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Management and mismanagement of tuberculosis dispensaries
September, lU20J
;'75
'l'UllERCLE
dlviduul is best served by living under the most stimulating conditions to which he can respond and there is little more to be said. "
Practical Possibilities. Tho idea.l, then, would seem to be 0. chain of sanatoriums in different climates 80 that overy plttiont could enjoy tho precise altitude 11.0,1 climnte that suited him best. The time will, no doubt, come when n. patient can be measured for his climate with the precision that a tuilor measures a customer for n. suit of clothes. Some years ago the medical officer of n. private sanatorium suggested 0. sort of II musical chairs" scheme according to which patients who Iound tho climatic or other conditions of one sanatorium unsuitnble should be circulated, sampling other institutions and settling down in the ono in which they' mude best progress. The scheme might have proved fruitful had tho sanatoriums in question been philanthropic institutions run only for tho benefit of their patients, and had thes? ~)een as objectively and accurately sensit.ivo to climatic conditions as 0. katu-thermometer. With tho advent of of tho State sanatorium tho .. musical chairs" system.t'modified and elnborated, no doubt, to meet the needs of tho working-class putiont, may yet come into it!'4 own.' Even at tho present stage of evolution of sanatorium treatmont, might not certain lnrge and populous nrons be served by two sanatoriums cach-e-one to cater for tho patient in need of a lonic, atimulating regime, tho other to suit tho patient whoso ago and infirmities rob him of tho benefits of n rigorous open-air lifo in n bracing climate? Under tho present rulo-oC·thumb conduct of certain sanntori.utnll many elderly and weakly pa.tlCnts return to their homes "owing ~ha.t death at homo is preferable to tho ICy terrors of sanatorium lifo. No doubt excosaive exposure to cold air will shortly share tho fate of tho exc essive 8tuflin~ of tho last docade : but thoro will nlwnys bo patients in neod of bracing stimuli and others who tolornto only the most modest calls on their
powers of response. In this mutter it is well to bear in mind Professor Hill's aphorism ;_fI It is not the wind which God tempers to tho shorn lamb, hut the skin of tho lamb to tho wind." (1) TicZ,.~kl'ift lor rlm Sor51.e Large/ormill(J, l!>20, 40, 1Gl.
(2) Tillukl'ift f or rlm NOl'Ikc LacgtforellillfJ, 1920, 40, ais. rS) .llerlicin.qk ReVllt, HJlI, p, 28. (4] ".~[cddele18or fra. Vcjlefjord Sanatorium," XII.
(5) fI The Influence 01 Stron~ rrovalcl1t Italn -beatlng Wind» on tho I'revnlence of Phthlsl«," 1910. London : H . K. Lewis, Br it. },fed. JO/trn., 1911, I, 4B2. B rit . Med. JOItr1l., 1!)l2, I, 2!H. Brit. Med. Journ., 1912, I, 773. Practitioner, 1913, 300. .. The Place 01 Olhnntology in ~[edicil1e," l!)1S. London: II. K. Lewis, Ddt Md. Jourw., 1!120, II, 6!1-1. (ll) :o.Cedical Ho :ol\rch Corn mi t te e . Special Report Serir«, No . 82, WI!). [1] Med iclli Reaearch Committee. Special
se,
Rr'TlQrt Series, Partll 1 nnd 2, No. 1H, 1918 ; l'l\rt S, No. 40, l!llO. [BJ JOUnl. of State ste«, 1920, 29, 131.
l\IANAGEME~T
AND l\IISMANAGE· MENT OJ? TUDERCULOSIS DISPBNSARIES.
A Report' has recently boon issued on the treatment of tuberculosis in London 11K an appendix to the L.C.C. Heport of tho C.M.O. nnd 8.M.a. Dr. P. N. K ~[enzio8, tho author of this Report, has infused llo remarkable amount of ~in~or into it : so far (rom adopting the comIortablo n.nc1 comforting policy of tho II o.ll.is _well- ,,1001) - peacefully- in. yourbells" attitude, ho analyses with merciless imp/lol'tin.lity tho numerous flaws in tho present conduct of various disponsaries. Some are named in connoction with theso flaws, and others aro permitted to WO BI' tho kindly cloak of anonymity. Orqanisatun: and Hours oj Work. From information given hy numorous tuberculosis oflicors, it transpires that tho timo nctunlly spont at work hy whole-time ollicers vnrios (rom thil·ty to forty-six hours, and it WlI.S noted with surprise tha.t short hours were frptJuently worked in disponaaries whore tho I
1'. S. King and SQlI, Ltd.
Price
tiR.
57G
TUBEnCLE
number of nttcndances per annum was very high. It is suggested that 0. wholetime officor should not give less timo to the ' work than thirty-six hours. Office work, it appears, takes on the average about ten hours n. woek; this portion of the work has recently grown considerably on account of war pension cases nnd reports. In some dispensnries the necessary clerical assistance is provided, in others it is inadequate or lucking altogether, with the result that tho T .O.'s time is wasted on clerical work. The average duration of sessions is between two-und-a-half and three hours, and the number of patients dealt with per hour varies considerably. In well-organised dispensaries tho average number of examinations per hour is about eight, and this Includes one new case, requiring twenty minutes £01' examination and record, two cases Cor re-examination, requiring tell minutes each, and five .. treatment" cases requiring four minutes each. These figures are necessarily approximate. but they are a rough guide to the number of patients who can be dealt with effectively in one hour. C01I(fe.~tion, In many dispensaries the T.O.s do not cnre to discharge patients with definite ill-health, hut indefinite diugnosis. They attend nbout onco n. fortnight for n. year or more. and IVI thoir number is being constantly augmented, congestion ensues, and no time is left for tho proper physical examination of even n. small fraction. Observation cases cea se to he observed, and tho prescription of drugs is all that ill done for them . Tho number of attendances at these congested dispcnsuries may be very imposing, hut it is mainly composed of children receiving treatment without diagnosis . In one dispensary it WIlS admitted that ro-cmminations wore so infrequent that intervals of six, nine, and oven twelve months occurred between each.
E.oic iellcy 1l'ith Intensive Study of each Cas«.
In some dispensuries great pains are taken to arrive at a diagnosis quickly I
LScptem her,
Hl20
and each case is studied intensively for a short period. When a patient has been submitted to such an intenaivo study for three to tour weeks without; a positive diagnosis being made, he is requested to attend the dispensary again in two or three months, and if no further positive evidence is available, he is discharged as e , probably not Buffering Cram clinical tuberculosis." lIe is then advised to report again in six months or earlier if new symptoms, appear.
The Super-Tuberculosis Consultant. Though the T.O. ranks, of course, as a. specialist and n. consultant, cases must inevitably occur in which 0. second opinion is desirable. But it appears that some T.O.'s consider they 0.1'0 unlikely to obtain any further assistance by referring the patient to n. consulting centre, and they Ienr that. in doing so they may be tacitly confessing to clinical incompetence. Tho majority of T.O.s do not Ieel the need for a consulting service, and in 1018 only 145 casea were referred by them to the consulting centres. Nearly 1\11 were cases of disease of special organs such as the throat and genito-urinary tract. Obseruaiion Beels. If, as the Report shows, the T.O. is unwi1li~g to refer to n SUpcl'-sIJecinlist. for advice, he should he provided with every facility for making un o.ccurato diagnosis himself. But bo does not. appear to be provided with the most. essential moans to this end-obsen'ntioll beds. Practically every T.O. feels tho n?ed o! them, both with a view to diagnosis and to determining tho most. suitable form of treatment. Latterly tho L.C.C. and the L.I.C. 11I\\'e l)rovidctl some observation bods. but T.O.s complain that they have no right of access to these patients, and many prefer to have them under their own supervision in a local homo.
Examination of Contacts. This important branch of tho dispensary scheme seems to be deplornLl~. neglected in many parts of London
September, 1020]
077
runnncr.s
During HJ18, 153 contacts were examined per 100 now cnsos in Hackney, and only l:i0 per 100 in Stoke Newington. This difference appoars to he tho measure of tho differenco in the energy of the public health staff in the two Boroughs. InNorth Kensington only about 1R per cent. of the estimntod number of contacts wore examined. Municipal dispensaries nro, in this matter, better situated than most voluntary dispensaries, and in Groenwich, for example, some 50 per cent. of the contacts of all notified cases appear to be examined in normal times. It is calculated that, assuming 80 per cent. of all contacts are oxurnined, l\ T.O. in charge of II. district with 120lGO deaths from tuberculosis per annum will probably spend three to four hours n, week on this work. Dr. Menzies' opinion of tho work dono in the matter of examining contacts stands revealed in the words-" The importance of this work needs to be strongly impressed on tuherculosis officers. . . ."
Visiting. Under the throe different headings : noma Consultations, Home Visiting and Home Visitn.tion-tho last named suggests a variety of visit amounting to an o.flIiction - the Report again exposes gravo sins of omission. It appears thnt tho T.O. of St. 'I'homns' Hospital is not allowo] hy the rules of tho hospital to consult at tho homos of patients. Tho Itcport procceds : II This i6 an unfortunate restriction, and it is desirable in the interests of efficiency that this rule should he revised." In some cases tho 1'.0. visits tho homos of most of his patlonts to inquire into nnd to remedy any home defects, and to examine contacts. He is thus enabled to study tho relation of environment to the disease in his nreu. Tho Report ndds : . . . . homo visiting in the CR.SO of tuberculosis i,; VOI'Y important, and it should bo tho rocoqnisod duty of the tuberculosis officor to visi t, nt If'l\!lt once, tho homo of every ono of his patients." At present pressure of work ot tho dispensaries, largely duo to overtreatment of patients, has considorably
reduced the amount of home visiting by the T.O., und thus to a largo extent one of the main functions and most - useful purposes of the tuberculosis' dispensnry is not fulfilled. ri.~itillfJ
b" the Nurse,
It appeo.rs that T .O.s rarely confer with tho hen.lth visitors or tho Public Health Depnrtment in their districts: tho work of these visitors is carried out without adequate relation to the dispensary, unrl " . . . tho tuborculosia ofIlcors deal with their patients practically without regard to their homo and othor circumstances ." The Roport procoods: II Tuberculosis is a disoase usually associnted with 11dective social conditions, and tho nssistanco of a truinod social worker who can deal effectively with prohlems which nrise from these conditions, would be nn immense advnntnge in every dispensary . . At present the tendency i!'l for almoners to work independnntly of tuberculosis oflicera, but if social workers are to be employed, it should be a sine qua non that they should work in intimate cooperation with, and -under the direction of. the tuberculosis officer." Ocer-treatment at the Dispensari), Tho Report hetrays mild exasporation 0\'01' tho conceptions of some T.O.A in tho matter of treatment. Except in tho case of 80n1O dlspensnries, where It few patients receive tuberculin, or other spccinl form of treatment, therapeutic measures should, according to tho Ileporf bo limited to ndvico as to hygiene. diet, oxorciso, &0., supplementod by tho troatment of spooiui symptoms. Unfortunutel y, tho pntiont« expect bottles of medici no . . . nne! tuberculosis officers fmqnctltly find it nocossnrv to ~h'o medicine fOI' tril1in~ symptoms, or oven for no spooinl modioal reason, in 01'11(11' to secure the rcgulnr attenrluneo of tho pnt.innb." In ono hospital dispcnsnry 4,!)li!) proscriptiona wore dispensed for 1\ total attondnnco of 4.A53, nnd 1,7R!) bottles of cod Iinw oil, &c.• wero given nwny. Another disponsnry 800m!'! to hnvo ~i\'on Virol with much protlign.1ity . Tho Report II
578
TUDEnOLE
proceods : .. The fact that patients expect and actually receive .m edicines, whether they really need them or not, necessarily tenus to make the patient rely more on the medicine and less on udvice given in regard to such essential matters as personal and homo hygiene, diet, &c."
Dlscharue of Di3pensal'Y Patients. T.O.s arc generally ruther nervous about discharging putients "probably not sullering from tuberculosis." The Report admits that some of these discharged cases may ultimately break down from tuberculosis, hut this unfortunate result will be more than counterbalanced by tho increased efliciency which will result from freeing dispensaries from prolonged attendance of these observation cases. At present they overcrowd some dispensaries and render the ohservution of themselves and athol'S ineffectivo. Supervision after Discharge. Tho Report deplores the fact that so fow dispensaries have any adequate system of following up their cnses. No dispensary system of supervision can ho regarded as efficient which permits patients to cease nttendanco without the knowledge of the tuberculosis officer. If n. patient ceases to attend, steps should be taken at once to ascertain the reason. Perhaps be may have had n. relapse, in which case ih is important that the tuberculosis officer should know at an early date, so that he may take such steps as are necessary in tho interests of the patient." II
Trouble witlt .1lcdical O.Diccl's of llealtlt. The Report touches but lightly on the serious grievnnces which T.O.s complain of in their relations to the M.O.I1. But it udmits that T.O.s would proler to hnvo reports on their patients sent to them direct instead of through the M.O.II. Tho arrangement by which all recommendations made by T.O.s for tho treatment of uninsured persons, and all requests hy the he.C. for progress reports upon patients who hnve rece ived troatment in residential institutions, are
[September,lD20
made through the l\I.O.II. of tho Dorough has leu to delay in the IJI\st, The Report recommends the revision of these arrangements and suggests that the T.O. should send all recommendations to, and receive 0.11 requests Cor reports direct from, the County Council. The case of the l\I.O.II. who gets himself appointed as T.O . and then sidetracks all tuberculosis work is not dealt with in the Report.
The X1cmber of T.O.s required ill London. It is calculated that a T.O. cannot deal efficiently with a population having ' more than IGO deaths (rom tuberculosis per annum. Provision should, thero(oro, be made in tho near future (or ono whole-time T.O. (or not lORS than ever}' 1GO deaths. On this basis 50 T,O.s would be required for London, i.e., ono for about each 90,000 of tho population: One T.O. for every 120 deaths would involve the appointment of GG T.O.s. i.o., one to about every 70,000 of tho population. Finance. The Report calculates that the cost ' of 0. dispensary service on tho scale contemplated in 1915 would amount to at least 50 per cent. more in 1920. Tho development of certain sections or tho work inadequately provided (or in the scheme for 1915 would also add to the cost. Thus, for London, tho estimated cost of 1\ dispensary sorvico would be as follows : 1<~8t1mll.tu for Hl15
.. .• . • £37,450 Add 60 per cent, to meet increased cost 18,72~ Add to moet cost of improved servico U,82~ (say) •.
-
Estimated total cost of revised service in 1020-21 .. J:GG,OOO
Siqnificance of the Ileport, Both the advocates and opponents of n state medical service will find in thi~ Report much to interest them, (or 011 1\ small scale it reveals both tho advantages and tho shortcomings of such u sorvico- The liberty of the indi vidual is certainly restricted : tho T.O. who expects his nppointment to be 0. bod of
September, 1920]
TUDEUCLE of the shorn lurnb whon his work hils been inspect ed IU ll1 his incompetenco exposed. On th o other hand . th e '1'.0. with initiative, efficiency and II capacity for hard work will find in this Report an encouraging loItimu lus .
roses in which he can repose undisturbed must be painfully disillusion ed when his sins of omission are publicly discussed, The T.O. whose conception of tubercu losis dispensary work is out of date and unpractical must suffer the discomforts
TUBERCULOSIS BIOGRAPHIES. II.- HUliGAHD. H:l51-1911. WILLIAM RICHAHD RUlWARD
WILS
born in IH51 at Kilcock, near Dublin. He graduated as M.D. of the Royal University of Ireland in 1875 and 0.8
W. R.
M.A. Il year later. During the earlier yeurs of hill medical career he worked in lunacy with Forbes- Winslow. wrote a few articles on matters connected with that subject, but gained a. very meagre income-r-ae meagre, indeed, 39
that when chance Bent him an invitution to settle at DIlNOS. he had to get into deht in order to pass the necessary examinations for the Swiss Federal Diploma ILt Geneva. He reached Duvos in IHH5. and there, while receiving loyal support from those who had
HUGGARD.
invited him-those. that is to SILY, who wore pri maril y concerned to develop the heulth rOBort-encountere·1 uneonipremising opposition (rom hill rivuls. It WILS 1\ long uphill fi~ht for existence. The sources of inforuiution about those
;'75
'l'UllERCLE
dlviduul is best served by living under the most stimulating conditions to which he can respond and there is little more to be said. "
Practical Possibilities. Tho idea.l, then, would seem to be 0. chain of sanatoriums in different climates 80 that overy plttiont could enjoy tho precise altitude 11.0,1 climnte that suited him best. The time will, no doubt, come when n. patient can be measured for his climate with the precision that a tuilor measures a customer for n. suit of clothes. Some years ago the medical officer of n. private sanatorium suggested 0. sort of II musical chairs" scheme according to which patients who Iound tho climatic or other conditions of one sanatorium unsuitnble should be circulated, sampling other institutions and settling down in the ono in which they' mude best progress. The scheme might have proved fruitful had tho sanatoriums in question been philanthropic institutions run only for tho benefit of their patients, and had thes? ~)een as objectively and accurately sensit.ivo to climatic conditions as 0. katu-thermometer. With tho advent of of tho State sanatorium tho .. musical chairs" system.t'modified and elnborated, no doubt, to meet the needs of tho working-class putiont, may yet come into it!'4 own.' Even at tho present stage of evolution of sanatorium treatmont, might not certain lnrge and populous nrons be served by two sanatoriums cach-e-one to cater for tho patient in need of a lonic, atimulating regime, tho other to suit tho patient whoso ago and infirmities rob him of tho benefits of n rigorous open-air lifo in n bracing climate? Under tho present rulo-oC·thumb conduct of certain sanntori.utnll many elderly and weakly pa.tlCnts return to their homes "owing ~ha.t death at homo is preferable to tho ICy terrors of sanatorium lifo. No doubt excosaive exposure to cold air will shortly share tho fate of tho exc essive 8tuflin~ of tho last docade : but thoro will nlwnys bo patients in neod of bracing stimuli and others who tolornto only the most modest calls on their
powers of response. In this mutter it is well to bear in mind Professor Hill's aphorism ;_fI It is not the wind which God tempers to tho shorn lamb, hut the skin of tho lamb to tho wind." (1) TicZ,.~kl'ift lor rlm Sor51.e Large/ormill(J, l!>20, 40, 1Gl.
(2) Tillukl'ift f or rlm NOl'Ikc LacgtforellillfJ, 1920, 40, ais. rS) .llerlicin.qk ReVllt, HJlI, p, 28. (4] ".~[cddele18or fra. Vcjlefjord Sanatorium," XII.
(5) fI The Influence 01 Stron~ rrovalcl1t Italn -beatlng Wind» on tho I'revnlence of Phthlsl«," 1910. London : H . K. Lewis, Br it. },fed. JO/trn., 1911, I, 4B2. B rit . Med. JOItr1l., 1!)l2, I, 2!H. Brit. Med. Journ., 1912, I, 773. Practitioner, 1913, 300. .. The Place 01 Olhnntology in ~[edicil1e," l!)1S. London: II. K. Lewis, Ddt Md. Jourw., 1!120, II, 6!1-1. (ll) :o.Cedical Ho :ol\rch Corn mi t te e . Special Report Serir«, No . 82, WI!). [1] Med iclli Reaearch Committee. Special
se,
Rr'TlQrt Series, Partll 1 nnd 2, No. 1H, 1918 ; l'l\rt S, No. 40, l!llO. [BJ JOUnl. of State ste«, 1920, 29, 131.
l\IANAGEME~T
AND l\IISMANAGE· MENT OJ? TUDERCULOSIS DISPBNSARIES.
A Report' has recently boon issued on the treatment of tuberculosis in London 11K an appendix to the L.C.C. Heport of tho C.M.O. nnd 8.M.a. Dr. P. N. K ~[enzio8, tho author of this Report, has infused llo remarkable amount of ~in~or into it : so far (rom adopting the comIortablo n.nc1 comforting policy of tho II o.ll.is _well- ,,1001) - peacefully- in. yourbells" attitude, ho analyses with merciless imp/lol'tin.lity tho numerous flaws in tho present conduct of various disponsaries. Some are named in connoction with theso flaws, and others aro permitted to WO BI' tho kindly cloak of anonymity. Orqanisatun: and Hours oj Work. From information given hy numorous tuberculosis oflicors, it transpires that tho timo nctunlly spont at work hy whole-time ollicers vnrios (rom thil·ty to forty-six hours, and it WlI.S noted with surprise tha.t short hours were frptJuently worked in disponaaries whore tho I
1'. S. King and SQlI, Ltd.
Price
tiR.
57G
TUBEnCLE
number of nttcndances per annum was very high. It is suggested that 0. wholetime officor should not give less timo to the ' work than thirty-six hours. Office work, it appears, takes on the average about ten hours n. woek; this portion of the work has recently grown considerably on account of war pension cases nnd reports. In some dispensnries the necessary clerical assistance is provided, in others it is inadequate or lucking altogether, with the result that tho T .O.'s time is wasted on clerical work. The average duration of sessions is between two-und-a-half and three hours, and the number of patients dealt with per hour varies considerably. In well-organised dispensaries tho average number of examinations per hour is about eight, and this Includes one new case, requiring twenty minutes £01' examination and record, two cases Cor re-examination, requiring tell minutes each, and five .. treatment" cases requiring four minutes each. These figures are necessarily approximate. but they are a rough guide to the number of patients who can be dealt with effectively in one hour. C01I(fe.~tion, In many dispensaries the T.O.s do not cnre to discharge patients with definite ill-health, hut indefinite diugnosis. They attend nbout onco n. fortnight for n. year or more. and IVI thoir number is being constantly augmented, congestion ensues, and no time is left for tho proper physical examination of even n. small fraction. Observation cases cea se to he observed, and tho prescription of drugs is all that ill done for them . Tho number of attendances at these congested dispcnsuries may be very imposing, hut it is mainly composed of children receiving treatment without diagnosis . In one dispensary it WIlS admitted that ro-cmminations wore so infrequent that intervals of six, nine, and oven twelve months occurred between each.
E.oic iellcy 1l'ith Intensive Study of each Cas«.
In some dispensuries great pains are taken to arrive at a diagnosis quickly I
LScptem her,
Hl20
and each case is studied intensively for a short period. When a patient has been submitted to such an intenaivo study for three to tour weeks without; a positive diagnosis being made, he is requested to attend the dispensary again in two or three months, and if no further positive evidence is available, he is discharged as e , probably not Buffering Cram clinical tuberculosis." lIe is then advised to report again in six months or earlier if new symptoms, appear.
The Super-Tuberculosis Consultant. Though the T.O. ranks, of course, as a. specialist and n. consultant, cases must inevitably occur in which 0. second opinion is desirable. But it appears that some T.O.'s consider they 0.1'0 unlikely to obtain any further assistance by referring the patient to n. consulting centre, and they Ienr that. in doing so they may be tacitly confessing to clinical incompetence. Tho majority of T.O.s do not Ieel the need for a consulting service, and in 1018 only 145 casea were referred by them to the consulting centres. Nearly 1\11 were cases of disease of special organs such as the throat and genito-urinary tract. Obseruaiion Beels. If, as the Report shows, the T.O. is unwi1li~g to refer to n SUpcl'-sIJecinlist. for advice, he should he provided with every facility for making un o.ccurato diagnosis himself. But bo does not. appear to be provided with the most. essential moans to this end-obsen'ntioll beds. Practically every T.O. feels tho n?ed o! them, both with a view to diagnosis and to determining tho most. suitable form of treatment. Latterly tho L.C.C. and the L.I.C. 11I\\'e l)rovidctl some observation bods. but T.O.s complain that they have no right of access to these patients, and many prefer to have them under their own supervision in a local homo.
Examination of Contacts. This important branch of tho dispensary scheme seems to be deplornLl~. neglected in many parts of London
September, 1020]
077
runnncr.s
During HJ18, 153 contacts were examined per 100 now cnsos in Hackney, and only l:i0 per 100 in Stoke Newington. This difference appoars to he tho measure of tho differenco in the energy of the public health staff in the two Boroughs. InNorth Kensington only about 1R per cent. of the estimntod number of contacts wore examined. Municipal dispensaries nro, in this matter, better situated than most voluntary dispensaries, and in Groenwich, for example, some 50 per cent. of the contacts of all notified cases appear to be examined in normal times. It is calculated that, assuming 80 per cent. of all contacts are oxurnined, l\ T.O. in charge of II. district with 120lGO deaths from tuberculosis per annum will probably spend three to four hours n, week on this work. Dr. Menzies' opinion of tho work dono in the matter of examining contacts stands revealed in the words-" The importance of this work needs to be strongly impressed on tuherculosis officers. . . ."
Visiting. Under the throe different headings : noma Consultations, Home Visiting and Home Visitn.tion-tho last named suggests a variety of visit amounting to an o.flIiction - the Report again exposes gravo sins of omission. It appears thnt tho T.O. of St. 'I'homns' Hospital is not allowo] hy the rules of tho hospital to consult at tho homos of patients. Tho Itcport procceds : II This i6 an unfortunate restriction, and it is desirable in the interests of efficiency that this rule should he revised." In some cases tho 1'.0. visits tho homos of most of his patlonts to inquire into nnd to remedy any home defects, and to examine contacts. He is thus enabled to study tho relation of environment to the disease in his nreu. Tho Report ndds : . . . . homo visiting in the CR.SO of tuberculosis i,; VOI'Y important, and it should bo tho rocoqnisod duty of the tuberculosis officor to visi t, nt If'l\!lt once, tho homo of every ono of his patients." At present pressure of work ot tho dispensaries, largely duo to overtreatment of patients, has considorably
reduced the amount of home visiting by the T.O., und thus to a largo extent one of the main functions and most - useful purposes of the tuberculosis' dispensnry is not fulfilled. ri.~itillfJ
b" the Nurse,
It appeo.rs that T .O.s rarely confer with tho hen.lth visitors or tho Public Health Depnrtment in their districts: tho work of these visitors is carried out without adequate relation to the dispensary, unrl " . . . tho tuborculosia ofIlcors deal with their patients practically without regard to their homo and othor circumstances ." The Roport procoods: II Tuberculosis is a disoase usually associnted with 11dective social conditions, and tho nssistanco of a truinod social worker who can deal effectively with prohlems which nrise from these conditions, would be nn immense advnntnge in every dispensary . . At present the tendency i!'l for almoners to work independnntly of tuberculosis oflicera, but if social workers are to be employed, it should be a sine qua non that they should work in intimate cooperation with, and -under the direction of. the tuberculosis officer." Ocer-treatment at the Dispensari), Tho Report hetrays mild exasporation 0\'01' tho conceptions of some T.O.A in tho matter of treatment. Except in tho case of 80n1O dlspensnries, where It few patients receive tuberculin, or other spccinl form of treatment, therapeutic measures should, according to tho Ileporf bo limited to ndvico as to hygiene. diet, oxorciso, &0., supplementod by tho troatment of spooiui symptoms. Unfortunutel y, tho pntiont« expect bottles of medici no . . . nne! tuberculosis officers fmqnctltly find it nocossnrv to ~h'o medicine fOI' tril1in~ symptoms, or oven for no spooinl modioal reason, in 01'11(11' to secure the rcgulnr attenrluneo of tho pnt.innb." In ono hospital dispcnsnry 4,!)li!) proscriptiona wore dispensed for 1\ total attondnnco of 4.A53, nnd 1,7R!) bottles of cod Iinw oil, &c.• wero given nwny. Another disponsnry 800m!'! to hnvo ~i\'on Virol with much protlign.1ity . Tho Report II
578
TUDEnOLE
proceods : .. The fact that patients expect and actually receive .m edicines, whether they really need them or not, necessarily tenus to make the patient rely more on the medicine and less on udvice given in regard to such essential matters as personal and homo hygiene, diet, &c."
Dlscharue of Di3pensal'Y Patients. T.O.s arc generally ruther nervous about discharging putients "probably not sullering from tuberculosis." The Report admits that some of these discharged cases may ultimately break down from tuberculosis, hut this unfortunate result will be more than counterbalanced by tho increased efliciency which will result from freeing dispensaries from prolonged attendance of these observation cases. At present they overcrowd some dispensaries and render the ohservution of themselves and athol'S ineffectivo. Supervision after Discharge. Tho Report deplores the fact that so fow dispensaries have any adequate system of following up their cnses. No dispensary system of supervision can ho regarded as efficient which permits patients to cease nttendanco without the knowledge of the tuberculosis officer. If n. patient ceases to attend, steps should be taken at once to ascertain the reason. Perhaps be may have had n. relapse, in which case ih is important that the tuberculosis officer should know at an early date, so that he may take such steps as are necessary in tho interests of the patient." II
Trouble witlt .1lcdical O.Diccl's of llealtlt. The Report touches but lightly on the serious grievnnces which T.O.s complain of in their relations to the M.O.I1. But it udmits that T.O.s would proler to hnvo reports on their patients sent to them direct instead of through the M.O.II. Tho arrangement by which all recommendations made by T.O.s for tho treatment of uninsured persons, and all requests hy the he.C. for progress reports upon patients who hnve rece ived troatment in residential institutions, are
[September,lD20
made through the l\I.O.II. of tho Dorough has leu to delay in the IJI\st, The Report recommends the revision of these arrangements and suggests that the T.O. should send all recommendations to, and receive 0.11 requests Cor reports direct from, the County Council. The case of the l\I.O.II. who gets himself appointed as T.O . and then sidetracks all tuberculosis work is not dealt with in the Report.
The X1cmber of T.O.s required ill London. It is calculated that a T.O. cannot deal efficiently with a population having ' more than IGO deaths (rom tuberculosis per annum. Provision should, thero(oro, be made in tho near future (or ono whole-time T.O. (or not lORS than ever}' 1GO deaths. On this basis 50 T,O.s would be required for London, i.e., ono for about each 90,000 of tho population: One T.O. for every 120 deaths would involve the appointment of GG T.O.s. i.o., one to about every 70,000 of tho population. Finance. The Report calculates that the cost ' of 0. dispensary service on tho scale contemplated in 1915 would amount to at least 50 per cent. more in 1920. Tho development of certain sections or tho work inadequately provided (or in the scheme for 1915 would also add to the cost. Thus, for London, tho estimated cost of 1\ dispensary sorvico would be as follows : 1<~8t1mll.tu for Hl15
.. .• . • £37,450 Add 60 per cent, to meet increased cost 18,72~ Add to moet cost of improved servico U,82~ (say) •.
-
Estimated total cost of revised service in 1020-21 .. J:GG,OOO
Siqnificance of the Ileport, Both the advocates and opponents of n state medical service will find in thi~ Report much to interest them, (or 011 1\ small scale it reveals both tho advantages and tho shortcomings of such u sorvico- The liberty of the indi vidual is certainly restricted : tho T.O. who expects his nppointment to be 0. bod of
September, 1920]
TUDEUCLE of the shorn lurnb whon his work hils been inspect ed IU ll1 his incompetenco exposed. On th o other hand . th e '1'.0. with initiative, efficiency and II capacity for hard work will find in this Report an encouraging loItimu lus .
roses in which he can repose undisturbed must be painfully disillusion ed when his sins of omission are publicly discussed, The T.O. whose conception of tubercu losis dispensary work is out of date and unpractical must suffer the discomforts
TUBERCULOSIS BIOGRAPHIES. II.- HUliGAHD. H:l51-1911. WILLIAM RICHAHD RUlWARD
WILS
born in IH51 at Kilcock, near Dublin. He graduated as M.D. of the Royal University of Ireland in 1875 and 0.8
W. R.
M.A. Il year later. During the earlier yeurs of hill medical career he worked in lunacy with Forbes- Winslow. wrote a few articles on matters connected with that subject, but gained a. very meagre income-r-ae meagre, indeed, 39
that when chance Bent him an invitution to settle at DIlNOS. he had to get into deht in order to pass the necessary examinations for the Swiss Federal Diploma ILt Geneva. He reached Duvos in IHH5. and there, while receiving loyal support from those who had
HUGGARD.
invited him-those. that is to SILY, who wore pri maril y concerned to develop the heulth rOBort-encountere·1 uneonipremising opposition (rom hill rivuls. It WILS 1\ long uphill fi~ht for existence. The sources of inforuiution about those