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is put down for a sanatorium, and during the interval before
he can be admitted he is perhaps sent to a convalescent
home or into some special hospital, only coming to the out-
patient department from time to time to see how he is

A child is sent by her doctor to the orthopaedic depart-
ment, and an expensive instrument is recommended. The
parents learn that the almoner will obtain a Sunday Fund
letter for them through their clergyman, and that they may
pay the rest of the cost in small instalments weekly, thus
dispelling a difficulty.


For the same reason it is carefully explained to those who
are refused treatment that if, at a future date, they may
need special treatment of any kind, they are at liberty to
attend again, but that the hospital is not for cases which can
be equally satisfactorily dealt with outside. Patients who
attend for special treatment are likewise told they must not
expect to be allowed to do so for every complaint from which
they may suffer. That it is possible for the poor, even
the very poor, to provide for themselves for the ordinary ills
of life is, I think, shown by the fact that in country parishes,
where there are no hospitals, they do so as a matter oi
course by joining Friendly Societies and Provident Dispen-
saries. More stringent measures adopted by the hospitals
generally would, I am convinced, result in an improved
public opinion among the poor in the towns upon this point.

The part of the work which is most open to criticism is,
I think, the inquiry work. It is impossible to check every
statement made in an almoner's office, and at first sight it
must appear that the almoner's post is merely encouraging
deceit on this account. I think the results of the work as so
far ascertained do not lead to this conclusion. The character
of each patient must be taken into consideration as he is
dealt with. For every one who plans a deliberate deception
there are, roughly, ten or twelve who will give the truth when
they understand that definite statements must be made instead
of the vague generalities with which they had hoped to get
through the inquiry ; and of those who do deliberately plan
deceit there is a still smaller proportion who have grasped the
fact that ' ars est celare artem ' they do not deceive artistic-
ally. The almoner interviews from twenty to twenty-five
patients daily, and a few years' experience in dealing with
these numbers must, I think, if she is ever ready to correct
impressions, be of even greater value to her than the power
to make a full inquiry in each case with which she has
to do.

Another safeguard to this branch of the work lies in the


general tone of the out-patient department. The attitude of
mind of the patients generally towards the almoner's office
has, I am convinced, an untold influence upon the statements
made in her room. If she can establish the belief that her
work is not one of oppression, but an endeavour, however
faulty, to deal justly, she has gained the confidence of
those with whom she has to deal, and those who practise
deceit through weakness rather than through wickedness are
no longer afraid to trust her openly. The proof, I think,
that the almoners are not living in a fool's paradise with
regard to this point is made by statistics. Take as an
example the loan system adopted to enable patients to obtain
what is needful at once. Sixty-nine patients were assisted in
this way at Westminster last year, and of these only two were
bad debts, to the extent of 6s. 3d. between them; while
38. 13s. 9d. was paid in in small sums weekly. I think this
is proof that the majority of the patients mean to deal
honestly by the hospital. By far the larger proportion were
trusted absolutely. Their addresses might have been false
and their references might have been false, but it appears to
me that the way in which they responded to the trust reposed
in them is one of the most hopeful signs that though we
cannot be too much on our guard against weakly allowing
ourselves to be taken in the patients on the whole do not
come to the hospital with the idea of cheating it. Further
proofs of this are of daily occurrence. It is not once only
fchat a patient has handed over his prescription paper to the
almoner on her telling him she considered he ought not to
have come, in order that she might see that he did not wish
to * impose upon the hospital ' by taking away his medicine,
though he was entitled to it as part of the * first treatment.'
Patients judged able to pay constantly ask to be allowed to
' put something in the box,' and there are numbers who only
need to have their duty pointed out with regard to provision
for medical treatment in the future to prevent them from
making a new application later on for treatment for slight



ailments. The insistenceolrrae^int that it is the medical
aspect of the case upon which eligibility for treatment is
based makes deception frequently unnecessary where is the
advantage of denying that the family income is 2, or even
more, when the case needs a specialist's careful watching, or
some delicate operation has to be performed ?

And now the question arises ' Are the results of the work
such as to justify the assumption that the principles upon
which it is based are good ones ? ' It is difficult to judge of
results, because an event has usually a multiplicity of causes.
We can therefore only look for signs of the times and cautiously
make deductions.

(a) The mass number of out-patients has gone down at
Westminster since an almoner has been appointed, but the
number attending the special departments has gone up.

(6) The dispensers lately complained that their work had
become heavier, though the number of out-patients was
smaller, because special prescriptions had more frequently
to be made up.

(c) The number of patients who bring their doctors'
cards is increasing, particularly in the special departments.

(d) Out of twenty out-patient ' books ' taken at random
from the shelf, three cases were for admission, one was to be
watched with a query as to admission later on, one was to be
X-rayed, two were sent up for special advice, three were for
operation, four needed prolonged treatment (one being loco-
motor ataxy, and one tubercular knee), one was evidently a
puzzle, and five only needed no particular consideration.

(e) A surgeon remarked recently that his cases which
needed watching have attended very much more regularly of

(/) The social status of those who attend is gradually
becoming what it should be that of the respectable poor.
A residuum of unhelpable people will no doubt always con-
tinue to attend, but out of a total of 102 cases referred to the
Charity Organisation Society for assistance last year, 72


were recommended by them, and of the remainder only 10
not recommended on the score of bad character or thriftless-
ness. (This statement is discounted to some extent by the
fact that an almoner knows more or less what cases not to
refer to them.)

If these facts can be claimed as results, it seems that they
are worthy of consideration ; for though the scheme cannot
claim to have solved the vexed question of out-patient abuse,
it appears to be working for the best interests of the hospital,
the general practitioner, and the patient himself.

H. G. N.




MAY I begin by assuming that most of us are discontented
with the result of our work in organising efficient treatment
from first to last for a case of consumption, for so few of
these cases seem to justify our large expenditure on them ?
If we are not discontented or disheartened, then I think we
ought to be, for, on the whole, we get very bad results, and
I think it is very much our duty to consider if it be not in
our power to do better in future, and also to stimulate other
workers amongst the poorer classes to do likewise.

As discouragement, up to a certain point, is an excellent
spur towards improvement or success, I will quote from a
sufficiently discouraging letter from Dr. Arthur Latham, who,
it will be remembered, was the winner of the King's Prize
which was recently given for the best essay on * The Erection
of a Sanatorium for Consumptives.' He says :

Sanatorium treatment for the poor is on rather a different
footing to sanatorium treatment for the rich. Personally, I am
convinced that it is absolutely necessary for poor people who have
had the disease brought to a quiescent stage, and so apparently
arrested, to be assisted to live under open-air conditions for at
least two years after leaving the sanatorium if they are to get
permanently well. Dr. Walther of Nordrach, in a recent letter
to me, says ' that if you send a patient of this class to a sanatorium
and allow him to return to his former conditions of life, at the end
of a few months he dies at an earlier stage than if you leave him
alone in his home.' Dr. Walther's experience is very great.


Sanatorium treatment for the poor necessitates a more or less
complete change of life after the patient leaves the institution if
this form of treatment is not to fall into disrepute.

Now I think this is sufficiently discouraging to make us
buckle on our armour and see that it be not through any
fault of ours that our patient is not able to maintain the
improvement made while under sanatorium treatment.

For now we have got far beyond the time when it was
held that there was no possible chance of cure for a con-
sumptive of the poorer class. This was when the well-to-do
were given all that care, comfort, and a warm sedative
climate could do to prolong their lives or keep the disease
in a quiescent stage. But we have only to visit the ceme-
teries of the south-west and south of France and Italy to see
that this extreme care to guard a consumptive patient from
any breath of cold wind was often in the end unavailing even
for the rich. Only isolated medical men, prior to forty years
ago, held any ideas of the curability of the disease, and in
England their ideas met with the derision and abuse that is
the fate of very many pioneers in Science.

How far have we of late years increased our knowledge of
the origin and better means of treating this disease ? Since
1865, when it was discovered that it could be transmitted to
animals by inoculation, the progress has been steady. Dr.
Koch in 1882 declared it to be an ' infectious disease,' due to
a bacillus, and Sir John Simon in 1887 classified it as a
* filth disease.'

Further we now know that, although this bacillus is
extremely virulent, it is perhaps the easiest of all to combat.
It cannot exist in pure air and sunlight, and on the other
hand, it thrives in dark, ill-ventilated surroundings. In
its moist state, i.e. in the sputum of the consumptive patient,
it does not infect the air, but in its dry state it is extremely
dangerous. The patient is therefore, in all but the earliest
stages, a source of danger to people living with him, by
reason of what he coughs up. The bacilli in his sputum,


when dry, are even capable of growing in an ordinary
temperature on wall papers, or in the dust of the room.
They will remain active for some months in the presence of
organic matter in dark, ill- ventilated rooms ; whereas, in
pure air and sunlight, they have lost their virulence almost
before the sputum is dry.

Tuberculosis, therefore, is unlike most infectious diseases,
and it should be comparatively easy to prevent the spread of it.
Absolute cleanliness does so much towards this that its in-
fectivity was doubted, until it was proved by Koch to be
infectious. It is, therefore, a PKEVENTABLE disease, and
not necessarily hereditary. What then are the predisposing
causes ? They are these :

A bad state of health either inherited or brought about
by overcrowded, stuffy, ill-ventilated rooms, or by insufficient
or bad food, intemperance or illness ; and it is contracted by
persons in a debilitated condition taking into their system
the germ of the disease. But for the healthy, living under
favourable conditions, there is little or no fear of infection.

Now what does sanatorium treatment mean ?

It is to provide perfect sanitation or cleanliness in
every detail ; pure air ; good food and regular medical
attendance. Dust and organic matter are most injurious
to the phthisical patient. The one excites his cough and
the other lowers his vitality; therefore dust is carefully
removed and avoided. And as the patient is always liabje to
further infection, scrupulous cleanliness is observed in order to
render this impossible.

Good food is also of the first importance in sanatorium
treatment, for the chief point of this treatment is to improve
the health of the patient by every possible means, so that
he may be able to resist the disease, and may get strong
enough to maintain his improvement, and prevent a future

Kegular medical supervision is at this point of the


disease viz. in its acute or febrile stage absolutely necessary
to watch and regulate the patient's movements.

Seeing, therefore, what are the chief points aimed at in
the treatment at the sanatorium, and roughly understanding
its common-sense reasons, I think it will not be difficult for us
to understand Dr. Walther's and Dr. Latham's remarks on
the after-treatment of the consumptive poor.

Our patient, we see, is at first in a debilitated state of
health. Therefore, while he is waiting for admission to a
hospital or sanatorium, he must have all we can give him
of good food and rest ; and fresh air must be advised or
enforced. But on his return we must be sure he is coming
to a home free from insanitary conditions, one capable of
through ventilation and light, and we must see that he
has plentiful and good food until such time as he may be
able to provide this for himself. For why ? The treatment
he has received has not always been continued long enough
to arrest the disease completely, or even if it be said to be
arrested, the damaged or weakened lung will want some
humouring to prevent it from again breaking down ; otherwise
we risk losing all the good he has gained, and the money
expended is wasted. So if we are to avoid the possibility of
being told that we may bring sanatoria treatment for the poor
into ' disrepute,' we shall have to expend plenty of thought,
organisation, and perhaps some considerable amount of
money, on each individual case. As, however, each case will
be different, there is certainly much scope for original
thought and action.

And although we must contemplate the possibility of
moving whole families and procuring different work for the
bread-winners, I do not think we need be much dismayed,
for if our work be good, good results will follow, and help
will eventually come from outside to lighten the task.

Let us for a moment consider why England, which was
probably the first to erect special hospitals for the treatment
of consumption viz. the Eoyal Sea-bathing Hospital at


Margate in 1791, and Brompton in 1814, &c. is now so far
behind in sanatoria ? The reasons are obvious. Even where
the patient is admitted free or by subscriber's letter, he has
to wait for sometimes from three to four months and more,
and the average duration of his stay is from six weeks to
two months, a period quite insufficient to be of permanent
good. On leaving he goes out to any sort of home sur-
roundings ; no care is taken to draft him to a country
sanatorium, and he can seldom be re-admitted within the

In contrast to this France has, besides other sanatoria,
two for consumptive boys and youths, where the patient
remains until he has recovered. In connection with these are
two agricultural colonies to which the patients are afterwards

But it is in Germany where the movement against tuber-
culosis has been most thorough and comprehensive. The
rapid progress there was due in the main to the Act passed
in 1889 for the compulsory insurance against sickness and
for old age of all whose incomes were under 2,000 marks, or
80 a year. This Act contained a clause permitting sick
clubs and insurance societies to devote part of their funds to
the treatment of their sick in lieu of sick pay. As it was
found that half the appli cations for sick pay between the
ages of twenty and twenty-nine were from patients suffering
from tuberculosis, it was natural that these societies should
devote much of their funds to the hygienic treatment of
that disease. So completely have results proved a gain in
economy to these societies, and, needless to say, an inestima-
ble gain to the working strength of the poor, that the move-
ment for the ' Fighting of Tuberculosis ' has now universal
support not only from legislative committees, sick benefit
societies and insurance companies, but from a sanatoria
society under the patronage of the Empress, from trade
societies, from large employers of labour, as well as from
private charities. And so convinced is public opinion of the



necessity of preventive methods, that already much has been
done by means of legislation, in State and private buildings,
and in the supervision of employments for young, growing
members of the working classes.

This movement has covered Germany with a network of
sanatoria, and Germans proudly boast they are before any
civilised country in this undertaking. And the results justify
their large expenditure and show an economic gain, for the
recruiting strength of the labouring classes is between the
ages of fifteen and sixty, and it has been proved that tuber-
culosis makes its heaviest inroads on persons between these
ages, babies in arms and aged people being practically immune.

In the autumn of 1902 there were already in Germany
fifty-seven free or societies' sanatoria and sixteen large private
establishments, besides others in course of erection or nearly
finished. They have already 7,000 beds, and can even now
treat 30,000 patients yearly. Thus they are becoming more
and more able to relieve society of a source of infection and
also of the burden of supporting patients permanently unfit
for work. There is, too, a further movement in Germany in
favour of model villages.

Therefore, although advocating much more individual
work on cases, we need not necessarily think we are making
our tasks impossible of accomplishment, for with Germany
so far ahead we cannot fail to follow. It is to our great
discredit that our country, once foremost in sanitation, and,
I suppose, the richest country in the world, should be so far
behind in so real a want as this. But it is often the British
character to wait doggedly for others to make the advance.
Let us hope, then, that soon, like the tortoise, we may over-
take the hare.

In October last a deputation was sent by our large
friendly societies to Germany to visit some of their sanatoria
and learn something of their methods. This deputation
represented some five million members, with 80,000,000
funds. Up to the present these societies have been giving


sick pay, half pay, and superannuation money, without any
effort to procure adequate treatment for their consumptive
members, which mode of procedure must be, to say the least,
economically wrong. We will trust, then, that this visit of
friendly society representatives to Germany will result in
some definite movement to benefit their members, and so
lighten the large demands on private charity.

A proposal to establish an agricultural colony in England
is, I believe, being considered by a large sanatorium which
has its own farm and dairy attached. The labour on this is
to be recruited from the sanatorium for poorer patients.

Finally, then, with some such hopes for the future,
Dr. Latham's warning will not make lay-workers quite hope-
less of any good resulting from their efforts to combat this
disease amongst the poor. But all the more, it behoves us
to deal thoroughly ourselves with every consumptive case
passing through our hands, and much in the following
manner :

It is not possible tp particularise, as the circumstances of
every case will be different. But while the patient is waiting
for admission to a sanatorium we must visit the home fre-
quently to see that he is keeping out of doors, if able ; and we
must also take care that he is having good and sufficient food.
If we ourselves are sure about the main points of sanitation,
it will not be difficult for us to impart our knowledge to
others in an interesting way. The poor spit everywhere, and,
especially when at home, in the fireplace. It is easy to explain
to them in simple language what has been the outcome of
this filthy habit ; what has been the result of it to themselves,
and how they are endangering the healths of others.

For, again, England is scandalously behind other en-
lightened countries in making expectoration in public places
a punishable offence. We are often more tenacious about
the liberty of the individual subject than observant of the
good of the majority.

To return to the home, it is simple to explain to the

D 2


housekeeper how sweeping a room only disturbs the dust,
and how the copious use of tea-leaves or damp sawdust will
help to collect it ; and how wiping with damp cloths wrung
out is preferable to dusting, &c., &c. We must also explain
about ventilation and judge if it be advisable for a patient to
return to the rooms he is in, even after they are disinfected,
cleansed and whitewashed as they should be. If new rooms
are procured, these should be properly cleansed before occupa-
tion, and other sanitary arrangements looked to.

And as we see that good nourishing food is of so much
importance in the building up of a debilitated body and its
importance cannot be exaggerated we must look to it that
our patient has this ; and again, most emphatically, he must
not return to unsuitable, ill- ventilated, dust -accumulating,
and dark rooms.

Do not let us undertake to begin to help a case if we
intend to permit this ; our idea is to cure our patient, not,
as Dr. Walther says, to hurry his death. Those of us who
are particular about ventilation, know how really painful
it is to be even a short time in a close room, and how
our heads soon ache, and how often afterwards we have a
sore throat.

To a tubercular patient, who has become accustomed
to pure air in the Sanatorium and who will never probably
be strong enough to do without plenty of it, it is all-
important that in every way his surroundings should be
favourable to his gradual improvement. And we must look
to the suitability of his employment. Employments that
put too great a strain on the weakened lung, and those that
necessitate the patient being in ill-ventilated, dusty workshops,
are unsuitable. Before going to a sanatorium he or she
must understand this thoroughly, and must consent to try
some other work on leaving. Where a single man is dealt
with it would be advisable for him to live an out- door life in
the country. This, of course, is advisable for all, but it is
not always feasible.


I am sure I shall be told that I am suggesting impossi-
bilities. I do not think so. Nothing is impossible. But I
would suggest, in order to facilitate matters, that, after the
preliminary inquiry, one visitor should take the case in hand
and be responsible for it. This responsibility will greatly
develop originality and initiation. Our patient has to be
regularly visited for some little time after his cure. After
one has walked in the Valley of the Shadow of Death
and been with others also in that Valley of the Shadow,
one is likely to be nervous at any idea of falling back.
Besides, too, a consumptive patient is often a little rash.
He will have found a friend in this special visitor, who will
know if some little extra food or only encouragement be

On the other hand, it is no use keeping a patient for
months and months at a sanatorium if he shows no definite
or sustained improvement ; he must then be referred to the
Poor Law, If he refuse to avail himself of the Infirmary,
we can still help, by our better knowledge of the rules of
sanitation, to prevent his family suffering in consequence.

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