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REHABILITATION OF THE TUBERCULOUS
1191
LETTERS TO THE EDITOR REHABILITATION OF THE TUBERCULOUS
SIR,-At last ! In your issue of Nov. 11 I perceived echoes of a voice-my own-which had cried long in the wilderness. Evidently there were ears in that wilderness, however, for now your correspondent " T. B." is crying in the same key and your leading article provides a harmonious and authoritative obbligato. Of course the rehabilitation of the tuberculous must be handled on a national basis. Of course it must provide "remunerative employment for ex-sanatorium patients either in colonies or in special Of course factories under medical supervision." regional control will prove more effective than " the isolated and independent action of separate local
authorities." I gather that " three national organisations with the word tuberculosis in their titles" are to appoint a liaison committee to consider these points; but is there, in fact, any need for a committee to confirm the obvious?!if Surely what this committee will need to do is to work out a scheme indicating (a) who is to provide the remunerative employment, (b) who is to meet the losses (if any) incurred and (c) where the capital is to come from. Local authorities, and even coalitions of local authorities forming a region, are likely to fight shy of anything in the nature of municipal trading: yet without trading how can there be remunerative employment ? And without the cooperation of the local authorities where is the financial responsibility to rest?!if It is a big problem. There are 70,000 sputum-positive cases in the country and only 30,000 beds for them (even in normal times). The scheme must therefore envisage the provision of "remunerative employment" for tens of thousands of people if it is to be anything more than a pious demonstration of benevolent intentions. In 1930, in collaboration with Mr. Reynell Wreford, I submitted a scheme to the Ministry of Health. The proposals were never seriously challenged. It was not disputed that they had merit. But nothing happened; the echoes died away, and the wilderness remained. In 1936 further efforts were made, in connexion with an interdepartmental committee, to draw attention to the necessity for the national organisation of rehabilitation. This time the scheme was extended to include all disabled persons, and not the tuberculous alone. But it might as well have included the denizens of the moon, for it evoked neither criticism nor action. Despairing of securing action-or even reaction-at home, I next incorporated the scheme in my address on the rehabilitation of the tuberculous for the 1939 conference of the International Union Against Tuberculosis to be held in Berlin last September. There was no lack of action this time. No sooner had proofs been circulated than war broke out. T
mn.
Sir.
vonra
faithfnllv.
solved, is how this X-ray examination should be carried out. Various methods have been suggested and are being investigated by the Ministry of Health. Of the alternatives, my opinion is as follows: 1. Fluoroscopy only is wrong, (a) because a certain number of lesions will not be seen even by the most experienced observer; arid (b) because such examination would form no permanent record. 2. Miniature radiography as carried out in this country at present would not be sufficiently accurate owing to the lack of detail in the films, at least, judging from those I have seen. I cannot say whether this is due to the technique employed or to the screen, camera, lens or film, for miniature radiograms taken in Germany and in America seem more satisfactory. 3. Paper films have passed the experimental stage and they could be used satisfactorily providing that they were taken by expert radiographers and viewed under proper conditions. Even then there would be cases in which celluloid films would be undoubtedly necessary for confirmation. 4. There is no doubt that the routine method of taking one 15 by 12 in. celluloid film in each case is the ideal, and that this or the paper film is the only method which can be immediately brought into use in the present emergency. Facilities for screening certain cases would also have to be provided. I am, Sir, yours faithfully, J. V. SPARKS.
SiR.—As one who has been engaged for some years in the examination of recruits for the forces I should like strongly to endorse the remarks made by " Chairman of a Board " in your issue of Nov. 11. Amongst the instructions laid down for the selection of recruits, the following were some of the requirements. A complete medical history; evidence of nervous stability; exercise-tolerance test, where there is any doubt about circulatory efficiency; auroscopic examination and hearing test; pupil reflex to light and accommodation, eye movements and colour vision; knee-jerks and other reflexes; and, of course, the usual measurements and a complete examination of the various bodily systems. Every medical man who knows his job is aware that it is impossible adequately to carry out an examination such as this in 5 minutes, much less in 2 minutes, as appears to be suggested by the authors of the present regulations. The remuneration received for this rather comic examination works out at Is. 4d. per recruit examined, or, in the case of the expert who takes only 2minutes, at 8d. per recruit. I suggest that the inscription, E. & 0. E. in bold letters of red ink should be written across each report and initialled by the chairman. I am,
PENDRILL VARRIER-JONES.
Sir,
yours
faithfully, B. J. COURTNEY.
Papworth Village Settlement, Cambridge, Nov. 21.
EXAMINATION OF RECRUITS
MR.,—There is obviously no doubt in the minds of medical men today, whether radiologists or clinicians, that an X-ray examination of the chest is desirable both in the interest of those going into the Services and of others who may be associated with them. Furthermore, the cost of such an examination will be negligible in comparison with that of paying pensions to those who are incapacitated as a result of such service. The real question, which has not yet been
INTESTINAL BACTERIA AND RESISTANCE TO OXYGEN-WANT a previous letter it was reported that resistance of white rats to anoxia may be definitely increased by feeding on a diet consisting wholly of carrots. Since then these results have been confirmed and the factors underlying this favourable effect include (a) low protein content, (b) presence of fibre, (c) presence of glutamine and (d) adverse
SiB,—In
the
1.
Lancet, 1938, 1, 914.
LETTERS TO THE EDITOR REHABILITATION OF THE TUBERCULOUS
SIR,-At last ! In your issue of Nov. 11 I perceived echoes of a voice-my own-which had cried long in the wilderness. Evidently there were ears in that wilderness, however, for now your correspondent " T. B." is crying in the same key and your leading article provides a harmonious and authoritative obbligato. Of course the rehabilitation of the tuberculous must be handled on a national basis. Of course it must provide "remunerative employment for ex-sanatorium patients either in colonies or in special Of course factories under medical supervision." regional control will prove more effective than " the isolated and independent action of separate local
authorities." I gather that " three national organisations with the word tuberculosis in their titles" are to appoint a liaison committee to consider these points; but is there, in fact, any need for a committee to confirm the obvious?!if Surely what this committee will need to do is to work out a scheme indicating (a) who is to provide the remunerative employment, (b) who is to meet the losses (if any) incurred and (c) where the capital is to come from. Local authorities, and even coalitions of local authorities forming a region, are likely to fight shy of anything in the nature of municipal trading: yet without trading how can there be remunerative employment ? And without the cooperation of the local authorities where is the financial responsibility to rest?!if It is a big problem. There are 70,000 sputum-positive cases in the country and only 30,000 beds for them (even in normal times). The scheme must therefore envisage the provision of "remunerative employment" for tens of thousands of people if it is to be anything more than a pious demonstration of benevolent intentions. In 1930, in collaboration with Mr. Reynell Wreford, I submitted a scheme to the Ministry of Health. The proposals were never seriously challenged. It was not disputed that they had merit. But nothing happened; the echoes died away, and the wilderness remained. In 1936 further efforts were made, in connexion with an interdepartmental committee, to draw attention to the necessity for the national organisation of rehabilitation. This time the scheme was extended to include all disabled persons, and not the tuberculous alone. But it might as well have included the denizens of the moon, for it evoked neither criticism nor action. Despairing of securing action-or even reaction-at home, I next incorporated the scheme in my address on the rehabilitation of the tuberculous for the 1939 conference of the International Union Against Tuberculosis to be held in Berlin last September. There was no lack of action this time. No sooner had proofs been circulated than war broke out. T
mn.
Sir.
vonra
faithfnllv.
solved, is how this X-ray examination should be carried out. Various methods have been suggested and are being investigated by the Ministry of Health. Of the alternatives, my opinion is as follows: 1. Fluoroscopy only is wrong, (a) because a certain number of lesions will not be seen even by the most experienced observer; arid (b) because such examination would form no permanent record. 2. Miniature radiography as carried out in this country at present would not be sufficiently accurate owing to the lack of detail in the films, at least, judging from those I have seen. I cannot say whether this is due to the technique employed or to the screen, camera, lens or film, for miniature radiograms taken in Germany and in America seem more satisfactory. 3. Paper films have passed the experimental stage and they could be used satisfactorily providing that they were taken by expert radiographers and viewed under proper conditions. Even then there would be cases in which celluloid films would be undoubtedly necessary for confirmation. 4. There is no doubt that the routine method of taking one 15 by 12 in. celluloid film in each case is the ideal, and that this or the paper film is the only method which can be immediately brought into use in the present emergency. Facilities for screening certain cases would also have to be provided. I am, Sir, yours faithfully, J. V. SPARKS.
SiR.—As one who has been engaged for some years in the examination of recruits for the forces I should like strongly to endorse the remarks made by " Chairman of a Board " in your issue of Nov. 11. Amongst the instructions laid down for the selection of recruits, the following were some of the requirements. A complete medical history; evidence of nervous stability; exercise-tolerance test, where there is any doubt about circulatory efficiency; auroscopic examination and hearing test; pupil reflex to light and accommodation, eye movements and colour vision; knee-jerks and other reflexes; and, of course, the usual measurements and a complete examination of the various bodily systems. Every medical man who knows his job is aware that it is impossible adequately to carry out an examination such as this in 5 minutes, much less in 2 minutes, as appears to be suggested by the authors of the present regulations. The remuneration received for this rather comic examination works out at Is. 4d. per recruit examined, or, in the case of the expert who takes only 2minutes, at 8d. per recruit. I suggest that the inscription, E. & 0. E. in bold letters of red ink should be written across each report and initialled by the chairman. I am,
PENDRILL VARRIER-JONES.
Sir,
yours
faithfully, B. J. COURTNEY.
Papworth Village Settlement, Cambridge, Nov. 21.
EXAMINATION OF RECRUITS
MR.,—There is obviously no doubt in the minds of medical men today, whether radiologists or clinicians, that an X-ray examination of the chest is desirable both in the interest of those going into the Services and of others who may be associated with them. Furthermore, the cost of such an examination will be negligible in comparison with that of paying pensions to those who are incapacitated as a result of such service. The real question, which has not yet been
INTESTINAL BACTERIA AND RESISTANCE TO OXYGEN-WANT a previous letter it was reported that resistance of white rats to anoxia may be definitely increased by feeding on a diet consisting wholly of carrots. Since then these results have been confirmed and the factors underlying this favourable effect include (a) low protein content, (b) presence of fibre, (c) presence of glutamine and (d) adverse
SiB,—In
the
1.
Lancet, 1938, 1, 914.