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Irregular discharges
july
152
1949
Irregular Discharges BY GEORGE DAY
Mundesley Sanatorium Once again our American colleague~ are showang grave concern at the high number of their tuberculous ex-Serwce men who discharge themselves from hospitals and sanatoria against their doctors' advice Between J u l y i946 and J u n e I947, nearly 6,0oo tuberculous veterans 'walked out on their treatment' as against fewer than 5,ooo who stayed the course This rate of 54 4 per cent Irregular discharges, moreover, is the lowest since the b e g m n m g of World War II In ~945 it reached 7~ 5 per cent In a pamphlet, 'Irregular Discharge', ~ssued by the Veterans Administration, U S A , are g~ver~ not onlv these facts and figures but also a painstaking rewew of the whole problem fiom every point of wow, social, economic and psychological The basic (alleged) causes of self-discharge are analysed and the valise of suggested preventative measures are consldezed The mere fact that the patients under d~scusslon are exSerwce men does not explain the h~g'h figure Men who had once subjected themselves to some sort of d~sc~phne m~ght be expected to accept the new dIsc~phne of tuberculosis more readily than c~whans w~thout that experience T h e p~oblem ~s nation-wide Klotz [~] found that durmg ~9e3 7t per cent of d~scharges among all classes of patient (men, women and children, eoloured and white) from the Tennessee National Sanatorture were '~rregular', and during I933, according to Whitney and Dempsey [ ~ , of 6,906 patients discharged ahve from 75 pubhc sanatoria m r6 States, at least 3~ per cent went w~thout their doctors' consent In Great Britain the irregular d~schargerate has never presented a sel~ous problem Not yet H o w can we make sure ~t never w~ll~ What can we learn from these American revelat]ons~ Appendix 'D' hsts all the hospitals and sanatoria w~th their annual turnover of tuberculous veterans and the:r percentages of
self-discharges The latter figule ranges from o o per cent (Phoemx) to 7~ 3 per cent (Fort Bayard) Why do some sanatoria have less difficulty in retalmng their patients than othersP Further study reveals that hospltal~ and sanatolla with an annual turnover of fewer than IOO tuberculous patients have an average I D rate of only ~5 per cent in comparison w~th the average of nearly 5 ~ per cent shown by estabhshments with a turn over of between 25o and 650 patients This accords w~th our own expectation that the larger the institution the greater is apt to be the amount ofreglmentat~on and the less the personal attention received by the mdlvtdual In the smaller estabhshments everybody knows everybody else The doctors know all the patients personally, and the patients know all the doctors, all the members of the nursing and domestic staff and most of the other patients Such a gloup possesses unity and morale Not that st does not have ]ts 'problem cases', but these cases ~mpmge on (he group as a whole, and the group can usually deal with them effectively Every sanatormm phys~clan ]s acquainted with the umntelhgent unco-operatlve patient, con stltutlonally unable to take a long wow of his dlness, with a psychopathm disregard not only for his own health but fol the health of his family, with the emotionally immature 'rebel' who flaunts all authollty and restrlc t~ons, with the 'barrack room lawyer' In a small estabhshment this sort of patient crops up from time to tnne, but being a sohtaly cxceptlon he cuts no ice and lacks the stablhty to dlsrupt the general mora]e He is regarded by his fellow-patients as a menace, and a general mgh of 1chef is heal d when he depalts without benefit of physicians He never heads a mass exodus Double, treble or quadruple the size of the estabhshment and the 'misfits' are multtphed paT z passl~ And when three or four such pattents get together their effect on the general community
*Irregular D~scharge The Problem of Hosp~tahzat~on of the Tuberculous October, ]948, pubhcat~onof the Veterans Adrn]n~str~t~on~Washmgton, 25 D C
July
1949
TUBERCLE
153
rises exponentially. In a larger and therefore dent except through the authorized channels, more loosely knit community they develop and by the time he gets there he is pretty and exercise much greater powers of spread- sure that the ground has already been cut ing disaffection. Weaker brethren are swayed tYom under his feet. To the patient the over, and almost anything may break out: general attitude of the institution seems to be, food strikes, booze-parties and similar mass- 'If you can't take it, you've had it. There are infringements of therapeutic regulations- hundreds waiting for your bed'. which seem to cry aloud for mass-disciplinary How do the patients appear to the staff in action. And the more the authorities have such an oversized community? History does to enforce discipline from above the less will not relate, but it is easy to surmise that they patients develop self-discipline- and down present primarily an administrative probwill go the morale even further[ lem: the ever-present problem of too small a The chief function of a sanatorium, after staff having to cope with too many bodies in all, is educational. Patients there are taught a day-to-day routine that leaves no margin how to overcome their disease. As soon as the tbr 'all this chit-chat'. One has heard it exnew patient is bedded down, his instruction as pressed, 'Tell the patient about himself and to how to set about healing has begun: but he he'll start worrying. Far better he should is not always told the reason for his regime. content himself with peaceful ignorance, beTo gain his full intelligent co-operation he come a cabbage and lct us do the worrying. has to be taught not only the nature of his It's our job and he can trust us to do our disease process and its extent but the why j o b . . . Besides, if the patients start worrying, and the wherefore of all that happens to him their relations get all worked up and come thereafter. This requires time and patience: buzzing round us like hornets. They always and an entlmsiasm that does not get dulled get hold of the wrong end of the stick and we by repetition. simply haven't got time to knock sense into In her lively narrative, 'The Plague and I', them'. There is some justification for this Miss Betty Macdonald [3] throws a great attitude when, for example, the doctordeal of light on the 'oppositional' patient- patient ratio reaches I to ~oo. But even in staff relationship which can develop in a these circumstances much can be done - and large sanatorium. To the patient the staff is done - to educate the patient, not in bookappears despotic, wilfully uncommunicative keeping, handicrafts or bird-watching, but and totally devoid of any appreciation of his in the mastery of his disease. Lectures, pep physical discomfort and mental suffering. talks, 'Any Questions?' sessions with groups, He is taught nothing about tuberculosis as a or broadcast over the internal broadcasting disease-process or as a personal problem. system stimulate interest and discussion and These things he has to learn from ilMnformed do much to alleviate the anxiety and resentfellow patients. He is kept in ignorance of his ment felt by patients who consider that they sputum tests and the interpretation of his are regarded only as Numbers, because there serial x-ray examinations. Every two months are simply not enough doctor-hours per week his case is subjected to routine assessment, for personal heart-to-heart talks. It is quite when he receives a routine reassurance- or impossible to eradicate discussion. If checked the reverse. At any moment he may be it merely goes underground. So it has to be whisked off in a wheeled chair not knowing led, directed and informed. Patients must whether it be for x-ray, thoracoplasty or a get everything off their chests be it sputum, dressing down from the headmaster, until he morbid anxiety or complaints about illgets there. In the daily routine he sees only served food. Ideally, however big the institution, an overworked i n t e r n e - in the company of the Ward Sister who acts as a buffer, He patients should be segregated into equalcannot approach the Medical Superinten- sized groups or 'Houses' of not more than 5%
July 1949
TUBERCLE
154
c o m p a r a b l e to the Houses making up a P u b l i c School - or a Butlin's H o l i d a y Camp. M o r a l e is m u c h m o r e easily established and m a i n t a i n e d w h e n h e a l t h y rivalry can be s t i m u l a t e d b e t w e e n groups in such little m a t t e r s as sports competitions, handicraft displays, and house concerts. Such Houses w o u l d soon be v y i n g w i t h each other in weightier matters such as m o n t h l y weightr e g a i n i n g averages, e a g e r acceptance of surgical i n t e r f e r e n c e - a n d low irregular discharge rate. U n f o r t u n a t e l y , each House w o u l d o f course require its own staff of doctors a n d nurses, who in order to become identified with the group would have to be m o r e or less p e r m a n e n t a n d not subject to too m u c h c h o p p i n g and changing around. A n d in these days o f m a r g i n a l staff this is impossible. T h e i m m e d i a t e choice appears to be: T r e a t a few patients well within the capacities of the staff, or give i n a d e q u a t e attention to a lot o f patients, h o p i n g the irregular discharge rate w o n ' t be quite so b a d as other people's, and c o m p l a c e n t l y writing off all irregular discharges as psychopathic personalities? I n three words: Q u a n t i t y or Quality?
References [~] Klotz, W. C. (I9~4) Amer. Rev. Tuberr m, 544. [2] Whitney, J. S., and Dempsey, M. V. (I94o.) Natl. Tubere. Assn. Social Research Series No. 8. r3] Macdonald, BetW 0948) "The Plague and I."
PRIMARY SEROUS PLEURAL EFFUSION (Continued from page I5r ) [4] Paine, A. L. (,94 I) Amer. Rev. Tub., XL~V,4o9. Fernand=, H. P. (I944) Tubercle, xxv, 8=. [6] Erwha, O. S. (~944) Tubercle, xxv, 44.
[7] Karron, I. G., and Purves, R. K. [8] Arborelius, M. (~93o) Svenska Lak 8allsk. LaMl., LW, II 5, [9] Israel, H. I., and Long, E. R. (;94 I) Amer. l?ev. Tub, XLIII~ 4 ~'.
[m] Montuschi, E., and Reeves, T. L. B.M.J., I7.5.47, 69a. [Ir] Close, H. G., Lancet,9.2.46, 193. [I~] Matte, R., and Saldias, E. (I944) Rev. Ghilel~ade Ped,, xv, 638, quoted by Thompson [3]. [13] Patterson, R. C. (I917) Arner. Rev. Tub., h 353. [~4] Petroff, S. A., and Stewart, P. W, (zges) .]ourm Immun., x, 677. [i5] Lemon, W, S,, and Montgomery, L. G. (I934) yourn. Thor. Surg., 6I~.
[I6] Howard, T,, and de Veer, J. A. (~936) Am,r. Rev, Tub., xxxm, 755.
Abstracts SCHWEIZ. MED. WOCHENSCHR. VOL. LXXWI ~947 NO. 24 BRUNNIgR, A. : The Treatment of Residual Lung Abscess Cavities by Lobectomy. Pp. 63o-63 I. Drainage of lung abscess not infrequently leads to the tbrmation of" epithelialized residual cavities with bronchial fistula or fistulae, which, in spite of adquate mobilization of the chest wall, fail to heal spontaneously. Because of the peculiar configuration of the inner surface, covered by bronchial epithelium, it was given the name of 'Gitterlunge'. These cavities inconvenience the patient not only by the necessity of fi'equent dressings but also because of interference with respiration. Some of the operative procbdures directed against the condition are discussed, that of muscle graft in particulal' but none appears to guarantee success. For lower lobe localizations the author has successfully performed lobectomy in three cases. Technical details of the operation are given, and the advantages of the method discussed. R E V I S T A DE LE ASOCIACION MEDICA ARGENTINA VOL. LXlI JULY I948 No. 6 3 3 - 4 AeEwDo, R. C., and ERmTEm, S.: Hipersensibilidad Profesional a la EstreptobincinaOccupational hypersensitivity to Streptomycin. Seven further cases are described of a rash occurring in nurses who had taken part in preparing or injecting solutions of streptomycin. The cases arose almost simultaneously some two months after beginning to handle the drug. The eruption began as small red intensively itchy papLLles on the fingers, and especially the thumb. In some cases there was preliminary erythema. The lesions became vesicular with' increase of itching. Much erythema, swelling and paronychia developed on the fingers. The folds of the elbows were sometimes involved. The eyelids became similarly affected with regulting oedema, conjunctival infection and photophobia. The eruption was transitory, but recurred with further exposure to the drug. Intradermal testing with ~oo units gave a definite reaction in four cases. Various ant{histamin drugs were used in treatment without success, and the authors emphasize the necessity for careful prophylaxis by wearing spectacles, rubber gloves and washing immediately after handling the drug. The American and Spanish literature on the subject ia reviewed.
152
1949
Irregular Discharges BY GEORGE DAY
Mundesley Sanatorium Once again our American colleague~ are showang grave concern at the high number of their tuberculous ex-Serwce men who discharge themselves from hospitals and sanatoria against their doctors' advice Between J u l y i946 and J u n e I947, nearly 6,0oo tuberculous veterans 'walked out on their treatment' as against fewer than 5,ooo who stayed the course This rate of 54 4 per cent Irregular discharges, moreover, is the lowest since the b e g m n m g of World War II In ~945 it reached 7~ 5 per cent In a pamphlet, 'Irregular Discharge', ~ssued by the Veterans Administration, U S A , are g~ver~ not onlv these facts and figures but also a painstaking rewew of the whole problem fiom every point of wow, social, economic and psychological The basic (alleged) causes of self-discharge are analysed and the valise of suggested preventative measures are consldezed The mere fact that the patients under d~scusslon are exSerwce men does not explain the h~g'h figure Men who had once subjected themselves to some sort of d~sc~phne m~ght be expected to accept the new dIsc~phne of tuberculosis more readily than c~whans w~thout that experience T h e p~oblem ~s nation-wide Klotz [~] found that durmg ~9e3 7t per cent of d~scharges among all classes of patient (men, women and children, eoloured and white) from the Tennessee National Sanatorture were '~rregular', and during I933, according to Whitney and Dempsey [ ~ , of 6,906 patients discharged ahve from 75 pubhc sanatoria m r6 States, at least 3~ per cent went w~thout their doctors' consent In Great Britain the irregular d~schargerate has never presented a sel~ous problem Not yet H o w can we make sure ~t never w~ll~ What can we learn from these American revelat]ons~ Appendix 'D' hsts all the hospitals and sanatoria w~th their annual turnover of tuberculous veterans and the:r percentages of
self-discharges The latter figule ranges from o o per cent (Phoemx) to 7~ 3 per cent (Fort Bayard) Why do some sanatoria have less difficulty in retalmng their patients than othersP Further study reveals that hospltal~ and sanatolla with an annual turnover of fewer than IOO tuberculous patients have an average I D rate of only ~5 per cent in comparison w~th the average of nearly 5 ~ per cent shown by estabhshments with a turn over of between 25o and 650 patients This accords w~th our own expectation that the larger the institution the greater is apt to be the amount ofreglmentat~on and the less the personal attention received by the mdlvtdual In the smaller estabhshments everybody knows everybody else The doctors know all the patients personally, and the patients know all the doctors, all the members of the nursing and domestic staff and most of the other patients Such a gloup possesses unity and morale Not that st does not have ]ts 'problem cases', but these cases ~mpmge on (he group as a whole, and the group can usually deal with them effectively Every sanatormm phys~clan ]s acquainted with the umntelhgent unco-operatlve patient, con stltutlonally unable to take a long wow of his dlness, with a psychopathm disregard not only for his own health but fol the health of his family, with the emotionally immature 'rebel' who flaunts all authollty and restrlc t~ons, with the 'barrack room lawyer' In a small estabhshment this sort of patient crops up from time to tnne, but being a sohtaly cxceptlon he cuts no ice and lacks the stablhty to dlsrupt the general mora]e He is regarded by his fellow-patients as a menace, and a general mgh of 1chef is heal d when he depalts without benefit of physicians He never heads a mass exodus Double, treble or quadruple the size of the estabhshment and the 'misfits' are multtphed paT z passl~ And when three or four such pattents get together their effect on the general community
*Irregular D~scharge The Problem of Hosp~tahzat~on of the Tuberculous October, ]948, pubhcat~onof the Veterans Adrn]n~str~t~on~Washmgton, 25 D C
July
1949
TUBERCLE
153
rises exponentially. In a larger and therefore dent except through the authorized channels, more loosely knit community they develop and by the time he gets there he is pretty and exercise much greater powers of spread- sure that the ground has already been cut ing disaffection. Weaker brethren are swayed tYom under his feet. To the patient the over, and almost anything may break out: general attitude of the institution seems to be, food strikes, booze-parties and similar mass- 'If you can't take it, you've had it. There are infringements of therapeutic regulations- hundreds waiting for your bed'. which seem to cry aloud for mass-disciplinary How do the patients appear to the staff in action. And the more the authorities have such an oversized community? History does to enforce discipline from above the less will not relate, but it is easy to surmise that they patients develop self-discipline- and down present primarily an administrative probwill go the morale even further[ lem: the ever-present problem of too small a The chief function of a sanatorium, after staff having to cope with too many bodies in all, is educational. Patients there are taught a day-to-day routine that leaves no margin how to overcome their disease. As soon as the tbr 'all this chit-chat'. One has heard it exnew patient is bedded down, his instruction as pressed, 'Tell the patient about himself and to how to set about healing has begun: but he he'll start worrying. Far better he should is not always told the reason for his regime. content himself with peaceful ignorance, beTo gain his full intelligent co-operation he come a cabbage and lct us do the worrying. has to be taught not only the nature of his It's our job and he can trust us to do our disease process and its extent but the why j o b . . . Besides, if the patients start worrying, and the wherefore of all that happens to him their relations get all worked up and come thereafter. This requires time and patience: buzzing round us like hornets. They always and an entlmsiasm that does not get dulled get hold of the wrong end of the stick and we by repetition. simply haven't got time to knock sense into In her lively narrative, 'The Plague and I', them'. There is some justification for this Miss Betty Macdonald [3] throws a great attitude when, for example, the doctordeal of light on the 'oppositional' patient- patient ratio reaches I to ~oo. But even in staff relationship which can develop in a these circumstances much can be done - and large sanatorium. To the patient the staff is done - to educate the patient, not in bookappears despotic, wilfully uncommunicative keeping, handicrafts or bird-watching, but and totally devoid of any appreciation of his in the mastery of his disease. Lectures, pep physical discomfort and mental suffering. talks, 'Any Questions?' sessions with groups, He is taught nothing about tuberculosis as a or broadcast over the internal broadcasting disease-process or as a personal problem. system stimulate interest and discussion and These things he has to learn from ilMnformed do much to alleviate the anxiety and resentfellow patients. He is kept in ignorance of his ment felt by patients who consider that they sputum tests and the interpretation of his are regarded only as Numbers, because there serial x-ray examinations. Every two months are simply not enough doctor-hours per week his case is subjected to routine assessment, for personal heart-to-heart talks. It is quite when he receives a routine reassurance- or impossible to eradicate discussion. If checked the reverse. At any moment he may be it merely goes underground. So it has to be whisked off in a wheeled chair not knowing led, directed and informed. Patients must whether it be for x-ray, thoracoplasty or a get everything off their chests be it sputum, dressing down from the headmaster, until he morbid anxiety or complaints about illgets there. In the daily routine he sees only served food. Ideally, however big the institution, an overworked i n t e r n e - in the company of the Ward Sister who acts as a buffer, He patients should be segregated into equalcannot approach the Medical Superinten- sized groups or 'Houses' of not more than 5%
July 1949
TUBERCLE
154
c o m p a r a b l e to the Houses making up a P u b l i c School - or a Butlin's H o l i d a y Camp. M o r a l e is m u c h m o r e easily established and m a i n t a i n e d w h e n h e a l t h y rivalry can be s t i m u l a t e d b e t w e e n groups in such little m a t t e r s as sports competitions, handicraft displays, and house concerts. Such Houses w o u l d soon be v y i n g w i t h each other in weightier matters such as m o n t h l y weightr e g a i n i n g averages, e a g e r acceptance of surgical i n t e r f e r e n c e - a n d low irregular discharge rate. U n f o r t u n a t e l y , each House w o u l d o f course require its own staff of doctors a n d nurses, who in order to become identified with the group would have to be m o r e or less p e r m a n e n t a n d not subject to too m u c h c h o p p i n g and changing around. A n d in these days o f m a r g i n a l staff this is impossible. T h e i m m e d i a t e choice appears to be: T r e a t a few patients well within the capacities of the staff, or give i n a d e q u a t e attention to a lot o f patients, h o p i n g the irregular discharge rate w o n ' t be quite so b a d as other people's, and c o m p l a c e n t l y writing off all irregular discharges as psychopathic personalities? I n three words: Q u a n t i t y or Quality?
References [~] Klotz, W. C. (I9~4) Amer. Rev. Tuberr m, 544. [2] Whitney, J. S., and Dempsey, M. V. (I94o.) Natl. Tubere. Assn. Social Research Series No. 8. r3] Macdonald, BetW 0948) "The Plague and I."
PRIMARY SEROUS PLEURAL EFFUSION (Continued from page I5r ) [4] Paine, A. L. (,94 I) Amer. Rev. Tub., XL~V,4o9. Fernand=, H. P. (I944) Tubercle, xxv, 8=. [6] Erwha, O. S. (~944) Tubercle, xxv, 44.
[7] Karron, I. G., and Purves, R. K. [8] Arborelius, M. (~93o) Svenska Lak 8allsk. LaMl., LW, II 5, [9] Israel, H. I., and Long, E. R. (;94 I) Amer. l?ev. Tub, XLIII~ 4 ~'.
[m] Montuschi, E., and Reeves, T. L. B.M.J., I7.5.47, 69a. [Ir] Close, H. G., Lancet,9.2.46, 193. [I~] Matte, R., and Saldias, E. (I944) Rev. Ghilel~ade Ped,, xv, 638, quoted by Thompson [3]. [13] Patterson, R. C. (I917) Arner. Rev. Tub., h 353. [~4] Petroff, S. A., and Stewart, P. W, (zges) .]ourm Immun., x, 677. [i5] Lemon, W, S,, and Montgomery, L. G. (I934) yourn. Thor. Surg., 6I~.
[I6] Howard, T,, and de Veer, J. A. (~936) Am,r. Rev, Tub., xxxm, 755.
Abstracts SCHWEIZ. MED. WOCHENSCHR. VOL. LXXWI ~947 NO. 24 BRUNNIgR, A. : The Treatment of Residual Lung Abscess Cavities by Lobectomy. Pp. 63o-63 I. Drainage of lung abscess not infrequently leads to the tbrmation of" epithelialized residual cavities with bronchial fistula or fistulae, which, in spite of adquate mobilization of the chest wall, fail to heal spontaneously. Because of the peculiar configuration of the inner surface, covered by bronchial epithelium, it was given the name of 'Gitterlunge'. These cavities inconvenience the patient not only by the necessity of fi'equent dressings but also because of interference with respiration. Some of the operative procbdures directed against the condition are discussed, that of muscle graft in particulal' but none appears to guarantee success. For lower lobe localizations the author has successfully performed lobectomy in three cases. Technical details of the operation are given, and the advantages of the method discussed. R E V I S T A DE LE ASOCIACION MEDICA ARGENTINA VOL. LXlI JULY I948 No. 6 3 3 - 4 AeEwDo, R. C., and ERmTEm, S.: Hipersensibilidad Profesional a la EstreptobincinaOccupational hypersensitivity to Streptomycin. Seven further cases are described of a rash occurring in nurses who had taken part in preparing or injecting solutions of streptomycin. The cases arose almost simultaneously some two months after beginning to handle the drug. The eruption began as small red intensively itchy papLLles on the fingers, and especially the thumb. In some cases there was preliminary erythema. The lesions became vesicular with' increase of itching. Much erythema, swelling and paronychia developed on the fingers. The folds of the elbows were sometimes involved. The eyelids became similarly affected with regulting oedema, conjunctival infection and photophobia. The eruption was transitory, but recurred with further exposure to the drug. Intradermal testing with ~oo units gave a definite reaction in four cases. Various ant{histamin drugs were used in treatment without success, and the authors emphasize the necessity for careful prophylaxis by wearing spectacles, rubber gloves and washing immediately after handling the drug. The American and Spanish literature on the subject ia reviewed.