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Light clinics at tuberculosis dispensaries
THE BRITISH JOURNAL OF
TUBERCULOSIS Vol. XXIV.
January, 193o.
No. 1.
ORIGINAL ARTICLES. LIGHT CLINICS AT TUBERCULOSIS DISPENSARIES. BY G. L I S S A N T COX, M.A., M.D. (CAlm), Central Tuberculosis Officer for the Palatine of Lancaster ; Vice-Chairman Joint Tuberculosis Council for England and Wales. , The
Lancashire
Dispensary
Scheme.
THE Administrative County of Lancaster (population 1,8ii,ooo, area 1,o5o,889 acres) is divided into five large dispensary areas with an average population of 340,000. The medical and nursing staff for each of these areas consists of one consultant ~uberculosis officer, two assistant tuberculosis officers, and four to seven tuberculosis health visitors. In addition, there are two small dispensary sub-areas, the consultant tuberculosis officers for which are the medicalsuperintendents of the High Carley and Elswick sanatoria. The consultant tuberculosis officers of the five areas (with one exception) also act as visiting medical superintendent of a pulmonary hospital at which are treated patients from their own areas ; in addition, each area has an X-ray apparatus and one or more light clinics. Two clinics were started in 1925 in dispensary areas I and 3 (Lancaster and Ashtonunder-Lyne), and after experimental work for two years, •light clinics-twelve in number--are at work in twelve dispensaries. This arrangement allows patients to be treated near their homes throughout the Administrative County. Actinotherapy
: Equipment
and
Cost of Tuberculosis
Clinics.
As a result of the trial of six types of lamps, the following has been found the most suitable equipment for the county dispensary light clinics : Two long-flame carbon arc lamps for general treatment ; one mercury vapour lamp (Jesionek or Hanovia type) for general or local treatment; one Kromayer water-cooled quartz mercury vapour lamp VOL. XXIV. I
2
THE,BRITISH
JOURNAL
OF
T UBERCULOS!S
for local t r e a t m e n t . T h e capital cost of t h e l a m p s a n d s u b s i d i a r y e q u i p m e n t has a v e r a g e d ~ 2 I O per c e n t r e . S e l e c t i o n o f C a s e s for A c t i n o t h e r a p y . T h e selection o f p a t i e n t s for light t r e a t m e n t is m a d e b y the c o n s u l t a n t t u b e r c u l o s i s officer, w h o confers w i t h the m e d i c a l a t t e n d a n t ; g e n e r a l l y it is f o u n d t h a t p a t i e n t s are a n x i o u s to avail t h e m s e l v e s of this form of t r e a t m e n t . T h e cases c h o s e n are a l m o s t e n t i r e l y those suffering f r o m n o n - p u l m o n a r y t u b e r c u l o s i s , a n d w h o are a b l e to a t t e n d the d i s p e n s a r y . O c c a s i o n a l l y cases are b r o u g h t in s p i n a l c a r r i a g e s or i n v a l i d chairs, b u t b e d r i d d e n cases are sent to a hospital. Results of Treatment by Artificial Light. T h e results of t r e a t m e n t of p a t i e n t s (all w i t h a c t i v e disease on c o m m e n c i n g light t r e a t m e n t ) at t h e d i s p e n s a r y light clinics are c o n t a i n e d in the following table : Num her ~f
Num-
• • •
.
.
.
Tre " me cing " at- Treat- centand'~ ment on • A - - a r - : Irax/z/28, m e n t ~ l n / P v ~, I r o v e d , x92o" entl~ IP
I
.
Skin (lupus and scrofulo. derma
C o n d i t i o n s of P a t i e n t s w h o s e T r e a t m e n t C o n c l u d e d in I 9 2 8 .
/
"/ ...... / -
68
168
45
27
I4o
I3
I25
52 49
Statmn= ary.
I ,
Wet e ~ s,
5
--
--
Adeuitis witi~ abscess-form a t i o n and skin involve-
ment Adenitis witilout softening" Bones, joints, and spine ... Abdomen ... -Other non-pulmonary conditions
Pulmonary tuberculosis :"' Lungs--sputum positive Lungs--sputum nega tive Bronchial glands ~] Pleura ... Pulmonary and non-pui-' menary combined : Sputum positive and bones ....... Sputu m positive and glands . . . . . .
27
75
II
28
.4
......
-
2
I
--
3
I
I
24
--
2
--
2
I 2
I53 Total for 1928
3
4
5 I
I
--
--
- -
--
2
--
--
?
--
I
23
io
573 726
J
I9o
99 14o3 [
I Includes: {I) Any patient who did not receive two months' treatment; (2) patients ceasing light treatment prematurely (e.g.. removals, unwilling or unable to continue) ; and {3) patients transferred to sanatoria or hospitals. Six centres only opened in x928, and consequently sufficient time did not elapse in which to complete the treatment of the majority of patients. a Adults, 419 ; children, 307.
LIGHT
CLINICS
AT DISPENSARIES
3
T h e results of treatment of cases of non-pulmonary tuberculosis in 1928 may be considered satisfactory, particularly for two groups of cases, namely: (i) Skin (lupus and scrofulo-derma)~ and (2) adenitis with abscess formation and skin involvement. These two conditions are usually refractory to other forms of treatment. The results of treatmer~t of other types of disease--e.g., tuberculosis of the bones and joints, adenitis (without softening), etc.-- have also in many cases been satisfactory, although the proof of efficiency of light treatment is not so strikinig , because those cases also respond fairly satisfactorily to other forms of treatment. Of the to#al ~batients attending the light clinics, 73 ~ber cent. were able to
continue their normal occupations during the course of treatment. The average gain in weight of the 19o patients who became " quiescent and apparently cured" was as follows : Adults, 3"05 lbs. ; children, 3"20 lbs. *The degree of pigmentation attained in these 19o patients was : Deep, 38 ; medium, 66 ; light, 54 ; none, 32. Photographic Records.
In order to record the progress made by patients, photographs have been taken of a number of cases treated by light at commencement, during the course of treatment, and on termination. On page 6 are inserted photographs of five patients which have been selected as illustrating the effect of light treatment. The upper photograph shows the condition prior to commencing light treatment, and the lower photograph the appearance of the affected part on or towards the conclusion of treatment. Average
D u r a t i o n of T r e a t m e n t .
The duration of treatment has, varied widely according to the type of non-pulmonary disease. Taking the several groups of cases in which the disease has become "quiescent and apparently cured " the average duration is as given in the table on page 4. T h e frequency of attendance of patients depends on several factors, but at eight of the clinics the great majority of patients attend twice per week, and at the other centres thrice per week. One-fourth of the patients were assisted b y the payment of railway, 'bus, or tram fares to the light clinic. Cost of Light Treatment.
The average number of patients under treatment in any one week was 399, and the average cost per patient per week was 5 d. for carbons and current, and 3 s. 8d. for standing charges (including proportion of time of tuberculosis officers and tuberculosis health visitors ; and proportionate cost of fuel, light, cleaning, rent, rates, a n d depreciation), making a total of 4 s. id. T h e cost of light treatment should, however, be considered in conjunction with other forms of treatment which
4
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
otherwise some of the patients would in all probability have received. Taking the i9o cases which have become quiescent after treatment at the ten light clinics, 48 of the cases would have been recommended for admission to special or general hospitals, 3 to sanatoria, and 62 for outpatient treatment at a. special skin hospital. TABLE
INDICATING
DURATION
OF
ACTINOTHERAPY
IN
TUBERCULOUS
CAs~S.
Form of Tuberculosis or Part of Body Affected.
For Comparzson : Number of Cases i Average Duration - (Active on Corn-~ . mencin Li ht T I Average tJuratlorl of Disease before ~g , g , reat'l of Light TreatCommencing ment) WhO oecame q .... -, "QuiescentandA 4 ment(montias/. L i g h t Treatment (Months). parently CuTed."
Skin (lupus and scrofuio-derma I: Adenitis with abscess formation and skin involvement ...... Adenitis without softening ... Bones, joints, and spine ...... " Abdomen Other non-pulmonary conditions Bronchial glands . . . . . . . . . Pleura . . . . . . . . . . . . .
All types of tuberculosis
45
7"77
161 "8 4
52 49 I9
5 '62 5"33 8'5X 5"51 4'8o 13 'oo 4'oo
23"59 22"24 36'15 14"13 820 43'oo 4"50
6 "46
56 "4°
15 5 4 i
......
19o
K n o w i n g the average duration of institutional treatment for such cases and the cost, one can make a comparison between the expense involved in light treatment for these 19o patients and ordinary institutional treatment : Actual complete cost of ' 19o patients cured by light treatment at county dispensaries... ~ i , I 5 o
Estimated cost of residential and out-patient treatment if patients h a d been sent to hospitals ... .~72,395
Thus, apart from other considerations, a very Considerable financial s a v i n g - - ~ I , 2 4 5 - - h a s been effected on the treatment of these I9o patients. , The
Lancashire
Results
in Relation
to other Schemes
and
Experiments. Recently Reports 1,2 have been issued by the Medical Research Council (responsible to the Privy Council) which deal extensively with the value of artificial light for the treatment of a number of complaints --e.g., wasting diseases, the common cold, anaemia, tuberculous ulcers, etc. The Council deprecated the extravagant claims which had been made for artificial light as a cure for all and sundry diseases, and called for further scientific research to prove its uses. Unfortunately the.se
LIGHT
CLINICS
AT DISPENSARIES
5
reports, when summarized i n t h e Press, have given rise to much misconception among the general public, and it was generally understood that the Medical Research Council had condemned the use of ultra-violet irradiation. This, however, is not the case, for, so far as the treatment of tuberculosis was concerned, the report 1 supported the use of artificial light, as the following extract shows : " There is much concordant testimony to the value of regulated skin exposure to artificial light, as being adjuvant in the cure of chronic infections like those especially of tuberculosis." The chief medical officei: :(Sir George Newman) of t~he Ministry of Health makes the position d e a r e r , for he states in his annual report for I928 that " t h e best results of artificial light therapy continue to be obtained in the treatment of rickets, lupus vulgaris, and surgical tuberculosis." The Scottish Board of Health in their 1928 report state that : " It is satisfactory to note that the facilities for artificial light therapy now available at many of the j out-patient clinics enable the less severe cases to be treated without the necessity of residential treatment.* Good results ,ate being obtained from light therapy in cases where the disease affects tt~e small bones or joint s (of the hand, etc.), in gland cases and cases of lupus." Treatment of tuberculosis by artificial light has also been provided by other authorities in England and Wales. The methods and results of three very large authorities are given below :
London County CounciL--Arrangements were made for the ~ispensary tuberculosis officers to send cases for light treatment at certain hospitals and centres thronghout London. Very little use, however, was made of the scheme, an average of six cases being sent from each of the nineteen boroughs in a period of nine months. The reports of the tuberculosis officers " disclosed practically no evidence of benefit having been derived by the patients from this form of treatment." Further, the experience gained in 1928 confirms the view '~ that the best results are obtained when light treatment is given as an additional method of treatment under suitable conditions in residential institutions in the country, where all methods of treatment are available, in addition to fresh air, good food, and a regular r6gime." a Wales (The King Edward V I I . National Memorial Association).-Scheme provides for the treatment of patients at light centres established at several of their tuberculosis hospitals and sanatoria and at one dispensary. " In non-puhnonary tuberculosis ultra-violet rays are of very great value indeed." For example, in lupus artificial sunlight is the only satisfactory method of treatment, and cure can be obtained by this means alone. In tuberculosis of the glands, especially if roken down and discharging, treatment by ultra-violet light is the most useful and beneficial method y e t devised. In tuberculous peritonitis the results obtained are equally satisfactory, and compared * M y italics.
6
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
with other methods show a definite shortening of the time required for treatment. 4 Birmingham.--Artificial light treatment is as a rule given to nonpulmonary patients when in the sanatorium and continued after they have been discharged. The light centre is situated at the City Sanatorium, Yardley Road, Birmingham. " T h e tendency to regard the application of artificial light to those suffering from tuberculosis as a complete method of treatment in itself should be guarded against. The best results can only be obtained when it is associated with other forms of treatment. ''5 It is remarkable that the cases tried in London have been so few and the results so disappointing. The tuberculosis officers of the Metropolitan boroughs do not, with few exceptions, themselves carry out the treatment as in Lancashire. Unless the incidence of the disease is vastly different from that in Lancashire, I suggest the dual control has caused the unsatisfactory results. Summar
F and Conclusions.
I. Artificial light treatment has continued to give satisfactory results, particularly in regard to patients suffering from tuberculosis of the skin and tuberculous adenitis with abscess formation and skin involvement, which conditions are very slow in yielding to other forms of treatment. 2. Of the total patients attending light clinics 73 per cent. were able to continue their normal occupations during the course of treatment. 3. One-fourth of the patients treated during the year were assisted by the payment of their railway, 'bus, o r tram fares to the dispensary light clinics. 4. In regard to the 45 skin cases which became " quiescent and apparently cured," the average duration of the disease before the patients commenced light t r e a t m e n t was 13 years and 6 months, whereas the average duration of light treatment was 7} months. 5- For the whole 19o cases which became " quiescent and apparently cured," the average duration of the disease before the patients commenced light treatment was 4 years 8 months, whereas the average duration of light treatment was 6½ months. 6. Of the 19o cases concluding treatment in 1928 on becoming "quiescent and apparently cured," the consultant tuberculosis officers would normally have recommended I13 for treatment at hospitals. Based on the average duration of treatment of such cases, the cost would have been not less than Z'2,395 , whereas their treatment at the dispensary light clinics actually cost (all i n c l u s i v e ) ~ I , I 5 o - - a saving of g-I,245. 7. "The Lancashire scheme has so far treated 95 °. patients, and it
/
C A S E I.--J. D., aged 2o. (6) Scrofulo-derma. Duration of disease before light treatment commenced, 3 years. Previous treatment, nil.
(£) Condition after nine months' treatment at dispensary light centre with general carbon :arc baths :and Kromayer locally. Gain in weight, 4½ lbs. ; slight pigmentation. Able to remain at work during light treatment. Disease now quiescent. (Photographs taken at Ashton-under-Lyne Dispensary,)
C A S E I I . - - J . F., aged 17. (a)Tuberculous adenitis with abscess formation and skin involvement. Duration of disease before light treatment commenced, 9½ years. Previous treatment ; incision and scraping at general and special hospitals. Condition in April, I928.
(b) Condition after ten months' treatment at dispensary light centre with general carbon arc baths and Kromayer locally. Gain in weight, 8 lbs. ; pigmentation fair. Ableto remain at work during light treatment. Disease quiescent. (Photographs taken at Ashton-under-Lyne Dispensary.)
C A S E IlL---A. S., aged 64. (6) An old s t a n d i n g case of l u p u s of t h e neck a n d cheek. D u r a t i o n of disease before light t r e a t m e n t c o m m e n c e d , 35 years. P r e v i o u s t r e a t m e n t : X-rays at a special hospital. P h o t o g r a p h shows condition of patient in March, 1928.
(b) Condition s h o w i n g i m p r o v e m e n t after eight m o n t h s ' t r e a t m e n t at d i s p e n s a r y light centre with general carbon arc b a t h s ; t h e white area below a n d b e h i n d t h e ear is occupied by a supple scar from which active loci of disease h a v e disappeared. P a t i e n t still u n d e r going light treatment. ( P h o t o g r a p h s taken at Chorlev DisDensarv3
C A S E I V . - - C . 0., aged 4 I. (a) Lupus of arm. Duration of disease before light treatment commenced, 12 years. Previous treatment : X-rays, ointment, etc., at a special hospital. Photograph shows condition in April, I928.
(b) Condition after ten months' treatment at dispensary light centre with general carbon arc baths and Kromayer locally. Gain in weight, 7 lbs. ; pigmentation slight. P a t i e n t able to remain at work during light treatment. Disease quiescent. (Photographs taken at Ashton-under-Lyne Dispensary.)
42ASE V . - - O . M., aged 18. (a) L u p u s , large scaly pink p a t c h e s on left wrist. Duration of disease before light t r e a t m e n t commenced, .~2 years. Previous t r e a t m e n t by ointment as an out-patient, a n d as in-patient at a special hospital, b u t t h e n occurred a break of three years w h e n no t r e a t m e n t was received owing to refusal of p a r e n t s until patient accepted artificial light t r e a t m e n t at t h e dispensary.
(b) Condition after two m o n t h s ' light t r e a t m e n t at dispensary with carbon arc and local t r e a i m e n t (plaster and K r o m a y e r lamp). Still c o n t i n u i n g treatment. W e i g h t stationary, p i g m e n t a t i o n deep. Able to r e m a i n at work d u r i n g treatment. Progress m a d e i n the two m o n t h s h a s b e e n remarkable. ( P h o t o g r a p h s taken at Eccles Dispensary.)
LIGHT
CLINICS
AT DISPENSARIES
7
has undoubtedly been successful: (a) In the results of treatment attained; (b) in convenience to the patients by permitting t r e a t m e n t near their homes and enabling three-fourths of them to continue their normal occupations ; and (c) in effecting a substantial saving over other forms of treatment. Its success has been due (i) in particular to the fact that the tuberculosis medical staff have had facilities given them by the County Council to specialize in light therapy, the experimental work lasting for two years before the scheme was applied over the whole administrative area; and (2)in general to the County dispensary scheme, consisting of a graded staff of consultant and assistant tuberculosis officers in charge of large areas, no large sanatoria, but the dispensary staff with their own hospital beds, and finally themselves using modern facilities for diagnosis such as X-rays. I~EFERENCES.
1 Report of the Medical R e s e a r c h Council for i927-28. " Irradiation a n d H e a l t h , " Special Report by Dr. D o r a Colebrook to the Medical R e s e a r c h Council, No. 131 , 1929 . 3 A n n u a l Report, L o n d o n C o u n t y Council, 1928, Vol. III.. " P u b l i c H e a l t h . " 4 W e l s h National Memorial Association, S e v e n t e e n t h A n n u a l Report, 1928-29. R e p o r t of Principal M O. 5 City of B i r m i n g h a m R e p o r t on T u b e r c u l o s i s for 1928.
THE AFTER.CARE OF T H E C O N S U M P T I V E P A T I E N T . 1 BY E. R I S T , M.D., P h y s i c i a n to the L a e n n e c Hospital, Paris.
WHEN we speak of the after-care of the consumptive we do not mean the same thing which we meant, let us say, fifteen years ago. W e had then in view the progressive readaptation to normal life and to work of patients whose lung lesions had become quiescent, inactive, and in some instances healed, under the influence of a prolonged air and rest cure. It was a delicate and difficult problem to decide when a formerly consumptive patient sufficiently advanced in this very slow and progressive process of natural and spontaneous healing could be allowed to proceed to a more or less normal activity. W h e n was it safe to let the patient take up work again ? H o w were we to prevent ever-impending recurrence of the disease ? W e are well aware that, whatever blessings the initiation of methodical air and rest cure and the original founders of the sanatorial institution have brought upon the early diagi S u b s t a n c e of a p a p e r presented in t h e T u b e r c u l o s i s Section of t h e Z u r i c h C o n g r e s s of the Royal I n s t i t u t e of P u b l i c H e a l t h , M a y I5-2o, 1929.
TUBERCULOSIS Vol. XXIV.
January, 193o.
No. 1.
ORIGINAL ARTICLES. LIGHT CLINICS AT TUBERCULOSIS DISPENSARIES. BY G. L I S S A N T COX, M.A., M.D. (CAlm), Central Tuberculosis Officer for the Palatine of Lancaster ; Vice-Chairman Joint Tuberculosis Council for England and Wales. , The
Lancashire
Dispensary
Scheme.
THE Administrative County of Lancaster (population 1,8ii,ooo, area 1,o5o,889 acres) is divided into five large dispensary areas with an average population of 340,000. The medical and nursing staff for each of these areas consists of one consultant ~uberculosis officer, two assistant tuberculosis officers, and four to seven tuberculosis health visitors. In addition, there are two small dispensary sub-areas, the consultant tuberculosis officers for which are the medicalsuperintendents of the High Carley and Elswick sanatoria. The consultant tuberculosis officers of the five areas (with one exception) also act as visiting medical superintendent of a pulmonary hospital at which are treated patients from their own areas ; in addition, each area has an X-ray apparatus and one or more light clinics. Two clinics were started in 1925 in dispensary areas I and 3 (Lancaster and Ashtonunder-Lyne), and after experimental work for two years, •light clinics-twelve in number--are at work in twelve dispensaries. This arrangement allows patients to be treated near their homes throughout the Administrative County. Actinotherapy
: Equipment
and
Cost of Tuberculosis
Clinics.
As a result of the trial of six types of lamps, the following has been found the most suitable equipment for the county dispensary light clinics : Two long-flame carbon arc lamps for general treatment ; one mercury vapour lamp (Jesionek or Hanovia type) for general or local treatment; one Kromayer water-cooled quartz mercury vapour lamp VOL. XXIV. I
2
THE,BRITISH
JOURNAL
OF
T UBERCULOS!S
for local t r e a t m e n t . T h e capital cost of t h e l a m p s a n d s u b s i d i a r y e q u i p m e n t has a v e r a g e d ~ 2 I O per c e n t r e . S e l e c t i o n o f C a s e s for A c t i n o t h e r a p y . T h e selection o f p a t i e n t s for light t r e a t m e n t is m a d e b y the c o n s u l t a n t t u b e r c u l o s i s officer, w h o confers w i t h the m e d i c a l a t t e n d a n t ; g e n e r a l l y it is f o u n d t h a t p a t i e n t s are a n x i o u s to avail t h e m s e l v e s of this form of t r e a t m e n t . T h e cases c h o s e n are a l m o s t e n t i r e l y those suffering f r o m n o n - p u l m o n a r y t u b e r c u l o s i s , a n d w h o are a b l e to a t t e n d the d i s p e n s a r y . O c c a s i o n a l l y cases are b r o u g h t in s p i n a l c a r r i a g e s or i n v a l i d chairs, b u t b e d r i d d e n cases are sent to a hospital. Results of Treatment by Artificial Light. T h e results of t r e a t m e n t of p a t i e n t s (all w i t h a c t i v e disease on c o m m e n c i n g light t r e a t m e n t ) at t h e d i s p e n s a r y light clinics are c o n t a i n e d in the following table : Num her ~f
Num-
• • •
.
.
.
Tre " me cing " at- Treat- centand'~ ment on • A - - a r - : Irax/z/28, m e n t ~ l n / P v ~, I r o v e d , x92o" entl~ IP
I
.
Skin (lupus and scrofulo. derma
C o n d i t i o n s of P a t i e n t s w h o s e T r e a t m e n t C o n c l u d e d in I 9 2 8 .
/
"/ ...... / -
68
168
45
27
I4o
I3
I25
52 49
Statmn= ary.
I ,
Wet e ~ s,
5
--
--
Adeuitis witi~ abscess-form a t i o n and skin involve-
ment Adenitis witilout softening" Bones, joints, and spine ... Abdomen ... -Other non-pulmonary conditions
Pulmonary tuberculosis :"' Lungs--sputum positive Lungs--sputum nega tive Bronchial glands ~] Pleura ... Pulmonary and non-pui-' menary combined : Sputum positive and bones ....... Sputu m positive and glands . . . . . .
27
75
II
28
.4
......
-
2
I
--
3
I
I
24
--
2
--
2
I 2
I53 Total for 1928
3
4
5 I
I
--
--
- -
--
2
--
--
?
--
I
23
io
573 726
J
I9o
99 14o3 [
I Includes: {I) Any patient who did not receive two months' treatment; (2) patients ceasing light treatment prematurely (e.g.. removals, unwilling or unable to continue) ; and {3) patients transferred to sanatoria or hospitals. Six centres only opened in x928, and consequently sufficient time did not elapse in which to complete the treatment of the majority of patients. a Adults, 419 ; children, 307.
LIGHT
CLINICS
AT DISPENSARIES
3
T h e results of treatment of cases of non-pulmonary tuberculosis in 1928 may be considered satisfactory, particularly for two groups of cases, namely: (i) Skin (lupus and scrofulo-derma)~ and (2) adenitis with abscess formation and skin involvement. These two conditions are usually refractory to other forms of treatment. The results of treatmer~t of other types of disease--e.g., tuberculosis of the bones and joints, adenitis (without softening), etc.-- have also in many cases been satisfactory, although the proof of efficiency of light treatment is not so strikinig , because those cases also respond fairly satisfactorily to other forms of treatment. Of the to#al ~batients attending the light clinics, 73 ~ber cent. were able to
continue their normal occupations during the course of treatment. The average gain in weight of the 19o patients who became " quiescent and apparently cured" was as follows : Adults, 3"05 lbs. ; children, 3"20 lbs. *The degree of pigmentation attained in these 19o patients was : Deep, 38 ; medium, 66 ; light, 54 ; none, 32. Photographic Records.
In order to record the progress made by patients, photographs have been taken of a number of cases treated by light at commencement, during the course of treatment, and on termination. On page 6 are inserted photographs of five patients which have been selected as illustrating the effect of light treatment. The upper photograph shows the condition prior to commencing light treatment, and the lower photograph the appearance of the affected part on or towards the conclusion of treatment. Average
D u r a t i o n of T r e a t m e n t .
The duration of treatment has, varied widely according to the type of non-pulmonary disease. Taking the several groups of cases in which the disease has become "quiescent and apparently cured " the average duration is as given in the table on page 4. T h e frequency of attendance of patients depends on several factors, but at eight of the clinics the great majority of patients attend twice per week, and at the other centres thrice per week. One-fourth of the patients were assisted b y the payment of railway, 'bus, or tram fares to the light clinic. Cost of Light Treatment.
The average number of patients under treatment in any one week was 399, and the average cost per patient per week was 5 d. for carbons and current, and 3 s. 8d. for standing charges (including proportion of time of tuberculosis officers and tuberculosis health visitors ; and proportionate cost of fuel, light, cleaning, rent, rates, a n d depreciation), making a total of 4 s. id. T h e cost of light treatment should, however, be considered in conjunction with other forms of treatment which
4
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
otherwise some of the patients would in all probability have received. Taking the i9o cases which have become quiescent after treatment at the ten light clinics, 48 of the cases would have been recommended for admission to special or general hospitals, 3 to sanatoria, and 62 for outpatient treatment at a. special skin hospital. TABLE
INDICATING
DURATION
OF
ACTINOTHERAPY
IN
TUBERCULOUS
CAs~S.
Form of Tuberculosis or Part of Body Affected.
For Comparzson : Number of Cases i Average Duration - (Active on Corn-~ . mencin Li ht T I Average tJuratlorl of Disease before ~g , g , reat'l of Light TreatCommencing ment) WhO oecame q .... -, "QuiescentandA 4 ment(montias/. L i g h t Treatment (Months). parently CuTed."
Skin (lupus and scrofuio-derma I: Adenitis with abscess formation and skin involvement ...... Adenitis without softening ... Bones, joints, and spine ...... " Abdomen Other non-pulmonary conditions Bronchial glands . . . . . . . . . Pleura . . . . . . . . . . . . .
All types of tuberculosis
45
7"77
161 "8 4
52 49 I9
5 '62 5"33 8'5X 5"51 4'8o 13 'oo 4'oo
23"59 22"24 36'15 14"13 820 43'oo 4"50
6 "46
56 "4°
15 5 4 i
......
19o
K n o w i n g the average duration of institutional treatment for such cases and the cost, one can make a comparison between the expense involved in light treatment for these 19o patients and ordinary institutional treatment : Actual complete cost of ' 19o patients cured by light treatment at county dispensaries... ~ i , I 5 o
Estimated cost of residential and out-patient treatment if patients h a d been sent to hospitals ... .~72,395
Thus, apart from other considerations, a very Considerable financial s a v i n g - - ~ I , 2 4 5 - - h a s been effected on the treatment of these I9o patients. , The
Lancashire
Results
in Relation
to other Schemes
and
Experiments. Recently Reports 1,2 have been issued by the Medical Research Council (responsible to the Privy Council) which deal extensively with the value of artificial light for the treatment of a number of complaints --e.g., wasting diseases, the common cold, anaemia, tuberculous ulcers, etc. The Council deprecated the extravagant claims which had been made for artificial light as a cure for all and sundry diseases, and called for further scientific research to prove its uses. Unfortunately the.se
LIGHT
CLINICS
AT DISPENSARIES
5
reports, when summarized i n t h e Press, have given rise to much misconception among the general public, and it was generally understood that the Medical Research Council had condemned the use of ultra-violet irradiation. This, however, is not the case, for, so far as the treatment of tuberculosis was concerned, the report 1 supported the use of artificial light, as the following extract shows : " There is much concordant testimony to the value of regulated skin exposure to artificial light, as being adjuvant in the cure of chronic infections like those especially of tuberculosis." The chief medical officei: :(Sir George Newman) of t~he Ministry of Health makes the position d e a r e r , for he states in his annual report for I928 that " t h e best results of artificial light therapy continue to be obtained in the treatment of rickets, lupus vulgaris, and surgical tuberculosis." The Scottish Board of Health in their 1928 report state that : " It is satisfactory to note that the facilities for artificial light therapy now available at many of the j out-patient clinics enable the less severe cases to be treated without the necessity of residential treatment.* Good results ,ate being obtained from light therapy in cases where the disease affects tt~e small bones or joint s (of the hand, etc.), in gland cases and cases of lupus." Treatment of tuberculosis by artificial light has also been provided by other authorities in England and Wales. The methods and results of three very large authorities are given below :
London County CounciL--Arrangements were made for the ~ispensary tuberculosis officers to send cases for light treatment at certain hospitals and centres thronghout London. Very little use, however, was made of the scheme, an average of six cases being sent from each of the nineteen boroughs in a period of nine months. The reports of the tuberculosis officers " disclosed practically no evidence of benefit having been derived by the patients from this form of treatment." Further, the experience gained in 1928 confirms the view '~ that the best results are obtained when light treatment is given as an additional method of treatment under suitable conditions in residential institutions in the country, where all methods of treatment are available, in addition to fresh air, good food, and a regular r6gime." a Wales (The King Edward V I I . National Memorial Association).-Scheme provides for the treatment of patients at light centres established at several of their tuberculosis hospitals and sanatoria and at one dispensary. " In non-puhnonary tuberculosis ultra-violet rays are of very great value indeed." For example, in lupus artificial sunlight is the only satisfactory method of treatment, and cure can be obtained by this means alone. In tuberculosis of the glands, especially if roken down and discharging, treatment by ultra-violet light is the most useful and beneficial method y e t devised. In tuberculous peritonitis the results obtained are equally satisfactory, and compared * M y italics.
6
THE
BRITISH
JOURNAL
OF TUBERCULOSIS
with other methods show a definite shortening of the time required for treatment. 4 Birmingham.--Artificial light treatment is as a rule given to nonpulmonary patients when in the sanatorium and continued after they have been discharged. The light centre is situated at the City Sanatorium, Yardley Road, Birmingham. " T h e tendency to regard the application of artificial light to those suffering from tuberculosis as a complete method of treatment in itself should be guarded against. The best results can only be obtained when it is associated with other forms of treatment. ''5 It is remarkable that the cases tried in London have been so few and the results so disappointing. The tuberculosis officers of the Metropolitan boroughs do not, with few exceptions, themselves carry out the treatment as in Lancashire. Unless the incidence of the disease is vastly different from that in Lancashire, I suggest the dual control has caused the unsatisfactory results. Summar
F and Conclusions.
I. Artificial light treatment has continued to give satisfactory results, particularly in regard to patients suffering from tuberculosis of the skin and tuberculous adenitis with abscess formation and skin involvement, which conditions are very slow in yielding to other forms of treatment. 2. Of the total patients attending light clinics 73 per cent. were able to continue their normal occupations during the course of treatment. 3. One-fourth of the patients treated during the year were assisted by the payment of their railway, 'bus, o r tram fares to the dispensary light clinics. 4. In regard to the 45 skin cases which became " quiescent and apparently cured," the average duration of the disease before the patients commenced light t r e a t m e n t was 13 years and 6 months, whereas the average duration of light treatment was 7} months. 5- For the whole 19o cases which became " quiescent and apparently cured," the average duration of the disease before the patients commenced light treatment was 4 years 8 months, whereas the average duration of light treatment was 6½ months. 6. Of the 19o cases concluding treatment in 1928 on becoming "quiescent and apparently cured," the consultant tuberculosis officers would normally have recommended I13 for treatment at hospitals. Based on the average duration of treatment of such cases, the cost would have been not less than Z'2,395 , whereas their treatment at the dispensary light clinics actually cost (all i n c l u s i v e ) ~ I , I 5 o - - a saving of g-I,245. 7. "The Lancashire scheme has so far treated 95 °. patients, and it
/
C A S E I.--J. D., aged 2o. (6) Scrofulo-derma. Duration of disease before light treatment commenced, 3 years. Previous treatment, nil.
(£) Condition after nine months' treatment at dispensary light centre with general carbon :arc baths :and Kromayer locally. Gain in weight, 4½ lbs. ; slight pigmentation. Able to remain at work during light treatment. Disease now quiescent. (Photographs taken at Ashton-under-Lyne Dispensary,)
C A S E I I . - - J . F., aged 17. (a)Tuberculous adenitis with abscess formation and skin involvement. Duration of disease before light treatment commenced, 9½ years. Previous treatment ; incision and scraping at general and special hospitals. Condition in April, I928.
(b) Condition after ten months' treatment at dispensary light centre with general carbon arc baths and Kromayer locally. Gain in weight, 8 lbs. ; pigmentation fair. Ableto remain at work during light treatment. Disease quiescent. (Photographs taken at Ashton-under-Lyne Dispensary.)
C A S E IlL---A. S., aged 64. (6) An old s t a n d i n g case of l u p u s of t h e neck a n d cheek. D u r a t i o n of disease before light t r e a t m e n t c o m m e n c e d , 35 years. P r e v i o u s t r e a t m e n t : X-rays at a special hospital. P h o t o g r a p h shows condition of patient in March, 1928.
(b) Condition s h o w i n g i m p r o v e m e n t after eight m o n t h s ' t r e a t m e n t at d i s p e n s a r y light centre with general carbon arc b a t h s ; t h e white area below a n d b e h i n d t h e ear is occupied by a supple scar from which active loci of disease h a v e disappeared. P a t i e n t still u n d e r going light treatment. ( P h o t o g r a p h s taken at Chorlev DisDensarv3
C A S E I V . - - C . 0., aged 4 I. (a) Lupus of arm. Duration of disease before light treatment commenced, 12 years. Previous treatment : X-rays, ointment, etc., at a special hospital. Photograph shows condition in April, I928.
(b) Condition after ten months' treatment at dispensary light centre with general carbon arc baths and Kromayer locally. Gain in weight, 7 lbs. ; pigmentation slight. P a t i e n t able to remain at work during light treatment. Disease quiescent. (Photographs taken at Ashton-under-Lyne Dispensary.)
42ASE V . - - O . M., aged 18. (a) L u p u s , large scaly pink p a t c h e s on left wrist. Duration of disease before light t r e a t m e n t commenced, .~2 years. Previous t r e a t m e n t by ointment as an out-patient, a n d as in-patient at a special hospital, b u t t h e n occurred a break of three years w h e n no t r e a t m e n t was received owing to refusal of p a r e n t s until patient accepted artificial light t r e a t m e n t at t h e dispensary.
(b) Condition after two m o n t h s ' light t r e a t m e n t at dispensary with carbon arc and local t r e a i m e n t (plaster and K r o m a y e r lamp). Still c o n t i n u i n g treatment. W e i g h t stationary, p i g m e n t a t i o n deep. Able to r e m a i n at work d u r i n g treatment. Progress m a d e i n the two m o n t h s h a s b e e n remarkable. ( P h o t o g r a p h s taken at Eccles Dispensary.)
LIGHT
CLINICS
AT DISPENSARIES
7
has undoubtedly been successful: (a) In the results of treatment attained; (b) in convenience to the patients by permitting t r e a t m e n t near their homes and enabling three-fourths of them to continue their normal occupations ; and (c) in effecting a substantial saving over other forms of treatment. Its success has been due (i) in particular to the fact that the tuberculosis medical staff have had facilities given them by the County Council to specialize in light therapy, the experimental work lasting for two years before the scheme was applied over the whole administrative area; and (2)in general to the County dispensary scheme, consisting of a graded staff of consultant and assistant tuberculosis officers in charge of large areas, no large sanatoria, but the dispensary staff with their own hospital beds, and finally themselves using modern facilities for diagnosis such as X-rays. I~EFERENCES.
1 Report of the Medical R e s e a r c h Council for i927-28. " Irradiation a n d H e a l t h , " Special Report by Dr. D o r a Colebrook to the Medical R e s e a r c h Council, No. 131 , 1929 . 3 A n n u a l Report, L o n d o n C o u n t y Council, 1928, Vol. III.. " P u b l i c H e a l t h . " 4 W e l s h National Memorial Association, S e v e n t e e n t h A n n u a l Report, 1928-29. R e p o r t of Principal M O. 5 City of B i r m i n g h a m R e p o r t on T u b e r c u l o s i s for 1928.
THE AFTER.CARE OF T H E C O N S U M P T I V E P A T I E N T . 1 BY E. R I S T , M.D., P h y s i c i a n to the L a e n n e c Hospital, Paris.
WHEN we speak of the after-care of the consumptive we do not mean the same thing which we meant, let us say, fifteen years ago. W e had then in view the progressive readaptation to normal life and to work of patients whose lung lesions had become quiescent, inactive, and in some instances healed, under the influence of a prolonged air and rest cure. It was a delicate and difficult problem to decide when a formerly consumptive patient sufficiently advanced in this very slow and progressive process of natural and spontaneous healing could be allowed to proceed to a more or less normal activity. W h e n was it safe to let the patient take up work again ? H o w were we to prevent ever-impending recurrence of the disease ? W e are well aware that, whatever blessings the initiation of methodical air and rest cure and the original founders of the sanatorial institution have brought upon the early diagi S u b s t a n c e of a p a p e r presented in t h e T u b e r c u l o s i s Section of t h e Z u r i c h C o n g r e s s of the Royal I n s t i t u t e of P u b l i c H e a l t h , M a y I5-2o, 1929.