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The Treatment of Soldiers Invalided for Tuberculosis.
1160
THE TREATMENT OF SOLDIERS INVALIDED FOR TUBERCULOSIS.
exert in the diminution of infantile mortality and due to service or climate. The reason given for this reguwas is more in lation the which even that men suffering from the disease also, perhaps important, promoting necessity the physical and intellectual welfare of the children who should be removed from contact with other soldiers, and it survive; and we see every reason to believe that the views was found that its adoption was followed by a great reducso well advocated by Dr. THRESH are as sound economically tion in the proportion of cases of tuberculous disease in as they are when regarded under their sanitary aspect. It is the army, and the committee strongly upholds the necessity certain that there are dairies in which proper precautions of so removing the patients. It points out that in pracwith regard to cleanliness and water-supply are even now tice the stringency of this regulation has been greatly enforced and which nevertheless yield satisfactory profits to mitigated, since the patients have usually remained in their proprietors. With regard to the cost of refrigeration military hospitals under proper care and with adequate preDr. THRESH points out that it would be easy for the smaller cautions for periods varying from four to six months, and dairy farmers of any locality to unite their forces for the have subsequently in many cases been sent to civil instituThe compurpose, and that the supply of refrigerating railway vans tions through private or regimental charity. has long been in operation in many foreign countries. mittee is of opinion that the State should admit responsiIf the Bill promised by Mr. BURNS should be found on its bility for the men and that suitable treatment should be introduction to be based somewhat upon the lines which organised. It supports this opinion not so much on the Dr. THRESH has laid down, it should, we think, receive claims of the patients themselves as on the necessity for favourable consideration from the trade as well as from th3 avoiding the danger to the civil population entailed by the public. The chief difficulty of enforcing its provisicns discharge to their own homes of men suffering from a disease would probably be found in the passive resistance to cleanli- with which they are likely to ibfect others. ness of workpeople long accustomed to the conditions of filth Having arrived at the conclusion that the State should in dairies than in afford means of treatment the committee has discussed two which now prevail rather any increase of cost or diminution of profits. What these conditions of alternative methods for so doing, the first of which was the filth are may be read in almost every report issued foundation of a central military sanatorium to which all the by the Local Government Board concerning the sanitary patients should be sent for treatment. This proposal the state and administration of any country locality; and committee rejected after careful consideration on the followthe details are usually so disgusting as to deprive us ing amongst other grounds. The results in America of a. of any temptation to dwell upon them. It is certain similar expedient have not been very successful, the benefit, that the customs in this respect which now prevail can only derived by the patients being markedly less than that be overcome by great determination and continuous and obtained in the majority of civil institutions. It was calclose supervision on the part of employers who should, of culated that the cost would not be less than that of the course, be made responsible for any negligence which they alternative proposal to be described below and that there permit. The Parliamentary opposition most to be dreaded would be in addition the large initial outlay necessary for is, we fear, that which will arise from interests which will buildings and equipment. It was further considered unbe really imperilled and which will be imperilled because desirable to augment the Royal Army Medical Corps by their continued prosperity is incompatible with the public the addition of a staff of specialists in sanatorium treatment as would be a necessity if the proposed welfare. central institution were to be carried on to the greatest
likely to
The proposal put forward by the committee The Treatment of Soldiers Invalided advantage. as the best solution of the problem is that the army for Tuberculosis. should make use of the rapidly increasing number of civi1 THE committee appointed by the War Office " to consider the care and treatment after discharge from the army of soldiers invalided for tuberculous disease" has issued a preliminary report describing in outline a scheme which it puts forward for dealing with the matter. The committee, which consists of Surgeon-General Sir A. H. KEOGH, K.C.B., Lord LUCAS, Lieutenant-Colonel J. E. B. SEELY, D.S.O.,
M.P., Sir J. BATTY TUKE, M.P., and Mr. T. SUMMERBELL, M.P., with Colonel Sir E. W. D. WARD, K C.B., K.C.V.O., as as
chairman and Mr. H. W. MOGGRIDGE of the War Office secretary, has heard the evidence of a number of expert
witnesses and has come unanimously to a general conclusion. Under the method at present in existence it is laid down that in the case of soldiers suffering from tuberculosis of the lung they shall be at once discharged from the army and sent to their own homes as soon as they are fit to travel, all responsibility in regard to them being then disowned. They are not awarded any pension unless they have earned it by length of service or unless it can be proved in any particular case that the disease was
sanatoriums and that some of these institutions should be approached with the request that a certain number of beds should be reserved for the sole use of the army. It has some reason to hope that a sufficient number of beds will be obtainable in this manner to afford treatment to all soldiers who require it for a period of from three to six months. Under this scheme all soldiers who were suspected (the word is italicised in the report) to have tuberculosis would
removed from the military hospital, each being sent to the sanatorium nearest to his own home at which a bed was available. They would, as at present, be at once discharged from the army and would return to their homes after their period of treatment at the sanatorium and they would not be allowed to re-enlist. It is admitted that on this scheme those cases in which the disease had reached an advanced stage before it was detected would require to be dealt with separately owing to their being ineligible for sanatorium treatment. It is stated that such cases are rare in the army and it is proposed that efforts should be made to get such patients be at
once
A GREEK MUNICIPAL HOSPITAL IN THE FIFTH CENTURY B.C. this that they should be discharged as at present, the committee being of opinion that advanced cases of this kind are less of a public danger than those who are less ill and therefore able to go about, a
into "incurable"wards,
or
failing
hardly likely to appeal to those who advocate the segregation of advanced cases. In regard to the cost of its proposal the committee states that the average number of soldiers invalided annually for tuberculosis of the lungs is about 400, and it estimates that, excluding the advanced cases and those who refused to remain in sanatoriums, view which is
the number remaining for treatment would not exceed 350 The committee suggests that in order to allow of sufficient accommodation 200 beds should be retained, each being able to accommodate two patients a year. It is thought that the cost of maintaining a bed will average about 30s. a week and the scheme would thus entail an expenditure of .815,600 per annum. The committee therefore estimates that the total cost of the scheme will not exceed ,620,000 per annum and that a part of this will be counterbalanced by the fact that tuberculous patients will remain in military hospitals for a shorter time than at present. It is suggested that at first the Army Council might make a reasonable contribution towards the extension of a sanatorium which proposed to increase its accommodation, such contribution, however, to be met by a corresponding reduction from the annual cost as estimated above. The proposal to make some effective provision for the treatment of the tuberculous soldier is one with which we are in full sympathy. At present, after discharge from the army the unfortunate sufferer from pulmonary tuberculosis has either to seek admission to one or another of the civil charitable or paying institutions, with the chance that by the time he is admitted his disease is too far advanced to render him suitable for sanatorium treatment, or else to remain at home endeavouring to earn enough to support himself, in which he is handicapped by his lack of experience of civilian occupations. The scheme suggested by the committee, though obviously not perfect, is a serious attempt to deal The proposals are admittedly with a difficult problem. tentative and are doubtless capable of modification in detail if the general principle is accepted by the Army Council, for the committee states in its report that if it is so accepted it will proceed to elaborate it in detail. It seems to us that there are some few matters in connexion with the report which require careful consideration. The first is that the practical withdrawal from the civilian population of even 200 sanatorium beds is a serious limitation of the already scanty accommodation available for those of the poorer classes of the community affected with pulmonary tuberculosis, and in our opinion it ought clearly to be emphasised that a sufficiency of new beds should be established to avoid any such detraction from the resources provided for the civilian sufferers. It may be doubted whether, given the provision of means for treatment, the yearly number of cases will prove to remain at the low figure of 400, especially if very early and suspicious cases are at once drafted to sanatoriums, since there will be less likelihood of concealment of the disease on the part of the sufferers. The results achieved by sanatorium treatment under the proposed conditions should be very satisfactory, as the cases for the most
part will
be
early
cases
in
previously healthy adults,
and
short
1161
of observation in a military hospital should be of value in the proper selection of cases One defective feature of the for sanatorium treatment. scheme is the proposal in regard to advanced cases, for which more adequate provision is necessary if the army is going to assume responsibility for the tuberculous soldier. In civil life, apart from the Poor-law infirmaries a
period
few incurable"wards homes, little and exists for treatment in institutions of advanced a
or
provision
cases, and if in regard to
the army is going to evade its responsibilities this section of its patients little advance has been made and it must not be forgotten that the failures from the sanatoriums will serve to swell the numbers of these "advanced" cases which, the view of the committee notwithstanding, are not the least dangerous from the point of view of
infectivity.
Annotations. " We quid nimis."
A GREEK MUNICIPAL HOSPITAL CENTURY B.C.
IN
THE
FIFTH
IN THE LANCET of Jan. 12th, 1907, p. 104, a drawing was given, in illustration of " The Medical Art in the Homeric Period," of a scene depicted upon a Greek vase of Achilles binding up the wound of Patroclus. Since those notes were published M. E. Pottier has edited in the "Monuments and Memoirs " of the Paris Academy, funds for which were provided by the late M. Piot, a still more interesting, from the medical point of view, piece of ancient ceramics under the title of " Une Clinique Grecque au Ve Siècle." Several other delineations of the first aid applied to wounded warriors have previously been noted and some published-notably, the amphora in the Hope collection showing Sthenelos binding up the hand of Diomedes ; a vase in the museum at Florence depicting soldiers binding each other’s wounds ; an Etruscan mirror at Bologna, showing Machaon, the primitive surgeon, performing the same office for Philoctetes ; and a seated warrior having his limb dressed by a surgeon, engraved upon a seal given in the Dictionary of Antiquities " of M. Saglio. There are also some figures of wounded legionaries having their limbs bandaged upon the Roman column of Trajan.1 It will be noted that all these instances are connected with injuries received in warfare, while the new vase, for a reproduction of which we are indebted to M. Pottier, depicts a scene in a hospital, or clinic, of some city, probably Athens, in times of peace, and so is unique. We know from the classics, but more particularly from inscriptions, that the Hellenic cities used to have public places supported by the citizens where physicians and surgeons, provided with the necessary appurtenances, attended to the medical needs of the poorer members of the community. The cost of such arrangement, including the payment of the operators, was defrayed by a special impost. The la.TPLX6v, and the post or edifice placed at the disposal of the surgeons was termed an tcc7-peov. This physicians’ tax is often mentioned in Grseso-Egyptian papyri but there was devoted to paying salaries to the civic medical officers who had to take part in post-mortem examinations, to combat epidemics, and to give certificates of births and deaths. M. Pottier, fortified by the advice of Dr. Pozzi who, he tells us, in addition to his qualities as a practitioner, possesses the ardour of an antiquary, is quite certain that the scene depicted upon the new vase is to be considered as being There is also a vase now at Athens representing wounded athletes to which we propose to refer on another occasion.
THE TREATMENT OF SOLDIERS INVALIDED FOR TUBERCULOSIS.
exert in the diminution of infantile mortality and due to service or climate. The reason given for this reguwas is more in lation the which even that men suffering from the disease also, perhaps important, promoting necessity the physical and intellectual welfare of the children who should be removed from contact with other soldiers, and it survive; and we see every reason to believe that the views was found that its adoption was followed by a great reducso well advocated by Dr. THRESH are as sound economically tion in the proportion of cases of tuberculous disease in as they are when regarded under their sanitary aspect. It is the army, and the committee strongly upholds the necessity certain that there are dairies in which proper precautions of so removing the patients. It points out that in pracwith regard to cleanliness and water-supply are even now tice the stringency of this regulation has been greatly enforced and which nevertheless yield satisfactory profits to mitigated, since the patients have usually remained in their proprietors. With regard to the cost of refrigeration military hospitals under proper care and with adequate preDr. THRESH points out that it would be easy for the smaller cautions for periods varying from four to six months, and dairy farmers of any locality to unite their forces for the have subsequently in many cases been sent to civil instituThe compurpose, and that the supply of refrigerating railway vans tions through private or regimental charity. has long been in operation in many foreign countries. mittee is of opinion that the State should admit responsiIf the Bill promised by Mr. BURNS should be found on its bility for the men and that suitable treatment should be introduction to be based somewhat upon the lines which organised. It supports this opinion not so much on the Dr. THRESH has laid down, it should, we think, receive claims of the patients themselves as on the necessity for favourable consideration from the trade as well as from th3 avoiding the danger to the civil population entailed by the public. The chief difficulty of enforcing its provisicns discharge to their own homes of men suffering from a disease would probably be found in the passive resistance to cleanli- with which they are likely to ibfect others. ness of workpeople long accustomed to the conditions of filth Having arrived at the conclusion that the State should in dairies than in afford means of treatment the committee has discussed two which now prevail rather any increase of cost or diminution of profits. What these conditions of alternative methods for so doing, the first of which was the filth are may be read in almost every report issued foundation of a central military sanatorium to which all the by the Local Government Board concerning the sanitary patients should be sent for treatment. This proposal the state and administration of any country locality; and committee rejected after careful consideration on the followthe details are usually so disgusting as to deprive us ing amongst other grounds. The results in America of a. of any temptation to dwell upon them. It is certain similar expedient have not been very successful, the benefit, that the customs in this respect which now prevail can only derived by the patients being markedly less than that be overcome by great determination and continuous and obtained in the majority of civil institutions. It was calclose supervision on the part of employers who should, of culated that the cost would not be less than that of the course, be made responsible for any negligence which they alternative proposal to be described below and that there permit. The Parliamentary opposition most to be dreaded would be in addition the large initial outlay necessary for is, we fear, that which will arise from interests which will buildings and equipment. It was further considered unbe really imperilled and which will be imperilled because desirable to augment the Royal Army Medical Corps by their continued prosperity is incompatible with the public the addition of a staff of specialists in sanatorium treatment as would be a necessity if the proposed welfare. central institution were to be carried on to the greatest
likely to
The proposal put forward by the committee The Treatment of Soldiers Invalided advantage. as the best solution of the problem is that the army for Tuberculosis. should make use of the rapidly increasing number of civi1 THE committee appointed by the War Office " to consider the care and treatment after discharge from the army of soldiers invalided for tuberculous disease" has issued a preliminary report describing in outline a scheme which it puts forward for dealing with the matter. The committee, which consists of Surgeon-General Sir A. H. KEOGH, K.C.B., Lord LUCAS, Lieutenant-Colonel J. E. B. SEELY, D.S.O.,
M.P., Sir J. BATTY TUKE, M.P., and Mr. T. SUMMERBELL, M.P., with Colonel Sir E. W. D. WARD, K C.B., K.C.V.O., as as
chairman and Mr. H. W. MOGGRIDGE of the War Office secretary, has heard the evidence of a number of expert
witnesses and has come unanimously to a general conclusion. Under the method at present in existence it is laid down that in the case of soldiers suffering from tuberculosis of the lung they shall be at once discharged from the army and sent to their own homes as soon as they are fit to travel, all responsibility in regard to them being then disowned. They are not awarded any pension unless they have earned it by length of service or unless it can be proved in any particular case that the disease was
sanatoriums and that some of these institutions should be approached with the request that a certain number of beds should be reserved for the sole use of the army. It has some reason to hope that a sufficient number of beds will be obtainable in this manner to afford treatment to all soldiers who require it for a period of from three to six months. Under this scheme all soldiers who were suspected (the word is italicised in the report) to have tuberculosis would
removed from the military hospital, each being sent to the sanatorium nearest to his own home at which a bed was available. They would, as at present, be at once discharged from the army and would return to their homes after their period of treatment at the sanatorium and they would not be allowed to re-enlist. It is admitted that on this scheme those cases in which the disease had reached an advanced stage before it was detected would require to be dealt with separately owing to their being ineligible for sanatorium treatment. It is stated that such cases are rare in the army and it is proposed that efforts should be made to get such patients be at
once
A GREEK MUNICIPAL HOSPITAL IN THE FIFTH CENTURY B.C. this that they should be discharged as at present, the committee being of opinion that advanced cases of this kind are less of a public danger than those who are less ill and therefore able to go about, a
into "incurable"wards,
or
failing
hardly likely to appeal to those who advocate the segregation of advanced cases. In regard to the cost of its proposal the committee states that the average number of soldiers invalided annually for tuberculosis of the lungs is about 400, and it estimates that, excluding the advanced cases and those who refused to remain in sanatoriums, view which is
the number remaining for treatment would not exceed 350 The committee suggests that in order to allow of sufficient accommodation 200 beds should be retained, each being able to accommodate two patients a year. It is thought that the cost of maintaining a bed will average about 30s. a week and the scheme would thus entail an expenditure of .815,600 per annum. The committee therefore estimates that the total cost of the scheme will not exceed ,620,000 per annum and that a part of this will be counterbalanced by the fact that tuberculous patients will remain in military hospitals for a shorter time than at present. It is suggested that at first the Army Council might make a reasonable contribution towards the extension of a sanatorium which proposed to increase its accommodation, such contribution, however, to be met by a corresponding reduction from the annual cost as estimated above. The proposal to make some effective provision for the treatment of the tuberculous soldier is one with which we are in full sympathy. At present, after discharge from the army the unfortunate sufferer from pulmonary tuberculosis has either to seek admission to one or another of the civil charitable or paying institutions, with the chance that by the time he is admitted his disease is too far advanced to render him suitable for sanatorium treatment, or else to remain at home endeavouring to earn enough to support himself, in which he is handicapped by his lack of experience of civilian occupations. The scheme suggested by the committee, though obviously not perfect, is a serious attempt to deal The proposals are admittedly with a difficult problem. tentative and are doubtless capable of modification in detail if the general principle is accepted by the Army Council, for the committee states in its report that if it is so accepted it will proceed to elaborate it in detail. It seems to us that there are some few matters in connexion with the report which require careful consideration. The first is that the practical withdrawal from the civilian population of even 200 sanatorium beds is a serious limitation of the already scanty accommodation available for those of the poorer classes of the community affected with pulmonary tuberculosis, and in our opinion it ought clearly to be emphasised that a sufficiency of new beds should be established to avoid any such detraction from the resources provided for the civilian sufferers. It may be doubted whether, given the provision of means for treatment, the yearly number of cases will prove to remain at the low figure of 400, especially if very early and suspicious cases are at once drafted to sanatoriums, since there will be less likelihood of concealment of the disease on the part of the sufferers. The results achieved by sanatorium treatment under the proposed conditions should be very satisfactory, as the cases for the most
part will
be
early
cases
in
previously healthy adults,
and
short
1161
of observation in a military hospital should be of value in the proper selection of cases One defective feature of the for sanatorium treatment. scheme is the proposal in regard to advanced cases, for which more adequate provision is necessary if the army is going to assume responsibility for the tuberculous soldier. In civil life, apart from the Poor-law infirmaries a
period
few incurable"wards homes, little and exists for treatment in institutions of advanced a
or
provision
cases, and if in regard to
the army is going to evade its responsibilities this section of its patients little advance has been made and it must not be forgotten that the failures from the sanatoriums will serve to swell the numbers of these "advanced" cases which, the view of the committee notwithstanding, are not the least dangerous from the point of view of
infectivity.
Annotations. " We quid nimis."
A GREEK MUNICIPAL HOSPITAL CENTURY B.C.
IN
THE
FIFTH
IN THE LANCET of Jan. 12th, 1907, p. 104, a drawing was given, in illustration of " The Medical Art in the Homeric Period," of a scene depicted upon a Greek vase of Achilles binding up the wound of Patroclus. Since those notes were published M. E. Pottier has edited in the "Monuments and Memoirs " of the Paris Academy, funds for which were provided by the late M. Piot, a still more interesting, from the medical point of view, piece of ancient ceramics under the title of " Une Clinique Grecque au Ve Siècle." Several other delineations of the first aid applied to wounded warriors have previously been noted and some published-notably, the amphora in the Hope collection showing Sthenelos binding up the hand of Diomedes ; a vase in the museum at Florence depicting soldiers binding each other’s wounds ; an Etruscan mirror at Bologna, showing Machaon, the primitive surgeon, performing the same office for Philoctetes ; and a seated warrior having his limb dressed by a surgeon, engraved upon a seal given in the Dictionary of Antiquities " of M. Saglio. There are also some figures of wounded legionaries having their limbs bandaged upon the Roman column of Trajan.1 It will be noted that all these instances are connected with injuries received in warfare, while the new vase, for a reproduction of which we are indebted to M. Pottier, depicts a scene in a hospital, or clinic, of some city, probably Athens, in times of peace, and so is unique. We know from the classics, but more particularly from inscriptions, that the Hellenic cities used to have public places supported by the citizens where physicians and surgeons, provided with the necessary appurtenances, attended to the medical needs of the poorer members of the community. The cost of such arrangement, including the payment of the operators, was defrayed by a special impost. The la.TPLX6v, and the post or edifice placed at the disposal of the surgeons was termed an tcc7-peov. This physicians’ tax is often mentioned in Grseso-Egyptian papyri but there was devoted to paying salaries to the civic medical officers who had to take part in post-mortem examinations, to combat epidemics, and to give certificates of births and deaths. M. Pottier, fortified by the advice of Dr. Pozzi who, he tells us, in addition to his qualities as a practitioner, possesses the ardour of an antiquary, is quite certain that the scene depicted upon the new vase is to be considered as being There is also a vase now at Athens representing wounded athletes to which we propose to refer on another occasion.