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A note on twenty-three years' sanatorium administration
~15·1
[July, 1937
TUBERCLE
whom a virulent human or bovine bacillus may give rise to any form of disease from a completely latent infection on the one hand to a fulminating miliary tuberculosis on the other. We arc indebted to the Medical Research Council for a grant in aid of this work. HEFERENCES. DOERR,
R., and
GOLD,
E.
Z. IIIl/ILlIIzjorsch., 1932, 74, 7.
LAXGE, B. Z. HYG. Injektkr.• 1922, 98, 229. SCHWAIlACHEH. H. Tubercle, 1937, 18, 199. W A)IOSCHER, L.. and STOECKLIX, II. ZhZ. WILSON,
G.
S.,
and
SCHWABACIIEH,
H.
Bakt., 1927, 104, Boiheft, p. 8G. 1'uuel'cZe, 1937, 18, 161.
A NOTE ON TWENTY-THREE YEARS' SANATORIUM ADMINISTRATION. l By ESTHER
CAHLING,
M.D.,
COllsulta1lt J.Vcclical Officcr. Berks alld Bucks Joi1lt Sanatoriulll, Pcppard C01/1II101l.
As, it does not fall to my lot to write the :i\Iedical Report this year I should like to refer to a few points which have a bearing on the general development of the Sanatorium rather than the immediate period· under consideration. Looking back over the twenty-three years of the Joint Committee's administration one sees that a profound change has come about. The great hopefulness, the feeling that tuberculosis was a foe to be conquered, has given way to the acceptance of a burden on the community at large and to the organisation of a machine to cope with it. Statistically we know tuberculosis is declining but sanatorium workers find this hard to realise. To them the" up-patient" has been replaced by the "bed-patient" and they look round in vain for the garden gang, the tray carriers, the sing-song parties of former days. Cheerfulness and high spirits still exist but they are found at the bedside and not at the carpenter's bench. 'Vhat actually has happened? Are figures or feeli"ngs to be trusted? Perhaps the change in local government policy accounts for a good deal of the discrepancy. The old workhouse infirmary has shifted its responsibility for the care of the homeless or dying tuberculous invalid to the "Sanatorium," which now in name alone resembles its prototype of earlier days. I This paper forllls par~ of the anllualrepor~ of the Berks and J3ucks Joint Sanatorium which was taken over from Dr. Esther Carling's privately owned Sanatorium in 1914 by the two named County Councils. As the .. ~Iaitland Cottage Sanatoriulll " the institution had been started in 1899 and was one of the fir~t worldng class sanatoria to be established in this countrJ·•
July, 1937]
SANATOIUUM
AD)IINlSTRATIO~
455
Here, at Peppard, it is still true however, that a proportion of early cases are admitted. Unfortunately they arc not the ones who stay longest. Their own mge to depart from the depressing companionship of the acutely ill is backed by the constant need to find beds for others. r!'he homeless cannot be discharged, and so at times newcomers have to enter at the expense of those who have homes even if they have not obtained the full benefit of a prolonged stay. Only by an increased number of beds can such a difliculty be overcome. Buildings have indeed been adapted to meet the altered needs. The open-~ir shelter has given way to the warmed small ward, a policy which has tended to contraet rather than expand numbers. " Extras" can less readily be accommodated if a solid building is the standard accommodation. Only large units can offer good grading facilities for patients. Here, since the earliest days, the occupation of patients has been an integral part of treatment. Probably no sanatorium committee has so generously provided instructors or built up a more careful scheme of varied interests. The" structure" remains but the available people to profit by it have largely vanished. The urgency of caring for the ill and homeless dominates the situation. This is not the only change: there is an altered outlook in regard to work as a factor of treatment. " Rest" has replaced" graduated exercise" and in addition there has been added the attempt to rest the lung locally by smgical means (artificial pneumothorax or other operative measures) . Hospitalisation, whether by necessity because of advanced disease, or by choice as the preferred mode of treatment, has tended to replace the whole idea of sanatorium life as a training ground for the resumption of working conditions. In this connection it is interesting to remember that tbe old ideal of the "tuberculosis colony" still claims very notable adherents. Certain successful examples are more than ever in the public eye. Indeed it would not be too much to say that in the view of many foreigners, of some industrial magnates or of Royal personages, those celebrated colonies represent the peak of this country's achievement as regards the problem of tuberculosis. Yet they remain isolated enterprises, the attempt to reproduce them as part of a general scheme has never materialised. The country as a wbole provides county and borough units of either hospital or sanatorium type. In these treatment is given for a few weeks or months and then no further residential treatment is available till a " breakdown" occurs and re-admission is advised. Nothing bridges the gap between the hospital of to-day and the resumption of industrial life. The idea of preparation by " graduated work" has fa"ded out. Can the nation really do no more than this '? Is there no half-way house between the heavily subsidised voluntary" colony" and the state provided sanatorium? The difficulty of providing sheltered employment on a large scale for sub-standard workers is very great, but if every tuberculosis institution took a small part and made a point of recruiting its employees from its ex-
456
TUDERCI,E
[July, 1937
patients a more hopeful and purposeful spirit could surely be recaptured. Part-time employment leading up to full service is the root idea of the Colony a_nd the possibility of its successful application to smaller units has again and again been demonstrated in this place. During its twenty-three years of work the Joint Committee has taken many risks in employing ex-patients. These risks have been converted lllto opportunities with repeatedly happy results. 1'0 use a recent simile of the Chancellor of the Exchequer such action has changed "Bleak House" into "Great Expectations" and it has done even more. Apart from and beyond the personal issue to the individual who has been helped, hope has been engendered in other lives which were still in the" Bleak House" of a broken existence. At the present time nine out of twenty-four nurseR have been patients themselves here or elsewhere. This is not a dramatic contribution to u. national problem but in its small way it represents a steady effort to get people back to work; over many years an attempt has been made to offer ex-patients such a chance and at times as many as one-third of the regular staff have been so recruited. Has the 'Sanatorium lost or gained by this policy-should it be looked upon as an extravagance or an economy, should it be encouraged or disparaged? As regards nurses it may be stated that the difficulty of recruitment by other means has often led to the appointment of an ex-patient. The advertisement of vacancies is unfruitful: often the only applicants are those with a tuberculous history. '1'he difficulty here has always been to attract nurses, not to keep them. There has been no reason to complain of the services rendered by the tuberculous. Steady work for thirty years in one case, for twenty-three years in another, for thirteen and seven in two other instances, are records of people on our nursing staff to-day. 1'here h3:ve been occasional periods of sickness but the Committee's scale of sick leave has usually covered the case and there have been few instances of special consideration; whenever sickness has occurred either in those with a- tuberculosis background or others it has been customary to make temporary replacements from outside. 1'his practice has prevented overpressure and has probably helped greatly to maintain a high health average among members of the staff. Amid the disappointments and disillusionments of work in tuberculosis the chief and steadiest satisfaction has been found in the colleagues who have been" restored to welfare and to work" through coming here for treatment. Should it be possible to extend such opportunities the Committee would not only contribute its quota to a national problem, it would undoubtedly reap its own benefit in the quality of loyal and grateful service it would acquire. Apart from the employment of ex-patients the stafling of a tuberculosis institution becomes year by year a more dillicult probl~m. Parents are increasingly averse to allowing sons or daughters (especially daughters) to work in such environment. Lately it ,vas found that even outside painters are" afraid." Service in hospitals everywhere requires a good deal of
July, 1937J
SANATORIU:.r ADlilNISTRATIO!\
reconditioning but nowhere is the need so urgent as in tuberculosis units. The general causes-operating particularly as regards nursing and domestic staffs-have to do with "living in," unfavourable hours, separation from family life, &c. 'Vhen to these is added the thought of possible risk of infection the need of employment must be acute to attract people to serve in tuberculosis hospitals, unless some local allurement turns the scale. In as far as the difticulty can be met by the employment of ex-patients it is obviously wise to do so. There ,,-ill come the further difliculty of " mixing" the tuberculous and non-tuberculous, but appropriate quarters and good handling can often avert trouble in this respect. 'rhe paramount consideration is the realisation of the human interests of the community's life. Staff and patients alike respond readily to discipline or limitations which are understood and accepted even if not at first attractive. It is interesting to note that, so far, there has never been any real difficulty to attract or retain a suitable staff of men workers here: Indeed, the usual field of women's labour has been encroached, for the kitchen has been staffed by lllen for many years, while male nursing orderlies and house porters have served the men patients, and recently even the children's block and the staff house have been partly staffed by men. Their" hours" have remained on the usual scale for lllen workers, but the scale for women has not been commensurately reduced. It seems unlikely that domestic or nursing shortage will be adjusted until the conditions that obtain in shops, factories and offices are introduced generally into hospital and other forms of community life. Such change is bound to come: is it better to be first in the field or lag behind '? Reasonable consideration has always been accorded to staffing problems here as they have arisen. Pel'haps an added touch of pioneering in the days ahead may solve internal difficulty and contribute to general hospital adjustment. 'l'he ne.r;t twenty-three years may record the results of many interesting experiments. Staff' and patients must ever form one whole, the welfare of the one is the ,vel fare of the other. It may not be possible to give in full measure to patients the renewed health they seek and crave; .it will always be the happiness and privilege of the workers to supply as substitutes support and comfort.
[July, 1937
TUBERCLE
whom a virulent human or bovine bacillus may give rise to any form of disease from a completely latent infection on the one hand to a fulminating miliary tuberculosis on the other. We arc indebted to the Medical Research Council for a grant in aid of this work. HEFERENCES. DOERR,
R., and
GOLD,
E.
Z. IIIl/ILlIIzjorsch., 1932, 74, 7.
LAXGE, B. Z. HYG. Injektkr.• 1922, 98, 229. SCHWAIlACHEH. H. Tubercle, 1937, 18, 199. W A)IOSCHER, L.. and STOECKLIX, II. ZhZ. WILSON,
G.
S.,
and
SCHWABACIIEH,
H.
Bakt., 1927, 104, Boiheft, p. 8G. 1'uuel'cZe, 1937, 18, 161.
A NOTE ON TWENTY-THREE YEARS' SANATORIUM ADMINISTRATION. l By ESTHER
CAHLING,
M.D.,
COllsulta1lt J.Vcclical Officcr. Berks alld Bucks Joi1lt Sanatoriulll, Pcppard C01/1II101l.
As, it does not fall to my lot to write the :i\Iedical Report this year I should like to refer to a few points which have a bearing on the general development of the Sanatorium rather than the immediate period· under consideration. Looking back over the twenty-three years of the Joint Committee's administration one sees that a profound change has come about. The great hopefulness, the feeling that tuberculosis was a foe to be conquered, has given way to the acceptance of a burden on the community at large and to the organisation of a machine to cope with it. Statistically we know tuberculosis is declining but sanatorium workers find this hard to realise. To them the" up-patient" has been replaced by the "bed-patient" and they look round in vain for the garden gang, the tray carriers, the sing-song parties of former days. Cheerfulness and high spirits still exist but they are found at the bedside and not at the carpenter's bench. 'Vhat actually has happened? Are figures or feeli"ngs to be trusted? Perhaps the change in local government policy accounts for a good deal of the discrepancy. The old workhouse infirmary has shifted its responsibility for the care of the homeless or dying tuberculous invalid to the "Sanatorium," which now in name alone resembles its prototype of earlier days. I This paper forllls par~ of the anllualrepor~ of the Berks and J3ucks Joint Sanatorium which was taken over from Dr. Esther Carling's privately owned Sanatorium in 1914 by the two named County Councils. As the .. ~Iaitland Cottage Sanatoriulll " the institution had been started in 1899 and was one of the fir~t worldng class sanatoria to be established in this countrJ·•
July, 1937]
SANATOIUUM
AD)IINlSTRATIO~
455
Here, at Peppard, it is still true however, that a proportion of early cases are admitted. Unfortunately they arc not the ones who stay longest. Their own mge to depart from the depressing companionship of the acutely ill is backed by the constant need to find beds for others. r!'he homeless cannot be discharged, and so at times newcomers have to enter at the expense of those who have homes even if they have not obtained the full benefit of a prolonged stay. Only by an increased number of beds can such a difliculty be overcome. Buildings have indeed been adapted to meet the altered needs. The open-~ir shelter has given way to the warmed small ward, a policy which has tended to contraet rather than expand numbers. " Extras" can less readily be accommodated if a solid building is the standard accommodation. Only large units can offer good grading facilities for patients. Here, since the earliest days, the occupation of patients has been an integral part of treatment. Probably no sanatorium committee has so generously provided instructors or built up a more careful scheme of varied interests. The" structure" remains but the available people to profit by it have largely vanished. The urgency of caring for the ill and homeless dominates the situation. This is not the only change: there is an altered outlook in regard to work as a factor of treatment. " Rest" has replaced" graduated exercise" and in addition there has been added the attempt to rest the lung locally by smgical means (artificial pneumothorax or other operative measures) . Hospitalisation, whether by necessity because of advanced disease, or by choice as the preferred mode of treatment, has tended to replace the whole idea of sanatorium life as a training ground for the resumption of working conditions. In this connection it is interesting to remember that tbe old ideal of the "tuberculosis colony" still claims very notable adherents. Certain successful examples are more than ever in the public eye. Indeed it would not be too much to say that in the view of many foreigners, of some industrial magnates or of Royal personages, those celebrated colonies represent the peak of this country's achievement as regards the problem of tuberculosis. Yet they remain isolated enterprises, the attempt to reproduce them as part of a general scheme has never materialised. The country as a wbole provides county and borough units of either hospital or sanatorium type. In these treatment is given for a few weeks or months and then no further residential treatment is available till a " breakdown" occurs and re-admission is advised. Nothing bridges the gap between the hospital of to-day and the resumption of industrial life. The idea of preparation by " graduated work" has fa"ded out. Can the nation really do no more than this '? Is there no half-way house between the heavily subsidised voluntary" colony" and the state provided sanatorium? The difficulty of providing sheltered employment on a large scale for sub-standard workers is very great, but if every tuberculosis institution took a small part and made a point of recruiting its employees from its ex-
456
TUDERCI,E
[July, 1937
patients a more hopeful and purposeful spirit could surely be recaptured. Part-time employment leading up to full service is the root idea of the Colony a_nd the possibility of its successful application to smaller units has again and again been demonstrated in this place. During its twenty-three years of work the Joint Committee has taken many risks in employing ex-patients. These risks have been converted lllto opportunities with repeatedly happy results. 1'0 use a recent simile of the Chancellor of the Exchequer such action has changed "Bleak House" into "Great Expectations" and it has done even more. Apart from and beyond the personal issue to the individual who has been helped, hope has been engendered in other lives which were still in the" Bleak House" of a broken existence. At the present time nine out of twenty-four nurseR have been patients themselves here or elsewhere. This is not a dramatic contribution to u. national problem but in its small way it represents a steady effort to get people back to work; over many years an attempt has been made to offer ex-patients such a chance and at times as many as one-third of the regular staff have been so recruited. Has the 'Sanatorium lost or gained by this policy-should it be looked upon as an extravagance or an economy, should it be encouraged or disparaged? As regards nurses it may be stated that the difficulty of recruitment by other means has often led to the appointment of an ex-patient. The advertisement of vacancies is unfruitful: often the only applicants are those with a tuberculous history. '1'he difficulty here has always been to attract nurses, not to keep them. There has been no reason to complain of the services rendered by the tuberculous. Steady work for thirty years in one case, for twenty-three years in another, for thirteen and seven in two other instances, are records of people on our nursing staff to-day. 1'here h3:ve been occasional periods of sickness but the Committee's scale of sick leave has usually covered the case and there have been few instances of special consideration; whenever sickness has occurred either in those with a- tuberculosis background or others it has been customary to make temporary replacements from outside. 1'his practice has prevented overpressure and has probably helped greatly to maintain a high health average among members of the staff. Amid the disappointments and disillusionments of work in tuberculosis the chief and steadiest satisfaction has been found in the colleagues who have been" restored to welfare and to work" through coming here for treatment. Should it be possible to extend such opportunities the Committee would not only contribute its quota to a national problem, it would undoubtedly reap its own benefit in the quality of loyal and grateful service it would acquire. Apart from the employment of ex-patients the stafling of a tuberculosis institution becomes year by year a more dillicult probl~m. Parents are increasingly averse to allowing sons or daughters (especially daughters) to work in such environment. Lately it ,vas found that even outside painters are" afraid." Service in hospitals everywhere requires a good deal of
July, 1937J
SANATORIU:.r ADlilNISTRATIO!\
reconditioning but nowhere is the need so urgent as in tuberculosis units. The general causes-operating particularly as regards nursing and domestic staffs-have to do with "living in," unfavourable hours, separation from family life, &c. 'Vhen to these is added the thought of possible risk of infection the need of employment must be acute to attract people to serve in tuberculosis hospitals, unless some local allurement turns the scale. In as far as the difticulty can be met by the employment of ex-patients it is obviously wise to do so. There ,,-ill come the further difliculty of " mixing" the tuberculous and non-tuberculous, but appropriate quarters and good handling can often avert trouble in this respect. 'rhe paramount consideration is the realisation of the human interests of the community's life. Staff and patients alike respond readily to discipline or limitations which are understood and accepted even if not at first attractive. It is interesting to note that, so far, there has never been any real difficulty to attract or retain a suitable staff of men workers here: Indeed, the usual field of women's labour has been encroached, for the kitchen has been staffed by lllen for many years, while male nursing orderlies and house porters have served the men patients, and recently even the children's block and the staff house have been partly staffed by men. Their" hours" have remained on the usual scale for lllen workers, but the scale for women has not been commensurately reduced. It seems unlikely that domestic or nursing shortage will be adjusted until the conditions that obtain in shops, factories and offices are introduced generally into hospital and other forms of community life. Such change is bound to come: is it better to be first in the field or lag behind '? Reasonable consideration has always been accorded to staffing problems here as they have arisen. Pel'haps an added touch of pioneering in the days ahead may solve internal difficulty and contribute to general hospital adjustment. 'l'he ne.r;t twenty-three years may record the results of many interesting experiments. Staff' and patients must ever form one whole, the welfare of the one is the ,vel fare of the other. It may not be possible to give in full measure to patients the renewed health they seek and crave; .it will always be the happiness and privilege of the workers to supply as substitutes support and comfort.