152

Irregular Discharges BY GEORGE DAY

Mundesley Sanatorium

Once again our American colleague~ are showang grave concern at the high number of their tuberculous ex-Serwce men who dis- charge themselves from hospitals and sana- toria against their doctors' advice Between Ju ly i946 and June I947, nearly 6,0oo tuberculous veterans 'walked out on their treatment ' as against fewer than 5,ooo who stayed the course This rate of 54 4 per cent Irregular discharges, moreover, is the lowest since the begmnmg of World War II In ~945 it reached 7~ 5 per cent

In a pamphlet , 'Irregular Discharge', ~ssued by the Veterans Administration, U S A , are g~ver~ not onlv these facts and figures but also a painstaking rewew of the whole problem fiom every point of wow, social, economic and psychological The basic (alleged) causes of self-discharge are analysed and the valise of suggested preventa- tive measures are consldezed The mere fact that the patients under d~scusslon are ex- Serwce men does not explain the h~g'h figure Men who had once subjected themselves to some sort of d~sc~phne m~ght be expected to accept the new dIsc~phne of tuberculosis more readily than c~whans w~thout that ex- perience The p~oblem ~s nation-wide Klotz [~] found that durmg ~9e3 7t per cent of d~scharges among all classes of patient (men, women and children, eoloured and white) from the Tennessee National Sana- torture were '~rregular', and during I933, according to Whitney and Dempsey [~ , of 6,906 patients discharged ahve from 75 pubhc sanatoria m r6 States, at least 3~ per cent went w~thout their doctors' consent

In Great Britain the irregular d~scharge- rate has never presented a sel~ous problem Not yet How can we make sure ~t never w~ll~ What can we learn from these American revelat]ons~

Appendix 'D' hsts all the hospitals and sanatoria w~th their annual turnover of tuberculous veterans and the:r percentages of

*Irregular D~scharge The Problem of Hosp~tahzat~on Veterans Adrn]n~str~t~on~Washmgton, 25 D C

july 1949

self-discharges The latter figule ranges from o o per cent (Phoemx) to 7 ~ 3 per cent (Fort Bayard) Why do some sanatoria have less difficulty in retalmng their patients than othersP Further study reveals that hospltal~ and sanatolla with an annual turnover of fewer than IOO tuberculous patients have an average I D rate of only ~5 per cent in comparison w~th the average of nearly 5 ~ per cent shown by estabhshments with a turn over of between 25o and 650 patients This accords w~th our own expectation that the larger the institution the greater is apt to be the amount ofreglmentat~on and the less the personal attention received by the mdlvtdual

In the smaller estabhshments everybody knows everybody else The doctors know all the patients personally, and the patients know all the doctors, all the members of the nursing and domestic staff and most of the other patients Such a gloup possesses unity and morale Not that st does not have ]ts 'problem cases', but these cases ~mpmge on (he group as a whole, and the group can usually deal with them effectively Every sanatormm phys~clan ]s acquainted with the umntelhgent unco-operatlve patient, con stltutlonally unable to take a long wow of his dlness, with a psychopathm disregard not only for his own health but fol the health of his family, with the emotionally immature 'rebel' who flaunts all authollty and restrlc t~ons, with the 'barrack room lawyer' In a small estabhshment this sort of patient crops up from time to tnne, but being a sohtaly cxceptlon he cuts no ice and lacks the stablhty to dlsrupt the general mora]e He is regarded by his fellow-patients as a menace, and a general mgh of 1 chef is heal d when he depalts without benefit of physicians He never heads a mass exodus Double, treble or quadruple the size of the estabhshment and the 'misfits' are multtphed paT z passl~ And when three or four such pattents get to- gether their effect on the general community

of the Tuberculous October, ]948, pubhcat~on of the

July 1949 T U B E R C L E 153

rises exponentially. In a larger and therefore more loosely knit community they develop and exercise much greater powers of spread- ing disaffection. Weaker brethren are swayed over, and almost anything may break out: food strikes, booze-parties and similar mass- infringements of therapeutic regulations- which seem to cry aloud for mass-disciplinary action. And the more the authorities have to enforce discipline from above the less will patients develop self-discipline- and down will go the morale even further[

The chief function of a sanatorium, after all, is educational. Patients there are taught how to overcome their disease. As soon as the new patient is bedded down, his instruction as to how to set about healing has begun: but he is not always told the reason for his regime. To gain his full intelligent co-operation he has to be taught not only the nature of his disease process and its extent but the why and the wherefore of all that happens to him thereafter. This requires time and patience: and an entlmsiasm that does not get dulled by repetition.

In her lively narrative, 'The Plague and I', Miss Betty Macdonald [3] throws a great deal of light on the 'oppositional' patient- staff relationship which can develop in a large sanatorium. To the patient the staff appears despotic, wilfully uncommunicative and totally devoid of any appreciation of his physical discomfort and mental suffering. He is taught nothing about tuberculosis as a disease-process or as a personal problem. These things he has to learn from ilMnformed fellow patients. He is kept in ignorance of his sputum tests and the interpretation of his serial x-ray examinations. Every two months his case is subjected to routine assessment, when he receives a routine reassurance- or the reverse. At any moment he may be whisked off in a wheeled chair not knowing whether it be for x-ray, thoracoplasty or a dressing down from the headmaster, until he gets there. In the daily routine he sees only an overworked i n t e r n e - in the company of the Ward Sister who acts as a buffer, He cannot approach the Medical Superinten-

dent except through the authorized channels, and by the time he gets there he is pretty sure that the ground has already been cut tYom under his feet. To the patient the general attitude of the institution seems to be, ' I f you can't take it, you've had it. There are hundreds waiting for your bed'.

How do the patients appear to the staff in such an oversized community? History does not relate, but it is easy to surmise that they present primarily an administrative prob- lem: the ever-present problem of too small a staff having to cope with too many bodies in a day-to-day routine that leaves no margin tbr 'all this chit-chat'. One has heard it ex- pressed, 'Tell the patient about himself and he'll start worrying. Far better he should content himself with peaceful ignorance, be- come a cabbage and lct us do the worrying. It's our job and he can trust us to do our j o b . . . Besides, i f the patients start worrying, their relations get all worked up and come buzzing round us like hornets. They always get hold of the wrong end of the stick and we simply haven't got time to knock sense into them'. There is some justification for this attitude when, for example, the doctor- patient ratio reaches I to ~oo. But even in these circumstances much can be done - and is done - to educate the patient, not in book- keeping, handicrafts or bird-watching, but in the mastery of his disease. Lectures, pep talks, 'Any Questions?' sessions with groups, or broadcast over the internal broadcasting system stimulate interest and discussion and do much to alleviate the anxiety and resent- ment felt by patients who consider that they are regarded only as Numbers, because there are simply not enough doctor-hours per week for personal heart-to-heart talks. It is quite impossible to eradicate discussion. If checked it merely goes underground. So it has to be led, directed and informed. Patients must get everything off their chests be it sputum, morbid anxiety or complaints about ill- served food.

Ideally, however big the institution, patients should be segregated into equal- sized groups or 'Houses' of not more than 5%

154 T U B E R C L E July 1949

c o m p a r a b l e to the Houses making up a Publ ic School - or a Butlin 's Ho l iday Camp. Mora l e is m u c h more easily established and ma in t a ined w h e n hea l thy r ivalry can be s t imula ted be tween groups in such little mat te r s as sports competi t ions, handicraf t displays, and house concerts. Such Houses would soon be vy ing wi th each other in weight ier mat ters such as month ly weight- regain ing averages, eager acceptance of surgical i n t e r f e r e n c e - a n d low irregular d ischarge rate. Unfor tuna te ly , each House would o f course require its own staff of doctors and nurses, who in order to become ident if ied with the group would have to be more or less p e r m a n e n t and not subject to too m uch chopping and changing around. A n d in these days o f marg ina l staff this is impossible.

T h e immedia t e choice appears to be: T r e a t a few pat ients well within the capaci- ties of the staff, or give inadequa te at tention to a lot of patients, hoping the irregular discharge rate w o n ' t be qui te so bad as other people 's , and complacen t ly writ ing off all i r regular discharges as psychopathic person- alities? I n three words: Q u a n t i t y or Quali ty?

References [~] Klotz, W. C. (I9~4) Amer. Rev. Tuberr m, 544. [2] Whitney, J. S., and Dempsey, M. V. (I94o.) Natl.

Tubere. Assn. Social Research Series No. 8. r3] Macdonald, Bet W 0948) "The Plague and I."

PRIMARY SEROUS PLEURAL EFFUSION (Continued f rom page I5r )

[4] Paine, A. L. (,94 I) Amer. Rev. Tub., XL~V, 4o9. Fernand=, H. P. (I944) Tubercle, xxv, 8=.

[6] Erwha, O. S. (~944) Tubercle, xxv, 44. [7] Karron, I. G., and Purves, R. K. [8] Arborelius, M. (~93o) Svenska Lak 8allsk. LaMl., LW,

II 5, [9] Israel, H. I., and Long, E. R. (;94 I) Amer. l?ev. Tub,

XLIII~ 4 ~'. [m] Montuschi, E., and Reeves, T. L. B.M.J., I7.5.47,

69a. [Ir] Close, H. G., Lancet,9.2.46, 193. [I~] Matte, R., and Saldias, E. (I944) Rev. Ghilel~a de

Ped,, xv, 638, quoted by Thompson [3]. [13] Patterson, R. C. (I917) Arner. Rev. Tub., h 353. [~4] Petroff, S. A., and Stewart, P. W, (zges) .]ourm

Immun., x, 677. [i5] Lemon, W, S,, and Montgomery, L. G. (I934)

yourn. Thor. Surg., 6I~. [I6] Howard, T,, and de Veer, J. A. (~936) Am,r. Rev,

Tub., xxxm, 755.

Abstracts SCHWEIZ. MED. WOCHENSCHR.

VOL. LXXWI ~947 NO. 24 BRUNNIgR, A. : The Treatment of Residual

Lung Abscess Cavities by Lobectomy. Pp. 63o-63 I.

Drainage of lung abscess not infrequently leads to the tbrmation of" epithelialized residual cavities with bronchial fistula or fistulae, which, in spite of adquate mobilization of the chest wall, fail to heal spontaneously. Because of the peculiar configuration of the inner surface, covered by bronchial epithelium, it was given the name of 'Gitterlunge'. These cavities in- convenience the patient not only by the necessity of fi'equent dressings but also because of inter- ference with respiration. Some of the operative procbdures directed against the condition are discussed, that of muscle graft in particulal' but none appears to guarantee success. For lower lobe localizations the author has successfully performed lobectomy in three cases. Technical details of the operation are given, and the advantages of the method discussed.

REVISTA DE LE ASOCIACION MEDICA ARGENTINA

VOL. LXlI JULY I948 No. 633- 4 AeEwDo, R. C., and ERmTEm, S.: Hipersen-

sibilidad Profesional a la Estreptobincina- Occupational hypersensitivity to Strepto- mycin.

Seven further cases are described of a rash occurring in nurses who had taken part in pre- paring or injecting solutions of streptomycin. The cases arose almost simultaneously some two months after beginning to handle the drug.

The eruption began as small red intensively itchy papLLles on the fingers, and especially the thumb. In some cases there was preliminary erythema. The lesions became vesicular with' increase of itching. Much erythema, swelling and paronychia developed on the fingers. The folds of the elbows were sometimes involved. The eyelids became similarly affected with regulting oedema, conjunctival infection and photophobia. The eruption was transitory, but recurred with further exposure to the drug.

Intradermal testing with ~oo units gave a definite reaction in four cases. Various ant{- histamin drugs were used in treatment without success, and the authors emphasize the necessity for careful prophylaxis by wearing spectacles, rubber gloves and washing immediately after handling the drug.

The American and Spanish literature on the subject ia reviewed.