WIL-5 Willesden Urban District Council. HOSPITAL REPORT FOR THE YEAR 1900. 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; and Medical Superintendent of the Isolation Hospital. London: Printed by Martin & Son, 211 High Road, KilbuRn. 1901. MEMBERS OF THE HOSPITAL VISITING COMMITTEE. Dr. W. W. STOCKER, Chairman. Dr. J. S. CRONE, J.P., Chairman of the Council (ex-officio). C. PINKHAM, J.P., Vice-chairman of the Council (ex-officio). E. C. FISK, L.D.S. J. T. FRIPP, L.D.S. A. W. GEORGE, M.D. G. H. JOHNSON. W. L. MORLEY. J. SABEY. HOSPITAL REPORT for 1900. To the Chairman and Members of the Willesden Urban District Council. Gentlemen, I beg to present my Report of the Hospital for the year 1900. SITUATION. The Hospital is situated on low ground, about 100 feet above sea level. The soil is a thin stratum of loam on two or three feet of clay with gravel underneath. There is a liability to mists in the autumn. Houses have been built within the last three years on the east side and partly on the north, the nearest part of any building being 30 feet from the fence. The first temporary iron building was opened for patients in August, 1892, the permanent buildings, consisting of an isolation block and two hospital blocks, were commenced to be occupied in November, 4 1894; they afford accommodation for 16 beds in each hospital block and 10 in the isolation, but by the addition of cots some increase has been made, although at the curtailment of floor space. One block is used for Diphtheria patients and the other for Scarlet Fever. In 1893 an iron building was put up for isolating a few cases of Small Pox but has not been used for that purpose since 1895; the building, after thorough disinfection, was disused for some time, but has latterly been made available as sleeping quarters for nurses on night duty; it is not well suited for the purpose, being very hot for sleeping in during the day time in summer and very cold in winter. During 1897 and 1898, owing to the great number of cases of Scarlet Fever and Diphtheria, temporary accommodation was provided at Stonebridge Farm and another iron building erected for Scarlet Fever cases. These temporary iron buildings are for 12 beds in each, so that the total number of beds, including cots, can be raised to 76. Stonebridge Farm was discontinued in the following spring. The accommodation, therefore, made for Scarlet Fever in the permanent and two iron buildings is 44 beds; Diphtheria, 20 beds and cots; in the isolation block 5 for observation and isolation of complicated cases, 12 beds. This arrangement allows of no accommodation for Enteric, and the patients have had to be placed in half of the isolation block. The isolating of Scarlet Fever with Diphtheria, Scarlet Fever and Measles, Whooping Cough and Chicken Pox, have been at times quite impossible, and these second diseases have consequently spread through the ward. TABLE No. 1. CASES UNDER TREATMENT. Scarlet Fever. Diphtheria. Typhoid Fever. Erysipelas. Other Diseases Total. Remaining on Dec. 31st, 1899 46 24 5 .. .. 75 Admitted 188 122 34 .. 4 348 Total 234 146 39 .. 4 423 Discharged 189 112 24 .. 4 329 365 Died 9 19 8 .. .. 36 Remaining on Dec. 31st, 1900 36 15 7 .. .. 58 6 TABLE No. 2. Wards and Other Districts from which Cases were admitted. Wards. Scarlet Fever. Diphtheria. Typhoid Fever. Influenza. Other Diseases. . Church End 42 27 5 .. .. 74 Harlesden 14 10 5 .. .. 29 Kensal Green 38 46 8 .. .. 92 South Kilburn 31 22 6 .. .. 59 Mid-Kilburn 20 5 3 .. .. 28 North Kilburn 15 2 2 .. .. 19 Willesden Green 25 9 3 .. .. 37 Other Districts 2 .. 2 .. .. 4 Staff 1 1 .. 2 2 6 Total 188 122 34 2 2 348 TABLE No. 3. Ages of those admitted. Under 1 year. From 1 to 2 yrs. Two to 5 years. Five to 10 years. Over 10 years. Total of Total M. F. M. F. M. F. M. F. M. F. Mls. Fms. Scarlet Fever 1 .. 4 4 29 16 32 36 30 16 96 92 188 Diphtheria 1 .. 5 2 21 10 19 27 18 19 64 58 122 Typhoid Fever .. .. .. .. 3 .. 2 2 17 10 22 12 34 Other Diseases .. .. .. .. .. .. .. .. .. 4 .. 4 4 Total 2 .. 9 6 53 26 53 65 65 69 182 166 348 7 Deaths. Under 1 year. From 1 to 2 yrs. Two to 5 years. Five to 10 years. Over 10 years. Total of Total M. F. M. F m. F. M. F. M. F. Mls. Fms. Scarlet Fever .. .. 2 1 .. 1 2 2 .. .. 4 4 8 Diphtheria .. .. 1 1 4 3 .. 6 2 2 7 12 19 Typhoid .. .. .. .. .. .. .. .. 4 2 4 2 6 Measles .. .. .. .. 1 .. .. .. .. .. 1 .. 1 Brain Disease .. .. .. .. .. .. 1 .. 1 .. 2 .. 2 Total .. .. 3 2 5 4 3 8 7 4 18 18 36 There was one death from Diphtheria, admitted in 1899, from Church End Ward, age 10. One patient admitted as Typhoid Fever was found to be suffering from Delirium Tremens, with Softening of the Brain, and another had Tubercular Inflammation of Brain; both died, no symptoms of Typhoid, after admission, appearing in either case; post-mortem examination in both cases. One case notified as Scarlet Fever was found to be suffering from Diphtheria, and was admitted under that head, as there were no evidences of Scarlet Fever perceptible. 8 One patient admitted with Typhoid Fever in 1899 developed rapid consumption and died in February, having become too ill to be removed. TABLE No. 4. DEATHS DISTRIBUTED TO THE VARIOUS LOCALITIES FROM WHICH THE PATIENTS CAME. Wards. Scarlet Fever. Diphtheria. Typhoid Fever. Other Diseases. Total. Church End 1 4 .. .. 5 Harlesden .. 1 2 .. 3 Kensal Green 2 10 .. .. 12 South Kilburn 2 2 1 1 6 Mid-Kilburn 3 1 . . 2 6 North Kilburn .. .. 1 .. 1 Willesden Green .. 1 1 . . 2 Other Districts .. .. 1 .. 1 Total 8 19 6 3 36 Cases were removed to hospital from 125 roads. Scarlet Fever patients were removed from 92 roads, from 52 of which only one case was removed during the year. Diphtheria patients were removed from 61 roads, from 39 only the one case removed. Enteric Fever from 27 roads. In 1895 and 1896, out of every 1,000 of the 9 population, 4.3 each year were admitted to hospital; in 1897 the proportion was 5.0; in 1898 4.7; in 1899 4.1; in 1900 3.0. Of Scarlet Fever alone the proportion in 1896 was 3.3; in 1897 3.5; in 1898 2.2; in 1899 2.1; in 1900 1.6. Of Diphtheria in 1896 it was 0.6 ; in 1897 14 ; in 1898 2.2; in 1899 1.7; in 1900 l.0. The admissions during the last five years have been as follows:— 1896 1897 1898 1899 1900 Scarlet Fever - 296 329 223 233 188 Diphtheria 53 137 221 189 122 Typhoid Fever 5 16 38 36 34 Other Diseases 16 5 .. 10 4 The following figures give the death rate per cent.* of cases admitted for the different diseases:— 1896 1897 1898 1899 1900 Scarlet Fever 4.0 2.7 3.3 4.0 4.1 Diphtheria 22.6 24.8 19.3 14.8 14.2 Typhoid Fever 42.8 12.5 10.5 9.7 17.3 All Causes 8.1 9.2 10.9 9.3 10.0 * Calculated in accordance with the Registrar-General's formula "by dividing the deaths, multiplied by 100, by half the sum of the admissions, discharges, and deaths for the year." 10 Although the number of cases admitted was less than the previous year it has been found impossible to take so many cases from outside districts; many applications have been obliged to be refused as the beds were required for our own cases at the time, the applications not coming, as in the previous years, during a slack time. Only four cases were able to be received—two of Scarlet Fever from Acton, and two of Enteric Fever from Wembley; one of the latter was in for a long time owing to brain symptoms, but he eventually recovered. SCARLET FEVER. Of the 188 cases, eight had also Diphtheria; seven were suffering from Measles; one had a severe bum, others with Chicken Pox, Inflammation of Brain, Whooping Cough. The complications with Diphtheria, however, were not limited to the above, as nine cases admitted into the Diphtheria Wards were found to have had Scarlet Fever at the same time. It happened on two occasions that the Scarlet Fever symptoms had subsided on admission, and the disease was not known until desquamation was seen. By this means on both occasions other patients in the wards contracted Scarlet 11 Fever, so that the building had twice to be cleared of patients and disinfected. ROSE RASH. An illness designated epidemic Rose Rash has been the cause of some children being sent to the hospital. The illness is one that it is extremely difficult to separate from Scarlet Fever, as there is slight sore throat and a scarlet blush on the chest, this latter only lasts for a short time, and the symptoms in 24 hours have pretty well subsided. The result has been that these children about a fortnight after admission have had Scarlet Fever in rather severe form. The following case occurred:—One of the house servants was taken with the above symptoms, and was obliged to be placed in the convalescent Scarlet ward. She was soon well, did not contract Scarlet Fever, and did not have any peeling or any sign of Scarlet Fever later. POST SCARLATINA DIPHTHERIA. There were four cases; two affecting the throat, one the larynx, which was fatal, and one the vagina and vulva, which was very severe; the child completely recovered, 12 DIPHTHERIA. As stated above, there were many cases complicated with Scarlet Fever which led to others taking the latter illness. I must again point out the want of facilities for isolating these cases with complications. Measles, Whooping Cough, Chicken Pox, all have caused a great deal of anxiety lest the other patients should contract a second ailment. Two children contracted Measles, but fortunately the cases of Whooping Cough could be removed so that others did not take it. TRACHÆOTOMY. Five children were operated on during the year, of whom four recovered. ANTITOXIN SERUM. In my report last year I said that 85 per cent. of the cases were treated with serum. During the present year 95 per cent. have been so treated. I have made very little alteration during the last year or two in the amount given, two doses of 2,000 units each being the usual amount, though in very severe cases double the quantity has been given. Cases 13 have recovered which at the first view have appeared hopeless. The importance of early treatment cannot he too urgently insisted upon, and I have been in several instances very glad to find that the remedy has been administered before admission. BACTERIOLOGY. In 1898 the Council gave me sanction to purchase the necessary appliances for Bacteriological examination. In Diphtheria it has been of the greatest value in the hospital, and also in diagnosing doubtful cases in their own homes; during 1900, over 60 specimens from throats, for examination, were sent to me by medical men; in several no Bacilli were found, and the cases consequently did not require notifying, but where Bacilli were found it enabled the case to be placed at once under treatment, with improved chances of success. ENTERIC FEYER. I have already made reference to some of these cases. The experience of the year has been that where a case has been complicated with a severe attack of Pneumonia, a fatal result is greatly to be feared; the deaths that occurred were mostly from this cause. 14 RETURN CASES OF SCARLET FEVER. This subject has been occupying a great deal of attention in all Fever hospitals for a long time past. In 1898 a special enquiry was instituted by the Metropolitan Asylums Board, and entrusted to Professor Simpson, of King's College. I have recently, through the courtesy of the Secretary, received a copy of his report. In my report for 1898 I referred to this subject, and quoted the opinions of Drs. Goodall and Washbourn, expressed in their work on Infectious Diseases, that these cases generally occurred on the 3rd or 4th day, but were "never more than a week." Dr. Simpson (without expressing any opinion as to the time), for the purposes of his report, has considered "all cases occurring in a house within a month of the return home of a patient" as return cases, and all such have been enquired into. After remarking on the difficulty of obtaining accurate information, he says, "It is necessary only to observe what goes on among children in crowded localities, to become cognizant of the variety of ways by which infection may be spread, if one of them happens to be infective. They play together, they kiss one another, place round each other their scarves, handkerchiefs and jackets, Willesven Arban District Council. Sanitary Department, Public Offices, Dyne Road, Kilburn, N.W. Medical Officer of Health: d. s. skinner, m.d. 24th June 1901. With the Compliments of the Medical Officer of Healthe 15 lend each other their whistles, trumpets and toys, &c." "I find it to be the general opinion that much of the infection of Scarlet Fever is received in this way from mild or unrecognised cases, and it can readily be understood that infection of this kind is well nigh impossible to trace to its source.'' His enquiry included a period of six months, and, during that time, 6,507 cases of Scarlet Fever and 3,275 of Diphtheria were discharged from the Board's hospitals. During the same period, there occurred within a month, in houses to which discharged cases returned, 253 cases of Scarlet Fever and 86 of Diphtheria, and he calculates the percentage of secondary cases on total discharges as 3.8 for Scarlet Fever and 2.3 for Diphtheria. Investigations, however, disclosed that in many instances the secondary cases were in no way connected with the return of the primary case. In those cases in which the evidence pointed to infectious clothing, he remarks, "My inquiries have led me to the conclusion that, while great attention is paid, as a rule, to the disinfection of infected bedding, similar attention is not usually paid to the wearing apparel, toys, playthings and belongings, of the infected child, and to the clothes which the mother is wearing whilst 16 nursing the child." "It is unsafe to rely on fumigation." Things allowed to remain for a considerable time in a closed receptacle in the dark, retain the "infectivity alive longer than would be the case if the infected article was left untouched in the room or exposed to the air." Acting on the same principle with regard to cases recurring within a month, I have examined into the circumstances of every case discharged from the hospital during the year. There were 189 cases of Scarlet Fever, and 112 of Diphtheria discharged, and the following table gives the number that came under consideration, these being the only cases where a fresh notification was received within a month. RETURN CASES OF SCARLET FEVER DIPHTHERIA. Date of Admission. Date of Diecharge. Date of Notification within a month. Date of Admission. Date of Discharge. Date of Notification within a month. l Oct. 31/99 Jan. 4/00 Feb. 4 .. .. .. 2 .. .. .. Dec. 7/99 Jan. 18/00 Feb 5 3 .. .. Feb. 1/00 Dec. 9/99 Jan. 18 .. 4 .. .. .. Dec. 14/99 March 22 March 28 5 Dec. 14/99 Fell. 1/00 Feb. 11 .. .. .. 6 .. .. June 29 March 15 June 21 .. 7 March 21 May 24 .. .. .. May 29 8 July 26 Sept. 13 Sept. 18 .. . . .. 9 .. .. .. March 13 June 14 June 22 17 Taking the cases of Scarlet Fever there were 3. The secondary disease notified in the instance of No. 7 was a different disease. This gives 1.58 per cent. as return cases; of the three instances No. 1 barely comes into the month. No. 5.—Two cases were treated at home, the third was removed to hospital, the fourth notified 10 days after the return of the third. It is difficult to say if all the infected articles from the two cases treated at home were disinfected. No. 8.-During the time that the primary case was in hospital the girl notified on September 18th had been on the fence of the hospital every day and was taken sick while at the fence. Of Diphtheria in the instances of Nos. 3 and 6 the secondary disease was a different one; in the case of No. 3 the child discharged on January 18th was re-admitted on February 1st with Scarlet Fever and Measles. No. 2.—There were 17 days between the return of the primary case and the notification of the second. The period of incubation in this disease is not a fixed period. Sir R. Thorne Thorne in his work on 18 Diphtheria says "the limit between an almost immediate operation of the infection and a delay of six or seven days practically covers the period of incubation for preventive purposes." Oertel in an article on Diphtheria says:" we may state positively that the latent course of Diphtheria occupies from two to five days." No. 4.—There were 4 cases occurred in this house after the return of the primary one on March 22nd, the cases being notified on March 28th, April 4th, 4th and 12th, there was thus a period of 22 days between the return of the first and the notification of the last case. No. 9 appears to have been undoubtedly a return case, because the report says that the primary case had a nasal discharge after returning home. This seems to illustrate the point mentioned by Dr. Simpson that "a warm bath immediately before discharge from the hospital and under the conditions which obtain in winter in this country has apparently, in the cases which I have investigated, especially in the more delicate and weakly children, aggravated or revived the infection." I was so much struck with 19 this opinion that since reading the report I have given instructions that if possible the children should be bathed the evening before leaving. Of course, it is necessary to remove the child after the evening bath away from the infected ward, but that has not always been found practicable, and the bath, therefore, given in the morning. In this case the child though free from nasal discharge at the time of leaving, may have taken cold after the warm bath and thus revived the infection. It has happened on a few occasions that discharge from the ear has been so persistent as to become chronic, and I have allowed the child to leave the hospital, the parents being informed of the risk of allowing the child to mix with others. I do not know of any instance of others being infected by the returned child. Undoubtedly it is very necessary that care should be exercised by the parents on the return of a child from the hospital. Dr. Simpson says with regard to this: "I think it very desirable that every parent or guardian, on the discharge of a child, should be furnished with printed instructions as to not allowing it to sleep with other children for at least a 20 fortnight." Instructions are always given to the person removing the child, but I propose to have printed papers given with every child. In my remarks on return cases I have referred to an instance of a girl being taken ill while leaning over the fence talking to the children inside. Repeated instructions and orders were given to these visitors to keep away but without avail, so many women and children made it a daily practice to come there that I found it necessary to ask the Committee to have the fence raised at that particular part near the Scarlet Fever blocks to prevent them from being able to climb up. This was afterwards done with the desired effect. DISINFECTING. This apparatus has been in constant operation during the year, not only for the bedding and clothing of the hospital, but also for the whole district. The number of cases notified during the year having been less than the year before, the work has been able to be carried on, but if a severe outbreak of Scarlet Fever or Diphtheria were to occur the apparatus would be found too small to cope with it; as it is there are 21 occasionally complaints that articles are kept so long before returned, but where a great deal has to be done a slight delay is unavoidable. The vans for collecting and returning the bedding, etc., to the houses will require some repairs during the ensuing year. AMBULANCE. This vehicle has had so much work that it is becoming shaky. The noise and rattling and the vibration are most trying to the patients, especially in Enteric. It is very desirable that improvements that have recently been introduced for these conveyances should be added so as to bring it in accordance with modern ideas. Owing to the great and rapid increase of the District (the population at the census has been found to reach the total of 114,815), I made an application for an assistant at the hospital. After some consideration, a Committee of the Council recommended that the two appointments of Medical Officer of Health and Medical Superintendent of the hospital should be separated; that I should give my whole time as Medical Officer of Health, and be Consulting Physician to the hospital. This arrangement was passed by the 22 Council, and confirmed by the Local Government Board. As this, consequently, will be my last report as Medical Superintendent, I append a few details of the hospital since its commencement. The first case was admitted on August 16th, 1892, and the total number of cases admitted up to April 30th, 1901, has been In the first temporary iron building, only Scarlet Fever cases could be admitted. The first case of Diphtheria was received on October 13th, 1894. I have already alluded to the complications connected with Scarlet Fever and Diphtheria. Altogether there have been 80 deaths registered as from Scarlet Fever, but, during the last five years, out of 51 deaths only 9 were certified as from Scarlet Fever alone, the remainder had different complications on admission; 24 had Diphtheria, 4 Rheumatic Fever, 5 Pneumonia, and 9 Brain and other complications. 23 DIPHTHERIA. There have been 177 deaths altogether; the death rate for the various years has been as follows:— 1895 28.8 per cent. 1896 22.6 „ 1897 24.8 „ 1898 19.3 „ 1899 14.8 „ 1900 14.2 „ In 1899, at eight hospitals of the Metropolitan Asylums Board, the average mortality was 15.38. In the years 1888, 1889, 1890, the mortality was much higher, being, in some of the large hospitals of London, over 40 per cent. About the year 1895, the plan of treating the disease with Antitoxin Serum was recommended, and it was in that year that I began to use it, although the great importance of this mode of treatment, and its early commencement, was not then recognised by me, for I find in my report for that year, in some remarks on the case of a child aged 16 months, "Antitoxin was injected the second and third day after admission, on the fourth day there was certainly 24 improvement, on the evening of the fifth day there was a relapse; the report says, "very bad diphtheritic membrane all over the soft palate." Antitoxin was again injected, with decided relief. The child eventually recovered. Having become convinced of the value of the Antitoxin Serum in the treatment, I increased the amount injected, and nearly every case, excepting it was of an exceedingly mild character, was so treated, and a reference to the percentage of deaths in each year is a corroboration of its value. It has, however, become more and more apparent that the earlier the treatment is commenced, the greater the hope of recovery. As shewing the importance of early treatment with antitoxin, I find in the report of the M.A.B. the following:— Mortality of cases treated on the 1st day of disease, 0 0 per cent. „ ,, 2nd ,, 5.09 „ „ „ 3rd ,, 14.38 „ „ „ 4th „ 18.11 „ ,, ,, 5th day and after 22.5 ,, In 1897 and 1898, during the time that Stone-bridge 25 Farm and the new iron buildings were in occupation, there were for a short period altogether 98 cases under treatment at one time, but in my report for 1897 I was able to say, "It was not long, after the increased accommodation enabled me to admit those requiring it, before the disease, Diphtheria, began to decline in the district." The Surveyor was requested to prepare preliminary plans for the permanent enlargement of the hospital. SMALL POX. The isolation of this disease was most beneficial. When I reflect upon the very serious outbreaks that have occurred at different times in other towns, I cannot but think that on two occasions the district has been in great danger of a serious epidemic of this terrible disease. In one instance the disease was undoubtedly brought by a travelling professional pugilist. It quickly spread among those who came in contact with him in his lodgings, but every case on becoming known was immediately removed. In one instance a family of seven were removed from a cottage in an area which has since been condemned as unhealthy; what the possibilities of infection under 26 those circumstances might have been can be readily conceived. There were two deaths and some recoveries from cases which were dreadful to behold during the height of the disease. During the year 1900, the following sums have been received on account of patients from other districts, the weekly charge for such being £3 3s.:— £ s. d. Acton 42 15 0 Wembley 89 2 0 £131 17 0 The average weekly cost for maintenance during the year has been for each patient, 4s. 11d.; for the Staff, 8s. 5¼d. I desire to express my thanks to the Council for the confidence reposed in me during these years. The sole medical charge of such a number of patients has naturally been a most serious responsibility, and one that has caused me, on very many occasions, the greatest anxiety. It is no exaggeration to say that it has been impossible to foretell what a day may bring EXPENSES. 1898. 1899. 1900. £ s. d. £ s. d. £ s. d. Land, Interest, &c. 143 1 11 189 7 4 185 0 8 Buildings 1253 7 1 1221 11 1 1189 14 0 Furniture 118 16 4 118 18 3 118 14 8 1515 5 4 1529 16 8 1493 9 4 Medical Officer 200 0 0 200 0 0 200 0 0 Staff 753 11 4 756 7 6 775 12 0 Provisions 1471 3 11 1461 3 10 1323 5 1 Furniture, including House Linen 92 8 10 62 9 10 113 2 2 Clothing 115 2 2 66 6 6 56 14 1 Necessaries, Household 103 5 3 119 7 7 113 4 3 Repairs 16 10 6 29 9 4 86 19 8 Coals 291 16 0 287 19 4 327 5 0 Gas 126 2 0 128 3 9 132 14 8 Drugs 13 6 6 21 6 9 17 2 0 ,, Antitoxin 25 15 6 28 11 6 28 10 0 Druggist Sundries 102 11 5 86 8 9 78 9 2 Printing and Stationery 34 8 0 29 12 9 19 2 8 Disinfectants 19 5 11 16 9 6 15 16 4 Plants 4 8 6 5 0 0 5 0 0 3369 15 10 3298 16 11 3292 17 1 4885 1 2 4828 13 7 4786 6 5 Wages: Gardener, &c. 88 8 1 66 5 0 66 6 0 Water 122 11 1 99 7 7 40 1 1 Gas Main Rates and Taxes, &c. 59 19 1 157 7 0 104 6 1 Insurance 10 2 2 10 2 2 13 6 2 Sundries 63 13 8 20 8 0 Repairs, Altering Ventilators, &c. 9 9 11 63 19 6 358 8 6* Rent of Land Maintenance of Telephone 23 0 0 50 13 0 20 14 0 Cost of Loan 16 18 6 Making up Roads 71 2 0 Gas at Stonebridge Farm 6 1 3 Advertisements 7 11 0 471 5 9 468 2 3 610 12 10 £5356 6 11 £.5296 15 10 £.5396 19 3 Disinfecting— Forage, Shoeing, &c. 42 16 0 70 8 4 61 10 3 Coachman and helper 36 0 0 41 16 0 64 16 0 Horse Hire 36 6 0 29 8 0 Engineer 29 18 0 31 4 0 32 10 0 Coals and Wood 17 0 0 17 10 8 21 1 6 162 0 0 190 7 0 179 17 9 Ambulance— Forage 21 8 0 35 4 2 30 15 0 Coachman 19 0 0 20 18 0 32 8 0 Ambulance Repairing 16 12 6 Purchase of Horses 33 12 0 71 10 0 74 0 0 144 4 8 63 3 0 *This item includes the expense of painting one of the large blocks and repairs to the roof of the Administration Block. 27 forth, or when an urgent summons might come through the telephone that a patient has to be fetched who, the Doctor has said, would require an operation. The last case of Tracheotomy occurred in the afternoon of the day of the funeral of Her late Majesty, Queen Victoria; very shortly after my return I received the messages; the case was an interesting one, as two days after the operation, the child had a severe attack of Scarlet Fever, but, I am glad to say, made a good recovery. I cannot conclude this report without expressing my obligations and thanks for the ever ready and willing assistance given to me by the staff. Next to myself, the Steward, Mr. Annal, has had the longest connection with the hospital, having been appointed in 1894; I am indebted to him for much clerical help. The Matron, Miss Stripp, was appointed in December, 1896; in the sudden emergencies of Tracheotomy cases she has rendered most effective aid, and inspired the most perfect confidence. She has been of the greatest help, and become a most able assistant in Bacteriological work; has supervised the instruction of Probationers, teaching them to become efficient 28 Nurses, and always shewn in a high degree that she has had the care of the patients, and the interests of the hospital, greatly at heart. The Medical Officer of such an institution can have very little peace with regard to his patients, unless he can feel thorough confidence in his Nurses. To be able to get such a feeling of confidence takes time. To all I desire to express my thanks, but, naturally, feel especially interested in those whose progress and improvement I have watched during 12 months and more, as Probationers, and who, one can see with great pleasure, are becoming well-informed and efficient Nurses. Nurses Duncombe, Cooper and Littleboy, having passed through their two years as Probationers, have remained as Nurses, and given great satisfaction. I have the honour to be, Gentlemen, Your obedient Servant, D. S. SKINNER.