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TUBERCULOSIS AND THE NATIONAL HEALTH SERVICE ACT
575
Letters
to
the Editor
TUBERCULOSIS AND THE NATIONAL HEALTH SERVICE ACT of the members of the regional SIR,-The boards may be published at any moment, and as soon as new appointed they will have to get to work on the organisation due to operate from next April. We also see that on July 8 the Minister of Health himself is to address the Commonwealth and Empire Health and Tuberculosis Conference (arranged by the National Association for the Prevention of Tuberculosis) on the National Health Service Act and its Effect on Tuberculosis Schemes. Tuberculosis, because of its effect not only on the patient but on the community, presents special problems and difficulties, as is generally admitted ; we note that the Minister of Health and the Minister of National Insurance have accepted the position that pulmonary cases will qualify for extra benefits, and the Ministry of Labour are planning special workshops for the tuberculous. No scheme for the prevention and treatment of tuberculosis can ever be efficient and effective unless the family is regarded as the unit. If separate medical staffs undertake separate parts of what should be a unified tuberculosis scheme, then we shall surely see return a state comparable with the days before the Astor report. Leading officials of the Ministry of Health have stated that it is the full intention to continue the best features of efficient tuberculosis schemes. How, then, can we ensure within the framework of the new Act the greatest possible integration of the several components which ought to constitute a workable and successful regional organisation ? I would like to make the following names
suggestions. (1) The Minister of Health,
after consultation with the Central Health Services Council, should have a Tuberculosis Advisory Committee to advise on policy and to provide technical guidance on tuberculosis, such course being permissible by section 2 (3) of the Act. (2) For the control and direction of the day-to-day tuberculosis work of diagnosis and treatment each regional board should appoint a tuberculosis committee to be assisted by a regional tuberculosis officer and staff. The committee could take the form of (a) selected members of the regional hospital board with coopted persons of experience in tuberculosis, or (b) an advisory technical body of mainly tuberculosis officers and medical officers of health, or (c) in large regions, both (a) and (b)that is, a tuberculosis committee aided by a technical
body. (3) The tuberculosis medical staff for each region should consist of one or more graded medical teams with clerical assistance and tuberculosis health visitors who would assist in the dispensary work and bring a first-hand knowledge of the family circumstances and conditions and contacts-so important in a scheme based on persuasion. Each team could be given responsibility for an area containing several hundred thousand population and preferably coextensive with one or two hospital management committee areas. The teams should perform both dispensary and sanatorium duties, work in the closest relation with the general practitioners, examine contacts, and be given the definite duty to assist the medical officers of health of county and county-borough councils in care work and in preventing the spread of infection. Each team should have a register of all the tuberculosis cases in their area and generally hold the tuberculosis service together so that they would always know what is happening to the patients, both
pulmonary and non-pulmonary. (4) Throughout the country
there are many small it is the intention gradually to eliminate these as separate units and to provide equivalent accommodation as part of the large and improved general hospitals. This may take a long time. Meanwhile how should the day-to-day management of the existing sanatoria be effected ? I suggest that they and the tuberculosis dispensaries be taken as a group in each region and administered by the regional tuberculosis committee, who could and should cooperate where advan-
tuberculosis institutions ;
tageous with hospital management committees in the region. The proposed transfer of the whole hospital and specialist services on April 1, 1948, will involve (along with general medical, dental, pharmaceutical, and ophthalmic services) a considerable feat of organisation. In the event of delay, and if the date fixed cannot be amended, I suggest that the county councils and county boroughs be asked to continue by contract the tuberculosis service on behalf of the regional boards until the transfer can be made on a well-planned basis. Church Stretton, Salop.
G. LISSANT COX.
SAND-FLY FEVER their article of April 5, Dr. Fleming and his SIR,-In colleagues state that since sand-flies were difficult to find in the Naples area they were not able to confirm their clinical diagnosis. This was not the experience of our American colleagues, who carried out extensive searches and satisfied themselves on this point in both the Naples and Caserta areas. The high incidence-in the summer of 1945 was probably due to the increase in the number of troops billeted in towns and villages which had been damaged in the previous year. It was noted in the Middle East that this illness was more common in Service people living in towns and villages than in troops engaged in active warfare in the open. From my personal experience, I am sure that the preicteric fever, when it occurs, heralds the onset of jaundice by four or five days at the most, and that during the latter part of this time the earliest gastrointestinal symptoms of nausea and anorexia manifest themselves. In the autumn of 1940 it was quite commonly found that men evacuated from the Western Desert 48 hours previously with a diagnosis of sand-fly fever, and with all the symptoms of this condition, arrived in hospital apyrexial but with an increasing jaundice. It would be interesting to know whether any of Dr. Fleming’s volunteers developed jaundice within 3-4 weeks of the inoculation of the serum of patients with sand-fly fever, because one feels that there may possibly be some similarity between the virus of sand-fly fever and that of infective hepatitis. GEORGE KOMROWER. Children’s Hospital, Birmingham. -
SOCIAL PATHOLOGY SiR,-After reading your admirable leader and Prof. Perrin H. Long’s fine factual and philosophical address, many physicians will ponder again and further over the subject of social pathology. Many will agree that social medicine should be a development in clinical medicine. - This is a fundamental idea which should be in the minds of the teachers of medicine, whichever age-group of patients may be their particular concern. The tendency to geographical divorcement of the patients and wards from the realities of the outside world has not been conducive to a complete study of the individual and his environment. It is increasingly apparent, however, that clinical teachers are making headway towards a better synthesis of the factors related to a person’s health or sickness. Moreover the added interest to physician, student, and nurse in knowing as fully as possible " what sort of a person is he ? " rather than the brief material approach of what has he got ? " gives a warmer climate to one’s work and enhances understanding of the all-round treatment required to make a patient better and happier. When a careful, tactful, yet comprehensive survey is made of their way of life, many patients gratefully recognise that something more than mere treatment of their particular disease is being attempted. One might argue that clinical medicine has always aimed at understanding the " whole man " ; and of course many practitioners daily practise the principle, even so far as, on occasion, to treat the person rather than the disease. It may well be that the hospital physician has been at a disadvantage in his assessment of a patient, in so far as he seldom possesses detailed knowledge of a patient’s home, work, and leisure. In the present better-regulated outpatient departments, which afford more time for inquiry, a full and purposive social history should form an essential part of the clinical approach. "
Letters
to
the Editor
TUBERCULOSIS AND THE NATIONAL HEALTH SERVICE ACT of the members of the regional SIR,-The boards may be published at any moment, and as soon as new appointed they will have to get to work on the organisation due to operate from next April. We also see that on July 8 the Minister of Health himself is to address the Commonwealth and Empire Health and Tuberculosis Conference (arranged by the National Association for the Prevention of Tuberculosis) on the National Health Service Act and its Effect on Tuberculosis Schemes. Tuberculosis, because of its effect not only on the patient but on the community, presents special problems and difficulties, as is generally admitted ; we note that the Minister of Health and the Minister of National Insurance have accepted the position that pulmonary cases will qualify for extra benefits, and the Ministry of Labour are planning special workshops for the tuberculous. No scheme for the prevention and treatment of tuberculosis can ever be efficient and effective unless the family is regarded as the unit. If separate medical staffs undertake separate parts of what should be a unified tuberculosis scheme, then we shall surely see return a state comparable with the days before the Astor report. Leading officials of the Ministry of Health have stated that it is the full intention to continue the best features of efficient tuberculosis schemes. How, then, can we ensure within the framework of the new Act the greatest possible integration of the several components which ought to constitute a workable and successful regional organisation ? I would like to make the following names
suggestions. (1) The Minister of Health,
after consultation with the Central Health Services Council, should have a Tuberculosis Advisory Committee to advise on policy and to provide technical guidance on tuberculosis, such course being permissible by section 2 (3) of the Act. (2) For the control and direction of the day-to-day tuberculosis work of diagnosis and treatment each regional board should appoint a tuberculosis committee to be assisted by a regional tuberculosis officer and staff. The committee could take the form of (a) selected members of the regional hospital board with coopted persons of experience in tuberculosis, or (b) an advisory technical body of mainly tuberculosis officers and medical officers of health, or (c) in large regions, both (a) and (b)that is, a tuberculosis committee aided by a technical
body. (3) The tuberculosis medical staff for each region should consist of one or more graded medical teams with clerical assistance and tuberculosis health visitors who would assist in the dispensary work and bring a first-hand knowledge of the family circumstances and conditions and contacts-so important in a scheme based on persuasion. Each team could be given responsibility for an area containing several hundred thousand population and preferably coextensive with one or two hospital management committee areas. The teams should perform both dispensary and sanatorium duties, work in the closest relation with the general practitioners, examine contacts, and be given the definite duty to assist the medical officers of health of county and county-borough councils in care work and in preventing the spread of infection. Each team should have a register of all the tuberculosis cases in their area and generally hold the tuberculosis service together so that they would always know what is happening to the patients, both
pulmonary and non-pulmonary. (4) Throughout the country
there are many small it is the intention gradually to eliminate these as separate units and to provide equivalent accommodation as part of the large and improved general hospitals. This may take a long time. Meanwhile how should the day-to-day management of the existing sanatoria be effected ? I suggest that they and the tuberculosis dispensaries be taken as a group in each region and administered by the regional tuberculosis committee, who could and should cooperate where advan-
tuberculosis institutions ;
tageous with hospital management committees in the region. The proposed transfer of the whole hospital and specialist services on April 1, 1948, will involve (along with general medical, dental, pharmaceutical, and ophthalmic services) a considerable feat of organisation. In the event of delay, and if the date fixed cannot be amended, I suggest that the county councils and county boroughs be asked to continue by contract the tuberculosis service on behalf of the regional boards until the transfer can be made on a well-planned basis. Church Stretton, Salop.
G. LISSANT COX.
SAND-FLY FEVER their article of April 5, Dr. Fleming and his SIR,-In colleagues state that since sand-flies were difficult to find in the Naples area they were not able to confirm their clinical diagnosis. This was not the experience of our American colleagues, who carried out extensive searches and satisfied themselves on this point in both the Naples and Caserta areas. The high incidence-in the summer of 1945 was probably due to the increase in the number of troops billeted in towns and villages which had been damaged in the previous year. It was noted in the Middle East that this illness was more common in Service people living in towns and villages than in troops engaged in active warfare in the open. From my personal experience, I am sure that the preicteric fever, when it occurs, heralds the onset of jaundice by four or five days at the most, and that during the latter part of this time the earliest gastrointestinal symptoms of nausea and anorexia manifest themselves. In the autumn of 1940 it was quite commonly found that men evacuated from the Western Desert 48 hours previously with a diagnosis of sand-fly fever, and with all the symptoms of this condition, arrived in hospital apyrexial but with an increasing jaundice. It would be interesting to know whether any of Dr. Fleming’s volunteers developed jaundice within 3-4 weeks of the inoculation of the serum of patients with sand-fly fever, because one feels that there may possibly be some similarity between the virus of sand-fly fever and that of infective hepatitis. GEORGE KOMROWER. Children’s Hospital, Birmingham. -
SOCIAL PATHOLOGY SiR,-After reading your admirable leader and Prof. Perrin H. Long’s fine factual and philosophical address, many physicians will ponder again and further over the subject of social pathology. Many will agree that social medicine should be a development in clinical medicine. - This is a fundamental idea which should be in the minds of the teachers of medicine, whichever age-group of patients may be their particular concern. The tendency to geographical divorcement of the patients and wards from the realities of the outside world has not been conducive to a complete study of the individual and his environment. It is increasingly apparent, however, that clinical teachers are making headway towards a better synthesis of the factors related to a person’s health or sickness. Moreover the added interest to physician, student, and nurse in knowing as fully as possible " what sort of a person is he ? " rather than the brief material approach of what has he got ? " gives a warmer climate to one’s work and enhances understanding of the all-round treatment required to make a patient better and happier. When a careful, tactful, yet comprehensive survey is made of their way of life, many patients gratefully recognise that something more than mere treatment of their particular disease is being attempted. One might argue that clinical medicine has always aimed at understanding the " whole man " ; and of course many practitioners daily practise the principle, even so far as, on occasion, to treat the person rather than the disease. It may well be that the hospital physician has been at a disadvantage in his assessment of a patient, in so far as he seldom possesses detailed knowledge of a patient’s home, work, and leisure. In the present better-regulated outpatient departments, which afford more time for inquiry, a full and purposive social history should form an essential part of the clinical approach. "