MAr 22, g920o THE CARE OF CRIPPLED CHILDREN. rDTCAL JOUWA 69.r M ~~~~THx BRITTEs

5. The need-in view of acidosis being a probableetiological 'factor in epileptic states-for careful in-vestigation, and the probabilitv tlhat, if suclh is tlhecase, efficient alkaline treatment may cure the condi-tion if recognized at the onset of the fits. Thie givingof bromides wvould seem to be dangerous in suclh astate, as it only tends to dull cellular activities; lateron it may be of use in treating nerve cells which haveacquired vicious habits.

6. The danger to the patient in not adoptina a firmattitude. If such cases are at once sent to hospitalbefore serious m-ental symptoms come on there wouldsoon be marked diminution in tlle admission rate atasyluims.

7. The predisposition to microbic diseases affordedby acidosis, above all to tuberculosis. As reaards-children, there are qtuestious wlicih can best beanswered by the general practitioner; for instance:

Wlhat is the relationship betwcen " biliousness" incliildlren- anid subsequent tuberculosis ? Are thesexes equally subject to acidosis? Does it tlhrowany liglit on the greater mortality of nale children?

Witlh regard to tuberculosis:Is it a question of' the optimum reaction of the

medium necessary for the growtlh of tlie tuberclebacillus ? In otlher words, do certain individuals, as aresult of errors of nutrition or-faulty cell metabolism,offer a more favourable pulmonary or lymplhatic culturemedium for the growthf of the tuberclc bacillus thando otliers?

Finially, is this wlhole question of acidosis, wi-tlhin limits,at the bottom of wlhat we understalnd by lheredity inrespect to disease processes ? Is it an effort on the partof tile organisim, to autolyze itself ? All these questionsare of extraordinary interest, and 'the wholei subject maybring us vastly nearer a proper comprehension of certainiprocesses whbiclh up to the present have been shrouded inmystery.

THE CARE OF CRIPPLED CHILDREN.BY

G. R. GIR;DL-ESTONE, M.B., F.R.C.S.,VISITING SURGEON, HEADINGTON ORTHOPAEDIC HOSPITAL; HONORARY

bURGEON, SHROPSHIRE SURGICAL HOME; HONORARY ASSISTANTORTHOPAEDIC SURGEON, RADCLIFFE INFIRMARY, OXFORD.

CRIPPLED clhildren need botlh treatment and education;on-ly thus can they be restored to active citizenslhip,lhealthy-minded and, so far as may be, healtlhy-bodied.

In a former. paper, publislhed in the BRITISH MEDICALJOURNAL, October llth, 1919, attention was called to thecrying need for effective treatment for crippled children,and a system of orthopaedic hospital-schools and out-patient clinics designed to carry out tlle work was out-lined. It was estimnated thlat about 10,000 beds wouldbe required for the wlhole of 'England and Wales, but itwas pointed out that new construction was not inlvolved tothis extent, boLlh because in some places hospitals carryinaout tlis work already existed, and in othler places thlerewere hospitals in iise by tlle War Office or Ministry ofPensions whiell would be suitable, and could eventually bemade available for this civil ortlhopaedic worlk.Those wlho lhave studied tlhe problem feel very strongly

that provision for tlhe treatment and all-round educationof crippled ellildren is the reverse of an extravagance, evenin the present financial straits. The following figures aretaken from the report on " An inquiry concerning plhysic-ally- defective aclults and ellildren " carried out by the Cityof Birmingham Education Committee in 1911. Theircapacity for work was a subject specially noted, and it wasfound that among 1,001 cripples over tlle age of 16 only111 were " able to do remunerative work at home," and 531were "unable to do auy remunerative work." Now it istlhe experience of those who work at lhospitals for cripplesthat 90 per cent. can be cured or improved sufficiently toenable thiem to take a slhare in industry if tlle disability istacliled early and efficiently and training given.

It is true that tlhere must be expenditure, perlhaps forsix months, during the active treatment of a crippled clhild.and that in some cases hlis education expenses afterwar smay be highi, but from tlle financial point of view alone i&is a clear economy, for he is thus enabled to become a pro-

ducer instead of a dependant for the manv years thatfollow. Furtlher, these crippled clhildren are already beingmaintained somewlhere aud by somebody. Many are inworkilouses, infirnma-ies, or industrial lhomes, and quite outof touclh witlh expert treatment. A large number lhave tobe admitted to general hlospitals on account of the severityof their condition; this is especially true of cases of tuber-culosis of the spine, hlip, and knee-tlhe very cases that needmany months or sevcral years of unirenmitting treatment inopelu-air wards iin tlle country witlh plenty of good food.,Thiese are the clhildren above all otlers for wlhom tlhelhospital-sclhool and continued supervision are needed. Onall tllese cllildren money is now beinig spent, but witlh veryimperfect results. On tlhe otlher lhand, a certain number ofortilopaedic lhospitals, orl.hopaedic departmients of generalhiospitals, and hospital-schlools for crippled clhildren arealready doing most excellent work; tlley can only dealwithi a miinority of the cases, yet tlhcir very existencemeans tlhat so muclh of thle capital cost lhas already beenfaced, and so much of tllo maintenance expense is alreadybeing found.

In some places new lhospital-schools for crippled chlildrenare nceded, but almost everywlhere tliere is waste and in-efficienicv due to lack of tlle comibination of education andtreatment, of tle fellow-workina of all the forces that lavehitlietlo worked apart, and of continuity of orthopaedicsupervision. Tlhe recogniition of tllis is neitlher new norsingular, as the following quotations will slhow.1. Report of the City of Birminhgham Education Committee

MAarch 29th, 1912:"More systematic co-operation and definite co-or(liniation

between the local education authority and the hospital audmedical charities, especially thiose wlich-deal with ortho-paedic cases, (are needed). In Enugland, speaking genierally,thie divorce betweeni these two organizationis aln(d theirrespective attitudes towards the clil(lren under their super-vision is complete. The success which has attend(le(1 thejoint work of eduication andci cuire of cripples in Arnerica an(don the Conitinent is in no small degree due to their closeco-operation anid idenitity of outlook."

2. Re1port of Censts of Clerclad?d, Ohio, 1916:" The need does not arise from failure to recogniize

separately the -me(lical ahid educational requiremeents, butthe failure to co-or(linate these and other forces affectilngthe life of eachi crippled child."

On tlle completion of thieir treatment most of tlle ellildrenwould be able to go to ordinary schools. In towns some"special sclhools" would be advisable, but certainly farfewer than are called for now, when many clhildreu areallowved to remain crippled needlessly. As the cases aresent in progressively earlier tlhe reduction of the numberof lchildren- too crippled to attend ordinary sclhools willbecomre greater in the same dearee.For a few clhildren, eitler very severely crippled or

living too far from a schlool, a " residential sclhool " wouldbe needed in each district, and this shbould be in the samnegrounds as the hospital-school. Onl their disclharge fromthe lhospital tlhese clhildren would then remain unjder thesupervision of the orthopaeclic surgeon and continue to.attend tlle scliool and workslhops. '-110e advantages wouldbe many, including administrative, educational, and work-.slhop economy, and facility of orthopaedic supervision.The publication of the paper already mentioned broualit

some of those whose wvork lay speciallv in the treatmsentof crippled children into touclr wvitlh othiers wh-1o had donemuclh for tlleir education and training. Tlhese mutualititerests lhave combined, alnd 'tle "Central Committee forthle Care of Cripples " lhas been formed. Its purpose -is torepresent and lhelp voluntary associations devoted to thewelfare of cripp'e , and to puslh foiwa d tlle work in everypossible way. 'T his com-lmittee lias becomne associated witlLthe "Central Council for Infant and Clhild Welfare," andhas an office at 20, Berkeley Street, W.Whenever Echemes are put forward or new associations

formed there is alarm amongst existing organizations, forthey naturally feel anxious lest their proved work is to be seton one side. In this case probably the feeling has been-", Issome new and tlheoretical system of State Service to startafre.sh with the slate wiped clean, and then perhap3 neverto work; withl thle same sympath1y aUnd enth1usiasm? " Thatis the lasLt' thling desired. Rathler is thle aim to unite' andhlelp thle present efforts, to combine thle workers and putbetter tools into thleir hlands, andc to make the attainmentof results easier and quick;er.

698 MAY 22, 1920] THE CARE OF CRIPPLED CHILDREN.

There is no need for new administrative machinery.The organization of this work must be moulded sothat it will fit into its place in tlle hlealth work of thenation-that system composed of central governmaent (bytlle State), local autlhority (locally elected), and the ultimatenetwork of hlealthi and social services, official and unofficial.Of this network the hospitals form nodal points; voluntaryin origin, tlley are becoming more and more link;ed up withState mecllanism by tlle system of capitation grants forthe treatment of various types of disability.

Tlle Hospital-Schools for Crippled Children will, it ishoped, be worked in close toucll with tlle medical officersof lhealtlh in their districts, and in affiliation to the generalhospitals. For the costs of maintenance each hospital-school will be largely dependent on capitation grants fromthe local authorities, whlo will pay only if they aresatisfied with tlle work that is being done, and if theinstitution lhas been approved by the Ministry of Healthand Board of Education, for with this approval 50 per cent.of the maintenance fecs paid out can be recovered. Insome dit%tricts several counties will be served by onehospital-school; these arrangements will be made toaccord witlh the geograplical conditions in various partsof England and Wales. On the other hand, in Londonand otlher big cities a fitting plan would be that each ortlho-paedic lhospital, or general hospital with an ortlhopaedicdepartment, should have its -section of the town, and itsbeds for crippled children in the country. -This wouldmake towards simplicity of- working, and continuity oftreatment and supervision of tlle patients present~andpast tlhrouhliout hospitals, special- schools, and *theirhomes.Guidance and help from the Ministry of Health and

Board of Education would be welcome, for an organiza-tion for the care of cripples, planned to give them all tllatthey need, must at the same time be moulded to fit intoits place exactly, and be linked up accurately with theexisting lhealth and education maclhinery, for only thuswill efficiency be quickly realized and permanently main-tained. It will be a small part of tlle whole structure, yetessential, for it is to deal with children to whom effectivecare alone can give lives active, happy, and self-supporting.

A HoSPITAL- SCHOOL FOR CRIPPLED CHILDREN.An attempt lhas been made to represent diagrammatic-

ally a lhospital-scllool of 200 beds, witlh its various partsindicated and grouped on a defiuite plan, and an asso-ciated " residential schlool." Thle plan is intended to serveas a means of illustrating some of the many points to bethought of in planning such a hiospital and as a stimulustowards furtlher consideration of the subject. No doors or

windows are indicated.

Types of Cases.The conditions for wlicll these lhospitals are needed can

quickly be grasped fromu suclh a table as that given in tllearticle on tlle Cure of Cripples, in the BRITISH MEDICALJOURNAL of October 1ltlh, 1919. It is now repeated-corrected in one parlicular-in tlle next column. It will beseen that the cases are grouped into three main categories:

1. Deformities.2. Paralyses.3. Surgical tuberculosis and other affections of bones

and joints.

Desiderata.1. Open Air Wards in the Country.-Probably only those

whiolhave worked in a lhospital wlhere the chlildren are inopen air nighlt and day can realize its marvellous effect ontheir vitality and powers of recovery.

2. A site on diy subsoil, fairly highl, with southernaspect, and a low rainfall. A low local rainfall can some-times be found in a district whlich as a whole has a

comparatively higll rainfall.3. A position in the neighbourhood of a main tozvn,

with good radiating railways and roads, and if possiblenear enouglh to the town to share in the advantages ofits electricity and gas and the transport, water, anddrainage systems.

4. Affiliationt with a good General Hospital.-Hospitalorganization is tending towards the co-ordination of thespecial hospitals in each neiglhbourhood with a "mother"general hospital. Tllis should give many advantages-

Table of Cases under Treatment.

shirop- Stoke. Total.shire.

Approximate population of area served... 425,000 246,307 671,307Approximate proportion of cases under

treatment to population 1... ... to 538 1 to 722 1 to 594

A. Deformities, congenital or acquired:Rickets ... ... ... 177 51 228Deformities of the foot 1n 51 122Scoliosis .8 14 22Congenital dislocation of hir . . 16 8 24Fractures, ilon-union and mat-union 15 10 25Other deformities... ... 43 43

Total ... ... ... ... 330 134 464

B. Paralyses:Infantile paraly-sis ... ... 211 72 283Infantile lheil)legia ... 4.. . 1 lSpastic paraplegia ... . J 11

Total. ... ... 254 94 348

C. Surgical tuberculosis:Spine. ... ... ... ...

Hip ... ..75 230Knee ... 26Other joints, etc.. 17

Total. ... 155 75 230 -

D. Other conditions:Osteoiuyelitis ... ... ... 33 11 44Various ... .16 28 44

Total ... 49 39 88

Grand total ... 788 342 1,130

for instance, the special hospitals would share in tlhebenefits of a first class pathological laboratory, and itshould bring the spirit of team work inito hospitalrelationslhips.

5. Sufficientt beds to meet the demand from the areawhiclh the lhospital serves. It is particularly importantto avoid the results of bed pressure: (1) Undue curtail-ment of treatment, and (2) a heavy waiting list.

6. A Unzit of Manageable Size.-Tlle lhospital shown isplanned for 200 patients. This is recommended as tlhebest size. Sufficiently large to justify the necessaryexpense of an expert staff, it is yet not too large to bedealt -witlh effectively by a clinical team consisting oforthopaedic surgeon, assistant ortlhopaedic sturgeon, twohouse-surgeons, plhysiotherapist, and masseuses.

7. Administrationz Offces.8-Where these hospitals are tobe managed by a committee, offices will be required for asecretary-accountant and Ihis clerk or clerks; for thematron and lher clerk; and for a housekeeper or steward.

8. Construction and Design.-The hospital as shown)night well be of semi-permanent construction and of" bungalow " type. Wood slhould not be used externally,owing to the great cost of maintenance idvolved. Besidethe general principle of placing all wards and living roomson the southern side of tlle hospital the following pointsillustrated in the plan may be mentioned:

(a) Ward uniiits-each main ward complete with its twoaccessory blocks.

(b) The conceitration of departments specially concerningthe surgeon (west end of centre block); the conjunction ofclinical rooms of surgeon and physiotherapist (49, 50).

(c) The aggregation of the departments requirilg heating orhot water supplies into a small number of groups. In each ofthe three main groups the heating plant can be situated underor close to a department requiring special heat-namely,(1) theatres in the surgical group, (2) the hydrotherapy room,and (3) the kitchen.

(d) The economy of service, heating, and hot water suppliesobtained by the grouping together of all the dining-rooms andthe resident quarters of the matron and the three medicalofficers.

(e) The advantage of locating entrance, kitchen, etc., on thenorthern side of the hospital, so that the southern may beclear.

(f) An arrangement of drive, short, but serving the principalpoints of supply.

I Thu JRnawMNDIOA Jouaxsra

MAY 22, !9201 -THE CARE OF CBIPrLED CHILDREN. *rTUZ snmL MEDICALr JlOUNAw* 699g

(g) The provision of covered walks between the variousbuildings of as slhort a total length as possible, yet so arrangedthat nurses or children can get from any one part of the institu-tion to any other without getting wet.

(hi) A convenient position shoul(d be found for the nurses'quarters. This buildling should stand in its own garden. Eachnurse should have a separate small bedroom. A reading roomrand a recreation and lecture room should bee provided.

9. Departments and TVards well eqguipped for Ortho-paedic Iorlk.-Points that may be mentioned haveregard to:

A. Exaininatioi Room.This should be long, so that patients may be seen walking,

warm, and with good light. There should be a waiting-roomfor patients. Evess if thie main clinical laboratory work is doneat the general hospital, simple equipment for the examinationof smears, etc., should be provided.

B. Theatr es.Two are indicated with the anaesthetic room between. Each

should be complete withi its whole outfit and one reserved ex-clusively for cAeancases. There shouldbe ample space and 3

light. Tle plan does :-: :-::.not show separaterooms for washing-up. The writer worksin a theatre devisedin accordaice witlha plan worked out byMr. A. P. Dodds-Parker which is re- _.commended as vervy2simple and extremelv 3_safe. It involves l.. 26 is 1merely a rathier --elongated theatre I7with one end reserved Zfor washinig-up and , H-_the sterilizing of in- L7strumenits. the otherfor operating. The Eenids are partiallyseparated by a cen -F__tral transverse baffle F _ CcQoming down f'rom ~. .---tle ceiling to within A 6s A67 ft. of the floor. DwFresh air is admittedto the operatitng area Jthrouglh ample inlets ° 100 20protected by a single i. Nurses' quarters. 27. Developing.av-er of muslin; at 2. Matron's bungalow. 28. Plaster cast

tlhe sarne time the 3. Kitchen offices. 29. Sterilizing.steamy air is pre- 4. Cooks' room. 30. Theatre forvented from spread- 5. Housekeeper's office. 31. Anaestheticing into this half of 6. Stores. 32. Tleatre forthelietre(an tiere 7. Larder. 33. Plaster.

the theatre (and there 8 Servants' room. 34. Splint store.con(lenising) by the 9. Kitchen. 35. Surgeon'sbaffle and by an ex- 10. Alstron's dining-room. room.han s t fani at the 11. Nurses'dining-rooni. 36. Nurses' chasouitliern end. 12. Girls' diniin-room. 37. Isolation a

A. room for aspira- 13. Iloys' dining-room,. sanitary.tiosAl nand mainor 14. Porter's room. 38. Iholation wa15. Telephone room. 39. Mother andoperations i n t h e 16. Matron's office. 40. Babies.south block is shown. 17. Matron's clerk. 41. RLecovery ws

18. Secretary's office.loa-lq ,P-fnvv

42. Ward anniex4A' 2 n tr wAr(

C. Plaster ]lZooncs. 20 Waitirg room (parents). 44 Centre wa:P I as t e r - co-Paris 21. Stores. 45. Ward ann

plays a great part 22. Ditto. 46. Reading ri

inl the work of these 23. Dispensary. 47. Play room.hospitals. The actual 24. Sewing room. 48. Waiting r

treameii ofcase in25. Photography. 49. Clinical r.

treatmen,t of casesia 26. Radiology. and clerplaoster the prepara- N.B.-Pathological laboratories and an on

which to make spinal be required if the hospital is not working in t

jackets or otlher ap-pliances, and record casts, together necessitate good provisionof plaster rooms. Two are showil isl the surgical block, anda third in the south block for the treatment of the cases there.They should be well heated and ventilated, and equipped with

an Abbott's framne, a good vertical suspension frame, and astrong table with arrangements for pelvic rests, etc.

D. Tihe Splintt and Appliance Workshops.These workshops are mentioned later.

E. The WFards.The four main wards slhown on our plan can be partitioned

further if thought desirable. They face directlv south, andon this si(de are open right up to the ceiling level, wbich shouldbe about 9 ft., the place of the south wall being taken bypillars.The beds would usually be ranged in a double row. When

driving1 raini beats inito tile war(d the frout row of beds could bepuslhed back. Further protection can be given by stout canvasroller blinds which' can be- pulled down between each pair ofpillara

Lrdex

100oc

k.

it-

-- All main wards should be lit and ventilated by windows on'the north side, in addition to being open to the south.The floor of the wards should slope slightly outwards.In these open-air wards the children need plenty of food,

plenty of blankets, and, in cold weather, a supply of artificialheat. Whether hot-bottles which have to be reheated or refilledseveral times a day or electrially-warmed mattresses will provemore economical is not yet clear. Possibly the latter systemwill gain on the score of economy due to the saving of hotwater, labour, alnd breakages; it is certainlya more efficientsource of couitrolled and steady heat. Information -on thispoint should soon be available from the Hayling Island annexoof Sir William Treloar's Alton Hospital.The southern block of the hospital could be specially devoted

to ases of- surgical tuberculosis. Diseases of the spine and hipaccount for the majority of such cases in hospital and meautreatment in bed for very long periods.Each main ward has attached to it:1. J-Vard Annexe, containing-A. Sister's room, 15 ft. by 9 ft., from which there is a good

view of the ward.B. Nurses' duty

room, 15 ft. by19 ft.; this isavailable for

dressingsannd theSs ~~~~~~~massage of cer-

tain bed cases,C. Bathing room,

15 ft. by 12 ft.,i~ Ia1 wi th tables on

which ca, onframes or inplaster can be

52. _3 ........... washed.a491O S53I 4 D. Ward kitchen,15 ft. by 5 ft.,with gas stove.

........... 4 7........

E. Bathroom , 15 ft.......... ..... s ----by 7 ft., withL7 _washing basins

and baths.F. Drying room,

15 ft. by 7 ft., fordamp clothes orbedelothes.

- b7 . _G.Kit and linenstore, 20 ft. by10 ft. south, 15 ft.by 10 ft. centre.

o 300 Rooms B, C, D,andE should be fitted

50. Clinical room, physio- with hot and cold,sand records. therapist. water. For B and C

51. Mfasseuses' duty room. w a r m t h combinedlseptic cases. 52. Hydrotberapy.room. 53. rlectricityandmassage, with thorough venti-clean cases. 53. Gymlnasiunma. lation is most im-

55. Medical officer's-quarters. portant, for it is56. Residential school dangerous to take

changing quarters. the m o r e delicate57. School.

nging room. 58. Covered playground, children into a stuffyLnnexe and 59. Workshops, room for washing or

60. Sanitary block (work- dressing, althoughurd. shops, etc.). they r em a i n freebaby. 61. South ward, girls. from bronchitis if

62. Wald sanitary block. treated continuouslyard. 63. Plaster.ce. 64. Minor operations. in the open ward.1,girls. 65 and 66. Schoolrooms. I t is exceedingly1,boys. 67. South ward, boys. difficult to keep these

ce. 63. Ward annexe. two rooms warm andOm. 69. Drive. airywitlhoutwindows

70. Asphalt or concrete area. which can be opened,m. 71. Asphalt or concrete slope, on either side andim, surgeon Garage, laundry, chasel on es. Further,not indicated. open fires. Further,

-patient department, though not,shown, will the nurses n dutyuch ith genral ospial.m us t be remem-

bered as well as thepatients.

The projection of this annexe in front of the ward gives somesbelter from cross winds, and adds to the stabilitv of thestructure.

2. Saniitary Block, connected to the centre of eachmain wardby a short cross-ventilated passage, and containing a slopsink, etc.

lVards for Isolation and Acclimatization.-The plan indicatesthree small wards (15 ft. by 10 ft.), with partially glazedpartitions, and a nurse's room from which the wards canbe overlooked. The south side of these wards consists ofdouble doors which can be opened inwards. The wards canbe used for infectious cases or for the acclimatization ofspecially delicate children to living in the open air. Observa-tion of newly admitted cases in special wards is not foundnecessary in open-air hospitals.

Babies' ar1ds.-On the south side of the west end of thecentral block are two wards-one for babies, the other for theadmission of both mother and baby when necessary; both canbe completely opened to the south.Recovery JJ'ardl.-In a children's hospital especially it is a

very great advantage to have a ward set aside for the reception

I

2

000,

I

70

1

X

tE

..iII

1.I

A11

IILI

a

7co MAY 22, 19201 X-RAY TREAT T OF ACNEVULGARIS. _---of cases for the first twelve or twenty-four hours after operations.It must be most harrowing for childreni to watch others gothrough the process of "coning round"" from an anaesthetic,and a most undlesirable prelimiinary to a subsequent operationon themselves.- Adolescenzts and .4dAilts.-No special wards are indicated fortlhese. The girls and boys are in distinct sides of the hospital,so that adults could be accommodated in one end of the ordinarywards.Payigq Patients.-Similarly lno wards are indicated. Small

bun,galows in suitable positions could be provided.

Edutcation.Regulations as to education in hospital-schools are laid

down by the Board of Education. In this plan no designof tlle sclloolrooms is indicated, but positions are suggested.The main school lies to tille east of the site and is surroundedby the workshops, residential school quarters, coveredplayground, reading and play rooms. Tlle main schoolblock would be attended by -walkers and chair cases fromthe central block of the lhospital, as well as by the childrenin the residential scllool quarters. The schoolrooms inthe centre of tlle south block are so placed that the childrenconfined to bed in this ward can be pushed to school easily,bed and all.

The residential school qttarters are for cllildren wlo,thouglh they no longer require hospital treatmient, wouldget no education if sent lhome, owing to the relation of thedegree of their disability to the distance of the sclhool fromtlleir lhome. Here, again, no internal structure is indicated,but as solue of tlle ellildren in these quarters will probablybe convalescent from tuberculous conditions, one or twoopen-air dormitories might well be provided. No cubiclesor dormjitories slhould be on the north side. The size oftllis particular building should not be regarded as areliable guide as to the residenitial selool needs of anarea requiring a hospital of 200 beds. A group of smallcottages would be an alternative metlhod of hiousing theolder children. The cllildren in lhospital and in residentialselool need reading rooms, play rooms, covered and openplaygrounds.

Tlle Workshops slhould supply training in various lhandi-crafts. Besides those of general application, such ascarpentry, cobbling, leatlher and basket work, in eachdistrict the local trades slhould be specially considered.

Spvlint Shop.-It is an immense gain to an ortlhopaedichospital tllat all the splints and appliances needed in thehospital slhould be prepared in its own workshops. Theinstrument makers cau then work in constant touch witlhthe ortlhopaedic surgeon, and so carry out hiis ideasexactly. Furtlher, in urgent cases special splints can bemade immediately.

It is recommzended that part of the workshops shotuldbe of the open-sided hlut type, and that all should bespecially well ventilated, for tlley will be used in thetraining of children in the lhospital and residential scllool.It will sometimes be possible to give p:-rmanent work asinstrument miiakers or instructors to cllildren wlho lhavepassed tlhrouglh the residential school and shown specialaptitude.

M11aintenance.Complete fulfilment of tlle conditions laid down by the

Ministry of Health and the Board of Education, whicilineluide arrangements for dental and refractive work, isnecessary so that the "approval " of these departmentsmay be obtained for work under (a) the Maternity andChild Welfare Act, (b) the Education Act (1918), and(e) the tuberculosis clauses of the Insurance Act.Great benefits will be derived from close association

with tlle medical officers of lhealth and tuberculosis officersof the group of local authlorities served by eaclh hospital-sclhool.

Definite working arrangements should be made with thelocal autlhorities by wlhlich the costs of maintenance,worlked out to an average for eaclh ellild and approved bythe Board of Education, are paid on a capitation basisby the local autlhority concerned in accordance with theActs mentioned above.

Expenditure.Thle following is an analysis of thle weekly exrpenlditure

per chlild at Baschlurch for thle quarter ending December

Food ... ,, 0 19 1Drugs and chemicals ... ... 0 1 9Instruments and appliancesX-ray apparatus ... 0 4 4Boots and leatherSalaries ... ... , 0 11 2

*Repairs and renewalsBuildings and machinery . 5 0Hardware and croclkery fFurniture and beddingOil and fuel ... ... ... ... 0 2 1ILaundry ... ... ... ... ... 0 1 0PrintingStationeryPostage, telegramsiRent, rates . .. 0 2 10CarriageRailway faresMiscellaneous J

Total ... ... ... 2 7 3 -The total weekly cost is seen to be greater than the estimate

of £2 given in the paper published in October. This is due tothe rise of prices, which unfortunately has not yet stopped.Beyond all tllese material advantages, there is needed

in the staff entlhusiasm for the work, orthopaedic experi-ence, with a balanced judgement of the values of variousmethods of treatment, the hiighest degree of slkill, and wellarranged clinical team work. Furtlher, the efficacy andpermanence of the work of such a hospital depends onearly recognition and treatment and on thorouuh after-care. The use of all the hlealth services of the district,official aInd voluntary, especially the work for infant andchild welfare, should lead to the early discovery ofcrippling conditions, alnd avail to bring them into touclwith orthopaedic treatment without delay. Similarly,eacll patient on discllarge from hospital slhould be attaclhedto one or other of the orthopaedic clinics scattered tlhrouglthe district. Careful after-treatment and supervision willthen malke for the attainment of the best result possible forevery child.

THE X-RAY TREATMENT OF ACNE VULGARIS.BY

.H. C. SE10N, M.A., M.D., M.R.C.P.,DERMATOLOGIST TO THE GREAT NORTHERN HOSPITAL, LONDON, N.

INTRODUCTORY.Iw spite of the general advance in dermato-therapy duringthe last decade, it is discouraging that few of the commonerskin diseases can be permanently cured. It is now estab-'lished that acne vulgaris-perhaps tlle most widespreadminor skin ailment in this country-no matter lhow ex-tensive, or in what stage it presents itself, can be per-manently cured by judicious x-ray treatment. I am wellaware that, in makinig tbis statemenit, I lay myself open tothe retort that radiotlherapy for so tri¶iAl a complaint is adangerous and quite unjustifiable rew-ely. The comnedoand pustular stages of the condition are, hlowever, veryobjectionable, and women especially cannot afford toregard the prospect of permanent disfigurewent by pittedor keloidal scars witlh equanimity. It is surprising to findthat most of tlle larger textbooks in'cline to the opiniontlhat x-ray treatment slhould be reserved for the most in-tractable cases. In tllese, lhowever, irremediable cica-trization will already have occurred, and the final appear-aice wlhen cure lhas been brought about may resemble theafter-effects of small-pox or lupus. It would seem to bean axiom of tllerapeutics that nearly all its most effectiveweapons are daugerous in unskilled or injudicious hands;but no reasonable nemnber of the profession would tlhere-fore limit the administration of salvarsan in syplhilis, ofemetine in dysentery, or of chloroform in the majoroperations of surgery. To relegate an invaluable andapproved remedy to the position of a last resource becausetllere have been disasters among the earlier cases, is toassume an attitude for whichl there is now no justification,and wlicih it is the main purpose of this article torepudiate.

Pathology.Acne vulgaris is mainly attributable to tlle activities ofa particular microbacillus first grown by Sabouraud.Every comedo contains it in more or less pure culture, ascan be proved hiistologically by suitable staining reagents.The acne pustule is tlle result of contamination of the