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The duration of sanatorium treatment
216
TUDEROLE
[February, 1925
'l'llE DURATION OF SANATORIUM TREATMENT. By 'V. C. FOW'Llm, M.D., B.S. MedicnZ Superintendent, PinewootZ Sanuioritnn, Wokillgham, Berka. PUDLIO authorities spending £2·3 per week and private patients spending anything up to 8 or 10 guineas for the treatment of tuberculosis. nrc both naturally concerned with the question: .. What is the duration of the treatment .~" It is n, question to which-as sanatorium physicians or tuberculosis officers-we are expected to be able to give some kind of uuthoritative reply on purely medical grounds, although there will alwa)·g. be economic, social, and temperamental factors to consider afterwards'. On medical grounds it might be argued that if sanatorium treatment is beneficial to the consumptive, the more treatment the better. In n theoretical senso this may be true, but in practice it does not work out so ..imply. 'Ve have all seen examples of the young consumptive, with recent hut active disease, making a wonderful response to sanatorium treatment Cor II, month or so, and then steadily drifting back again under the same regime. 'I'his is also true of many chronic cases, who a~ways respond to a change, hut never for long. Home troubles, home Sickness, or love affairs lDay influenco the progress and make further stay in a sanatorium useless nlthough the case may be very suitable otherwise for prolonged treatment~ Dr, Bardswell made the following statement this year in an article published in Tubercle [I}: In my judgment the ensemble of a patient's home environment, his housing, work, habits, temperament, and standard of living determine the consumptive's futuro to a much greater degree than docs his period of sanatorium treatment." He goes on to say: U As things are to-day it is conceivable that, in regard to the moderately advanced cases. the money representing the additional cost of six months compared with three months' sanatorium treatment might be more usefully expended in the interests of tho patient and his family.': 'I'here wero just over 13,000 sanatorium beds available in this country for the treatment of tuberculosis (not including hospital beds) in 1923. '1'h080 have to serve for, roughly, 05,000 notified cases. It is quite clear that oven when thoso cases are excluded which do not appear to be in need of sanatorium treatment, the available accommodation must be very economically utilised if adequate treatment for suitable cases is to be given. This can only be dono by considering what are the factors which should influence us in rccounnending prolonged treatment up to eighteen months or two years, and what cases can do with two or three months only. Unfor- · tunatoly, many of the statistics of results of treatment, either immediate or remote, do not specify the length of treatment except as an avernge for0.11 types of cnsc. This docs not help in the least, as with the same ycarl)' average length of stay for all patients, two different medical advisers lUa)' obtain entirely different results. One may give all patients three or four months' treatment irrespective of type, and another may uso experience and clinical acumen to sort out those who require a sbort stay frorn those Cor whom a long period is desirable, and thus benefit both types of casethe one by an eo.rly release and tho other by prolonged treatment. 'I'he economic cffed of the war and the temporary increase in tho number of notified cases of tuberculosis resulted in very unsll.tisfactory II
I
I
February, 1025]
SANATORIUM TUEATl\IEN'l'
217
compromises in this problem; one county insurance committeo during the war actually gave a fixed period of six weeks to all cases, early or advanced, irrespective of medical advice. Most county sanatoriums during that period maintained an average of ten to twelve weeks, though in London in 101B 67 per cent. of the soldiers and sailors were treated for less than eight weeks, and only 13'5 per cent. stayed for more than twelve weeks. The civilian patients fared somewhat better, their figurcs being 55'0 pcr cent. and 18'6 per cent. respectively for male patients [2J. The years IOU) and H)20 [3 J showed a progressive increase in the length ohtay, the figure G7 per cent. staying less than eight weeks was reduced to 34 per cent. and 27 per cent. respectively, while the 13'0 per cent. staying over twelve weeks became 51 per cent. and 50 per cent. respectively. It. is obvious that the shorter duration of stay was very much influenced by Iactors other than medical, some of which are now fortunately Jess acute. At the Trudeau Sanatorium, United States, the average length of stay in 1022 was 161 days, and the average of thirteen sanatoriums in Minnesota was 217 days [3J. In Canada, the grouped average length of stay in HJ20 was 158 days, the maximum average for anyone institution being 255 days. 'I'he report of the consultants states thnt 40 per cent. of the relapses were traced to insufficient treatment [5]. In Germany, Dr. Helm, the Secretary of the Central Committee forCombating Tuberculosis, wrote saying that the usual period is now threemonths but that one insurance society claims to get useful results with six weeks treatment. I am promised more detailed figures which have not. yet come to hand. Professor Reiche advocates more than one course of treatment and states that 24 per cent. of his cases had two courses, and 7 per cent. had three courses. His results show that even after seventeen or more years 4G'0 per cent. of his cases were fit for work and 35'2 per cent. dead [6]. Some years ago IL more or less elaborate system of analysis of the afterhistories of sanatorium patients came into vogue and has steadily increased in popularity and accuracy. The results after five to ten years' interval were so different from the glowing records of the condition of patients on discharge that a general outcry was raised for more and moro treatment. A higher ideal would have been more and Letter treatment, but quantity is more easily obtainable than quality. At the same time attention was focused on the classification of cases as regnrds optimum length of treatment in n sanatorium, and IL few of the statistical records now show something more tangible than hitherto. In n. very exhaustive annual report for the year HJ22, Dr. G. Lissant Cox analyses the after-histories of 3,ti04 adult cases of pulmonary tuberculosis occurring in the county of Lancashire, who completed one or more courses of snnntorium treatment associated with home treatment and dispensary supervision or treatment. The average length of stay for each oC the groups of early, intermediate and advanced cases is given, both for II positive" and II negntive " sputum types of case. For the years 1014-1921 inclusive, tho average length of stay for early cases with negativesputum or no sputum WILS from OU to 144 days: for early cases with positive sputum from 111 to lBG days: for intermediate cases with negu-
218
TUDERCLE
[February,
1D~5
tivo or no sputum, from 102 to 138 days; for intermediate cases with positive sputum from 132 to 168 days. 'I'he actual report states tho stay in mouths but for comparison I have converted the figures into days. Houghly speaking, .. positive" sputum cases received an average of ono more month's treatment than negative sputum cases, and practically no distinction occurred between tho average length of stay of early and intermediate cases of either group. 'I'he annual reports of different county and other sanatoria during the past two or three years show an average length of stay varying from 10·! to 180 days. In the case of the sanatoria belonging to the King Edwo.rd VII \Velsh Nutional Memorial Association, the figures kindly supplied to me by the director, relating to lUO consecutive' cases o.t three different sanatoris for early and intermediate cases, show an average length of stay for sputum "nego.tive" cases of 232, 175 and 161 days respectively, while for sputum .. positive" cases the figures are 171, 2:.!4 and 158 days respectively. The maximum sto.y for "nego.tive" sputum cases was 685 days and for "positive" sputum cases was 490 days, tho minimum stay being fifty·two and fifty-four days respectively. It seems clear tho.t in Wales II negative" sputum cases are considered to be deserving of no less prolonged treatment than" positive" sputum Co.SOR. On the other hand o.t the Faksingo Sanatorium, Denmark, J. Ostcnleld reports [7] the average duration of treatment for various stages as follows: En.rly cases with negative sputum 125 days, and with positive sputum 103 days. Intermediate cases with negative sputum 14U days, and with positive sputum 100 days. This shows an increase of 22 rer cent. and 3-1 per cent. in tho duration of stay on account of the presence of tubercle bacilli in the sputum. The results of this sanutorium show that alter five or more years 82 per cont. of the early cases wero working and 5 per cent. were dead, whito 67',1 per cent. of the intermedio.to cases were working and 16'8 per cent. were dead. 'I'hesc aro remarkably good results. Dnrdswellnnd Thompson reported in n. Medical Itoaenrch Council inquiry that the average length ot 8tn.y at Midhurst was 120 to 150 days, and that amongst comparable groups of patients the average condition three to five years after discharge was tho aamo as that of Adirondack Sanatorium patients, investigated by Elderton and Perry, whilo six to eight years after discharge the average results at Midhurst werc better, in spite of tho fact that the Adirondack nverugo length of stay was much longer. Taking other factors, such as age of patients, into consideration, tho authors infer tho.t tho Adirondack figures arc slightly more Iavourable than the Midhurst figures, but not more 80 than tho differenco in social and financial conditions might account for. 'l'here remains to be considered the question as to whether unUsually long periods of treatment are worth while. Attention has been directed lately to certain American figures which appear to show remarkably good results lrom sanntoeiuni treatment for twelve months or thereo.bouts. It must bo confessed, howover, that tho more one examines these results the 110S9 impresaivo thoy become. For insto.nco, Billings and Hawes [8] describe tho after-reBults of 1,056 putients discharged between 1912 and 1U14 from 'cour differont sanatoria in Massachusetts, of which 82 per cent. Were
l!~ebruary,
1025]
SANATOUIUM TREATMRNT
intermediato and advanced cases, and only 17 per cent. are described as being incipient on admission. They consider that the treatment showed Hself to be beneficial directly in proportion to the length of stay, which varied Cram three to six months, but it is disconcerting to find that 45 per cent. were dead and only 29 per cent. were ' at work. Moreover, the moderately advanced cases on admission showed better after-resulte than the incipient cases. tt is clear that these figures require more minute statistical inquiry beforo the conclusion stated above can be said to be of value. Still more striking, apparently, are the results quoted by Hawk, Dublin and Knudsen (or the Mt, McGregor Sanatorium [n] . 'I'he early cases .stayed on an average seven months, the intermediate cases 121moilths, and 4dvanced cases 14! months; average (or all cases ten months. Tho results collected from one to seven years later showed that of the early cases 00 per cent. were at work and 3 per cent. were dead; of the intermediate cases 70 per cent. were at work, and of the advanced cases 20 per cent. were at work. It is to be noted, however, that 70 per cent. of all cases admitted were described as U incipient." This unusually high figure is perhaps explained when one finds that the sanatorium is for the treatment of employees of the Metropolitan Life Insurance Company, New York, who number 18,000, and that in seven years U53 cases were admitted for treatment. If the County of London indulged in tuberculosis to the same extent it would produce 53,000 cases yearly and require 18,000 sanatorium beds, It seems probable that the 70 per cent. "incipient OJ cases reflect tho excessive Iear of tuberculosis that is prevalent in America, and possibly 4180 excessive value placed on radioscopic findings, without which many of tho" intermediate" group would be classed as early, and mnny of the ...early" group would have gone to the seaside for a holiday instead, with ('lqualJy beneficial results. ~rhe British Ministry of Health arc so suspicious of the cases of tuberculosis in discharged soldiers and sailors requiring more than six months' treatment that Circular 307 demands n. special rcview of such cases by tho tuberculosis officer and medical superintendent 'without fee, although in Circular 280 they admit the necessity for long treatment for early cases, and suggest re-admission from time to time for intermediate cases, In conclusion, one may say that temperamental, financial nnd social considerations must modify any purely medical dogma as to tho ideal duration of treatment, but as n basis for discussion it is suggested that "'sputum negative" cases without marked toxmmia or physical signs should have three months' treatment, If physical signs or toxmmia are well marked they should be given as long 0. treatment as "sputum positive" caaes. 1.'ho early U sputum positive OJ case requires six to seven months, and the intermediate case must be judged entirely on tho progress; any permanent increase in physical signs, oven if tho general health is hetter, should bo an indication for a change of treatment, but a progressive improvement in physical signs should justify anything up to twelve months, or even longer, it tho home conditions are likely to be reasonably good on return. For advanced cases, no sanatorium treatment should be given at all, but open-ale hospital treatment, where attention is given to education as to infection.
220
')'UDERCLE
[1] [2] lUiS." [3] [41 [r,] [G]
[February, l!)25
REFERENCES. Tubercle, May, 1024, p.374. "Annual Report or Insurance Committee Cor County oC London Cor Year
Ibid. Ior Years uno and 1920. American Reoieui of Tuberculosis, 1921, p. 57. Summary of Report, Tubercle, July, 1921, p. 4GO. Beitr. z, lain. d. Tuberk., 1923, liv, 210. [7 J Ugc.•krift for Laeqer, 1920, p. 6G9 et scq. [~] American lievieu: of Tuberculosis, 1018, p. GG3. 19] Ibid., October, 1922.
'l'IIE RESULTS OF SANA'l'OHIUl\I TREATl\IEN1.'.l Dy NOEL
D.
DAllDSWELL,
M.V.O., M.D.,
n.n.c.i-,
Conlftltin!l l'hy.ician, KinU Edward I'll Sanatorium, Midlturat. THE subject is llo big one and may be approached from many points of view: medical, social, financial, l~C. I propose to devote myself, chiefly, to 0. consideration of the sanatorium as ?' means of treating pulmonary tuberculosis. In this respect, apart from Impressions resulting from many years' experience, I am able to put before you some definitely ascertained Incts; namely, tho mortality experienced by patients subsequent to their treatment in 0. sanatorium. Such mortality experiences give a good impression of tho expectation of lifo enjoyed by patients when they leave 0. sanatorium. \Vo have three studies of the mortality amonc sanatoriulU patients, each of them of much interest, but additionally val~nble, collectively, inasmuch as, though made independently and dealing with different patients, treated in different institutions, the results show a striking simi. larity. This agreement is presumptive evidence of their accuracy. In 1Ul::J, Elderton and P~rry~ published t~o m.ortality ~xpericnced by 3,000 cnses treated at tho Adirondack Sanatorium 10 Amenca during the years 1885-HHl. This work prompted me in 1U17 to undertake a similn.r invostigution" in connection with 1,700 patients discharged from King Edwal'll VII Banatorium, Midburst, from HJ07-H114. '!'his has Leen Iollowcd, quite recently, by a study,' on precisely similar lines, of the alterhistories of 3,73B patients discharged from the Brompton lIospitnl Sanaturium at Frhuley during the years HI05-HH4. 'I'he principle followed in these three investigations was tbo same, 'l'ho various putients in each sanatorium wero first classified into the customary groups; early, moderately advanced and advanced. The number of deaths that had occurred in each group, during E.OWe years subsequent to their discharge from tho sanatorium, was then C01Uparc{\ with the number of deaths that would have been expected dUring 0. liko period had the groups of patients been samples of the general population 1 Tho Opening AdJrcllllln a Dlecusslon convened by tho lIarveian Society.
•
, .. MorLlI.my of tho TuberculouK," Elderton and Perry. Dulau and Son, 1913• ... 2lIortn.lity after Sandorium Trealment,"llaruswell and Thompson: Medical Ueaearch Counulttee, 1\119• ... After.Illstoriea of Patients treateu at l·'rlmlcy Sanatorium," Hartley, WingfielJ 'rLompao n• Medical Ileaearch Committee, 192·"
and
TUDEROLE
[February, 1925
'l'llE DURATION OF SANATORIUM TREATMENT. By 'V. C. FOW'Llm, M.D., B.S. MedicnZ Superintendent, PinewootZ Sanuioritnn, Wokillgham, Berka. PUDLIO authorities spending £2·3 per week and private patients spending anything up to 8 or 10 guineas for the treatment of tuberculosis. nrc both naturally concerned with the question: .. What is the duration of the treatment .~" It is n, question to which-as sanatorium physicians or tuberculosis officers-we are expected to be able to give some kind of uuthoritative reply on purely medical grounds, although there will alwa)·g. be economic, social, and temperamental factors to consider afterwards'. On medical grounds it might be argued that if sanatorium treatment is beneficial to the consumptive, the more treatment the better. In n theoretical senso this may be true, but in practice it does not work out so ..imply. 'Ve have all seen examples of the young consumptive, with recent hut active disease, making a wonderful response to sanatorium treatment Cor II, month or so, and then steadily drifting back again under the same regime. 'I'his is also true of many chronic cases, who a~ways respond to a change, hut never for long. Home troubles, home Sickness, or love affairs lDay influenco the progress and make further stay in a sanatorium useless nlthough the case may be very suitable otherwise for prolonged treatment~ Dr, Bardswell made the following statement this year in an article published in Tubercle [I}: In my judgment the ensemble of a patient's home environment, his housing, work, habits, temperament, and standard of living determine the consumptive's futuro to a much greater degree than docs his period of sanatorium treatment." He goes on to say: U As things are to-day it is conceivable that, in regard to the moderately advanced cases. the money representing the additional cost of six months compared with three months' sanatorium treatment might be more usefully expended in the interests of tho patient and his family.': 'I'here wero just over 13,000 sanatorium beds available in this country for the treatment of tuberculosis (not including hospital beds) in 1923. '1'h080 have to serve for, roughly, 05,000 notified cases. It is quite clear that oven when thoso cases are excluded which do not appear to be in need of sanatorium treatment, the available accommodation must be very economically utilised if adequate treatment for suitable cases is to be given. This can only be dono by considering what are the factors which should influence us in rccounnending prolonged treatment up to eighteen months or two years, and what cases can do with two or three months only. Unfor- · tunatoly, many of the statistics of results of treatment, either immediate or remote, do not specify the length of treatment except as an avernge for0.11 types of cnsc. This docs not help in the least, as with the same ycarl)' average length of stay for all patients, two different medical advisers lUa)' obtain entirely different results. One may give all patients three or four months' treatment irrespective of type, and another may uso experience and clinical acumen to sort out those who require a sbort stay frorn those Cor whom a long period is desirable, and thus benefit both types of casethe one by an eo.rly release and tho other by prolonged treatment. 'I'he economic cffed of the war and the temporary increase in tho number of notified cases of tuberculosis resulted in very unsll.tisfactory II
I
I
February, 1025]
SANATORIUM TUEATl\IEN'l'
217
compromises in this problem; one county insurance committeo during the war actually gave a fixed period of six weeks to all cases, early or advanced, irrespective of medical advice. Most county sanatoriums during that period maintained an average of ten to twelve weeks, though in London in 101B 67 per cent. of the soldiers and sailors were treated for less than eight weeks, and only 13'5 per cent. stayed for more than twelve weeks. The civilian patients fared somewhat better, their figurcs being 55'0 pcr cent. and 18'6 per cent. respectively for male patients [2J. The years IOU) and H)20 [3 J showed a progressive increase in the length ohtay, the figure G7 per cent. staying less than eight weeks was reduced to 34 per cent. and 27 per cent. respectively, while the 13'0 per cent. staying over twelve weeks became 51 per cent. and 50 per cent. respectively. It. is obvious that the shorter duration of stay was very much influenced by Iactors other than medical, some of which are now fortunately Jess acute. At the Trudeau Sanatorium, United States, the average length of stay in 1022 was 161 days, and the average of thirteen sanatoriums in Minnesota was 217 days [3J. In Canada, the grouped average length of stay in HJ20 was 158 days, the maximum average for anyone institution being 255 days. 'I'he report of the consultants states thnt 40 per cent. of the relapses were traced to insufficient treatment [5]. In Germany, Dr. Helm, the Secretary of the Central Committee forCombating Tuberculosis, wrote saying that the usual period is now threemonths but that one insurance society claims to get useful results with six weeks treatment. I am promised more detailed figures which have not. yet come to hand. Professor Reiche advocates more than one course of treatment and states that 24 per cent. of his cases had two courses, and 7 per cent. had three courses. His results show that even after seventeen or more years 4G'0 per cent. of his cases were fit for work and 35'2 per cent. dead [6]. Some years ago IL more or less elaborate system of analysis of the afterhistories of sanatorium patients came into vogue and has steadily increased in popularity and accuracy. The results after five to ten years' interval were so different from the glowing records of the condition of patients on discharge that a general outcry was raised for more and moro treatment. A higher ideal would have been more and Letter treatment, but quantity is more easily obtainable than quality. At the same time attention was focused on the classification of cases as regnrds optimum length of treatment in n sanatorium, and IL few of the statistical records now show something more tangible than hitherto. In n. very exhaustive annual report for the year HJ22, Dr. G. Lissant Cox analyses the after-histories of 3,ti04 adult cases of pulmonary tuberculosis occurring in the county of Lancashire, who completed one or more courses of snnntorium treatment associated with home treatment and dispensary supervision or treatment. The average length of stay for each oC the groups of early, intermediate and advanced cases is given, both for II positive" and II negntive " sputum types of case. For the years 1014-1921 inclusive, tho average length of stay for early cases with negativesputum or no sputum WILS from OU to 144 days: for early cases with positive sputum from 111 to lBG days: for intermediate cases with negu-
218
TUDERCLE
[February,
1D~5
tivo or no sputum, from 102 to 138 days; for intermediate cases with positive sputum from 132 to 168 days. 'I'he actual report states tho stay in mouths but for comparison I have converted the figures into days. Houghly speaking, .. positive" sputum cases received an average of ono more month's treatment than negative sputum cases, and practically no distinction occurred between tho average length of stay of early and intermediate cases of either group. 'I'he annual reports of different county and other sanatoria during the past two or three years show an average length of stay varying from 10·! to 180 days. In the case of the sanatoria belonging to the King Edwo.rd VII \Velsh Nutional Memorial Association, the figures kindly supplied to me by the director, relating to lUO consecutive' cases o.t three different sanatoris for early and intermediate cases, show an average length of stay for sputum "nego.tive" cases of 232, 175 and 161 days respectively, while for sputum .. positive" cases the figures are 171, 2:.!4 and 158 days respectively. The maximum sto.y for "nego.tive" sputum cases was 685 days and for "positive" sputum cases was 490 days, tho minimum stay being fifty·two and fifty-four days respectively. It seems clear tho.t in Wales II negative" sputum cases are considered to be deserving of no less prolonged treatment than" positive" sputum Co.SOR. On the other hand o.t the Faksingo Sanatorium, Denmark, J. Ostcnleld reports [7] the average duration of treatment for various stages as follows: En.rly cases with negative sputum 125 days, and with positive sputum 103 days. Intermediate cases with negative sputum 14U days, and with positive sputum 100 days. This shows an increase of 22 rer cent. and 3-1 per cent. in tho duration of stay on account of the presence of tubercle bacilli in the sputum. The results of this sanutorium show that alter five or more years 82 per cont. of the early cases wero working and 5 per cent. were dead, whito 67',1 per cent. of the intermedio.to cases were working and 16'8 per cent. were dead. 'I'hesc aro remarkably good results. Dnrdswellnnd Thompson reported in n. Medical Itoaenrch Council inquiry that the average length ot 8tn.y at Midhurst was 120 to 150 days, and that amongst comparable groups of patients the average condition three to five years after discharge was tho aamo as that of Adirondack Sanatorium patients, investigated by Elderton and Perry, whilo six to eight years after discharge the average results at Midhurst werc better, in spite of tho fact that the Adirondack nverugo length of stay was much longer. Taking other factors, such as age of patients, into consideration, tho authors infer tho.t tho Adirondack figures arc slightly more Iavourable than the Midhurst figures, but not more 80 than tho differenco in social and financial conditions might account for. 'l'here remains to be considered the question as to whether unUsually long periods of treatment are worth while. Attention has been directed lately to certain American figures which appear to show remarkably good results lrom sanntoeiuni treatment for twelve months or thereo.bouts. It must bo confessed, howover, that tho more one examines these results the 110S9 impresaivo thoy become. For insto.nco, Billings and Hawes [8] describe tho after-reBults of 1,056 putients discharged between 1912 and 1U14 from 'cour differont sanatoria in Massachusetts, of which 82 per cent. Were
l!~ebruary,
1025]
SANATOUIUM TREATMRNT
intermediato and advanced cases, and only 17 per cent. are described as being incipient on admission. They consider that the treatment showed Hself to be beneficial directly in proportion to the length of stay, which varied Cram three to six months, but it is disconcerting to find that 45 per cent. were dead and only 29 per cent. were ' at work. Moreover, the moderately advanced cases on admission showed better after-resulte than the incipient cases. tt is clear that these figures require more minute statistical inquiry beforo the conclusion stated above can be said to be of value. Still more striking, apparently, are the results quoted by Hawk, Dublin and Knudsen (or the Mt, McGregor Sanatorium [n] . 'I'he early cases .stayed on an average seven months, the intermediate cases 121moilths, and 4dvanced cases 14! months; average (or all cases ten months. Tho results collected from one to seven years later showed that of the early cases 00 per cent. were at work and 3 per cent. were dead; of the intermediate cases 70 per cent. were at work, and of the advanced cases 20 per cent. were at work. It is to be noted, however, that 70 per cent. of all cases admitted were described as U incipient." This unusually high figure is perhaps explained when one finds that the sanatorium is for the treatment of employees of the Metropolitan Life Insurance Company, New York, who number 18,000, and that in seven years U53 cases were admitted for treatment. If the County of London indulged in tuberculosis to the same extent it would produce 53,000 cases yearly and require 18,000 sanatorium beds, It seems probable that the 70 per cent. "incipient OJ cases reflect tho excessive Iear of tuberculosis that is prevalent in America, and possibly 4180 excessive value placed on radioscopic findings, without which many of tho" intermediate" group would be classed as early, and mnny of the ...early" group would have gone to the seaside for a holiday instead, with ('lqualJy beneficial results. ~rhe British Ministry of Health arc so suspicious of the cases of tuberculosis in discharged soldiers and sailors requiring more than six months' treatment that Circular 307 demands n. special rcview of such cases by tho tuberculosis officer and medical superintendent 'without fee, although in Circular 280 they admit the necessity for long treatment for early cases, and suggest re-admission from time to time for intermediate cases, In conclusion, one may say that temperamental, financial nnd social considerations must modify any purely medical dogma as to tho ideal duration of treatment, but as n basis for discussion it is suggested that "'sputum negative" cases without marked toxmmia or physical signs should have three months' treatment, If physical signs or toxmmia are well marked they should be given as long 0. treatment as "sputum positive" caaes. 1.'ho early U sputum positive OJ case requires six to seven months, and the intermediate case must be judged entirely on tho progress; any permanent increase in physical signs, oven if tho general health is hetter, should bo an indication for a change of treatment, but a progressive improvement in physical signs should justify anything up to twelve months, or even longer, it tho home conditions are likely to be reasonably good on return. For advanced cases, no sanatorium treatment should be given at all, but open-ale hospital treatment, where attention is given to education as to infection.
220
')'UDERCLE
[1] [2] lUiS." [3] [41 [r,] [G]
[February, l!)25
REFERENCES. Tubercle, May, 1024, p.374. "Annual Report or Insurance Committee Cor County oC London Cor Year
Ibid. Ior Years uno and 1920. American Reoieui of Tuberculosis, 1921, p. 57. Summary of Report, Tubercle, July, 1921, p. 4GO. Beitr. z, lain. d. Tuberk., 1923, liv, 210. [7 J Ugc.•krift for Laeqer, 1920, p. 6G9 et scq. [~] American lievieu: of Tuberculosis, 1018, p. GG3. 19] Ibid., October, 1922.
'l'IIE RESULTS OF SANA'l'OHIUl\I TREATl\IEN1.'.l Dy NOEL
D.
DAllDSWELL,
M.V.O., M.D.,
n.n.c.i-,
Conlftltin!l l'hy.ician, KinU Edward I'll Sanatorium, Midlturat. THE subject is llo big one and may be approached from many points of view: medical, social, financial, l~C. I propose to devote myself, chiefly, to 0. consideration of the sanatorium as ?' means of treating pulmonary tuberculosis. In this respect, apart from Impressions resulting from many years' experience, I am able to put before you some definitely ascertained Incts; namely, tho mortality experienced by patients subsequent to their treatment in 0. sanatorium. Such mortality experiences give a good impression of tho expectation of lifo enjoyed by patients when they leave 0. sanatorium. \Vo have three studies of the mortality amonc sanatoriulU patients, each of them of much interest, but additionally val~nble, collectively, inasmuch as, though made independently and dealing with different patients, treated in different institutions, the results show a striking simi. larity. This agreement is presumptive evidence of their accuracy. In 1Ul::J, Elderton and P~rry~ published t~o m.ortality ~xpericnced by 3,000 cnses treated at tho Adirondack Sanatorium 10 Amenca during the years 1885-HHl. This work prompted me in 1U17 to undertake a similn.r invostigution" in connection with 1,700 patients discharged from King Edwal'll VII Banatorium, Midburst, from HJ07-H114. '!'his has Leen Iollowcd, quite recently, by a study,' on precisely similar lines, of the alterhistories of 3,73B patients discharged from the Brompton lIospitnl Sanaturium at Frhuley during the years HI05-HH4. 'I'he principle followed in these three investigations was tbo same, 'l'ho various putients in each sanatorium wero first classified into the customary groups; early, moderately advanced and advanced. The number of deaths that had occurred in each group, during E.OWe years subsequent to their discharge from tho sanatorium, was then C01Uparc{\ with the number of deaths that would have been expected dUring 0. liko period had the groups of patients been samples of the general population 1 Tho Opening AdJrcllllln a Dlecusslon convened by tho lIarveian Society.
•
, .. MorLlI.my of tho TuberculouK," Elderton and Perry. Dulau and Son, 1913• ... 2lIortn.lity after Sandorium Trealment,"llaruswell and Thompson: Medical Ueaearch Counulttee, 1\119• ... After.Illstoriea of Patients treateu at l·'rlmlcy Sanatorium," Hartley, WingfielJ 'rLompao n• Medical Ileaearch Committee, 192·"
and