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MEDICAL OFFICERS OF SCHOOLS ASSOCIATION
950
MEDICAL SOCIETIES MEDICAL OFFICERS OF SCHOOLS ASSOCIATION AT the annual meeting of this association, held at the rooms of the Medical Society of London on
A prill7th, with Dr. J. LAMBERT (Wellington College), the president, in the chair, a discussion took place on Administrative Difficulties in the Construction of a School Sanatorium Dr. R. E. SMITH (Rugby School) said in building sanatorium the governing body had to consider not only the site and the cost, but also problems which arose in consultation with the selected architect. The latter should have had a wide experience of hospital construction, and this of itself was some guarantee that money would not be wasted. The Royal Institute of British Architects, in regard to competitive buildings, discouraged the award of the work automatically to the one whose tender was lowest, and a Fellow of that body would listen to constructive suggestions. Rugby School had a population of 600, and the number of days spent by boys in the sanatorium in three successive years was as follows :a new
Sp ring term.
Summer term.
2762 2340 1486
897 925 1508
1933 1934
....
1935
....
....
The average
......
......
......
population
Winter term. 858 1421 884
......
......
......
in the sanatorium
was
30,
12, and 12 respectively in the three terms. The position of the site depended to some extent whether all cases were to be dealt with in one building. In some schools infectious cases were housed in a separate building, but the modern tendency was to have all departments under one roof, when medical and nursing attention was more efficient. Dr. Smith had never seen an infection transmitted from an in-patient to an out-patient. A sanatorium in a central situation was visited more readily by boys than one at a distance, and also more convenient for housemasters. The number of beds in a sanatorium depended on many factors, discussed by Sir Weldon Dalrymple-Champneys in 1928. Less than the proportion formerly recommended (10 to 20 beds for each hundred boys) was now being advised by medical experts. Preparatory schools, where the number rendered immune by a previous attack of acute infectious diseases was relatively low, would need a higher proportion of beds than schools for older boys. Measles could now be controlled by convalescent serum therapy; at boarding schools this disease showed a biennial periodicity if attempts were not made to prevent contacts from returning. Diphtheria was the one disease against which prophylaxis was almost perfect; it had a low incidence in residential schools. Scarlet fever was troublesome, as patients had to be subjected to a long quarantine. Four weeks had been shown to be a better quarantine period than six weeks. The best policy, however, was active immunisation. Dr. Smith’s view was that 10 beds for each 100 boys sufficed for a school sanatorium, provided each house in the school had in addition one sick room for every 30 boys. He was strongly in favour of a number of single-bed wards; two-bed wards he regarded as useless. Moreover, cases of measles were far better on
nursed in single rooms than in large wards, though they should be transferred during convalescence. Only in this way could droplet infection be reduced to a minimum, and such serious complications as pneumonia, otitis media, and mastoiditis be avoided. The cubic capacity of the single-bed wards need not exceed 1500 ft., especially in the presence of adequate cross-ventilation. Possibly school sanatoria erected in the future would be equipped with air-conditioning plants. As to windows, his own preference was the
double-sash window with metal chain sash cords. A fanlight above the door facilitated cross-ventilation. The public at large still needed convincing of the great value of the open,window in pyrexial illnesses so long as the patient was kept warm. The provision of facilities for operating in public schools was useful and might assist schools to secure the right type of men as health officers, though admittedly some conditions were best dealt with in For sterilising purposes Dr. Smith a general hospital. preferred electricity. The provision of sufficient recreation rooms was most important, as the management of boys during convalescence taxed the medical resources of the doctor as much as did the acute phase of their illness. Large wards should have coal fires in them and a varied library. Every effort should be made to reduce noise to a minimum. Mr. LIONEL PEARSON, F.R.I.B.A., showed pictures of the new Masonic sanatorium for girls at Rickmansworth, designed by Mr. Denman, which was held to be one of the best sanatoriums in the country. Many of the points made by Dr. Smith were insisted upon in the Ministry of Health memorandum, but the school sanatorium presented rather a different problem when infectious disease and cases of ordinary illness were treated in the same building. Mr. Pearson had reason to believe that there was a strong desire among medical men for the provision of cubicles for cases of infectious diseases, one reason for this being that the length of stay of the patient was thereby shortened. It had been said on good authority that there were only two ways of dealing with children in hospitals : to segregate them into cubicles, or to insist on their wearing masks to prevent the spread of infection. He shared Dr. Smith’s disapproval of two-bedded wards, though something could be said for them from the social standpoint of avoiding tedium. His own view was that the difficulty was best overcome by having cubicles with glass divisions, as supervision was very important. As to cubic capacity, it was no longer considered essential to provide 1500 cubic feet space for each acute case. The important point was floor space ; for a single patient in a cubicle the floor space should be 12 by 10 ft., and in open wards 10 by 10 ft. per patient. Similarly a height of 15ft. was no longer demanded, as nothing over 10 ft. from the floor apparently made any difference. A distance of at least 8 ft. between the centres of adjacent beds was important in order that infection should not be conveyed by coughing. A schoolmaster told him he had materially reduced the incidence of illness by forbidding coughing in class-rooms ; boys with the urge to cough had to leave the class. If screens were objected to, the barrier system of preventing spread of infection could be adopted. As to fittings, sash windows tended to rattle in a wind and disturb sleep ; casement windows were much more popular with matrons and He asked whether cross-ventilation was nurses. essential if plenty of air was entering the ward. In
NORTH OF ENGLAND OBSTETRICAL AND GYN29COLOGICAL SOCIETY
951
side-lighted rooms fanlights over the doors would only were to be used for hospitals and sanatoria. provide sufficient air currents. Air-conditioning he The chief inquiry made by parents concerning a did not particularly favour ; it must include filtering school was about the provision made for caring for and washing the air, and unless the school was them when sick. The PRESIDENT expressed his leaning towards situated in a slum area there would be ample direct contact with the outside air. For heating he single cubicles and separate rooms for school sanatoria. preferred radiators under the windows, but, despite At the beginning of a school term a number of boys the trouble of stoking and cleaning, open fires were had a temperature and the uncertainty as to what would develop made a particular need for single good and cheering in a ward. cubicles. School sanatoria should have sufficient Dr. G. E. FRIEND (Christ’s Hospital) said that occasionally he had to cope with a considerable number of single cubicles, and sufficient three- or four-bedded sick boys, and in the presence of mixed epidemics it rooms. necessary to convert one of the school houses into hospital. Hopper windows were put in and proved satisfactory; the time of convalescence was reduced by 25 per cent. in the improvised building thus fitted, compared with the infirmary building. He thought the variations of hospital design in different countries might be largely dictated by the average amount of sunshine. Dr. W. G. WILLOUGHBY (Eastbourne) said that in. the infectious diseases hospital with separate blocks there was no difficulty about having the windows
was
NORTH OF ENGLAND OBSTETRICAL AND GYNECOLOGICAL SOCIETY
a
open in summer; the difficulty arose in winter, especially when cross-ventilation existed. In blocks built in 1902 open fires were provided ; air coming in was heated by the fire and distributed throughout the ward without draughts. He referred to the grave illness and mortality statistics in inhabitants of back-to-back houses, due mainly to the lack of through ventilation. It was important to employ an architect with special experience. Dr. L. R. LEMPRIERE (Hailey bury) endorsed the praise given to the design of the Rickmansworth Hospital. He was opposed to the provision of an operating theatre in school sanatoria. Most public schools were conveniently near a well-equipped and well-staffed provincial hospital, and it was very much better, in his opinion, that operation cases should be dealt with there. He did not think that any school medical officer could be expected to be operating surgeon to the school, since his hand could easily lose its cunning when few operations were required. He was against coal fires in wards, quite apart from the dirt and the trouble of keeping them going. They failed to maintain an equable temperature, and schools catered not only for infectious cases, but for acute cases and convalescents. As soon as he was fit, the in the recreation room, a should be down boy put provision which most school architects ignored. An objection to large windows was that the blinding sun on a hot day could not be properly shut out. The amount of sunlight reaching patients in the summer could be overdone; it might interfere with sleep. The perfect flooring for a sanatorium had not yet been achieved, but the nearest approach, he thought, was cork. He agreed with the objection to two-bedded wards ; a public school sick house could possibly be a starting-point of immorality. A vital necessity was the provision of a detention room. Sick boys who might be incubating an infectious disease must not be mixed with convalescents. He would like to see every sanatorium equipped with a dark room, for transillumination aids to diagnosis. The provision of a parents’ room was desirable. Mr. DENMAN, F.R.I.B.A., spoke of the modifications made from reasons of economy of his original design for the Rickmansworth sanatorium. Mr. H. M. FAIRWEATHER, F.R.I.B.A., did not think there would be agreement as to the best kind of window ; he would be sorry to feel that metal windows
A MEETING of this society was held in Liverpool March 20th, with Dr. RUTH NICHOLSON, the president, in the chair. Two cases of
on
Simmonds’s Disease
reported by Mr. J. ST. GEORGE WILSON. He said that this syndrome, which is commoner in women, was first described in 1914, and is typified by progressive loss of weight and senile changessuch as loss of hair, an aged appearance, inhibition of genital function, and amenorrhcea. Lassitude and weakness are conspicuous. The basal metabolism is much lowered and the pulse is slow. There is ansemia and there may be hypoglycsemia. Radiologically there may be enlargement of the sella turcica if the lesion is a neoplastic destruction of the
were
pituitary. The first patient, aged 29, had complained of loss of weight, following a normal confinement; her weight, previously Ist. 7 lb., had been reduced to 5 st. 11 lb. within four years. There had been daily vomiting, dizziness, and loss of power in the left hand. She had, however, no loss of hair and did not look prematurely aged. She had complained of amenorrhoea for the last 12 months, her periods having previously been irregular. On examination she was found to be poorly nourished. The blood pressure was 114/72 mm. Hg and the pulserate 44. The cervix was multiparous and the body of the uterus small. X ray photographs of the skull revealed no abnormality. The blood-sugar was 81 mg. per 100 c.cm., non-protein nitrogen 33 mg., Wassermann negative. She was treated with injections of insulin and Pregnyl and with extra salt in the diet. The second patient, aged 37, also dated her symptoms to a confinement. She had complained of loss of weight for 21 months, nausea for 20 months, and weakness for 6 months. She was stated to be looking much older than previously, and had had amenorrhcea for 28 months. On examination her weight was found to be 4 st. 10 lb. She had hair on the face, pigmentation of the abdomen, a blood pressure of 98 mm. Hg, and a pulse-rate of 42. The urine was normal and a radiogram of the skull revealed no abnormality. She had complained of amenorrhcea constantly for the last 12 months, having previously had scanty periods at intervals of 5-6 months. On pelvic examination the uterus was found to be senile. She was treated by injections of Antuitrin S and GEstroform and was given olive oil. Eight months later she had gained 3 st. in weight.
In the discussion, Mr. S. B. HERD commented on the fact that in each patient the condition had closely He wondered if in the past followed pregnancy. these cases had merely been considered as instances of superinvolution.-Mr. T. N. A. JEFFCOATE said he considered superinvolution of the uterus always to be due to pituitary disease. He also questioned whether there was not in Simmonds’s disease an element of suprarenal dysfunction as well.-Dr. E., A,.
MEDICAL SOCIETIES MEDICAL OFFICERS OF SCHOOLS ASSOCIATION AT the annual meeting of this association, held at the rooms of the Medical Society of London on
A prill7th, with Dr. J. LAMBERT (Wellington College), the president, in the chair, a discussion took place on Administrative Difficulties in the Construction of a School Sanatorium Dr. R. E. SMITH (Rugby School) said in building sanatorium the governing body had to consider not only the site and the cost, but also problems which arose in consultation with the selected architect. The latter should have had a wide experience of hospital construction, and this of itself was some guarantee that money would not be wasted. The Royal Institute of British Architects, in regard to competitive buildings, discouraged the award of the work automatically to the one whose tender was lowest, and a Fellow of that body would listen to constructive suggestions. Rugby School had a population of 600, and the number of days spent by boys in the sanatorium in three successive years was as follows :a new
Sp ring term.
Summer term.
2762 2340 1486
897 925 1508
1933 1934
....
1935
....
....
The average
......
......
......
population
Winter term. 858 1421 884
......
......
......
in the sanatorium
was
30,
12, and 12 respectively in the three terms. The position of the site depended to some extent whether all cases were to be dealt with in one building. In some schools infectious cases were housed in a separate building, but the modern tendency was to have all departments under one roof, when medical and nursing attention was more efficient. Dr. Smith had never seen an infection transmitted from an in-patient to an out-patient. A sanatorium in a central situation was visited more readily by boys than one at a distance, and also more convenient for housemasters. The number of beds in a sanatorium depended on many factors, discussed by Sir Weldon Dalrymple-Champneys in 1928. Less than the proportion formerly recommended (10 to 20 beds for each hundred boys) was now being advised by medical experts. Preparatory schools, where the number rendered immune by a previous attack of acute infectious diseases was relatively low, would need a higher proportion of beds than schools for older boys. Measles could now be controlled by convalescent serum therapy; at boarding schools this disease showed a biennial periodicity if attempts were not made to prevent contacts from returning. Diphtheria was the one disease against which prophylaxis was almost perfect; it had a low incidence in residential schools. Scarlet fever was troublesome, as patients had to be subjected to a long quarantine. Four weeks had been shown to be a better quarantine period than six weeks. The best policy, however, was active immunisation. Dr. Smith’s view was that 10 beds for each 100 boys sufficed for a school sanatorium, provided each house in the school had in addition one sick room for every 30 boys. He was strongly in favour of a number of single-bed wards; two-bed wards he regarded as useless. Moreover, cases of measles were far better on
nursed in single rooms than in large wards, though they should be transferred during convalescence. Only in this way could droplet infection be reduced to a minimum, and such serious complications as pneumonia, otitis media, and mastoiditis be avoided. The cubic capacity of the single-bed wards need not exceed 1500 ft., especially in the presence of adequate cross-ventilation. Possibly school sanatoria erected in the future would be equipped with air-conditioning plants. As to windows, his own preference was the
double-sash window with metal chain sash cords. A fanlight above the door facilitated cross-ventilation. The public at large still needed convincing of the great value of the open,window in pyrexial illnesses so long as the patient was kept warm. The provision of facilities for operating in public schools was useful and might assist schools to secure the right type of men as health officers, though admittedly some conditions were best dealt with in For sterilising purposes Dr. Smith a general hospital. preferred electricity. The provision of sufficient recreation rooms was most important, as the management of boys during convalescence taxed the medical resources of the doctor as much as did the acute phase of their illness. Large wards should have coal fires in them and a varied library. Every effort should be made to reduce noise to a minimum. Mr. LIONEL PEARSON, F.R.I.B.A., showed pictures of the new Masonic sanatorium for girls at Rickmansworth, designed by Mr. Denman, which was held to be one of the best sanatoriums in the country. Many of the points made by Dr. Smith were insisted upon in the Ministry of Health memorandum, but the school sanatorium presented rather a different problem when infectious disease and cases of ordinary illness were treated in the same building. Mr. Pearson had reason to believe that there was a strong desire among medical men for the provision of cubicles for cases of infectious diseases, one reason for this being that the length of stay of the patient was thereby shortened. It had been said on good authority that there were only two ways of dealing with children in hospitals : to segregate them into cubicles, or to insist on their wearing masks to prevent the spread of infection. He shared Dr. Smith’s disapproval of two-bedded wards, though something could be said for them from the social standpoint of avoiding tedium. His own view was that the difficulty was best overcome by having cubicles with glass divisions, as supervision was very important. As to cubic capacity, it was no longer considered essential to provide 1500 cubic feet space for each acute case. The important point was floor space ; for a single patient in a cubicle the floor space should be 12 by 10 ft., and in open wards 10 by 10 ft. per patient. Similarly a height of 15ft. was no longer demanded, as nothing over 10 ft. from the floor apparently made any difference. A distance of at least 8 ft. between the centres of adjacent beds was important in order that infection should not be conveyed by coughing. A schoolmaster told him he had materially reduced the incidence of illness by forbidding coughing in class-rooms ; boys with the urge to cough had to leave the class. If screens were objected to, the barrier system of preventing spread of infection could be adopted. As to fittings, sash windows tended to rattle in a wind and disturb sleep ; casement windows were much more popular with matrons and He asked whether cross-ventilation was nurses. essential if plenty of air was entering the ward. In
NORTH OF ENGLAND OBSTETRICAL AND GYN29COLOGICAL SOCIETY
951
side-lighted rooms fanlights over the doors would only were to be used for hospitals and sanatoria. provide sufficient air currents. Air-conditioning he The chief inquiry made by parents concerning a did not particularly favour ; it must include filtering school was about the provision made for caring for and washing the air, and unless the school was them when sick. The PRESIDENT expressed his leaning towards situated in a slum area there would be ample direct contact with the outside air. For heating he single cubicles and separate rooms for school sanatoria. preferred radiators under the windows, but, despite At the beginning of a school term a number of boys the trouble of stoking and cleaning, open fires were had a temperature and the uncertainty as to what would develop made a particular need for single good and cheering in a ward. cubicles. School sanatoria should have sufficient Dr. G. E. FRIEND (Christ’s Hospital) said that occasionally he had to cope with a considerable number of single cubicles, and sufficient three- or four-bedded sick boys, and in the presence of mixed epidemics it rooms. necessary to convert one of the school houses into hospital. Hopper windows were put in and proved satisfactory; the time of convalescence was reduced by 25 per cent. in the improvised building thus fitted, compared with the infirmary building. He thought the variations of hospital design in different countries might be largely dictated by the average amount of sunshine. Dr. W. G. WILLOUGHBY (Eastbourne) said that in. the infectious diseases hospital with separate blocks there was no difficulty about having the windows
was
NORTH OF ENGLAND OBSTETRICAL AND GYNECOLOGICAL SOCIETY
a
open in summer; the difficulty arose in winter, especially when cross-ventilation existed. In blocks built in 1902 open fires were provided ; air coming in was heated by the fire and distributed throughout the ward without draughts. He referred to the grave illness and mortality statistics in inhabitants of back-to-back houses, due mainly to the lack of through ventilation. It was important to employ an architect with special experience. Dr. L. R. LEMPRIERE (Hailey bury) endorsed the praise given to the design of the Rickmansworth Hospital. He was opposed to the provision of an operating theatre in school sanatoria. Most public schools were conveniently near a well-equipped and well-staffed provincial hospital, and it was very much better, in his opinion, that operation cases should be dealt with there. He did not think that any school medical officer could be expected to be operating surgeon to the school, since his hand could easily lose its cunning when few operations were required. He was against coal fires in wards, quite apart from the dirt and the trouble of keeping them going. They failed to maintain an equable temperature, and schools catered not only for infectious cases, but for acute cases and convalescents. As soon as he was fit, the in the recreation room, a should be down boy put provision which most school architects ignored. An objection to large windows was that the blinding sun on a hot day could not be properly shut out. The amount of sunlight reaching patients in the summer could be overdone; it might interfere with sleep. The perfect flooring for a sanatorium had not yet been achieved, but the nearest approach, he thought, was cork. He agreed with the objection to two-bedded wards ; a public school sick house could possibly be a starting-point of immorality. A vital necessity was the provision of a detention room. Sick boys who might be incubating an infectious disease must not be mixed with convalescents. He would like to see every sanatorium equipped with a dark room, for transillumination aids to diagnosis. The provision of a parents’ room was desirable. Mr. DENMAN, F.R.I.B.A., spoke of the modifications made from reasons of economy of his original design for the Rickmansworth sanatorium. Mr. H. M. FAIRWEATHER, F.R.I.B.A., did not think there would be agreement as to the best kind of window ; he would be sorry to feel that metal windows
A MEETING of this society was held in Liverpool March 20th, with Dr. RUTH NICHOLSON, the president, in the chair. Two cases of
on
Simmonds’s Disease
reported by Mr. J. ST. GEORGE WILSON. He said that this syndrome, which is commoner in women, was first described in 1914, and is typified by progressive loss of weight and senile changessuch as loss of hair, an aged appearance, inhibition of genital function, and amenorrhcea. Lassitude and weakness are conspicuous. The basal metabolism is much lowered and the pulse is slow. There is ansemia and there may be hypoglycsemia. Radiologically there may be enlargement of the sella turcica if the lesion is a neoplastic destruction of the
were
pituitary. The first patient, aged 29, had complained of loss of weight, following a normal confinement; her weight, previously Ist. 7 lb., had been reduced to 5 st. 11 lb. within four years. There had been daily vomiting, dizziness, and loss of power in the left hand. She had, however, no loss of hair and did not look prematurely aged. She had complained of amenorrhoea for the last 12 months, her periods having previously been irregular. On examination she was found to be poorly nourished. The blood pressure was 114/72 mm. Hg and the pulserate 44. The cervix was multiparous and the body of the uterus small. X ray photographs of the skull revealed no abnormality. The blood-sugar was 81 mg. per 100 c.cm., non-protein nitrogen 33 mg., Wassermann negative. She was treated with injections of insulin and Pregnyl and with extra salt in the diet. The second patient, aged 37, also dated her symptoms to a confinement. She had complained of loss of weight for 21 months, nausea for 20 months, and weakness for 6 months. She was stated to be looking much older than previously, and had had amenorrhcea for 28 months. On examination her weight was found to be 4 st. 10 lb. She had hair on the face, pigmentation of the abdomen, a blood pressure of 98 mm. Hg, and a pulse-rate of 42. The urine was normal and a radiogram of the skull revealed no abnormality. She had complained of amenorrhcea constantly for the last 12 months, having previously had scanty periods at intervals of 5-6 months. On pelvic examination the uterus was found to be senile. She was treated by injections of Antuitrin S and GEstroform and was given olive oil. Eight months later she had gained 3 st. in weight.
In the discussion, Mr. S. B. HERD commented on the fact that in each patient the condition had closely He wondered if in the past followed pregnancy. these cases had merely been considered as instances of superinvolution.-Mr. T. N. A. JEFFCOATE said he considered superinvolution of the uterus always to be due to pituitary disease. He also questioned whether there was not in Simmonds’s disease an element of suprarenal dysfunction as well.-Dr. E., A,.