Children in secondary schools receive fuller medical attention than those in elementary schools .sx All forms of treatment available for elementary school children , except dental treatment in Liverpool , are also available for secondary schools children ; while routine inspections are more frequent .sx In elementary schools the children are inspected on an average once in three years .sx In secondary schools , on the other hand , inspections occur annually in Liverpool , Birkenhead , and Wallasey ; and biennially in Bootle .sx In one respect only are secondary school children less well cared for than elementary school children ; there is no dental inspection in secondary schools in any of the four boroughs .sx It is apparent from Table IX which shows the percentage of children found defective at inspections in secondary schools that similar discrepancies in the standard of ascertainment prevail .sx Statistics of defects found at inspections , as we have seen , yield little information regarding the health of the school child .sx In the case of children in elementary schools , however , light is thrown by the mortality statistics published by the Registrar-General .sx Table X shows the mortality among children of what is roughly the elementary school age group in three recent census years ; and though Merseyside still has much leeway to make up , it is at once apparent how great an improvement has been witness since the first decade of this century .sx TUBERCULOSIS .sx Tuberculosis is a disease which presents a local health authority with a difficult problem .sx It is an infectious disease , and to trace the source of the infection is , therefore , a matter of the first importance ; yet in its early stages the symptoms are often unrecognized .sx Generally speaking prolonged and expensive treatment is necessary if a cure is to be effected ; while the benefits of such treatment are rendered largely nugatory if there is no adequate provision for after-care and if the patient , on leaving the sanatorium , returns to just those conditions of housing and want of proper food and fresh air in which he contracted the disease .sx In these circumstances Parliament has rightly made tuberculosis a notifiable disease .sx Table XI shows the number of cases notified in each Merseyside borough in 1931 , and also the number of notifications per 10,000 of the population .sx Each borough has a dispensary or dispensaries for dealing with tuberculous cases , and the table also shows the number of persons on the dispensary register ( that is the number of persons attending the dispensary ) in each borough at the end of the year .sx A comparison of this figure with the number of notifications during the year might suggest that there are not enough centres to cope with the work in Liverpool .sx The explanation is that in Liverpool a somewhat different function is assigned to the dispensary , which is used mainly for the diagnosis of new cases and not for the medical supervision of patients .sx Medical supervision is entrusted to private practitioners at a cost of some 7,500 a year to the City Council .sx From the dispensary patients are referred to various institutions according to the form which the disease has taken and the stage which it has reached .sx Thus in Liverpool there are two sanatoria with accommodation for patients of all ages , one poor law hospital with wards for adult pulmonary cases unsuitable for the sanatorium treatment , one children's hospital under the Public Health Act xxxxx tuberculosis in children , and beds in the Liverpool Consumption Hospital at Delamere in Cheshire .sx Owing to the way in which the accommodation is thus scattered between a number of different institutions , it is impossible to gauge the adequacy of hospital and sanatorium provision in the different boroughs .sx A very rough estimate gives 1,000 beds in Liverpool , 150 in Birkenhead , and 100 each in Wallasey and Bootle .sx If this figure is at all near the mark , it means that there is institutional accommodation sufficient to provide a treatment of some four to five months' duration for every notified patient in Liverpool , Birkenhead , and Bootle .sx In Wallasey , on the other hand , it would appear that a treatment of something like double that length could be provided .sx But this is to leave out of account the quality of the provision ; and in Birkenhead and Bootle we find that there is no provision at all for adult , non-pulmonary cases or for child pulmonary cases , in Wallasey no provision for adult non-pulmonary cases .sx The importance of after-care has already been stressed ; yet we find that the very large sums of money that are spent in providing costly institutional treatment are largely thrown away through fear of incurring the still larger sums that would be involved by the provision of a proper environment for ex-sanatorium cases .sx Except in Liverpool , aftercare is confined to the visiting of such cases by the health nurses .sx In Liverpool domiciliary nursing is undertaken by the Queen Victoria District Nursing Association , which receives a grant for this purpose from the City Council , though only 312 cases were nursed by this body in 1931 .sx Ex-patients are also attended by medical practitioners in Liverpool .sx It might be thought that the success of this service could be judged by the number of persons remaining on the notification register .sx But the difficulty of writing cases off as cured , even after the disappearance of any signs of active disease , leads different authorities to adopt different policies in this regard .sx We are thus confronted once more with the kind of difficulty already met with in the case of the school medical service .sx But here again we can fall back upon mortality statistics ; and it is satisfactory to find from the figures given in Table XII that the last twenty years have seen a decline in mortality from tubercular diseases at least as raid as the decline in mortality from all other causes .sx HOSPITAL PROVISION .sx The greatest importance attaches to this aspect of the health services .sx To the well-to-do member of the upper or middle classes a hospital or nursing home is simply a place where he receives residential treatment for a fee .sx To the insured or non-insured worker and his dependents , on the other hand , it plays in addition the part of Harley Street in London and of Rodney Street on Merseyside .sx There alone are to be had on terms that are within their reach those specialist and consultant services which are an essential part of " personal " medical attention .sx It is possible to add up the number of beds in Merseyside hospitals and sanatoria and thus to gauge the amount of residential accommodation available in each area .sx This is done in Table XIII ; but too much significance should not be attached to the individual figures .sx In theory the municipal hospitals are distributed among the four county boroughs ; but in practice this is hardly so .sx It would be equally correct , and perhaps equally misleading , to speak of Liverpool and Bootle as one hospital authority and Birkenhead and Wallasey as another .sx Until 1929 the largest public hospitals were administered by the Guardians , and though they have since been transferred to the health authorities within whose boundaries they happened to be situated , the services they render are still to some extent pooled among all the constituent authorities of each poor law union .sx Thus Walton , the largest hospital on Merseyside , was the principal institution of the old West Derby Union .sx It is now transferred to Liverpool City Council ; but Bootle , as a constituent of that Union , has a claim upon the accommodation provided , and in computing the number of hospital beds available in Bootle allowance should be made for this fact .sx In looking at the type of accommodation in the hospitals somewhat similar considerations have to be borne in mind .sx In a general hospital the allocation of beds and wards between different diseases and conditions is not fixed and unalterable .sx Indeed it would be most undesirable if it were so , and the opinion is now rapidly gaining ground that in the past there was too much rigidity and specialization .sx Again , it is by no means always a retrograde step actually to reduce the number of beds in hospital .sx Misguided enthusiasm has sometimes led to such an overcrowding of wards that good management is impaired and the conditions most favourable to the quick recovery of patients are not attained .sx Lastly , the adequacy of the in-patient accommodation in a hospital is profoundly affected by the number and qualifications of the doctors attached to it .sx The more numerous and the more expert is the medical staff , the more rapidly will the patient's condition be correctly diagnosed and the appropriate treatment begun .sx For this reason the figure for the number of in-patients treated per annum , were it obtainable , would furnish a far better index of hospital .sx " capacity " than the mere number of beds provided .sx In the twenty-two hospitals associated with the Merseyside Hospitals Council some 35,000 new in-patients were admitted during 1931 , and though only a rough estimate of the total annual turnover in all Merseyside hospitals is possible , it is probable that it falls little if at all short of 100,000 .sx To estimate the capacity of the hospitals to provide consultant and specialist advice is a matter of equal difficulty ; but it is of interest to find that the out-patient departments of the same twenty-two voluntary hospitals dealt with no less than 222,688 new out-patient cases in 1931 , or rather more than six times the number of new in-patients admitted .sx How are these services provided ?sx The growth of the hospitals has been little less haphazard than that of the specific xxxxx during a serious illness were nursed and cared for in their homes .sx Now they enter private nursing homes ; and it is not for them that the hospitals , either " voluntary " or municipal , have been built .sx The voluntary hospitals , which began to be founded after the dissolution of the monasteries , were intended to provide residential accommodation for those who could not afford to be nursed at home .sx The poor law hospitals represent an adaptation of the general mixed workhouse to meet the special needs of the sick poor .sx Not altogether dissimilar from the voluntary hospitals in their origin , they have come to resemble them more closely with the passage of time .sx Like the voluntary hospitals they have added out-patient departments to their in-patient wards ; while the very wide definition of " destitution " already referred to , which has been countenanced by the Local Government Board and the Ministry since the beginning of the present century , has enabled them to spread their net far beyond the category of those who are classed in common speech as destitute , and since 1930 the Public Assistance Order of that year has expressly legalized the practice of admitting private patients .sx The remaining municipal hospitals trace their origin either to the realization in the latter part of the last century of the need for segregating infectious cases , or , as in the case of maternity homes and tuberculosis sanatoria , to the still more recent growth of the special services .sx The earliest hospitals were strictly charitable foundations ; and though the accommodation in municipal hospitals now exceeds that in voluntary hospitals , nevertheless the lines along which the hospital services have evolved have been largely determined by the charitable conceptions out of which they were born .sx The voluntary hospitals were founded and are partly maintained out of funds derived from private subscriptions and bequests ; the municipal hospitals are dependent in a similar way upon grants from the rate funds of the various local authorities .sx But all alike make a point of recovering from the patient so much of the cost of treatment and maintenance as it is within his means to pay .sx It would have been possible to finance the provision of hospital services by means of insurance schemes , either statutory or voluntary ; and in the sickness benefit given un the National Health Insurance Act we may perhaps discern the beginnings of a statutory scheme of this kind .sx But alongside this statutory scheme there have sprung up in recent years a number of voluntary insurance schemes of varying character , among which the Merseyside " Penny in the Pound " Fund is one of the most interesting examples .sx ( 2031 ) .sx