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are so frequently mistaken for signs of phthisis that onelady medical inspector in another part of the country hasrecently attempted to show that some 14 or lb per cent.of the elementary school children in that district areconsumptive.

Underfed Children.Dr. Kerr’s critical remarks on this subject deserve atten-

tive consideration. He tabulates evidence derived fromcertain of the London schools, showing the average amountof underfeeding, or rather of improper feeding, discovered inthat portion of the school population; the principle ofclassification being (a) the degree of nutrition (good,indifferent, and bad), and (b) the amount of ansemia, as

tested by colour (normal, pale, and very pale). With respectto the kind of food ordinarily given to school childrenexperience shows that the children of the poor, and not

necessarily the very poor, never eat fresh vegetables, thatthey rarely have fresh milk, and never enough of it; goodeggs are unknown to them. They appear to live largely onbread, tea, and broth, with an occasional meal of bacon orfrozen meat. This is the result either of carelessness or ofignorance, and is largely due to the fact that the mothersoften have more to do than they can manage. From carefulinquiry it appears that the usual breakfast of school childrenconsists of tea with bread and butter, such cheap and whole-some food as oatmeal porridge, milk, and dripping beingalmost entirely denied them. The schools examined for theaforesaid purpose are arranged under three heads : (1) goodschools, (2) medium schools, and (3) poor schools, and foreach group tables are given in the report which deserveattentive study. "It is at once evident," says Dr. Kerr,"that although there is no direct connexion betweenanagmia and bad nutrition, both conditions are commonestin the poorer schools. Ill-nutrition is related largely to wantof employment and consequent privation. It is also relatedin other cases largely to bad housing ; to want of sleep andlarge families. Anaemia, seems to be also intimately asso-ciated with the presence of adenoids, enlarged tonsils, andother similar conditions. Regarding the schools as a whole,these three conditions seem to have about equal effects, butto be principally evidenced as want of food in the poorer,want of sleep and proper domestic hygiene in the mediumschools, and want of exercise and effects of debilitatingdisease in the better class schools."

I7afectios Diseases in Schools.

A considerable portion of this report is devoted to a con-sideration of the extent to which school attendance ishindered by outbreaks of infectious disease. Among diseasesof children of school age, the notification of which is notcompulsory, the principal are measles, whooping-cough,mumps, chicken-pox, ringworm, ophthalmia, and scabies.With the exception of the first two, these diseases,although seriously affecting school attendance, are not

dangerous to life. Among children’s diseases measlesclaims the heaviest death-toll, largely because of theignorance of parents. The first special inquiry concerningmeasles was undertaken at Woolwich five years ago atDr. Kerr’s suggestion, and has been continued ever since byDr. C. J. Thomas in cooperation with Dr. Sidney Davies, Ithe local medical cmcer of health. It may be said to haverevolutionised our ideas on the subject, for it has givenvaluable information regarding the distribution and the treat-ment of outbreaks of measles in schools. It has resulted in a

great saving of school attendance and has shown incidentallythat measles fatality is capable of further reduction. The

following procedure has been adopted in London generally,with the approval of the Local Government Board. Thehead teacher makes inquiry as to the measles history of everyinfant on admission to school. If a child has already hadmeasles the fact is recorded in the register ; if the child isnot known to have suffered that fact likewise is recorded. Therecord thus established shows the proportion of children pro-tected by previous attack to those unprotected, and it is uponthis knowledge that all action is based. Immediately on theoccurrence of a case of measles in a school a card is dis-tributed to each of the unprotected children in the room

warning the parents of the danger of infection and pointingout the serious character of measles. The case is then

reported to the medical officer, who determines the pre-cautionary measures desirable in view of the proportion ofsusceptible children in the room. School closure in

outbreaks of measles is undertaken solely as a preven-tive measure, since it has been proved to be futile totake this step when once measles is established in a school;it is therefore carried out only on the first appearance ofthe disease in a class-room. Even when carried out success-

fully, closure in London only postpones an attack for afew months, and is of little value except when applied tobabies’ rooms.

Scarlet fever and diphtheria are the only notifiablediseases which to any material extent affect childrenat school. Charts are inserted in the report showing theincidence of both these diseases during the period undernotice. Whilst the inquiries into the natural history ofmeasles and of diphtheria have led to practical means of

dealing with these diseases and have effected diminution inloss of school attendance, scarlet fever has not furnished asimilar return. "We have ascertained," writes Dr. Kerr,"that the peeling stage of scarlet fever is of little import-ance as regards infectivity, and also that a large proportionof people escape the disease." Again he writes : " Closure ofa school or department for scarlet fever, as it is now met

with, may be relegated to the list of crude and unscientificmeasures...... ill-considered measures of closure signifyfailure to detect the sources of spread, unrecognised casespossibly continuing to spread disease unchecked out ofschool. "

In scarlet fever outbreaks occurring in London we learnthat closure is now seldom applied, individual inspection andexclusion of suspicious cases being found to be of much

greater utility in controlling the disease. Diphtheria is con-trolled in the metropolis by means of bacteriological investi-gation, and the exclusion and notification of children foundto be harbouring bacilli. School closure for diphtheria,except in unusual circumstances, may mean loss of controlof dangerous cases.

GRATUITOUS MEDICAL RELIEF INSCOTLAND.

IN our second article on the Report of the Poor-lawCommission on the position in Scotland we referred tothe prominent place assigned in it to the gratuitousservices rendered by medical men to the poor, to theabuse of medical charities in towns by those well ableto pay for treatment, and to the absence of providentdispensaries and of medical service organised upon a pro-vident basis. Whatever undesirable features at times andin individual cases may distinguish medical assistancethus obtained and paid for by combinations of workingmen, it implies a quality of thrift and independence of

charity which we might expect to find existing no less norththan south of the Tweed. Not to offer remuneration for thatwhich is given gratuitously to those too poor to pay for itmay be a tendency arising out of a thrifty disposition, butthe idea of becoming dependent upon charity is repugnant tomany, and although hospitals offer temptation by openingtheir doors freely to the necessitous poor, and exist for thatpurpose, the medical man is in a different position. He, noless than his humblest patients, pursues his calling with aview to earn his living, and to ask him to supply medicalattendance as an act of charity is no less begging than topetition his neighbour, who may be a merchant, for its

pecuniary equivalent. Why, then, should medical charity,public and private, or the abuse of it, take the place inScotland, as apparently it does, of that medical aid whichthe Poor-law should pay for and of which it should regulatethe distribution ?The report of the Poor-law Commission supplies the answer

and contains evidence distributed through its pages ofcauses which have led to an absence of deterrent shame inconnexion with the seeking of free medical aid. More pax-ticularly, an appendix following the report brings before us ina compendious memorandum by Professor Smart on "TheHistory of the Scots Laws prior to 1845," the circumstancesin which begging became, as it were, part of the systemof Poor-law relief. The memorandum referred to is an

interesting document, tracing the law relating to vagrancyin Scotland back to two statutes passed in the reign of

THE LANCET, Dec. 17th, 1909, p. 1768.

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James I. (of Scotland). These were directed against able- Ibodied vagabonds refusing to work and preferring to live byI sorning," or sponging upon their neighbours. The first ofthese Acts passed in 1424-25 deliberately distinguishes theable-bodied from those for whom begging is to be recognisedif not as a profession, at any rate as furnishing means ofexistence. "It is ordained " in it "that na thiggar be

thollyt to thig, neither in burgh nor to land, betwixt fourteenand seventy years of age, but they be seen by the council ofthe town or the commons of the country that they may notwin their living otherwise." Those thus ’’ seen " are to befurnished with a "token" " by the local authorities, andfor beggars not able to display their tokens and refusingto work penalties are provided. They are to work for theirliving or to be burnt on the cheek and banished. The secondAct, passed in 1425-26, defines the mode of inquiry with regardto idle men having no visible means of subsistence, and theprinciples laid down in the two Acts referred to are traceablein successive statutes relating to the subject. So far as theyconcern the matter under discussion they may be summarisedby saying that a licence to beg was long recognised as theprovision naturally to be adopted for those unable to work.The" sturdy," "strong," or "masterful" " beggar was to bepunished. He was on the border-line of criminality and notover-particular as to when or where he might cross it.Included with him were all "sornars," " bards," or "feignedfools," and sic-like runners about." Those, on the otherhand, who might not win their living otherwise " found inthe "awmous," or alms, a provision for their sustenance

recognised by statute, subject to their compliance with thelaw in the matter of having a badge. This was the onlylegal provision made for them in the fourteenth and fifteenthcenturies.The badge or token appears at first to have been a licence

to beg generally, but in 1535 an Act for the" Stanching ofMaisterful Beggars " ordered that "na beggars be tholed tobeg in ane parochin that are born in another," and afterthat each parish made its own tokens for its own beggarsand extra-parochial mendicancy was an offence. Not muchlater than this, in 1597, the Kirk Sessions were assigned theduty of administering the Poor-laws and were enabled to"stent" or levy contributions from the inhabitants ofthe parish for the relief of the poor. The power of com-

pulsory assessment for poor-relief was, however, adopted withreluctance, and very gradually through succeeding genera-tions, the free contributions of parishioners to the offertorybeing almost universally preferred, and there are still four

parishes in Scotland which have no legal assessment for therelief of their poor. We are not now tracing the history ofthe Scottish Poor-law or discussing the merits of the

voluntary charity once administered universally by the KirkSessions, and now largely superseded by the levying of acompulsory rate. Nor are we concerned with the convenienceor inconvenience of licensing beggars to solicit alms from doorto door within prescribed areas, and its results with regardto general mendicancy in modern times. We mention, however,as a matter of some interest that although the licensed beggarhas practically disappeared the Commission found a survivorin the person of a first-cousin of the provost of a certaintown. He is stated to be an imbecile man, having the sumof <E190 (a legacy) held in trust for him, enabling him to payiS.3 half-yearly as rent, and being also permitted to collect theother necessities of life by "going through the houses." Oursubmission, however, is that legal approval of licensedbegging and the subsequent elaboration of a system ofpoor-relief by church alms must have accustomed those in aposition to help their neighbours to regard it as a duty, oras a more or less necessary obligation to do so, and thatthose who could give medical aid have naturally done so,either in addition to, or in the place of, money doles tothe beggar and contributions to the offertory. Naturallysuch a tradition must have accustomed the modern poorto expect voluntary aid from the medical man rather thanto pay him a small fee out of the money which the admini-strators of parochial alms supplied.The licensed beggar may well have had the same feeling

from the earliest days of his legal recognition, and it mustoften have been convenient to the medical man to help pro-fessionally rather than pecuniarily a class the membership ofwhich between the ages of 14 and 70 years was only grantedby law to " cruikit folk, blind folk, impotent folk, and waikfolk. " The poorer Scot has, in fact, been trained by the

tradition and practice of centuries to seek personal ratherthan official assistance ; and his neighbour, often not muchbetter off than he, has in like manner inherited a willingnessto assist him freely and without legal compulsion.The expenditure in Scotland upon medical aid given under

the Poor-law has increased slowly at first but more rapidlyin recent years ever since the Poor-law Medical Relief Actof 1845 and the Medical Relief Grant of 1848. The sum so

spent amounted in 1851 to but 20,311, and had risen in1891 to .642,566 ; 10 years later it was .655,278 ; and in 1905.666,651. In the large towns voluntary hospitals, and

everywhere the charity of medical practitioners, assist inthe care of the sick, some of whom are fit cases for Poor-law treatment, some of whom are properly objects of suchcharitable aid as the voluntary hospital and the privatemedical man can most advantageously supply, and of thesea considerable number are persons capable of paying fortheir treatment but deliberately avoiding doing so. We readin the report of the Commission that the general hospitals ofGlasgow are taxed to their fullest extent, the Western

Infirmary having a waiting list of between 400 and 500patients, and that similar conditions prevail at such centresas Edinburgh, Dundee, and Aberdeen. We note in thesame page (p. 149) the prevalence in Scotland of ’’sub-scribers’ lines " (giving the privilege of treatment),and also that I no general infirmary or hospital, so far aswe have been able to ascertain, has made any systematicattempt, either by appointment of an almoner or otherwise,to institute inquiries into the circumstances of personsapplying for treatment." We are told as an example ofthe effect of this laxness of the patient of a private medicalpractitioner at Glasgow who was removed to a generalhospital, where he died, and who was afterwards found to bepossessed of estate valued at .610,000. The gentleman whohad attended him, and to whom, at the time of his removal,he owed &pound; 100 for treatment, had in the meanwhile remon-strated ineffectually with the professor who had the patientunder his care in the charitable institution. The professorhad no power to prevent the abuse of charity himself andwas unwilling to invoke the interference of the directors ofthe hospital. It is added that other examples of a similarcharacter might easily be given, and that in the case in

question the admission was by " a guinea subscriber’s line."Outdoor medical relief in large towns is spoken of by the

Commissioners (p. 152) as "very largely supplemented " bythe medical charities and the gratuitous attendance of privatepractitioners. It is observed that although medical reliefdoes not involve disfranchisement the stigma of pauperism issometimes believed to prevent the poor from having recourseto the Poor-law until their cases have become incurable. "Atthe same time," the Commissioners add, "we cannot fail toobserve that on this matter we have received fewer com-plaints from Scotland than from England. The abundanceof medical charities may in great part account for this." Insmall towns and lowland rural districts the Commissionersfind that there is no evidence of inadequate medical attend-ance on the poor, although they think it not improbablethat the gratuitous attendance of private practitioners largelysupplements the aid given under the Poor-law. In the

Highlands and Islands the case is different. Owing to thepoverty of their inhabitants many of the smaller parishescannot maintain a medical officer, and a private practitionercan hardly earn a decent living in them. The problem arisingout of the abuse of medical charity can scarcely occur in suchlocalities, but is most conspicuously before us in those largetowns which form the antithesis to them. There, it isestimated by one of the witnesses mentioned in the report,gratuitous medical treatment amounts in some cases to asmuch as 30 per cent. of the total practice of the practitionersaffected. The degree in which such medical treatment is

given to patients who otherwise would necessarily be treatedunder the Poor-law, or would go unattended, is a questiondiscussed by different witnesses (see p. 158) without veryexact conclusions being arrived at.The remedy of such a state of things as we have referred

to must come gradually ; but if legislation follows the reportsof the Commissioners upon the lines suggested by them,voluntary aid councils eventually should cooperate withthe medical profession in the selection of cases suitable fortreatment either in voluntary hospitals or in their homes bythe charitable kindness of a profession ever ready to give itsassistance where the gift is really and honestly needed. At

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the same time public assistance authorities will eliminatefrom the patients of the man who now is forced by circum-stances and custom to treat them as an act of charity thosefor whom public funds should provide medical aid. Untilsuch legislation is accomplished it is to be hoped thatimproved administration of the existing Poor-law willdiminish that which can but be regarded as an unjusttax upon the charitable institution and upon the privatemedical practitioner. The development of a healthier publicopinion condemning the cadging upon voluntary hospitalsand upon medical men of those who can afford to pay mayalso be hoped for. The organisation of medical aid upon aprovident basis, moreover, does not require legislation tobring it into being where it does not now exist.

COLOUR VISION.

AT a meeting of the Royal Society of Arts on Feb. 9th,Dr. F. W. EDRIDGE-GREEN read a paper on Colour-Blind-ness. He first explained the theory which he has adoptedto explain vision and colour vision,l including the evolutionof the colour sense, and described briefly his spectrometerfor its estimation, showing how with this instrument thelimits of visibility on each side of the spectrum could beascertained, as well as the exact size of portions of thespectrum which appear monochromatic to different persons.Proceeding to discuss the test which he advocates for sailorsand engine-drivers Dr. Edridge-Green said :-On account of the arrangement of signals by sea and

land, it is necessary that persons employed in the marine andrailway services should be able to recognise and distinguishbetween the standard red, green, and white lights under allconditions in which they are likely to be placed.

It is not only necessary to find out whether a person isable to distinguish between the red, green, and white lights,but to ascertain as well that he thoroughly understandswhat is meant by colour, and the individual characteristicsof red, green, and white respectively. Too little attentionhas been paid to this in construcfing tests for colour-blind-ness, and those who have had much practical experiencein testing for this defect are aware of the ignorance whichexists among uneducated persons with regard to colours.Many are under the impression that every shade of a colouris a fresh colour, and others have the most novel ideas withrespect to colour. It is necessary that a sailor or engine-driver should be able to recognise a red, green, or white

light by its character of redness, greenness, or whiteness

respectively ; that is to say, that the examinee has definiteideas of colour and is able to reason with respect to them.All persons who are not able, through physical defect, tohave definite ideas of the standard colours, and to be able todistinguish between them, must be excluded from themarine and railway services. In constructing a test forcolour-blindness we must not forget the element of

colour-ignorance, because an engine-driver or sailor hasto name a coloured light when he sees it, not to matchit. He has to say to himself, " This is a red light, thereforethere is danger ; " and this is practically the same as if hemade the observation out loud. Therefore, from the verycommencement we have colour-names introduced, and it isimpossible to exclude them. Making a person name acolour is an advantage, because the colour-name excludesthe element of shade. If, as some persons have said, test-ing by colour-names is useless, then the whole series ofcolour-names is useless. But if I say to a friend, " That tileis red," and he agrees with me, it is evident that one object,the colour of which is by him classed as red, is also classedas red by me. The ordinary colour-names, red, blue,yellow, and green, form excellent bases for classification.The engine-driver is told that red is a "danger" signal,green a "caution" signal, and white an "all right" "

signal. Therefore it is very necessary that he should knowwhat is meant by these colours. It must be noticed that itis on account of there being so many variations in hue thatsuch great difficulty has been found in constructing anadequate test for colour-blindness, as it is the definitecolours and not the variations of them of which we wish toknow the number. It will be seen that it is not merely a

1 THE LANCET, Oct. 2nd, 1909, p. 986.

matter of shade as far as the colour-blind are concerned, buta distinct difference in tint. The normal-sighted could dividethe green of the spectrum into yellow-green, green, and blue--green, and would, in the majority of cases, be able to rangeall greens under these three classes. The dichromic colour-blind see two colours only and name colours in this way.We wish to exclude all those individuals who are included

in the following three classes : 1. Those who see three or lesscolours in the spectrum. 2. Those who, whilst being ableto perceive a greater number of colours than three, havethe red end of the spectrum shortened to a degree incom-patible with their recognition of a red light at a distance oftwo miles. 3. Those who are unable to distinguish betweenthe red, green, and white lights at the normal distance

through insensitiveness of the retinal-nervous apparatus whenthe image on the retina is diminished in size.The dichromic regard green and red as almost, but not

quite, identical, and this fact is one which it is nearlyimpossible to make a person who has not thoroughly studiedcolour-blindness comprehend-either the colour-blind him-

self, the public, or an unqualified examiner. They find thatmany colour-blind persons are able to recognise differentcolours and correctly name them, and therefore set down themistakes made to want of education in colours.

It is astonishing with what accuracy many colour-blind(dichromic) persons name colours. I have met with severalwho were nearly always correct when they named a colour.One educated adult in particular had become so expert thathe was often able to baffle attempts made by his friends toshow that he was colour-blind. When I asked him thenames of various coloured objects he was nearly alwayscorrect, and did not content himself with using the ordinarycolour-names but employed such terms as cerise. He toldme the means he adopted ; he said all colours appeared modi-fications of blue and yellow. The brightest and purestyellow was yellow ; slightly darker and not so pure, green ;darker still, red. The brightest and most typical blue,violet ; less bright, blue ; blue with a tinge of grey (dirtyblue), purple; very impure blue, cerise. This colour

appeared to him blue by day, yellow by gaslight.The following will show how it is that the colour-blind

are able, under ordinary circumstances, to distinguish betweenthe colours included in one of theirs. All colours have nota similar degree of luminosity; thus, yellow is much thebrightest colour. Red, yellow, and green have, to thedichromic colour-blind, as far as colour is concerned, a verysimilar appearance. They are not exactly alike in colour.

It is very important that persons belonging to the secondclass should be excluded, and yet none of the ordinarily usedtests detect them. The rays of red at the extreme left ofthe spectrum are the most penetrating, as may be seen bylooking at a light or the sun on a foggy day, or throughseveral thicknesses of neutral glass. It is chiefly by theserays that we recognise a red light at a distance, and it istherefore of great importance that a sailor or engine-drivershould be able to perceive them. The third class is one inwhich a person is able to distinguish colours easily when theyare close to him, but fails to distinguish them at a dis-

tance, owing to insensibility or to the nerve-fibres supplyingthe central portion of his retina being impaired. As a lightat a distance occupies the central portion of the visual field,it is essential that the corresponding portion of the retinashould be normal. We also do not wish to exclude personswho, though partially colour-blind, have a colour-perceptionsufficient for all practical purposes. If the persons to betested have to distinguish between the standard red andgreen lights these lights should be used as the basis of thetest, because if any other test were used we should still havethe same problem before us from a practical point of view. Asailor might (with reason) object to any other test, and saythat because he cannot distinguish between a green and agrey wool it is no reason why he should be unable to dis-tinguish between the red and green lights. The candidate’scapacity in this respect may be tested with a lantern which Inow show. By using a lantern with slides containing standardred and green glass we can obtain the necessary colours.But there are few colour-blind persons who cannot

distinguish between the red and blue-green lights at a

short distance. A simile will show how they are able to dothis. If a normal-sighted person were to take two colouredglasses, green and blue-green, and place them in a lantern ata short distance, he would be able to distinguish between