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94
Annual Report of the London County Council, 1911.
An arrangement already reported on was carried out by Jubilee nurses in Shoreditch and Bethnal
Green during 1909-10. The scheme here, owing to the absence of local hospitals or dispensaries,
was not considered to have had a fair chance, and after an experimental trial of six months was
abandoned as unsatisfactory. Its result was that of 405 children selected for treatment, the nurses
treated 133, paying 5,014 visits to the homes. In 31 cases the discharge ceased and the ears remained
dry, but in 61 other cases stimulated by the scheme, but not handled by the nurses, recovery was
obtained from other sources. The cost of each case healed by the nurses' attention averaged £2 18s.,
but if the other cases are included as a result of the scheme, the average cost to the Council of each
case recovered was a trifle under £1. As a financial transaction the Shoreditch scheme was therefore
good value, but as an efficient means of dealing with discharging ears among a mass of school
children it was a failure in that it left the majority of the cases no better than it found them. The
cause of failure was chiefly want of medical prescription without which the nurses would not act,
further, there were difficulties with parents, who refused to trouble about the nurses, and it was
doubtful whether the nurses' work was sufficiently skilfully done.
On the termination of this experiment, another district of London was selected in Paddington,
where the existence of St. Mary's Hospital and the Paddington Green Children's Hospital made
conditions very favourable. Lists of children with discharging ears were compiled by the doctors
and nurses in seventeen schools. The parents were notified that careful nursing is often efficacious,
and a nurse called at the home and explained the necessity for treatment and how it could be
obtained by the parent getting a prescription. Three weeks1 daily treatment was given by the
nurse in accordance with the medical prescription, and at the expiry of that time the nurse's record
card was reviewed by the doctor. Every case was followed as far as possible. The majority were
medically examined and prescribed for without cost to the Council. When inspected later by
the Council's officials, discharge had recurred in certain cases; they were, therefore, returned
for treatment as new cases. During the year, including the period in the early autumn when
there was some interruption, the work may be summarised as having 245 cases put forward for
treatment, of which 167 cases were handled by the nurses, 88 were returned as cured or relieved to the
extent of not requiring further treatment, and 38 remained on hand. There were 8,088 visits paid to
homes, of which 284 were preliminary. The cost of the nursing service to the Council was £90, so
that each visit costs 2.67 pence. There were also 75 hospital vouchers used by the cases, so that this
brings the cost up to £97 10s. Neglecting the 38 cases on hand and counting all the 88 as permanent
cures this means an average cost per case cured of £1 2s. 2d., which is extremely moderate, and good
value for the money spent. They represent about one-third of the number of cases sent forward, probably
a better result than has ever been obtained from any systematic attempt to cure discharging
ears among children on a considerable scale.
Tonsils and
adenoids.
The children who suffer from enlarged tonsils and adenoids form the bulk of cases requiring
treatment. No teacher should think herself fit to have charge of an elementary school class who
cannot give a just opinion in the majority of cases as to whether a child is suffering seriously in
this respect. Certain powers of destroying or digesting hurtful foreign elements, whether living or
dead, and possessed by nearly all the body cells, were described in previous reports. In the more
specialised structures these powers are in comparative abeyance, but are prominent in some leucocytes
or white corpuscles, and especially those found in lymphatic structures. The defensive powers of these
lymphatic cells may be seriously lowered by poisons such as alcohol, or the chemical products of fatigue
they may also be raised by certain chemical vaccines now prepared. These powers should be vigorous
and active in ordinary good health. The normal tissues about the surfaces of the nasal and mouth
cavities are chiefly exposed to noxious foreign elements, of which perhaps the most dangerous are living
organisms. In individuals of robust health the leucocytes have such powers that conditions of chronic
inflammation rarely show, but in others of less vigorous constitution, or debilitated by depressing
surroundings, or such causes as want of food or fatigue, chronic inflammatory conditions soon show
themselves.
The tonsils on each side of the fauces are the most easily seen of such lymphatic masses. All
degrees of enlargement may be seen. It may be such that from mere mechanical obstruction correct
articulation is prevented (this is noticed sometimes even in pupil teachers), or the enlargement may
cause increased efforts at breathing resulting in mouth breathing. The accumulation of decomposing
secretions on the surface and in the crypts of the tonsils often lead to the production of offensive and
poisonous bacterial material. The surface of the tonsil itself appears as a weak spot for the entrance
of various organisms, being a main portal for instance for the entry of rheumatic, scarlatinal, diphtheritic,
or other dangerous blood infections. The enlarged tonsils are usually indicators of further changes.
The lymphatic masses about the upper part of the naso pharynx, and the mucous tissues about the
posterior ends of the turbinate bones especially, are liable to become greatly hypertrophied and sometimes
cause much trouble from their chronic irritation whether by mechanical substances in the air or
more commonly micro-organisms, from want of proper drainage of the surfaces, from actual deformities
in development of the upper jaw, or from want of development, due to the habit of mouth-breathing
having become established at an early age. Mere catarrh started probably by the baby's comforter
is apt to set up mouth breathing. Catarrhal attacks may result in infection of the lymphatic tissues
and in children of low vitality the infection sets up chronic inflammation. Thickening of the soft
palate leads to impaired tones in the nasal sounds. Discharges sometimes start pharyngitis, which gives
the child an excoriated upper lip and the appearance of having nasal trouble. A remote result not