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The future of the chest clinic
PUBLIC
HEALTH
The Journal of the Society of Medical Officers of Health Vol. LXXI
THE
July 1957
FUTURE
OF
THE
No. 4
CHEST
CLINIC
GREATLY against our inclination we have been prevented by lack of space from publishing any report of an important conference which took place in .October 1956 under the joint sponsorship of the Society of Medical Officers o f Health and the National Association for the Prevention of Tuberculosis. We still see no opportunity of reporting it at length, but we feel that we cannot let it pass entirely without comment. The Society was represented on the platform by the President, who took the chair, and by Dr. H. D. Chalke and Dr. C. K. Cullen, who contributed papers, the three remaining papers being read by Dr. H. M. C. Macaulay, Dr. W. H. Tattersall (Senior Chest Physician, Bournemonth) and Mr. V. C. Thompson (Surgeon, London Chest Hospital). It has been cogently argued, by Dr. Chalke among others, that at the present time tuberculosis is an epidemic disease in decline. It is, however, a matter of history that a dying epidemic, like the traditional wounded lion, is likely to lash out lethally, and though there may be very good reason for hope there is none for complacency. On this sober and sensible note the conference started, Dr. Cullen reminding it that as mortality falls survival increases and that the difficult middle-aged chronic group is demanding more attention than formerly. He made another important point, when he said that decreasing incidence is accompanied by decreasing natural immunity and that in the immediate future the extension of B.C.G. vaccination might be of cardinal importance. The tuberculosis dispensary has become a chest clinic in name, initially, at any rate, because it was felt that the public might feel less fear if the dreadful word " tuberculosis " could be suppressed. But with the decline in active tuberculosis it has started to evolve into a chest clinic in fact--a clinic in which all diseases of the chest may be dealt with. It was this aspect of its evolution to which the conference turned after the introductory warning notes had been sounded. Both Dr. Cullen and Dr. Tattersall were functional rather than regional in their approach--" chest" signified the respiratory rather than the circulatory organs--and firmly convinced that the clinic could and should survive outside the hospital's walls but linked closely with both the hospital and the health department. Mr. Thompson, putting the surgeon's point of
122
PUBLIC HEALTH
VOL. L X X I
NO. 4
view, strongly disagreed, and here controversy, not without acrimony, enlivened an already lively meeting. We accept his contention that the hospital is the place to which the patient with carcinoma of the lung should go as soon as possible, but we are unimpressed by such evidence as he adduced, or any evidence we have yet seen or heard elsewhere, to the effect that the chest clinic is a source of delay. Particularly in a period of carcinophobia, the man with a cough is much more likely to go to a chest clinic in the hope of hearing that he has bronchitis than to a hospital where the very presence of a thoracic surgery unit would, for him, seem to pre-judge the issue. If every person with a cough could go at once to a thoracic surgeon for bronchoscopy and the rest, no doubt more lung cancer would be treated in the most favourable stage, but this is a practicaJ impossibility. The patient will continue to filter to the thoracic surgeon via either a hospital out-patient department or a chest clinic and we see no reason whatever why the latter procedure should be slower than the former, On the contrary, there are several reasons why it might be quicker. Accepting the idea of a filter, with a competent specialist in respiratory diseases in charge, we consider that for the majority of patients, who suffer from diseases other than cancer, the chest clinic has advantages over the hospital. Not only does it provide more accessible facilities, but it has, and can maintain, a close link with environmental medicine. The environmental factors in pulmonary tuberculosis have been cardinal and, apart from the question of infection, environment plays a very substantial part in the development and continuance of the other respiratory diseases ; we might instance particularly the influence of emotional response to stress in the asthmatic and the effect of the inhalation of irritant substances associated with certain occupations. The most valid argument on the other side was implied, rather than overtly expressed, by Dr. Macaulay--that the way to make the hospitals interested in preventive medicine is to give them more preventive work to do, We agree with him that hospital departments of preventive and social medicine must come and we look forward to their coming sooner rather than later. But there is, as he said, a border territory between the functions of Regional Hospital Board and Local Authority where the two can and m ~ t overlap, unless a dangerous gap is to be left. The Chest Clinic, though its present status must be anathema to the tidy administrator, is an outpost of both and the exclusive property of neither. What it does in the next few years may give a very important lead in this vexed business of co-ordination o f the parts of the N.H.S.
HEALTH
The Journal of the Society of Medical Officers of Health Vol. LXXI
THE
July 1957
FUTURE
OF
THE
No. 4
CHEST
CLINIC
GREATLY against our inclination we have been prevented by lack of space from publishing any report of an important conference which took place in .October 1956 under the joint sponsorship of the Society of Medical Officers o f Health and the National Association for the Prevention of Tuberculosis. We still see no opportunity of reporting it at length, but we feel that we cannot let it pass entirely without comment. The Society was represented on the platform by the President, who took the chair, and by Dr. H. D. Chalke and Dr. C. K. Cullen, who contributed papers, the three remaining papers being read by Dr. H. M. C. Macaulay, Dr. W. H. Tattersall (Senior Chest Physician, Bournemonth) and Mr. V. C. Thompson (Surgeon, London Chest Hospital). It has been cogently argued, by Dr. Chalke among others, that at the present time tuberculosis is an epidemic disease in decline. It is, however, a matter of history that a dying epidemic, like the traditional wounded lion, is likely to lash out lethally, and though there may be very good reason for hope there is none for complacency. On this sober and sensible note the conference started, Dr. Cullen reminding it that as mortality falls survival increases and that the difficult middle-aged chronic group is demanding more attention than formerly. He made another important point, when he said that decreasing incidence is accompanied by decreasing natural immunity and that in the immediate future the extension of B.C.G. vaccination might be of cardinal importance. The tuberculosis dispensary has become a chest clinic in name, initially, at any rate, because it was felt that the public might feel less fear if the dreadful word " tuberculosis " could be suppressed. But with the decline in active tuberculosis it has started to evolve into a chest clinic in fact--a clinic in which all diseases of the chest may be dealt with. It was this aspect of its evolution to which the conference turned after the introductory warning notes had been sounded. Both Dr. Cullen and Dr. Tattersall were functional rather than regional in their approach--" chest" signified the respiratory rather than the circulatory organs--and firmly convinced that the clinic could and should survive outside the hospital's walls but linked closely with both the hospital and the health department. Mr. Thompson, putting the surgeon's point of
122
PUBLIC HEALTH
VOL. L X X I
NO. 4
view, strongly disagreed, and here controversy, not without acrimony, enlivened an already lively meeting. We accept his contention that the hospital is the place to which the patient with carcinoma of the lung should go as soon as possible, but we are unimpressed by such evidence as he adduced, or any evidence we have yet seen or heard elsewhere, to the effect that the chest clinic is a source of delay. Particularly in a period of carcinophobia, the man with a cough is much more likely to go to a chest clinic in the hope of hearing that he has bronchitis than to a hospital where the very presence of a thoracic surgery unit would, for him, seem to pre-judge the issue. If every person with a cough could go at once to a thoracic surgeon for bronchoscopy and the rest, no doubt more lung cancer would be treated in the most favourable stage, but this is a practicaJ impossibility. The patient will continue to filter to the thoracic surgeon via either a hospital out-patient department or a chest clinic and we see no reason whatever why the latter procedure should be slower than the former, On the contrary, there are several reasons why it might be quicker. Accepting the idea of a filter, with a competent specialist in respiratory diseases in charge, we consider that for the majority of patients, who suffer from diseases other than cancer, the chest clinic has advantages over the hospital. Not only does it provide more accessible facilities, but it has, and can maintain, a close link with environmental medicine. The environmental factors in pulmonary tuberculosis have been cardinal and, apart from the question of infection, environment plays a very substantial part in the development and continuance of the other respiratory diseases ; we might instance particularly the influence of emotional response to stress in the asthmatic and the effect of the inhalation of irritant substances associated with certain occupations. The most valid argument on the other side was implied, rather than overtly expressed, by Dr. Macaulay--that the way to make the hospitals interested in preventive medicine is to give them more preventive work to do, We agree with him that hospital departments of preventive and social medicine must come and we look forward to their coming sooner rather than later. But there is, as he said, a border territory between the functions of Regional Hospital Board and Local Authority where the two can and m ~ t overlap, unless a dangerous gap is to be left. The Chest Clinic, though its present status must be anathema to the tidy administrator, is an outpost of both and the exclusive property of neither. What it does in the next few years may give a very important lead in this vexed business of co-ordination o f the parts of the N.H.S.