406 pressure is kept up for two to five minutes, changes in blood pressure and pulse-rate at the end of that time being carefully noted. With a healthy heart acting normally there is a rise of from 5 to 15 mm. of mercury in the blood pressure, while the pulse-rate remains the same or is slightly diminished. With a hypertrophied heart a rise of from 15 to 40 mm. is observed, and the pulse remains the same or is increased. With slight cardiac insufficiency the blood pressure does not rise, and the pulse-rate is unchanged or increased ; whilst a marked insufficiency shows itself by a reduction of blood pressure and an increase in the pulse-rate. The method has the advantage of being simply and easily applied, but it is necessary to guard against excitement which might affect the result. Multiple Arterial Thrombi. In a recent paper in Praxis Medici Dr. 1. Sturza criticises the common diagnosis of embolism where occlusion of large vessels and sudden death occur in patients suffering from mitral lesions. He is inclined to view the process as thrombotic, on the ground that the large masses found on the vessels are often altogether out of proportion to the small and delicate excrescences upon the diseased valves. Even if thrombi are present in the left auricle, their smooth surface argues against the possibility of embolism. In a case recently under his observation the abdo- minal aorta from 10 cm. above the bifurcation, together with the left and right femorals, the superior mesenteric, the left renal, splenic, right pulmonary, left inferior thyroid and left carotid arteries were found filled with clot. The immediate cause of death was occlusion of the mesenteric artery, and though the patient died half an hour after the acci- dent, the intestines were already the seat of a heemor- rhagic infarction and peritonitis was beginning. The autopsy was performed four hours after death. To decide the question of thrombosis or embolism, the walls of the affected vessels were examined micro- scopically and intense inflammation was discovered in them, probably set up by the cntrance of bacteria into the vasa vasorum, incident to a recurring endo- carditis. On this explanation, he holds, it is not difficult to understand that a thrombosis may set in as suddenly and with the same signs as an embolism. The number of vessels occluded is often surprising, but the patients may have relatively few symptoms. Public Health Services. REPORTS OF SCHOOL MEDICAL OFFICERS. I * Not given. t Excluding dental defects and uncleanliness. Bootle. Dr. F. T. H. Wood, of Bootle, calls attention to the progress and expansion of the school work made possible by the increasing interest and cooperation of parents and teachers. Special inspections have risen from 4790 to 5280, largely owing to the attendances at the rheumatism clinic established early in the year ; over 60 per cent. of the sources of reference at the special inspections were direct requests from the parents. Dr. Wood stresses the value of the attendance of parents at the routine inspections. He believes that the education of parents in sound nutrition and domestic care, the improvement of facilities for the drying of clothing of children arriving wet at school, the provision of dry dwellings, and prompt early attention to chills and illness such as tonsillitis will all play an important part in the conquest of rheumatism. He notes that 84 per cent. of all the skin diseases were due to conditions closely associated with uncleanliness and that nearly 3000 school days were lost by exclusion indirectly due to the same cause ; the annual cost to the ratepayers of the inspection and treatment of uncleanliness in school- children was at least 2300. He is convinced that the source of infection of all habitually verminous children is the home and not the school, and that if further progress is to be made it must be through education of the parent. On the subject of dental treatment he holds that the surprising difference in the conditions of the children’s teeth and in the number of consents given for treatment among schools of similar standing can only be explained by the varying degrees of interest and enthusiasm shown by teachers, who are also urged to devote attention to the prevention of flat-foot, which mostly begins in later childhood. He draws attention to the importance in this con- nexion f (1) avoidance of muscular fatigue in the growing child and provision for ample sleep; (2) supervised training of the whole muscular system, especially that of the legs ; (3) ordering a proper type of boot, which should be so fashioned that the inner side of the boot is kept straight and the end of the boot opposite the big toe; and (4) teaching the child to walk and stand with feet kept parallel and not pointed outwards. In walking the child should rise on the balls of the toes with each foot in succession. Dr. A. G. Williamson, the assistant medical officer, analyses 111 of the first cases of rheumatism seen at the clinic. He states that no new features have come to light. The great majority of the cases started between the ages of 5-12, and that as the heart was so often affected in insidious and unsuspected cases the value of the clinic was emphasised. The spread of scalp ringworm was also inquired into, and in the 18 cases closely investigated the infection was not of school origin-a feature that is in harmony with the keynote of Dr. Wood’s report, that the most important influence on the child is to be found in the home. Leeds. Dr. A. Wear notes the changes in the 20 years since the first report on the school medical work was issued; the work in general has increased in extent and efficiency, while the special work has come to include orthopaedic treatment with massage and artificial sunlight, X rays, clinics for ear, nose and throat, eyes and skin, and searching ascertainment, registration, and administrative action for exceptional children. The clinic work began in one top room with one nurse (Miss Webster), who to-day superintends the school nursing service of Leeds (covering nearly 320,000 patients every year), of which she was once the sole representative. Owing to the indefatigable work of the nurses, with the help of the teachers, the presence of lice and nits, almost inevitably found in these early days, has become " distinctly rare." There is now a generally improved physique and more careful dental and general cleanliness, and the establishment of a health conscience, particularly among the girls, is becoming noticeable. On the value of fresh air in elementary schools Dr. Wear is emphatic. He cites two otherwise similar schools; one with better ventilation had a percentage of 6-5 cases of infectious illness, another less well ventilated had a percentage of 137. It is surprising that the report contains no direct
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pressure is kept up for two to five minutes, changes inblood pressure and pulse-rate at the end of thattime being carefully noted. With a healthy heartacting normally there is a rise of from 5 to 15 mm. ofmercury in the blood pressure, while the pulse-rateremains the same or is slightly diminished. With ahypertrophied heart a rise of from 15 to 40 mm. isobserved, and the pulse remains the same or isincreased. With slight cardiac insufficiency the bloodpressure does not rise, and the pulse-rate is unchangedor increased ; whilst a marked insufficiency showsitself by a reduction of blood pressure and an increasein the pulse-rate. The method has the advantage ofbeing simply and easily applied, but it is necessary toguard against excitement which might affect theresult.
Multiple Arterial Thrombi.In a recent paper in Praxis Medici Dr. 1. Sturza
criticises the common diagnosis of embolism whereocclusion of large vessels and sudden death occur inpatients suffering from mitral lesions. He is inclinedto view the process as thrombotic, on the groundthat the large masses found on the vessels are oftenaltogether out of proportion to the small and delicateexcrescences upon the diseased valves. Even ifthrombi are present in the left auricle, their smoothsurface argues against the possibility of embolism.In a case recently under his observation the abdo-minal aorta from 10 cm. above the bifurcation,together with the left and right femorals, the superiormesenteric, the left renal, splenic, right pulmonary,left inferior thyroid and left carotid arteries werefound filled with clot. The immediate cause ofdeath was occlusion of the mesenteric artery, andthough the patient died half an hour after the acci-dent, the intestines were already the seat of a heemor-rhagic infarction and peritonitis was beginning. Theautopsy was performed four hours after death. Todecide the question of thrombosis or embolism, thewalls of the affected vessels were examined micro-scopically and intense inflammation was discoveredin them, probably set up by the cntrance of bacteriainto the vasa vasorum, incident to a recurring endo-carditis. On this explanation, he holds, it is notdifficult to understand that a thrombosis may set inas suddenly and with the same signs as an embolism.The number of vessels occluded is often surprising,but the patients may have relatively few symptoms.
Public Health Services.
REPORTS OF SCHOOL MEDICAL OFFICERS. I
* Not given. t Excluding dental defects and uncleanliness.
Bootle.
Dr. F. T. H. Wood, of Bootle, calls attention to theprogress and expansion of the school work madepossible by the increasing interest and cooperation ofparents and teachers. Special inspections have risenfrom 4790 to 5280, largely owing to the attendances
at the rheumatism clinic established early in the year ;over 60 per cent. of the sources of reference at thespecial inspections were direct requests from theparents. Dr. Wood stresses the value of the attendanceof parents at the routine inspections. He believesthat the education of parents in sound nutrition anddomestic care, the improvement of facilities for thedrying of clothing of children arriving wet at school,the provision of dry dwellings, and prompt earlyattention to chills and illness such as tonsillitis willall play an important part in the conquest ofrheumatism. He notes that 84 per cent. of all theskin diseases were due to conditions closely associatedwith uncleanliness and that nearly 3000 school dayswere lost by exclusion indirectly due to the samecause ; the annual cost to the ratepayers of theinspection and treatment of uncleanliness in school-children was at least 2300. He is convinced that thesource of infection of all habitually verminous childrenis the home and not the school, and that if furtherprogress is to be made it must be through educationof the parent. On the subject of dental treatmenthe holds that the surprising difference in the conditionsof the children’s teeth and in the number of consentsgiven for treatment among schools of similar standingcan only be explained by the varying degrees ofinterest and enthusiasm shown by teachers, who arealso urged to devote attention to the prevention offlat-foot, which mostly begins in later childhood.He draws attention to the importance in this con-nexion f (1) avoidance of muscular fatigue in thegrowing child and provision for ample sleep;(2) supervised training of the whole muscular system,especially that of the legs ; (3) ordering a propertype of boot, which should be so fashioned that theinner side of the boot is kept straight and the end ofthe boot opposite the big toe; and (4) teaching thechild to walk and stand with feet kept parallel andnot pointed outwards. In walking the child shouldrise on the balls of the toes with each foot insuccession.
Dr. A. G. Williamson, the assistant medical officer,analyses 111 of the first cases of rheumatism seen atthe clinic. He states that no new features have cometo light. The great majority of the cases startedbetween the ages of 5-12, and that as the heartwas so often affected in insidious and unsuspectedcases the value of the clinic was emphasised. Thespread of scalp ringworm was also inquired into, andin the 18 cases closely investigated the infection wasnot of school origin-a feature that is in harmonywith the keynote of Dr. Wood’s report, that the mostimportant influence on the child is to be found inthe home.
Leeds.
Dr. A. Wear notes the changes in the 20 yearssince the first report on the school medical workwas issued; the work in general has increased inextent and efficiency, while the special work hascome to include orthopaedic treatment with massageand artificial sunlight, X rays, clinics for ear,nose and throat, eyes and skin, and searchingascertainment, registration, and administrative actionfor exceptional children. The clinic work began inone top room with one nurse (Miss Webster), whoto-day superintends the school nursing service ofLeeds (covering nearly 320,000 patients every year),of which she was once the sole representative. Owingto the indefatigable work of the nurses, with thehelp of the teachers, the presence of lice and nits,almost inevitably found in these early days, hasbecome " distinctly rare." There is now a generallyimproved physique and more careful dental andgeneral cleanliness, and the establishment of a healthconscience, particularly among the girls, is becomingnoticeable. On the value of fresh air in elementaryschools Dr. Wear is emphatic. He cites two otherwisesimilar schools; one with better ventilation had apercentage of 6-5 cases of infectious illness, anotherless well ventilated had a percentage of 137.It is surprising that the report contains no direct
407
reference to the lack of an open-air school. Thislack is the more striking because the percentage ofdefects found is unusually high (32-7 per cent.)which reflects both thorough medical inspection andadverse local conditions. There may be some localfactor which explains this omission, nowadays veryrare. Provision seems to be made for all exceptionalchildren apart from the delicate and pre-tuberculousclass, and it is especially this class which benefits somuch from prophylactic treatment. There are specialschools for the physically and mentally defective,for the blind and the deaf, and there is a nurseryschool. For anaemia, rickets, malnutrition, andtuberculous conditions artificial sunlight treatment hasbeen available since June, 1927, and recently thesefacilities have been improved. Dr. Wear commentson the low earning capacity of the ex-pupils of thespecial mental deficiency schools, and thinks that moreattention should be given to manual training, andhe also suggests that a larger proportion of scholarsmight be allowed to leave school for suitable employ-ment after reaching the age of 14. But wouldnot, however, this system defeat its own object ?The child leaving at 14 usually gets into a blindalley job from which he is turned away at 16 when hisemployer is faced with payments under the InsuranceAct. He is then workless, untrained, and unsocialised,and for the defective lad the moral and social outlooksare deplorable. If this possibility were borne inmind in the interpretation of the phrase suitableemployment this danger might be avoided, but thenumber of children finding permanent work would besmall. Improvement is to be hoped for along theother lines indicated in this report-better manual(semi-vocational) training continued until 16 yearsof age, and close cooperation with the employmentexchanges.
Despite the immense amount of routine worktime has been found for some special inquiries, and forpropaganda in the best sense of that word-includingthe award of prizes for the child with the bestcared-for teeth and for the best essays on the subject.
Stockport.Dr. N. Gebbie draws attention to the fact that in
Stockport, as elsewhere, the number of children foundto be suffering from defects at the very beginningof their school life is still unduly high, and suggeststhat it is to a more complete supervision of the infantand the toddler by means of an extended maternityand child welfare service that we must look forimprovement. This conclusion is not altered by thecircumstance that the percentage of defects at laterages does not differ greatly from that of the entrants,for many defects may persist and others are revealed-e.g., errors of refraction-as school life progresses.But the care of the toddler is not so much in theprovince of the infant welfare centre as in that ofnursery schools, the universal and adequate provisionof which is an ideal not yet likely to be attained.They do not exist in Stockport, and it is not indicatedin the report how far the facilities of the schoolclinics are made use of for infants below school age.A considerable extension of the dental work has beenmade possible by the appointment of an additionaldentist in August, 1928. There have been inspectionsin 20 schools, compared with six in the previous year.Steps have also been taken to reduce the number ofcasual cases, though six sessions per week out of 24are reserved for treatment of urgent necessitous cases.A complete orthopaedic scheme has not yet beenestablished, but good work is being done by meansof a special arrangement with the Stockport Infirmary,and the interest taken in the welfare of the crippledchildren by Mr. E. S. Brentnall. the hon. orthopaedicsurgeon of the infirmary. The facilities providedinclude massage, exercises, and artificial sunlighttreatment. Some beds are allotted at the infirmaryto school-children, and cases are also sent to theShropshire Orthopaedic Hospital at Oswestry. Ithas been decided to provide an open-air school at
Woodbank, where there is an ideal site, with accom-modation on modern lines for approximately100 children. Three class-rooms of the open-airtype are in use in a temporary building at FlydeLodge High School. A voluntary organisation knownas the " George Fearn Trust," aided by a grant ofj3150 from the local authority, maintains 15 beds atthe Ormerod Convalescent Home at St. Anne’s-on-theSea. There is no organiser of physical training, butin the elementary schools this training is given byteachers who have paid special attention to thesubject, and in the secondary schools for girls remedialexercises when required are discussed by the visitingdoctor with the drill instructor. Owing to the pro-longed illness of the specialist teacher the class forstammering children could not be held. It is evidentthat the work in Stockport, as far as the facilitiesallow, has been thoroughly carried out.
Margate.Margate is one of those smaller places where
practically all the general work is done by one person.Dr. Cowan McCombe has to turn his mind from largeengineering questions like main water-supply to smallerones like the cure of blepharitis or the giving of ananaesthetic, and constantly has new duties to facesuch as the care of rheumatic children and thelicensing of nursing homes. He has help in the specialbranches of dental, aural, and ophthalmic work, andhis burden is lightened by the nurse (there isapparently only one full-time nurse) and by thesanitary inspectors. He has also the cooperation ofthe attendance officer and the teachers, to all of whomhe gives especial thanks. It is perhaps becauseDr. McCombe is known so well personally that thepercentage of parents attending the medical inspec-tions is unusually high-nearly 80 per cent. Anotherfeature of a small area with good local interest is thelarge share taken by voluntary bodies ; the provision ofmeals for necessitous cases is carried out independentlyof the authority, and the occupation class for the in-educable mentally defective was run privately. The riskattached to such voluntary service was made obviouswhen the lady responsible for this class was unableto continue and it had to be dropped at least tem-porarily. This is the more unfortunate because thereis no home for mentally defective children in Kent,and it is almost impossible to get institution treatmentfor them. Another disadvantage of areas of this sizeis the impossibility of establishing any local specialschools; use has to be made of joint or borrowedaccommodation. The education authority has recentlycooperated with the county council in the orthopaedicscheme. The clinic is held at Broadstairs, where anorthopaedic surgeon attends twice a month and atrained nurse weekly. Hospital accommodation isprovided in suitable cases and surgical appliancesare supplied for out-patients when necessary. Thereare 65 delicate children who would benefit from anopen-air school, but this, unfortunately, does notexist.
Ilford.Dr. A. H. G. Burton, whose school medical report
was again one of the earliest to appear, shows clearlywhat has been done in Ilford and what extensions ofactivity are essential. The authority has establishedan adequate and well-planned open-air school towhich 90 children have already been admitted. Itis designed to allow the maximum amount of sun-light and air into the class-room, the whole of whichcan be opened on the south side by folding doors.Arrangements have been made for the conveyanceof those who live in outlying parts of the borough.The next step forward will be the establishment ofan orthopaedic scheme, which is not a very easymatter owing to the position and size of Ilford.Cooperation with the Essex County Council has beenconsidered, but the nearest centre is at Romfordwhich is too far for Ilford children to attend. Thenearest hospital at which there is an orthopaedicsurgeon is in London. The authority would therefore
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need (1) to make arrangements for in-patient ortho-psedic treatment in London; (2) to appoint an ortho-paedic surgeon whose salary would be some 80 guineasa year if he attended fortnightly ; and (3) to establishand fit up clinics for massage and remedial exerciseswith a whole-time trained masseuse at a salary of 2200.At present valuable remedial exercises are beingcarried out for postural defects and slight deformitiesby Mr. F. T. Roberts, the supervisor of physicaltraining, whose interesting report is here included.Extended facilities for dentistry are much needed.The present scope of the work is very limited, and thelow percentage of acceptances (45-9 per cent.) shouldbe raised when the appointment of a second dentistmakes it possible to undertake educational propa-ganda among the parents and children.
INFECTIOUS DISEASE IN ENGLAND ANDWALES DURING THE WEEK ENDED
tinued fever, 1 ; dysentery, 16 ; and ophthalmianeonatorum, 81. No case of cholera, plague, or
typhus fever was notified during the week.The number of cases in the Infectious Hospitals of the
Metropolitan Asylums Board on August 13th-14th was asfollows : Small-pox, 132 under treatment, 5 under observa-tion (last week 134 and 9 respectively) ; scarlet fever, 1326 ;diphtheria, 1491 ; enteric fever, 13 ; measles, 330 ;whooping-cough, 276 ; puerperal fever, 27 (plus 13 babies) ;encephalitis lethargica, 123 ; and " other diseases," 23.At St. Margaret’s Hospital there were 12 babies (plus sixmothers) with ophthalmia neonatorum.Deaths.-In the aggregate of great towns, including
London, there were no deaths from small-pox, 3 (1)from enteric fever, 28 (5) from measles, 1 (0) fromscarlet fever, 25 (6) from whooping-cough, 33 (6)from diphtheria, 60 (5) from diarrhoea and enteritisunder two years, and 15 (4) from influenza. Thefigures in parentheses are those for London itself.
Of the deaths from measles 5 were reported from
Liverpool and 5 from Bradford ; those from diarrhoea andenteritis included 6 each from Manchester and Liverpool,5 each from Birmingham and Sunderland, 4 each from Hulland Stoke-on-Trent, and 3 each from Leeds and Newcastle-on-Tyne.The number of stillbirths notified during the weekwas 305 (corresponding to a rate of 49 per 1000 totalbirths), including 59 in London.
FELLOWSHIP OF MEDICINE AND POST-GRADUATEMEDICAL AssociATiox.—From Sept. 9th to 14th the Bromp-ton Hospital will hold an all-day course in diseases of chest.Facilities will be given for attending the practice of thevarious departments of the hospital, and instruction willbe by lecture and demonstration. Under Dr. Eric Pritchard’sdirection there will be a course at the Infants Hospitalfrom Sept. 9th to 22nd. This is designed mainly for thoseengaged in infant welfare work, and visits will be paid tocentres other than the hospital. From Sept. 10th toOct. 5th a course of lecture-demonstrations in psycho-logical medicine will be given at the Bethlem Royal Hospitalon Tuesday and Saturday mornings. An intensive coursein medicine, surgery, and the specialties for men only willbe given at the Westminster Hospital from Sept. 16th to28th, from 10.30 A.M. until 5.30 P.M. daily. The Prince ofWales’s Hospital and the North Middlesex Hospital willhold a course in gastro-enterology from both medical andsurgical aspects from Sept. 30th to Oct. 4th. The Metro-politan Hospital will hold its first course under the auspicesof the Fellowship, in medicine, surgery, and the specialties,from Oct. 21st to Nov. 2nd. A second evening course forthe M.R.C.P. examination from Oct. 15th to Dec. 6th.Further information and syllabuses may be had from theSecretary of the Fellowship at 1, Wimpole-street, London,W. 1.
WE announced last week the death, on Sunday,August llth, in his 81st year of Dr. William Ewart.This will have come as no surprise to those who knewhim, since for several years he had been in a very pre-carious state of health ; but in spite of his increasinggeneral weakness and his painful lameness he remaineduntil the end a familiar figure in the Athenaeum, anda regular attendant at the Comitia of the RoyalCollege of Physicians of London.William Ewart was the son of an English father
and Xenie Guillet, a French lady, and he was educatedpartly in
England andpartly at theUniversity o fParis, where heobtained the ediploma ofBac. es Lettres.He joined themedical schoolof St. George’sHospital in1869, and as astudent saw
service withthe Frencharmy in theF r a n c o -German war.
He obtainedthe diplomasof the EnglishColleges in duecourse, becom-ing house phy-sician to thehospital in1873. In thefollowing yearhe took thediploma ofM. R. C. P.Lond., and in DR. WILLIAM EWART.
1 8 7 5 was S [Photograph by ElIwtt and Fry,
elected housephysician to Addenbrooke’s Hospital, Cambridge, atthe same time gaining at Gonville and Caius a
scientific scholarship. In 1876 he graduated in thefirst class of the Natural Science Tripos, and pro-ceeded to the degree of M.B., which he obtained in1877. After some post-graduate work in Berlin hereturned to St. George’s Hospital as curator of themuseum, lecturer on physiology, and demonstratorof physiological chemistry, was appointed patho-logist to the hospital in 1879, and in 1882 waselected assistant physician. He had previously takento the M.D. Camb., and been elected F.R.C.P.
Ewart’s connexion with St. George’s Hospital wasa long and honourable one. He was assistantphysician for seven years, during which time he wasassiduous in the conduct of out-patient practice, andan informative if whimsical demonstrator of thevaried clinical material which came under his eye.Many students of St. George’s will rememberEwart’s demonstrations, for they formed a curiousdifference from anything like stereotyped teaching intheir rapid deductions and explanations and theiralternate brevity and diffuseness. Patients, also,were often disconcerted by his methods of cross-
examination-he was not really trying to convictthem of inaccuracy, but his questions were oftenoddly worded, while he seemed impatient at thedelay or confusion in the replies brought about byhis own use of words. But who attended the
