WIL 62 WILLESDEN Urban District Council. HOSPITAL REPORT FOR THE YEAR 1895, BY D. S. SKINNER, M.D., Member of the Royal College of Surgeons, Eng.; Licentiate of the Royal College of Physicians, London; Fellow of the Society of Medical Officers of Health; Medical Officer of Health for Willesden. London: Printed by Ford & Son, office of "The Post," 5, High Road, Kilburn. 1896. WILLESDEN Urban District Council. HOSPITAL REPORT FOR THE YEAR 1895, by D. S. SKINNER, M.D., Member of the Royal College of Surgeons, Eng.; Licentiate of the Royal College of Physicians, London; Fellow of the Society of Medical Officers of Health; Medical Officer of Health for Willesden. London; Printed by Ford & Son, office of " The Post," 5, High Road. Kilburn. 1896. HOSPITAL REPORT, 1895. To the Chairman and Members of the Willesden Urban District Council. Gentlemen, I beg to present my Report for the year 1895. As this is the first year that the Hospital has been in full working order, I propose to enter somewhat into the details of the buildings and general arrangements. The permanent buildings consist of seven:—1, the porter's lodge and visitors' waiting room; 2, the administration house; 3, 4 and 5, wards; 6, the laundry and disinfecting chamber; 7, the stable, coach-house for ambulances, coach-houses (separate for two vans), the coachman's rooms over the stable and coach-houses, and the mortuary form the seventh block; the mortuary is at the end of the building; the stable, coach-houses and coachman's rooms form really a distinct portion, having been added after the other part was finished. There are also the original temporary iron buildings, one being available for patients and the other used as a dormitory for night ( 4 ) nurses; a room in the latter buildings is proposed to be used for religious services. These all stand on acres of ground, there being a space for another ward block remaining and space for two permanent buildings where the iron ones now stand. A main sewer runs under a roadway in the centre of the ground, and there are automatic flushing tanks at the head of each set of drains. Of the three blocks for patients, one is known as an isolation block, and is the recognised plan of the Local Government Board; it consists of two distinct sections facing in opposite directions, each section having two wards and a duty-room between, all opening on to a verandah. The Government plan leaves the verandah open on the one side, and thus exposed to the weather, during heavy rain, the water collected to such an extent that it ran into the wards. I consequently asked to have the one exposed to the south-west enclosed, with the exception of the entrance, and it has been found an immense improvement, as the nurse can now pass from one ward to the other without having to pass through a pool of water. The verandah facing the east has not been closed, but it would be a great improvement to have it done. Glass windows with sliding frames have been put in so that a good open space can be had in fine weather. The Hospital blocks consist of two wards each with a nurse's duty-room between. They were built ( 5 ) to allow of nearly 3,000 c. ft. of air space for each bed; the lower 3 ft. of the walls have tiles, the upper portion is faced with Parian cement. The wards are warmed with Boyd's hygienic stoves; there is a special exhaust air ventilator passing up by the side of the chimney, but not connected with it. The proportion of window space to wall surface is in accordance with the requirements of the Local Government Board. There are bath rooms by the side of the entrances, and water closets and sinks at each end. The laundry consists of wash-house, mangling and ironing room, and drying chamber. The water is heated by steam laid on from an upright boiler in a room adjoining; this boiler also supplies steam to the Washington Lyon's disinfector. It will be desirable at no very distant date to have a small refuse destructor. The cost of the Hospital has been nearly £20,000. £ s. d. Land 2,512 16 2 Buildings 16,358 14 7 Furniture 1,008 0 0 Total £19,879 10 9 ( 6 ) The furniture loan account contains also, viz: — £ s. d. Ambulance 77 0 0 Vans 89 0 0 Horse 42 0 0 Harness 23 0 0 Dispensary equipment and instruments 50 0 0 Total £281 0 0 There was a balance of £7 left at the end of the year. The permanent buildings have accommodation for 42 beds besides cots, and without reducing the air space below 2,000c. ft., could afford room for 54 patients; the iron building could also accommodate 16 beds, so that there is room altogether for 70 patients; even this has been barely sufficient on one or two occasions, and considering our population of 80,000, does not come up to Dr. Thorne Thorne's estimate of one bed for every 1,000 of population, and at our present rate of increase will soon fall far short of it. PATIENTS. There have been 364 patients under treatment during the year, including 17 that were remaining in the Hospital on January 1st. There have been on an average 46 patients every day throughout the year. (7) TABLE No. 1. Cases under treatment:— Scarlet Fever. Diphtheria. Typhoid Fever. Sore Throats. Influenza. Blood Poisoning. Small Pox. TOTAL. Remaining on December 31st, 1894 13 2 2 - - - - 17 Admitted 252 66 13 5 2 1 8 347 Total 265 68 15 5 2 1 8 364 Discharged 207 45 10 5 2 - 6 275 Died 13 19 3 — — — — 35 Remaining on December 31st, 1895 45 4 2 - - 1 2 54 TABLE No. 2. Wards from which the new cases were admitted:— Scarlet Fever. Diphtheria. Typhoid Fever. Small Pox. Other Diseases. TOTAL. 1. North Western 11 9 1 - - 21 2. South „ 15 3 2 1 — 21 3. „ Central 46 13 1 — — 60 4. „ Kilburn 71 25 3 2 — 101 5. Mid „ 44 13 1 — — 58 6. North „ 25 - 1 2 - 28 7. „ Eastern 29 1 4 1 - 35 Staff 2 2 — 2 8 14 From other Districts 9 — — — — 9 Totals 252 66 13 8 8 347 ( 8 ) Of the scarlet fever cases. 76 were under five years of age, and 23 of diphtheria, making in all 99 cases of children under five; the youngest child was three weeks old, having been admitted with the mother, both suffering from scarlet fever, the youngest child admitted, without the mother, was months. SMALL POX. A boy was admitted from North Kilburn suffering from small pox, and at the urgent request of the friends, and on offering to pay for her maintenance, the grandmother was allowed to accompany him; it proved afterwards that she was herself affected with the disease before entering the Hospital, and was taken ill within the incubative period. A man was admitted from Harlesden who was engaged in the milk trade. A man was also admitted who was employed at the East End of London, his sister subsequently was admitted, he having been staying in her house when the disease was recognised. Being able to promptly isolate the cases, prevented the spread of the disease in any of the districts. All the members of the staff not considered to be protected were vaccinated, but unfortunately two took it. As mentioned in my Annual Report, one member of the staff had scarlet fever and small pox; it is the only instance in my knowledge of the two diseases running concurrently. She made a good ( 9 ) recovery. The fact of the above case having been first of all taken into the scarlet fever ward caused me very grave anxiety with regard to the other patients, but no patient in the Hospital has ever become affected with it. TABLE No. 3. The following table distributes the deaths in the various Wards from which they came, viz.:— wards. Scarlet Fever. Diphtheria. Enteric Fever. Total. North Western - - - - South „ 1 1 1 3 „ Central 3 3 — 6 „ Kilburn 4 7 — 11 Mid „ 3 6 1 10 North „ 1 — — 1 „ Eastern 1 2 1 4 Totals 13 19 3 35 It will be seen from Table 1 that there were 35 deaths altogether, which gives an average death rate of the cases admitted during the year of 10.08 per cent., or of the actual cases under treatment of 9.6 per cent. Death rate of case mortality. Scarlet Fever 5.1 of cases admitted. Diphtheria 28.8 „ Enteric Fever 23.0 „ Small Pox 0.0 „ ( 10 ) The general death rate in the Hospitals of the Metropolitan Asylums Board is stated in 1S95 to have been 9.8. Dr. Thorne Thorne in his work on diphtheria says that the case mortality of that disease at St. George's Hospital was 38.4 per cent.; at St. Thomas's during three years it averaged 46.3 per cent.; and at the Hospitals of the Metropolitan Asylums Board was 42.5. During the year only four cases that had been notified were admitted from Willesden into London Hospitals, and all proved fatal. These statistics point to the difficulties that present themselves in Hospitals in the treatment of this disease. It frequently happens that cases which have not perhaps been thought serious for some days, gradually assume alarming symptoms, and then application is made for the patient to be admitted to Hospital. During the year several cases were admitted when it was apparent at once that they could not live. Early treatment and efficient nursing are of the utmost importance in diphtheria. EXPENSES. The expenses in connection with the daily routine of the Hospital, when the number of patients and variety of diseases are taken into consideration, must be heavy, a large item being the capital and interest account. The loan for the purchase of the land has to be repaid in 50 years; that on the ings in 30 years; and on the furniture in ten years. (11) The amount paid on each during the year was as follows, viz.: — £ s. d. Land 110 11 3 Buildings 1,057 18 8 Furniture 118 19 11 Total £1,287 9 10 This will be a decreasing sum every year. HOSPITAL. £ s. d. Medical Superintendent l50 0 0 Staff 536 4 1 Provisions 978 9 0 Miscellaneous (including household requisites, clothing, gas, coals, drugs, &c.) 380 12 0 Water 53 16 0 Repairs 37 5 0 Total £2,136 6 1 disinfecting. stabling total. £ s. d. £ s. d. £ s. d. Utensils, Shoeing, Forage, &c. 35 5 0 17 1 0 52 6 0 Coachman 40 7 6 20 11 9 60 19 3 Engineer's Wages 28 12 0 28 12 0 Coals, Wood, &c. 18 15 0 18 15 0 Totals £122 19 6 £37 12 9 £160 12 3 SUMMARY. £ s. d. Capital and Interest 1,267 9 10 Hospital 2,136 6 1 Disinfecting 122 19 6 Stabling 37 12 9 Total £3,584 8 2 ( 12 ) The sum of £161 0s. 0d. was received during the year for patients admitted to the Hospital from other districts. The above total gives an expenditure per patient of £9 17s. 0d., but deducting the disinfecting and stabling which are distinct from the Hospital, the average would be £9 8s. 0d. There might be a further small sum deducted from capital and interest account for buildings, for disinfecting and stabling, but I have not thought it necessary to do so. The cost of each patient in the Hospitals of the Asylums Board was £10 13s. 5d., the number of cases admitted into the eight Hospitals was 8,958. which gives an average of 1,120 patients to each Hospital, or rather more than three times as many as we had. HOSPITAL STAFF. Our staff consisted of medical superintendent, matron, three charge nurses, three night nurses, three probationers, one seamstress, ten subordinate staff, steward, porter, who also had charge of the boiler and disinfecting apparatus, and his wife, coachman and wife, and three laundry staff, a total of 30, but I feel that the number of nurses has at times been insufficient, and that for the future we ought to have a fourth trained nurse and an advanced probationer, or assistant nurse, who could temporarily take on the duties when any of the charge nurses are ill, or absent on leave, or when a ( 13 ) nurse is obliged to be detained for special duty. It is essential for health and the effectual performance of their duties that the nurses should have at stated times, a day off duty for change and recreation, it being remembered that Sunday is a day of as much work as other days, and therefore cannot be a recognised "day of rest." The sudden removal of a nurse and servant to attend upon a small pox patient at once entails loss of time off duty on the whole staff. The day nurses go on duty at 8 o'clock in the morning till 8 in the evening; the night nurses being on for the other twelve hours. The total number of the staff in the Hospitals of the Metropolitan Asylums Board was 1,455, or an average of 181 for each Hospital; at that rate we should have had nearly a third of that number. In making my comparisons with the Asylums Board, I have assumed that the capital and interest account was included in the statement of accounts that were published in the daily papers, but I have not been able to obtain positive information; one statement that I saw in the British Medical Journal, of December 28th, was "According to the last Annual Report of the Metropolitan Asylums Board, upwards of £300,000 was expended in the year ending September 29th, 1894, on the isolation and treatment of fever and small pox cases in their Hospitals," but the total number of cases admitted multiplied by TABLE No. 4. The following table will give some idea of the working and cost of such Hospitals, viz.:— No. of beds. Patients admitted. Death rate. No. of Staff. Cost of each patient. Annual Cost. Cost per bed. £, s. a. £ S. d. £ The eight Hospitals of the M. A. Board 3,278 8,958 9.8 1,455 10 13 5 300,000 0 0 91 Average of each Hospital 410 1,120 9.8 181 10 13 5 37,500 0 0 91 Isolation Hospital, Willesden 70 347 10.0 30 9 8 0 3,423 6 0 49 the cost. £10 13s. 5d.. of each patient, come to less than £100,000, so that I am rather at a loss in making these comparisons. ( 14 ) ( 15 ) ANTITOXIN. Some cases were treated with Serum, and the general opinion was favourable regarding it. but in some cases neither Antitoxin nor anything else seemed to have any influence on the disease. In many cases the disease was so far advanced that it was not thought of any use to use it, in fact, the children were practically dying and lived only a few hours after admission. In one case where the first notes stated that the throat was very bad with diphtheritic membrane on it. and there was discharge from the nose, after two injections the report says, "Throat much better, a quantity of membrane has come away," and on the following day, "Throat nearly clean." Another case where a. child aged 16 months had whooping cough also, the Antitoxin was injected the second and third day after admission, and on the fourth day there was certainly improvement, on the evening of the fifth day there was a relapse; the report says "Very bad: not apparently likely to last long: diphtheritic membrane all over the soft palate." Antitoxin was again injected with decided relief; throat cleaner, but discharge from nose and both ears on the following day. The child eventually made a good recovery. In three adult cases, two of which were followed by severe paralysis of the throat and general weakness, the Serum was injected with apparently very decided benefit. The nursing staff were so convinced of the effect that they requested, if they should be attacked with the ( 16 ) disease, that I would inject Antitoxin. The cases are too few to make any positive deductions from, but I hope to continue the use of it with still more success. Of course the cases were not treated solely with it. Several cases were admitted suffering from scarlet fever and diphtheria combined; these caused a great deal of anxiety lest the latter disease should spread among the other patients as, with the Hospital so full, the cases were obliged to remain in the scarlet fever wards. REPORT ON MAINTENANCE OF PATIENTS IN HOSPITALS FOR INFECTIOUS DISEASES. In accordance with instructions from the late Local Board, I forwarded certain questions to various Local Authorities, and the result of my enquiries was as follows. Replies were received from 37. To the question: Is any payment required ? the following answers were received, viz.:— From Residents: "No" from 15. Yes" „ 9. Payment by Poor Law Authority, viz.:— "No" from 3; "Yes" from 21. The amount varying from 10s. 6d. to £1 1s. 0d., and in two or three instances £2 2s. 0d. ( 17 ) In several cases where the answer is "Yes" as to payments from residents, information is given that payment is not enforced. The opinion is given in some answers very decidedly lhat requiring payment deters patients from going to the Hospital. No. 6 Town replies : ''Yes; but not enforced." „ 9 „ "We found that payment acted as a great deterrent to coming, so abolished payment last year." ,, 11 „ "Not for ordinary cases." „ 12 „ "Not unless a private room is required." ,, 14 „ "No; it is considered that it would cause some difficulty in getting patients in." „ 15 „ "Only for those sent by Poor Law Authority and for visitors." „ 17 „ "No proceedings taken." „ 21 „ "Free to ratepayers. Hospital becoming popular." „ 22 „ "In some cases in which payment might be made, report of payment acts as a deterrent." „ 29 „ "The charge seems to be very deterrent." To the question : Is there any charge for disinfection? The answers were, viz.:— "No'' from 24 Not answered 9 Small „ 4 I have the honour to be, Gentlemen, Your obedient servant, D. S. SKINNER, Willesden, 1896. Medical Superintendent.