for the heart to be especially affected. Number of children suffering. Although necessarily, in the absence of general notification of disease, it is not possible to give accurate figures, the size of the problem can be gauged with a fair degree of accuracy. From reports made by the school doctors it may be computed that there are in the London area certainly not less than 10,000 children who have 124 suffered or are suffering from rheumatic symptoms. The great majority of these of course, are not in need of any special treatment other than that they are already receiving, but they require careful watching. They are mostly attending school, and under the observation of the school medical service, and are known to the school care committees, who give the parents such advice and help as is, from time to time, desirable. There are about 1,000 of these children attending special (physically defective) schools whose hearts have been seriously and permanently injured; and there are from 600 to 700 children absent from school for long periods on account of rheumatism. These last represent 25 per cent. of the chronic invalidity amongst children, and include all, or almost all, the children for whom special arrangements are still necessary. A census is taken each year, in November, of the number of children reported chronically out of school, and the numbers of these for the past four years are set out in the following table in which those absent on account of rheumatism are also shown separately. 1922. 1923. 1924. 1925. Total chronically absent 2,902 2,726 2,686 2,485 Rheumatic cases 682 652 672 614 Percentage due to rheumatism 23.5 23.52 25.02 24.71 The 614 rheumatic children absent in November, 1925. are classified as follows:— Boys. Girls. Total. Rheumatism 51 93 144 Heart disease 86 138 224 Chorea 75 171 246 This table demonstrates the greater incidence of rheumatism generally upon girls (65 per cent.), and the very special incidence on the nervous system in school children shown by the very high proportion of chorea to the total (40 per cent.). This is especially to be noted, as it illustrates a point which is to be emphasised, that rheumatism often steals in upon children like a thief in the night and does not come as a sudden acute illness, for the onset of chorea is generally very insidious, and it is usually first noticed at school. Children with chorea are largely treated as outpatients at the hospitals, but it is highly desirable that all children with active chorea should be treated by rest in bed, as the development of rheumatic endocarditis in these patients is a frequent occurrence. The relief to the hospitals, which further convalescent provision for rheumatic children would afford, might result in a number of choreic cases receiving adequate treatment with a corresponding reduction of the incidence of cardiac complications. About 11 per cent. of the children admitted on account of heart disease to the physically defective schools gave a history of previous chorea. It is obvious that special consideration will be required for the choreic child as part of the whole problem of rheumatism. The deaths in London in 1924 from rheumatism at ages below 25 were:— 0-5 5-15 15-25 Rheumatism and rheumatic fever 4 65 41 Heart disease 13 147 257 Chorea 1 5 4 Total 18 217 302 The annual number of children admitted for heart disease to the Council's special schools is at present between 250 and 300. This number has increased during the past few years largely because the hospital physicians have become better acquainted with the facilities, and in consequence of the very close co-operation, which has grown up between the hospital authorities and the Children's Care Organisation of the Council, in regard to the after-care of rheumatic children. 125 Map of London indicating the Location of Cases of Children suffering from acquired Heart Disease and attending the Council's Special (P.D.) Schools in December, 1925. The hatched line is a contour line 50 feet above sea level. The numbers indicate the courses of old rivers:— 1. Stamford Brook. 2. Counters Creek. 3. West Bourne. 4. Ty Bourne- 5. Hole Bourne or Fleet. 6. Wall Brook. 7. Shore Ditch. 8. Black Ditch. 0. River Lea and Hackney Brook. 10. Beverley Brook. 11. River Wandle. 12. Falcon Brook. 13. River Effra. 14. Neckinger. 15. Ravens Bourne. Map of London showing Distribution of Cases of Illness notified as due to Encephalitis Lethargica, 1924-1925. 13651 126 Geographical distribution. The incidence of rheumatism is not uniform either in the country or in the London area itself. It is commonly held that rheumatism is apt to cling to low-lying clay soils. Dr. Jean Shrubsall, working in the London School Medical Service, found, in 1912, that children suffering from rheumatic heart disease were not uniformly distributed over the county area, but there was a definite aggregation of cases along the lines of the alluvial valleys marking the ancient courses of rivers, such as the Hole Bourne or Fleet, the West Bourne, the Bridge Creek (Notting Dale), the Wandle and the Effra. The inquiry has been repeated by Dr. F. C. Shrubsall in order to ascertain whether these observations made in 1912 are confirmed in the figures for 1925, and the result is shown in the diagram on page 125. For purposes of comparison cases of encephalitis lethargica, during 1924 and 1925, are placed upon the map appearing below that relating to heart disease. Tn the case of encephalitis the distribution of the cases appears to be governed in the main bv densitv of population. The 614 rheumatic children chronically absent from school in London in November, 1925, were distributed as follows:— Education District. No. of cases. No. of children of school age Per 1,000 I. Camberwell 63 64,200 .98 II. Chelsea 31 72,400 .43 III. City, Stepney 79 49,500 1.59 IV. Greenwich 66 65,800 1.00 V. Hackney 64 63,200 1.01 VI. Islington 55 67,000 .81 VII. Lambeth 37 45,600 .81 VIII. Paddington 10 39,100 .22 IX. Poplar 80 57,200 1.39 X. St. Pancras 34 42,400 .8 XI. Southwark 64 59,500 1.07 XII. Wandsworth 30 70,700 .42 The unequal distribution of cases has a bearing upon the question of coordination of effort between the various institutions and authorities dealing with the problem. Prevention. The widespread incidence, the serious complications, the permanent injury, especially to the heart, the reduction in expectation of life of sufferers and the diminished capacity for work make it especially important, in the interests of the public health, that facilities should exist for the early and adequate treatment of all cases of rheumatic nature in childhood. In the present stage of knowledge, it is not possible to suggest specific steps whereby attacks of rheumatism can be prevented. Attention to the health of illnourished, debilitated and anaemic children is being carried out by the school care committees. The entry of the infection is generally believed to be by the route of the tonsils, and Sir George Newman has suggested that the diminution of the more severe cases of rheumatism in childhood has been associated with the greater attention to nose and throat ailments which the School Medical Service has secured. In addition to this factor, improvement in the housing conditions and in home care of children must have a considerable effect in reducing the incidence of the disease. At the present time the most hopeful measures appear to be those which may be taken to mitigate the serious sequelae of rheumatism, and consist in the extension of special facilities for convalescent treatment. All authorities are agreed that prevention of cardiac involvement and cure of the early heart disease are obtained most certainly in cases of rheumatism by prolonged rest in bed under supervision, followed by graduated activity, such as could only be secured in special convalescent -homes. The experiment of sending rheumatic children to ordinary convalescent homes has not proved successful. 127 The Invalid Children's Aid Association has provided two special convalescent homes serving such children in London, and the results are claimed to be especially favourable. There is no doubt that the lack of adequate provision for convalescence has very unfavourable reactions upon the hospital accommodation in London. In the first place, the rheumatic children are retained in the hospitals much longer than those suffering from any other complaint, and they are retained so long purely for the reason that there is no place suitable for them to be sent. This is exceedingly wasteful, as it follows that hospital beds in London are being used for cases in the convalescent stage, and this limits the provision for acute cases which is urgently required, while many cases have to be treated as out-patients which should be admitted to the wards. In the second place, although a comparatively lengthy stay is given in the hospital, the children are, nevertheless, discharged too soon to their homes, with the result that relapses and advancing heart disease are more frequent than would be the case if adequate provision for convalescence existed. In his latest annual report (1924) on the Health of the School Child, Sir George Newman states: "There can be no doubt that children suffering from rheumatic infection are better for early hospital treatment, and there is need for more institutional accommodation for such children. Preferably they should not be mixed with other invalid children, but dealt with in separate open-air hospitals or residential recovering schools. . . . The admission to such institutions should be upon a selection basis, and much care, skill and foresight are necessary for their proper management." Present provision for treatment of rheumatic children. Acute rheumatism in its various manifestations is dealt with by the special children's hospitals as well as the general and special hospitals in London. It is impossible to state the total number of children admitted during a given year, but at the five great children's hospitals which issue annual medical reports 377 children suffering from rheumatism, or its after-effects, were admitted as in-patients during 1924. The length of time spent in a hospital bed in the case of rheumatism is prolonged as compared with all other diseases. Dr. Poynton gives the average length of stay as 60 days in 1919-20, at Great Ormond Street Children's Hospital, compared with 25-30 days for other diseases. The reasons for this protracted use of accommodation which should be available for acute and urgent cases have already been discussed. Poor Law cases are admitted to the infirmaries, but information as to the number of such cases cannot be given, although the number of rheumatic children admitted to the Metropolitan Asylums Board's country hospitals was 228 in 1924. There is very little special provision for convalescent treatment of rheumatic children other than that provided by the Poor Law. Impressed by the urgent need for such provision the Invalid Children's Aid Association established their two small homes at Hartfield, Sussex, and at Willesden, but the waiting lists are very long and the need for further accommodation is manifest. More than in any other complaint, perhaps, is swift action imperatively called for in cases needing convalescent care; to return a child to an unsatisfactory home, while waiting for a convalescent bed, is to court almost certain permanent injury to the heart. It is evident that, in dealing with a widespread problem, such as rheumatism, in any scheme that is adopted, the necessity for co-ordination must be kept prominently in mind, and the principle of selection, insisted upon by the Board of Education, must be followed. The precedents which have been established in the cases of ophthalmia, poliomyelitis and encephalitis lethargica appear to hold with special force in the case of the rheumatic diseases of children. There is even a closer parallel between the problem of the rheumatic child and that of the tuberculous child; and the model of administrative action which has been worked out in the case of tuberculosis should prove a secure guide to the action which is required in the case of acute rheumatism and its sequelae. 13651 I 2 128 Playground classes. Open-Air Education. In 1925 arrangements were made for the formation of 117 open-air classes. The number of open-air classes in 1924 was 95. There are four types of classes:— A and B—Composed of delicate children selected on grounds of health by the school doctor from (a) one or (b) more schools. C and D—Ordinary school classes working in the open either (c) for the whole season or (d) for shorter periods in turn with other classes. 41 classes of type A or B were held and 76 of type C or D. 71 were held in school playgrounds and 46 found accommodation in parks, open spaces, squares or gardens placed at the Council's disposal. The educational reports are regarded as distinctly favourable to the policy of open-air classes. The inspectors' reports show that the teachers in charge of the classes took a lively interest in their work and did their best to make the classes a success. There is agreement that the main object of the classes, viz., the physical well-being of the child, is being attained. Preparations are being made for the increase in the number of these classes to 137 in the coming year under the three-year programme. Special reports have been received from the assistant medical officers on more than 30 open-air classes in which the children have been kept under special medical observation. On the whole, the weather during the past summer was more favourable for open-air activities than that during the summers immediately preceding. Without exception the reports are favourable. The average increase in weight of the children in six months is about 4½ lbs. under open-air conditions. The remarkable freedom from infectious disease is remarked upon even in classes held in neighbourhoods where infectious disease was unduly prevalent. General freedom from colds in children who were previously subject to them is also reported inde pendently by many of the school doctors, and no doubt, as a consequence of this, improvement or cure of a number of children, noticed at the outset to have enlarged cervical glands, is often remarked upon. Some of the classes, particularly such as are held in parks and open spaces, are singled out as having been especially successful, and some valuable and detailed reports have been received on these. Amongst these may be mentioned: The Johanna-street (girls') class, type B, which was held in Brockwell-park. Dr. Adam reports that 24 girls who attended constantly from June to October were all found to have improved in physique, and to have put on an average increase in weight of over four pounds. Out of 11 children suffering from anaemia, nine were reported cured, and of ten with debility at the outset, all improved. Five children with enlarged glands in the neck showed improvement. Untreated dental caries in the case of three girls affected their progress, but in several other cases dental treatment was obtained. The Hawley-crescent open-air class (boys'), type B, held in Regent's-park, in a most suitable spot. Dr. Vawdrey reports that the improvement in physique was most satisfactory, and greater than in previous years, owing to the warmer summer. Rest periods and milk meals for this type are most important. Improvement in mental conditions was noted. One boy put on as much as 10.3 kilos (about 22½ lbs.). St. Giles-in-the-Fields open-air class (girls'), type A, held in St. Giles churchyard by the courtesy of the rector of St. Giles and with help (caretaker, etc.), supplied by the Holborn guardians. Dr. Raffle reports that the general health was excellent. No case of infectious disease occurred amongst the 33 girls, although there was much in the district. A great point was made of complete rest for half an hour at mid day. Several girls with defects became quite normal. One girl, however, who had thorea when admitted, became worse in August, and was admitted to 129 hospital, and another pupil suffered in August from an attack of appendicitis, from which she died. It is to be noted that in neither case was the class open when the girls were taken ill. Dr. Raffle reports it to be an excellently conducted class on an admirable site, and every effort should be made to retain the class. The St. James'-park open-air class (girls'), type A. Dr. Danvers-Atkinson has sent in a very detailed and careful report upon all the children attending this class. There are medical records of 47 children; in spite of certain difficulties, such as the distance away of lavatory accommodation, the results were very remarkable. The gain in health to the children who stayed in the class for the whole period was manifest. The disappearance of cough and night sweats in pulmonary cases formed an outstanding feature. The parents who attended the examinations were unanimous in considering that their children were much benefited by their sojourn in the class, particularly pointing out how much more bright and alert they were. Although many children received milk in the class, Dr. Danvers-Atkinson suggests that each child should automatically be placed on milk, except in cases where it actively disagrees, and thinks the provision of an oil stove for heating the milk in cold weather would be an added advantage. Eleven of the children were simultaneously under observation at the tuberculosis dispensary; all these improved greatly, and in many the symptoms entirely disappeared. There is no doubt at all that the results of the open-air classes during the past year have been exceptionally good, and they have been the means of restoring to health a number of children of that anæmic and debilitated type which is sometimes referred to as pre-tubercular. School journeys. No less than 372 school journeys required the services of a medical officer to inspect the children before leaving. This made necessary the examination of no less than 12,832 children, of whom 74 or 0.58 per cent. were rejected. The complaints which caused rejection were mainly minor infectious or contagious conditions, but there were in addition 4 rejections for heart trouble, 7 for otorrhoea, 2 for enuresis, 1 for epilepsy and 1 for rheumatism. The necessity for medical inspection is very pressing in the case of children going upon school journeys, as the danger of a party being upset by the outbreak of infectious disease in a strange place is always to be borne in mind. Several children with tonsilitis and other preliminary symptoms of infectious disease were detected by the medical officers. In the case of a party from a "hard of hearing" school, one child fell ill upon the journey and unfortunately died. It is noteworthy that this child escaped medical inspection and was included in the party without a medical certificate. Not only may the excursions be spoilt by the illness of one or two children, but the expenses of such an illness are rather heavy, and the Government Auditor during the past year drew attention to certain cases. The conclusion was arrived at that the authority should only pay the expenses in those illnesses which the medical officer certified were due to the school journey. This decision is one peculiarly hard to make, but the moral of the experience gained is that it is better to avoid any risk, even at the expense of upsetting the parents, than to take the responsibility of including children in a school journey party who are not in good and able physical health. Day open-air schools. An additional open-air school for non-tuberculous children was opened in the autumn at Aspen House, Brixton Hill, and preparations are being made for a further school of this type overlooking Hampstead Heath. With Aspen House, the open-air schools in London for non-tuberculous children number five at present, the others being Stowey House on Clapham Common, Birley House at Forest Hill, Shrewsbury House at Shooters Hill and Bow Road in the East End. 130 Stowey House. Much interest has been evinced in the experimental attempt to exploit the healing powers of ultra-violet rays of natural sunlight at the Stowey House Open-air School, and the following reports were made by the officers concerned:— (a) Report by head master.—The experience gained during the years 1923 and 1924, when elder lads from the senior school were chosen to undergo treatment in the sun class, encouraged me to attempt treatment in 1925 with boys chosen from the junior school. The smallest and youngest lads were selected by the school medical officer. The majority of these were suffering from the ill-effects of exposure during air-raids in shelters and under railway arches. They were debilitated owing to improper and irregular feeding and were generally of that poor anaemic type for which the open-air school was instituted. They appeared languid and unheeding —actually taking no interest in anything happening around. Somewhat indolent and careless in any work they had to do. A mental test gave extremely bad results. They were nervy and neurotic. Early in May, 1925, after consultation with the parents of the children chosen, the class started with 34 boys and continued until 30th October without a break. The senior girls in their needlework lessons made 34 pairs of slips from orange yellow casement cloth, and into these the boys changed each morning, wearing socks and shoes. Miss Green, the class teacher, in her accompanying report gives details of the procedure adopted. A mental test in October proved the children to have become much more mentally alert as a result of the treatment. The school medical officer's report will give the medical results, which are also highly satisfactory. The vitality of the children increased amazingly, and from listless indolent lads they became keenly observant, energetic, mischievous youths. On occasions it was difficult to suppress them. All desired to talk at the same time, to tell of what work they were doing, and all eager to go on with their sun treatment. Visitors who saw the class during the summer expressed amazement at the condition of the children, and were delighted with the keenness they put into their occupations, whether manual or otherwise. I am so satisfied with the results that I propose next year to make accommodation at the outh end of the garden where the younger girls can undertake a course of sun treatment. It will be necessary to segregate this class, and during the winter months the gardening classes are preparing this portion of the grounds by building a protective bank and planting shrubs to form a solarium. (b) Report by class teacher—General.—The sun class for junior boys started on 12th May and ended, as regards outdoor clothing, on 30th October. During the first month the boys gradually exposed their limbs, chest and back, and by the fourth week nothing was being worn but very short shorts, sun hats, socks and shoes. Particular attention was paid to the reddening or browning of the skin, the boys frequently changing their positions in order to obtain full benefit from sun and air. During above period on 47 days shorts were worn and boys were out all day fully exposed. On 24 days partial clothing was worn, and children were out working part of the day. For the remainder of the period, rain kept the children in the sheds, but all clothes were loosened. All boys were given perfect liberty to wear their shirts for a short period if ever they felt cold, but this rarely happened. Work.—The ordinary school time table was carried out, but taken in a more practical manner than otherwise would have been done. Each child was provided with its own chair and table which were easily carried from the sheds. Special exercise books were made from pastel tinted paper by the boys to avoid sun glare. Nature study and drawing received special attention, as the facilities for these subjects were great. 131 Mornings were given over to these and kindred subjects, while the afternoons were spent in manual work, gardening, and handwork. Gardening was the favourite with the boys, and a large plot was cleared of thistles and weeds. Plots were formed, and the children formed little gangs under their own chosen leaders, and keen competition was shown in digging and trenching. Weather observations formed a special feature of the work. A sunshine recorder was made with a globe of water—a barometer with another bottle of water. Sundial, rain, direction of wind, appearance of sky, etc., were noted and records kept by children, who were changed weekly. These daily records were compared with official newspaper readings. Breathing exercises were taken at regular intervals, while singing and singing games formed part of every morning's work. A certain amount of laxity was allowed in regard to the working of the time table, an occasional game, song or march obviating all danger of chill, while the passing of aeroplanes, flights of birds, and later, showers of leaves, gave additional stimuli to the interest of the children. Effect on children.—At the start the children were inclined to be listless. Their entrance examination showed very poor results, and in many ways they were extremely weak. A great improvement in energy, vitality and powers of observation is now seen in every child, and it has been difficult in some cases to restrain the children's activities. The results of the October examination, though not up to a desired standard yet show an increased mental improvement. The children now are bright, eager and alert. Attendance.—The attendance throughout the period has been extremely good. The children have been regular and the average weekly percentage of attendance, 15th May to 30th October, has been 90.1. (c) Report by school doctor.—-The class consisted of 30 of the youngest boys in the school, all but two being between 8 and 10 years of age. The class started on 12th May and ended on 30th October, the boys being out on 71 days. With three exceptions the boys were all suffering from anaemia, malnutrition or enlarged glands, in many cases from all three conditions. The three exceptions were one of fibrosis of lung, an old empyema and an old rickets with doubtful lung condition, these three all improved considerably in general condition. Great improvement was noted in all but three, both in physical condition and most markedly in the general increase in vivacity and mental alertness, and browning was most satisfactory. The three exceptions were boys with all three defects—anæmia, malnutrition and enlarged glands, they browned very slightly, and although two of them improved in colour there was little or no change otherwise. As has been noted before in connection with the sun class in practically every case anaemia disappeared, in many cases there was considerable improvement in nutrition and in a few cases the glandular enlargement was lessened. All gained in weight except one boy who remained stationary. Weight Minimum gain Kg. 0.6 Maximum Kg. .34 Average Kg. 1.6 Height „ „ Cm. 0.5 „ Cm. 2.5 „ Cm. 1.7 Expansion „ „ Cm. 0.5 „ Cm. 2.0 „ Cm. 1.0 6 stationary. Shooter's Hill School occupies a very exposed position, and the following record Shooter's by the Head Teacher, Mr. Broughton, of the school during wintry weather is of great interest:— The school was opened nearly 18 years ago and has functioned through 15 132 winters, but none have been so difficult as the present one. The changeable character of our climate has usually provided short spells of alternating bad and good weather which have given corresponding periods of strain and relaxation for both staff and scholars. During this winter days of relief have been rare. Parents have allowed the boys and girls to attend sometimes, only because the children have pleaded so hard to come, and several times we have had to send scholars home since they were unfit to remain. October was a very wet month; of 24 school days 10 could be described as really wet during school hours and the total rainfall was 2.07 inches (school days only). Except that more time than usual was spent in the classrooms, the work of the school went on quite normally. But if October's weather was bad, that of November was worse. The 3rd was a very wet day and, owing to continuous heavy rain, I had an early lunch brought over to the classrooms and delayed dinner in order to comply with the regulations for a double session, and, at the same time, save a journey between the school and the dining shed. Several showery days were followed by frost which began on November 9th and continued till December 5th. There was snow on November 10th and 27th, and conditions were so bad that I closed the school for the morning of Saturday, November 28th. In addition to frost, December 4th was noteworthy for persistent fog even at the top of Shooter's Hill. We found that with extra food and exercise we can make the children warm during the mornings, and, wrapped in blankets, can do some effective work. Later in the day their vitality is much lower and they do not appear to have the energy for vigorous exercise, consequently they begin to suffer from the cold during the afternoons. The last days of the term were both wet and cold. On the 21st we were marooned in the dining sheds owing to heavy rain which began during dinner-time. After a short period of rest we had reciting and music with the aid of the school gramophone, thus passing the time tolerably well until the rain ceased, when tea was served and the school dismissed. The new term opened in fog and the mild holiday weather gave place to renewed cold. On January 14th, the temperature in the classrooms was only 28 degrees (F.) at 10 a.m., while the minimum temperature under cover during the night showed 11 degrees of frost. January 15th gave us 4 inches of snow. To add to our discomfort, the freezing of water in the meter deprived us of the gas cookers and we were faced with a new problem. With the help of friends and neighbours, however, we managed to keep going until the meter could be cleared again, though the regularity of meal times was broken. We had double sessions on 14th and 15th, and the school was closed on Saturday, January 16th. A further innovation seemed desirable lest the general educational progress should be less than usual—we offered to set and mark home lessons. Although the work was quite optional, practically every child in the school has taken advantage of the opportunity, and, in addition, they have provided their own stationery for the purpose. On January 18th the snow began to thaw but very slowly, although there was sunshine. On the afternoon of that day we gave the older children the choice of remaining under cover or going outside for the "Rest" period. About half preferred to go outside and there was room for them on the wooden slats which were clear of snow and quite dry. I took charge myself as I was anxious to watch the experiment. It was evident that every child was comfortable and they slept soundly though all round was white with snow. At the end of the period the children were still warm. It was a striking demonstration of the value of sunshine and shelter from wind. Since January 18th we have had alternating frost and thaw resulting in bad ground conditions. The experiences make clear that deciduous trees are of little use as wind-breaks during winter, and we must rely on walls or high evergreen hedges for the shelter 133 we need. In the arrangement of buildings it is very important that attention should be paid to their use as wind-breaks; first and foremost from northerly winds; but fortunate is the school which is provided with many nooks and corners, each big enough for a class, so that teachers may choose a sheltered spot whatever the direction of the wind. It would be a tremendous advantage also to have well-made paths and a small area provided with a hard surface for drill and games. We have had classroom fires on 21 days. They look bright and cheerful, and are useful for drying boots and clothes. Floor heating would be of much greater service. Bow-road. Bow-road Open-air school.—Dr. Argles reports on the Bow-road Open-air School, there has been very little change in the type of child admitted to the school during the past twelve months. Several children have been submitted for examination between the ages of 13 and 14, and in certain of these cases the physical condition has not varied to any extent for some considerable period prior to admission. It is a pity that these children were not brought forward earlier as much valuable time has been lost especially in those cases where the parents do not wish them to remain in school after the age of 14 years. In a number of cases it has been ascertained that the children, before admission, were hardly ever in school, and that since coming to the open-air school their attendance has been regular. I give below a few particulars of such cases:— (1) C.P.—Admitted in June, 1924, with a history of having been in a sanatorium for five years—anæmia, poor nutrition, enlarged cervical glands, cough. Discharged December, 1925, much improved, no cough, nutrition average. Has attended regularly except for an absence due to scabies. (2) J.W.—Admitted August, 1922, weight 23.4 kgms., at age 10½. Had not attended school for about five and a half years, well nourished, glands in neck palpable, old signs of T.B. at right apex, anaemia, rickety chest. Report September, 1925, heart and lungs nil, glands palpable, anaemia much improved, weight 29 kgms., regular attendance. (3) B.P.—The school captain. In four different sanatoria prior to admission in January, 1924, weight 32 kgms., anæmia, poor nutrition, enlarged glands in the neck, now weight is 47 kgms. Boy is never away, very active and intelligent, rather thin, eats and sleeps well, no physical signs in lungs. (4) S.W.—This girl is the outstanding case of the year. Prior to admission in January, 1922, she had been out of school for four years, weight 34 kgms., thin and pale, a pulmonary murmur. She started to improve and has done so ever since, and is now discharged as "fit," weight 45 kgms. Since my last report the catering has been taken out of the hands of the contractor and is now done at the school. The dietary has been carefully considered from the points of view of variation and monotony. A child never knows for certain what it is going to get for dinner, and I regard this as a point of considerable value. It would appear that the change of organisation has been for the good when a comparison is made of the average increase in weight in the periods September-December in 1924 and 1925. No attempt has been made to select the cases, which are of all ages. Girls— Average increase September-December, 1924, equals 1.43 kgms. Average increase September-December, 1925, equals 2.02 kgms. Boys— Average increase September-December, 1924, equals 1.56 kgms. Average increase September-December, 1925, equals 1.97 kgms. The percentage of attendance for the year is 76—an increase of 3 per cent. over last year, and owing to the fine summer, meals were taken out on two hundred and twenty-three days and mid-day rest on one hundred and seventeen. 134 Discharges for the year are as follows:— Discharged "fit" at age 14 21 Discharged below age of 14 and at parents' request Nil Discharged by A.M.O. as fit to return to E.S., therefore under 14 26 Removed, over 14 years, but not marked as "fit" 20 It has not been found necessary to return any child to elementary school as physically unfit for the open-air schools' curriculum, but one boy, it is anticipated, will be transferred to M.D. school. The number of minor ailments treated at the school during the year is 686. Personal hygiene.—Out of 5,636 examinations, only 58 cases were found to have nits. These occurred mostly after the holiday period. It will be seen from these remarks that in spite of the unpromising locality the school is a great benefit to the children of East London. Residential open-air, schools. The institutions available for London children who require a stay in the country for a short time on health grounds in a convalescent school number four. They remain open throughout the year. Boys are sent to the King's Canadian Camp School, Bushy Park (where there is accommodation for 300 boys) for a month's stay. Provision is made for extension of stay in exceptional cases. For girls there are three smaller schools—viz., Wanstead House at Margate, Barham House at St. Leonards-on-Sea, and the Russell-Cotes Home at Parkstone. The girls remain for 6 weeks, with the exception that at Barham House the normal stay is four weeks. King's Canadian Camp School. At the King's Canadian School 3,325 boys passed the roll during the year. A feature of the school is the arrangement for special attention to defects. A wellequipped dental centre presented by the Canadian Government affords an opportunity of putting the mouths of all the boys in a complete state of health during their stay. Special remedial exercises are practised and the boys instructed during their stay to persevere with the exercises after their return home. 1,501 boys were given special exercises, these including cases of kyphosis 246, scoliosis 54, lordosis 52, flat fleet 237, mouth breathers 76, deformed chest 26, wryneck 3, old infantile paralysis 6, postural defects 672, round shoulders 123, massage after fractures 6. Dr. Sidney Lee reports: I am glad to say there has been very little sickness among the children at this school during the past year, and I speak with great satisfaction of the general improvement in health and physique of the boys, considering the short term of their stay—a month to six weeks. It is particularly noticeable in the case of children coming from crowded districts. Every opportunity is utilised for healthy exercise on scientific lines, care being given to those requiring such special medical treatment as massage and remedial exercises. Other defects, such as children are liable to (sores, slight injuries and minor ailments) are treated immediately. The special treatment of unhealthy gums and other dental defects contributes largely towards the general health. On the whole I think they are a happy contented crowd of children, but it is unfortunate that there can be so few "extensions," and that in particularly suitable cases only a fortnight longer is granted. The average gain in weight is 3 lbs., and height half an inch per child, with a distinctly better tone all round. I should like to advocate a stay of twelve consecutive weeks in the case of particularly needy children, especially when they are of school-leaving age, and no other such opportunity can be given them. Wanstead House. Wanstead House, Residential School, Margate.—Dr. McCombe, the Medical Officer of Health of Margate, reports that this school has well maintained its usual excellent bill of health throughout the year ended December 31st, 1025. Out of 535 children admitted in the year the following is a list of the cases which received medical treatment. 135 During January we had 17 children with influenza, it was quite of a mild type and it was only necessary to keep the children in bed for a few days. The whole class of 32 children were detained one week longer than the usual time. We had a few cases of tonsilitis, which was also of a mild type. None of the children contracted an infectious disease such as measles, chicken-pox, etc., which is rather remarkable and speaks very highly for the care which is taken in selecting them before being sent down. The average gain in weight equalled 4 lbs. 7 oz., the highest individual gain being 12 lbs. 12 oz. Naturally we think that Margate has no rival as a health resort for children, and the results obtained at Wanstead House fully justify the idea. Wanstead House itself occupies an excellent position in the best part of the town, standing high on the Eastern Esplanade. All the children's quarters—diningroom, play room and dormitories—are large airy rooms, possessing two sets of windows; those on the north side facing the sea and scarcely a stone's throw away. The others on the South Side admitting a large amount of sunshine. These windows are open day and night all the year round, thus ensuring a constant supply of pure air. During last summer the children enjoyed far greater facilities for bathing and paddling than ever before, owing to private use of a new bathing hut erected by the L.C.C. on the sandy beach at the Palm Bay end of the town. Personally, I think a six weeks' visit all too short, especially as the first week is more or less wasted, on account of the unsettling influence of new routine and altogether strange environment. Our weaklings must have their chance and there are sufficient data to show that the Residential Open-Air School is no longer a luxury but a necessity. Barham House. Barham House.—Dr. F. C. Lewis reports that the total number of children visiting the school during the year was 355—i.e., 291 girls and 64 boys. In all, twelve schools contributed a quota. The first batch did not leave until the latter end of May, owing to the school being closed prior to that for building alterations. The only party of boys (from Hamond Square School) left London in August, by which time accommodation was available at the school for 64. As a result of the four weeks' stay, the majority of the children showed a marked improvement in physical condition, especially so during the summer months, when it was possible to bathe daily. That the Camp School is appreciated is shown by the number of children who are desirous of going a second time. In the case of Hamond Square School, there are children, who have been yearly for three years, but this will not be possible in future as the contributory schools are to be drawn from a wider area. There is some difficulty in getting parents to send children in the early part of the year, but I am sure that the stay at the camp school is of great benefit to the children going there. In the case of the really "air hungry" children of Hoxton, the month passed in airy rooms with regular meals and enforced personal cleanliness makes a wonderful improvement and, one hopes, teaches habits of personal hygiene which cannot well be learnt in an elementary day school. RussellCotes Home. The Russell-Cotes Home at Parhstone.—The Russell-Cotes Home is maintained by the Shaftesbury Society. The Council sends 30 girls for a six weeks' stay at the home all the year round. As soon as the children arrive they are weighed and measured, inspected by the doctor, and if necessary ordered special treatment, seen by the dentist and then graded for school work. The children are weighed fortnightly. The school doctor states that all the children have benefited by their stay, but the improvement is more marked in summer than in winter. After the first 14 days the change in the physical condition is very marked. The advantages of a regular and nutritious diet are shown in the increased weights. 136 Dr. Nicol has formed the opinion that a twelve-weeks' stay would be more satisfactory to the children and staff. Physical Training. The three years' programme included the formation of 100 "health classes" in the schools. These classes are composed of children selected by the school doctor for various incipient deformities, including postural curvature of the spine, flat feet, and defective expansion of the chest. An experienced teacher takes the children for special physical exercises daily, and the class is supervised by the school doctor and the organiser of physical education. 84 classes were organised during 1925, and it is hoped that the total of 100 will be reached early in 1926. Reports from the school doctors testify to the great advantages arising from this preventive work. Two of the reports, that of Dr. E. K. Macdonald on the Gideon Road class and Dr. C. E. Thornton on the Smallwood Road class, are appended as illustrations of the excellent results obtained. Report on the Health (Remedial Exercises) Class of Gideon Road School (G.), Battersea S., for 1925.—This class is held daily during term time for 15-20 minutes, and during 1925, 22 girls have attended for varying periods. Of these, 13 have been in the class for at least twelve months, and these all show satisfactory improvement with the exception of two especially noted below. All 13 gained in weight, the average for two months being 4.08 kgs.; 12 gained in height, average being 5.4 cms.; all increased the total chest measurement figures by in. to 2 in. increase; 8 increased the chest expansion figures, 3 remained stationary, and the remaining 2 lost ¼ in. in their expansion. General improvement in stature, in the condition of enlarged glands, and in the various forms of curvature was considerable. Of the two children noted above, one has still definite anaemia and slight scoliosis; her general condition is not good, and although she has been recommended to go to Bournemouth on several occasions, this has not yet been possible. The other is a very tall kyphotic girl who has been attending St. Thomas's Hospital for her back for a long time. Five other children have attended the class for periods varying from five to nine months; all show an increase in weight, the average being 1.8 kgs., four out of the five have gained an average of 1.4 cms. in height; three show definite improvement in their scoliosis; one is under observation with choreic movements, and the last of these five does not show much improvement in her scoliosis, but the condition of her lungs has improved. Of the remaining four children, two have left to go to an open-air school, and two were discharged as sufficiently improved. Remedial Exercise Class (G. Dept.), Smallwood Road.—The results obtained in connection with this class continue very satisfactory, and one must again pay tribute to the class teacher (Miss Tayer), to whose efforts these results are entirely due. From the appended table it will be seen that the defects are of the usual types, kyphosis predominating Defects. No. Discharged cured. Continuing. Left. Improved. No change. Kyphosis 22 13 1 1 1 Scoliosis 10 3 6 — 1 Kypho-Scoliosis 4 3 1 — — Flat Feet 1 — 1 — — Totals 37 19 15 1 2 137 Organised games form an important part of the Council's scheme for physical education. The following table, taken from a report by the Education Officer, shows the number of hours' play available each week during 1925:— Number of hours' play available in organised games:— Council's parks and open spaces. Sites under control of Education Committee. Royal parks, Borough Councils' sites, etc. Total number of hours' play each week. Cricket 3,618 184 440 4,242 Football 2,725 138 368 3,231 Netball 1,830 49 277 2,156 Rounders 1,942 20 — 1,962 Hockey 28 — — 28 The figures in the foregoing table refer only to the accommodation available for organised games during school time. The Education Officer reports that assuming that it were possible to use all the pitches for the whole time they are at the disposal of the schools, 93,324 boys could play a game of cricket for an hour a week during school time. Similarly, 71,082 boys could play a game of football for one hour a week. Unfortunately, however, the distribution of the pitches is not that of the schools and in the central areas of London the provision is quite inadequate. The organiser of physical education (Major A. H. A. Gem) in his report to the Education Committee in 1925, points out that the Committee requires that three periods a week, each of 20 minutes, shall be devoted to syllabus work in physical exercises. Where a boy gets a games period and a visit to the baths in addition, the time devoted to physical education would appear as adequate; but, generally speaking, games and swimming only affect the top classes of the school, and the lower classes only get three periods of 20 minutes, which is really inadequate. Major Gem suggests that, as the allowance of the Board is a maximum of 125 minutes, or in congested areas 140 minutes a week, the Council might usefully consider extending the period for physical exercises in the case of those not taking swimming and games. The Council recently made a free issue of a kit sack, containing 4 footballs, 12 small rubber balls, 32 yards of rope and 4 sets of team colours for all schools. The number of boys taught to swim between April, 1924, and March, 1925. was 24,129. Major Gem refers to Games and Athletics Outside School Hours: "London boys owe a tremendous debt of gratitude to those teachers who give up so much of their own time to foster and organise sports and games. It should always be remembered that the inter-school matches, district meetings, etc., represent only a very small part of this work. Before such things can be attempted there is much solid coaching to be done. It should also be realised that this work is, in the main, borne by the few. A school is fortunate if three or four members of the staff interest themselves in out-of-school games; in many cases there is only one such teacher who, winter and summer, gives his own time to the work. Such reap their reward in the affection and loyalty of the boys for whom they work, and they have the consciousness of doing most valuable work, not only for the health, but also for the character of their boys." A sign of the times is the fact that girls in the elementary schools are taking more and more part in athletic contests and athletic sports. At swimming galas in London during 1925 there were 11,500 competitors amongst the elementary school children of whom possibly 4,000 were girls. While strenuous exercise is an essential stimulus to development, care must be taken that artificial exercise is not too severe. Special care should be taken to avoid prolonged maximum exertion. There is a great difference between the physiological condition of the child up to the age of puberty and the child after this period. 138 The question arises whether in these unofficial or semi-official contests out of school the need for care in this respect has been sufficiently in the minds of the organisers. The case of a girl of 13 who died in a swimming race at a west London school gala in the autumn led to this question being carefully considered. A questionnaire was sent to the school doctors asking for their experience in regard to the participation of girls in athletic sports. In their replies specific instances were reported in which there was evidence of heart strain or dilatation, as the result of engaging in athletic contests, particularly swimming. Healthy games and recreations are a necessity for school children, and the community owes a debt of gratitude to those teachers who expend so much of their time in encouraging and organising opportunities for sports. It is to be hoped that nothing here said will tend to damage the ardour and enthusiasm which is voluntarily expended. But it is felt that careful consideration should be given to the selection of children to take part, and that tasks set should be adjusted to the capacities of the children according to age and sex in the cases where the competitive element enters between child and child and school and school. As a result of their attention being drawn to the question the Executive of the London Schools' Swimming Association have drawn up the following rules as safeguards, and if adopted generally these should reduce danger to the minimum in the case of swimming contests:— (1) That the attention of children be drawn to the grave danger incurred in partaking of any food either solid or liquid immediately before a competition. (2) That before entering a child for competition the medical card be consulted. If there is any suggestion of heart trouble there should be further medical examination. (3) That arrangements be made for a doctor to be present at all swimming competitions, a fee being paid if necessary. (4) That an addition be made to the entry form for the annual competitions by which teachers entering children guarantee that they are able to swim the distance for which they are entered. (5) That no child be allowed to compete in more than one ind vidual swimming championship. (6) That the bath for the annual competition be not more than 33½ yards long. School Meals. The number of school dinners provided from January to December, 1925, was 653,395, the number of milk meals was 1,236,466, and the number of cod liver oil "meals" 179,363. Milk or oil meals in school are always given on the advice of the school doctor, who keeps the children under observation. They are weighed regularly by the school nurses. The feeding centres where dinners are supplied to necessitous children are visited regularly by the school doctors who satisfy themselves as to the palatableness and suitability of the meals; at the same time samples are taken of the meals, which are analysed in the chemical laboratory in order that the nutritional value of the meals can be scientifically estimated. Supervision of dietaries. The systematic examination of samples of milk supplied to necessitous and other children has been continued during the year. The total number of samples analysed was 1,500. Of this number 176 (11.7 per cent.) were found to be "unsatisfactory": 111 (7.4 percent.) containing added water and 65 (4.3 per cent.) showing a deficiency of fat. The maximum addition of water in any one sample was 27 per cent., whilst the greatest abstraction of fat was 59 per cent. Appropriate action was taken in all cases. 139 In connection with the provision of meals at Feeding Centres, 31 meals were submitted to examination in the Council's Central Laboratory, and when necessary attention was drawn to the need that existed for an increase in the nourishing and heat-giving constituents. Personal Hygiene. The number of examinations made at rota visits during 1925, by the school nurses, was 1,937,588 ; verminous conditions were present in 323.020 instances, or 16.6 per cent., as compared with 16.1 per cent. in 1924, and 18.1 per cent. in 1923. The results of the work under the Cleansing Scheme, for the last five years are:— Year. Examinations at rota visits. Verminous conditions noted at rota visits. Per cent. Verminous children referred to centres. Subsequently cleansed by parents. Verminous children cleansed at centres. Scabies cases bathed at centres. 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,£01 371,790 18.1 79,702 26,469 53,233 2,935 1924 2,059,590 332,695 16.1 74,643 22,012 52,631 2,155 1925 1.937,588 323,020 16.6 88.859 27,647 61,212 2,077 In addition to these figures, the numbers dealt with at the head cleansing centres during the past five years, were 13,586 (1921), 24,637 (1922), 24,516 (1923), 23,986 (1924), and 23,947 (1925). A slight decrease is recorded in the number of examinations made. Considerable calls were made upon the time of the school nurses in connection with the control of infectious diseases in the schools, with consequent disturbance to the rota work. The tendency of this disturbance was to postpone visits to the cleaner schools whilst endeavouring to maintain those at the less clean schools; this tendency would, possibly, explain the very slight apparent increase in the percentage of verminous conditions noted, as the results at the worst schools were not diluted to the normal extent by those at the better schools. It should be explained that rota visits are those on which all children in the departments are inspected; subsequent visits in which absentees and special cases are seen, not being counted in the above figures. All cases of verminous infestation are noted under the headings of (a) verminous heads only, (b) nits only, (c) verminous bodies and/or clothing, the last named group including those cases which show signs of flea bites. Of the total number of verminous conditions noted in 1925, i.e., 323,020, no less than 209,666 were noted as infested with nits only. For a child to be passed as "clean" there must be no sign whatever of verminous infestation. Treatment of scabies. The number of children suffering from scabies continue to decline, being 2,077 in 1925, as compared with nearly 10,000 in 1920. It was in 1920 that Dr. Louis Parkes, Medical Officer of Health for Chelsea, drew the attention of the School Medical Officer to an article in the "Lancet" of the 18th December, 1920, by Dr. Svend Lomholt, M.D., on the "Danish Treatment of Scabies," in which it was stated that one single inunction of an ointment composed by Mr. Marcussen, of Copenhagen, sufficed to cure scabies. Dr. Lomholt gave the detailed technique of this ointment, and the preparation has since been used with satisfactory results in some of the cleansing centres in London. The Council can, however, only undertake the treatment of school children, and there is always the possibility of re-infection where adult members of the family are similarly afflicted. In this connection it is interesting to record that Dr. Lomholt states that:— "The greatest advantage of the treatment is probably the fact that it is very suitable for ambulatory use. Under these circumstances the patient has to rub himself just before going to bed. In the morning he can wash his hands and carry out his daily work. The next evening he must give his hands a new treatment, and take a final bath on the following morning." 140 There are now 18 sanitary authorities with whom the Council has agreements respecting the cleansing of verminous children, and in addition, there are seven centres organised by voluntary committees for head cleansing work. These, with the Council's own 10 centres, make a total of 35 centres, which are available for the cleansing of school children throughout London. Whilst in 1925 no new stations were opened or made available for children, extensions to existing facilities were provided at the stations of the Deptford, Chelsea and Hammersmith Borough Councils, and the Council's own centre at Trafalgar-square School (Stepney), but the head cleansing centre at Hammersmith, organised by a voluntary committee, ceased work at the end of March. Cleansing scheme. Under the Council's cleansing scheme, there were, in 1925, 88,859 verminous children, whose condition was brought to the notice of the parents by means of advice cards, and who were referred to the cleansing centres for following up. Of this number, 40,134 attended voluntarily at the various centres for cleansing, but in 24,558 cases it was necessary to serve, after a further re-examination, statutory notices in accordance with Section 87 of the Education Act, 1921. Following upon these notices, 6,017 children attended the centres voluntarily for cleansing, but of the remainder, 15,061 were found verminous after a still further examination, and were taken compulsorily by the nurses for cleansing. Among the latter, 810 were subsequently found to have relapsed, and police-court proceedings were instituted in 689 of these cases. It is convenient here to give a brief outline of the machinery of the Cleansing Scheme. Each district school nurse has under her charge a group of from 7 to 15 adjacent schools. Each school is visited in accordance with a rota prepared each term, all children are inspected, and in appropriate cases advice cards are forwarded to the parents. In the more severe cases, the facilities provided for cleansing at the various centres are brought to the notice of the parents, and all such cases are referred to the nurse working at the bathing centre. The latter nurse visits the schools, re-examines all the cases which have been referred to her by the school nurse, and where the condition justifies it she communicates with the attendance branch, which arranges through the attendance officer for the service personally on the parents of a statutory notice, as provided by the Education Act. This notice again draws the attention of the parent to the facilities provided by the Council at the various centres for cleansing, but a warning is also given that failure to observe properly the directions as to cleansing may lead to the child being taken to the centre and cleansed as a compulsory matter. Police Court proceedings against parents are only instigated where a child is found to have relapsed to a verminous condition after having been compulsorily cleansed. It is the practice of the nurses to ascertain whether there are any extenuating home circumstances before asking for the institution of court prosecutions; in many cases, indeed the parents concerned are invited to the centres to discuss the matter with them. Children taken for compulsory cleansing are taken either "by hand" in the care of a nurse, or by means of motor conveyances. The advantage of these conveyances is that schools in outlying areas remote from cleansing centres are brought within reach of the centres. During the previous year only one motor conveyance was available capable of holding 20 children, which was seldom used to its full capacity. At the early part of 1925, two vehicles were substituted with comparatively slight additional cost, and with the advantage of greater flexibility in the arrangements ; the number of children conveyed by motor conveyance in 1925 was 7,865, as compared with 4,531 in 1924. 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 General Powers Act 1922. During 1924, 141 reports were received in regard to 1,949 homes visited; out of this number disinfestation or destruction of bedding or disinfestation of homes was carried out in 755 instances. In the remaining 1,194 instances, although disinfestation or destruction of bedding was not needed, in many cases advice was given to the parents by the health visitors. In 1924, the corresponding figures were 2,282 homes visited, action taken in 819 cases. Methods ot cleansing. On all advice cards and statutory notices referred to above information is given for the benefit of parents as to the methods for eradicating the mischief. Paraffin is advised for the killing of actual vermin, and a mixture of borax and soft soap is recommended as a shampoo. It is found that this latter preparation loosens the cement with which nits are attached to the hair, and if followed after a few minutes by the use of a special metal comb, the nits will slide off the hair. With body cases, the treatment is, however, more complicated, and resort must usually be had to the cleansing centres where baths and sterilisers, the latter for disinfestation of clothing, are available. At the centres themselves, however, paraffin alone is seldom used for a verminous head. Instead, a mixture made up of 5 per cent. wood tar oil, 20 per cent. cotton seed oil, 74 per cent. paraffin oil and 1 per cent. oil of lemon grass is used. This preparation is well rubbed into the scalp, and after a few minutes the hair is combed by the attendant, with a metal toothed comb. After this process nits are dealt with by the borax and soft soap mixture already referred to. In the more serious cases the child is bathed, the clothes meanwhile receiving treatment in a steriliser. Head cleansing. Whilst the Cleansing Scheme proper is carried out in conjunction with centres where baths and sterilisers are installed, the Council has made arrangements with seven voluntary committees for the cleansing of children suffering from slight verminous infestation, i.e., those cases in which some difficulty would be experienced in inducing parents to attend at an ordinary cleansing centre. Most of these voluntary committees were able to make use of one or two otherwise vacant rooms on the premises where they were already undertaking the medical treatment of school children under the Council's Medical Treatment Scheme. One, two, or three basins with hot and cold water sprays were installed, the Council making a grant towards the initial cost of equipment and adaptation. A modified form of advice is issued to the parents of children found to be but slightly infested, and the parents are invited to accompany the children to the centres to see the actual process of cleansing, and in order to secure their co-operation in the matter. This scheme has worked very smoothly. Use of public washing facilities by school children. Reference was made in the last annual report to negotiations which were on foot to extend to other boroughs the arrangements whereby parties of children were taken, under the charge of school nurses, during school hours to the public washing baths in Camberwell and Kensington. During the year 1925, the borough councils of Lambeth, Stepney and Shoreditch agreed to the provision of the necessary facilities, and the numbers of baths given during the year at the public washing baths of these boroughs under this scheme were—Camberwell, 4,043; Kensington, 7,060; Lambeth, 1,685; Shoreditch, 2,294; Stepney, 2,073. The teachers in the schools contributing to the scheme have warmly welcomed the scheme, not only on account of its direct results, but also for its effect upon the children in inculcating a desire for cleanliness which survives after the children have left school. That the scheme is appreciated by the children is shown by the following extract from a letter received from the head master of a school in Lambeth:— "The scheme of bathing for school children has been very successful. The boys who have attended the baths have derived great benefit, and the institution is extremely popular, more boys desiring to go than for whom there is accommodation." 13651 K 142 Co-operation of Parents, Teachers, School Attendance Officers and Voluntary Bodies. Apart from a relatively small minority of parents who stand aloof, the parents show a great and growing interest in the physical welfare of their children and in the arrangements made for their physical care. In 64 per cent. of all examinations a parent was present with the doctor. At the examination of leaving boys, however, only 29 per cent. of mothers attended, whereas in the case of the leaving girls 43 per cent. of mothers were present. This is, however, not due to want of interest on the part of the parents, but is due to the fact that the leaving boy hates to be thought to be tied to his mother's apron-strings. In the case of entrants, no less than 87 per cent. of mothers attended equally in the case of boy and girl infants. Refusals to submit children to routine inspection were encountered in only 149 instances during the year, fifteen refusals were withdrawn upon further explanation, and in 13 cases the official schedule was filled in by a private practitioner or a medical certificate produced. The Teaching Staff as a whole gives enthusiastic support to the School Medical Service. It has been pointed out repeatedly by the medical officers that the results of following-up at a particular school will largely depend upon the attitude of the head teacher and the time he or she is able to devote to co-operation. The teachers notify immediately to the School Medical Officer and to the local Medical Officer of Health every case of infectious disease or suspected infectious disease amongst their pupils. They also issue the invitations to the parents to attend medical and dental inspections. Many teachers go far beyond the nominal duties in their devotion to the care of the children. In a large number of instances they act as the secretary of the school care committee, and many arrange for lantern lectures and talks to the parents upon such conditions as dental caries and physical development. The attendance officers devote a large part of their time to assisting in the work. Without them it is safe to say that important sections of children's care would cease to function at all. During the annual scheduling they note the existence of all crippled and defective children under school age; these are reported to the School Medical Officer and placed under the supervision of the Invalid Children's Aid Association. The attendance officers confer with the school medical staff and the care committee organising staff on all children absent from school. Special officers in the attendance branch assist the school care committees in following up difficult cases where medical treatment is urgently required, and it is due to their efforts that the necessary attention is eventually secured. During the prevalence of measles the attendance officers visit absentees in the infants' department, concentrating especially upon those under five and give prompt information to the borough medical officers of all children found to be suffering, in this way enabling home nursing to be provided, and contributing largely to the reduction of mortality. The attendance officers also deliver the statutory notices under the Children's Act in all cases where it is necessary to proceed on account of verminous conditions and neglect of personal cleanliness. The part played by the officers of the attendance department in all these activities cannot be too highly praised and they share to a very large extent the credit for the improvement in the children's condition which has taken place. The London system has always, broadly speaking, been based fundamentally upon the principle of co-operation with voluntary bodies working in the field of children's care. There are over one thousand school care committees, consisting of voluntary workers giving their time and enthusiasm to the care of school children. They are united in 27 local associations and are guided and directed by a staff of organisers who are skilled social experts. 143 The care committee's representative attends medical inspection, interviews the parents, applies for vouchers for medical treatment, follows up the individual children, ensures regular attendance at the treatment centres, and sees that the recommendations of the doctor are carried out in the homes. The school care committees decide whether the charge for medical treatment should be remitted in appropriate cases, and also decide whether children should be placed upon the list for school feeding. In cases of persistent neglect to obtain treatment, the help of the National Society for Prevention of Cruelty to Children is invoked, and if refusal is maintained, the Society takes legal proceedings under Section 12 of the Children's Act. During 1925 there were 675 cases reported to the Society. Many of these children had two or more ailments. They included 345 vision cases, 284 dental cases, and 119 cases of other defects. Many of the treatment centres are provided and managed by the local general practitioners, one of whom gives his services as secretary of the centre. The District Nursing Associations are identified with the school medical service ; they supply the nursing staff at the treatment centres for the treatment of minor ailments and the Council's agreements with them ensure the visiting of children in their homes when necessary. The care committee organisers maintain a close co-operation with the almoners of the general and special voluntary hospitals dealing with school children. One or more organisers are attached to every hospital with which the Council has arrangements under the Treatment Scheme; in addition to this, hospitals outside the scheme have asked for the attachment to their almoner's department of one of the Council's officers, and in this way an extension of children's care has been effected which has been productive of the very best results. Co-operation with Guy's Hospital. The following report has been received of the work done in the hospital during the year, among the school children, in connection with the Children's Care Committees of the Council's schools. The three organisers at this hospital see the children in the departments where they work, and, in conjunction with the Care Committees, endeavour to ensure regular attendance, and that the recommendations of the doctors, as to treatment, are carried out. This means considerable correspondence, and visiting of the homes on the part of the care committees, and the result has been most encouraging this year. The arrangements by which the L.C.C. Ambulance calls at the hospital to take home children after tonsils and adenoids operations has been continued this year, and is working well. In the Orthopaedic Department 286 new children attended, and 541 are at present attending hospital at regular intervals for supervision. The children referred for treatment in the Massage Department have also attended well on the whole. The number of new cases which attended in the Skin Department was 1,338. Of these 31 were suffering from scabies, and 57 from ringworm of the head. In the Aural Department, 2,302 new children were seen, and 481 operations for removal of tonsils and of adenoids were done—876 were discharged by the hospital and 366 were reported by the care committee as not returning for treatment. In the Eye Department, 1,665 new children attended, and 941 of these were tested for glasses. Of the 818 for whom glasses were ordered 726 are known to have obtained them. The attendances of children in all departments have, on the whole, been more regular. Many reports for the information of the care committees, and also for the divisional officers, on children attending in other departments of the hospital, have been obtained by the Almoner. These are of great assistance to the care committees in dealing with the child concerned, and to the attendance officers in regard to school attendance. The Almoner's kind co-operation in all matters relating to the care committee work in the hospital has been invaluable. 13651 K 2 144 Co-operation with the tuberculosis service. In order to reduce congestion at the tuberculosis dispensaries and to maintain supervision over children attending school who are contacts with cases of tuberculosis in their homes a system of mutual exchange of information is adopted between the tuberculosis officers and the school medical service. The school children notified by the tuberculosis officers fall into three groups— (1) unsatisfactory cases whether contacts or not, (2) satisfactory contacts, (3) contacts refusing examination. Children in class (1) are weighed monthly by the school nurse and then at intervals by the school doctor; those in class (2) are weighed termly by the school nurse; those in class (3) are seen as soon as possible by the school doctor and referred to classes (1) or (2) for further observation. Conferences are held between the divisional medical officers and the tuberculosis officers at which cases are discussed and discharged when possible. A short account of the work done in supervising tuberculous contacts amongst school children in each division follows:— Eastern Division.—Dr. Chaikin points out that the bulk of the children dealt with are contacts whose own health has not come under question (viz., class (2)), and that about 14 per cent. of children from tuberculous homes refuse examination at the tuberculosis dispensaries; it is in these cases that the school medical service is of special help in following up. In this division 726 children were notified by the tuberculosis officers during the year of whom 168 were unsatisfactory contacts, 463 satisfactory and 95 were contacts refusing examination at the dispensaries. South Western Division.—Dr. Argles reports that 699 cases were dealt with, made up of 212 in class (1) and 487 in class (2). The periodical inspections necessitated 856 special examinations by the school doctors during the year. Not many cases were referred back to the tuberculosis dispensaries but a large number were nominated for attendance at day open-air schools. South Eastern Division.—Dr. Kidner reports the current cases on 31st December, 1925, to be 1,471, discharged during the year 252, referred back to tuberculosis dispensary 8, examinations by school doctors 1,212. North Eastern Division.—Dr. Lewis points out that the periodic examination of tuberculosis contacts has undoubted advantages, as the children are brought to notice more frequently, and this enables them to be recommended for camp schools, for which so many are eminently suitable. The total number of cases under observation in this division was 889; ten were referred back to the tuberculosis officer for further treatment and 88 were referred to him on leaving school before discharge: 598 were discharged from observation after conference with the tuberculosis officer and 203 remained in the scheme. North Western Division.—Dr. Sikes reports that 1,450 children have been kept under observation by the school doctors. Admission examinations. Defective children. The total number of examinations conducted under the Education Act during the year was 26,054—an increase of 890 on 1924. 5,289 admission examinations were held as compared with 5,418 in 1924. 1,997 children (1,053 boys and 944 girls) were deemed suitable to attend elementary schools, 70 (34 boys and 36 girls) schools for the blind, 237 (92 boys and 145 girls) schools for myopes, 127 (53 boys and 74 girls) Swanley, 1,106 (528 boys and 578 girls) physically defective schools, 917 (511 boys and 506 girls) mentally defective school,s 21 (16 boys and 5 girls) open-air schools, 87 (37 boys and 50 girls) schools for the hard-of-hearing, 103 (58 boys and 45 girls) schools for the deaf; 51 (27 boys and 24 girls) were epileptic, 474 (247 boys and 227 girls) invalided from 145 school attendance; 80 (44 boys and 36 girls) deemed to be imbeciles; 4 (2 boys and 2 girls) deemed to be feeble-minded; and 15 (4 boys and 11 girls) idiots. The following statement shows the nature of the conditions found among the children certified suitable for admission to physically defective schools at the admission examinations during the year:— Morbid condition. Boys. Girls. Total. Infantile paralysis 52 45 97 Cerebral paralysis 6 12 18 Various paralyses 38 35 73 Tuberculosis of bones and joints 131 113 244 Congenital deformities 15 7 22 Other deformities 78 66 143 Heart disease— Congenital 22 33 55 Acquired valvular 133 197 330 Acquired non-valvular 20 33 53 Other diseases 33 38 71 528 578 1,106 Examinations were also conducted of 123 cases with a view to ascertaining fitness for education in industrial or reformatory schools. Rota visits to the schools. 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 20,108; in addition, 534 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. As a result of the visits and re-examinations, the following reclassification took place: 256 returned on improvement to elementary schools; 15 were transferred to schools for the deaf and hard of hearing; 16 to schools for the blind and partially blind; 17 from schools for the physically defective to schools for the mentally defective; 2 from schools for the mentally defective to schools for the physically defective; 33 were excluded as imbecile, 64 were invalided on medical grounds; and 506, over 14 years of age, were excluded as no longer certifiable. Residential schools. There are 4 residential industrial schools and 6 residential schools (2 for the blind, 2 for deaf, 1 for defective deaf, and 1 for mentally defective children) with a total accommodation for 826 residential and 222 day scholars. To each institution is allocated a medical officer, and provision has been made for dental inspection and treatment. During the year 669 boys were admitted to Pentonville Road Place of Detention, and 241 girls and infants to Ponton Road. 366 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 following results:— Fit for Central School 4 Fit for Mentally Defective Centre 13 „ „ Elementary School 19 „ „ Physically Defective Centre 1 „ „ „ „ (front row) 88 Imbecile or Idiot ... 4 „ „ Hard of Hearing Centre 82 Invalided 11 „ „ Deaf School (Normal) 87 Advice given 45 „ „ „ „ (Defective) 12 * Including 29 revision cases. *366 In the cases found suitable for special education the cause of deafness has been classified as under: Congenital 35, acquired 119, doubtful 11—total 165. The congenital cases were made up as follows: True hereditary deafness 10, sporadic deaf-birth 23, aphasia 2—total 35. The acquired cases were due to the following causes: Meningitis (various forms) 12, infectious fevers 19, congenital syphilis 5, primary ear diseases (catarrh, suppuration, or results thereof) 79, injuries 4—total 119. 146 The percentage of cases in which deafness may be attributed to congenital syphilis has fallen since 1919:— 1919. 1920. 1921. 1922. 1923. 1924. 1925. 9.1 8.8 8.7 7.3 4.7 5.2 4.2 Advice to parents with hard of hearing children. The success of the education given to hard-of-hearing children depends, in a great measure, on the action of the parents in the home, and, with a view to securing their co-operation, the following pamphlet has been prepared. This pamphlet is circulated to the parents and guardians who bring children to the County Hall for examination, and arrangements have been made whereby copies of the pamphlet are forwarded to the teachers of the hard-of-hearing schools for distribution if, and when, necessary. Your child has been examined and found to be sufficiently Hard of Hearing to require special education at a Partially Deaf School for a time, and he (she) will be admitted to one as soon as possible. If you will read the following explanation you will see how it will materially help in your child's education. The Partially Deaf School is not a Deaf School, but a small class at which special teaching in lip-reading is combined with practice in an ordinary hearing class. Your child will not come into contact with "deaf and dumb" children but only with children of the same degree of deafness as him (her) self. At this Centre the children are merely taught to help their partially deaf ears by using their eyes in lip-reading. Your child will pass one-third of the school time in the special class for lip-reading and the remaining two-thirds in hearing classes. Therefore he (she) will be in contact with hearing children for the greater part of the school day. As soon as he (she) has made sufficient progress in lip-reading and has gained confidence in its use, he (she) will be returned to his (her) own school, where he (she) will be able once more to enter fully into the work there. You are advised to see the teacher frequently to consult on the child's progress and to assist in the education by every means in your power. Scholarships for partially blind and partially deaf pupils. The Council has decided to award scholarships to partially blind and partially deaf pupils who are not able to pass the necessary medical examination for ordinary scholarships. The number of children suitable for such scholarships is not likely to be great. The awards for the partially deaf are tenable at a junior technical school, and a maintenance grant is given to enable a partially blind child to attend suitable day classes whilst learning a trade or training for some definite vocation, provided that the parent take full responsibility for the cost of training and the risks involved thereby. Special scholarships are awarded without written examination to assist pupils from myope schools who have shown evidence of exceptional ability, and who are more suited for a secondary school course than trade training, provided that the parents accept full responsibility for the risks involved in training. It has also been decided that pupils who are successful in the ordinary scholarship examination, but who are disqualified by the School Medical Officer owing to myopia, shall be allowed to hold their awards at certain selected secondary schools where special arrangements for training are obtainable on parallel lines to those that have proved successful in myope or sight-saving classes in the elementary schools. Where the selected school is more than two miles from the pupil's address, an allowance may be made for travelling expenses over and above the ordinary maintenance grant. 147 Children in blind and deaf residential schools whose condition is attributable to venereal disease. The medical records of the children in the Council's residential schools for the blind and deaf have been examined with a view to ascertaining the number of cases whose defect was attributable to venereal disease. The total number of records examined was 298 (100 blind, 198 deaf), and the data obtained were as follows:— Defeet. Venereal disease a reasonably certain antecedent. Venereal disease a possible antecedent- Congenital syphilis. Ophthalmia neonatorum. Congenital syphilis. Ophthalmia neonatorum. Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Blind 9 1 20 4 4 2 1 2 2 Deaf 3 | 1 — — 1 1 — — Blind or deaf children who are also mentally defective. The Association of Directors and Secretaries for Education have been informed in reply to enquiries that the numbers of children (other than imbeciles) who have shown mental deficiency combined with another defect during the past four years are as follows:— Boys. Girls. Total. Mentally defective and epileptic 53 30 83 ,, ,,blind 3 1 4 ,, ,, deaf 26 28 54 „ „ physically defective 85 63 148 Dr. F. C. Shrubsall'n enquiry concerning Mongol* During the year Dr. Shrubsall has collected data concerning mentally defectives of the type known as Mongols. This type was so named from the superficial resemblance of some of the sufferers to certain members of the Northern branches of the Mongolian races of mankind; a resemblance which extends not only to certain facial traits, but to the sitting posture with the legs crossed and the feet resting on the thighs with the soles uppermost. Mongols have small rounded heads, with flattened occiputs and faces, but full foreheads. The nose is usually squat, the palpebral fissures narrow and oblique, and the epicanthic fold is frequently present. Owing to the shortness of the palate from the fold backwards, the tongue appears too large for the mouth, and the papillae are often found to be enlarged; the palate is short but appears high and narrow owing to the thickening of the mucous structures. Ears are small, skin rough, the hands broad, with shortened little fingers and handmarkings of a simple pattern. The circulation is usually poor, and congenital malformations of the heart are not uncommon, while these children are very liable to suffer from catarrhs and adenoids. Mongols are usually placid, good-tempered, fond of listening to music, though most are undoubted imbeciles and capable of but very limited improvement; it is a type in which an unduly optimistic prognosis is popularly given. The subjoined table shows the mental and chronological ages of 322 mongols at the time of their examinations. Mental age. Chronological age. Total. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 1 2 — — — 6 1 1 — 2 — 1 — — — 14 2 1 3 2 1 6 47 23 3 5 2 3 1 _ 1 98 3 — 1 1 47 36 25 6 12 8 3 5 2 2 148 4 1 4 6 6 4 7 3 4 2 1 2 40 5 — — — — — 1 1 1 1 3 3 2 1 2 — 15 6 1 - 1 2 - 4 7 — — — — — — — — — — — — - — 3 3 Total 2 5 3 2 7 105 67 36 17 26 17 12 10 5 8 322 It will be seen that the mental age rarely exceeds 5. Mongols are usually popular in special schools, but only rarely do they make such progress as to justify their 148 The cause of mongolism is as yet unknown, but it has been noted that they are frequently, though not exclusively, the last children of elderly parents; sometimes they come at the end of very large families; the place in family of 315 children is tabulated below. Place in family. No. of children in family. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 13 12 7 5 2 — — 1 — — — — — — — — 2 — 22 13 1 1 — — — — — 1 — — — — — 3 — — 19 8 3 — 2 2 — — — — — — — — 4 — — — 25 7 2 — — — — — — — — — — 5 — — — — 28 6 4 2 — — — — — — — — 6 — — — — — 20 4 2 1 — — — — — — — 7 — — — — — — — 2 5 — — — — — — — 8 — — — — — — — 15 2 2 1 — — — — — 9 — — — — — — — — 13 1 1 — 1 1 — — 10 — — — — — — — — — 7 3 1 1 — — — 11 — — — — — — — — — — 7 2 2 2 — — 12 — — — — — — — — — — — — — — — — 13 — 3 3 14 — — — — — — — — — — — — — 1 1 — 15 — — — — — — — — — — — — — — — — 16 — — — — — — — — — — — — — — — 2 The ages of the parents of 294 such children are shown in the subjoined table:— Father's age. 18 to 20 21 to 23 24 to 26 27 to 29 30 to 32 33 to 35 36 to 38 39 to 41 42 to 44 45 to 47 48 to 50 Over 50 Total Mother's age. — — — — — — — — — — — — — Over 50 — — — — — — — — — — — — — 48-50 — — — — — — — — — — 1 — 1 45-47 — — — — — — 1 — 3 4 6 3 17 42-44 — — — — — 3 1 9 20 14 9 5 61 39-41 —- — — — 1 4 7 31 15 5 2 2 67 36-38 — — — 2 2 8 18 14 6 3 2 3 58 33-35 — — — 1 2 11 8 4 1 1 1 1 30 30-32 — — — 2 9 7 2 2 — — — — 22 27-29 — — 1 13 4 1 2 1 — — — — 22 24-26 — — 2 — 4 2 — — — — — — 8 21-23 — 3 2 — 1 — — — — — — — 6 18-20 — 1 1 — — — — — — — — — 2 Total _ 4 6 18 23 36 39 61 45 27 21 14 294 It may be noted that in a very considerable number of cases the mother is older than the father—a condition much more frequently met with in cases of mongolism than in any other type of mental defect. Mongolism may occur in families of any social class, though in data collected from the public elementary schools the proportion met with in the middle classes is likely to be underestimated. After taking out the percentage of distribution of the social class and occupation of the parents of 272 mongols, and comparing it with a similar percentage as revealed by the data of the Registrar-General, it will be noted that there are relatively more examples whose parents belong to the middle or distributing classes, or mixed occupations, which include service in the army, navy, retention for a lengthy period. In one or two occasional instances, artistic tendencies have enabled them to show slight promise of being able, in part, to earn a living 149 Social status of parent. or mercantile marine, police, and the like, and fewer belonging to the artisan or unskilled labour classes, and poverty is evidently not a factor in the causation. Social class. Families with a Mongol child. Per cent. Normal families. Per cant. 1. Middle 2. Distributing 3. Skilled Artisan 4. Mixed Occupations 5. Unskilled Labourers Totals 12.1 22.1 25.8 22.4 17.6 100.0 11.8 18.9 29.0 20.1 20.2 100.0 It is often stated that mongols die at or about the age of puberty and that in the survivors, as they grow older, the characteristic features become less obvious. 48 cases are known to have died; their ages at death and the causes of death being as shown below :— 1-3. 4-6. 7-9. 10-12. 13-55. 16-18 years. Total. 4 0 20 11 8 5 48 Cause of Death. No. Tuberculosis 5 Rheumatism 1 Bronchitis 2 Scarlet Fever 3 Pneumonia 9 Influenza 1 Meningitis 2 Heart 2 Measles 1 Cause of Death. No. Diphtheria 1 Congestion of Lungs 1 Cerebral Haemorrhage 1 Tumour on Brain Brain Disease 1 Not known 17 Total 48 Family history. The family histories throw comparatively little light on the aetiology of the condition. The most important features in the history of 210 instances being as follow • History of. No. of cases. Acquired Insanity34 Mental Deficiency12 Epilepsy 14 Hysteria, Neurasthenia, Asthma, Chorea 33 History of. No. of cases. Deaf Mutism 8 Intemperance 31 Tuberculosis 78 Total 210 At the beginning of the year the position of 254 of the survivors who have been followed up since their date of ascertainment was as follows:—Under supervision, 167; in Mental Hospitals, 3; in certified institutions, or Poor Law Institutions, 57; removed from London. 27. Incidence of heart disease in P.D. schools. During the year special inquiry has been made into the incidence of heart disease as revealed by cases seen at examinations for admission of children to schools for the physically defective. The heart cases in the special schools may be divided into two main categories. Those in which the condition is one of congenital malformation, whether as a result of imperfect development or of some ante-natal disease, and those in which the heart is affected as a result of disease during childhood, chiefly following rheumatic fever, scarlet fever, or diphtheria. Of those children who suffer from congenital malformations, a considerable number never attain to the compulsory school age and many others are so cyanosed and short of breath that any form of school attendance is impossible. In this class no form of treatment is of any avail, and all that can be done is to keep them under conditions which avoid strain and protect them so far as is possible from acquiring other illnesses. The worst cases usually die in early adolescence, though some survive to the middle period of life. In a few, the physical 150 effect of the malformation is so slight that they may pass through life with little incapacity ; such are to be found in the ordinary elementary schools. The acquired cases comprise those whose heart lining and muscular wall have been damaged as a result of previous illness, though this may have been so slight as to have attracted little attention. In this type the most important point, from the standpoint both of cure and prevention, is to secure care under healthy conditions, with graduated exercise and adequate rest, as soon as possible after the acute attack. The first stages of this care can, without doubt, be better carried out in a residential institution or in a convalescent home, than in a day school of any kind, though the supervision afforded by the school is better, in many cases, than the complete freedom which follows when children, not having been admitted to institutions or homes, remain at home on genuine certificates of invalidity, but are sent out to play by their parents. Formerly comparatively few cases were presented for admission to special schools at the very earliest phase, though matters in this respect are improving through the greater co-operation between the hospitals and the Children's Care Organisation. There are now arrangements whereby certain hospitals notify cases of rheumatism, in which event the children are kept under observation and, in some cases, the Children's Care Organisation are able to assist in the matter of convalescence and the like. Whenever a child is likely to do better in a day school for the physically defective, special arrangements are made for its examination for this purpose. Some of the best results have followed the admission of children to the physically defective school after attacks of rheumatism or chorea, when there was only a lack of tone in the heart showing weakness of the muscle, but, as yet, no valvular incompetence. Several such have been able, after a time, to attend the ordinary elementary schools and to follow the full curriculum with safety. Others have been able to leave school fit for employment, which would probably not have been the case had they not received care in the critical years. The main reason why a number of the heart cases leave thus is that rheumatism is a disease of the middle and later periods of school life rather than of the earlier period, so that many cases come to notice between the ages of 10 and 13, and so have reached the age of 14 + before their heart musculature is restored to a reasonable state of normality. Up to the present time, however, the majority of the children dealt with have come up for admission at a later stage when the heart mechanism has been definitely, and often, permanently, impaired, in some instances too late for any modification of school work to be of avail, but in many still at a stage in which careful graduation of exercise and compulsory rest at intervals may make all the difference to their future prospects. For all of these a mid-day rest is most valuable. The aim of school treatment in all these heart affections is to avoid sudden strains, and gradually to accustom the heart to increasing efforts until the normal regime can be resumed. Under supervision any signs of failing effort can be noted at once, and steps taken to increase the rest, or, if the condition be more serious, to send the child back for further medical treatment. Without such supervision the condition of strain may remain and may have done material damage before it sufficiently attracts the attention of the less observant Barents. The number of children on the roll of P.D. schools suffering from heart disease or from rheumatism, or chorea, at the end of 1925, was as follows:— Numbers. Morbid condition. Boys. Girls. Total. Congenital malformation 99 112 211 Acquired valvular disease 330 555 885 Acquired non-valvular disease 18 21 39 Recurrent or recent rheumatism 18 22 40 Recurrent or still present chorea 18 32 50 Since heart disease is often a sequel of rheumatism, the number of cases in any given year will depend on the frequency of rheumatism in previous years. It is 151 believed by some that there is an increased prevalence of rheumatism in dry seasons in places which are relatively damp. The distribution of heart and rheumatic cases in the P.D. schools is indicated on the map on page 125. Also, it has been noted that more cases come to notice in some years than others—e.g., there was a marked increase in the numbers during 1923. There has been a distinct increase in the numbers admitted to special schools since 1908; this may, to some extent, represent a real increase in the number affected, but, in large part, is to be explained by the more sympathetic attitude to and better understanding of the nature and use of special schools by the medical profession, especially by the hospital physicians. Formerly, children with heart disease were kept out of school altogether, for long periods, on unimpeachable certificates; now, it is commoner for the physician to suggest that his little patient might attend a P.D. school, or in some cases, residential institutions. Juvenile delinquents. Dr. F.C. Shrubsall, senior medical officer, who visited America during the Summer recess of 1924, and whose report on mental examinations in places of detention appeared in the annual report for 1924 (pp. 112 to 120) gave evidence before the Departmental Committee on the Treatment of Young Offenders. After careers reported by the London Association for the Care of the Mentally Defective. The after careers of children formerly attending special (mentally defective) schools are here set out. Male. Female. Total. (i.) Number of children born in or subsequent to 1907 who have left special schools and who have been on the books of the Association 1,007 785 1,792 (ii.) Since died 1 1 2 (iii.) Number known to be incapable by reason of mental or physical defect of undertaking employment— (a) Notified and sent to institutions 8 5 13 (6) Notified and placed under supervision 17 11 28 (c) Not certifiable (i.e., home circumstances satisfactory at present) 52 59 111 (iv.) Number employed in— (a) Industrial or manual occupations (i.e., factory work, trade or any part of a trade) 441 280 721 (b) Agricultural or rural occupations 11 2 13 (c) Domestio occupations 9 190 199 (d) Commercial, shop assistants or selling behind a counter, office boys or girls 27 7 34 (e) Army or navy 5 — 5 (/) Blind alley or other precarious occupations (i.e., vanboys, newsboys, errand boys and girls, selling from a barrow) 121 7 128 (v.) Judged to be employable but out of work 113 76 189 (vi.) Number whose careers have not been traced or who have left the neighbourhood 201 145 346 (vii.) No action possible 1 2 3 The blind, deaf and crippled cases were notified to the After Care Association for blind, deaf and crippled children, who have hitherto furnished information in regard thoreto. The Association were approached with a view to obtaining data for this report, and the information will be forwarded to the Board in due course. Nursery Schools. There are in London eleven Nursery Schools. Of these, two belong to the London County Council and nine are voluntary. The total accommodation is for 518 children, the average number on roll during the year 1925 being approximately 580. In five schools routine medical inspection of the children is carried out by Council doctors, and in the remaining six by practitioners appointed by the Managers. In nine small schools with total accommodation for 288, children are medically examined once a term. In the Rachel McMillan Schools (L.C.C. and Voluntary), 152 with accommodation for 230, they are examined at least once a year, special cases being seen more frequently. Arrangements are made in all schools for urgent cases to be seen without delay, either by the school doctor or at a Council Treatment Centre. Treatment of teeth, tonsils and adenoids and minor ailments is generally carried out at Council Clinics, though in a few cases the school doctor living locally attends to minor ailments and ordinary children's complaints. Eight of the eleven schools are visited, as a rule daily, by a Council Nurse, the work being undertaken in the other three schools by an experienced teacher. Each school is inspected regularly by a Council doctor regarding all matters relating to the health of the children. The Council undertakes responsibility for the control of infectious disease, each case being notified from the Nursery School to the School Medical Officer. On the outbreak of an epidemic a visit is paid by a Council doctor to advise as to its control, and where necessary to examine children and swab throats. Children in affected schools arc inspected daily by a Council Nurse, or, exceptionally, by an experienced teacher. The following summary of the records of medical inspection in the eleven schools has been calculated in the case of the nine smaller schools for the first term of 1925, when all children present in these schools were examined, and in the case of the two larger schools for the whole year: Number of children examined. 533; number with defects, 392; rickets, 122; throat and nose, 216; eyes and eyelids, 12; squint, 11; ears, 27; lungs, 79; heart, 26; skin, 20; teeth, 72; other defects, 75. The numbers of children with 2 defects, 3 defects, and 4 or more defects, were 45, 21 and 18 respectively. The number of children treated was 140—teeth, 60; squint, 5; nose and throat, 46; ears, 8; other defects, 21. Examination of Pupils at Secondary Schools, &c. Pupils at secondary schools are examined at entrance and a complete examination of all is made at the ages of 12 and 15. Those with defects are kept under observation. The health of all pupils is reviewed annually and a medical examination is made of any pupil where it appears desirable. Treatment under the Council's scheme is offered to scholarship holders on the same terms as elementary scholars, but other pupils are expected to pay the full cost if treated under the Council's arrangements. 7,653 pupils in the secondary schools were examined in detail, and 2,337 were in addition inspected. 1,820 pupils in technical institutions were examined in detail and 396 were also inspected. 1,093 students in training colleges were examined in detail and 215 were also inspected. In the secondary schools 1,045 boys and 972 girls were examined in the 12 year age group and 1,174 boys and 1,004 girls in the 15 year age group. In the following tables the condition of the children in the secondary schools at the age of 12 is compared with that of the children of the same age in the elementary schools. Boys— Cleanliness unsatisfactory, Carious teeth. Defective vision. Defects of heart. Defects of lung. Anaemia. Elementary schools 4.8 30.8 42 2.6 1.8 2.8 Secondary schools 2.0 25.3 28.7 2.7 .4 4.7 Girls— Elementary schools 14.8 29.9 45.9 3.8 1.6 2.8 Secondary schools 2.0 21.9 32.7 3.9 1.6 3.9 The pupils in the secondary schools compare very favourably with those in the elementary schools not only in personal cleanliness but also in the condition of the teeth and correction of visual defects. There is more anaemia, however, returned from the secondary schools, probably because the secondary school pupils have less time if not opportunity for play and recreation. 153 Comparing the 15 year old girls in secondary schools with those of 12 years of age it is found that the percentages of those with carious teeth and visual defect are stationary; on the other hand there is an increase in defects of the heart from 3.9 per cent. to 5.8 per cent., and in anaemia from 3.9 per cent. to 4.6 per cent. In addition to the primary examinations recorded above, 2,486 pupils in higher education institutions who had recorded defects were reinspected. Of 771 cases of defective vision, 449 were found to be remedied, 132 improved and 200 not improved. Of 94 external eye or ear disease and minor ailments, 30 were remedied, 42 improved and 22 not improved. Of 99 nose and throat defects, 41 were cured, 28 improved and 30 unremedied. Of 924 dental cases, 452 were remedied, 120 improved and 352 unremedied. Juvenile Employment. The Council's by-laws make it necessary for all school children engaged in employment out of school to obtain a certificate of health from the school medical officer before a licence is granted. During 1925, 3,845 applicants were seen, of whom only 61 were girls. In 106 cases certificates of health were refused, two of which concerned girls. The medical reasons for rejection comprised in the case of boys: epilepsy or fits, 2; general debility, 30; heart defect, 14; flat foot, 2; visual defect, 16; ear disease, 3; anaemia, 10; tonsilitis, 5; mental condition, 1; dental decay, 7; tuberculous glands, 2; skin disease, 2. Certificates were refused on general grounds, such as unsuitability of work or of hours, in 10 cases. Of the two girls refused certificates one suffered from general debility and one from myopia. 311 additional children were granted conditional certificates, 205 subject to medical treatment being obtained, and 106 upon other conditions, which included periodical re-examination, limitation in regard to weights to be carried, additional nourishment and provision of proper boots. The certificate was withdrawn in two cases after issue, in one the reason for this was that it was ascertained that the employment was not as represented in the application, the boy being required to carry coal to flats three storeys high, in the other case the reason for withdrawal was lack of progress in school work, the boy being tired and listless. One boy was not only unsuitable for work out of school, but was found to be in such a poor physical condition that he was unfit even to attend school, another suffering from heart disease, who applied for an employment certificate, was passed for a special school for the physically defective. The various forms of employment for which certificates were sought, were as follows:—Delivering of milk, 277; of newspapers, 2,441; of goods and parcels, 472; employment in or about a shop, 283; coal yard, 9; industrial work at home, 5; housework, 34; messenger, 69; employment not defined, 58. Theatrical Children. For licences to take part in stage entertainments, 153 children were seen during the year. 27 of these were boys. Since the introduction of the statutory rules in regard to the employment of children on the stage a very great improvement in their condition has been effected. Whereas formerly a large number of these children were found in a deplorable condition of personal hygiene, now the greatest care is exercised, since neglect will inevitably lead to cancellation of licences. Only one child during the year was refused a licence on account of verminous infestation There would be great advantage if the rules could be extended to young persons above the age of 14. A mother visited the department with her daughter, who was above the age of 14, and had been away with a touring party. The girl was in a neglected condition, and the mother explained that, while the child was of 154 school age, scrupulous care had been followed, but on cessation of supervision by the authority neglect occurred. Several types of child can be distinguished amongst those sought for to take part in theatrical entertainments, and great contrasts are found. Many of the children are of perfect physique and carriage, and these contrast with another group, who are selected because they are dwarfs. The rules prevent children under 12 being employed, and to represent on the stage very young children, a hunt is made for very diminutive children who have reached the age of 12. Amongst the latter class, of course, the signs of old rickets or even angular curvature of the spine are found. Another class of child is of the beautiful fairy type, and these require the greatest care. They are frequently pale, often with nutritional disorders, and they easily become tired. It is necessary to see that they are not overworked. 26 of the children were of this type, and in all cases special nourishment and directions for hygienic care were prescribed. Dental attention was required in 16 and spectacles in 14 cases, and the licences were made conditional upon the necessary treatment being carried out. Special Enquiries and Research. The ever growing volume of work and the calls upon the time of the staff make it difficult to carry out systematically research into the various problems affecting the growth of the school child. Assistance is being given by the staff to two of the concerted lines of research indicated by the Board of Education, namely, the vision enquiry and the anthropometric enquiry. Dr, Nairn Dobbie has been associated with the enquiry into vocational guidance carried out by the National Institute of Industrial Psychology, Dr. Elizabeth M. McVail has made an enquiry into the physical and mental condition of backward children, Dr. E. H. Norman has made an investigation into the occurrence of albuminuria in school children, and Dr. Mabel Russell has investigated the condition of children living in canal boats. Abstracts of the reports of these officers are appended. Dr. Nairn Dobbie's investigation on the relation of medical examinations to vocational guidance. An important experiment in vocational guidance carried out in the Council's schools by the National Institute of Industrial Psychology was initiated in August, 1924. It is held that by considering the natural aptitudes, physical and mental, of each child, and as the result of this consideration guiding him into an occupation for which he is naturally fitted, it may be expected that industrial fatigue will be lessened, output be increased, greater interest be shown by the worker in his work and industrial accidents be reduced. Some months were occupied by the workers of the National Institute in preparation and exploration of the field. In March, 1925, the experiment actually commenced in the schools. Two equal groups of boy and girl leavers were taken at random, one group was submitted to detailed investigation with vocational guidance, the other group being followed up as a control. The detailed investigation of each child in the former group comprises (a) the investigation of home and family circumstances, (b) the record of physique and general health, (c) intelligence tests, (d) manual dexterity tests, (e) mechanical ability tests, (f) assessment of temperament and character, (g) school reports. Dr. Nairn Dobbie, one of the Council's assistant medical officers, in association with the workers of the National Institute in this investigation has made a careful medical examination of each pupil in relation to vocational capacity under heading (b) above. The following account is taken from Dr. Dobbie's report on the physical condition of the children. 237 boys and girls all within a few months of 14 years were examined between March and Christmas, 1925. The fundamental assessment in physical examination of the child is that of nutritional state. Dr. James Kerr states, "Nutrition is the most important thing . . . the only reliable way of assessing nutrition is from the estimate built up by a trained observer during clinical examination." 155 A clinical division of the children was made in three categories as regards general health and appearance, 80 were assessed as robust, 114 as average and 43 as "delicate." Analysing the 80 robust leavers according to height and weight, it was found that 53 were above the average weight for height, 21 about the average weight for height, and 6 were below the average weight for height. A similar analysis of the 43 clinically" delicate "children showed that one was above the average weight for height, 14 were about the average, and 28 were below. H.G Using Vierordt's formula (W = —240 where W is weight in kilograms, H is height in centimetres and G is chest girth in centimetres) the clinical assessment could be compared with the results deduced from measurements. Clinical assessment. Average weight. Kilograms. Average height. Centimetres. Average girth. Centimetres. Weight by formula Kilograms. Boys— Nutrition I. 46.7 152 73.66 46.6 Nutrition III. 34.5 145 67.3 40.6 Girls— Nutrition I. 45.5 155 7.11 45.9 Nutrition III. 35 147.5 67.9 41.3 The general approximation of clinical assessment with the deductions from physical measurement are interesting. Both boys and girls classed as robust corresponded in weight with that deducible from Vierordt's formula, while the "delicate" children clinically fell short by about six kilogrammes of their theoreitcal weight. Next, or equal in importance, to the assessment of physique is the assessment of mental state. A highly strung unstable person may be capable of sudden bursts of dynamic energy which will, however, not be maintained for any length of time, those lacking in intelligence cannot adapt themselves effectively to their environment while the mentally bright make their own environment. A classification of the three nutritional groups into three groups mentally "bright," "fairly bright" and "dull" shows a preponderance of dull children amongst the ill nourished. Bright. Fairly bright. Dull. Nutrition 1 11 20 10 Nutrition 2 32 58 49 Nutrition 3 9 22 26 Fatigue leads to defective concentration and diminished control and, amongst many other signs, tremor of the small muscles is an important one. Dr. Henry Head states that " tremor of the hands is of great importance . . . and points to some defect in static control." Of 16 boys and 25 girls classed as robust (Nutrition I.), 1 boy and 5 girls were noted with tremor of the outstretched hands, while of 36 boys and 25 girls classed as delicate (Nutrition III.), no less than 25 boys and 13 girls were noted with tremor. Much may be learnt regarding the physical efficiency of a pupil by an assessment of the condition of the skin. Dr. Mumford, at the Manchester Grammar School, has recently classified a series of boys into four mental groups corresponding with skin conditions defined as follows:— (1) Pernio—Blue cold moist hands, goose skin, chilblains—mentally slow, diminished capacity for rapid effort. (2) Fine skinned.—Active metabolism, face, hands, and ears bright- red, skin warm and moist, little or no hair, spare build, quick heart, physically and mentally active (3) Oily skinned.—Skin thick, pigmental, coarse, hairy, short, obese, early sexual development, muscular but not agile. (4) Dry skinned.—Under-active thyroid, backward mentally and physically. 156 Using these groups Dr. Dobbie found the following distribution :— Robust (Nutrition I.) Delicate (Nutrition III.). Fine. Pernio. Oily. Dry. Fine. Pernio. Oily. Dry. Boys 13 2 1 Nil 19 9 1 7 Girls 14 3 6 2 7 6 1 7 Totals 27 5 7 2 26 15 2 14 The preponderance of pernio and dry-skinned children amongst those classed as Nutrition III. is noteworthy. Vascular tone estimated on a three point scale according to the condition of the skin gave a great preponderance of defective states in the " delicate " section. Nutrition I. Nutrition III. Vascular tone 1 2 3 1 2 3 Boys 5 10 1 Nil 20 16 Girls 4 18 3 Mil 9 12 A similar estimation based upon the condition of the heart showed that there were two cases of functional heart murmurs amongst the robust, while 17 cases occurred in the delicate group, in addition to two cases of organic disease. Muscular tone was assessed on the appearance of muscular development, the poise and activity of the body, firmness of muscles to touch and the degree of protuberance of abdomen. A three point scale for muscular tone showed very remarkably the correspondence of the assessment of muscular tone with that of nutritional state. Nutrition I. Nutrition III. Muscle tone 12 3 12 3 Boys 10 6 Nil Nil 4 32 Girls 7 18 Nil Nil 5 15 While enlarged tonsils and adenoids were equally incident upon children classed as Nutrition I. and Nutrition III. respectively, there was a great difference in the case of enlarged cervical glands. Not a single child in the robust class was marked with enlarged glands as opposed to 26 in the delicate group. Dr. Dobbie sums up the characteristics of the two groups as follows:—"Children of good nutrition, whatever the level of their native intelligence, are sprightly and bright, and they are of stable temperament; the well functioning of the body enables the mind to function to full advantage. The weight is relatively high to the height, the body is well poised, alert and active, the muscular and vascular tone is good and the skin is clear, fine and smooth with a good layer of subcutaneous fat. In those of poor nutrition there is a definite syndrome, irrespective of intelligence, they are often highly strung and nervous and are easily fatigued, their muscles are flabby and ill developed, they are often round shouldered or pot bellied. The skin is unhealthy, either dry and thin or mottled and accompanied by cold and moist hands, there is pooling of the blood in the abdominal veins, cardiac abnormalities are relatively common and enlargement of the cervical glands is often found. An important part of Dr. Dobbie's share in the investigations consisted in the signalling, as a result of the physical examination of the child, contra-indications to certain features characterising groups of occupations. The medical form filled in by him in the case of each individual child contains the following section:— Occupational contra-indications negativing occupations that involve— Standing. Dusty atmosphere. Dry hands. Nervous strain. Sitting. Good hearing. Cold. Muscular strain. Good sight. D mp. Heat. Indoor work. Climbing. Exposure. 49 boys out of 128 examined showed 103 contra-indications, a little over 2 per boy, and 40 girls out of 109 examined showed 80 contra-indications. Amongst the boys muscular strain was contra-indicated in 19 cases, dry hands in 16, exposure in 157 14, standing in 8, good sight, dusty atmosphere, nervous strain in 7 each, climbing in 5, dampness in 3, hearing in 3, cold and heat in 2, colour vision in 2. Amongst the girls nervous strain was contra-indicated in 16, muscular strain in 15, dry hands in 13, exposure in 11, standing in 8, good sight in 7, damp in 3, hearing, cold and heat, one each. Following are the considerations on which the signal for contra-indication was based by Dr. Dobbie in certain of the categories named : Standing in the human subject is an active posture ; persons with poor muscular tone soon grow weary, a reversed S position is assumed, muscles, tendons and ligaments are stretched where the strain falls and flat foot, round shoulders and prominent abdomen results. Persons with circulation embarrassed whether by heart, lung or vessel defect do not endure the strain of the constant erect position without excessive fatigue and the formation of varicose veins and haemorrhoids. Dusty occupations are especially prejudicial to mouth breathers, persons with a tendency to chronic inflammatory conditions of the ear, nose and throat and respiratory system generally, or to exudation conditions of the skin such as eczema. Exposure is contra-indicated in those of poor circulation; the vessel walls do not respond to rapid changes of temperature and easily become fatigued, remaining either dilated or contracted. In the former case chilling results; in the latter there is congestion of the deep viscera and difficulty in quick response. Employments requiring dry hands are contra-indicated in many children both of the robust and delicate types. When the hands are large, blue, cold and beefy, moist palms are the rule and close examination reveals minute visible beads of perspiration. There was a rather large number of children in whom this contraindication existed. Dr. McV ail's investigation of backward children. Dr. Elizabeth McVail has minutely investigated the previous history and physical condition of 69 children in backward classes, Laycock-street (Girls) School, where there are two backward classes, was selected for this enquiry. One of the classes contains girls between 9 and 12 years of age (Class II.), the other contains girls of 12 to 14 (Class I.). On leaving the first class at the age of 12, some children pass into an ordinary standard, but others pass directly to the second class, thus remaining in backward classes possibly from the age of 9 to the end of school life. 33 girls in class II. and 36 in class I. were investigated. The intelligence quotients of all the girls were obtained on the Binet scale, and in each case the cause of dulness and backwardness was investigated, so far as it was possible to do so. A. Class I. consisting of girls of 12 or over. The average age of these 34 girls was 13 years and 4 months; the intelligence quotients on the Binet scale (100 being normal) ranged from 66 lowest to 108 highest; the average being 79. Nine girls had an intelligence quotient of 90 and upwards. The reasons for backwardness in these nine girls of relatively high natural intelligence are particularly interesting to trace. They were in order of intelligence. (1) L.C., age 12 1/1½ I.Q. 108. Average attendance 95 per cent. over 5 years.— This child with an intelligence quotient well above the normal, has no physical defect, and has always attended school with a high degree of regularity. She shows much ingenuity in ordinary affairs of life, but is inattentive in school, and is described by the teacher as "scatterbrained." This is the type of child which is the despair of the teacher; of high native ability, the child is temperamentally unsuited to ordinary education, takes no interest in lessons, and lacks application; she will fit into no educational scheme. (2) L.D., age 121/1 ½. I.Q. 98. Average attendance 92 over 5 years. This child attends regularly, has no physical defect, and has had no serious illnesses. She is of good native intelligence, yet is backward and makes no progress in school work. 13651 l 158 She is lazy, according to the teacher. A great contrast to No. 1, yet the result is the same ; she is a misfit in the educational system. (3) I.N., age 128/12 I.Q. 97. Average attendance 72 over 4 years.—This child, of good intelligence, is backward owing to irregular attendance. She is frequently kept at home to look after a bed-ridden mother. She has no physical defect and has had no serious illness. (4) L.D., age 134/12. I.Q. 97.—A recent admission. Attendance irregular at other schools. History of rheumatism and chorea, slight cardiac dilatation. Previous otorrhcea and hearing still slightly defective. Absent for 7 months with scarlet fever, whilst in Infant school. In 1923, absent with chorea and rheumatic heart for 3 months. In this case interrupted education through illness appears a sufficient reason for backwardness. (5) F.B., age 136/12. I.Q. 96. Average attendance 83 over 5 years. Has slightly defective hearing, previously otorrhcea. Was in hospital for 6 months in 1924, owing to ear trouble. Her attendance in 1923-24 was very poor. Since she began to attend more regularly, is getting on well with her work. Backwardness due to irregular attendance owing to illness. (6) K.D., age 134/12 I.Q. 96. Average attendance 84 over 5 years. Suffers from bronchitis, heart murmur, rickety chest, wears glasses. Backwardness due to frequent short absences owing to chest trouble and parental neglect. (7) E.H., age 131/12. I.Q. 95. Average attendance 88 over 5 years, suffered from gastritis and probable appendicitis. Made only 336 attendances Has of 409 last year, owing to stomach trouble. Was in ordinary class until her illness. Backwardness clearly due to ill health and loss of attendance. (8) M.E., age 1402/12 I.Q. 93. Average attendance 93 over 5 years. Previously suffered from otorrhcea. Hearing formerly very dull is now slightly defective. This child is considered by the teacher to be similar to No. 1 temperamentally. She is "scatterbrained." It is probable that habits of inattention due to defective hearing have persisted after improvement of hearing. (9) M.C., age 139/12 I.Q. 92. Broken attendance. Has lived partly in London and partly in the country, and her school life has been irregular and discontinuous. Is very capable in ordinary affairs. No physical defects or history of illness. Backwardness due to discontinuity of education. Of these nine girls of backward intelligence, there are, therefore, two for whose backwardness no cause can be given, except that their character and temperament unfits them for the ordinary methods of education, and these are of the highest intelligence of the class. In the other seven, interrupted education is a cause; in two of these the irregular attendance had no connection with illness, but in five cases, illness is to be regarded as a main, if not the sole cause, of backwardness. In three cases defective hearing is a contributory cause, and it is possible that defect of hearing is the most common preventible cause at present of backwardness amongst school children. Case No. 8 is an interesting one, as it is suggested that a habit of mind inimical to progress educationally was set up by deafness, which had so improved as no longer itself to be a continuing cause. It is not possible, for reasons of space, to set out in detail the histories of the remaining 27 children in Class I. They will, therefore, be dealt with in categories according to their intelligence quotients. There were 7 children with intelligence quotients falling between 80 and 90. Of these, two had been regular attenders (98 and 97 per cent. of attendances respectively), while five had had their attendance sadly interfered with by illness. Two had suffered from defective hearing, one from ringworm and two from bronchitis. One of the children with hearing defect had passed some years in a deaf school. 16 children had intelligence quotients ranging from 70 to 80. 10 of these were were regular attenders, and were considered to be naturally dull; one of them was 159 anaemic, 2 had defective vision; 1 had both defective vision and defective hearing. Five in this category had been absent from school for long periods ; two were of the neurotic type, one was a spoilt child at home, frequently absent without adequate reason, two had ear trouble and hardness of hearing. There remain four children with an intelligence quotient below 70. Two of these have always attended regularly, but one of them suffers from chronic otorrhœa and defective hearing. The other two have frequently been absent from school for long periods, one for scabies, the other for jaundice. B. Class II. 33 girls were investigated in this class, whose ages ranged from 9 to 13. Their intelligence quotients varied from 72 to 105 ; average being 88. No less than 11 girls had intelligence quotients of 90 and upwards. The salient features and the history of these children were as follows:— (1) J.D., age 129/12 I.Q. 105. Average attendance over 3 years 76.—This girl is a sad case, thin, probably underfed, was absent for four months with scarlet fever in 1923, and for three months with diphtheria in 1924. A drudge at home, missing attendances for one or two half days every week. Here is a bright intelligent girl, who is backward merely through neglect and hard circumstances at home, combined with very irregular school attendance. (2) A.B., age 8.11/12 I.Q. 100. Average attendance 95 over 3 years.—The child is of the neurotic t11ype, suffers from night terrors, was considered in the infants' department to be bright; attends very regularly. Is backward especially in arithmetic. This is a well known type of child with good general intelligence, but is weak in one or other faculty. (3) G.D., age 96/12 I.Q. 97. Average attendance over 3 years 90.—Suffers from enlarged glands and chest trouble. Under treatment at Chest Hospital off and on for five years. Was regarded in infants' department as very bright (top girl in St. I.). Backwardness clearly due to illness. (4) I.P., age 94/12 I.Q. 95. Average attendance 91 over 3 years. Was regarded as bright in infants' department. Has had an operation for tonsils and adenoids. Was absent for some months with infectious disease. Hearing normal. Backwardness due to illness. (5) L.P., age 1011/12. I.Q. 95. Average attendance over 3 years 92. No serious illness. No physical defect. Is kept at home for a few days occasionally to mind younger children. No obvious reason for backwardness. (6) E.X., age 107/12 I.Q. 93. Average attendance 91 over 2 years. History of abdominal trouble ; attendance irregular last year owing to illness. (7) A.I., age lO6/12 I.Q. 91. Average attendance over 2 years 92. Often late for school, lacks supervision at home ; child is "lazy" and miserable when made to work. (8) D.I., age 9 6/12 I.Q. 90. Average attendance over 2 years 96. Suffered from bronchial catarrh in 1923. No serious illness. Child is in backward class because of poor arithmetic. (See case 2.) (9) N.N., age 9 7/12 I.Q. 90. Average attendance over 3 years, 89. Bronchitis in 1920. Frequent headaches and sickness. Uncontrolled at home. (10) M.Q., age 12. I.Q. 90. Average attendance over 3 years 99. Defective vision, wears glasses irregularly. Now improving. (11) I.T., age 10 1/12 I.Q. 90. Average attendance over 3 years, 64. Pneumonia in 1919, followed by fibrosis of lung. Anaemic, vision defective. Backwardness due to illness and consequent loss of attendance. Of these eleven children, who may be regarded as falling within the normal limits of intelligence, four appear to be backward, not through illness or defect, but chiefly owing to adverse home conditions, two are backward in special subjects, owing to weakness of a particular faculty, though of normal general intelligence; five are backward owing to illness or defective vision. 13651 L 2 160 12 children in the class had intelligence quotients of between 80 and 90. Only two were irregular attenders, one of them had had chorea in 1923, and tuberculous glands before that, with very serious loss of attendance ; the other suffered from nervous debility and had lost much school time in consequence. Two children who attend well have myopia; the remaining 8 were merely naturally dull, there being no defect or illnees to account even partially for their condition, although unsatisfactory home conditions existed in one or two cases. There were a further 10 children whose intelligence quotient was below 80. No less than 8 of these suffered from illnesses or defects, which have interfered with their progress. One has defective hearing, another has defective hearing and heart disease following rheumatism, two have some visual defect, one is tuberculous, one has had a long absence for scarlet fever, and two are of very poor physique and illnourished. The remaining two children in this set have no physical defects to account for backwardness, one (I.Q. 78) has recently been admitted from a country school, and the other (I.Q. 79) comes from a poor home where the mother is a drunkard. It is significant that the ten children with the lower intelligence quotients (70-80) should show such a preponderating number in which chronic illness and physical defect have occurred, compared with the group of children whose intelligence quotients are between 80 and 90, who appear mainly to be naturally dull children, the cause of whose backwardness is mental rather than physical. Dr. McVail's conclusions resolve themselves into a plea for special medical oversight and care for backward children, and for smaller classes. The proportion of children with physical defects is much higher than amongst normal children. In the two classes combined, 16 per cent. had defective vision, 16 per cent. defective hearing, and 4.3 per cent. organic heart disease, while lung trouble and general debility were also much above the average incidence. It is of interest to note that the effects of illness and disease persist long after the disease has been cured. Habits of inattention acquired owing to defect of the special senses remain when the defects are themselves corrected. A further interesting question arises out of this very valuable investigation. Psychologists interested in mental testing have tried during recent years to maintain the fatalistic theory that "intelligence" is an attribute of the individual, inborn and immutable. Nothing, they say, can happen after birth to increase the native intelligence of the child, and they seem to imply that equally nothing can happen to diminish that intelligence. The study of these backward children from a physical as well as a mental point of view, demonstrates, conclusively, that whatever view may be taken of the first part of this thesis, medical opinion must take a firm stand in regard to the converse. It is quite clear that defects of the special senses of seeing and hearing can diminish the intelligence quotient of the individual, as can equally chronic constitutional disease. As these causes have from time immemorial acted upon children, we must therefore claim that by preventive medicine, hygiene and general care, the intelligence of a generation can be improved. Dr. R. H. Norman's investigation into the occurrence of albuminuria in elementary school boys Owing to obvious considerations, a full and complete medical examination cannot be conducted in the conditions under which medical inspection in schools takes place. Little is, therefore, known of the incidence of albuminuria upon elementary school children generally. Dr. R. H. Norman has found it possible, side by side with his routine examination, to undertake the investigation of the incidence of albuminuria amongst 1,787 boys attending five schools in St. Pancras. Every boy in each school was examined. Salicyl-sulphonic acid was used as the reagent to determine the presence of albumin. All who showed an albuminous urine, whether slight, moderate or marked, were examined a second time after the lapse of a few weeks. 161 The number of boys examined, their ages, and the number found with albumin, are shown in the following table:— Age. 1 7' 8. | 9. 10. 11. 12. 13. 14. 15. Total Number examined . 60 241 1 268 251 274 287 301 80 25 1,787 Number with albuminuria 6 46 51 57 66 65 86 27 10 414 Percentage with albuminuria 10 19 | 19 22.7 24 22.6 28.5 33.7 40 23.1 From nine years, upwards, there is an increasing incidence of albuminuria with age. Dr. Norman says that it has not hitherto been appreciated sufficiently, how frequently albuminuria is to be found. It has been noted in older schoolboys and young adults, and for this reason it has been termed "adolescent albuminuria," but it must be noted that it frequently occurs at the ages below ten, although it increases in incidence as puberty approaches. An important point about the typical albuminuria of early life is the irregularity of its appearance. Because of its usual absence in the urine passed on rising after a night's rest, and its presence later in the day, it is frequently termed " orthostatic albuminuria." On re-examination of those boys found on the first occasion to have albuminuria, it was found that amongst the 7 year old boys 50 per cent. had ceased to be albuminuric, of the 8 year old 47.9 per cent., of the 9 year old 51 per cent., of the 10 year, 49.2 per cent., of the 11 year old 39.4 per cent., of the 12 year year old 40 per cent. of the 13 year old 34.9 per cent., of the 14 year old 26 per cent., and of the 15 year old 20 per cent. So that in addition to the incidence increasing with age amongst school boys. there is also an increased persistence with age. Dr. Mabel Russell's report on the condition of canal boat children. Ihe Barge Class (Union Place. Padding ton Wharf).—Ihis class is composed of children from the various barges which from time to time come to anchor in Paddington Wharf. The class is held in a room on the ground floor of the "Boatman's Institute" (a mission to canal workers), Union Place, and the children attend for the short period during which the barges to which their respective families are attached are loading or unloading, these periods varying from a single session to three days or rarely a week at a time. Open-air drill and play take place in the adjoining street (practically a cul-de-sac). The children of the bargees were originally gathered together by the missioner at the Institute and these were formed into a class and taken over by the L.C.C. in June, 1924, being attached to the girls' department of St. Michael's, Star Street, Paddington, under the direction of Miss Cole, the Head Teacher. There are 76 children on the roll, but the number present during any single session varies from day to day—i.e., one day during the week that the school was visited there were 31 children in attendance, while the day following only 13 were present, and one of the difficulties that the class teacher has to contend with is this variability of numbers. Most of the bargees voyage between Paddington Wharf and West Drayton carrying building materials, but a few travel to parts of the country as far distant as Birmingham. Up to the time of the formation of this class only one or two of the children had attended any school, and those only for short periods, and there are children of 13 and 14 who do not even know their letters. The children on the roll (of both sexes) vary in age from 5 to 14 years, attendance is voluntary and the existence of the class is made known to the parents through the agency of the Mission and Institute, and it may be stated that having once attended, the same children return to the class each time as opportunity occurs. 162 Medical inspection has been carried out for the first time during this (Autumn) term and three visits have been paid, every child present in school on the day of the visit being examined irrespective of age. The children themselves are rather like the small, wild things of the forest, very timid at first and needing much coaxing, but when they realise that the medical officer is not a kind of Lord High Executioner, who performs major operations on the spot, they become very friendly and anxious to help in small ways. At the first visit this term several children absented themselves, but this has not happened since. The general health and physique of the children seen, on the whole compares favourably with that of the children of the same social status attending elementary schools, though general cleanliness, foot-gear and clothing are far below that of the elementary school child of the same status and are reminiscent of the conditions met with some sixteen years ago. It is stated by the Head Teacher that when first admitted to the class, the majority of the children were in the filthiest condition imaginable; they came with hair matted together thick with dirt and grime and crawling with vermin—one girl was so covered with dust and cement that she "looked like an old woman," and it is of interest to note that the same child when examined during a recent visit was comparatively clean. There is now a marked improvement in personal hygiene, hands and faces are washed at least twice a day in school, hair combed and the verminous condition is improving and the children are becoming more humanised in every way. The school nurse has taken a great interest in this work and visits the class whenever she has a few minutes to spare, and would have done so more often, but having six schools to visit for measles, she has been prevented; she has, however, paid visits to some of the parents on the barges and shown them how to cleanse the heads, for it is useless to send the ordinary printed instructions as very few can read or write, and parents have been grateful for her help or advice—and it would be very useful if this side of the work could be developed by allocating more time to it on nurse's rota. Nurse states that up to the present she has not found any evidence of body vermin, though bugs have been present on the clothing. Up to date of writing this report, 32 children (21 girls and 11 boys) have been thoroughly examined. The following are some of the data obtained. The figures for boys are put in brackets: Vnvaccinated, 15 (10); nutrition, normal, 21 (10), subnormal, 0 (1); cleanliness, head nits, 14 (5); body fleabitten, 3 (2); teeth, 3 or more carious, 3 (1); throat, very slight tonsillar enlargement, 3 (2); enlarged but not causing symptoms, 1; enlarged and glandular enlargements (1). On the whole, the throats of these children appear much healthier than the ordinary elementary school child. Vision, of the 19 girls over 7 years of age only 11 could be tested as having some knowledge of letters and of these 1 read 6/18 with one eye, 1 had extensive corneal ulceration in one eye, leucoma in the other, and appeared generally neglected (now under the N.S.P.C.C.). A sister, it is stated, is totally blind, and another child has corneal ulcers. The remaining 9 girls read 6/6 or 6/9. Of the 8 boys only 5 could be tested and all of them read 6/6 or 6/9. Of the other physical conditions noted, 1 boy had a slight mitral lesion with fair compensation—the result of rheumatism after scarlet fever, 1 girl had a slight bronchial catarrh, 3 girls and 1 boy had slight degrees of anaemia, 1 girl was definitely mentally defective and had marked inco-ordination, and a second child appeared to be a border-line case. Defects needing treatment. Defects needing observation. Dental 4 Mitral incompetence 1 Vision 1 Mental conditions 2 Corneal ulcers 1 Tonsils 1 163 In conclusion, it may be stated that the great difficulty lies in getting the children treated, for often a child seen one day may have left the Wharf the following day for an indefinite period; then, again, parents need much educating, and up to the present none of them have attended the inspections; it is hoped in the future that we shall be able to get them up and in this way much may be done in the way of advice for general treatment. Even so, there remains the difficulty of getting treatment for definite defects, it being difficult for parents to leave the barges and travel any distance to clinics, etc.; and again in the treatment of minor ailments, children cannot be sent alone to clinics as is the case with the ordinary elementary school child, for they are not used to the streets or locality, and I understand that there have been a fair number of skin cases, ears, etc. It would be very useful if the school nurse could attend at intervals for the treatment of these on the premises. 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 yeer was 7,019, an increase of 533 or 8 per cent. over the previous year. The total number of examinations was 8,749. The candidates may be classified as (a) candidates for entrance to the permanent service; (6) candidates for the award of scholarships Candidates for permanent service. The total number of candidates examined was 1,215 (564 males and 651 females), but of these candidates 46 attended for their first examination in the previous year. There were, however, 1,465 examinations (684 males and 781 females); in 250 cases (120 males and 130 females a second or third examination was necessary. Of the number thus referred remedial treatment was satisfactorily obtained in 231 cases, 1 was rejected, 11 withdrew their applications, 57 were still under consideration at the end of the year. The total number rejected was 11, the reasons being: defects of vision, 4; heart disease, 3; unsatisfactory general health, 3; deficient chest measurement, 1. Candidates for the award of scholarship*. The scholarships and awards granted by the Council fall into three divisions, C each of which requires different treatment in so far as the medical examination of candidates is concerned: (a) County scholarships enabling candidates to proceed to institutions of university rank; (6) Technical scholarships, enabling candidates to receive instruction in trades, and special scholarships; (c) Awards enabling candidates to prepare for the teaching profession. The total number of candidates examined was 5,804; these include 46 who attended for their first examination in the previous year. There were, however, 7,284 examinations, the excess being due to the fact that in 1,480 cases a second or third examination was necessary; of the number thus referred 1,241 obtained satisfactory treatment and were on re-examination certified as fit. 153 were rejected, 114 as the result of their first examination, and 39 as the result of subsequent examinations. The reasons for rejections were : Defective vision, 91; unsatisfactory general health, 22; unsatisfactory condition of heart, 22; miscellaneous defects, 21; three candidates were rejected for two defects. Cases specially referred. There are also referred to the public health department:— Special cases of employees in the education service absent owing to 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 proceeding overseas under the interchange scheme. Cases of teachers returning to duty after extended leave of absence (a) owing to personal illness; (b) for educational purposes; (c) married women under E. 22 of the Regulations in regard to education service. Cases of teachers about to apply for a breakdown allowance. 164 Applications for special consideration owing to wounds, etc., of teachers demobilised from H.M. Forces. Claims received from teachers and others in the permanent service for exceptional treatment, as regards sick pay and reimbursement 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 3,695. The major part of these were teachers, of whom 598 were men and 2,735 women. In connection with sick leave, 62 per cent. of the teachers were over 40 years of age; this figure corresponds with that of the previous year. Dr. Fairfield's report on infirmities leading to a premature termination of the services of teachers. Dr. Fairfield has made a preliminary survey of the infirmities which have led to a premature termination of the teacher's career, either by death or disablement, in the year ended 31st December, 1925, among the 19,874 teachers (6,126 men, 13,748 women) in the service of the Council. The following table shows the infirmities which led to death:— Morbid condition. Æ. 20— Æ. 30— Æ. 40— Æ. 50— Æ. 60— All ages. M. F. M. F. M. F- M. F. M. F. M. F. Respiratory dis. non. T.B. — — 1 — — 2 — 3 1 1 2 6 Pulmonary T.B. 4 1 — — — — — 4 1 Influenza 1 — — 2 1 2 2 — 4 4 Nervous system — — — — — — 1 — — — 1 — Rheumatism — — — — — — — 1 — — — 1 Digestive system —- — — — 1 2 3 1 — 1 4 4 Circulatory system —- 1 — 4 — 1 4 Accidents* 1 1 1 — — — 2 2 — — 4 3 Cancer 1 2 2 — 4 — 1 2 8 Cause unknown — — — — 3 2 1 3 — 5 4 Total 1 1 8 2 3 15 9 14 6 3 27 35 2 10 18 23 9 62 *Two under the age of 30 were drowned. During the year there were 73 teachers who broke down prematurely, and the morbid conditions are shown in the following table:— Morbid condition. Æ. 20— Æ. 30— Æ. 40— Æ. 50-54. Æ. 55—59. All ages. M. F. M. F- M. F. M. F- M. F. M. F. Respiratory dis., non T.B. — — — — — 1 — 1 — — — 2 Pulmonary 7.B. — — 1 — — 2 — — — — 1 2 Nervous diseases— Organic. — — — — — — 1 2 1 3 2 5 Functional* — — — 1 2 5 4 4 2 3 8 13 Rheumatism — — — — 2 1 — — — — 2 1 Digestive system — — — — — 1 — 1 — 1 — 3 Circulatory system — — — — — 1 — 5 1 9 1 15 Cancer — — — — — — — 1 — — — 1 Aural — — — — — — 1 5 — 2 1 7 Ophthalmic — — — — — — 1 2 — — 1 2 Miscellaneous! — — — 1 — — — 3 1 1 1 5 Total — — 1 2 4 11 7 24 5 19 17 56 — 3 15 31 24 73 * 7 Insanity. † 2 Osteo arthritis; one each, Grave's disease. Hodgkin's disease, kidney disease, and pernicious anaemia. 165 Analysis of cases referred for examination. Dr. Fairfield has also made the following analysis of 650 cases of women teachers examined by her after reference to the School Medical Officer on account of absences for periods of one month and over. Respiratory diseases (non-tubercular) (Including 18 bronchitis and pleurisy, 25 laryngitis.) 75 Influenza (58 of these were January to June, 10 July to December.) 70 Rheumatism (Acute and subacute rheumatism 12, arthritis 14.) 26 Digestive system (Appendicitis 23, gastric 25, intestinal 13, haemorrhoids and fissure 0, gall stones 10.) 70 Circulatory system (Cardiac 23, arterio-sclerosis 7.) 47 Accidents 25 Diseases of women . (Hysterectomy for fibroids 22.) 44 Miscellaneous (Fevers 13, ear, nose and throat 27, malignant 7, hyperthyroidism 13, etc.) 80 Nervous system (Functional neurosis 171, insanity 4, organic 36.) 211 The neurosis figures are disproportionate owing to the Councils regulation which requires that all teachers sending in certificates indicating nervous affection of any sort shall be referred to the School Medical Officer immediately. The 171 cases of functional nervous disorders include many long absences, some extending to 12 months, and, taken altogether, they show that this is a very important cause of ill-health among teachers. Both prevention and treatment are on a less satisfactory basis than is the case with purely physical disorders. The causes are often obscure and complicated and are frequently not recognised by the patient herself. It can be safely said, as a result of a survey of this series, that the severity of the breakdown is in inverse ratio to the gravity of the alleged cause. Where there has been a really severe shock, such as loss of relatives, or serious overwork, the teachers (excepting one or two of the elderly cases) were back at work in a month or less, however tragic had been the disaster. Where the supposed cause was vague or trivial, and the real difficulty was an unresolved mental conflict or temperamental weakness, the illness is apt to be prolonged and recurrent, and may lead to permanent incapacity. It is found that there is often an unfortunate tendency to rely too exclusively on rest and change of scene in the treatment of neurotics, and to ask for prolonged leave without attempting to ascertain the real cause of strain. Not a few cases of long standing neurosis in this series have been cleared up by suggesting a visit to the dentist, to a laryngologist, or even to the family solicitor, or by dispersing an unfounded and hitherto unconfessed dread of cancer or insanity. The recovery of a patient is often further prejudiced by a tendency to attach too much importance to trivial incidents in the school, to the neglect of much more significant factors in familv and home life. Physical sducation cf beachers. All applicants for admission to the Council's course of physical instruction for teachers were examined. During the year, of the 302 candidates examined, 25 were rejected. Accidents and sudden illness at County Hall The arrangements made in 1922, whereby medical aid and advice could be given in the event of cases of accident or sudden illness at the County Hall were continued in 1925, and aid was rendered and advice given in 250 cases. Generally the cases were of a minor character, and of the 46 cases of injury, only one was serious. Some of the cases were detained in the rest room, the average period of detention being about 45 minutes. 166 Medical Inspections, 1925. (a) ROUTINE INSPECTIONS. (6) OTHER INSPECTIONS. Age group. Boys. Girls. Total. | Boys. Girls. Total. Entrants 41,642 40,567 82,209 Special inspections* (l) 22,253 20,629 42,882 Age 8 25,171 24,700 49,871 (2) 16,813 16,662 33,475 Age 12 33,025 32,597 65,622 Re-inspections — — 159,388 Leavers 20,451 20,560 41,011 Total— Elementary schools 120,289 118,424 238,713 Special Schools 894 758 1,652 *(1) Special cases where individual notes are made. (2) Cases seen en masse where individual notes are not made unless noted for treatment or observation, e.g., camp school nominations, school journey children, etc. (infectious disease contacts are not included in this figure). TABLE II. (a) Defects found at Medical Inspections in 1925. ELEMENTARY AND SPECIAL SCHOOLS. Disease or defect. Routine inspections. Special inspections. Defects. Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation only. E.S. SS. E.S. S.S. Malnutrition 664 1 1,003 3 536 541 Skin— Ringworm—Head . 9 — 3 — 75 24 Body 71 — 1 66 6 Scabies 80 — 1 351 50 Impetigo 375 1 8 471 29 Other disease (non-tubercular) 1,113 11 141 1 873 123 Eye— Blepharitis 966 7 101 — 322 34 Conjunctivitis 387 5 28 360 39 Keratitis 2 1 6 33 9 Corneal opacities 8 — 7 97 22 Defective vision (excluding squint) 17,557 136 5,899 93 3.605 371 Squint 1,677 6 535 4 585 53 Other conditions 266 3 73 217 49 Ear— Defective hearing 639 18 281 7 516 119 Otitis media 2,165 26 686 6 998 166 Other ear disease or defect 766 1 255 286 43 Nose and throat— Enlarged tonsils 9,416 30 8,165 26 2,207 573 Adenoids . 1,648 16 838 2 571 93 Enlarged tonsils and adenoids 3,109 5 660 666 53 Other conditions 1,301 15 507 2 634 140 Enlarged cervical glands (non-tubcrcular) 783 1 2,427 7 414 345 Defective speech 96 1 199 112 60 Teeth, dental disease 69,778 394 1,112 4 4,637 112 Heart and circulation— Heart disease—Organic 42 190 2 25 17 Functional 37 387 2 3 11 Not stated 246 — 3,962 20 473 997 Anasmia 1,735 15 1,355 3 1,590 497 Lungs— Bronchitis 1,823 7 1,796 3 596 294 Other non-tubercular 319 2 1,061 6 185 370 167 Disease or defect. Routine inspections. Special inspections. Defects. Defects. Requiring treatment. Requiring observation. Requiring treatment. Requiring observation only. e.s. s.s . e.s. s.s. Tuberculosis— Pulmonary—Definite 20 - 12 —. 38 16 Suspected 45 - 66 1 78 202 Non-pulmonary—Glands 26 - 15 — 52 20 Spine 2 - 1 — 2 6 Hip 1 — 2 — 12 19 Bones and joints 4 - 6 — 15 16 Skin 14 3 — 13 6 Other forms 13 _ 18 — 32 26 Nervous disease— Epilepsy 46 2 67 2 157 116 Chorea 93 - 81 — 283 192 Paralysis 43 — 58 1 278 242 Other conditions 99 2 169 2 Deformities— Rickets 141 47 — 58 25 Spinal curvature 779 8 363 — 198 58 Other deformities 369 2 227 2 172 61 Other conditions 3,413 12 1,467 2 3,948 1,521 (b) Children found at routine medical inspection to require treatment (excluding uncleanliness). Age group. Inspected. Found to require treatment. Percentage requiring treatment. Entrants 82,209 38,573 46.9 Age 8 49,871 22,418 45.0 Age 12 65,622 25,934 39.5 Leavers (age 13J) 41,011 15,608 38.1 Total—Elementary schools 238,713 102,533 42.9 Special schools 1,652 620* 37.5 * Not including the special defect for which the child is attending a special school. TABLE III. Exceptional Children in London in 1925. Blind (including partially blind)— Boys. Girls. T otal. (i.) Suitable for training in a school or class for the totally blind Attending Certified Schools or Classes for the Blind 171 142 313 Attending Public Elementary Schools — 1 1 At other Institutions — At no School or Institution 6 6 12 (ii.) Suitable for training in a school or class for the partially blind Attending Certified Schools or Classes for the partially Blind 394 491 885 Attending Public Elementary Schools 11 14 25 At other Institutions — — At no School or Institution 6 6 11 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 329 322 651 Attending Public Elementary Schools — 1 1 At other Institutions — — — At no School or Institution 12 4 16 168 Deaf—continued. Boys. Girls. Total. (ii.) Suitable for training in a school or class for the partially deaf Attending Certified Schools or Classes for the partially deaf 72 76 148 Attending Public Elementary Schools 4 6 10 At other Institutions — — — At no School or Institution 1 — 1 Mentally defective. Feeble-minded (cases not notifiable to the Local Control Authorities) Attending Certified Schools for Mentally Defective Children 3,745 2,889 6,634 Attending Public Elementary Schools 6 8 14 At other Institutions 293 195 488 At no School or Institution 57 61 118 Notified to the Local Control Authority during the year Feeble-minded 53 61 114 Imbeciles 72 64 136 Idiots 7 12 19 Epileptics. Suffering from severe epilepsy Attending Certified Special Schools for Epileptics 46 40 86 In Institutions other than Certified Special Schools 23 20 43 ††Attending Public Elementary Schools 2 1 3 At no School or Institution 109 101 210 Suffering from epilepsy which is not severe Attending Public Elementary Ordinary 260 263 523 Special 100 77 177 At no School or Institution — — — Physically defective. Infectious pulmonary and glandular tuberculosis *At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 137 167 304 At Certified Day Open-air Schools 146 107 253 At other Institutions 3 3 6 At no school or Institution 27 29 56 Non-infectious but active pulmonary and glandular tuberculosis *At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 36 23 59 At Certified Residential Open-air Schools — — — At Certified Day Open-air Schools 97 72 169 ‡At Public Elementary Schools 72 64 136 At other Institutions 1 1 2 Delicate children (e.g., pre- or latent tuberculosis, malnutrition debility, anosmia,etc. At no School or Institution — — — At Certified Residential Open-air Schools 3,464 1,087 4,551 At Certified Day Open-air Schools 710 391 1,101 At Public Elementary Schools 3,822 3,708 7,530 *At other Institutions 121 97 218 At no School or Institution 204 189 393 Active non-pulmonarj tuberculosis *At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 422 373 795 (Note.—Cases of more 01 less quiescent tuberculosis attend the special Day Cripple Schools) JAt Public Elementary Schools 54 54 108 At other Institutions 3 4 7 At no School or Institution 23 18 41 Crippled children (other than those with active tubercu lous disease), e.g. children suffering from paralysis, etc. and including those with severe heart disease At Certified Hospital Schools 7 18 25 At Certified Residential Cripple Schools 17 10 27 **At Certified Day Cripple Schools 2,119 2,057 4,176 At Public Elementary Schools 1,548 1,983 3,531 *At other Institutions 381 224 605 At no School or Institution 218 381 600 * Some of these may not have come to the notice of the School Medical Officer, but have been dealt with throughout by the Guardians. ‡Discovered at medical inspections and referred for treatment, ††Awaiting admission to Colonv. ** These figures include about 1,000 children suffering either from non-pulmonary tuberculosis more or leas quiescent, or from the after-effects of such disease. 169 TABLE IV. Defects treated during 1925. TREATMENT TABLE. Group I.—Minor Ailments (excluding uncleanliness, for which see Group V.). Disease or defect. Defects treated or under treatment. Under Council's scheme. Otherwise. Total.###] Skin. Ringworm—Head 1,167* 817 l,984† Ringworm—Body 2,077 Scabies 1,284 Impetigo 793 Other skin diseases Eye disease. (External and other, but excluding cases falling in Group II.) 88,447 1,534 92,058 Ear disease. 2,077 Cases in which operative treatment [e.g., mastoid operations, etc.) is given are excluded. Miscellaneous. (Minor injuries, bruises, sores, chilblains, etc.) 91,691 2,351 94,042 *1,034 by X-Ray. †1,303 by X-Ray. Group II.—Defective Vision and Squint (excluding eye defects treated as Minor Ailments, Group I.). Defect or disease. Defects dealt with. Under Council's scheme. Otherwise. Total. Errors of Refraction (including Squint, but excluding perations for Squint). 34,356 1,520 37,876 Other defect or disease of the eyes (excluding those in Group I.). 2,000 (estimated) Children for whom glasses were prescribed under Council's scheme 25.555 „ who obtained or received glasses under Council's scheme 22,957 Group III.—Treatment of Defects of Throat and Nose. Number of defects. Received operative treatment. Received other forms of treatment. Total number treated. Under Council's scheme. Private practitioner or hospital. Total. 10,546 1,633* 12,179 4,520 16,699 *184 by private practitioners, 1,449 at hospitals. 170 Group IV.—Dental Defects. (1) Number of children who were:— (a) Inspected by the Dentist—Age Groups— 5 years and under 9,471 11 years and under 48,922 6 „ „ 34,390 12 „ ,, 10,526 7 ,, ,, 32,305 13 „,, 13,163 8 „ ,, 10,345 14 „ over 6,924 9,, ,, 46,474 l0 „ ,, 49,962 262,482 (b) Found to require treatment, 182,524 (69,54 per cent.). (c) Actually treated, 112,964 (including (d) ). (d) Re-treated as the result of periodical examination, 27,358. (2) Half-days devoted to—Inspection, 2,240. Treatment, 18,932—Total 19,172. (3) Attendances by children for treatment, 183,178. (4) Fillings—Permanent teeth, 78,947 Temporary „ 30,231—Total 109,178. (5) Extractions—Permanent teeth, 46,545 Temporary „ 290,002—Total 336,547. (6) Administrations of general anesthetics for extractions, 56,345. (7) Other operations—Permanent teeth Temporary „ Total25,467. Group V.—Uncleanliness. (а) Average number of visits per school made during year by School Nurse, 6. (б) Examinations of children in the schools by school nurses, 1,937,588. (c) Instances of uncleanliness, 323,020. (d) Children cleansed under Council's arrangements, 100,821. (e) Cases in which legal proceedings were taken :— (i.) Under the Children Act, 1908—689. (ii.) Under School Attendance By-laws—Nil. CHAPTER III. PUBLIC HEALTH. Tuberculosis. 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 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 growth and development of these arrangements are referred to in detail in Chapter I. of this volume (pp. 58-69). In order to provide more residential accommodation for advanced cases of adults suffering from tuberculosis, the Metropolitan Asylums Board is reconditioning its institution at Grove-park, Lee, accommodating upwards of 300 patients, for the reception of advanced cases of both sexes. It is anticipated that this institution will become available in 1926. The dispensary service was the subject of special survey in 1920f. Recommendations for the improvement of the service are made from time to time by the Council and the Minister of Health to the metropolitan borough councils. In connection with an application of a metropolitan borough council for * Scheme for the treatment of tuberculosis in Lor,don. No. 2183. Price 4d. †Tuberculosis in London. Report of the Public Health Committee. 1st July, 1920. No. 2035. Price 6d. 171 approval to the provision and equipment of premises for the purpose of giving artificial or natural sunlight treatment for tuberculosis, consideration was given to the question whether artificial light should be used to a greater extent for the treatment of tuberculosis under the Council's scheme. The Council was not prepared to approve, for grant purposes, as part of the arrangements at borough tuberculosis dispensaries, the provision by metropolitan borough councils of facilities for artificial light treatment; but steps have been taken, in consultation with the Ministry of Health, with a view to provision being made at suitable institutions for a test on an adequate scale of the advantages of artificial light treatment. With the object of reducing the number of cases of arrested disease under supervision at the dispensaries after they have reached a stage at which they may reasonably be regarded as " cured arrangements for the cessation of dispensary treatment or supervision of cases of tuberculosis on a definite basis came into force on 1st January, 1925. In consultation with the Minister of Health the Council has approved of arrangements in several cases during the year for the post-graduate instruction of tuberculosis officers. A conference was held in May, 1925, with representatives of the tuberculosis care committees, at which various matters concerning the work of those committees were discussed. Under the Council's scheme, the contributions received from parents or guardians towards the cost of the residential treatment of children are paid into a fund, known as the Tuberculosis Contributions Fund, which is applied towards the provision of institutional treatment in certain cases, clothing, surgical appliances, etc., the Invalid Children's Aid Association undertaking the necessary arrangements. The use of the Fund has been extended and applied towards defraying the cost of boarding out children removed temporarily from homes infected with tuberculosis, certain children on discharge from sanatoria, other weakly children living under conditions likely to subject them to infection from tuberculosis, and children, in suitable instances, whose parents are under treatment for tuberculosis, and whom it would appear desirable to deal with in the manner indicated. The Invalid Children's Aid Association has undertaken these arrangements also during an experimental period of one year, the cost, less any amounts received by way of contributions from parents, being met out of the Fund. The chairman of the Public Health Committee gave evidence on behalf of the Council before the Royal Commission on National Health Insurance in support of the Council's representations that consideration should be given to the questions whether:— (i.) Grants should be made from national health insurance funds in aid of approved work centres at which post-sanatoria cases could be employed under the medical supervision of the tuberculosis officer; (ii.) The statutory maximum period of sickness benefit should be extended in the case of tuberculous persons; (iii.) Allowances should be made from insurance funds to tuberculous insured persons capable ot part-time, but incapable of whole-time, work; and (iv.) The surpluses available under the National Health Insurance Act for "additional benefits" should be utilised, at the discretion of the approved societies, in part for certain benefits in kind, financial aid, etc., on a similar basis to the provision made for ex-service men by the British Red Cross and United Services Fund. Reference is made on p. 177 to the ^presentations on the subject of providing suitable employment for tuberculous members of urban populations which were made made by the deputation which attended before the Minister of Health in June, 1925. 172 Poliomyelitis The Annual Report for 1924 (Vol. III., p. 126) contains particulars of steps taken to secure early and efficient diagnosis and treatment of poliomyelitis, and increased facilities for treatment of the resulting infantile paralysis. Arrangements have been made for persons suffering from the disease in its later stages to be referred through the Council's organisation to the Metropolitan Asylums Board, for treatment at the Board's Orthopaedic Hospital at Carshalton. The Invalid Children's Aid Association has agreed to assess and collect contributions from parents on the basis of the arrangements which apply in the case of contributions towards the cost of treatment of children for tuberculosis, and these contributions, less a small deduction for expenses, are handed over to the Board. Venereal disease. Details are given in the Annual Report for 1921 (Vol. III., p. 63) of the scheme for the diagnosis and treatment of venereal diseases in the county. The scheme provides for the participation of certain authorities near London in the facilities afforded by selected hospitals for the purpose. The arrangements for 1925 provide for free treatment and diagnosis for in-patients and out-patients at 28 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 for diagnosis purposes on materials obtained 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 borne as to 75 per cent. by the Ministry of Health and as to the remaining 25 per cent. by 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 1925 and preceding years are given in Chapter I., pp. 69-71. The Council's venereal diseases 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 (now the British Social Hygiene Council)— has, subject to conditions, exercised on behalf of the Council certain of its powers relating to propaganda work. The Council undertakes publicity work which can most usefully be directed through official channels. Rescue and preventive work. A central council representing public authorities and voluntary agencies concerned in rescue and preventive work in London undertakes the co-ordination of rescue and preventive work among women and girls in London. The Council has four representatives on the central council. Health propaganda. The Council decided to apply to Parliament in the session of 1926 for authority to enable it to undertake and contribute towards the cost of health propaganda work and also to enable the metropolitan borough councils to undertake such work. Child adoption. The departmental committee appointed by the Home Secretary to examine the problem of child adoption from the point of view of possible legislation and to report upon the main provisions which in their view should be included in any Bill on the subject have issued two reports, but the questions in which the Council is mainly interested and on which it submitted evidence to the departmental committee are reserved for a later report. These questions relate to the amendment of Part I. (Infant Life Protection) of the Children Act, 1908. (See Annual Report for 1920, Vol. III., p. 113). 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 173 48 hours. At the end of 1925, 2,515 foster-mothers and 3,540 nurse-infants were under inspection. Power is given to remove to a place of safety an infant in the charge of a foster-mother who is unfit to have the care of it owing to negligence, ignorance, inebriety, immorality, criminal conduct or other similar cause. Similar action may be taken where the premises are overcrowded, dangerous or insanitary, or if the infant is being kept by a person or in any premises in contravention of the Act. The Act also empowers a local authority to exempt either partiallv or wholly premises which are so conducted as to render ordinary inspection unnecessary. Particulars of action taken in recent years 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 1924 7 4* 26 274 267 7 7 1925 3 1* 38 263 261 2 2 Lying-in homes. * Partial. 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 1924, 275 premises were on the register, 40 were added during the year, and 38 entries were removed (owing to discontinuance of user, removal, etc.), leaving a net total of 277 on the register at the end of 1925. Nine premises carried Midwives. on by registered medical practitioners were exempted during the year. 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, profess ona! 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 1925, to 31st March, 1926, the Council's expenditure under this head was £4,056 18s., of which £1,241 16s. 1d. was recovered. Further details of the Council's work are given in Chapter I, pp. 71-73. 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 n proportion to population at the last census, and the Council's proport on for the year 1925 was £639. Notifications by midwives of intention to practise during the year numbered 843; of intention to practise for specific periods less than a year, 40; and of having acted in specific cases, 18. Houses divided into separate tenements. In February, 1924, the Council provisionally approved under the powers conferred by Section 26 of the Housing, Town Planning, etc., Act, 1919, as amended by Section 14 of the Housing, etc., Act, 1923, revised by-laws with regard to houses divided into separate tenements. The sections of the Acts referred to were repealed, 13651 m 174 but their provisions were re-enacted in Sections 6 and 7 of the Housing Act, 1925. The revised by-laws were communicated to the metropolitan borough councils for their observations, and a conference was held with representatives of those borough councils which submitted observations. The by-laws were subsequently amended in certain particulars, and, as amended, were approved by the Council on 17th November, 1925, and submitted to the Minister of Health for confirmation. Census of homeless persons. Particulars are given in Chapter I (p. 56) of the result of the census of homeless persons taken in February, 1925, in order to ascertain the use made of common lodging-houses, and the provision existing for the accommodation of persons of the poorest class. The total numbers of homeless persons found in the streets, on staircases and under arches at the censuses in recent years were:— 1915, 178; 1916, 44; 1917, 28; 1918, 9; 1919, 8; 1920, 51; 1921, 56; 1922, 112; 1923, 141; 1924, 82; and 1925, 118. Common lodging houses. Particulars with regard to common lodging-houses licensed by the Council are as follows:— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious disease. 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 1924 174 17,519 nil nil nil 1 1925 168 16,930 3 3 £8 19s. 6d. 1 Seamen's lodging- houses. Particulars of seamen's lodging-houses licensed by the Council are as follows:— Year. Houses licensed. Lodgers authorised. Prosecutions. Convictions. Penalties and costs. Cases of infectious disease. 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 1924 38 1.128 4 4 £14 3s. 2 1925 33 1,092 7 7 £41 8s. – Under the powers conferred on 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. Offensive businesses. The following table gives particulars of licensed slaughterhouses, knackers yards and registered offensive businesses:— Year. Slaughterhouses. Knackers' yards. Offensive businesses. 1921 158 4 60 1922 153 4 60 1923 147 4 101 1924 136 4 *230 1925 132 4 *209 * Inclusive of the businesses of a dresser of furskins and a slaughterer of poultry. During 1925 sanction was given in three cases to the establishment anew of the business of a dresser of fur-skins and in one case to the establishment anew of the business of a slaughterer of poultry. Two applications for sanction to the establishment anew of the business of a slaughterer of cattle and of a slaughterer of poultry respectively were refused. By-laws— Slaughter of cattle. The Council amended its by-law for regulating the method of slaughter of cattle in the county so as to provide that the by-law should not apply to any person professing the Mohammedan religion when engaged in the slaughtering of any animals intended for the food of Mohammedans in accordance with the procedure prescribed by Moslem law and custom, if no unnecessary suffering is inflicted upon such animal. The amending by-law was confirmed by the Minister of Health. 175 Cowhouses, The numbers of cowhouses licensed by the Council in the past five years were as follows 1921, 101; 1922, 100; 1923, 98; 1924, 89; 1925, 84. Tuberculous milk. Under the powers conferred on 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 1925, 2,300 samples from milk consigned to London railway termini from 33 counties were submitted for bacteriological -examination. Of these samples, 107, or 4.6 per cent., yielded tubercle baccilli as against 5.04 per cent. present in 1924. In connection with these samples the veterinary inspector visited 98 farms and examined 2,864 cows. It was found that 53 cows, i.e., 1.8 per cent., showed signs of tuberculosis or were otherwise unhealthy; 30 ccws supposed to have been tuberculous had been slaughtered prior to the inspector's visits. In each case the farmer undertook to have the animal removed. In addition the inspector re-visited 596 farms, and inspected 14,139 cows; all the animals examined at these re-visits were found to be in a satisfactory condition with the exception of 75 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, and 41 cows were examined. No cases of generalised tuberculosis were found, but it was ascertained that two cows suspected to be suffering from tuberculosis had been slaughtered prior to the inspector's visit. During 1925, as an experiment, samples of milk from the cows at all the Council's mental hospitals have been examined at intervals of six months. One of these samples was found, on bacteriological examination, to be tubercleinfected. All the cows at the hospital were, therefore, examined, and two which showed signs of generalised tuberculosis, were slaughtered. At an inspection of the cows at another mental hospital, one animal affected with advanced generalised tuberculosis was ordered to be slaughtered. Arrangements have also been made for the Council's inspector to examine and Teport on the cows at two of the Council's industrial schools whenever he is in the neighbourhood of these schools. During the year eight cows were examined, and one was found to be in an unsatisfactory state of health, although not actually tuberculous. An intimation was received from a metropolitan borough council that a sample of milk retailed in the borough had been found on examination to be tubercle-infected. As the retailer concerned obtained his supply of milk from various sources, the Council's inspector visited three farms and examined 84 cows. One cow was found to be infected with generalised tuberculosis, and arrangements were made with the farmer for its disposal. During 1925 four inspections were made of the cows in London cowsheds, and the total number of examinations made was 6,163. One case of generalised tuberculosis was detected, and the animal affected was voluntarily slaughtered by the owner. In 108 cases other unhealthv conditions were found. Tuberculosis Order, 1925. The Ministry of Agriculture and Fisheries on 13th July, 1925, issued the Tuberculosis Order, 1925, which came into force on 1st September, 1925, and revoked the Tuberculosis Order of 1914. The Order is made under the Diseases of Animals Acts, 1894 to 1925, and the Council is the local authority for enforcing the Order in the County outside the City ot London. The Order aims at the destruction of every cow suffering from tuberculosis ot the udder or giving tuberculous milk and every bovine animal suffering from tubercular emaciation or trom a chronic cough and showing definite signs of tuberculosis, a bovine animal being defined as meaning a bull, cow, ox, heifer or calf. Under Part V. of its General Powers Act, 1904, the Council had power to seize and slaughter any cow suspected to be suffering from tuberculosis of the udder, and under this Act all cows in London sheds have been examined quarterly by the 13651 m 2 176 Council's veterinary inspector. The practice of the Council, therefore, so far as bovine animals in London are concerned, will be modified only to a slight extent by the operation of the Order. Under the Order, local authorities will receive from the Treasury 75 per cent. of the gross cost of compensation. The Diseases of Animals Act, 1925, legalises the payment of Exchequer grant, and for the purposes thereof no deduction is to be made in respect of any sum received by the local authority from the sale of carcases. Following previous practice, the Council proposes to require that the whole carcase of any diseased animal shall be destroyed so that none of it shall be used for human consumption. The Council approved the necessary arrangements for putting the Order into operation, and appointed Mr. A. E. Dunbar, veterinary inspector in the publichealth department, as a veterinary inspector under the Order. Milkshops and dairies. The Milk and Dairies (Consolidation) Act, 1915, came into operation on 1st September, 1925, and under section 1 of that Act the Minister of Health is authorised to issue Orders on many matters designed to secure the protection of milk against infection or contamination, etc. Section 21 (3) of the Act provides for the repeal at the end of one year after the coming into operation of the Act of so much of any local Act as relates to any of the matters dealt with by any of the provisions of the general Act. Part IV. of the London County Council (General Powers) Act, 1907, under which the Council has exercised powers with regard to the taking and examination of samples of milk will therefore continue in operation only until 31st August, 1926, and the position arising will then call for consideration. The bulk of the Act, so far as London is concerned, falls to be administered by the metropolitan borough councils. Greengrooery. Consideration was given to the question of the possible risks to public health of the present methods of exposing greengrocery for sale, and the Council decided to ask the Minister of Health to consider, in connection with the issue of any future regulations relating to the sale of food, the advisability of dealing with the conditions under which greengrocery (particularly fruit and vegetables which are eaten uncooked) is stored before sale and subsequently exposed or offered for sale either in shops or on street stalls or barrows. Appeal Committee. The Appeal Committee are the statutory appeal committee under the Metropolis Management Act, 1855, section 212. The Committee also hear and decide all appeals made to the Council under any other Act of Parliament (except appeals under section 20 (5) of the Public Health (London) Act, 1891, against decisions of the Public Health Committee). Six appeals were heard during the year 1925. Of these, twowere allowed and four were dismissed. London health services. A deputation from the Council was received by the Minister of Health on 8th June, 1925, in support of the undermentioned resolutions of the Council of 17th March, 1925— That, in the opinion of the Council, the undermentioned matters in connection with London health services call for action by the Government— (i.) The need for settlement of the arrangements for the future administration of Poor Law medical services. (ii.) The consideration, in relation to (i.) above, of the question whether, in the event of the health functions of the London Poor Law authorities being transferred substantially on the lines indicated in the Maclean report, it would be desirable that hospitals or infirmaries drawing patients from local areas should be locally managed. (iii.) The need for amendment, in matters of administrative detail, off Part I. (Infant Life Protection) of the Children Act, 1908. (iv.) The need for amendment of the Cleansing of Persons Act, 1897. 177 (v.) The need for regulations, under which the Council should be the authority in the administrative county of London, for objects similar to those of the Public Health (Influenza) Regulations, 1918. (vi.) The need for comprehensive legislation dealing with the question of smoke abatement. (vii.) The need for revision and consolidation of the Acts relating to health services in London. (viii.) The need for investigation by the Ministry of Health of the question of the disposal of house and other refuse. (ix.) The advisability of a comprehensive technical inquiry by the Ministry of Health into the problem of dealing as a whole with the drainage of London and adjacent areas draining naturally into the Thames and its tributaries. (x.) The desirability of instituting an inquiry as to the steps which should be taken to provide suitable employment for tuberculous members of urban populations. The deputation was introduced by the Chairman of the Council and was sympathetically received by the Minister of Health, who in his reply indicated the intention of the Government to deal with the questions of Poor Law Reform and of smoke abatement. The Minister also undertook that an inquiry should be made into the question of the disposal of refuse. On the question of drainage, the Minister stated that he proposed to draw up a suggestion for a committee of technical experts with whom the Council's chief engineer would be associated to go into the matter. As regards the after-care of tuberculous men and women, the Minister stated that he was in negotiation with the Treasury on the question of assisting the setting up of experimental workshops under medical supervision. Diseases of Animals; The Diseases of Animals Acts, 1894 to 1925, 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 1925 the incidence of the principal animal diseases so far as London is concerned was as follows:—Glanders, including farcy, nil; swine fever, 2 outbreaks in which 191 animals were involved; anthrax, nil; parasitic mange, 73 outbreaks involving 106 animals; and foot and mouth disease, nil. 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 1925 no fewer than 20,870 swine were examined at feeders' premises. 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, 30,053 dogs were seized bv the police during 1925 and 22,039 were destroyed. Parasitic mange. On the outbreak of the Great 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 1925 the returns of cases in London showed a slight increase. The following figures relate to 1925 Outbreaks, 73; horses affected, 106; infringements, 18; written cautions sent, 12; cases referred to solicitor, 6; convictions, 6; penalties and costs, £37 5s. For the purposes of comparison, it may be pointed out that the number of outbreaks in 1924 was 67, affecting 102 horses. 178 Foot and month disease. The Minister of Agriculture and Fisheries, on 8th February, 1921, appointed a Departmental Committee to consider the outbreak of foot and mouth disease which occurred in 1923-1924. In their report, dated 2nd February, 1925, the Departmental Committee "regret that many of the recommendations put forward by the 1922 Committee, on which four members of the present Committee served, appear to have received little attention," and they state that "while we cannot claim that their adoption would have prevented the outbreak of 1923, we do feel that its effects would have been materially curtailed." The only important matter arising out of the report, so far as the Council is concerned, beyond the recommendations relating to the policy to be adopted in connection with outbreaks of foot and mouth disease, is that of finance. At the present time contributions towards the expenses of defraying the expenditure in connection with this disease are made from the Local Taxation accounts. The sum expended by the Ministry of Agriculture and Fisheries from 31st March, 1921, to 31st March, 1924, amounted to approximately £4,000,000. Towards this sum the Local Taxation accounts have contributed about £1,200,000. As a result of representations by the Departmental Committee on Foot and Mouth Disease that provision should be made for the automatic imposition of " standstill" restrictions in any case in which a veterinary inspector of a local authority is of opinion that foot and mouth disease exists or that there are reasonable grounds for suspecting its existence, the Minister of Agriculture and Fisheries made an Order entitled the Foot and Mouth Disease (Emergency Restrictions) Order of 1925, which came into operation on 11th February, 1925. The diagnosis of foot and mouth disease rests with the Minister of Agriculture, and the principal object of the new Order was to prevent all movement out of an area having a five-mile radius from the premises concerned even when foot and mouth disease is only suspected by an inspector of the local authority to exist. In such cases a veterinary inspector is required to issue a certificate and send it to the Minister and also to notify the local authority, the police and the railway authorities. Heavy penalties are provided in the case of unlawful movement. The restrictions imposed by the Order operate for two clear days unless withdrawn or extended by an inspector of the Ministry, Suspected cases of disease rarely occur in London, but instructions have been given for the provisions of the new Order to be made known as and when occasion arises. Further, as the result of recommendations of the Departmental Committee on Foot and Mouth Disease, the Minister of Agriculture and Fisheries issued an Order, which came into operation on 19th November, 1925, entitled the Foot and Mouth Disease (Packing Materials) Order of 1925. The object of the Order was to prevent the spread of disease by hay, straw, etc., used as packing materials. The necessary steps were taken to bring the provisions of the Order to the notice of persons concerned. The Minister of Agriculture and Fisheries addressed a circular letter dated 29th October, 1925, to local authorities under the Diseases of Animals Acts, emphasising the need for veterinary inspection of all animals exposed in markets and asking for particulars of the steps taken to secure such inspection. The only cattle market in the County of London is the Metropolitan Cattle Market, Islington, which is owned by the City Corporation and is under the supervision of a veterinary surgeon, appointed and paid by that body. This officer has also been appointed by the Council, without salary, to act as a veterinary inspector under the Diseases of Animals Acts for the market area. Animals are brought to the market by road, rail and float, and on arrival are subjected to a strict veterinary examination. There are subsequent examinations before sale or removal. Precautions are also taken to ensure the strict observance of the Council's regulations as to the disinfection and cleansing of vehicles used for the conveyance of animals and to secure the disinfection of lairages, markets and slaughterhouses. 179 In view of the recrudescence of foot and mouth disease the Minister of Agriculture issued an Order, entitled the Midlands and South of England (Regulations of Movement of Animals) Order of 1925, which came into operation on 17th November, 1925. The main purpose of the Order, which applied to 37 counties, was to prevent the holding of any markets of store stock in the regulated area and to control the movement of store animals generally whilst allowing every possible facility for the disposal of fat stock intended for immediate slaughter. Markets, sales and exhibitions of animals were prohibited except in the case of markets or sales of fat stock for immediate slaughter (such markets to be held under a licence from the local authority) and sales of animals on farm premises. Arrangements were made by the exhibition of posters throughout the County for the provisions of the Order to be brought to the notice of persons affected. Animals in Transit. The Animals (Transit and General) (Amendment) Order of 1925, which came into operation on 16th March, 1925, was made by the Minister of Agriculture and Fisheries with a view to preventing the movement along a road, either on foot or in any vehicle, of cattle or other animals which, owing to old age, infirmity, illness, injury, fatigue or any other cause, cannot be so moved without unnecessary suffering. The Order supplements the provisions of the Animals (Transit and General) Order, 1912, which relate to the conveyance of unfit animals by rail or vessel, and empowers an inspector of the Ministry, or of the local authority, to prohibit the movement of such animals by road on the service of a notice. The necessary steps were taken to make known the provisions of the new Order. To ensure that the requirements of the several Orders in force from time to time 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 1925 numbered 2,798, the animals examined being—horses 3,292, cattle 48,589. sheep 67,513, swine 7,390, making a total of 126,784. There were 34 infringements, 26 written cautions, 8 cases of legal proceedings and 5 convictions, with penalties and costs amounting to £99. Smoke nuisance. In consequence of a suggestion made by a stipendiary magistrate in connection with legal proceedings instituted by the Council against a railway company in respect of smoke nuisance, it was arranged during the year with the co-operation of all the railway companies running steam-driven trains in London for a series of joint observations to be made by the Council's coal officers and the officials of the companies. These observations extended over the whole of the portions of the companies' lines within the County. At the suggestion of the officials of two of the companies, the coal officers concerned took journeys on the foot-plates of engines with a view to becoming acquainted at first hand with the difficulties and working arrangements of railway traffic. Each of the companies showed a desire to make the joint observations successful and afforded full facilities for this purpose. The results of the observations showed that, although in the normal working of a railway locomotive, smoke nuisance need not arise, nevertheless, in a variety of ways, owing to negligence on the part of the company or its servants, nuisance may, and in fact does sometimes occur. On the other hand it has to be admitted that, in certain circumstances, the emission of smoke cannot be altogether avoided. It was felt that the joint observations would prove of considerable value in the limitation of smoke nuisance from railway locomotives. During the year the question was considered of promoting legislation with a view to securing more satisfactory powers to the Council in connection with the emission of sparks, cinders, etc., from railway locomotives. The question is already dealt with by legislation to some extent. In the exercise of their statutory powers railway companies are authorised (Railways Clauses Act, 1845, section 86) to use and employ locomotives, and the effect of this section is to absolve them from liability for damage caused by sparks to which they would otherwise be subject 180 where there is no negligence. The liability was, however, by the Railway Fires Act, 1905, as amended by the Railway Fires Act (1905) Amendment Act, 1923, restored so far as it related to damage to agricultural land or agricultural crops by fire arising from sparks or cinders emitted from a locomotive, to the extent of £200 in anv case. The Royal Commission on Fire Brigades and Fire Prevention dealt with the matter in their report dated 20th July, 1923, and recommended that the problem of the most efficient method of preventing the emission of sparks from locomotives should be further investigated. The Royal Commission also stated in paragraph No. 32 of their report that the problem of preventing the emission of sparks without impairing the efficiency of the engine appeared to be one which could not be regarded as having been satisfactorily solved. Having regard to these considerations, it was not thought that legislation having for its object the compelling of railway companies to prevent the emission of sparks and cinders from their locomotives or to penalise them if such emission is permitted or to increase their liability for damage resulting from such emission, would be likely to succeed at the present time. While it might be reasonable to take action with a view to penalising railway companies for causing damage by sparks to other than agricultural land and crops the opinion was expressed that Parliament would almost certainly take the view that the matter, if dealt with at all by means of legislation, was one which should be considered from the standpoint of the whole country and be dealt with by a public Bill. In all the circumstances it was decided in June, 1925, to take no action in the matter. Proceedings as indicated below were taken by the Council during 1925 with regard to smoke nuisance from railway and road locomotives, and some proceedings were also instituted by the sanitary authorities in respect of smoke nuisance from trade premises. As regards railway locomotives, section 114 of the Railway Clauses Consolidation Act, 1845, requires that every locomotive shall be constructed on the principle of consuming its own smoke, and section 19 of the Regulation of Railways Act, 1868, enacts that, if a locomotive fails to do this, the railway company shall be guilty of an offence. Fifty-four prosecutions were instituted against railway companies; 51 convictions were obtained, penalties and costs amounting to £117 19s. 6d. being imposed. Seven prosecutions instituted in respect of smoke nuisance from road locomotives were all successful, the penalties and costs imposed amounting to £5 13s. 6d. Particulars of the work carried out during the year in connection with the suppression of smoke nuisance are as follow:— (1) Railway locomotives:—Nuisances reported—65. Prosecutions—57. Convictions—51. Total of fines imposed—£82 8s. Total of costs imposed—£35 11s. 6d. (Proceedings outstanding in 3 cases.) (2) Road locomotives:—Nuisances reported—12. Prosecutions—7. Convictions—7. Total of fines imposed—£4. Total of costs imposed—£1 13s. 6d. (3) Premises:—Reports made as to alleged nuisances—161. Cases in which legal proceedings were taken by metropolitan borough councils as the result of such reports—3. Convictions—2. Total of fines imposed—£7. Total of costs imposed —£21. In one case in which a conviction was not obtained the summons was dismissed on payment of £15 15s. costs. Smoke nuisance— Electrification of railways. In connection with the question of smoke prevention, the question was raised whether pressure should be brought to bear upon the railway companies to electrify all railways operating in the London area. The Minister of Transport was approached with a view to obtaining such statistics as were available as to the extent to which 181 electrification had already been carried out in the County of London and also particulars as to schemes of electrification in the same area which were in hand or were definitely to be undertaken in the near future. Inquiry was also made whether the Minister had taken or was contemplating taking any action with a view to encouraging the more speedy electrification of railways in London. In his reply the Minister forwarded a list of electrification schemes actually carried out, and to be carried out. As regards the inquiry whether action had been taken with a view to encouraging the more speedy electrification of railways in London, the Minister forwarded a copy of a question asked on the subject in the House of Commons on 30th June, 1925, and of his reply thereto, which was to the effect that the Government were considering the whole question of electricity, and that it might be assumed that any improvement in the supply and distribution of electricity would facilitate its use as a motive power on railways, as well as in other directions. The Minister of Transport was subsequently asked to furnish such figures as were available showing the total mileage of railways in the Comity of London which had actually been electrified or were in process of electrification as compared with the total mileage upon which steam-driven trains were still being run, and an inquiry was also made whether, so far as the Minister was aware, any scheme of electrification was in contemplation on the Great Eastern Section of the London and North Eastern Railway, particularly in the districts of Shoreditch, Bethnal Green, Cambridge Heath, and in the vicinity of Liverpool-street station, these being the districts to which special attention had been drawn as regards the existence of smoke nuisance. In his reply the Minister stated that the returns rendered to the Ministry did not show the proportions of electrified and non-electrified lines within the County of London, and added that he was not aware that the London and North Eastern Railway Company contemplated putting forward at present any scheme for electrification in the districts mentioned. Inquiry from the railway company in question elicited the information that they had not in contemplation any scheme of electrification so far as their lines in the districts specified were concerned. While full sympathy was expressed with the object sought to be achieved, namely, the prevention of smoke nuisance, and while the Council would view with favour any further electrification of railways in London, it was felt that no useful purpose would be served by making representations to the railway companies concerned in the direction suggested. Arrangements were, however, made for special observations to continue to be kept in order to detect cases of smoke nuisance from railway locomotives. CHAPTER IV. MAIN DRAINAGE. Drainage area and statistics. The district drained by the Council's main drainage system has an area of nearly 149 square miles with an estimated population of 5,480,000, This includes an area of nearly 32 square miles, with a population of 868,000 outside London. The quantities of sewage, etc., dealt with during 1925 were as follows:— Sewage treated— Million gallons. Northern outfall 55,30 4.6 „ „ (daily average) 151.5 Southern outfall 35,921.2 „ „ (daily average) 98.4 Sludge sent to sea— Tons. Northern outfall 1,480,800 ,, „ (daily average) 4,057 Southern outfall 906,400 „ „ (daily average) 2,483 182 The sludge vessels made 1,842 trips and travelled altogether 202,628 nautical miles. Sewage treatment. For some years past experiments have been undertaken in connection with the biological treatment of sewage on the activated sludge basis. During the year tanks have been used for agitating the sewage by two different processes, namely (i.) the diffusion of air through the sewage by means of porous tiles fitted in the bottom of the tank; and (ii.) the agitation of the sewage by paddle wheels which constantly expose fresh layers of the sewage to the air. The experiments have established the fact that London sewage responds to this treatment. Later experiments have been directed towards the treatment of the effluent discharged into the river from the settling or sedimentation channels and it has been found that effluent can be more expeditiously dealt with than crude sewage. The tanks have been altered from time to time and the quantities of liquid which can be dealt with have been largely increased. The restricted flow of fresh water from the upper reaches of the Thames during the summer decreased the means of dilution of the effluent discharged at the outfalls, and consequently it was considered advisable to treat the sewage with chemical re-agents until the flow of the river became more normal. This treatment lasted for a period of 4½, weeks and expenditure of £1,729 was incurred in this respect. Deposit of sludge at sea. The solids, known as sludge, which are obtained from the sewage after sedimentation at the outfalls are conveyed to, and deposited in, the Black Deep in the Thames estuary. The Deep is also used by other authorities for the deposit of waste materials, and during the year an enquiry was held by the Board of Trade into allegations that deposits in the Deep tended to cause the shoaling of the Edinburgh Channel, one of the principal means of access to the Port of London for large ships, and into the suggestion that the position of the area for such deposits should be altered. The Council was represented at the enquiry, and on its behalf it was pointed out that the average cargo of the sludge vessels contained no less than 92 per cent. of water. The amount of inorganic material deposited by the Council does not exceed 1,000 tons a week. Spread over so large an area as the Deep this quantity of solid matter is negligible. Evidence was adduced by other depositors and the Board, after considering the various factors, decided that there was not sufficient evidence to prove that the silting up of the Edinburgh Channel was due to the deposit of materials in the Black Deep and that it saw no valid reason for discontinuing at present the use of the Deep for the purpose. The cost of buoying the Black Deep deposit area is apportioned among the various authorities using it for that purpose. The Council's proportion for the year 1925 amounted to £182 14s. 10d. Sludge vessels. The policy of constructing new ships to take the place of the old fleet of sludge vessels has been continued during the year. The s.s. G. W. Humphreys, constructed by Vickers, Limited, of Barrow, was put into commission on 23rd January, 1925. As in the case of the other new vessels, the G. W. Humphreys has a cargo capacity of 1,500 tons. The cost was approximately £46,000. The Council has decided to obtain a further vessel of similar capacity, to be named John Perring. and has accepted the tender amounting to £55,300 of William Beardmore and Company, Limited, of Dalmuir, for the construction of the vessel. When the new vessel is delivered the fleet will consist of the Bazalgette, commissioned in 1887 and reconditioned in 1921, of 1,000 tons capacity, the Henry Ward (commissioned in 1923), the J. H. Hunter (commissioned in 1924), the G. W. Humphreys and the John Perring, giving a total carrying capacity of 7.000 tons as compared with 6,000 tons of the six old vessels. The tender of Mr. T. C. Pas, of Scheveningen, Holland, amounting to £8,010 (including provision money), for the purchase of the three old vessels, the Barking, the Binnie, and the Burns, was accepted. The overhaul and quadrennial survey of the s.s. Bazalgette was undertaken during 183 the year at a cost of £1,411. The sludge vessel J. H. Hunter was damaged as the result of a collison with an ocean-going liner (s.s. Surrey), and was repaired at a cost of £2.556. Northern outfall. The work of extending the pier at the Northern outfall to accommodate the larger type of sludge vessels was completed by C. J. Wills and Sons, Limited, at a cost of approximately £5,826. The s.s. Surrey, which collided with the s.s. J. H. Hunter, as stated in the previous paragraph, also caused serious damage to the pier and the recently finished extension. Steps are being taken to put in hand the necessary repairs. The general work of repairing the pier, which is being carried out over a period of vears, was continued during the year at a cost of approximately £1,200. Some of the machinery at the outfall, which had been installed for 36 years, was practically worn out. Tenders for four new pumping engines and two surface condensing sets were invited, and the tender of Peter Brotherhood, Limited, of Peterborough, amounting to £5,549, was accepted. Arrangements have been made for the demolition of the disused liming station at the outfall. The painting of the overhead sludge tanks was advanced beyond the normal time for repainting in order to provide additional employment, and the Council on 9th September, 1925, accepted the tender of Arthur H. Inns, Limited, amounting to £362 1s. 1d. for the work. For the same reason the repair or roads at the outfall was put in hand at an estimated cost of £1,500. The construction of a new concrete bed for draining refuse from the screens at an estimated cost of £350 was commenced. Southern outfall. The overhaul of the main beam engines and pumps at the Southern outfall has been proceeding continuously since 1915, when completion of the engines and pumps in the new engine house offered an opportunity for stopping the old machines in rotation. Up to date the work has cost approximately £9,000, of which £2,000 was sanctioned during the year 1925. In order to provide additional employment the Council authorised the repairs of roads at the outfall at an estimated cost of £950 and the painting of the interiors of the precipitation engine and boiler house, etc., at a cost of £1,031. Abbey Mills pumping station. Apart from the work in connection with the enlargement of Abbey Mills pumping station which is referred to under the heading of "Flood relief works," the works undertaken at the station during the year apart from repair work included the filling in and raising the long wall forming the bank of the Channelsea river which passes the station on its eastern side, and the repainting of the station, which latter works were expedited with a view to providing employment. Outfall, intercepting and main sewers. Repairs, etc., have been carried out during the year to intercepting and main sewers as follows:— £ Fleet Sewer at an estimated cost of approximately 5,400 Hackney Brook Sewer 3,000 Pennington Street Sewer 3,000 Ranelagh Relief Sewer 2,000 Ratcliff Highway Sewer 3,000 Regent Street Sewer 3,600 Wick Lane Sewer 3,600 Effra Branch Sewer 5,000 The work of removing from the sewers deposits which accumulate there is one of considerable magnitude. For this purpose the county is divided into four districts, each district being made the subject of a separate contract. Contracts are based upon prices for the cartage and disposal of the deposit which is removed from the sewers bv the Council's staff. The cost of this work in 1925 was approximately £3,350. 184 Questions have arisen from time to time with regard to the Council's jurisdiction over the rivers Wandle and Graveney. The Metropolis Management Act, 1855, describes the stream or streams as commencing at a point where the parishes of Streatham and Tooting intersect the river to the point where the river Wandle discharges into the river Thames at Wandsworth. No such point as that mentioned in the Act exists, but there was evidence to show that the river Graveney was formerly known as the Wandle or Wandle Branch, and there is a point on the Graveney where the above-mentioned parishes meet. The Council has exercised jurisdiction over the river Graveney from Hermitage Bridge, Streatham, to its confluence with the river Wandle and thence over the river Wandle to the point of discharge into the river Thames. Contrary opinions as to the Council's jurisdiction were held by other authorities interested in these rivers, and the Council decided to apply to Parliament for a definition of the sewer in order to remove any doubts upon the matter. The erection of the new building for the Daily Sketch in Gray's Inn Road and Gough Street necessitated works of repair which are being carried out to the main sewer in the latter thoroughfare. The cost of the works, estimated at £2,000, will be refunded to the Council by the owners of the building. In consequence of the increasing weight of traffic passing along Victoria Street, the arch which carries the King's Scholars' Pond sewer over the Metropolitan District required to be strengthened. Advantage was taken of the opportunity afforded by repairs which were in progress to the roadway in Victoria Street to carry out further strengthening works to the sewer under that thoroughfare. North Woolwich rising main. In August, 1919, a burst occurred in the rising main from North Woolwich pumping station to the Northern outfall and flooded a shed in which was stored a quantity of wool belonging to the Ministry of Munitions. The loss was valued by the Disposal and Liquidation Commission at £3,110 15s. 1d. Liability was denied on the part of the Council and legal proceedings were commenced in the High Court. After negotiations, the case was settled by payment of £1,000 by the Council, each party bearing its own costs. Flood relief works. The Council on 22nd July, 1919, had before it a comprehensive scheme of works to mitigate floodings in various parts of London on both sides of the river Thames during time of heavy rainfall. The scheme, which is described in the Annual Report for 1920 (vol. III., p. 121), specified seventeen works and the total estimated cost, based on pre-war conditions, was £2,467,150. The first work undertaken was the construction of the north-eastern storm relief sewer from Kelvin-road, Highbury, to the Thames at Shadwell, which was commenced in 1921. In order to provide additional employment the Council on various dates subsequently decided to accelerate the work on other portions of the 1919 scheme, particularly those which would provide work suitable for unskilled or partly skilled labour. The works selected were the improvement of the river Graveney, the Wandle Valley sewer, the Charlton storm relief sewer, flood relief works at Hammersmith, the enlargement of the Isle of Dogs and Abbey Mills pumping stations, the construction of the south-western storm relief sewer, and of storm relief sewers in Lewisham and Woolwich, and of the north-western storm relief sewer, and the installation of additional machinery at Shad Thames pumping station. All these works have been approved for grant by the Unemployment Grants Committee. During the year the Council decided to proceed with the construction of the Beverley Brook relief culvert; this work not ranking for Government grant. Of the 17 specified works included in the scheme of 1919, 12 have been completed or are in hand. The estimated final cost shows an increase of about 75 per cent. on pre-war figures. 185 The completed works comprise the improvement of the river Graveney completed in January, 1923 (cost, approximately £200,000), the Wandle Valley sewer (first portion) completed in January, 1924 (£175,000), Charlton storm relief sewer completed in March, 1924 (£150,000) and the north-eastern storm relief sewer completed in September, 1924 (£750,000). Further particulars of these works are given in previous Annual Reports. Details of the schemes which were completed during the year under review or were still in hand at the end thereof are given below. Flood relief works at Hammersmith. The relief scheme for the low-level area in west London of about 2,500 acres in Fulham, Kensington and Hammersmith provides for the construction of a sewer about a mile in length having an outlet to the Thames near Hammersmith Bridge and the erection of a new pumping station near the outlet. The sewer has been completed and at the end of 1925 practically the whole of the machinery at the pumping station had been delivered and erected, and the station was nearing completion. 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. At the end of 1925 the whole of this work with the exception of the pipe work was practically completed. Isle of Hogs pumping station enlargement. In addition to the pumping carried out at Abbey Mills pumping station in connection with the drainage of the low-lying areas in Poplar and the Isle of Dogs, storm water from these areas is pumped direct into the Thames at the Isle of Dogs pumping station and the general flood relief scheme of 1919 provides for the enlargement of this station and the substitution of gas for steam power. At the end of the year the enlargement of the station was nearly completed, the engines and pumps for the supply of which tenders had been accepted being still to be provided. Southwestern storm relief sewer. The south-western storm relief sewer has been designed to assist the drainage of Clapham, Streatham, Brixton, West Norwood and Dulwich. If required the sewer can be extended southward to relieve the Effra Branch sewer at West Norwood. The length from Effra Road to Nine Elms is 23/8 miles, and in order to expedite the work it was made the subject of two contracts—(i.) between Effra Road and Clapham Road, completed in February, 1924; and (ii.) from Clapham Road to the Thames, begun in March, 1923, and still in progress. Storm relief sewers in Lewisham and Woolwich. The scheme of relief sewers in Lewisham and Woolwich is described in the Annual Report for 1923 (vol. III., p. 128). The construction of the Lewisham branch sewer (Bell-green, Lower Sydenham, to a junction with the southern highlevel sewer No. 2 near Court Hill Road, Lewisham), and of a branch sewer from Catford station had not been completed by the end of the year. Owing to the nature of the ground encountered in the progress of the work it was decided to carry out the construction of the Lewisham branch sewer between George-lane and Court-hill Road in iron instead of brickwork, and to use compressed air in connection with this portion of the work. The additional estimated cost in this respect is £5,000. The construction of the Eltham sewer (from the junction of the Council's existing Eltham sewer and the local sewer in Eltham-road, near Eltham-green, to the southern highlevel sewer No. 2 at Charlton), was also in progress. Shad Thames pumping station. Shad Thames pumping station, opened in 1909, was designed to accommodate six pumping sets, but as a first instalment three only were put in. The flood relief scheme of 1919 included proposals for completing the equipment of this station. Considerable progress has been made with the erection of the engines. Northwestern storm relief sewer. The north-western storm relief sewer will extend from Kilburn to Hammersmith and has been designed to relieve floodings in Willesden, Paddington and North Kensington. The works comprise the construction of the principal sewer which will be connected with the Ranelagh sewer in Shirland-road, Kilburn, and will run to the nearest point on the Thames, at Hammersmith, connecting with 186 various main sewers on the way. Branch sewers will be constructed to connect the new sewer with the middle level sewer in Ladbroke-grove, and with the Woodlane sewer at Wormwood Scrubs. A connection will also be made with the new pumping station at Hammersmith. Altogether the construction of about miles of sewer is involved. The section between the Thames and Notting Hill, to which reference is made in the annual report for 1924, is in progress of construction. Tenders for the work in the remaining section between Notting Hill and Kilburn and Hammersmith were invited and the tender of Messrs. Kinnear, Modie and Company amounting to £208,094 9s. for a brick sewer, with the proviso that if so required by the Council any parts of the sewer will be constructed in ironwork, has been accepted. Work was commenced on 18th May, 1925, and is in progress. Beverley Brook. The negotiations, for the most part abortive, with authorities outside London for contributions towards the cost of a relief scheme to deal with the overflowing of Beverley-brook are referred to in the Annual Report for 1924 (vol. III., p. 129). Negotiations, however, with the Barnes Urban District Council have been brought to a conclusion and the arrangement has been ratified in the London County Council General Powers) Act, 1924. The principal item is the construction of a culvert, not less than 8 feet in diameter, to draw off storm water from the brook at a point near Priest's-bridge, Upper Richmond-road, and to discharge it into the Thames by the most direct route. The approximate estimate of the cost is £39,500, towards which the District Council will contribute one-fifth or £8.000, whichever is less. The tender of Topham, Jones and Railton, Limited, amounting to £38,047 0s. 7d. has been accepted. Work was begun on 17th September, 1925, and by the end of the vear about one-fifth of the contract had been completed. Sewer in Streathamhill and Brixton-hill. The Annual Report for 1923 (vol. III., p. 129) describes the negotiations with the Lambeth and Wandsworth Borough Councils for the construction by the Council of a new 4-foot sewer in Streatham-hill and Brixton-hill 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 will therefore be taken over by the Council as a main sewer. The present local sewer in Streatham-hill and Brixtonhill 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. The work is in progress. Out-county drainage. The London County Council (General Powers) Act, 1925, provides for the drainage into the London Main drainage system of sewage from the Urban Districts of Ley ton and Walthamstow. The arrangements embodied in the Act are described in the Annual Report for 1924 (vol. III., pp. 140-1). In accordance with the provisions of section 60 of the Act, the Hackney Metropolitan Borough Council is entitled to require that the sewers from Leyton and/or Walthamstow shall be constructed of such size as the Borough Council may require in order to permit of the discharge of sewage from Hackney, the Borough Council paying the extra cost involved. It has been arranged that each of the sewers shall be constructed of a diameter of 4 feet. Arising out of the works recently undertaken for the improvement of the river Graveney, it was discovered that certain properties in Mitcham were being drained into the London system in addition to those provided for in the agreement, dated 7th March, 1907, with the Croydon Rural District Council under which the Council continues to receive the drainage from an area of about six acres transferred from London to Mitcham in 1904, upon payment of an annual sum of £10. An arrangement has been made with the Wandle Valley Joint Sewerage Board (which succeeded 187 to the duties of the Croydon Rural District Council in this matter) to make an increased payment, at the rate of £20 a year to cover all the properties now being drained into the London main drainage system, such payment to be subject to variation in proportion to any subsequent changes in the rateable value of the properties drained. 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 1925 the construction or reconstruction of 122,190 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 1925 the Council gave its consent in 18 such cases. Staff. The staff in the Public Health Department employed under the direction of the Main Drainage Committee and working at the outfalls was fixed by the Council. The staff (excluding chemists who are employed under the direction of the Establishment Committee) comprises two laboratory assistants, two laboratory attendants and eight samplers. The increased allowance granted by the Council on 20th January, 1925, of l½d. an hour to engineering mechanics for shift work and for work on Sundays or public holidays, placed certain employees working in a supervisory capacity in a worse position than the men working under them and also had a relative bearing upon the rates of pay of other engineering mechanics who by reason of the special conditions of their work, were not entitled to shift allowance. The remedying of these anomalies was effected at an estimated cost of £350 a year. CHAPTER V. HOUSING. Powers and duties of the Council. Prior to the passing of the Housing Act, 1925, which came into force on 1st July, 1925, and which reproduces in a consolidated form the permanent law relating to the housing of the working classes, the powers of the Council in this matter were derived from the Housing Acts, 1890 to 1924. The financial provisions of the Housing, etc., Act, 1923, and the Housing (Financial Provisions) Act, 1924, dealing with Exchequer contributions towards the cost of the construction of houses were not incorporated in the Act of 1925. These Acts were passed for the purpose of encouraging building in the immediate future, and were thus in the nature of temporary expedients. Particulars of the provisions of these Acts are set out in the Annual Report for 1924 (vol. III., pp. 142 and 143). Apart from administrative duties, the main divisions of the Council's housing 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. Houses completed. Since the war the Council has, up to 31st December, 1925, completed 11,193 houses and flats, which contain a maximum accommodation on the basis of two persons a room for about 84,600 persons. The houses and flats completed during the year 1925 totalled 2,023 with accommodation for 14,848 persons. Altogether since the completion of the first dwellings in 1894, the Council has provided accommodation for about 140,000 persons in 21,178 tenements and houses and three lodging-houses with 1,880 cubicles. These figures cover the whole of the Council's 188 housing operations for the periods mentioned, including rehousing in connection with schemes lor the clearance of unhealthy areas and other public improvements. The programme of work in hand is very considerable, comprising the erection of 15,000 additional houses under Part III. of the Housing Act, 1925, apart from the rehousing required under slum clearance schemes. Unhealthy areas. The Minister of Health is empowered to make contributions from the Exchequer towards the expenses incurred by local authorities in carrying out improvement schemes under Part II. of the Housing Act of 1925, such contributions being limited to one-half of the estimated average annual loss. The Minister has intimated that he is prepared to consider proposals involving contributions from the Exchequer amounting to £50,000 a year, and a comprehensive programme of slum clearance is being carried out by the Council. The schemes now in operation or about to be commenced are 11 in number, and include 20 separate areas comprising 92½ acres. The displacement of 25,245 persons of the working classes is involved and rehousing accommodation for about an equivalent number has to be provided, of whom 18,189 have to be accommodated within the limits of the improvement areas. Particulars of the schemes are given later. Clearance schemes— Assessment of compensation. In assessing compensation in connection with the acquisition of property required for clearance schemes, difficulty is often experienced because of the doubt which exists as to the interpretation of section 46 (1) of the Housing Act, 1925. From this section it is not clear whether compensation should be awarded on the basis that the cleared site value properly includes the advantages conferred by section 13 (5) of the London Building Act, 1894 (viz., permission to re-erect a building on the old foundations), or on the basis that the cleared site value of the land does not include such advantages. In order that a decision of the High Court might be obtained as to the proper interpretation of the sub-section referred to, the Council, on 1st December, 1925, decided to make an application to the High Court to direct the arbitrator to state a special case on a certain claim. The decision on the test case is awaited. Building grants. Particulars of the Council's scheme for the administration of the subsidy provisions of the Housing, etc., Act, 1923, were set out in the Annual Report for 1923 (Vol. I., pp. 132-3). Up to 31st December, 1925, the Council had approved proposals submitted by private builders for the erection of 1,876 houses to qualify for subsidy on completion, the number of houses, approved during the year being 784. Supply of labour. The supply of houses by normal methods of construction since the war has been restricted owing to the shortage of certain classes of skilled labour in the building trades. In October, 1924, the Minister of Health set up a committee known as the Building Industry Committee to advise him in carrying out the scheme embodied in the Housing (Financial Provisions) Act, 1924, particularly as regards the development and co-ordination of the supply of labour for house building. Local Building Industry Committees have been constituted in each area throughout the country, the Council being represented on the committee for the London area which functions within a radius of 15 miles from Charing Cross. It has been decided to effect the augmentation of the number of operatives mainly by an apprenticeship scheme, and at the instance of the Minister of Health the Council has decided to make it a condition of all its future housing contracts that the contractor shall be required to give effect in the execution of the contract to such arrangements as to the employment of apprentices as might be made trom time to time by the Local Building Industry Committee. New methods of construction. The full effect of the apprenticeship scheme cannot be felt for some time to come, and in the meantime the Council has endeavoured to surmount the difficulties created by the absence of an adequate supply of labour and materials by the adoption in certain cases of methods of construction other than that of brick, designed to 189 eliminate or reduce to a minimum the employment of those classes of skilled labour of which there is the greatest deficiency. The Committee (known as the Moir Committee) appointed in September, 1924, by the Minister of Health (Mr. Wheatley) to enquire and report as to new materials or methods of construction which were or might be available for the building of houses, and to make recommendations as to the organisation required for securing their adoption and use, issued during the year three intreim reports in which the undermentioned forms of construction were dealt with:— (1) Houses faced with steel plates. (2) Concrete houses in various forms. (3) Houses with a steel framework and various kinds of infilling or external casings. (4) (i.) Houses of normal timber construction built entirely of timber; (ii.) houses with timber framing and infilling of various other materials. (5) Schemes where factory construction might be possible in suitable units and the work of assembly carried out on the site. (6) Various forms of clay construction. (7) Substitutes for particular materials, e.g., plaster, and for roofing materials. The Council on 21st July, 1925, approved the adoption of any of these methods of construction in its housing estates. The Council had previously experimented with houses built of concrete, and, commencing in 1921, had built a considerable number of such houses of various types. The Chairman of the Housing Committee, accompanied by the technical advisers of the Council, visited Scandinavia in August, 1925, to make investigations into types of houses of wooden construction in use in those countries. As a consequence purchase was made of some types of wooden houses which appeared to be most suitable for use in England. These houses, 19 in number, and four timber-framed houses of the Council's design, were erected on the Council's estate at Becontree. A number of houses of other forms of construction were also provided by the Council during the year lor demonstration purposes at Downham and Bellingham. Six of these were of steel construction (two each of the "Atholl," "Weir," and "Telford" types), two were of steel and concrete ("Dennis-Wild" type), six of wood and concrete ("Tibbenham" type), and four were constructed on the " Prefacto" (Burney) system of blocks of a patented material known as "Factocrete" and consisting of compressed wood fibre and cement. On completion, the experimental houses were kept open for public inspection for from two to four weeks. Simplified type of tenement dwelling. The question of providing a type of dwelling which can be rented by the poorer classes of the community is a difficulty which continually confronts local authorities carrying out slum clearance schemes. There is need for accommodation which will span the gap that exists between the common lodging-house and the tenement occupied by the more prosperous class of worker, and for which a lower rent can be charged without upsetting the normal rent standard. The Council accordingly on 26th May, 1925, decided to adopt a simplified type of construction of four-storey dwellings, in which certain of the domestic offices are shared by two tenants. Each family letting will have its own sink in a small scullery and its own water closet, but the wash room and bath will be communal to the two adjacent lettings. A proportion of one-room tenements will be provided of a bed-sitting room type, suitable for the accommodation of single persons or aged couples without children. These will be equipped like the ordinary living room and will have, in addition, a metal bedstead to shut up during the day time in a ventilated recess, and also a cupboard for hanging clothes, etc. The provision of dwellings of this type will, in the 13651 n 190 opinion of the Council, supply a pressing need for accommodation at low rents. Stated in general terms, the rent is based on the rent standard prevailing in the neighbourhood for similar accommodation. In fixing the rents consideration is given to the value of the amenities provided by the accommodation. Hence by an alteration in the distribution of those amenities a lowering of rent becomes feasible without in any way sacrificing any essential hygienic requirement. In slum clearances the cost of the scheme affects the rents only indirectly, but evidently, if cheaper construction can be obtained, it will have an important bearing on the general question of rents. White Hartlane Estate. Particulars 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 by the erection of 710 houses and flats was completed in 1923. Arrangements were subsequently made for the development of the remainder of the estate under the financial provisions of the Housing Act, 1924. The erection of 138 dwellings and two shops along the Lordship-lane frontage of the estate was completed during 1925, and the scale of weekly net rents (exclusive of rates and water charges) has been fixed as follows:—Two-roomed flats, 9s. 3d. and 9s. 9d.; five-roomed (two-storey) dwellings, 14s. 3d. and 14s. 9d. In May, 1925, the Council accepted the tender of F. Bracey (Roads) Limited, amounting to £9,224 16s. 3d., for the construction of the necessary sewers and roads on the remaining portion of the estate. On 28th July, 1925, the Council approved a capital estimate of £229,468 for the completion of the remainder of the estate, with the exception of one small site which cannot be dealt with at present. The scheme provided for the erection of 346 houses and flats and nine shops. Tenders were invited by public advertisement, but the Council could not see its way to accept any of the offers received, and the question of the best course to be adopted to secure the erection of the houses was still under consideration at the end of the year. During the year a site on the estate was sold to the Wesleyan Church Authorities for the erection of a church. 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 and a part of the second section has been completed by the erection of 792 houses. Tenders for the erection of 422 houses and administrative buildings to complete the development of the estate were invited in December, 1924, but none of the tenders was accepted. On 3rd March, 1925, the Council decided to accept the offer of C. J. Wills and Sons, Limited, to carry out the work on the basis of actual cost with a variable fee or commission. As some of these houses were nearing completion, on 20th October, 1925, the Council fixed the scale of weekly net rents for typical houses as follows:—Three-roomed houses, 11s. 6d. and 12s.; four-roomed (nonparlour) houses, 12s. 6d.; four-roomed (parlour) houses, 13s. 6d.; five-roomed houses, 14s. 6d. Forty-five of the houses on the estate are to be erected under the provisions of the Housing, etc., Act, 1923, governing State aid, while the remainder (1,169) will be provided under the Assisted Scheme of 1919. During the year expenditure was sanctioned of £713 for laying out an open space on the estate, and of not exceeding £100 for the provision of fencing in connection with the utilisation of a vacant plot of land as a children's playing ground. Becontree. The estate known as Becontree, situated in the county of Essex between Chadwell Heath on the north and Ripple Road on the south, comprises about 2,800 acres, and was purchased with the aid of compulsory powers obtained in 1920. The development of the estate, which has been entrusted to C. J. Wills and Sons, Limited, on a cost plus profit basis, is being carried out in sections, and is being proceeded with from three different directions—viz., the north-west, or Ilford 191 section; the south-east, or Dagenham section; and the north-east, or Valence section. At the end of the year 5,590 houses on the estate had been completed, about 2,000 were in course of building, and orders had been issued to the contractors for the erection of about 2,500 others. The development of a further section by the erection of about 2,728 houses on the poured concrete system of construction was approved during the year, and the order to commence will be given as soon as the plans are ready and the necessary preliminary arrangements have been made. The weekly net rents (exclusive of rates) for accommodation on the Dagenham (No. 6) section have been fixed on the basis of the rents charged for accommodation on the adjoining section, viz. Three-roomed houses, 10s.; four-roomed (non-parlour) houses, 10s. 6d. and 10s. 9d.; four-roomed (parlour) houses, 11s. 6d. to 13s.; five-roomed houses, 12s. 6d.; two-roomed flats, 7s. 6d. The weekly net rents on the Valence (No. 4) section have also been fixed as follows Houses—Three rooms, 10s.; four rooms (non-parlour), 11s.; four rooms (parlour type), 12s.; five rooms, 13s.; Flats—Two rooms (ground and first floor), 8s. During 1925 the Council sold three sites for the erection of churches—namely, one for £1,000 to the Roman Catholic Church Authorities, one for £1,000 to the Church of England Authorities, and one to the Council of the Baptist Union for £690. Three sites were sold to the Essex County Council for £1,400, £875, and £1,350 respectively for the erection of elementary schools. Other sites were let on building lease for 99 years for the erection of shops, and a site in Green-lane was let on lease for the erection of a cinematograph hall. A site in Valence-avenue was sold to the Postmaster-General for £1,000 for the erection of a post-office, and a site in Bennett's Castle-lane was let on lease to a medical practitioner. During the year a revised agreement was entered into with the Gas Light and Coke Company for the installation of gas to houses and flats at Becontree, the company laying the mains and service pipes, carcassing the houses and providing all necessary fittings in consideration of payments by the Council in respect of each dwelling, as follows:—Valence (No. 4) section, £4 10s. ; Ilford (No. 5) section, £3; Dagenham (No. 6) section, £1 10s.; Valence (No. 7) section, and any other sections at the option of the Council, nil. Beliingham. The total area of Beliingham is 252 acres, and under the main contract, completed in 1923, for the development of the portion of the estate devoted to workingclass dwellings (176½ acres) 2,090 houses and flats were erected. Two or three small sites remain on which it is proposed, with the approval of the Minister of Health, to erect about 30 houses which will qualify for State aid under the Assisted Scheme of 1919. On 10th November, 1925, the Council agreed as an experiment to the erection on one of these sites of the six houses of the "Tibbenham" type, already referred to in the paragraph dealing with new methods of house construction, the essential feature of this form of construction consisting of walls built of an oak frame with a filling of concrete. Downham. The main portion of the housing estate at Downham (Lewisham and Bromley), which is altogether about 520 acres in extent, was acquired under compulsory powers. A small addition of about 52/3 acres was made to the estate in 1925 at a cost of £2,000. The development of the Bromley-road (No. 1) section is being carried out under a cost contract by Holland & Hannen and Cubitts, Limited. The original contract was for 2,000 houses, but this number was subsequently increased to 2,178, and a supplemental capital estimate of £110,000 to cover the cost of the additional houses was approved by the Council on 15th December, 1925. A hundred of the houses to be erected on this estate have been allocated to meet the special needs of the Bermondsey Metropolitan Borough Council in connection with the clearance of an unhealthy area in the borough. The arrangement has been 13651 n2 192 embodied in an agreement under section 14 of the Housing (Financial Provisions) Act, 1924, whereby the borough council agrees to pay a sum of £4 10s. a house per annum for at least 40 years in consideration for the right to nominate tenants for the houses. No houses are specially earmarked as being provided for the borough council, but houses will continue to be let, as available, to the borough council's nominees so as to maintain the quota of 100 houses until the cessation of the annual payment under the agreement. During the year the question of raising the rents for accommodation at Downham was considered. The houses are subject to the financial provisions of the Housing Act, 1924, which, while aiming at securing rents in each locality equivalent to the rents prevailing there for working-class houses built before the war, contemplates that such rents shall be charged as will be remunerative after allowance is made for the combined subsidies from the State and the local authority of £13 10s. a year under the Act. To secure this result it was found necessary to increase all the rents fixed in 1924 by 1s. a week for new tenancies. The weekly net rents of typical houses and flats as thus revised are as follows:—Two-roomed flats, 10s.; three-roomed houses, 11s. 6d.; four-roomed (non-parlour) houses, 12s. 6d.; fourroomed (parlour) houses, 13s. 6d.; five-roomed houses, 14s. 6d. Arrangements were made during the year for the collection of the rates on the houses with the weekly rents, subject to an allowance or commission from the rating authority to the Council for the services rendered. During 1925, the Council sold two sites, one slightly more than an acre in extent, for £1,000 to the Church of England authorities for the erection of a church, and the other to the Bromley Town Council for £2,150 for the erection of an elementary school. Two sites in Bromley-road were let on lease for 99 years for the erection of shops with living accommodation over. Two small portions of land were sold for £70 to the owner of an adjoining estate. The lay-out of the estate provides for the construction of a main (tramway) road across the estate from Bromley-road to Grove-park station. This will be wider than that which would normally be required for the development of the housing estate, and the Council on 13th October, 1925, decided that the additional cost of the road over and above that involved by the normal estate development road should (apart from the charges to the tramways account in respect of the construction of the tramways and the paving of the tramways area) be regarded as expenditure in respect of a street improvemeut. Baring-road, on the eastern boundary of the estate, is to be widened to 50 feet, and the houses to be erected along the frontage to that thoroughfare will be set back to such an extent as to permit of the widening not only to 50 feet, but also to 60 feet if considered necessary in future. The lay-out of the estate provides for certain subsidiary roads of a width of 30 feet with 16 feet carriageways, which is less than the width required by the local by-laws. The Bromley Town Council has approved the construction of the roads as proposed, subject to an undertaking by the Council that if at any time, in the opinion of the Minister of Transport, it becomes necessary to widen these roads, the necessary land shall be surrendered free of cost to the Town Council. East: Hill estate. The East Hill estate, Wandsworth (8 acres), was purchased in 1924 at a cost of £19,000. The dwellings to be erected on the site, which will contain about 535 tenements, will afford accommodation for over 3,200 persons, and are intended primarily for rehousing purposes in connection with the clearance of unhealthy areas. On 27th January, 1925, the Council accepted the tender of J. E. Billings and Co., Limited, amounting to £71,997, for the construction of the superstructures of the first five blocks on the estate, consisting of 160 tenements with accommodation for 956 persons. On 14th July, 1925, the Council accepted the tender of HeathPritchard, Limited, amounting to £1,656 3s., for wiring and fitting the first five 193 blocks for electric light. By the end of the year the first block of dwellings, known as Whitby House, with accommodation for 348 persons, had been completed. On 26th May, 1925, the Council approved a capital estimate of £54,000 for the erection of a further five blocks of dwellings, consisting of 284 rooms with accommodation for 568 persons, an estate office and workshops, together with eight bicycle and perambulator sheds; and on 7th July, 1925, the Council accepted the offer of J. E. Billings and Company, Limited, the contractors for the construction of the first five blocks of dwellings, of £52,266 1s. 1d. for the work. The Council on 28th July, 1925, fixed the scale of weekly net rents for accommodation in the first five blocks of dwellings (each with scullery and bath) as follows:— Ground floor—Two rooms, 8s. 6d. to 8s. 9d.; three rooms, 10s. 6d. to 11s.; four rooms, 12s. First and second flows—Two rooms, 9s. to 9s. 3d.; three rooms, 11s. to 11s. 6d.; four rooms, 12s. 6d. Third and fourth floors combined—Three rooms, 10s. to 11s.; four rooms, 11s. 9d. to 13s.; five rooms, 13s. 6d. to 14s. The accommodation for 348 persons in Whitby House has been allocated as part of the rehousing accommodation required to be provided under the Hickman's Folly scheme. The following names have been selected for the blocks of dwellings which will be designated "Houses":—Brixham, Falmouth, Fleetwood, Grimsby, Lowestoft, Milford, Newlyn, Plymouth, Ramsgate, St. Ives, Swansea, Whitby and Yarmouth. Watling estate. The Watling estate, which is situated astride Edgware-road in the Hendon urban district, is being acquired partly through the exercise of compulsory powers and partly by agreement. The main portion of the estate, about 400 acres in extent, lies to the east of the main road at Burnt Oak on the Edgware extension of the London Electric Railway. On the west side of Edgware-road it is proposed to purchase about 80 acres of the land which the Council has power to acquire compulsorily. On 7th July, 1925, the Council approved a capital estimate of £1,800,000 in respect of the partial development of the main portion of the estate, including the •construction of roads and sewers and the erection of about 3,000 houses. It was felt that the most efficient arrangement for a work of this magnitude would be to entrust the whole of the operations to one firm with large resources and powers of organisation at its command. Tenders were invited by public advertisement, and as it was considered impracticable to obtain offers at a firm price, the tenders were invited on the basis of the Council financing the undertaking and paying to the -contractor a variable fee or commission for his services. In response, 32 tenders were received, but it was not found possible to accept any of them, and negotiations were opened with C. J. Wills and Sons, Limited, the contractors for the development of Becontree, with a view to the company also undertaking the development of the Watling estate, the contracts relating to Becontree and the Watling estate being combined. As a result of the negotiations an arrangement was agreed to as follows:— (i.) The date up to which orders may be given for work at Becontree to be extended to 31st May, 1929. (ii.) The scale of commission for Becontree to be stabilised at 2½ per cent. (iii.) The contractors to be required to observe at Becontree as well as at the Watling estate the provisions as to the enrolment of apprentices as approved by the Ministry of Health. (iv.) The development of the Watling estate to be undertaken at a percentage of 2½ on the revised total value of the work, but without regard to the number of houses being more or less than the 3,000 named in the form of contract. (v.) The general management of the work at Becontree and the Watling estate may be put in the hands of one director of C. J. Wills and Sons, Limited. 19-1 A contract was entered into with the company on these lines, and the order to commence work was issued to the contractors about the end of the year. Castelnau estate. On the application of the Council, the Minister of Health, by an Order dated 7th February, 1925, conferred upon the Council powers of compulsory acquisition for housing purposes of a site of about 51¼ acres at Castelnau, Barnes. Steps were taken to put into force the powers of the compulsory order, and the question of arranging for the development of land was under consideration at the end of the year. TabardStreet, etc., scheme. The Tabard-street and Grotto-place, Southwark, and Crosby-row, Bermondsey, scheme under Part I. of the Housing Act, 1890, relates to three areas of about 17 acres, comprising 875 houses with a population of 4,593. Rehousing accommodation has to be provided on the Tabard-street area for not fewer than 2,580 persons. The reconstructed area is known as the Tabard Garden estate. Chaucer, Becket, Geoffrey, Harbledown, Rochester and Huberd Houses with accommodation for 2,124 persons were completed between 1916 and 1923. Tabard House, containing 42 tenements with accommodation-for 256 persons, was completed during 1925. The central portion (about 5 acres) of the Tabard-street area is to be laid out as a public open space, and part of it is being used temporarily as a playground for children. A number of the old houses are, however, still standing on the site, and great difficulty is being experienced in obtaining vacant possession of the property for demolition on account of the acute housing shortage. The Council has accordingly under consideration the steps to be taken to provide further rehousing accommodation for the people who have yet to be displaced in order that the scheme for the permanent lay-out of the open space may be proceeded with. Another small public open space is about to be provided on the Grotto-place area (about a mile distant from the Tabard-street area) by the Southwark Metropolitan Borough Council, to whom the Council agreed during the year to sell about 11 acres of the land for the purpose. Brady-street scheme. The Brady-street scheme, which relates to an area of about 7 acres in the metropolitan borough of Bethnal Green, is being carried into effect under Part II. of the Housing Act, 1890. About 1,875 persons of the working classes will be displaced, and accommodation has to be provided for 1,600 persons on the cleared site and for 265 persons elsewhere. In part fulfilment of the rehousing obligation under the scheme, a block of dwellings known as Whiston House, containing 12 tenements toaccommodate 90 persons has been erected by the Council at Goldsmith's-row, Shoreditch, and 35 cottages with accommodation for 175 persons have been provided on a site at Walthamstow by the freeholders of a large part of the property required for the clearance scheme. The first block of dwellings (Bullen House) to be erected on the improvement area, named Collingwood estate, was completed in 1923. The second block of dwellings (Pellew House), which consists of 48 tenements, was completed during the year. On 30th June, 1925, the Council accepted the tender of Messrs. Rowley Brothers, amounting to £24,096, for the erection of the third block (Fremantle House), which will contain accommodation for 294 persons in 48 tenements. On 27th January, 1925, the Council fixed the weekly net rents (exclusive of rates) for accommodation at Pellew House as follows:—Ground floor—Two rooms, 9s.; three rooms, 10s. 6d. to 11s.; four rooms, 13s. First and second floors—Two rooms, 9s. 6d.; three rooms, 11s. to 11s. 6d.; four rooms, 13s. 6d. Third and fourth floors—Three rooms, 10s. 6d. to 11s. 6d.; four rooms, 12s. 6d. to 13s.; five rooms, 14s. 6d. Offers of the Bethnal Green Metropolitan Borough Council and the Gas Light and Coke Company to fit up Fremantle House for electric lighting and for gas supply for cooking purposes free of cost to the Council have been accepted. 195 Ware-street scheme. The scheme for dealing with the Ware-street area, Hoxton (9¼ acres), under Part I. of the Housing Act, 1890, involves the displacement of about 2,648 persons of the working classes, and the scheme as confirmed by the Minister of Health requires rehousing accommodation to be provided for that number, of which not fewer than 2,160 are to be accommodated within the area. Rehousing accommodation for 378 persons has been provided in 72 three-storey cottage flats on the White Hart-lane estate. The first block of dwellings (Archer House) to be erected on the reconstructed area (to be known as the Whitmore estate), with accommodation for 228 persons in 39 tenements, was completed during the year. On 28th July, 1925, the Council approved a capital estimate of £16,835 for the extension of Archer House by the provision of 12 additional tenements (33 rooms) and the erection of another small block, to be known as Arrow House, to contain 18 tenements (48 rooms). On 8th December, 1925, the Council accepted the tender of Messrs. R. Woollaston and Company, amounting to £15,589 14s. for the building work. The Council on 28th July, 1925, approved a capital estimate of £8,500 for the purchase of certain properties for addition to the area, which were required in order to improve the lay-out. There are no blocks of artisan dwellings in the immediate vicinity of Archer House, and the Council therefore took as a basis for comparison, in fixing the rents for the accommodation provided, the rents charged for accommodation on the Boundary-street estate. The weekly net rents for accommodation at Archer House were accordingly fixed by the Council on 14th July, 1925, as follows:—Ground floor—Two rooms, 9s. 3d. to 9s. 6d.; three rooms, 11s. 3d. to 12s. 3d.; four rooms, 13s. 9d. First and second floors—Two rooms, 9s. 9d. to 10s.; three rooms, 11s. 9d. to 12s. 9d.; four rooms, 14s. 3d. Third and fourth floors combined—Two rooms, 10s.; three rooms, 11s. to 12s. 3d.; four rooms, 12s. 9d. to 13s. 6d.; five rooms, 14s. 6d. The question of arrangements for lighting and cooking in the dwellings was considered during the year. For general lighting it was decided to employ electricity, and the Shoreditch Metropolitan Borough Council agreed for a period of 12 years to provide the fittings and lamps and maintain the installation, with the exception of the lamps, which are renewable by the tenants, free of cost to the Council, for all the dwellings to be erected on the estate. The staircases will also be lighted by electricity, the cost of the installation being borne by the Council. The Gas Light and Coke Company also agreed to carcase the tenements for gas cooking and heating free of charge, leaving each individual tenant to decide whether gas cooking or heating stoves should be installed. Equal facilities will be afforded the borough council and the gas company to canvass incoming tenants as regards the supply of electricity or gas for cooking or heating purposes. Hickman's Folly scheme. Another area which is being dealt with by the Council under Part I. of the Housing Act, 1890, is the Hickman's Folly area, Bermondsey (6 acres), to be known after reconstruction as the Dickens estate. About 1,645 persons of the working classes will be displaced, and the order of the Minister of Health confirming the scheme requires the provision of accommodation for 1,660 persons, of whom not fewer than 1,000 are to be accommodated within the area. For the purpose of providing part of the rehousing accommodation required under the scheme, the Council decided to erect a block of dwellings in Staple-street, Southwark, which had been cleared under the Tabard-street, etc., scheme, and on 30th June, 1925, accepted the tender of Messrs. Rowley Brothers, amounting to £21,252, for the building work. The dwellings, which will be known as Strood House, will contain accommodation for 264 persons in 32 tenements. With a view to meeting to some extent the difficulty experienced in providing accommodation suitable for many of the persons to be displaced, some small structural alterations in design have been made in order to enable tenants who may so desire to sub-let 196 one room as a bed-sitting room. Every such room has two windows and is large enough (about 150 square feet) to permit of its use for this purpose. The room, which is approached directly from the entrance lobby to the tenement, is provided with a ventilated food and crockery cupboard, and light cooking may be done at the stove, which is provided with a swing trivet for this purpose. If the experiment should not meet with sufficient success to justify its continuance, the tenements can be utilised for single occupation in the usual way without any structural alteration. On 1st December, 1925, the Council accepted the tender of Messrs. E. D. Winn and Company, amounting to £25,352, for the erection of the first block of dwellings (Pickwick House) to be erected on the Dickens estate. The dwellings will contain 51 tenements comprising 148 rooms with accommodation for 296 persons. The Council on 20th January, 1925, agreed to a sale and exchange of lands with the Sisters of the Convent of Mercy, the effect of which will be to reduce the liability of the Council to provide housing accommodation under the scheme to the extent of two cottages, and at the same time, while enabling the Council to effect the extension and widening of Virginia-row as required by the scheme, will leave the Sisters of the Convent in possession of nearly all their land which they require fo the purposes of the Roman Catholic School in George-row. The Council also on 23rd June, 1925, agreed to an arrangement with the freeholders of the "George" public-house in Flockton-street, for the sale and exchange of some small strips of land to facilitate the improvement of the property. Bell-lane and Ellen-street scheme. The Bell-lane and Ellen-street scheme under Part I. of the Housing Act, 1890, provides for the clearance and reconstruction of two areas known as the Bell-lane area, Spitalfields (4 acres) and the Ellen-street area, St. George-in-the-East (1½ acres). Under the scheme as confirmed, dwellings have to be provided for the accommodation of 1,705 persons of the working classes, of whom not fewer than 600 are to be accommodated within the Bell-lane area, and the remainder elsewhere. The name "Holland estate" has been selected for the area when reconstructed. The Council on 21st July, 1925, approved a capital estimate of £23,870 for the erection of the first block of dwellings on the estate (Bernard House), but owing to unavoidable delay in obtaining possession of the site it was decided to proceed with the arrangements for the erection in the first instance of the second block (Carter House). Certain property in the Bell-lane area intended for the erection of a telephone exchange was excluded from the scheme as approved by the Minister of Health. This proposal was eventually abandoned, and, with a view to facilitating the clearance and reconstruction of the area, the Council on 28th July, 1925, with the approval of the Minister of Health, decided to purchase the property by agreement for inclusion in the scheme. George'sroad and Brand-street scheme. A scheme for dealing with two unhealthy areas, known as the George's-road and Brand-street areas, Holloway (3¼ acres), was made by the Council on 27th November, 1923, and amended on 29th July, 1924. Altogether, 1,320 persons of the working classes will be displaced, and it is proposed to provide accommodation for an equal number of persons of whom not fewer than 900 will be accommodated on the cleared areas. The scheme was confirmed by the Minister of Health on 31st July, 1925. The properties forming the George's-road area which are included in the scheme consist of two detached groups of houses about 60 yards apart. An opportunity offered for purchasing, at a reasonable price, a block of flats with a plot of land in the intervening space, and on Nth February, 1925, the Council approved an estimate of £1,950 for the purpose. Plans for the lay-out of the Brand-street area were well advanced at the end of the year. 197 Baker's-alley, Birchfieldstreet and Bromleyplace scheme. The scheme made by the Council in 1924 for the clearance of three insanitary areas in the Metropolitan Borough of Poplar, known as the Baker's-alley (l1/3 acres), Birchfield-street (¾ acre), and Bromley-place ( acre) areas was sanctioned by the Minister of Health, subject to modifications, on 10th December, 1924. The Order specifies that accommodation for not fewer than 190 of the 740 persons required to be rehoused shall be provided on the Birchfield-street area. The acquisition of the property included in the scheme is being proceeded with, and the plans for the new dwellings were in course of preparation at the end of the year. Prusom- street scheme. The scheme made by the Council under Part I. of the Housing Act, 1890, for dealing with the Prusom-street area in Wapping (8½ acres), as confirmed by the Minister of Health, involves the displacement of 2,601 persons of the working classes and the confirming order requires the provision of accommodation for an equal number, of whom not fewer than 1,000 are to be accommodated on certain defined lands within the area. The name "Wapping Estate" has been selected for the area when reconstructed. On 21st July and 13th October, 1925, the Council approved a capital estimate of £17,867 in respect of the erection of the first block of dwellings to be known as Willoughby House, and on 13th October, 1925, accepted the tender of Allen Fairhead and Sons, Limited, amounting to £16,323, for the work. On 3rd February, 1925, the Council agreed to an exchange with the Roman Catholic Church authorities of lands included in the scheme for the purpose ot an extension of their school in Dundee-street. Watergatestreet area. Official representations under Part I. of the Housing Act, 1890, were made to the Council on 19th January and 3rd February, 1925, by the Medical Officers of Health of Deptford and Greenwich with reference to an unhealthy area known as the Watergate-street area, which comprises about 210 houses of two and three storeys in height in Watergate-street, Hughes-fields, Trevithick-street and Deptford-green. Most ot the houses are very old and badly arranged, and the Council being satisfied that the evils existing could onlv be remedied by means of an improvement scheme under the Act, decided on 10th February, 1925, to make such a scheme. The area includes three licensed premises. Adjoining the area are small plots of surplus lands belonging to the Council as well as the sites of houses pulled down under demolition orders which can with advantage be utilised for housing in connection with the reconstruction of the area and which were included for making the scheme efficient. The execution of the scheme as proposed, which comprises about 7¼ acres, will involve the displacement of about 1,927 persons of the working classes, and the scheme provides for the accommodation of this number of people on part of the cleared sites. Incidentally, by means of a re-arrangement of boundaries and the acquisition of a long strip of undeveloped land, the public recreation ground in Hughes-fields will be improved and certain small street widenings will be effected. The cost of acquisition and clearance is estimated at £80,000. The scheme was duly submitted to the Minister of Health for confirmation, and a public local inquiry into the proposal was held on 28th and 29th July, 1925. At the end of the year the decision of the Minister was still awaited. In order that there should be no delay in commencing the erection of dwellings on the area when the scheme was confirmed, the preparation of plans for the first two blocks was at once proceeded with, and the Council on 3rd November, 1925, approved a capital estimate of £1,000 to cover preliminary expenses in connection with the reconstruction of the whole area. Ossulstonstreet area. An official representation under Part I. of the Housing Act, 1890, was made to the Council on 12th January, 1925, by the Medical Officer of Health for St. Pancras, with reference to an unhealthy area, known as the Ossulston-street area (about 8 acres in extent) lying between Euston and St. Pancras railway stations. The Council came to the conclusion that an improvement scheme under the Act ought 198 to be made in respect of the area and decided on 10th February, 1925, to make such a scheme, the execution of which will, it is estimated, involve the displacement of about 2,700 persons. It is proposed that rehousing accommodation for not fewer than that number shall be provided within the area. Apart from the cost of the new dwellings, the cost of acquisition and clearance is estimated at approximately £150,000. The scheme includes a church as well as a school which can both remain without unduly interfering with a scheme of re-development, but an adjustment in the eastern boundary of the school may be required. The sub-station of the Metropolitan Railway Company, certain other property facing Euston-road and the licensed premises at the corner of Ossulston-street and Weir's-passage have been excluded from the scheme, but five licensed premises are included. The site offers an exceptionally favourable opportunity for the Council to adopt a scheme for the erection of dwellings within the provisions of the London Building Acts which will be higher than anything hitherto attempted in connection with clearance schemes, and a proposal to provide blocks of nine storeys with quickly moving lifts and other amenities is under consideration. The scheme was submitted to the Minister of Health, and a public local inquiry into the proposal was held on 11th and 12th August, 1925. The decision of the Minister was still awaited at the end of the year. China-walk, Hatfield street and Wyndhamroad areas. Official representations under Part I. of the Housing Act, 1890, were made to the Council on various dates in 1924 and 1925 by the respective borough medical officers of health with regard to four unhealthy areas known as (i) the China-walk area, Lambeth, (ii) the Hatfield-street and Hankey-place areas, Southwark, and (iii) the Wyndham-road area, Camberwell. The Council being satisfied as to the necessity for improvement, decided on 3rd February and 5th May, 1925, to make a scheme under the Act for dealing with the four areas. The China-walk area is a very congested area of about 5 acres lying between Kennington-road and Walnut-Tree-walk, and is bounded on the north by the Lambeth public baths. The lay-out is bad, the houses are decayed, and the evils existing are remediable only by the clearance of the old property, and the re-arrangement of the ground plan. The frontage to Lambeth-walk has been omitted from the scheme, but certain properties fronting on Kennington-road and one small beer-house are included. The displacement of about 1,840 persons of the working-classes is involved, and housing accommodation for about 1,450 persons can be provided on the cleared site. The Hatfield-street area, which is about 2¾ acres in extent, consists of a group of courts and places situated on both sides of the street known as Paris-garden to the south of Stamford-street and west of Blackfriars-road, and immediately adjoins the disused graveyard of Christ Church, Southwark. To the north of the area are two modern printing works and the power station of the London Hydraulic Power Company. The area includes one licensed public-house. The closeness and bad arrangement of the streets and houses and the dampness of the latter are predominant features, and the only remedy lies in complete clearance and reconstruction. The Hankey-place area, adjacent to the Tabard-street area, comprises eight old, damp and badly arranged houses, and a large shed. For some time past the Council had been endeavouring to arrange terms for the acquisition of a site of about half an acre adjoining the Hankey-place area, with a view to the erection of dwellings thereon, and as it did not appear likely that satislactory terms could be arranged, the opportunity was taken of obtaining compulsory powers over the site by including it for rehousing purposes in the scheme. The number of persons of the working classes residing in the Hatfield-street area and Hankeyplace areas is about 1,012. 199 The Wyndham-road area lies in the angle between Camberwell-road and Camberwell New-road, and the portion included in the official representation consists of some small groups of old, worn-out houses, covering some 3 acres, which should be dealt with as insanitary property. To the south of these, however, there are a number of small cottages with large gardens which, with part of the gardens of some houses in Camberwell New-road, cover an area of about 4 acres. With the two congested sections the whole will give four compact building sites having a total area of some 7 acres in a central district which will form a most desirable site for rehousing purposes, and will greatly assist in the practical carrying out of this and other clearance schemes in south London. The displacement of about 762 persons of the working classes is involved, and it will be possible to provide housing accommodation on this area for about 2,020 persons. Altogether 3,532 persons of the working classes will be displaced, and it is proposed to provide rehousing accommodation under the scheme for an equal number of persons. The surplus accommodation which can be provided on the cleared areas will be devoted to purposes other than the rehousing of persons displaced by the scheme. The preliminary estimate of the cost of acquisition and clearance amounts to £150,000. The scheme was duly submitted to the Minister of Health for confirmation and a public local inquiry lasting five days was held into the proposals between 19th-25th November, 1925. At the end of the year the decision of the Minister was still awaited. In order that there should be no delay in proceeding with the erection of dwellings on the Wyndham-road area, the Council on 28th July, 1925, approved a capital estimate of £700 in respect of the preparation of working drawings and other preliminary expenses, and plans for the first block were submitted to the Minister of Health for approval. Hornsey-rise estate. The Council on 31st March. 1925, decided to purchase for housing purposes for £11,250 the freehold property known as the Hornsey-rise Training College, fronting on Hazelville-road, Islington, formerly used as an orphanage. The site, which is within a short distance of the Highgate tube railway station and two other stations, has an area of about 3 acres, exclusive of roads. It was partly occupied by buildings of an institutional character which it was decided to demolish. No new roads will be required for the development of the site, and accommodation for 1,168 persons will be provided, in three blocks of dwellings, comprising 188 tenements In order that arrangements might be made for the development of the site, which is to be known after reconstruction as the Hornsey-rise estate, the Council on 28th July, 1925, approved a capital estimate of £3,000 in respect of expenditure involved in the preparation of working drawings and other preliminary expenses in connection with the erection of the dwellings. At the end of the year bills of quantities for the first block of dwellings were in course of preparation and working drawings for the second block were approaching completion. Old Oak estate. On 21st July, 1925, the Council approved an estimate of £9,550 in respect of the erection of 14 houses and certain road work on the site of the disused temporary school od the Old Oak estate, Hammersmith, and at the end of the year the bills of quantities for the work were in an advanced stage. Wormholt estate. On 28th July, 1925, the Council decided to purchase the undeveloped part of the Wormholt estate, belonging to the Hammersmith Metropolitan Borough Council, and approved a capital estimate of £60,000 for the purpose. The purchase price amounted to £56,000. The area of the land is approximately 66 acres, of which about 13 acres will be required for the extension of Western-avenue, one of the arterial roads leading from London through Acton. Some of the roads on part of the land are already made up, while others are sewered but otherwise not yet made up. The site adjoins the 200 Council's Old Oak estate, and an economy will be effected by combining the two estates for purposes of administration. At the end of the year a preliminary scheme had been prepared, providing for the erection of about 800 houses. White Hart street site, Kennington In view of the difficulty of obtaining suitable sites for housing purposes within the County, the Council, on 17th November, 1925, decided to take advantage of an opportunity to obtain possession of a site of about 2.3 acres in White Hart-street, Kennington, the property of the Duchy of Cornwall. The Duchy were unable to dispose of the freehold, but agreed to grant a lease of the land for a term of 120 years, the rent to be a peppercorn for the first 10 years, £650 a year for the next 50 years, and £1,300 a year for the remaining 60 years. The site, a part of which is occupied by houses and other buildings, is very suitable for re-development by the erection of dwellings which will be capable of accommodating about 900 persons. On 15th December, 1925, the Council approved an estimate of £2,700 for the preparation of contract particulars. St. Helier estate. During the year the attention of the Council was directed to certain sites, situated mainly in the parishes of Morden and Carshalton, which were eminently suitable for development as part of the programme of work to be undertaken to meet the housing needs of the County of London. The site, which extends from along the Epsom road on the north west to beyond the Sutton road on the south-east, will be served by two railways—viz., the City and South London Railway which is being extended to Morden, and a branch of the Southern Railway between Wimbledon and Sutton for which Parliamentary powers have been obtained. The Sutton by-pass, which is in course of construction, passes across the land. On 15th December, 1925, the Council made an Order for the compulsory acquisition of the property, comprising altogether about 846 acres, and approved an estimate of £500,000 in respect of the purchase and partial development of the site. The Order was duly submitted to the Minister of Health for confirmation and a local inquiry will be held in due course. The estate will be known as the St. Helier estate. Bush-green House. The Council has decided to adapt the upper floors of the disused lire-station at Shepherd's Bush for rehousing purposes. The ground floor and basement will be let for commercial use. The building when remodelled will be known as Bush-green House. Accommodation of tuberculous persons. Ihe question of the rehousing of persons aftected with tuberculosis who are living in unhealthy or overcrowded areas has been considered, and it has been arranged that, where cases of special hardship involving families which include a person or persons suffering from tuberculosis arise, such cases should be specially considered with a view to the available accommodation being allotted to cases likely to derive the greatest benefit from the improvement in home conditions. Prizes for gardens and window boxes. Carrington House. During the year the Council made grants not exceeding £80 in all out of the interest on deposits paid by tenants on taking up tenancies, for distribution to prize funds for the best kept gardens and window boxes on the Council's estates. Expenditure not exceeding £250 has been sanctioned for the purpose of the conversion of seven additional cubicles at Carrington House into special cubicles, including the provision of the necessarv furniture. Selection of tenants. In view of the fact that the Council's housing operations involve a heavy loss which has to be met out of rates levied over the whole county, it was felt that some relationship should be established with the requirements of the metropolitan borough councils who should each receive a definite share of the accommodation provided. The Council accordingly on 21st October, 1924, decided, as an experiment for one year, that a part not exceeding 50 per cent. of its new accommodation provided under Part III. of the Housing Act, 1890 (now Part III. of the Act of 1925), should be allocated amongst suitable applicants recommended by the several metropolitan borough councils in proportions based upon existing conditions of overcrowding 201 in such boroughs. The number of applicants recommended by the several metropolitan borough councils during 1925 was 1,698. Of these, 595 were accommodated on the Council's estates; 156 were offered accommodation which was refused; 368 were refused accommodation as being unsuitable; and 579 were still awaiting the offer of accommodation at the end of the year. Besides these persons preferentially treated on the recommendation of the borough councils, 925 persons from the various boroughs were accommodated preferentially on account of special hardship.. Workmen s trains, etc. The Council's action in earlier years with regard to workmen's trains at cheap fares was dealt with in the Annual Report for 1920 (Vol. I., p. 77). In the Annual' Report for 1923 (Vol. III., pp. 139-40) particulars are given of the proceedings before the Railways Rates Tribunal at which representations were made by the Council on the subject of the charges to be made for workmen's fares and season tickets on London railways. During 1924 schedules of the standard charges proposed to be made by the companies in respect of the conveyance of passengers and goods were submitted to the Tribunal and formal objections to the proposals were lodged on behalf of the Council (Annual Report for 1924, Vol. III., p. 153). As a result of the Council's representations, the Railway Companies submitted forms of schedules of charges for workmen's fares and season tickets. The Council secured an amendment of the schedules submitted by the companies in regard to workmen's fares with the result that the schedules were approved by the Tribunal in such a form as to enable it at the proper time to consider the Council's suggestions in regard to the fixation of the actual tares to be charged.. After the form of schedules had been settled the Tribunal proceeded to ascertain the standard revenue of the companies in 1913, and the next stage of the inquiry, which was commenced on 5th October, 1925, was to determine the estimates of railway working expenses after the fares and charges to be fixed by the Tribunal shall have come into operation. The allocation of the gross revenues to be raised as between passenger and goods traffic will then have to be determined and subsequently the schedules of the standard charges. The Council is represented by counsel at the inquiry which at the end of the year was still proceeding. CHAPTER VI. ACCOUNTS AND STATISTICS. Memorandum by the Comptroller of the Council (Mr. C. D. Johnson) on the Housing Accounts for the Year Ending 31st March, 1926. These accounts are prepared, subject to audit, in advance of the annual abstract of the Council's accounts, for the financial year ending 31st March, 1926. They contain provisional figures, mainly in respect of deficiencies on the schemes of metropolitan borough councils, which will be subject to adjustment. The accounts show the financial results of the Council's operations under the Housing Act, 1925 (clearance of unhealthy areas and rehousing under Part II, and housing under Part III of that Act), and of rehousing under various street improvement, etc., Acts. They are divided into four sections, distinguishing the nonassisted schemes from the assisted schemes covered by the subsidy provisions of the Housing Acts of 1919, 1923 and 1924, respectively. Each of the first three sections 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 "Dwellings" sub-sections deal with the dwellings both for rehousing and for housing on estates under Part III. 202 A.—Non-Assisted Schemes. This section comprises the accounts of schemes carried out by the Council without financial assistance from the State. The section includes all schemes, whether for the 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. This year it also includes transactions in regard to advances under Section 92 of the Housing Act, 1925, hitherto provided for under the Assisted (1923) Scheme. With the exception of Calverley House and Hornsey Rise estate, which have been provided to rehouse persons displaced from properties acquired for school sites, and Bush Green House, provided to rehouse persons displaced from property acquired for a street improvement, the whole of the non-assisted dewllings were erected prior to the enactment of the Housing, Town Planning, etc., Act, 1919. Clearance schemes.—In the year 1925-26, 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, was £45,363 14s. 5d., and this sum has been charged to the special countv rate account. Working-class dwellings.—The results of the year's working compared with those of the previous year are as follows:— Dwellings— 1925-26. 1924-25. Housing Act, 1925— £ s. d. £ s. d. Part II. Surplus 22,874 19 4 Surplus 22,371 11 7 Part III. Surplus 27,654 1 7 Surplus 27,309 5 5 Total—Housing Act Surplus 50,529 — 11 Surplus 49,680 17 — Improvement, etc., Acts Surplus 14,614 2 10 Surplus 15,053 16 8 65,143 3 9 64,734 13 8 Advances under section 92 of the Act Surplus *4,620 6 6 Deficiency 185 9 2 Total—Non-assisted schemes Surplus 69,763 10 3 Surplus 64,549 4 6 The surplus (£50,529 -s. 11d.) for 1925-26 on the dwellings erected under the Housing Act, with the balance brought forward at 1st April, 1925 (£94,229 Is.), which was held in reserve, together amount to £144,758 Is. 11d. Of this sum £29,553 7s. 2d. is applied to meet the deficiencies for the year 1925-26 in respect of certain operations under the Assisted (1923) Scheme, the balance (£115,204 14s. 9d.) 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 Improvement, etc., Acts, is £14,614 2s. 10d. and is disposed of as follows:— Surpluses transferred—- £ 8. d. To General County Account—Sundry Improvements 15,368 — 2 To Tramways Account—Rehousing, Greenwich power station site 104 11 — Less— 15,472 11 2 Deficiency charged to Education Account—Rehousing, sundry school sites 858 8 4 14,614 2 10 The operations under section 92 of the Act of 1925 show a "surplus" (see note *below) for the year of £4,620 6s. 6d. There was a deficiency at the beginning of the year of £185 9s. 2d., and it is proposed to carry forward to the year 1926-27 the net balance of £4,434 17s. 4d. *The "surplus" for the year consists mainly of the amount by which the sums received in advance for survey fees and expenses exceed the costs incurred during the year and is carried forward as a balance on the account to meet the costs arising in the following year. 203 B.—Assisted Scheme—Housing, etc., Act, 1919. This section comprises the whole of the Council's operations under the first (Addison) Assisted Scheme, and, as provided in the Act, includes the losses incurred by the metropolitan borough councils, together with the deficiency in connection with the issue by the Council of Local Bonds for Housing for the purpose of financing the schemes of the borough councils under the Act of 1919. The Council's Housing Accounts thus embody the financial results of all the schemes subject to the 1919 Act for the County of London as a whole. The annual deficiency (as approved by the Minister of Health) under this Act in excess of the produce of a penny rate is met out of moneys voted by Parliament. The results for the year 1925-26, compared with those for the previous year, are as follows:— 1925-26. 1924-25. £ s. d. £ s. d 1. Clearance schemes Surplus 1,784 9 4 Deficiency 8,016 13 5 2. Dwellings Deficiency 426,915 3 2 Deficiency 402,030 8 5 3. Schemes of metropolitan borough councils Deficiency 248,669 7 11 Deficiency 240,011 15 11 4. Local bonds (for housing) Deficiency 29,132 5 8 Deficiency 32,395 3 8 Total deficiency 702,932 7 5 682,454 1 5 The "surplus" on clearance schemes is due to adjustment of the accounts of past years, following agreement with the Ministry as to the areas which should be deemed to belong to the 1919 and 1923 schemes respectively. The total deficiency is provided for as follows:— 1925-26. 1924-25. £ s. d. £ s. d. Chargeable to Special County Account (produce of penny rate £180,007 3s. 3d., less adjustments (see below) 169,794 8 3 177,773 18 10 Exchequer subsidy 533,137 19 2 504,680 2 7 702,932 7 5 682,454 1 5 The accounts of 1925-26 include an adjustment necessary to remove from the subsidy account the amounts of rates collected from tenants and paid in bulk by the Council since the commencement of the assisted scheme, the Ministry having decided that these transactions, being at the discretion of the Council, should not be brought into account in the loss as computed for subsidy purposes. The arrangement is to the Council's financial advantage. 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 additonal charge on the county rate. As regards the deficiency under the head of dwellings, £35,716 11s. 11d. is attributable to "estates in course of development," the debt and other charges in respect of which, less receipts in aid, are shown separately in the detailed statements appended to 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.—A sum of £248,669 7s. 11d. is provisionally included to cover the borough councils' losses for the year 1925-26 as compared with £240,011 15s. 11d. for the year 1924-25. The amount is subject to revision, and any variation will be reflected in the amount of the Exchequer subsidy. 204 C.—Assisted Scheme—Housing, etc., Act, 1923. This section covers (a) clearance schemes, and the consequent rehousing, the deficiency in respect of which is met to the extent of 50 per cent. by State subsidy, (b) various schemes for providing additional housing accommodation, under the conditions as to subsidy prescribed in the (Chamberlain) Act, i.e., at the rate of not exceeding £6 a house annually for 20 years, and (c) assistance given by the Council to metropolitan borough councils and to private enterprise in the form of grant. The annual subsidy of not exceeding £6 a house is receivable in aid of the Council's expenditure on grants to private enterprise. Assistance to private enterprise in the form of loans under section 5 of the Act of 1923 (now Section 92 of the Housing Act, 1925), is calculated not to involve any charge on either the Exchequer or the rates, and the transactions are included under the section "Non-Assisted Schemes." The net deficiency under all heads for the year 1925-26 was £69,402 18s., as follows:— 1925-26. 1924-25. Schemes undertaken by the Council— £ s. d. £ s. d. Clearance and rehousing (Part II) 25,142 6 11 5,425 6 8 Dwellings (Part III) 38,496 7 2 20,454 3 2 Schemes of metropolitan borough councils— Contributions by the Council 1,110 — — 270 — — Schemes undertaken by private enterprise—- Debt charges on capital grants, and sundry expenses 4,654 3 11 2,029 5 5 Total deficiency 69,402 18 — 28,178 15 3 The deficiency for 1925-26 is provided for as follows:— Exchequer subsidy 25,857 5 7 Balance falling on the Council— £ s. d. Met out of reserved surplus on non-assisted dwellings 29,553 7 2 Chargeable to special county rate account 12,565 9 2 Chargeable to general county rate account 1,426 16 1 43,545 12 5 69,402 18 — D.—Assisted Scheme—Housing, etc., Act, 1924. The operations under this (Wheatley) scheme cover Part III housing only, the State subsidy being at the rate of £9 a house annually for 40 years, subject to compliance with "special conditions" as to the letting of the houses. The net deficiency for 1925-26 was £63,829 9s. 9d., which includes £169 7s. 2d. for preliminary expenses in connection with assistance to private enterprise under the Act of 1924. Towards this deficiency the subsidy due from the State was £5,598, and a sum of £58,202 4s. 9d. is charged on general county account. At 31st March, 1926, the bulk of the capital expenditure related to estates in course of development, but as the completed houses increase in number, the State will bear a correspondingly larger share of the deficiency. Net Deficiency, 1925-26—How Met. The financial results for the year under the several sections are as follows:— £ s. d. Total expenditure 1,812,850 4 3 Total income 1,001,085 4 11 Net deficiency 811,764 19 4 205 This is met or disposed of in the following manner— (a) Exchequer subsidy and (b) special contributions by metropolitan borough councils. Transfers to or from Rate, etc. Accounts. (a) Carried for- ward or (b) disposed of by internal transfers. Special County Account. General County Account. Other Accounts. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Non-assisted schemes-- clearance (deficiency, £45,363 14s. 5d.) — 45,303 14 5 — — — Dwellings, etc. (surplus,£69,763 10s. 3d.) — — 15,368 — 2 *753 17 4 (a)25,596 (b)29.553 7 3 2 Assisted (1919) scheme (deficiency, £702,932 7s. 5d.) 533,137 (a) 19 2 169,794 8 3 — — — Assisted (1923) scheme (deficiency, £69,402 18s. -d.) (a)25,857 5 7 12,565 9 2 1,426 16 1 — (b)29,5 3 7 2 Assisted (1924) scheme (deficiency, £63,829 9s. 9d.) (a)5,598 (b) 29 5 — — 58,202 4 9 — — 564,622 9 9 227,723 11 10 44,261 — 8 753 17 4 (0)25,596 — 3 £811,764 19 4 *£104 l1s. -d. transferred to Tramways Account and £858 8s. 4d. contributed by Education Account. The total charge for the year on the rate and other accounts concerned is thus £272,738 9s. 10d. 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 from the revenue account of the non-assisted schemes to the fund are based on definite estimates of the dates and intervals at which particular kinds of repairs and renewals will fall to be undertaken. As a provisional measure the transfers in respect of Part III dwellings assisted under the 1923 and 1924 Acts have been calculated at 20 per cent. of the rental. As regards dwellings ranking for subsidy 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, and the same course has been followed in the accounts of rehousing (Part II) schemes (50 per cent. subsidy) under the Act of 1923. The regulation on the point is due for review at an early date. Meanwhile, representations have been made to the Minister as to the inadequacy of the allowance. Local Bonds for Housing. The original issue of these Bonds (bearing interest at 6 per cent.) ceased on 30th July, 1921, the total amount raised being £3,955,605. During 1925-26 bonds with a five-year currency, amounting to £1,560,415, fell due for repayment. The Council decided to make a fresh issue, bearing interest at 5 per cent., with the following result— £ Expiring bonds conveited 985,680 Fresh money raised 534,330 1,520,010 Less—Amount of bonds maturing £1,500,415 Deduct—Amounts provided otherwise than from proceeds of new issues 274,040 1,286,375 Additional money available [to 7th April, 1920) 233,635 13651 0 206 Hitherto, the proceeds of Local Bonds have been used solely for loans to metropolitan borough councils for the purposes of their schemes under the Act of 1919. It is proposed to use the additional money now available for other housing purposes, viz., advances under Section 92 of the Housing Act, 1925. The accounts relating to Local Bonds have accordingly been removed from their former position as a part of the accounts of the 1919 Scheme and now show as a separate section; the net charge arising is transferred thence to the appropriate accounts. Capital Expenditure and Debt. The total capital expenditure in respect of housing up to 31st March, 1926, amounts to £20,399,992 5s. 7d., as follows:— Non-assisted schemes. Assisted (1919) scheme. Assisted (1923) scheme. Assisted (1924) scheme. £ s. d. £ s. d. £ s. d. £ 8. d. Clearance schemes 2,734,733 13 11 46,681 10 9 58,492 5 3 — Erection of dwellings 3,044,354 3 4 9,842,075 7 1,421,751 16 11 2,151,473 8 5 Advances to private enterprise 1,041,930 — — — — — Lump sum grants to private enterprise Net debt outstanding — — 58,500 — — — 6,821,017 17 3 9,888,756 17 9 1,538,744 2 2 2,151,473 8 5 4,247,080 6 9 10,844,900 (a) 13 5 1,644,106 (a) 12 6 2,276,494 (a) 12 3 (a)Including £1,260,857 7s. 6d., £121,503 17s. 9d. and £128.116 15s. 10d.. respectively, 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. Assistance to Private Enterprise, etc.—Advances on Loan. A statement appended to the accounts shows the extent of the Council's assistance by way of loans to builders and other persons, both under section 92 of the Housing Act, 1925, and under the Small Dwellings Acquisition Acts. Expansion of Council's Housing Activities. Housing Estates.—Memorandum by the Valuer (Mr. Frank Hunt). 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 1925-26 shown a continuous increase. This is the natural consequence of the expansion of the Council's housing activities, including the acquisition of land and the clearance of slum areas, caused by the housing legislation passed in recent years. New dwellings provided during the year. At the end of March, 1925, 9,638 dwellings had been erected under Assisted Schemes in accordance with the provisions of the Housing Acts of 1919, 1923 and 1924. During the year 1925-26, 2,350 additional dwellings were provided, 46 of which were erected under the Act of 1919, 1,396 under the Act of 1923 and 908 under the Act of 1924. The total number of dwellings completed and brought into charge under Assisted Schemes at the end of March, 1926, was thus 11,988. Of the houses erected on the various estates during the year, 1,564 are situated at Becontree, 38 on the White Hart Lane Estate, 39 at Roehampton, 108 at East Hill, Wandsworth, 562 on the Downham Estate and 39 on the Whitmore Estate, Shoreditch. The dwellings on the East Hill Estate and Whitmore Estate are fiats in block dwellings, while all the others are cottages or cottage-flats. The dwellings, almost all of them erected before 1914 under Non-Assisted schemes, numbered 9,993, so that the actual number of dwellings in charge at the end of the year under review was 21,981 or more than double the number before the War. 207 Total accommodation provided. The dwellings erected under Non-Assisted Schemes comprise 6,551 flats in block dwellings, 3,148 cottages and 294 cottage-flats, providing accommodation for 57,047 persons on the basis of two persons a room. There are also the three lodginghouses (Bruce House, Carrington House and Parker-street House), with cubicles providing accommodation for 1,880 persons. The accommodation under NonAssisted Schemes thus provided was for 58,927. Adding to this figure the accommodation in dwellings under Assisted Schemes, the Council's dwellings and lodginghouses provided, at the end of March, 1926, accommodation, calculated on the basis of two persons a room for 149,726 persons. Schemes under which over 12,000 houses at cottage estates and approximately 2,500 tenements in block dwellings are projected at Becontree, Roehampton, Downham, on the Watling Estate (Hendon), White Hart-lane, the Wormholt Estate (Hammersmith), Castlenau, East Hill, (Wandsworth), the St. Helier Estate (Morden), and in various slum areas to be cleared. The work involved in 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. A considerable amount of work has been created owing to the enquiries which have had to be made into cases notified by the Metropolitan Borough Councils, as well as other possible cases of hardship by reason of the applicants living in insanitary or overcrowded conditions. There has also been a large amount of preliminary work in connection with the development of proiected new estates. Demand for accommodation. There has been no abatement of the great demand for accommodation on the Council's estates. During the year 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 the 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 67,000, an average of 218 a day, while over 53,055, an average of 172 a day, were made by letter as to the possibility of obtaining living accommodation on the Council's estates. These figures represent an increase of over 16,000 persons calling to make enquiries and of over 15,000 letters received, as compared with the numbers for the preceding year, 1924-25. Allocation of accommodation between residents of different boroughs In October, 1924, the Council decided that, as an experiment for one year, a part, not exceeding 50 per cent., of the new accommodation provided under Part III. of the Housing Act, 1925, should be allocated amongst suitable applicants recommended by the several Metropolitan Borough Coimcils in proportions based upon existing conditions of overcrowding in such boroughs. The position was reviewed towards the end of 1925, with the result that on 26th January, 1926, the Council agreed to continue the scheme, except that in future the quota should include families preferentially accommodated, otherwise than on the direct recommendation of the Borough Councils. To a considerable extent advantage has been taken of this scheme by the majority of the Borough Councils and under this arrangement it has been possible to accommodate about 512 families at Becontree and 301 at Downham, 8 at Roehampton and 3 on the White Hart-lane Estate. The Borough Council concerned is notified periodically in ftll cases in which applicants are accommodated on one of the Council's estates. 13651 o* 208 Having regard to the large number of applications from persons residing in the county of London, it has been decided that, except in very special cases, all applications from persons residing outside the county shall 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 so small as to render them ineligible for accommodation in dwellings other than those of the smallest types. Method of allotting. 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 the county of 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. In some cases it has been necessary during the year to decline to entertain applications on the ground that the family income of the applicants was inadequate to enable them to pay the rents, although these are less than remunerative and involve heavy expenditure out of public funds. On the other hand some applications have been declined as it was considered that the financial position of the applicants did not justify their being accepted as tenants of State Assisted accommodation. Under the tenancy agreements tenants are not allowed to take lodgers or to sublet. 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 1920-25, however, the Council rehoused 2,184 persons. During 1925-26, 1,346 persons were rehoused, who had been displaced mainly by the following schemes:—Ware-street Scheme, Shoreditch; Hickman's Folly Scheme, Bermondsey; Tabard-street Scheme, Southwark; Bell-lane Scheme, Shoreditch; Prusom-street Scheme, Stepney; Brady-street Scheme, Bethnal Green; Lena Gardens Scheme, Hammersmith and Salisbury-street Scheme, Bermondsey. Of these 1,346 persons 209 were accommodated on the East Hill Estate, 204 on the Downham Estate, 180 on the Whitmore Estate, 117 on the Boundary-street Estate and the remainder on other estates. The total number of persons rehoused up to 31st March, 1926, was 5,286. Transfers. During the year 1,076 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. Mutual exchanges of tenancies 209 are facilitated at the request of, and in the interests of, the persons concerned, and a special register is kept whereby it is possible to arrange transfers between Council's tenants, when both parties are agreeable. Removals and empties. During the year 958 tenants left, of whom 63 were given notice to quit, either for non-payment of rent, unsatisfactory conduct, or some other cause. The remaining 895, about 5 per cent. of the total number of tenants, gave notice and left to suit their own convenience. Enumeration of tenants and overcrowding The annual enumeration of tenants was taken in January, 1926, when it was found that the actual population of the dwellings was approximately 90,500 persons, which is greater than that of Ilford or Hornsey or the Metropolitan Borough of Hampstead and almost as great as that of Northampton or Southend-on-Sea. 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 has been fixed at two adults a room, children up to the age of five not being taken into account, and each child between the age of five and ten being regarded as half an adult. This year the number of Non-Assisted Scheme tenements not complying with this standard was 342 out of a total of 9,993, and in Assisted Scheme dwellings, 24, out of a total of 11,988. At last year's enumeration it was found that 313 Non-Assisted Scheme dwellings and 18 Assisted Scheme dwellings exceeded this limit. The excess 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 the standard of overcrowding laid down in the by-laws made under the Public Health Acts. The crowding will be remedied as opportunities occur by transfers to larger tenements. occupations of tenants. Particulars of the occupations of the tenants have been obtained. These particulars, while conveying a general idea of the different occupations of the tenants, in some respects do not adequately describe the nature of employment owing to the individual tenants' varying descriptions of their employment. The information is obtained from the tenants who, it will be realised, do not in many cases give clear and precise descriptions of their occupations. Thus, it is impossible to say how many of the 346 tenants who describe themselves as "Conductors" are tramway conductors or omnibus conductors,while it may be observed that 806 tenants describe themselves as "Motor Drivers" and 40 tenants simply as "Drivers." For example, also, the description "Civil Servant," probably includes such employees as postmen and messengers as well as clerical employees, while 808 tenants describe themselves as "Post Office Workers," an occupation which might by some be regarded as coming under the heading "CivilServants." It "may be noted that the two most numerous categories of tenants are "Clerks, etc.," of whom there are 1,937, and "Labourers," of whom there are 1,294. Of the tenants, 460 describe themselves as "Railway Workers," and 407 as "Tramway Workers." Adding to these figures the number of tenants who describe themselves as "Conductors," "Drivers," "Motor Drivers," and "Engine Drivers" and probably a considerable number of the "Engineers" and "Labourers," it is clear that a large proportion of the tenants are engaged in the transport service. Fixation of rents. The rents charged for the dwellings are fixed on the basis of pre-war rents of similar accommodation in the neighbourhood, the 40 per cent. increase allowed by the Increase of Rent, etc., Acts, being added and due variations being made having regard to size, amenities and position. RentRestrictions Acts. Under the Increase of Rent and Mortgage Interest (War Restrictions) Act, 1915, the additional rates which the Council had to pay in respect of the dwellings were added to the rents payable by the tenants while, in accordance with the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920, the rents were further 210 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 21,000 tenements with varying rents and rateable values and situated in the areas of nearly thirty different local rating authorities. Vital statistics. The health conditions on all the estates continue to be satisfactory. Ihe population of the Council's dwellings in the different metropolitan boroughs is, of course, small in proportion to the borough population in each case and properly comparable vital statistics are therefore not obtainable. The statistics available are such, however, as to justify the inference that the health conditions in the Council's dwellings are better than those in the boroughs concerned and in the county of London as a whole. Financial results. In the Housing Accounts for 1925-26 details are given of the financial results of the Council's housing schemes up to 31st March, 1926, but it may be apposite to repeat here some of the more important figures. In this connection it is necessary to preserve a clear distinction between the Non-Assisted Schemes and the Assisted Schemes promoted under the Housing, Town Planning, etc., Act, 1919, the Housing, etc., Act, 1923, and the Housing (Financial Provisions) Act, 1924. Dealing first with the Non-Assisted Schemes, the aggregate capital expenditure on dwellings provided and in course of erection at Hornsey-rise Estate and Bushgreen House to 31st March, 1926, was £3,044,354. The gross rental (including rates) for the year was £351,117. From this amount should be deducted the losses, which were, however, infinitesimal, arising out of empties and rent irrecoverable. The financial result of the year on the Non-Assisted dwellings, as a whole, after providing for interest and sinking fund charges on the capital expenditure, was a surplus of £65,112, as compared with a surplus for the preceding year of £64,914. In regarding this surplus it should be borne in mind that when the percentage increase under the Increase of Rent, etc., Acts, was fixed, allowance was made, having regard to the altered financial conditions, for an increase of one per cent. on the interest on the original capital expenditure. As regards Assisted Scheme dwellings provided under the Act of 1919 the aggregate capital expenditure on schemes wholly or partially completed up to 31st March, 1926, was £9,842,075. The gross rental (including rates) for the year, of dwellings erected by the Council, excluding shops and sundry other items deemed to be outside the scheme for purposes of subsidy, was £394,576. The financial result, after providing for interest and sinking fund charges on the capital expenditure was a deficiency of £390,827. The annual deficiency under this Act in excess of a penny rate is met by subsidy out of the National Exchequer. The aggregate capital expenditure, up to 31st March, 1926, on Assisted Scheme dwellings erected and on estates in course of development under the Act of 1923 was £1,421,752. The gross rental (including rates) for the year, of dwellings erected by the Council was £59,792. The financial result, after providing for interest and sinking fund charges on the capital expenditure was a deficiency of £16,138, towards which the Government provide a subsidy partly to the extent of 50 per cent of the annual loss, and as regards the remainder on the basis of £6 per annum per house, the balance of loss falling on the rates. The aggregate capital expenditure up to 31st March, 1926, on Assisted Scheme dwellings erected and on estates in course of development under the Act of 1924 was £2,151,473. The gross rental (including rates) for the year, of dwellings erected 211 by the Council was £13,261. The number of dwellings erected under this Act which came into charge during the year was relatively small and a large proportion of the dwellings was not occupied until the year was well advanced. The financial result after providing for interest and sinking fund charges on the capital expenditure, was a deficiency of £2,683, towards which the Government provide a subsidy of £9 per annum per house, the balance of loss falling on the rates. Rent irrecoverable. About 116 tenants left during the year without paying arrears of rent, but the amount irrecoverable amounted only to £417, or about .05 per cent. of the total collected. Of the amount irrecoverable £28, or .008 per cent. of the amount collected arose on Non-Assisted Schemes, while £389, or .083 per cent. of the amount collected, arose on the Assisted Schemes. Empties. The loss by empties during the year was £856, or .10 per cent. of the rent, as compared with .14 per cent. in 1924-25. These empties were caused entirely by dwellings having to be cleaned and repaired in connection with changes of tenancv. Repairs. The high standard of upkeep, both as regards repairs and cleanliness, has been fully maintained. The necessary repairs to the dwellings are carried out by direct employment of labour. The number of repairs workmen employed varies largely according to the season, but, during the year 1925-26, the average number of workmen employed was about 320. The amount expended on this work in 1913-14 was £23,934. In 1920-21, when there was practically no repairs work on dwellings erected under Assisted Schemes, the expenditure had risen to £69,662, this increase being due to the higher wages, to the rise in the prices of material, 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 £47,560, and to £15,825 on Assisted Schemes. It will be seen that by this time there had been relatively a substantial decrease in the expenditure under this head, 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. During the year 1924-25 the expenditure on Non-Assisted Schemes amounted to £47,725, and to £36,517 on Assisted Schemes. During the year 1925-26, the expenditure on Non-Assisted Schemes amounted to £51,004, and to £46,048 on Assisted Schemes. The increase in the expenditure on Assisted Schemes is due, of course, to the growth of the number of dwellings coming into charge in 1920 and in subsequent years. Printed by Odhams Press Ltd., Long Acre, W.C. 2. For the information of the Press. London County Council. ANNUAL REPORT OF THE COUNCIL, 1935-VOLUME III (PART I)-REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH. The London County Council announces the publication of Vol. Ill (Part i) of the Annual Report of the Council for 1935, consisting of a section of the report of the County Medical Officer of Health, Sir Frederick Menzies. The volume, which can be obtained from the Council's publishers, P. S. King & Son, Ltd., price Is., deals with a great variety of subjects, including vital statistics, slum clearance, the treatment of tuberculosis, the Midwives Acts and a wide range of other aspects of public health work. Other volumes of the report, published separately, deal with the Council's hospitals and with the school medical service, and the whole provides evidence of the manifold ramifications of the work of the Council as public health authority. P. 7 Two interesting points which emerge from the section on "vital statistics" are that there has been a noteworthy reduction in the number of deaths from street accidents (from 752 in 1934 to 531 in 1935), and that the infant mortality rate, 58 Per 1,000 births, is the lowest recorded for London. pp. 8-13 Details are given as to the migration of population, so far as the County is concerned, during the period 1841-1931. Until l88l there was a definite inflow into the County, but since that date the flow has been outwards. The maximum migration "in" was in the decennium 1841-51, when it was 251,185. The maximum migration "out" was in 1901-11, when it was 523,091. During 1921-31 the migration "out" was 324,698, and in the same period there was an increase of 8ll,26l in the population of the "outer ring" of London. These figures for the administrative county show the net result of immigration and emigration, and 1. disclose that even when the net migration "out" is large, there is migration "in" at certain ages, especially of girls aged 15 to 20 and of young men aged 20 to 25. PP. 13-23 p. 13 Particulars are included of the incidence of infectious diseases in the County, and full details given of two cases of anthrax, one the result of using an infected brush which had been overlooked at the back of a drawer when the rest of the oonsignment was destroyed in 1930. There has been no case of smallpox in London since June, 1934. pp. 18-22 P. 24 It is very satisfactory to note that the maternal mortality rate for 1935 is the lowest hitherto recorded, being 2.58 per thousand live-births. The death rate for tuberculosis, also .68 per thousand living, was the lowest ever recorded in London. p. 35 The work of slum clearance has made good progress, 4,409 houses being dealt with in 1935, making a total of 10,227 houses between the passing of the 1930 Housing Act and the 31st December, 1935. PP. 36-37 The results of an inquiry into the disposal and utilisation of waste food and other waste materials are shown in detail. It may be surprising to know the quantity of such material dealt with. For instance, one firm alone collected and disposed of 14,470 tons of fish offal in the County during 1935. The report PP. 38-39 PP. 39-41 deals with the collection and use made of old rags, which may be sorted into as many as 600 or 700 different grades, depending on colour, fineness of weave, etc. The problems of dealing with old bottles, scrap metals, and waste paper are also referred to. PP. 67-73 Among the various activities of the Council's central chemical laboratory may be mentioned the fact that 18,747 samples of various kinds were analysed. As an example of the extraordinary duties falling to this branch of the department may be mentioned an inquiry into the nature of "itching powder" put down the back of one schoolboy by another. The County Hall, S.E.I. 20th October, 1936. G. H. GATER, Clerk of the Council. 2.