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passed for sale. In this connection the importance of keeping a record of the batch number of the
remedy given to each patient is highly important. This does not seem to be realised in many clinics
where the batch number is never recorded.
Standards of cure.—While in most clinics the medical officers stated they required satisfaction
of a fair number of stringent tests before discharging a patient under Item 5 of the annual report ("discharged
after completion of treatment and observation"), enquiries left, in the majority of cases,
the impression that medical officers had made up the standard they required on the occasion of our
inspection, and that the practice was not clearly defined. It appears desirable that medical officers
of clinics should come to an agreement in regard to the tests which should be applied to a patient before
discharging under Item 5 of the annual report, and note definitely on the case record the results of these
tests. At present in most cases the decision is left to someone long after the patient has gone, and it
does not appear to us that the records of most clinics under Items 3b and 5 are of any value. In private
practice a medical adviser is asked to give a definite opinion on these questions, and will not do so if
he is wise until he has applied certain definite tests. It does not seem too much to ask medical officers to
apply just as stringent tests and to record their opinions just as definitely in the case of public as of
private patients.
In-patient accommodation.—Under the agreements between the participating authorities and the
hospitals every venereal disease clinic must have at its disposal at least one male and one female bed
for in-patient treatment. In the great majority of hospitals the in-patient accommodation for this
purpose is far in excess of the minimum requirement, and the total accommodation for the 28 venereal
disease clinics is not less than 250 beds.
In certain hospitals it is stated that there is still an insufficient provision made for the in-patient
treatment of cases of complicated gonorrhoea. It would be desirable to draw the attention of the
hospitals concerned to this fact.
Patients ceasing to attend before completion of treatment.—The statistics of new and old patients
in attendance at the venereal disease clinics indicate that a very large percentage of the patients fail to
complete the course of treatment. The average for the whole of the London clinics cannot be put at
less than 30 per cent., and is probably higher. So serious a defect in the efficiency of the clinics has
naturally called for very careful and detailed enquiry. The investigations on this point have not been
confined to those institutions where the figures are exceptionally unsatisfactory, but the practice has
been to conduct special enquiries into the matter at each one of the clinics.
Although irregular attendance is a constant feature, actual disappearance of the patients
at an early stage of treatment, whilst still in an acutely infectious state, does not make up a
large proportion of those who fail to complete treatment. The really serious difficulty arises from the
fact that so many patients, when they have got over the initial stages of the disease, think that it is
unnecessary to continue attendance until the medical officer of the clinic discharges them. The practical
outcome of this is that the patient remains a carrier of infection, and from the Public Health point of view
the money is wasted. Even in those cases where the chances of infection have been considerably
diminished the fact remains that late sequelae of the disease are not avoided. In the case of syphilis,
this may mean that the subsequent development of conditions, such as locomotor ataxia, general paralysis
of the insane, etc., which often result in the patients becoming inmates of public institutions, and consequently
a charge upon the public. The following are a few of the many reasons given to us for patients
failing to complete the course of treatment:—
(1) The incurable optimism of patients who judge themselves cured as soon as their
symptoms have markedly abated.
(2) The difficulty of accounting for their repeated absences from work or from their
homes.
(3) Engagement in seafaring occupations which naturally involve in some instances long
absences from London. Similarly in the cases of commercial travellers, race-meeting followers,
etc.
(4) Many patients visit the clinics and then leave or go on to other clinics or seek treatment
elsewhere for a variety of trifling reasons, e.g., "Not satisfied with the treatment"—"Dislike
of doctor or nurse"—"Hurt by injection," etc., etc.
(5) Carelessness and ignorance on the part of patients are still, unfortunately, not infrequent
causes.
The above reasons account for a number of patients who fail to complete their course of treatment,
but the overcrowding of the clinics, where it occurs, accompanied as it must be with long periods of
waiting, and insufficient concentration upon the patient, is also a factor of great importance. It is
obvious that in those cases where the medical officer of the clinic is unable, owing to great pressure of
work, to give to his work the consideration and attention which it deserves and requires, there must
arise in the mind of the patient the feeling that he is not, after all, suffering from a very serious disease.
Moreover, in such circumstances, the medical officer is unable sufficiently to impress upon the mind
of the patient the immense importance of regular attendance at the clinic and the absolute necessity
for such attendance to be continued until informed that he may now safely discontinue attendance.
The usual practice is to write a patient off the list after an absence of three months or more. In
some of the clinics an effort has been made to induce a patient to return to the clinic for examination and
treatment when it has been observed that attendance has been in default for some weeks. For this
purpose a very carefully drafted non-committal letter is sent to the address given by the patient. In
the vast majority of cases the letter is ultimately returned from the "Dead Letter" office owing to
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