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Provision for (1) Observation Beds, (2) Acute, Emergence, etc., Cases, (3) Middle and
Chronic Progressive Cases, (4) Advanced Cases.
The provision for these four classes of cases can best be dealt with together, as they each involve
much the same problem. Tuberculosis officers are divided in their views as to the most suitable
provision. Broadly speaking, the difference of opinion resolves itself into the question of provision by—
(а) Large institutions;
(б) Small local institutions in the area of the dispensary.
That it would be possible in practice to deal adequately with the large number of cases included
in these four groups by means of small local institutions is, I feel sure, an utterly hopeless proposition.
That small local institutions may be useful for a small number of patients who will probably not
go to large institutions for various personal reasons, there is no doubt, but it is equally certain that the
greatly increased expense per bed owing to staff, etc.: greatly increased difficulty of administration and
local management; the practical impossibility of obtaining a sufficient number of suitable houses with
adequate grounds; the objections which would almost certainly be raised in some areas by local inhabitants,
etc., etc., render such a method of dealing with the large numbers of patients involved
impracticable.
(1) Observation Beds.—(For cases which are difficult of diagnosis, and also where some doubt
exists as to the most suitable form of institutional treatment in particular cases.) It is reasonable to
assume that to some extent tuberculosis officers who favour small local institutions, for these and other
patients, are influenced by their natural desire to vary the monotony of their tuberculosis dispensary
work as at present conceived by them. But whether this is so or not, there can be no possible doubt that
the provision of observation beds for these cases will fail of their object, unless they are provided in
institutions wherein are to be found not only all modern facilities for assisting in diagnosis, etc., e.g.,
X.Rays, Laryngological Department, Bacteriological and Chemical Laboratories, etc.; but also the
wide outlook and mature experience which are the special gifts of the consulting staff of such institutions.
Bearing these facts in mind then, it would appear that at least, so far as observation beds are concerned,
the most suitable arrangement would be for the Council to make provision for such beds in several of
1 he large general and special hospitals, and I would suggest that instead of the present consulting service
system with linked.up hospital and the system of medical referees, both of which in practice have proved
to be failures, six such institutions should be selected, e.g.:—
London Hospital (E. and S.E.). University College (Central London).
Victoria Park (E. and N.E.). St. Thomas's Hospital (S.W. and W.).
King's College Hospital (S.E.). Brompton Hospital (S.W. and W.).
Each of these hospitals would form a mother hospital for certain groups of dispensaries within
a reasonable distance. Details could be worked out later when the principle is accepted.
Something like 200 beds would be required for London as a whole. These beds would be reserved
primarily for observation purposes. Admission would be by order of the county medical officer of
health, and tuberculosis officers would be encouraged to refer cases difficult of diagnosis and cases for
determining the most suitable form of institutional treatment to such beds. Arrangements would be
made for the beds to be in charge of acknowledge 1 specialists in the various forms of tuberculosis. Tuberculosis
officers would be given right of access to see the patients and the clinical and other records
of their patients during reasonable hours daily, and a special feature should be made of consultations
on one or more afternoons weekly, not only upon inpatients but also of other patients brought to the
hospital by the tuberculosis officer. By such an arrangement it is believed that several very desirable
improvements on the present consulting service arrangements would be ensured. They may be summarised
thus :—
(i.) Difficult and doubtful cases would be subjected to detailed study and every possible
facility known to modern science would be available for arriving at a definite diagnosis promptly.
(ii.) In cases where doubt exists as to the most suitable form of institutional treatment
similar advantages would obtain.
(iii.) The work of the tuberculosis officers would be greatly increased in interest and the
educational advantages would be considerable.
(iv.) The cost to the Council in proportion to the efficiency gained would be money well
spent.