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Tuberculosis, giving rise to physical defects of a marked character, was only noticed in 16
cases and all were healed or quiescent. The cases included: Spine 2, hip 6, knee 3, ankle 3, shoulder 1,
elbow 1.
This number of cases is very small, but must be accepted as representing the true state of the
case, as it is excessively rare for tuberculosis of any of these parts to get well without leavirg fairly
obvious traces of its presence in the class of children under consideration.
On the other hand, experience shows that these are the commonest diseases treated in hospital.
How is the discrepancy to be explained ; what becomes of these cases ? Some, with the disease active,
are kept at home ; others, especially where the deformity is considerable, are in attendance at the
special cripple centres, some in benevolent institutions. These can hardly account for all, and one is
forced to the conclusion that these cases of surgical tuberculosis—the mortality of which per se is not
great—in course of time disappear, succumbing not to their original disease but to some intercurrent
affection which would probably leave a child without tuberculous taint unscathed. From our point
of view the importance of tuberculosis is in the effects that remain after its cure.
The results of treatment so far as eradication of disease is concerned were all that could be
desired, but in many cases after-treatment had not been carried out, so that often great deformity had
resulted, joints becoming ankylosed and knees which should have been straight being acutely bent.
These results must be expected until sanatoria for surgical tuberculosis can be established where children
may remain until completely cured, instead of as at present being admitted to hospital for operation
and then sent out in splints to homes undesirable hygienically and wanting in the careful handling
necessary for these cases.
The best treatment would be a country invalid school intermediate between the hospital and
the special school for physically defective children. Such invalid school of rest to which children
could be sent for 3, 6, 9, or 12 months would be a great economic gain, especially as so many of the
victims of tuberculosis are gifted with brains worth cultivating to the highest degree.
In the "Wald Schule," as carried out in Germany, the children attend a day school in the pine
forests, particularly around Berlin. Only the chronic cases of debility and early disease are admitted,
and they are taught in small classes entirely in the open air. A mid-day two hours' sleep, as is
common all over Germany, is allowed.
Our climate raises difficulties in the way of such schools, but some special educational treatment
is necessary for the debilitated children who require fresh air, sunlight, moderate school work of a
literary nature and plenty of a recreative character to prevent the development of strumous or tubercular
disease of a fatal or crippling kind.
Congenital Malformations were of a very varied nature, deformities of the hands
being the commonest. Five cases were girls with congenital dislocation of the hip. They were old
enough for the maximum effect of the deformity to show, and none had had any surgical treatment except
in one case. The shortening of the limb was not extensive and by thick soles or raising the boot they
could all get about without difficulty, there was no pain, and one could not have recommended operation
without considerable hesitation.
Fractures.—In two cases of separation of the epiphysis at the lower end of the humerus
the hand could not be raised to the mouth. Two cases of fracture of the femur walked with a limp.
A case of fracture of base of the skull four months previously was interesting from the symptoms—impairment
of memory and change for the worse in the character of the child who had become inattentive
and fidgetty.
Rickets..—Only 31 cases in this series presented marked evidence of rickets. Rickets, which
may be said to be present in the majority of infants seen in London hospitals, profoundly affects the
nutrition, being associated with retarded mental development, delay in the appearance of the teeth,
and sometimes with lamellar cataract. It also leads to certain marked changes in the bones. Mr.
R. C. Elmslie has studied the occurrence of rickets so far as the evidence of the bones affords. Between
3 and 8 years of age 1240 bovs and 1075 girls were examined and 158 bovs and 170 girls between
10 and 11.

Between 10 and 11, rickets could only be recognised with certainty in 1 out of 170 girls and 0
out of l58 boys. Only 7 per cent. of the cases of rickets were of such severity that treatment would be
advisable for relief of the deformity. Only one case, a girl aged 13½ years, of the rare variety of
"continued rickets" was seen.
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