67 years on the national healthBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7182.511 (Published 20 February 1999) Cite this as: BMJ 1999;318:511
She was aged 70 when I took her over in outpatients; Irish, cheerful, overweight, cyanosed; larger than life. She had always lived in Hammersmith. She regarded the outpatient clinic as her second home, and the doctors, nurses, and health visitors as her extended family. Not surprising really, since she had attended hospitals, clinics, and dispensaries for 55 years since she developed pulmonary tuberculosis at the age of 15.
Why do I remember her? Firstly, for her remarkable medical history. Her pulmonary tuberculosis smouldered on in spite of collapse treatment for 10 years until she had a three stage left lung thoracoplasty in 1941. She was pronounced cured [“denotified”] in 1945. After living for 31 years with one functioning lung, and smoking, she was admitted to the Hammersmith in 1972 in cor pulmonale. When I saw her 15 years later (1987) her FEV1 was rock bottom (0.5 l or 25% predicted) and her arterial O2 saturation was 89%. Two years later she had an oxygen concentrator, which she used for at least 20 hours a day for the next eight years. It enhanced her quantity and quality of life. Control of oedema was a problem. From 1993, she needed a wheelchair. Her general practitioner was very supportive, visiting every six weeks. She died last year aged 81. Fifty seven years on one lung.
I also remember her for the whisky. She was teetotal, but on the clinic visit nearest to each Christmas (even an appointment moved back to October) she would appear with her husband—also Irish and with a heart of gold— with a bottle of Scotch (“for you, doctor”) and a box of chocolates (“for your dear wife.”) Useless to refuse—and, anyway, it wouldn't have been kind.
The third reason, and the most remarkable, was that buried at the back of her hospital notes were the records of her tuberculosis treatment from 1931 to 1947; attendance at the Hammersmith Tuberculosis Dispensary, records of the local public health department, assessments of the family income, housing conditions, requests for assistance with nourishment and clothing, correspondence between medical officers of health, general practitioners, tuberculosis officers, the tuberculosis after care committee, and poignant letters from the patient and her mother. A mine of social and medical history.
These are three examples. From the medical officer of health of London County Council: “The council has provided a bed for your child at the East Anglian Children's Sanatorium… arrange for her to be at Liverpool St at 11.30 o'clock, 4th instant. The committee's nurse will be at the ticket barrier; Platform 7, LNE Railway. Please tie a white handkerchief round the upper part of left arm.” In relation to her sanatorium treatment (she was there for 15 months): “On the recommendation of the tuberculosis care committee it has been decided that the rate of contribution should be nil per week.” Hammersmith Tuberculosis Dispensary notes (83 visits from 1933 to 1947): “19.6.39: mother seen and wishes daughter to be approached over smoking, but not to say mother had mentioned it.”
In the first half of this century the scourge of tuberculosis was contained by the public health authorities' meticulous attention to the welfare of those infected. A network of care existed which, for the treatment of tuberculosis, represented “a national health service” well before the founding of the NHS in 1948. Even though we now have effective chemotherapy, the network of community and outpatient care must be maintained; where and when it fails multidrug resistant tuberculosis emerges to haunt us.
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