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The dispensary treatment of tuberculosis
THE
PROBLEM
OF TUBERCULOSIS
IN I N D I A
193
after acquiring from the Madras Government some 250 acres of land at Thambaram, situated a few miles from Madras on the slope of the hills, laid out the estate as a garden colony and built on one side a tuberculosis sanatorium, which was opened in April, 1928, by the Right Hon. V, S. Srinivasa Sastry, P.C. Only half the sanatorium, with three wards on each side of the administrative building, quarters for medical officers and nurses, has been built so far and occupied. Each ward has two rooms with verandahs for two patients. When complete there will be six wards for men and six wards for women, besides administrative offices, quarters for visitors, for post-graduate course, etc. But the whole scheme is too big for a private individual to undertake alone, however enthusiastic he may be. Lack of financial help from the Government and t h e Indian public has prevented the writer from putting into operation the full programme as sketched out in the above plan. A f t e r thirty years of sanatorium experience both in England and India he is convinced that such a garden settlement opened in each of the Presidency capitals at first and extended to other parts would go a long way to solve the immense problem of tuberculosis in India.
THE DISPENSARY TREATMENT OF TUBERCULOSIS. BY A. P. F O R D , M.R.C.S., L.R.C.P.~ D.P.H. Tuberculosis Officer, Deputy Medical Officer and School Medical Officer for the County of Hertfordshire.
WHEN discussing the r61e of the dispensary in a tuberculosis scheme it is always necessary to remember that the primary object of all such schemes is to prevent the spread of tuberculosis, and that consequently much of the time of the Tuberculosis Officer must be occupied in the examination of doubtful cases and, as far as possible, of all contacts. These examinations, however, are by no means the only duties t o be performed by the Tuberculosis Officer. If a scheme for dealing with tuberculous cases is to be successful it is essential that all patients suffering from the disease should be kept under constant supervision, and that o v e r s considerable period of time. No matter how conscientious both the patient and the physician may be, it very frequently occurs that unless some form of treatment is also given the patient begins to lose his enthusiasm and ceases to attend at the. dispensary. It is therefore necessary that, viewed from the point of view of prevention,
I94
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
some form of treatment should be provided. This treatment should be much more than merely prescribing cod-liver oil or a creosote mixture. If the dispensary is to maintain its proper place in our tuberculosis scheme, the treatment provided should, whenever possible, be some special form of treatment that the patient cannot readily obtain from his general practitioner. There are many such special forms of treatment which can be carried out at the dispensary. At the moment the three most common are treatment (i) by tuberculin, (2) by the mMntenance of an artificial pneumothorax, and (3) by the administration of sanocrysin. The two latter measures must, of necessity, be commenced in an institution, and it is also often advisable that a patient commencing tuberculin treatment should have the first few doses given in an institution unless the home conditions are particularly favourable. In the carrying out of an artificial pneumothorax and in the administration of tuberculin it is very rarely possible for the patient to remain in a sanatorium for a sufficiently long period to complete the course of treatment and so, by continuing these forms of treatment at the dispensary, they frequently become available to patients who otherwise would not be able to have them. With/. regard to the use of sanocrysin, although it is essential for the patient to remain in an institution until the first course of the treatment is concluded, it is frequently possible to prevent relapse by giving further minute doses at the dispensary at intervals of from four to six weeks. In carrying on this form of treatment, however, arrangements must be made for the urine to be examined for the presence of albumin for a few days before and after the dose is given. Tuberculin treatment must be considered a great asset to the Tuberculosis Officer at the dispensary. Although the results are rarely dramatic, marked improvement is frequently obtained, particularly with children suffering from tuberculosis of the cervical, tracheobronchial, or mesenteric glands. In order to carry out this treatment the patient must be provided with a thermometer and chart and be taught to keep a careful record of his or her own temperature. It is surprising how easily even children can learn to do this. The various tuberculins should be carried in separate bottles in dilutions of I-IO, 1-1o% I-I,OOO and i-io,ooo, so that by means of a small pipette an accurate dose can be made for each patient. Apart from the specific results obtained, the patients having tuberculin treatment always appear to be so much happier than others. They feel that something is being done for them, whereas after a few months of medicinal treatment consumptives and other tuberculous subjects a r e liable to become despondent. Artificial pneumothorax refills can quite easily be given at the dispensary, provided there is a couch available on which the patient
DISPENSARY
TREATMENT
OF TUBERCULOSIS
I95
Can rest after the refill, and that arrangements can be made for an occasional X-ray examination. Most forms of a p p a r a t u s - - e . g . , q Lillingston's and Vere Pear~on s - - c a n be carried by car from one dispensary to another without fear of breakage. B y the foregoing remarks it is not suggested that dispensary treatment can take the place of treatment at the sanatorium, but rather that dispensary treatment should be regarded as an adjunct to sanatorium treatment. , Even the earliest case of tuberculosis requires, on an average, two years of active treatment before it can be considered quiescent ; and it is only in very rare cases that patients are able to remain in an institution for the whole of such a long period. By arranging to continue special forms of treatment after the patient has left the sanatorium it is frequently possible to prevent that " b u g b e a r , of all tuberculosis workers--namely, the " r e t u r n case." On the other hand, it must not be forgotten that dispensary treatment is only applicable to ambulatory cases. Rest is the first essential of all forms of treatment of tuberculosis, and if a patient who should be at rest is encouraged to attend the dispensary in order to obtain some special form of treatment then only harm can result.
A TUBERCULOSIS MUSEUM. By S. H. D A U K E S , O.B.E., M.D,,
D.P.H.,
Director, W e l l e o m e M u s e a m of Medical Science, 33, G ordon Street, L o n d o n , W . C . i ; A u t h o r of " The Medical M u s e u m : Mode rn D e v e l o p m e n t , Organization, and T e c h n i c a l M e t h o d s based on a New S ys t e m o£ V i s ua l T e a c h i n g . "
THe functions of a medical museum are many, and, during recent years, the acknowledged need for instruction of the publlc has increased the educational scope of such museums. It is possible to classify these functions under seven heads: (i) Collection of material; (2) preservation of material; (3)identification of specimens; (4)classification and description; (5)demonstration and display (specific teactiing); (6) research; (7) propaganda (popular education). The relative importance of {hese various objects must naturally depend upon the type of student for whom the museum has been established. Three groups will be especially interested in a museum dealing with the subject of tuberculosis : (I) The tuberculosis expert, whether engaged in clinical or preventive work; ( 2 ) t h e general practitioner; (3) those members of the general public who take a practical interest in preventive medicine or are personally concerned with the disease in their homes. It is obvious that each of these groups will demand a different type
PROBLEM
OF TUBERCULOSIS
IN I N D I A
193
after acquiring from the Madras Government some 250 acres of land at Thambaram, situated a few miles from Madras on the slope of the hills, laid out the estate as a garden colony and built on one side a tuberculosis sanatorium, which was opened in April, 1928, by the Right Hon. V, S. Srinivasa Sastry, P.C. Only half the sanatorium, with three wards on each side of the administrative building, quarters for medical officers and nurses, has been built so far and occupied. Each ward has two rooms with verandahs for two patients. When complete there will be six wards for men and six wards for women, besides administrative offices, quarters for visitors, for post-graduate course, etc. But the whole scheme is too big for a private individual to undertake alone, however enthusiastic he may be. Lack of financial help from the Government and t h e Indian public has prevented the writer from putting into operation the full programme as sketched out in the above plan. A f t e r thirty years of sanatorium experience both in England and India he is convinced that such a garden settlement opened in each of the Presidency capitals at first and extended to other parts would go a long way to solve the immense problem of tuberculosis in India.
THE DISPENSARY TREATMENT OF TUBERCULOSIS. BY A. P. F O R D , M.R.C.S., L.R.C.P.~ D.P.H. Tuberculosis Officer, Deputy Medical Officer and School Medical Officer for the County of Hertfordshire.
WHEN discussing the r61e of the dispensary in a tuberculosis scheme it is always necessary to remember that the primary object of all such schemes is to prevent the spread of tuberculosis, and that consequently much of the time of the Tuberculosis Officer must be occupied in the examination of doubtful cases and, as far as possible, of all contacts. These examinations, however, are by no means the only duties t o be performed by the Tuberculosis Officer. If a scheme for dealing with tuberculous cases is to be successful it is essential that all patients suffering from the disease should be kept under constant supervision, and that o v e r s considerable period of time. No matter how conscientious both the patient and the physician may be, it very frequently occurs that unless some form of treatment is also given the patient begins to lose his enthusiasm and ceases to attend at the. dispensary. It is therefore necessary that, viewed from the point of view of prevention,
I94
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
some form of treatment should be provided. This treatment should be much more than merely prescribing cod-liver oil or a creosote mixture. If the dispensary is to maintain its proper place in our tuberculosis scheme, the treatment provided should, whenever possible, be some special form of treatment that the patient cannot readily obtain from his general practitioner. There are many such special forms of treatment which can be carried out at the dispensary. At the moment the three most common are treatment (i) by tuberculin, (2) by the mMntenance of an artificial pneumothorax, and (3) by the administration of sanocrysin. The two latter measures must, of necessity, be commenced in an institution, and it is also often advisable that a patient commencing tuberculin treatment should have the first few doses given in an institution unless the home conditions are particularly favourable. In the carrying out of an artificial pneumothorax and in the administration of tuberculin it is very rarely possible for the patient to remain in a sanatorium for a sufficiently long period to complete the course of treatment and so, by continuing these forms of treatment at the dispensary, they frequently become available to patients who otherwise would not be able to have them. With/. regard to the use of sanocrysin, although it is essential for the patient to remain in an institution until the first course of the treatment is concluded, it is frequently possible to prevent relapse by giving further minute doses at the dispensary at intervals of from four to six weeks. In carrying on this form of treatment, however, arrangements must be made for the urine to be examined for the presence of albumin for a few days before and after the dose is given. Tuberculin treatment must be considered a great asset to the Tuberculosis Officer at the dispensary. Although the results are rarely dramatic, marked improvement is frequently obtained, particularly with children suffering from tuberculosis of the cervical, tracheobronchial, or mesenteric glands. In order to carry out this treatment the patient must be provided with a thermometer and chart and be taught to keep a careful record of his or her own temperature. It is surprising how easily even children can learn to do this. The various tuberculins should be carried in separate bottles in dilutions of I-IO, 1-1o% I-I,OOO and i-io,ooo, so that by means of a small pipette an accurate dose can be made for each patient. Apart from the specific results obtained, the patients having tuberculin treatment always appear to be so much happier than others. They feel that something is being done for them, whereas after a few months of medicinal treatment consumptives and other tuberculous subjects a r e liable to become despondent. Artificial pneumothorax refills can quite easily be given at the dispensary, provided there is a couch available on which the patient
DISPENSARY
TREATMENT
OF TUBERCULOSIS
I95
Can rest after the refill, and that arrangements can be made for an occasional X-ray examination. Most forms of a p p a r a t u s - - e . g . , q Lillingston's and Vere Pear~on s - - c a n be carried by car from one dispensary to another without fear of breakage. B y the foregoing remarks it is not suggested that dispensary treatment can take the place of treatment at the sanatorium, but rather that dispensary treatment should be regarded as an adjunct to sanatorium treatment. , Even the earliest case of tuberculosis requires, on an average, two years of active treatment before it can be considered quiescent ; and it is only in very rare cases that patients are able to remain in an institution for the whole of such a long period. By arranging to continue special forms of treatment after the patient has left the sanatorium it is frequently possible to prevent that " b u g b e a r , of all tuberculosis workers--namely, the " r e t u r n case." On the other hand, it must not be forgotten that dispensary treatment is only applicable to ambulatory cases. Rest is the first essential of all forms of treatment of tuberculosis, and if a patient who should be at rest is encouraged to attend the dispensary in order to obtain some special form of treatment then only harm can result.
A TUBERCULOSIS MUSEUM. By S. H. D A U K E S , O.B.E., M.D,,
D.P.H.,
Director, W e l l e o m e M u s e a m of Medical Science, 33, G ordon Street, L o n d o n , W . C . i ; A u t h o r of " The Medical M u s e u m : Mode rn D e v e l o p m e n t , Organization, and T e c h n i c a l M e t h o d s based on a New S ys t e m o£ V i s ua l T e a c h i n g . "
THe functions of a medical museum are many, and, during recent years, the acknowledged need for instruction of the publlc has increased the educational scope of such museums. It is possible to classify these functions under seven heads: (i) Collection of material; (2) preservation of material; (3)identification of specimens; (4)classification and description; (5)demonstration and display (specific teactiing); (6) research; (7) propaganda (popular education). The relative importance of {hese various objects must naturally depend upon the type of student for whom the museum has been established. Three groups will be especially interested in a museum dealing with the subject of tuberculosis : (I) The tuberculosis expert, whether engaged in clinical or preventive work; ( 2 ) t h e general practitioner; (3) those members of the general public who take a practical interest in preventive medicine or are personally concerned with the disease in their homes. It is obvious that each of these groups will demand a different type