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Treatment Without Sanatorium
150
May 1955
Treatment Without Sanatorium* Including Results at Five Years By PETER STRADLING Consultant Chest Physician, Hammersmith Chest Clinic and Hammersmith Hospital; Lecturer in Tuberculosis, Postgraduate Medical School of London The long waiting lists for admission in I9455 o, caused by a great post-war shortage of sanatorium beds, stimulated some chest physicians to develop treatment services on new lines. The results of such schemes have been gratifying and throw considerable doubt upon the assumption, still widely accepted, that admission to sanatorium should remain the ideal and standard practice for the treatable tuberculous patient. Conditions in the Borough of Hammersmith during I948, temporarily aggravated by the advent of the National Health Sen,ice, were most unsatisfactory. Access to general hospital beds .had been lost in the reorganization and the wait for sanatorium admission lengthened to nine months at a time when i5 o patients awaited urgent treatment. Although it was still believed, at this time, that anything less than sanatorium admission was undesirable the early results of others (Heller, 1949; Wynn-Williams et al., i95o; Cuthbert, i95o; Toussaint, i95o ) were encouraging and the critical position fully justified the institution of alternative treatment methods.
Clinic Management In collaboration with the Postgraduate Medical School, eight beds were allotted in Hammersmith Hospital to which the clinic staff had sole right of admission ('clinic' beds). Patients were admitted in quick succession for initiation of essential collapse therapy. Long periods of domiciliary maintenance followed and a proportion of the patients were finally transferred to sanatoria or rehabilitation centres. Such transfer depended on various factors such as availability of vacancies, home conditions, and the stage of treatment
at the time that the bed was offered. This subsequent institutional admission was encouraged but proved far from possible in every case. Ambulant or hasty pneumothorax inductions were not practised. The scheme was an attempt to institute, without sanatorium facilities, collapse therapy principles and general measures as then practised in the Regional Sanatoria. All the initial treatment, however, was undertaken without sanatorium and before chemotherapy became freely available. The scheme is more fully described in a previous paper (Stradling, I95i ) but the administrative arrangements are summarized in fig. x.
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CLINIC MANAGEMENT. Fill, I.
The term 'Domiciliary Management' as usually applied to such schemes should be abandoned, although m u c h o f the work was, and still is, done in the patients' homes. Home and hospital treatment are complementary. Close teamwork between the chest
*A paper read to the B.T.A. on September 24, x954.
lday
1955
151
TUBERCLE
clinic staff and the ancillary services leads to a nice balance of the time spent by the patient at home, in a clinic bed, and as an out-patient of the clinic. It is a fluid balance that can be adjusted according to need and circumstance. 'Clinic Management' is thus a more accurate term, since the full social, clinical and administrative handling of the patient is based upon the chest clinic. The scheme in Hammersmith was started too recently to enable the presentation of a large five-year survey, but nevertheless something can be learned from a pilot five-year follow-up of the first small group of patients treated by Clinic Management.
tion. It is thus likely that the group approximates to a sanatorium population but one cannot go farther than this and draw any strict comparisons with other groups. Nevertheless enough is known of the likely position of sputum-positive patients five years after diagnosis to make the presentation of these figures worth while. TREATMENT EPISODES
Type of lrealment
Clinic Beds
P.P. and/or phrenic crush (48) ..
47
I Sanatorium
The Material A.P. with adhesion There are 64 patients in this series, all of II 21 section (3 ~) .. whom were newly diagnosed between J u n e Surgical collapse (6) z 5 1948 and J u n e z949 and wcre admitted to the clinic beds for collapse therapy. Twelve Resection (4) -2 2 fell into the Ministry of Health Classification Group BI, 41 into B2, and II into B3. FIG. 2, They were selected for this survey partly by Active Treatment Applied choice and partly by circumstanccs and therefore the group cannot be considered as With only 8 clinic beds available very few a representative cross-section of the newly major surgical operations were undertaken diagnosed tuberculous population. Those in these but 8o per cent of the patients were very difficulties causing a change of policy treated by medical collapse therapy alone made a controlled trial of such a policy and the majority of this was managed withimpossible. Various factors of selection out sanatorium. In fact 49 (77 per cent) of operated, such as the varying availability of the patients completed their active therapy beds, the patient's attitude to sanatorium under Clinic Management although a proadmission, the presence of a suitable relative portion (75 per cent) had a period of institutional convalescence elsewhere (conat home, and so on. There were, however, certain selecting valescent home or sanatorium) because of factors common to all these patients. They the necessity for a quick turnover in so few were all sputum positive; by the standards clinic beds. Additional active therapy was accepted at the time, they all necded given to only z5 patients (32 per cent) after collapse therapy and, if this were instituted, admission to sanatoria for continuation or had a reasonable prospect of quiescence. extension of their initial treatment. Details of the treatment episodes are They were in fact patients who would have been admitted directly to sanatorium for given in fig. 2. Only 6 B2 and 5 B3 patients active therapy if such beds had been received streptomycin during their primary treatment (2 in clinic beds, 9 in sanareadily available. It is worth remembering here that most torium). Complications and Relapse sanatorium patients are also preselected in a somewhat similar manner and cannot be In the early days of Clinic Management it representative of the tuberculous popula- was predicted by sceptics that m a n y corn-
TUBERCLE
152
plications would ensue. This series does not confirm these fears; perhaps because criteria for pneumothorax induction were ahvays strict. The number of complications is so small that it is impossible to observe any comparative trends here. Three pneumothoraces were abandoned following effusions
May 1955
tical selection of cases operated. One must be content with looking at the group as a whole and seeing if the survival rate is reasonable in spite of the unorthodox method of managing a large proportion of the treatment. The position of the patients five years later is summarized in fig. 3.
5yr. FOLLOW UP
B.1 12 cases
100"/0 survival
13.2 41 cases
937. survival
i;i
B.3
11 cases
": ~~",~:; :
82*/. survival
....... :"-<'~.~~ ' : : , " - " : " ~ :: "~"-':'-: ::i"::;~"-- =: , V Z ~ / / / ,
~ QUIESCENT
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~
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DEAD
Fro. 3.
(I in sanatorium, 2 during clinic management); two haemothoraces developed after adhesion section (i in sanatorium, I in a hospital bed) and two sinuses were seen after sanatorium surgery, Subsequent relapse was seen in I6 patients rendered quiescent by the initial treatment and all these received chemotherapy. Quiescence was regained by Io whilst 6 appear amongst those active at five years. Results at Five Years It would have been desirable when assessing the results at five years to compare the follow-up findings in .those of the group subsequently entering sanatorium with those that did not, and to have assessed the difference between the two. However, no valid conclusions could be drawn from such a comparison when the numbers are so small and no properly controlled statis-
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Fro. 4. - Proportion of 5-year period spent under various circumstances.
It is interesting to note that quiescence was obtained without active treatment in sanatorium in z I of the i2 B I group, in
May 1955
TUBERCLE
3 ° of the 41 B~ (73 per cent) and in only 6 of the ix B3. T h e effect of extent of disease at the time of diagnosis in lengthening the subsequent treatment is thus obvious. This problem can be solved in part by a drive for early diagnosis; an essential factor for successful Clinic Management (Stradling, I948 ). Although not statistically comp.arable, as already stated, it is instructive at this stage to recall the five-year survival rates in 2 well-known large series of B2 sanatorium patients. Simmonds and Martin (I948) reported a 71.6 per cent survival rate; Foster-Carter et al. (i952) 87.6 per cent. In the present small series the rate was 93 per cent for the B2 group. Even if one assumes that the ~3 per cent of B2 cases who received streptomycin during their initial treatment would all have died without it (a most unlikely contingency) then the survival rate is still 8o per cent. Discussion
Simmonds and Martin (I948) when assessing the value of sanatorium treatment rated the thorough application of collapse therapy as the most important single factor in encouraging sputum conversion and survival. Results in this small survey support once again this now little-doubted fact. Collapse therapy was applied early in all cases in this series and the survival rates compare favourably with the best yet recorded. With others, Tattersall (I947) has coneluded that simple sanatorium regime without active therapy is of little value. Again the results given here do not contradict this. At least there is presented a group of patients who have received the major part of their management outside sanatorium and who have fared no worse than is usual for sanatorium-treated patients. These results were obtained with minimal hospital facilities and a much better picture can be expected with the fuller service now provided. If then there is really little to choose in purely clinical end-results between sanatorium and clinic m a n a g e m e n t is it possible
153
to reach more definite conclusions as to the value of sanatorium by studying other factors? When this is done m a n y obvious advantages are found to lie with Cfinic Management. Consideration should first be given to the time factor in relation to the place and form of treatment. Six arbitrary groups have been used for the systematic consideration of the patients from this point of view and the position is best understood from fig. 4 which presents in proportional form the averages of the times that the patients spent in these groups over the five-year period under consideration. It will be seen that the time spent in sanatorium is only I/I2th of the total period of treatment and observation. If the average period spent in sanatorium for active therapy is estimated then this constitutes only ~/4oth of the total period under review. By far the major part of the patients' clinical supervision was thus the responsibility of the clinic. This included hospital care, domiciliary management in the patients' h o m e surroundings and often a long period of regular weekly attendances at the clinic for the maintenance of collapse therapy. Can the short sanatorium stay be of more training value than prolonged contact with. the home-visitor, hospital, and clinic staff over m a n y months or years? It is believed not. There is plenty of opportunity to replace the clinical and educative facilities usual to a sanatorium, by equally effective action within the clinic organization. Sanatorium admission severely breaks continuity of treatment which is of considerable significance when treating an illness where continuous management under one physician is of incalculable clinical value. Furthermore, the differences of opinion, and changes of treatment likely to be inflicted upon the transferred patient, only bewilder him, undermine his confidence, and make h i m sceptical of medical opinion and care. This is avoided in clinic management. The regular presence at clinical con-
154
TUBERCLE
May 1955
ferences of the home visitors and almoner, such an extent that return to work becomes who know the whole family thoroughly, a major psychological adjustment. Patients enable a grasp to be h a d of the situation treated entirely from chest clinics and in which is impossible in an institution many local hospital beds do not suffer this psychic miles from the patient's home. Close liaison trauma in more than a minor degree. They between patient, physician, hospital, clinic, attend a hospital or clinic whcrc other and the sufferer's family encourage a sound diseases arc dcalt with and arc not segrej u d g m e n t of needs based upon knowledge of gated in a separate community. They remain all the available factors. in attenuated touch with the outside world One of the unfortunate disadvantages in and modified contact with their families. the sanatorium m a n a g e m e n t of tuberculous They can still perceive something very patients is the placing of sanatoria well out obvious for which to recover and live. of the cities and thus usually many miles A sense of isolation can apply also to the from the patient's own home. Under these staff of sanatoria. In most instances they are circumstances visits from the family become not near large general hospitals and could extremely difficult and will bc reduced to a with great advantage have closer contact minimum, partly because of the travelling with colleagues in other branches of meditime involved, but often bccause of the lack cine. Chest clinics, when located in general of funds for repeated long journeys. T h e hospitals, ha~'e this advantage which benefits patient is thus lonely and homesick and self- not only the physician but the patients. discharges are not uncommon. Frequent Superficially the sanatorium has certain (usually daily) visiting, which is possible to advantages, particularly in segregating the the local hospital ward, is a grcat source of infectious and in group activitics. Infection comfort and strength to the patient who may can, however, be adequately suppressed in be undergoing major surgical operations. general hospitals, as shown by Ball and his There is a number of patients who could not colleagues (195o), whilst, with the newer have bccn managed in sanatorium, or who methods of sputum disposal (Stradling, failcd to complete their course at sanatorium i953) , chemotherapy and education, infection bccausc of domestic difficultics, whose treat- at home can be controlled (Grenville-Mathers ment has come to a successful conclusion and Trenchard, z953). Planned recreation, when managed in hospital near their own diversional therapy, education, discipline homes. Some of the more clderly in par- and group morale also can be accomplished ticular will often accept a short stay in by an integrated clinic team of Physician, hospital for collapse therapy and prolonged Health Visitor, Almoner and Occupational treatment at home although refusing to Therapist. enter sanatorium. Conclusion On the other hand, if the home background is deplorable a hospital bed can It is now submitted that the admission of a provide sufficient relief from this without patient to sanatorium has no more beneficial the 'segregation' of the sanatorium. effect u p o n the clinical course of his tuberThe sense of stigma that many patients culosis than has management by an adequate feel is well known to tuberculosis physicians. clinic organization, where domiciliary, hosT h e sanatorium by its very nature tends to pital and outpatient treatment are flexibly foster this feeling; it contains patients who integrated according to need. Furthermore all have the same disease and it is set well such m a n a g e m e n t of tuberculous patients away from civilization. This segregated by the Chest Clinic has such great and retreat from life is of questionable value: it obvious advantages, not only in continuity often actively damages morale and under- of treatment, but socially, psychologically mines the patient's sense of social security to and administratively that the idea of admis-
May 1955
TUBERCLE
sion to sanatorium being the ideal for tuberculous patients should be abandoned. Emphasis in the future could, with advantage, be placed on expanding and combining, under Chest Physicians, Clinic and Local Hospital facilities to form Departments of Chest Disease sited in General Hospitals. These units could replace sanatoria as we know them today and would offer physicians a fuller clinical life than that now enjoyed in sanatorium practice. Pulmonary disease is a narrow enough speciality without restricting it further to the treatment of cases of tuberculosis already selected by one's colleagues. Long-term patients can be handled weU in these circumstances and, in any case, modern chemotherapeutic treatment is often shortening the period of so-called 'sanatorium regime' and raising grave doubts as to its absolute necessity. Thoracic Surgical Units also could with advantage be based on selected general hospitals and not sanatoria. These could serve perhaps more than one clinic whose physicians should have beds of their own in the hospital where the surgical unit is situated. At Hammersmith, for instance, the scheme described earlier has been expanded since I949: there are more clinic beds available and a considerable number of major surgical procedures are now undertaken directly from these beds. Repeated readmission as need arises, with home rest and possibly chemotherapy in the interim, can now be arranged for many cases. This is a far more integrated and economical use of beds than is obtained by admission to a sanatorium throughout the period of treatment. It should be possible for all phases of a patient's treatment to be managed outside sanatorium (with the attendant advantages already outlined) provided clinics are well equipped and staffed and enough associated beds are available. To what use then should we put the sanatoria? O f course for a while they must continue to provide the service that they do. There are not enough clinic beds yet to deal with all cases and in these circum-
155
stances really long-term patients, and those with very unsuitable homes, must still enter sanatorium. To build new sanatoria, however, would be quite out of place. Unless another social catastrophe should overtake us, one can look forward to the day when this country will present a similar picture to that now seen in Scandinavia: empty beds awaiting the discovery of sufficient patients to fill them. Although there is surely enough tubercle to keep the present generation of sanatorium physicians busy one must accept the fact that 'the crisis in the sanatorium' will eventually be upon us. The clinic organization on the other hand has a wide variety of interests already and is flexible enough to retain a position in preventive medicine whilst continuing (particularly if associated with hospitals) to provide the diagnostic and treatment service necessary in chest medicine as a whole. Sanatoria might ifl the future function chiefly as rehabilitation centres for those patients who cannot easily return to their previous employment. (Even this group will probably dwindle as early diagnosis becomes more common in the future.) Perhaps such institutions should be more closely associated with the Ministry of Labour, expanding facilities for occupational therapy, aptitude assessment, industrial rehabilitation and re-training courses, particularly parttime. A properly equipped and medically staffed organization of this sort could accept patients early in their grading-up period so shortening the time out of employment. The wider use of such centres could greatly improve the resettlement of tuberculous patients in industry. Although vital in the return of the tuberculous family to sociaI independence, this return to employment is still one of the most difficult steps to take. Whatever the future functions of sanatoria may be, however, improving facilities in general hospitals and clinics must lead to the acceptance of clinic management as a standard practice. A steady move in this .
156
May 1955
TUBERCLE
direction is right: it will be to the advantage not only of the patients b u t of the physicians themselves.
Summary (z) Conditions existing in Britain after the war, which led to trials of new methods of management for tuberculous patients, are briefly outlined. (2) A scheme is described involving short-term admissions to General Hospital beds, under Chest Clinic direction. Here necessary collapse therapy was initiated, followed by long-term management of patients both at home and as out-patients of the clinic. Some entered sanatoria for convalescence and a few received additional active treatment there. (3) The term 'Domiciliary Management' commonly used for such schemes should be replaced by 'Clinic Management' since they are run entirely from clinics although much of the work is done i n hospital beds and some in the homes. (4) A series of 64 sputum-positive patients treated in this w a y and followed for five years, is presented. There are z2 BI, 4I B2, and z z B3 patients in the group, 77 per cent of whom completed their active treatment under 'Clinical Management'. Only x z received streptomycin during their initial treatment and complications were negligible. (5) The five-year follow-up figures reveal a survival rate of zoo per cent for the Bz patients, 93 per cent for the B2, and 82 per cent for the B3, the comparable figures for quiescence at five years being IOO per cent, 7 6 per cent and 6 4 per cent. (6) Some of the disadvantages of sanatorium admission, and the ability of 'Clinic Management' to overcome these, are pointed out. In particular the attainment of continuity of treatment, the daily visiting by relatives, the complete knowledge of the home and social background, the absence of segregation and stigma are stressed. (7) It is concluded that sanatorium admission has no more beneficial effect upon the clinical course of tuberculosis than
has management by an adequate clinic organization. The advantages of the latter, clinically, psychologically, socially and administratively, are such that fuller development of chest clinics, with allied hospital beds and thoracic surgical facilities, should eventually replace the sanatorium system. References
Ball, K. P., et al. (I95o) Lancet, I~, x2I. Cuthbert, J. (195o) Tubercle, x x x b 131. Foster-Carter, A. F., et al. (1952) Brompton Hos,~ital Reports, xxz, I.
Grenville-Mathers, R, and Trenchard, M.J. (x953) Proceedings o f Royal Society of Medichze, xLvl, 8o9. Heller, R. (x9J,9) Tubercle, x x x , 2o4. Simmonds, F. A. H., and Martin, W.J. (1948) Amer. Rev. Tuberc., LWll, 537Stradling, P. (x948) Brit. Aired. 07.,n, 832. Stradling, P. (i95z) Lancet, Ix, 63o. Stradling, P. (x953) Lancet, xl, xz85. Tattersall, W. H. (19H) Tubercle, xxvm, 85. Toussaint, G. H. C. (x95o) Nathanlal Bishop Harman Prize Essay. Wynn-Willlams, N., Shaw, J. B., and Mashiter, W. E. 0950) Lancet, ~, e~I. BRONCHUS UND TUBERKULOSE. By Dr A. Huzly. Stuttgart-Gerlingen, and Dr F. Bohm Uberruh. Isny (in German) Georg Thieme. Pp. 138 with 273 illustrations. Price DM57. Over 3,213 bronchoscopies and 2,372 bronchograms in tuberculous patients form the basis for the opinions expressed in this book. From this mass of material the authors have described the correlated bronchial changes to be found in all types of lesions from small parenehymal shadows to the large generalized infiltrations. They include the altered appearances to be found in pleural reactions, and have an interesting cbapter on the bronchi in the presence of glandular lesions. Treatment is based on these bronchial changes, so that the appearances and results of pneumothoraces, phrenic crushes, and lung resections are well described, and the follow-up of cases carefully recorded. The book is concise, and well presented. The illustrations are good. The coloured pictures of the bronchoscopic appearances being particularly effective. While one may not be in full agreement with all the viewpoints expressed by the authors, there is much of interest which is based upon a wealth of experience.
May 1955
Treatment Without Sanatorium* Including Results at Five Years By PETER STRADLING Consultant Chest Physician, Hammersmith Chest Clinic and Hammersmith Hospital; Lecturer in Tuberculosis, Postgraduate Medical School of London The long waiting lists for admission in I9455 o, caused by a great post-war shortage of sanatorium beds, stimulated some chest physicians to develop treatment services on new lines. The results of such schemes have been gratifying and throw considerable doubt upon the assumption, still widely accepted, that admission to sanatorium should remain the ideal and standard practice for the treatable tuberculous patient. Conditions in the Borough of Hammersmith during I948, temporarily aggravated by the advent of the National Health Sen,ice, were most unsatisfactory. Access to general hospital beds .had been lost in the reorganization and the wait for sanatorium admission lengthened to nine months at a time when i5 o patients awaited urgent treatment. Although it was still believed, at this time, that anything less than sanatorium admission was undesirable the early results of others (Heller, 1949; Wynn-Williams et al., i95o; Cuthbert, i95o; Toussaint, i95o ) were encouraging and the critical position fully justified the institution of alternative treatment methods.
Clinic Management In collaboration with the Postgraduate Medical School, eight beds were allotted in Hammersmith Hospital to which the clinic staff had sole right of admission ('clinic' beds). Patients were admitted in quick succession for initiation of essential collapse therapy. Long periods of domiciliary maintenance followed and a proportion of the patients were finally transferred to sanatoria or rehabilitation centres. Such transfer depended on various factors such as availability of vacancies, home conditions, and the stage of treatment
at the time that the bed was offered. This subsequent institutional admission was encouraged but proved far from possible in every case. Ambulant or hasty pneumothorax inductions were not practised. The scheme was an attempt to institute, without sanatorium facilities, collapse therapy principles and general measures as then practised in the Regional Sanatoria. All the initial treatment, however, was undertaken without sanatorium and before chemotherapy became freely available. The scheme is more fully described in a previous paper (Stradling, I95i ) but the administrative arrangements are summarized in fig. x.
CUNIC/
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.
.
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OS n~CQ$~ry
#7 d,verQ,~l lh~r~y ~x:x:r d~nq ~:'Jt h o ~ ~Ips Gn1~J1~.t~c¢sQryLc|
CLINIC MANAGEMENT. Fill, I.
The term 'Domiciliary Management' as usually applied to such schemes should be abandoned, although m u c h o f the work was, and still is, done in the patients' homes. Home and hospital treatment are complementary. Close teamwork between the chest
*A paper read to the B.T.A. on September 24, x954.
lday
1955
151
TUBERCLE
clinic staff and the ancillary services leads to a nice balance of the time spent by the patient at home, in a clinic bed, and as an out-patient of the clinic. It is a fluid balance that can be adjusted according to need and circumstance. 'Clinic Management' is thus a more accurate term, since the full social, clinical and administrative handling of the patient is based upon the chest clinic. The scheme in Hammersmith was started too recently to enable the presentation of a large five-year survey, but nevertheless something can be learned from a pilot five-year follow-up of the first small group of patients treated by Clinic Management.
tion. It is thus likely that the group approximates to a sanatorium population but one cannot go farther than this and draw any strict comparisons with other groups. Nevertheless enough is known of the likely position of sputum-positive patients five years after diagnosis to make the presentation of these figures worth while. TREATMENT EPISODES
Type of lrealment
Clinic Beds
P.P. and/or phrenic crush (48) ..
47
I Sanatorium
The Material A.P. with adhesion There are 64 patients in this series, all of II 21 section (3 ~) .. whom were newly diagnosed between J u n e Surgical collapse (6) z 5 1948 and J u n e z949 and wcre admitted to the clinic beds for collapse therapy. Twelve Resection (4) -2 2 fell into the Ministry of Health Classification Group BI, 41 into B2, and II into B3. FIG. 2, They were selected for this survey partly by Active Treatment Applied choice and partly by circumstanccs and therefore the group cannot be considered as With only 8 clinic beds available very few a representative cross-section of the newly major surgical operations were undertaken diagnosed tuberculous population. Those in these but 8o per cent of the patients were very difficulties causing a change of policy treated by medical collapse therapy alone made a controlled trial of such a policy and the majority of this was managed withimpossible. Various factors of selection out sanatorium. In fact 49 (77 per cent) of operated, such as the varying availability of the patients completed their active therapy beds, the patient's attitude to sanatorium under Clinic Management although a proadmission, the presence of a suitable relative portion (75 per cent) had a period of institutional convalescence elsewhere (conat home, and so on. There were, however, certain selecting valescent home or sanatorium) because of factors common to all these patients. They the necessity for a quick turnover in so few were all sputum positive; by the standards clinic beds. Additional active therapy was accepted at the time, they all necded given to only z5 patients (32 per cent) after collapse therapy and, if this were instituted, admission to sanatoria for continuation or had a reasonable prospect of quiescence. extension of their initial treatment. Details of the treatment episodes are They were in fact patients who would have been admitted directly to sanatorium for given in fig. 2. Only 6 B2 and 5 B3 patients active therapy if such beds had been received streptomycin during their primary treatment (2 in clinic beds, 9 in sanareadily available. It is worth remembering here that most torium). Complications and Relapse sanatorium patients are also preselected in a somewhat similar manner and cannot be In the early days of Clinic Management it representative of the tuberculous popula- was predicted by sceptics that m a n y corn-
TUBERCLE
152
plications would ensue. This series does not confirm these fears; perhaps because criteria for pneumothorax induction were ahvays strict. The number of complications is so small that it is impossible to observe any comparative trends here. Three pneumothoraces were abandoned following effusions
May 1955
tical selection of cases operated. One must be content with looking at the group as a whole and seeing if the survival rate is reasonable in spite of the unorthodox method of managing a large proportion of the treatment. The position of the patients five years later is summarized in fig. 3.
5yr. FOLLOW UP
B.1 12 cases
100"/0 survival
13.2 41 cases
937. survival
i;i
B.3
11 cases
": ~~",~:; :
82*/. survival
....... :"-<'~.~~ ' : : , " - " : " ~ :: "~"-':'-: ::i"::;~"-- =: , V Z ~ / / / ,
~ QUIESCENT
g ~ ' / - z . "
~
J~ ACTIVE
DEAD
Fro. 3.
(I in sanatorium, 2 during clinic management); two haemothoraces developed after adhesion section (i in sanatorium, I in a hospital bed) and two sinuses were seen after sanatorium surgery, Subsequent relapse was seen in I6 patients rendered quiescent by the initial treatment and all these received chemotherapy. Quiescence was regained by Io whilst 6 appear amongst those active at five years. Results at Five Years It would have been desirable when assessing the results at five years to compare the follow-up findings in .those of the group subsequently entering sanatorium with those that did not, and to have assessed the difference between the two. However, no valid conclusions could be drawn from such a comparison when the numbers are so small and no properly controlled statis-
..~\ SIkHJkTOR/uH ,
/ j
fit for wwk
s
J/
LIIVIc
•/
whilst aL work
Clinicsupervisionwith
1
/
MANAGE~,J~ ¢--"
Fro. 4. - Proportion of 5-year period spent under various circumstances.
It is interesting to note that quiescence was obtained without active treatment in sanatorium in z I of the i2 B I group, in
May 1955
TUBERCLE
3 ° of the 41 B~ (73 per cent) and in only 6 of the ix B3. T h e effect of extent of disease at the time of diagnosis in lengthening the subsequent treatment is thus obvious. This problem can be solved in part by a drive for early diagnosis; an essential factor for successful Clinic Management (Stradling, I948 ). Although not statistically comp.arable, as already stated, it is instructive at this stage to recall the five-year survival rates in 2 well-known large series of B2 sanatorium patients. Simmonds and Martin (I948) reported a 71.6 per cent survival rate; Foster-Carter et al. (i952) 87.6 per cent. In the present small series the rate was 93 per cent for the B2 group. Even if one assumes that the ~3 per cent of B2 cases who received streptomycin during their initial treatment would all have died without it (a most unlikely contingency) then the survival rate is still 8o per cent. Discussion
Simmonds and Martin (I948) when assessing the value of sanatorium treatment rated the thorough application of collapse therapy as the most important single factor in encouraging sputum conversion and survival. Results in this small survey support once again this now little-doubted fact. Collapse therapy was applied early in all cases in this series and the survival rates compare favourably with the best yet recorded. With others, Tattersall (I947) has coneluded that simple sanatorium regime without active therapy is of little value. Again the results given here do not contradict this. At least there is presented a group of patients who have received the major part of their management outside sanatorium and who have fared no worse than is usual for sanatorium-treated patients. These results were obtained with minimal hospital facilities and a much better picture can be expected with the fuller service now provided. If then there is really little to choose in purely clinical end-results between sanatorium and clinic m a n a g e m e n t is it possible
153
to reach more definite conclusions as to the value of sanatorium by studying other factors? When this is done m a n y obvious advantages are found to lie with Cfinic Management. Consideration should first be given to the time factor in relation to the place and form of treatment. Six arbitrary groups have been used for the systematic consideration of the patients from this point of view and the position is best understood from fig. 4 which presents in proportional form the averages of the times that the patients spent in these groups over the five-year period under consideration. It will be seen that the time spent in sanatorium is only I/I2th of the total period of treatment and observation. If the average period spent in sanatorium for active therapy is estimated then this constitutes only ~/4oth of the total period under review. By far the major part of the patients' clinical supervision was thus the responsibility of the clinic. This included hospital care, domiciliary management in the patients' h o m e surroundings and often a long period of regular weekly attendances at the clinic for the maintenance of collapse therapy. Can the short sanatorium stay be of more training value than prolonged contact with. the home-visitor, hospital, and clinic staff over m a n y months or years? It is believed not. There is plenty of opportunity to replace the clinical and educative facilities usual to a sanatorium, by equally effective action within the clinic organization. Sanatorium admission severely breaks continuity of treatment which is of considerable significance when treating an illness where continuous management under one physician is of incalculable clinical value. Furthermore, the differences of opinion, and changes of treatment likely to be inflicted upon the transferred patient, only bewilder him, undermine his confidence, and make h i m sceptical of medical opinion and care. This is avoided in clinic management. The regular presence at clinical con-
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ferences of the home visitors and almoner, such an extent that return to work becomes who know the whole family thoroughly, a major psychological adjustment. Patients enable a grasp to be h a d of the situation treated entirely from chest clinics and in which is impossible in an institution many local hospital beds do not suffer this psychic miles from the patient's home. Close liaison trauma in more than a minor degree. They between patient, physician, hospital, clinic, attend a hospital or clinic whcrc other and the sufferer's family encourage a sound diseases arc dcalt with and arc not segrej u d g m e n t of needs based upon knowledge of gated in a separate community. They remain all the available factors. in attenuated touch with the outside world One of the unfortunate disadvantages in and modified contact with their families. the sanatorium m a n a g e m e n t of tuberculous They can still perceive something very patients is the placing of sanatoria well out obvious for which to recover and live. of the cities and thus usually many miles A sense of isolation can apply also to the from the patient's own home. Under these staff of sanatoria. In most instances they are circumstances visits from the family become not near large general hospitals and could extremely difficult and will bc reduced to a with great advantage have closer contact minimum, partly because of the travelling with colleagues in other branches of meditime involved, but often bccause of the lack cine. Chest clinics, when located in general of funds for repeated long journeys. T h e hospitals, ha~'e this advantage which benefits patient is thus lonely and homesick and self- not only the physician but the patients. discharges are not uncommon. Frequent Superficially the sanatorium has certain (usually daily) visiting, which is possible to advantages, particularly in segregating the the local hospital ward, is a grcat source of infectious and in group activitics. Infection comfort and strength to the patient who may can, however, be adequately suppressed in be undergoing major surgical operations. general hospitals, as shown by Ball and his There is a number of patients who could not colleagues (195o), whilst, with the newer have bccn managed in sanatorium, or who methods of sputum disposal (Stradling, failcd to complete their course at sanatorium i953) , chemotherapy and education, infection bccausc of domestic difficultics, whose treat- at home can be controlled (Grenville-Mathers ment has come to a successful conclusion and Trenchard, z953). Planned recreation, when managed in hospital near their own diversional therapy, education, discipline homes. Some of the more clderly in par- and group morale also can be accomplished ticular will often accept a short stay in by an integrated clinic team of Physician, hospital for collapse therapy and prolonged Health Visitor, Almoner and Occupational treatment at home although refusing to Therapist. enter sanatorium. Conclusion On the other hand, if the home background is deplorable a hospital bed can It is now submitted that the admission of a provide sufficient relief from this without patient to sanatorium has no more beneficial the 'segregation' of the sanatorium. effect u p o n the clinical course of his tuberThe sense of stigma that many patients culosis than has management by an adequate feel is well known to tuberculosis physicians. clinic organization, where domiciliary, hosT h e sanatorium by its very nature tends to pital and outpatient treatment are flexibly foster this feeling; it contains patients who integrated according to need. Furthermore all have the same disease and it is set well such m a n a g e m e n t of tuberculous patients away from civilization. This segregated by the Chest Clinic has such great and retreat from life is of questionable value: it obvious advantages, not only in continuity often actively damages morale and under- of treatment, but socially, psychologically mines the patient's sense of social security to and administratively that the idea of admis-
May 1955
TUBERCLE
sion to sanatorium being the ideal for tuberculous patients should be abandoned. Emphasis in the future could, with advantage, be placed on expanding and combining, under Chest Physicians, Clinic and Local Hospital facilities to form Departments of Chest Disease sited in General Hospitals. These units could replace sanatoria as we know them today and would offer physicians a fuller clinical life than that now enjoyed in sanatorium practice. Pulmonary disease is a narrow enough speciality without restricting it further to the treatment of cases of tuberculosis already selected by one's colleagues. Long-term patients can be handled weU in these circumstances and, in any case, modern chemotherapeutic treatment is often shortening the period of so-called 'sanatorium regime' and raising grave doubts as to its absolute necessity. Thoracic Surgical Units also could with advantage be based on selected general hospitals and not sanatoria. These could serve perhaps more than one clinic whose physicians should have beds of their own in the hospital where the surgical unit is situated. At Hammersmith, for instance, the scheme described earlier has been expanded since I949: there are more clinic beds available and a considerable number of major surgical procedures are now undertaken directly from these beds. Repeated readmission as need arises, with home rest and possibly chemotherapy in the interim, can now be arranged for many cases. This is a far more integrated and economical use of beds than is obtained by admission to a sanatorium throughout the period of treatment. It should be possible for all phases of a patient's treatment to be managed outside sanatorium (with the attendant advantages already outlined) provided clinics are well equipped and staffed and enough associated beds are available. To what use then should we put the sanatoria? O f course for a while they must continue to provide the service that they do. There are not enough clinic beds yet to deal with all cases and in these circum-
155
stances really long-term patients, and those with very unsuitable homes, must still enter sanatorium. To build new sanatoria, however, would be quite out of place. Unless another social catastrophe should overtake us, one can look forward to the day when this country will present a similar picture to that now seen in Scandinavia: empty beds awaiting the discovery of sufficient patients to fill them. Although there is surely enough tubercle to keep the present generation of sanatorium physicians busy one must accept the fact that 'the crisis in the sanatorium' will eventually be upon us. The clinic organization on the other hand has a wide variety of interests already and is flexible enough to retain a position in preventive medicine whilst continuing (particularly if associated with hospitals) to provide the diagnostic and treatment service necessary in chest medicine as a whole. Sanatoria might ifl the future function chiefly as rehabilitation centres for those patients who cannot easily return to their previous employment. (Even this group will probably dwindle as early diagnosis becomes more common in the future.) Perhaps such institutions should be more closely associated with the Ministry of Labour, expanding facilities for occupational therapy, aptitude assessment, industrial rehabilitation and re-training courses, particularly parttime. A properly equipped and medically staffed organization of this sort could accept patients early in their grading-up period so shortening the time out of employment. The wider use of such centres could greatly improve the resettlement of tuberculous patients in industry. Although vital in the return of the tuberculous family to sociaI independence, this return to employment is still one of the most difficult steps to take. Whatever the future functions of sanatoria may be, however, improving facilities in general hospitals and clinics must lead to the acceptance of clinic management as a standard practice. A steady move in this .
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direction is right: it will be to the advantage not only of the patients b u t of the physicians themselves.
Summary (z) Conditions existing in Britain after the war, which led to trials of new methods of management for tuberculous patients, are briefly outlined. (2) A scheme is described involving short-term admissions to General Hospital beds, under Chest Clinic direction. Here necessary collapse therapy was initiated, followed by long-term management of patients both at home and as out-patients of the clinic. Some entered sanatoria for convalescence and a few received additional active treatment there. (3) The term 'Domiciliary Management' commonly used for such schemes should be replaced by 'Clinic Management' since they are run entirely from clinics although much of the work is done i n hospital beds and some in the homes. (4) A series of 64 sputum-positive patients treated in this w a y and followed for five years, is presented. There are z2 BI, 4I B2, and z z B3 patients in the group, 77 per cent of whom completed their active treatment under 'Clinical Management'. Only x z received streptomycin during their initial treatment and complications were negligible. (5) The five-year follow-up figures reveal a survival rate of zoo per cent for the Bz patients, 93 per cent for the B2, and 82 per cent for the B3, the comparable figures for quiescence at five years being IOO per cent, 7 6 per cent and 6 4 per cent. (6) Some of the disadvantages of sanatorium admission, and the ability of 'Clinic Management' to overcome these, are pointed out. In particular the attainment of continuity of treatment, the daily visiting by relatives, the complete knowledge of the home and social background, the absence of segregation and stigma are stressed. (7) It is concluded that sanatorium admission has no more beneficial effect upon the clinical course of tuberculosis than
has management by an adequate clinic organization. The advantages of the latter, clinically, psychologically, socially and administratively, are such that fuller development of chest clinics, with allied hospital beds and thoracic surgical facilities, should eventually replace the sanatorium system. References
Ball, K. P., et al. (I95o) Lancet, I~, x2I. Cuthbert, J. (195o) Tubercle, x x x b 131. Foster-Carter, A. F., et al. (1952) Brompton Hos,~ital Reports, xxz, I.
Grenville-Mathers, R, and Trenchard, M.J. (x953) Proceedings o f Royal Society of Medichze, xLvl, 8o9. Heller, R. (x9J,9) Tubercle, x x x , 2o4. Simmonds, F. A. H., and Martin, W.J. (1948) Amer. Rev. Tuberc., LWll, 537Stradling, P. (x948) Brit. Aired. 07.,n, 832. Stradling, P. (i95z) Lancet, Ix, 63o. Stradling, P. (x953) Lancet, xl, xz85. Tattersall, W. H. (19H) Tubercle, xxvm, 85. Toussaint, G. H. C. (x95o) Nathanlal Bishop Harman Prize Essay. Wynn-Willlams, N., Shaw, J. B., and Mashiter, W. E. 0950) Lancet, ~, e~I. BRONCHUS UND TUBERKULOSE. By Dr A. Huzly. Stuttgart-Gerlingen, and Dr F. Bohm Uberruh. Isny (in German) Georg Thieme. Pp. 138 with 273 illustrations. Price DM57. Over 3,213 bronchoscopies and 2,372 bronchograms in tuberculous patients form the basis for the opinions expressed in this book. From this mass of material the authors have described the correlated bronchial changes to be found in all types of lesions from small parenehymal shadows to the large generalized infiltrations. They include the altered appearances to be found in pleural reactions, and have an interesting cbapter on the bronchi in the presence of glandular lesions. Treatment is based on these bronchial changes, so that the appearances and results of pneumothoraces, phrenic crushes, and lung resections are well described, and the follow-up of cases carefully recorded. The book is concise, and well presented. The illustrations are good. The coloured pictures of the bronchoscopic appearances being particularly effective. While one may not be in full agreement with all the viewpoints expressed by the authors, there is much of interest which is based upon a wealth of experience.