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Beginning with a hesitating adoption of
the principle here and there in isolated
centres, public opinion got more and more
crystallized until there came to be a wide-
spread demand in its favor. Today not
one form of tuberculosis only but tuber-
culosis in all its manifestations is compul-
sorily notifiable throughout England. The
same will shortly be effected for Scotland.
It is noteworthy that some of the leading
opponents of the measure, when it was
first proposed, have wheeled round and
become active movers in the reform.

Side by side with the growing insistence
on notification, there has been forged
machinery for dealing eflfectively with the
immense mass of tuberculous material in
the community. Such special machinery
is necessary because of the protean char-
acter of tuberculosis. Consideration is
needed not only as to the amount of disease,
but also to its extremely varying manifesta-

. tions. The latter is of paramount impor-
tance.

If I have succeeded in showing that the
need for the earlier diagnosis of tubercu-
losis is pressing, there is no less need for
satisfactory classification and proper assort-
ing of the varying types of case.



It was considerations such as these which
led to the institution of a coordinated
scheme for dealing with tuberculosis in all
its phases and stages. It was the practical
needs of the situation which led to the
creation of the tuberculosis dispensary as
an information bureau, receiving house,
centre of diagnosis, clearing house, centre
for treatment in certain cases, centre for
examination of contacts, centre for after-
care and centre of education.

With the development of the tuber-
culosis dispensary and its possibilities of
satisfactory classification, the call became
imperative for suitable distribution of the
different types of case to different types of
instituticm. A claim was made for the
erection of several specialized institutions,
so that the early and readily curable cases
might be separated from the more advanced
and incurable cases.

In this sense the sanatorium for incipient
cases and the hospital for less early cases
are developmentally extensions of the col-
lecting and distributing centre — ^the tuber-
culosis dispensary — which must exist in
every community if the tuberculous material
of the given area and the problems which
attach thereto are to be handled in accord-
ance with modern scientific principles and
to the best advantage of the citizens.

The institution of the Tuberculosis
School and Farm Colony was evolved for
the same reason and in the same kind of
way.

The larger outlook on the tuberculosis
problem which followed the determination
of the close etiological relationships of
childhood raised practical questions of
much importance. Foremost among these
was the provision of schools for different
groups of tuberculous children. The estab-
ishment of these has constituted a fruitful



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experiment. Tuberculosis schools are now
beyond the experimental stage. To be
really effective, such schools must be linked,
on the one hand, with the coordinated anti-
tuberculosis scheme and, on the other, with
the educational authorities.

The essential in the conduct of such
schools is that those in charge should be
primarily concerned with the physical
health and development of the child. Edu-
cation in the ordinary sense of the word
must take a second place. The needs of
each child must be viewed from that stand-
point. Educational methods must be
adapted to the individual case. The tuber-
culosis school is thus an extension of the
tuberculosis dispensary or the sanatorium
or both, the medical staff deciding what
patients are suitable for transference to the
school and being responsible for the physical
care of the child during its attendance.

The great defect of the older outlook on
tuberculosis was its limitation to the care
and treatment of individual patients — ^and
these commonly in an advanced stage of
disease.

The outlook of today is quite another.
The individual patient is taken in hand no
less than before. The latest advances in
medical science are utilized with a view to
diagnosis at the earliest possible moment
and the subsequent treatment of his case.
If it be possible to treat the patient at home,
his dwelling is re-created on physiological
lines. So far as is possible, the home be-
comes a sanatorium. If it is desirable for
him to be removed from his surroundings,
either in his own interest or that of others, a
suitable institution is found for him.
Whether that be the sanatorium, or the
hospital for more advanced cases, or the
farm colony, or the tuberculosis school, de-
pends on the character of the case, the age
of the individual, and other such factors.



But more than that. Instead of waiting,
as in the old days, until tuberculous patients
are brought for examination because of
pronounced symptoms — which commonly
means an advanced stage of the illness — ^a
systematic search is made for the earliest
manifestations of tuberculosis. This is
espyecially significant in relation to th^
homes of the poor, but is applicable in every
household. The detection of one case is
made the occasion to have a "March-Past"
of all the members of the household. In
this way, tuberculosis is discovered while
the weed is still at the seedling stage. It is
much easier to deal with the seedling than
with the grown tree.

The dwelling of the patient, likewise, is
thoroughly taken in hand, whether the pa-
tient has been removed to an institution or
is being treated at hc«ne. The inmates are
taught in what respects the home conditions
are faulty and learn how to re-create the
dwelling in accordance with the principles
of aerotherapy. To propose, as is some-
times done, to remove all patients from
their surroundings — ^to institutionalize all
cases of tuberculosis — is to plead ignorance
of the pathology and treatment of the dis-
ease. The proposal is impossible and for-
tunately unnecessary.

It is the function of the practitioner
trained in tuberculosis to attack the prob-
lem in the household, in the nursery, and in
the schoolroom, among the rich or the poor.
It is one of the cardinal principles of the
tuberculosis dispensary that an endemic
disease must be followed to, and met in the
home. Thus once again we are up against
the great housing problem. On this I
may not further enter save to dissent from
the view that it is impossible to treat tuber-
culosis satisfactorily in a two-roomed house.
The experience of the tuberculosis dispcn-

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sary is in entire exposition to this. With
the re-creation of the dwelling, which is ef-
fected every day by our tuberculosis doc-
tors and nurses, tuberculous cases are
treated in such homes with excellent results.
More than this, it is becoming a common-
place that it is possible to introduce effec-
tively into these humble dwellings — ^pro-
vided there be no radical defect of construc-
tion — a higher standard of physiological liv-
ing than is frequently found in the many-
roomed mansions of the rich. The housing
problem involves much more than mere in-
crease in the number of rooms or the size
of the dwelling. We cannot give to every
household a large house, but with a little
trouble we can teach the household how to
live, so as to prevent disease.

I am unwishf ul to disturb a peaceful even-
ing by allusion to the provisions of the
Insurance Act, even in so far as it relates to
tuberculosis. In thus consulting our mutual
comfort I crave you will allow me a single
reference to the work of the Departmental
Committee which was appointed to advise
the Government r^;arding general policy in
respect of the problem of tuberculosis in
the United Kingdom. That committee has
wisely insisted that whatever antituber-
culosis measures are available for insured
persons must be made applicable likewise
for the entire population of the country.
You will agree with me that that is essen-
tial. An effective antituberculosis scheme
must concern itself in the fullest degree with
every aspect of the problem.

If the proposals of the committee, as em-
bodied in their two reports, are essentially
sound and sufficiently wide, there still re-
main many practical difficulties in carrying
the proposals into effect. We cannot shut
our eyes to the magnitude and delicacy of
the issues. None the less, with the fullest
realization of the difficulties, I remain per-



fectly sanguine that, when the remarkable
change in the tuberculosis horizon, to which
it has been my privilege to point you to-
night, has been recognized and appreciated,
the "passing of tuberculosis'* will be ad-
mitted by anticipation. All the events of
the past thirty years seem to me to justify
the view that in a reasonably progressive
community the "passing of tuberculosis"
should practically be an accomplished fact
within a generation and a half.

Towards this happy consummation it is
perfectly clear that the chief influence lies
with the general body of practitioners. It
is to a united movement and common action
on their part that we must look for the
achievement of the result. It is in that
belief that I have ventured to avail myself
of the opportunity your kindness has given
me to submit for your consideration certain
aspects of this vast question.

I trust no one will conceive that any of the
suggestions I have made can in any way
trench on the proper domain, or restrict the
energy of the general practitioner. If my
anticipations be just, you will share my
view that, for many years to come, the
amount of work available to each practi-
tioner will certainly not be lessened. But
the hopelessness of ineffectual effort will be
removed. The work will have the inspira-
tion of expectation based on scientific cer-
tainties and legitimate calculation.

If, for some of our communities, the
registrar general has been able to report
that the mortality from tuberculosis has
already fallen more than forty per cent, in
ten years' time, there would seem to be little
ground to doubt that, with the enlargement
of knowledge and widening possibilities we
have considered tonight, the mortality from
tuberculosis should, within the period I
have predicated, fall little short of the
vanishing point.



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THE ECONOMIC DIFFIOULTIES OF

THE GENERAL PBAOTITIONEBr-.

THEIR PRINCIPAL CAXTSES

AND REMEDIAL

MEASXTRES.

BY

HERMAN B. SHEFFIELD, M. D.

Instructor in Diseases of Childr^i, N. Y. Post-
gra4uate Medical School and Hospital;
Visiting Physician (Diseases of Chil-
dren) to the Philanthropin Hospital
and North-Weetem Dispensary,
etc.

New York.

The rank and file of the medical profes-
sion like the ordinary wage earner and
struggling business man, is sorely expe-
riencing the imperative need of social and
industrial justice. Indeed, in some respects
the general practitioner is by far more help-
less than the common laborer. For, while
the cost of living is steadily climbing to
standards entirely beyond the reach of his
ever shrinking income, he is not in the posi-
tion to promiscuously raise his fees for the
following reasons: Firstly, being obedient
to the traditional oath of medicine, to be
merciful to the sick and indigent, he is loath
to break away from the sacred path of his
predecessors and to be looked upon as a
trader; and, secondly, were he to do so,
without the strong backing of a union, he
would soon be left in the lurch by the
majority of his patients who could readily
obtain medical aid from his less presump-
tuous competitors. In consequence there-
of he has to be content with a yearly in-
come of barely nine hundred dollars — ac-
cording to most recent statistics— out of
which sum, in addition to his daily bread,
the public expects him to clothe himself and
his dependents cleanly and neatly; to re-
side in a comfortable, well furnished apart-
ment ; to hire help to tend to his household
and office, and to have the convenience of



a telephone and other less expensive com-
modities of life. These plaints of the
medical men were first discussed cautiously,
behind closed doors, either among friends
and colleagues or in medical societies.
Finding, however, that these secret gather-
ings and mutual — ^sympathy — sessions not
only failed to ameliorate their sad economic
condition but, on the contrary, permitted
additional hundreds of ambitious young
men yearly to enter the already over-
crowded profession, under the impression
(judging by the outwardly prosperous ap-
pearance of physicians) that medicine of-
fered a fruitful field of affluence, some phy-
sicians deemed it wise to ventilate their
grievances in the daily press, hoping to
arouse public opinion in their favor.

Thus far their appeals met with no re-
sponse whatever, and, I believe, justly so,
since they utterly failed to make out a good
case. Whereas they presume that their
economic embarrassment is due solely to
colossal abuses supposed to be perpetrated
by the laity against the medical profession,
it can clearly be shown, that the people are
least culpable in this direction; but that it
is the physicians themselves who are an-
nihilating their financial resources. Let us
impartially study the situation.

Up to about thirty years ago, before the
era of strict surgical cleanliness (asepsis),
the public looked upon hospitals with the
same degree of infernal fear as we do to-
day upon the morgue. Owing to the dread-
ful complications (gfangrene, erysipelas and
general sepsis) that forced the death rate
in surgical cases up to about 75 per cent.,
only such patients could be induced to go
to hospitals, as were either picked up by
the ambulance, were entirely homeless or
invalided beyond expectation of recovery.
At that time the medical profession, except



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the few individuals absorbed in the study
of some special subject for teaching^ pur-
poses, took no interest whatever in hospital
positions. There was nothing in them
financially! As a rule, the sick were re-
signed to take a chance on the nauseating
draughts of the apothecary and to die at
home, rather than to linger for months in
the dingy wards of the hospital and then to
be brought home for burial. Therefore
even those barely able to spend but a few
dollars on a doctor and medicines surely
stayed at home, and hence, though the
doctor's fee was small, he had ample op-
portunity to earn a comfortable livelihood.
However, with the epoch making introduc-
tion of sterilization and antisepsis; the
marvelous improvement in surgical tech-
nique, which completely revolutionized the
methods of treatment of disease and their
results, and the establishment of training
schools for nurses, whose intelligent co-
operation made it possible to maintain all
the latest achievements in hospital manage-
ment at a high degree of efficiency, the atti-
tude of the public towards modern hospitals
soon assumed an entirely different aspect.
Slowly but surely the people began to ap-
preciate that a well regulated hospital, far
from being a hot-bed of death and despair,
quite the contrary, was a fountain of hope
and life. And as even the very rich in case
of grave sickness began to prefer the
sanitary accommodations of the hospital to
their ' gorgeously furnished, dust — and
germ — ^laden mansions, the physicians of
influence hastily monopolized every hos-
pital position in sight. With these posi-
tions exhausted other equally keen physi-
cians soon went about to establish new
semi-private hospitals — ostensibly to accom-
modate the poor but in reality to cater to
the rich. When we bear in mind the



enormous cost of construction of these
modem, so-called charity edifices, the high
interest on the heavy mortgages, the im-
mense disbursements for salaries, food-
supply, drugs, dressings and instruments,
and all other hospital necessities, we can
readily appreciate the extraordinary sources
of revenue required for their maintenance,
and the enormous amount of hustling the
hospital staff has to do to meet the de-
mands. For, as is well known, it is the
physicians who directly or indirectly are
burdened with the support of these institu-
tions !

Prom sad experience physicians have
learned to know, that only those physicians
are recognized by the public as able doctors,
who hold positions in one big hospital or
another, irrespective of their actual ability.
Hence, whenever a physician desires to
benefit by the prestige of a certain hospital,
he bends every effort to get there. When
he applies for a position to the lay or med-
ical board, he is usually referred to some
one in authority — ^the so-called boss — who
politely informs him either that for the
present there were no positions vacant, or
that there were several applicants for the
vacancy. But ( !), if he could find his way
clear to donate a goodly sum of money to
start with (which ranges between $500 to
$5,000), as for example, for the endowment
of one or two beds, and, furthermore, see
to it that the hospital received yearly a cer-
tain income through patrons or pay-
patients, some sort of a satisfactory ar-
rangement would be made, sooner or later.
It stands to reason that only the rich can
or need apply, and as the rich doctor is
not concerned about his own income and is
only interested in proving his capacity to
furnish funds to the hospital, in order to
hold his position, he scours every nook and



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corner for patients able to pay for a private
room, regardless of his personal remunera-
tion. Nay, he even offers a commission
(fee-splitting!) to the general practitioner
for referring cases to him instead of to his
former consultant, in order to make a good
showing. Now, when we realize that every
hospital of renown has anywhere between
fifty and a hundred "solicitors'* of this kind,
and that, for example, in the city of New
York about thirty per cent, of the doctors
are under such oppressive obligations, is
there any wonder that the remaining
seventy per cent, have but small chance to
get and to keep pay-patients, and that they
are compelled to live from hand to mouth ?
But this is not all !

Finding this benevolent bestowal of hos-
pital honors upon the highest bidders ex-
tremely profitable, and the demands for
such unmerited tutelage steadily growing,
the hospital management deemed it wise
(of course, as usually, for the good of the
service!), to create additional positions by
splitting up the hospital service in a num-
ber of subdivisions. For instance, while
originally a surgeon was privileged to oper-
ate on man, woman, or child alike, as the
cases came along, nowadays the majority
of hospitals have special surgeons in each
department. That this innovation was not
intended, as claimed, for the welfare of the
community, can easily be proven by the fact
that this rule applies only to strictly charity
cases, i. e., ward cases, whereas every sur-
geon has full power to operate on all his
private patients, irrespective of age or sex.
Furthermore, instead of, as before, having
only visiting physicians and adjunct visit-
ings, the managers have created additional
positions, in the form of "attendings," "as-
sociates," and "assistant adjuncts," the oc-
cupants of which are all forced to work



like Trojans to keep the hospital coffers
full. Now, the general practitioners would
have little interest in these endless self-
admiration faculties, were it not for the
fact that these half-baked professors make
the public believe that they are real special-
ists in their respective branches, and as al-
ready told, gobble up the greater portion of
the pay-material that would otherwise go
to the general practitioners and help them
earn a livelihood.

Now and then medical men arouse con-
siderable agitation over the supposed abuse
of free dispensaries by patients able to pay
private physicians. These statements are
not based upon actual investigation. The
fact that a woman wears a diamond ring
that she has, perhaps, inherited from one
dearest to her and hence considers it sacri-
lege to part with, is no indication of her
capability to pay a doctor. Her breadwin-
ner might possibly, for the time being, have
been out of work which forced her to visit
a free dispensary to obtain treatment for
her poor baby! The sight of human suf-
fering on every bench of the dispensary
waiting room ; the obligation to rub elbows
with all sorts of people who often are
neither clean nor well mannered, and the
frequency of being disappointed by not
meeting the doctor she is looking for, are
ample deterrents from visiting dispensaries,
except to the very poor who cannot help
themselves, or to those few people who are
either morbid on clinics, or after becoming
richer, continue to indulge in the habit of
going to dispensaries acquired during the
period of their poverty. Dispensary abuse
should by all means be stopped, but we
should also remember that dispensary
material is indispensable to teachers of
medicine, who are often only too glad to
waive their fee and to persuade their own



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pay patients to visit the clinic for demon-
stration. Besides, many a poor young doc-
tor has succeeded gradually to acquire a
fair practice through his kind treatment of
dispensary patients.

Physicians have surely much more reason
to complain about the abuse of contract
(lodge) practice. As is well known, con-
tract practice was originally intended to in-
sure the poor man and his family against
disease, especially with the object in view
of obtaining relief at home instead of in
clinics and hospitals. It was particularly
beneficial to the poor foreigner who, for a
few dollars a year, enjoyed the privilege of
selecting a physician who understood his
language, traditions and habits. The phy-
sicians were entirely satisfied with this ar-
rangement. However, as years passed by
the original plan of serving the deserving
poor has changed very materially. In the
course of time many of the previously poor
have become more or less rich, but, this
notwithstanding, they continue to take ad-
vantage of the doctor's attendance. Nay,
being usually the "bosses" of the lodges
they exact much more attention than their
poor brethren. As a matter of right and
justice they should waive that privilege, in
order to allow the lodge doctor more time
for the care of the poor members ; and they
should engage the services of private phy-
sicians and pay reg^ar fees according to
their pecuniary circumstances.

In a recent address before the N. Y.
Academy of Medicine on the "Future of
the Physician," a prominent specialist laid
particular stress upon the fostering of hy-
giene and sanitation as a cause of the phy-
sician's economic difficulties. In other
words, by teaching the public how best to
take care of their health, the doctors grad-
ually lose more and more of their sources



of revenue. While on superficial considera-
tion this view meets with some plausibility,
more thoughtful analysis shows its fallacy
beyond a shadow of doubt. It is certainly
true that owing to the self-sacrificing labors
of medical men epidemic and endemic af-
fections, such as yellow fever, typhus fever,
cholera and hookworm disease, have been
banished where civilization reigns; it is
true also that, through the achievements of
the bacteriologist and clinician, diphtheria
and syphilis are practically curable, and ty-
phoid and meningitis among others are
soon to cease being the dread of the com-
munity. But it is equally true that by pre-
venting communicable diseases and by re-
ducing the high mortality that prevailed a
few decades ago, thousands and millions of
people are alive today needing medical care



Online LibraryNew York (State). Board of Railroad CommissionersAmerican medicine → online text (page 43 of 131)