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66
sanatorium. Prolonged residence obviously results in more beds being required
and premature discharge increases the liability to relapse. The experience during
the war period was a tendency to short periods of treatment. There were
several factors to account for this. Those outstanding may be summarised as
follows:—
(1) the failure to appreciate the need for treatment when the patients
ceased to feel ill.
(2) the ease with which employment was obtainable.
(3) the number of cases known as " educational" cases, i.e., patients in
whom permanent arrest could not be expected, but whose lives could be prolonged
by training for short periods under institutional conditions as to how to look after
themselves, and
(4) the fact that "sanatorium" treatment when provided under the
National Insurance Acts was regarded as a " right," which resulted in a considerable
demand for beds in excess of the number obtainable within the financial
limits imposed upon the London Insurance Committee. This was met by
limitation of period of treatment.
The constant direction of effort to bring under sanatorium treatment the
" early " cases where permanent benefit may be expected, the increased appreciation
on the part of patients of the importance of remaining under treatment so long
as the medical superintendents consider it necessary, and the policy of the Council
of allowing treatment until the maximum benefit is derived, have all tended to
increase the period of treatment.
It is now desirable to turn to the results of treatment. In the earlier years
of the working of the scheme, as indicated in the observations made above as to
the dispensary service, and as to the procedure in respect of the selection of cases,
a large proportion of the cases recommended for treatment were not sanatorium
cases in the strict sense. Moreover, the great demand for labour under war conditions
had the effect of keeping back from treatment favourable cases until completely
incapacitated from work, and patients frequently discharged themselves prematurely
against medical advice in their anxiety to return to profitable employment. The
after histories of patients treated by the Council in 1914 and 1915 were traced to
the end of 1919, and a similar course was followed by the London Insurance Committee.
The results in both investigations indicated a high proportion of deaths
as shown in the tables on page 67. These results were confirmed by investigations
in various parts of the country and considerable discussion followed as to whether
" sanatorium " treatment is an effective means of treating pulmonary tuberculosis.
In the annual report for 1920 there is a statement on this matter (p. 37) to the effect
that the examination of the figures in detail shows clearly that there has been considerable
misconception of the meaning of the term " sanatorium treatmeut," not
only by the general public but also by medical men, and further that in more than
50 per cent. of the cases sent to sanatoria the disease was too advanced for sanatorium
treatment to be of permanent benefit to the patients.
It has not been considered to be of value to work out the results of treatment
in respect of patients treated between 1916-20, as at best no improvement could
be expected, owing to the continuance of the methods of recommendation and
selection in operation during the war period till at least the middle of 1920, and
to the disturbed conditions both in the medical profession and the general life of
the community which persisted for some years after the war. The improved
methods for searching out and examining contacts and the arrangements for more
rigid selection of cases for sanatorium treatment, including the provision for
examination of selected cases at County Hall and the systematic use of
" observation " beds described earlier in this report, were expected to improve the
results.