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ANNUAL REPORT FOR 1906 OF THEMEDICAL OFFICER OF HEALTH OFTHE ADMINISTRATIVE COUNTY

OF LONDON.1

III.

IF justification were required of the policy of the LondonCounty Council in combining under one authority theadministrative functions of public health and elementaryeducation, it is difficult to conceive how this could have beenmore completely accomplished than by the publication of thecomprehensive and instructive report that lies before us.The second appendix to this report is from the pen of Dr.

James Kerr, the Council’s medical officer for education. This

report shows that, as regards the metropolis, a goodbeginning has been made to give effect to some of the chiefrecommendations of the Duke of Devonshire’s Committee onPhysical Deterioration. It will be remembered that one of themost important of these recommendations was that a medicalexamination should be made as to the mental and physicalcondition of every child on admission to an elementaryschool. Even a cursory reading of this report will suffice toindicate that a very serious amount of mental as well as ofphysical defect has been discovered among children in attend-ance at those of the London schools which have already beenmedically examined. To some of these we propose verybriefly to allude.

It will surprise no one to &eegr;ear that supreme importanceis attached by the education authority to the medical

inspection of the very youngest children-the "infants," asthey are technically classed. It is at the earliest ages that

slight defects or diseases have a profoundly modifyinginfluence on the future ; and it is of special importance thatchildren of from three to five years should be examined inorder that the beginnings of tuberculous bone and jointdiseases amongst others may be detected, and thus permanentcrippling may in all probability be avoided. With the stafEat present at the department’s disposal detailed examinationis impracticable, but an attempt has been made by samplingto ascertain what medical inspection of infants really meansand what it is likely eventually to lead to when effectuallycarried out. For this purpose examination was made byDr. E. M. Niall of 14 schools, varying from the slumareas of Vauxhall, through the artizan areas of Lambeth,to the better class districts of Brixton and Norwood.The effect of environment appears at once from the factthat the survivors of the slum children at the age offive are as a rule sturdier and quicker than the more

carefully nurtured cihldren who have not been exposed tohard climatic conditions, but who on the other hand appearto present larger numbers of dull and backward children withanæmia, nasal obstruction, and glandular troubles. Two

neighbouring schools, Lollard-street and Walnut Tree Walk,presented respectively the highest and the lowest number ofdefectives. Lollard-street, the school with the highest pro-portion (27 per cent.), is in a poor district abounding in fried-fish shops. Many of the mothers are wage-earners, return-ing home late at night too tired to look after the children.As might have been anticipated, semi-starvation and homeneglect are factors in these unhealthy surroundings. The

high percentage of defectives in this school was due in partto the presence of large numbers of children below theaverage in mental ability in one of the classes-a dullards’class containing 47 per cent. of children with some obviousdefect. It is for such a class as this more particularly thatearly medical inspection is imperatively necessary, for bythis means many cases of corneal ulceration, marginalblepharitis, incipient ophthalmia, and otitis may be detectedand presumably remedied. Very harmful are what are

designated "dirt conditions," especially in relation to theeyes, nose, and ears, ulceration of the corneal surface oftenleaving permanent damage. In many cases the parents willdo nothing, even when asked by the teachers. These " dirt "

inflammations in children of debilitated constitution are thechief conditions of slum schools.But Dr. Kerr is careful to remind us that general medical

inspection must eventually lead to the establishment of4, school clinics " for treatment in ways which he takes pains 1 Previous notices of this report appeared in THE LANCET of Jan. 25th,

p. 250, and Feb. 8th, 1908, p. 445.

to define. Without such treatment mere medical inspectionis, in his judgment, incomplete and generally means time andtrouble wasted. Most of these cases are neglected. Somefew are attended to at hospital, but generally this is unsatis-factory and of late very many cases have been refusedtreatment.

If individual medical inspection of school children becomesgeneral, we are warned that all the hospitals in London wouldnot provide for the treatment of one-tenth of the childrenthat would require treatment for diseases of the eyes, ears,and teeth alone. In order to cope with these cases Dr. Kerrsuggests that the question of school clinics ought to becomea subject of careful inquiry and as a question of elementaryeducation should receive the early consideration of the

County Council. To anyone fairly conversant with theuntoward conditions normally obtaining among the infantdenizens of our slum neighbourhoods it will occasion no

surprise that of all the morbid conditions revealed bymedical examination of school children by far the mostimportant are those in which tuberculosis in one or other ofits forms plays a prominent part. In the course of an

investigation concerning the prevalence of tuberculosis inelementary schools Dr. Annie C. Gowdey reported on

the condition of the spinal column of more than 400 younggirls at Addison-gardens school. Of these girls, whose agesvaried from six to 16 years, not less than 64 per cent. showedmore or less abnormality. Very many of these girls had"round backs," whilst the scapulæ of not fewer than halfof them were reported to be "growing out," with or

without some lateral curvature. Unless the state ofmatters at this school be exceptionally bad, and ifthe condition of the children there is typical ofwhat obtains among school children of the same ageelsewhere, it is obvious that further investigation isrequired with a view of obviating some of the incidents ofschool life which, at this school at any rate, appear to haveproduced deplorable results. Dr. Kerr comments on theexcessive prevalence of deformity of the back among girls ascompared with boys, and points out that this is due to somespecific cause, such, e.g., as a want of regular development ofthe trunk muscles induced by various constrictions and supportsin the way of binders and corsets. Meantime, he suggeststhe desirability of directing the attention of teachers whosuperintend drill to the many causes that have been assignedfor this condition, such as the imperfect lighting of school-rooms, the habit of sitting cross-legged, and of standing withthe weight of the body constantly resting on one leg.The examination of girls in the secondary schools has

also been carried out on a limited scale during 1906.In so doing Dr. Janet M. Oampbell found it possible toconduct inquiry respecting the general physique of thegirls with more detail than was possible in the case ofthe elementary school children before referred to. Outof 604 girls examined, 138 showed definite lateral curva-ture. Definite osseous deformity, not admitting of correc-tion, was presented by seven of these girls, their agesbeing from 15 to 22 years. In all the other cases thedeformity could be made to disappear by changes of posture.These girls migrate, for the most part, from the elementaryschools, and their average standard of physique is not high.As they have all been previously examined medically, manydefects had already been remedied. Of the 138 girls withspinal curvature, 10 were above and 37 were below theaverage in general physique.Exaggerated and even alarmist reports having appeared

from time to time to the effect that pulmonary tuberculosisis excessively prevalent among children of school age, themedical officer has very usefully addressed himself to thetask of ascertaining how far children at school age are reallyaffected with pulmonary tuberculosis, and also how far theyare likely to be a danger to others. It should be premisedthat in the metropolitan schools there has long existed thesalutary regulation that whenever a child is supposed to besuffering from consumption, and especially if he coughs andexpectorates, he is forthwith excluded from school. Teacherssimilarly affected are likewise excluded for at least 12months. The risks of infection from persons obviouslysuffering from pulmonary tuberculosis are therefore believedto be small. In order to ascertain by careful medicalinspection the extent to which children of school age areactually suffering from pulmonary tuberculcsis, the boys andgirls, 1670 in number, in attendance at two large schoolssituate in Latimer-road and Addison-gardens respectively,were examined and the results tabulated for the present report.

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From this examination there were certain indirect resultsthat are worthy of note. For instance, we learn that child-ren, not necessarily consumptive, were found to be sufferingfrom physical defects which either interfered with school

progress or were likely seriously to influence the future lifeof the children, and for these medical treatment was

enjoined. Many cases of heart trouble, greatly enlargedtonsils or adenoids, and carious teeth were thus detected andplaced under treatment. As to the actual returns respectingthe two schools above specified, out of 1670 childrenexamined, signs in the lungs that would justify a diagnosisof tuberculosis were found in eight cases only. In 14 otherchildren slight signs were found-prolonged expiratorybreath sounds, or dry fine crepitation at the margin of thelungs-which might possibly be due to tuberculous infection.Even if these are included as actual cases of tuberculousdisease, the percentage of possible pulmonary tuberculosisreaches only 1. 3 per cent. There is a further small pro-portion in which enlarged veins on the chest suggest thepossibility of enlargement of bronchial glands due totuberculous changes, but without any evident lung affection.Nearly three-fourths of the children examined presentedenlargement of the cervical lymphatics and over 40 per cent.had enlarged tonsils.

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Within the administrative County of London there are atthe present time 23 invalid schools containing about 1800physically defective children. These children are daily con-veyed to and from school in 35 ambulances and 11 omnibuses,and their conveyance to school as well as their care thereare provided for by the employment of 24 nurses. Theadmission of an invalid or crippled child to these schools ispermitted only after medical examination. In most casesthe decision as to whether or not a child is fit for admissionis an easy matter. But there is clearly an advantage insecuring for special cases the opinion of an expert surgeon.It is necessary to have regard to the possible future of thechild in each particular case. Some children would be thebetter for gentle exercise or work suited to their strength,whilst for others absolute rest is a necessity. During thepast year Mr. R. C. Elmslie has carefully examined everycase on admission to school with manifest advantage to thechildren under his care. He has examined more than athousand children in 15 " physically defective centres, andhas noted in each case the nature of the disease or defect,the prevalence of active disease or of deformity, and theefficiency of any treatment adopted. Of these cases in the

aggregate 80 per cent. began before the age of seven yearsand 67 per cent. below five. Of the spinal cases 72 percent. occurred before the fifth year of life, whilst of thehip cases 64 per cent. occurred between the ages of two yearsand six. In the large majority of cases of tuberculous diseaseof the spine the onset of the disease occurs quite early inlife, somewhere between the second and the fifth year.Tuberculous disease of the hip-joint is evident at a some-what later age than spinal caries. The age distribution oftuberculous disease of the knee-joint is much more even thanthat of the two preceding forms of infection, the diseaseappearing for the most part about equally in each year of thtfirst nine. Of the 83 cases observed two were bilateral, in27 of which the disease was active and in 54 inactive. Veryinteresting particulars are given of the results of tuberculousbone disease, as regards deformity, crippling, &c., but forthese reference must be made to the report itself.

SANITARY REFORM IN INDIA.

I.AN important letter has been recently addressed by the

Secretary to the Government of India, Home Department,to all local governments and administrations upon the

subject of sanitary reform. We reproduce it verbatim and

hope that our readers will appreciate the fact that a grandeffort is now being made to improve the public health of ourenormous Eastern Empire:-

1. I am directed to address you on the important subject ofthe improvement of the sanitary services in India and thedevelopment of the present establishment on lines whichwill bring it abreast of modern requirements.

2. The history of sanitary administration in India wasreviewed in the Home Department Resolution of Sept. 8th,1904, in which the appointment of a Sanitary Commissioner

with the Government of India was announced. That resolu-tion concluded with the expression of a hope that, with theassistance of the Sanitary Commissioner’s advice and in con-sultation with local governments, substantial progress mightin the course of time be made towards a complete reorganisa-tion of the Sanitary Department. The Governor-Generalin Council is of the opinion that the time has come when anendeavour may be made to realise expectations and I amaccordingly directed to offer for consideration the followingsuggestions regarding the nature and direction of the advancewhich should now be made.

3. The administrative machinery of the sanitary depart-ment is already, in most respects, fairly complete andefficient. Additional deputy sanitary commissioners are

probably needed in some provinces, and I am desired torequest that the question of increasing their numbers may beborne in mind. These officers are at present recruited solelyfrom the Indian Medical Service, and though that arrange-ment must probably continue for some little time, theGovernment of India are disposed to think that the appoint-ment should not be reserved exclusively for officers of thatservice, but should be open also to the medical officers ofhealth referred to below. And they are further of the opinionthat no officer of the Indian Medical Service should be

appointed a deputy sanitary commissioner, unless he is of lessthan seven years’ service and has secured a degree or diplomain public health. The latter condition would be applied toall candidates whether members of the Indian MedicalService or not.

Sanitary Boards.4. Another part of the administrative machinery which

has been developed in different degrees and has attainedpositions of varying usefulness in different provinces is theSanitary Board. The Government of India believe thatthese boards are beneficial in emphasising the importance ofthe subject of sanitation, in correlating sanitary schemeswith administrative exigencies, and in securing direct dis-cussion between sanitary experts and those who are in aposition to appreciate and represent the attitude of thegeneral population. They are disposed to think that theBoard should consist of from three to five members, includinga senior officer of the Civil Service, who is in close touchwith the local administration, the sanitary commissioner, andthe sanitary engineer as experts, and one or two natives ofIndia, preferably non-officials. If the chief engineer and thehead of the Provincial Medical Service are placed on theboard the local government is deprived of the independentexpert advice which it requires when dealing with theboard’s recommendations. The functions of these boardshave hitherto been mainly advisory, but it is possiblethat they might be so constituted as to be able torelieve local governments of much work of minor import-ance. I am directed to suggest that the question of theconstitution and powers of the sanitary board should beexamined and to request that the Government of India

may be favoured with your opinion and proposals uponthis question.

Medical Officers of -Health.5. Turning now to the executive establishment the first

defect that forces itself upon the attention is the inadequacyof the staff of medical officers of health. The Presidency townsand a few other cities have such officers, but speaking gene-rally the civil surgeon is the only health officer of the townsin a district. It is often difficult for him to give sufficientattention to the sanitary requirements even of the head-quarters town. It is quite impossible for him to do morethan make an occasional inspection of other towns. A com-

plete and qualified staff of sanitary experts is a necessarypreliminary to any substantial improvement of sanitation.If reforms are to be planned on right lines and carried outwith efficiency and economy the work cannot be left in thehands of officers who have only a general knowledge of thesubject and whose time is largely occupied by other duties.

6. The Indian Plague Commission of 1900 recommendedthat a special European medical officer of health should beattached to every town which contains a population of100,000 inhabitants, and that one European assistant healthofficer should be provided for each additional 100,000inhabitants. The Government of India consider that thestandard of population suggested is reasonable and moderate.They are of opinion, however, that it is unnecessary andeven inexpedient to require that all these health officersshould be Europeans. A sanitary service offers a suitable and