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With regard to the staff required, provided the majority of contacts attend at the dispensary
and assuming 80 per cent, of all contacts are examined, a tuberculosis officer of a dispensary area having
from 120.160 deaths from tuberculosis per annum will probably spend from 3 to 4 hours a week on this
work. This point should be borne in mind in connection with the staff required for dispensaries. It is
impossible to say what additional nursing staff would be necessary but it is certain that in many areas
the number would have to be increased.
Method of dealing with definite cases of pulmonary tuberculosis.—With one or two exceptions, the
tuberculosis officers recommend sanatorium treatment for all cases of pulmonary tuberculosis in
which they consider there is a prospect of arrest of the disease. Men who are not feeling seriously ill
frequently object to this recommendation for financial reasons and married women on the ground that
they cannot arrange for the care of their children during their absence. Persuasion and explanation
on the part of the tuberculosis oficer, however, and assistance on the part of the care committee by
helping to make suitable arrangements for the care of the family, the provision of necessary outfits, etc.,
is not infrequently successful in inducing these patients to accept the treatment recommended. One
tuberculosis officer said that in his experience the number of patients who could be induced to go to
sanatoria varied directly with the trouble taken by the tuberculosis officer. This is undoubtedly true to a
large extent but even then a considerable number of patients in the poorer area, amounting sometimes to
as much as 60 per cent., do not respond to persuasion. There is considerable scope for the extension
of the work of care committees in supplementing the efforts of the tuberculosis officer in this
direction.
In one area, and to a less extent in several other areas, the practice of the tuberculosis officer
is to recommend all cases with favourable prognosis among ex.service men and the civilian insured for
a preliminary period of observation in a residential institution. In the case of the uninsured with
favourable prognosis living under satisfactory conditions and having an adequate income, his practice
is to keep them under observation and treatment at the dispensary for a period of from six to eight weeks.
If they respond well to treatment he continues to treat them at home and states that in his opinion they
do quite as well as in a sanatorium. Patients who are unable to hold their own or show the slightest
sign of going back or do not five under suitable conditions, etc., are recommended for sanatorium
treatment. There is something to be said in favour of this method of dealing with suitable cases, provided
it is skilfully applied and limited to those patients where great hardship would ensue if sanatorium
treatment were insisted upon.
It should be remarked that tuberculosis officers have found a very real difficulty in obtaining
adequate sanatorium treatment for all suitable cases and that there is considerable delay in securing
admission. The interval between recommendation for and admission of the patient to a sanatorium was
at the time of the enquiry generally stated to be 7-14 days in the case of an ex.soldier; 28 days in the
case of insured persons and uninsured adults, and about 8-12 weeks in the case of children. This interval
has been reduced latterly in the case of uninsured adults and children owing to the increase in the number
of beds available.
The great majority of tuberculosis officers thought that a short period of treatment, say two
months in a residential institution for purposes of education and restoration of general health, was
desirable for cases of middle and chronic progressive disease and that this should be rep ated as occasion
required. It is evident that further accommodation in residential institutions is needed for this class
of case. There was some difference of opinion amongst tuberculosis officers as to the type of institution
to which such patients should be sent. The majority were in favour of an institution in the suburbs
conducted on sanatorium lines. The minority favoured the treatment of these cases in a smaller institution
within the area of the dispensary. Only one tuberculosis officer considered prolonged sanatorium
treatment desirable. Many tuberculosis officers recommend the more favourable cases of this type
for sanatorium treatment, with the result that sanatorium beds are not properly utilised. The London Insurance
Committee have recently attempted to deal with this difficulty by asking that the certificates
relating to patients in whom there is a reasonable prospect of the arrest of the disease should be marked
A and those relating to patients in whom there is a prospect of improvement be marked B ; under B a
number of these middle and chronic progressive cases are recommended for treatment.
Similarly in cases of advanced disease every tuberculosis officer felt the need for additional accommodation.
Many of them favoured the provision of small local nursing homes for this class of cases
mainly because they thought that these homes, in addition to the advantage of being readily accessible
for relatives and friends, could be rendered more attractive and homely to the patient than was possible
in the larger institutions. Some of the tuberculosis officers thought the supervision of such a local home
should be entrusted to them.
It was generally felt that some provision was needed for cases of haemoptysis, pleurisy and other
acute conditions occurring in patients living at home. A small percentage of these patients are admitted
to general hospitals, others by virtue of special arrangements made by the London County Council or
Insurance Committee secure admission to residential institutions at an earlier date than would otherwise
have been the case. The majority, however, have to be treated at home where the facilities for nursing
and adequate attention are usually lacking. A limited amount of provision is certainly required for these
cases and it must be of such a nature that immediate use can be made of it when required. About half
the tuberculosis officers thought this provision should be made by earmarking special beds in general and
special hospitals for the purpose. The remainder thought provision should be made for them in local
homes established for observation and other cases and that such homes should be under the supervision
and control of the tuberculosis officer.