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further information on what must be considered, from amedical point of view, the most important section of thework, treating as it does of the causes of the deaths of notfewer than 90, 000 of our fellow citizens in the course of asingle year. We have no difficulty, however, in selecting forexceptional comment Mr. Shirley Murphy’s remarks regard-ing the part played by school attendance in relation to thespread of diphtheria and scarlet fever, two diseases which havein recent years shown increased prevalence in London, andtherefore caused much trouble both to the school managersand to the hospital authorities of the metropolis.

Mr. Shirley Murphy gives tables showing the notifiedcases of diphtheria and scarlet fever in London, togetherwith the mortality incidental thereto in recent years. TheLondon death-rate from diphtheria in 1893 was more thandouble the rate in any of the largest English towns, exceptWest Ham ; it was ten times as great as the death-rate inNottingham, and six times as great as that in Liverpool.But it is not until the age incidence of fatal diphtheria inLondon comes to be studied that a clue is afforded to the

probable cause of the recent increase in the fatality of thisdisease. Statistics, the preparation of which must havecost much labour, have been compiled for the purposesof this report, and from a careful examination ofthese Mr. Shirley Murphy draws the following con-

clusions. 1. That antecedently to 1871 - 80, when thediphtheria death - rate at all ages was rising, the rate

at school ages (three to ten years) rose in less degreethan the all-age rate ; and when the all-age rate was fallingthe rate at ages three to ten years fell in even greater degreethan the all-age rate. 2. That in the decade 1871-80, with ageneral decline of the diphtheria mortality at all ages, thereoccurred at ages three to ten years a relatively higher diph-theria death-rate than before-that is to say, the diphtheriamortality at ages three to ten years did not fall in 1871-80in anything like the same degree as did the diphtheriamortality at all ages. This new departure is most conspicuousan London, but it is also noticeable in a less degree in otherparts of the country with which London has been com-pared. If the metropolitan rates of 1891-93 are contrastedwith those of 1855-60, it is found that in 1891-93, while theall-age death-rate had increased 313 per cent., that at-theages three to ten years had increased 457 per cent. ;and again, if compared with the rates of 1861-70, itis found that the all-age death-rates in 1891-93 hadincreased 196 per cent., whilst that at the agesthree to ten years had increased 309 per cent. Now itis important here to note that in 1871, the year imme-

diately following that in which the Elementary EducationAct first came into operation, there was in London a notice-ably increased incidence of diphtheria mortality at schoolages, which increase has been maintained ever since andhas in later years been much accentuated. With the

object of ascertaining, if possible, how far school attendanceis influencing the spread both of diphtheria and scarlet feverin London, Mr. Shirley Murphy has constructed diagramsshowing the registered weekly number of cases of diphtheriaand scarlet fever respectively in relation to the mean weeklynumber for the entire year. For this purpose the cases ofboth diseases notified in 1893 have been divided into threeclasses : (a) those occurring in children under three years ofage, (b) those in children from three to thirteen years ofage, and (c) those in persons above thirteen years old.The sick cases may therefore be considered in relation.to school operations, these three groups representingpractically (a) those who are too young to attend school,(b) those at the school period of life, and (e) those who havefor the most part left school. Accordingly, curves have beenconstructed showing the number of cases occurring in each4f these groups ; and in respect of both diphtheria andscarlet fever practically the same important fact at once

becomes apparent-namely, that in the four weeks of August,1893, there was a most remarkable depression in the curvefor all ages, the depression being much more strongly accen-tuated in the curve relating to children of school age. These

diagrams show clearly that, whatever the cause, there was in1893 a sudden and noteworthy diminution in the prevalenceof diphtheria and scarlet fever in London during the periodwhich corresponds generally with the closure of the LondonBoard schools, and that very shortly after their reopeningearly in September an almost equally serious increase in theprevalence of both diseases took place.Having regard to the limited period for which returns of

notifiable infectious diseases are as yet available in London,we are not surprised that the county medical officer ofhealth contents himself for the present with placing beforethe Council the facts bearing upon the important subject ofschool attendance in relation to the spread of certain com-municable diseases. When, however, the facts for a few

more years are forthcoming, we shall hope to bear more ona subject which is of transcendent importance, whetherviewed in relation to public health or to elementaryeducation.

THE EXHIBITION OF HYGIENE ANDCONGRESS ON PRACTICAL SANI-

TATION AT PARIS.

THE Exhibition of Hygiene will be inaugurated at Parisby M. Felix Faure, President of the Republic, on the 27th ofthis month. We have already explained that this Exhibitionwas organised in view of the new law which compels allhouses in Paris to drain directly into the sewers, for as yetonly 5447 blocks of buildings out of about 80,000 are drainedin this manner. In view of this great reform, a reformwhich will be extended as rapidly as possible to pro.vincial towns, a new sanitary society has been formed inFrance. It is called the Society of Sanitary Architectsand Engineers of France. Its headquarters are at 10,Cite Rougemont (Hotel des Ingénieurs Civils), and its

object is to group together those architects and engineerswho have studied questions relating to practical hygiene,to encourage such studies, to spread knowledge of hygieneamong the artisans engaged in these professions, andto bestow such honours and recompenses as may stimulatethe knowledge of sanitation among those concerned in thepractical realisation of sanitary reform. In the execution ofthis programme the society in question has determined tohold a "Congres d’Assainissement et de Salubrit6 " at theExhibition of Hygiene. The opening of this Congress willcoincide with the inauguration, at which the members of theCongress will assist, of the vast irrigation grounds and sewagefarm of Achere on Sunday, July 7th. The sittings of theCongress will be held in the locale of the Exhibition-namely,the Palace of the Liberal Arts at the Champs de Mars.Though not, strictly speaking, an international congress,foreign adherents will be heartily welcome, and members fromBelgium, Denmark, England, and Spain have already beenenrolled. The admission fee is twenty francs, to cover the costof printing the report of the Congress and its free distribu-tion to members. All communications should be addressedto the Secrétariat General du Congres, Palais des ArtsLiberaux, au Champs de Mars, Paris. Anyone taking anactive part in sanitary reform can become a member of theCongress. It is needless to say that this Congress ispatronised and encouraged by the French Government, andthat its members will have a unique opportunity of studyingand visiting all the sanitary services in Paris, as also theExhibition, to which they will be admitted free of charge.One of the principal subjects of discussion will be thedrainage of small towns or large villages. This is a phaseof sanitation which has been, comparatively speaking,neglected. The other subjects are the treatment and utilisa-tion of domestic slops ; the rules that should govern private

THE LANCET, April 6th, 1895.

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thoroughfares; public baths; the conditions governingthe application of syphon traps to the interior of inhabiteddwellings ; the disposition of rooms in dwellings ; the neces-sity of an effective control of the sanitary services in privatedwellings ; the rational warming of dwellings ; the profes-sional teaching of hygiene; and the unification of methodaemployed in drawing np sanitary statistics. The latter

subject will be treated by Dr. J. Bertillon, Chief of the ParisStatistical Department. On most of these questions printedreports will be distributed to the members before the

Congress meets, and these reports will be discussed at themorning sittings. In the afternoons private members mayintroduce other questions for discussion. This Congress will,in conjunction with the Exhibition, have the advantage oflifting sanitary questions out of the domain of mere

theory, and of compelling everyone to face and study thedifficulties of practical application. As an ounce of practiceis worth a pound of theory the Exhibition and Congressshould be well supported.

A MATTER OF ETIQUETTE.

WE publish below what we may hope is the final cor-

respondence in a matter to which we have previouslyreferred upon several occasions-namely, the relationsbetween the Vestry of St. George’s, Southwark, and Dr.

Waldo, their medical officer of health. To recapitulateshortly, the Vestry demanded of Dr. Waldo that he shouldrevise other medical men’s certificates, unknown to them, forthey were not always satisfied with the certificates sub-

mitted. Dr. Waldo refused absolutely to commit such abreach of medical etiquette. He appealed to the LocalGovernment Board, and the Board has decided that he isright. We congratulate Dr. Waldo on the stand he has madefor courtesy and righteous dealing. Now the case of theSchool Board and its discourteous resolution of May 30thstands on exactly the same footing. The School Board hasappointed medical men to revise other medical men’scertificates, presumably unknown to the original authorsof the certificates, and at the bidding, moreover, ofthe divisional superintendent, a layman. It is to be hopedthat the Education Department will convey to the Board anopinion that the Board have acted in, to say the least of it,an impolitic manner. The question, we suppose, will comeup at the forthcoming meeting of the Board, and if theBoard is wise it will rescind a resolution which ought nevereven to have been submitted. The following is the corre-spondence alluded to above :-

St. George-the-Martyr, Southwark,Vestry Hall, Borough-road,

To the Secretary, May 23rd, 1895.Local Government Board.

DEAR SIR,-I am desired by the Vestry of St. George-the-Martyr, Southwark, to ask the advice and guidance of yourBoard in the following difficulty:-When Dr. Waldo was appointed medical officer in the year

1892 he signed the enclosed list of regulations, and in accord-ance with Regulation No. 19 he bound himself to visit pro-fessionally the employes of the Vestry when sick, as theVestry allow sick pay, and they are not always satisfied withthe medical certificates submitted, for they fear thatmalingering is not unknown. In carrying out this regulation,Dr. Waldo finds himself in a position of difficulty. If hecalls on any employe without communication with themedical attendant who gave the certificate, he informs theVestry that he will be guilty of a serious breach of medicaletiquette, and if he gives notice to the employ6’s medicalattendant and arranges a formal consultation the Vestry feelthat the value of such visit will be lost, and they will beinvolved in considerable expense.

If Dr. Waldo finds himself obliged to report to the Vestrythat the certificate of the medical attendant was not justifiedby the patient’s condition, his relations with the localmedical men will become strained and his work as medicalofficer of health suffer. Some members of this Vestry, on theother hand, are of opinion that the Post Office, the largesupply associations, and some large friendly societies, requirethat visits (with the object of detecting malingering) shouldbe paid by their own officers. They see no reason whyDr. Waldo should not accordingly fulfil the terms of his

engagement, without prejudice to his status in the medicalworld and without offence to medical etiquette.

Yours faithfully,(Signed) A. MILLAR, Vestry Clerk.

Local Government Board, Whitehall, S.W.,June 12th, 1895.

, SiR,-I am directed by the Local Government Board toacknowledge the receipt of your letter of the 23rd ult., relativeto the duty undertaken by Dr. F. J. Waldo, the medicalofficer of health for the parish of St. George-the-Martyr,Southwark, "to attend, if required, the flushers and sewersmen and other employes of the Vestry during illness," andrequesting the Board’s advice and guidance in the difficultywhich has arisen in regard thereto. The Board have carefullyconsidered the representations on the subject submitted inyour letter and in the report of Dr. Waldo which aocom-panied it.On the general question the Board would observe that as re-

gards duties of a somewhat analogous character which at timesdevolve on the medical officer of health under the InfectiousDisease (Notification) Act, they have laid it down that evenwhen question arises as to the good faith of a certifying medicalpractitioner the medical officer of health should, if it becomesnecessary to revise a certificate, not only seek the oc6pera,tion of the medical practitioner concerned, but should alsoobserve, as far as possible, the customs that usually governthe relations of medical practitioners to each other. On theparticular case submitted in your letter of the 23rd ult. theBoard do not gather that the undertaking entered into byDr. Waldo "to attend if required" on certain employesduring illness " involves any obligation on his part to reviseeither the diagnosis or the certificates granted by othermedical practitioners who have been called in to attend onsuch persons. I am, Sir, your obedient servant,

(Signed) W. E. KNOLLYS,Assistant Secretary.

A Millar, Esq., Vestry Clerk, Borough-road, S.E.

THE ASSOCIATION OF FELLOWS OF THEROYAL COLLEGE OF SURGEONS

OF ENGLAND.

A MEETING of the committee of the Association ofFellows of the Royal College of Surgeons of England washeld at 101, Harley-street, at 530 P.M., on June 26th.Mr. T. Holmes, one of the Vice-Presidents, occupied the

chair, in the unavoidable absence of the President, Mr.

George Pollock, and there was a large attendance of mem_bers of the committee. The minutes of the last meetingof the committee were read and confirmed. The honorarysecretary, Mr. Percy Dann, reported that he had dulyissued the circular-letter addressed to the Fellows adoptedat the previous meeting of the committee. He then readletters from five Fellows of the College desirous of beingelected as Members of the Association. These were proposedand seconded by members of the committee and unanimouslyelected.The honorary secretary reported the proceedings at the

deputation to the committee of the Council which tookplace on the 10th inst., as already reported in THE LANCETof June 15th. In reference to this matter the honorarysecretary reported that the deputation had been asked by thecommittee of Council to draw up a p’l’éais of the argumentsadduced in favour of their propositions for amending thecharters and by-laws, and that the subcommittee appointedby the committee of the Association at a recent meeting hadalready commenced this yrrecis and now submitted it to thecommittee. After some discussion, the committee approvedgenerally of the work of the subcommittee, and requestedthem to complete it as K)on as possible.A resolution was proposed, seconded, and unanimously

passed, expressing the hope that all the members of theAssociation would record their votes in favour of Mr. Willett,Mr. Norton, and Dr. Ward Cousins.With respect to the annual general meeting of the Associa-

tion it was decided that the date should be fixed by thecommittee after the election at the College on the 4th prox.

This concluded the business of the meeting, and the com,..mittee adjourned.