923
CLINICAL PRACTICE
Letters to
patients: improving communication in cancer care
Numerous studies have shown that patients are usually dissatisfied with the information they receive during clinical consultations with medical specialists. Therefore, a randomised study design has been used to assess the role of personal letters to patients outlining their cancer consultation. Compared with the control group, patients receiving letters were more satisfied with the amount of information given, and tended to have greater and more accurate recall of the consultation. A survey of referring doctors revealed general support for the idea of sending to cancer patients letters that outline the substance of their consultations. The study shows that letters to patients are a useful method of improving patient satisfaction and recall in clinical consultations. They also provide a permanent record of the consultation, which can be kept for future reference, and encourage greater patient involvement in their care. Introduction
Despite increasing recognition of the need for effective doctor-patient communication, numerous reports show that patients are still less than satisfied with the information they receive.’1 Dissatisfaction may arise when too little information is given, when it is not presented clearly enough, or when it is not registered or remembered by the patient. Adequate understanding and recall enables patients to be more actively involved in their management. Attempts to improve doctor-patient communication and patient understanding have included the provision of printed information. Although pamphlets, posters, and information sheets are often useful, material specifically adapted for individual patients can be more comprehensive and helpful, without the inclusion of irrelevant and potentially confusing details. Such "tailor-made" information may be provided-in various ways. In a study by Hogbin and Fallowfield,2patients with cancer found that audiotapes of their initial visits to a surgeon were very useful, even when the tapes contained distressing information. The use of short notes outlining diagnosis, management, prognosis, and follow-up arrangements has also been found in one study to substantially improve patients’ understanding and recalJ,3 but not in another.4 Tattersa1l5,6
reported that his practice of sending his general medical patients letters summarising their consultations (ie, copies of the usual correspondence with general practitioners [GPs]) has been very well received by both patients and their families. We here report a randomised study to see whether letters to patients outlining the oncology consultation influence their satisfaction and recall of information and whether they are useful to cancer patients and their families. We have also sought the views of referring doctors about this approach to improving doctor-patient communication.
Patients and methods Patients attending a general oncology outpatient clinic for a follow-up consultation were eligible for the study. Those presenting for "check-ups" only (no discussion of treatment strategies, change in disease status, or intercurrent disorders) were excluded from the study (38 patients). Patients who did not speak English (14) or who were considered too ill or disabled to be interviewed (7) were also excluded. A total of 48 patients were eligible for the study, and all agreed to take part. Table i shows the demographic and medical characteristics of these patients. All patients had met with the consultant previously (median number of previous consultations 6; range 1-20). At the end of the consultation, patients were randomised to either receive or not receive a letter outlining their consultation. Assignment of patients to experimental (letter) or control (no letter) groups was done by the use of pre-randomised forms numbered to correspond with the patients’ order of entry into the study. After each clinic, the consultant noted the salient points raised in the consultation for all patients, and dictated letters to those in the letter group. The 24 letters were written specifically for each patient and were not copies of reports sent to their referring doctors. Use of medical terminology was reduced to a minimum; none of the patients said that they had difficulty understanding the letters. All subjects were later followed up with a structured telephone interview. These interviews were conducted by one of us (D. D., who was present at all consultations), and it was emphasised to patients that they would remain anonymous. Patients were asked to indicate how satisfied they were with eight aspects of the consultation (table I:). Satisfaction was assessed by a ADDRESSES: Department of Cancer Medicine, University of Sydney (D Damian) and Department of Medical Oncology, Royal Prince Alfred Hospital (Prof M. H. N. Tattersall, FRCP), Australia. Correspondence to Prof M. H. N Tattersall, Department of Cancer Medicine, Blackburn Building, University of Sydney, 2006 Australia.
924
TABLE II-REPORTED SATISFACTION AT FOLLOW-UP
TABLE I-DEMOGRAPHIC AND MEDICAL CHARACTERISTICS OF PATIENTS
Data
are
median
(range)
*p=0014
5-point scale, with scores of 1 ("completely dissatisfied") to 5 ("completely satisfied"). Patients’ recall of the consultation was also assessed (both unprompted and prompted) and any misunderstanding was recorded. Patients in the control group were then asked if they thought that a letter outlining their consultation would be useful or distressing to them. Patients in the letter group were asked a series of open-ended questions about the letter they had received, and were asked to indicate their attitude to the letter by a 5-point scale, with values of 1 ("not at all") to 5 ("completely")
(table in). 42 of the 48 patients had one or more referring doctors who involved in their cancer care and who were receiving correspondence from the oncologist (M. H. N. T.). This group consisted of 45 GPs and 26 specialists (surgeons, gynaecologists, and psychiatrists). All were sent questionnaires (with sample letters enclosed) seeking their views on the use of such letters in cancer care. Responders were told that they would remain anonymous. Statistical analysis of the patient and letter satisfaction scales was done with the Wilcoxon rank sum test to compare responses of the two groups.’ Linear regression analysis of correlation between recall and time from consultation to interview was carried out with the SPIDA statistical package.8 Student’s t test was used for the remainder of the comparisons made. were
Results Structured interviews with patients took place within 3 to 19 days of the consultation (median 8 days for the letter group, 7 days for the control group). All patients were asked if they felt that the consultation had differed in any way from with the oncologist. Only 6 patients believed the consultation to be substantially different: 4 thought that it was longer and more informative than usual, and 2 felt that the doctor had been especially honest with them this time. An additional 7 patients noted the presence of a medical student (D. D.) but did not think that this affected the consultation. The oncologist (M. H. N. T.) did not believe the study to have altered his usual manner of consultation. Although content of the letters varied with each consultation, most included details of treatment choices and strategies (83%), test results (71%), current disease status (67%), clinical findings (63%), and follow-up/referral arrangements (54%). Other areas commonly mentioned were prognosis (33%), side-effects of treatment (33%), further investigations required (29%), and explanation of symptoms (29%). Patients were generally very satisfied with their consultations (table 11). Compared with the control group, patients in the letter group were more satisfied with the amount of information given to them (p 0-014) and the median total scores were higher (p 0-014). In particular, 13
previous meetings
patients in the letter group reported "complete satisfaction" with the consultation overall compared with only 4 control patients. There was no significant difference in percentage of items recalled by the two groups, although patients receiving a letter were given more items to remember than the control group. Median (range) number of recorded points per patient was 6 (3-13) in the letter group and 5 (4-9) in the control group. Amount of information recalled was 85% (50-100) and 75% (50-100), respectively. There was no significant relation between recall and interval from consultation to follow-up. Patients who wrongly remembered items were more likely to be in the control group than in the letter group (7 control patients recalled at least one piece of wrong information compared with 2 in the letter 16
group). patients in the control group (67%) thought that a letter outlining their consultation would be useful, especially as a reminder of what was said during the consultation. Most patients said that they would like a letter even if it contained "bad news"; 3 said that they would only want to see "good news" in writing. Of the patients receiving a letter, 20 (83%) had found it useful. Reasons given included the letter’s ability to clarify, improve understanding, and provide a permanent record of the consultation. 4 patients did not find the letter useful; 3 said that they already knew and remembered all the important points in the consultation, and 1 preferred "not to know about it unless it was good news". Patients receiving letters were also asked to classsify their consultation as either good news or bad news. Most of those with bad news consultations were pleased to have received the letter (83%), although 5 (42%) reported that it had been distressing. The letter satisfaction scale revealed that patients who had received bad news found the letter significantly more useful in helping them to understand and remember what they had been told during the consultation than did patients receiving good news (table III). As we TABLE III-REPORTED USEFULNESS OF THE LETTER
=
=
Data
are
shown
as
median
score
(range).
*p < 0 001, tp - 0 016, tp = 0 002.
925
TABLE IV-ATTITUDES OF REFERRING DOCTORS TO QUESTION, "DO YOU FEELTHAT A LETTER OUTLINING THE ONCOLOGY CONSULTATION WOULD BE USEFUL TO PATIENTS?"
expected, letters outlining bad news consultations made patients significantly more anxious than did those outlining good news (p 0 002), although fewer of those receiving bad news thought that the letter "seemed useless". Patients read their letters an average of 2-6 times (range 1 to 8), and 20 of =
spouse
(13 patients),
to at least 1 other person--eg, their friends (7), other family members (7),
their doctor (5). 62 (87%) of the 71 referring doctors completed a questionnaire about the use of letters to cancer patients (40/45 GPs and 22/26 specialists). Most responders welcomed the idea (table iv). The questionnaire also asked whether there were any circumstances in which a letter would be either especially helpful or best not sent. Answers to the former included situations in which patients would be most likely to misunderstand or forget information-for example, after the initial consultation (37%) or when a consultation contained distressing news (13%). 11 responders (35%) considered it best not to send a letter when there was potential for causing distress. By contrast, 14 (22%) felt that there were no situations in which a letter should not be sent, and that even bad news must be faced realistically. The reponses also reflected the viewpoint that a letter must not be sent at the expense of supervision by the referring doctor. 75% of GPs (30/40) and 86% of specialists (19/22) thought that copies of the letters should be sent to the patients’ medical advisers. or
Discussion
Although most patients were highly satisfied with their consultations, total satisfaction scores were higher in the group randomised to receive a letter, with more of these patients reporting complete satisfaction with the consultation overall. Patients who received a letter were also satisfied with the amount of information given to them. These fmdings contrast with those of Reynolds et al,4 who found no significant difference between a control group and patients receiving supplementary written information. However, George et al9 noted that general practice patients given information leaflets about their medication were more satisfied with their treatment,overall. Whilst patients receiving bad news found the letter more useful in helping them to understand and remember what they had been told at the consultation, such benefits should be balanced against broader questions of patient welfare. Letters may be distressing to patients, especially when they contain bad news. Cassileth et all in a study of 256 cancer patients, investigated this possibility in relation to those who more
their illness by avoiding or denying distressing information. Although the provision of detailed information helped many patients to sustain hopeful attitudes, this will not be so in all cases. In our study, almost half the patients receiving bad news found their letter distressing to some extent; however, with 1 exception, all patients were pleased to have received it. A few patients (most of whom were in the control group) said that they would prefer not to see bad news in writing, but would welcome seeing any good news "in black and white". To ensure a satisfactory balance between recall, understanding, and patient wellbeing, supplementary information may be most beneficial when provided on an individual basis. We thank Dr Phyllis Butow, Dr Stewart Dunn, and Ms Jenny Taylor for their assistance in planning this study, and we are most grateful for the statistical advice of Prof Alan Coates.
GP=general practitioner
the 24 had shown it
coped with
REFERENCES 1. Ley P. Communicating with patients: improving communication, satisfaction and compliance. New York: Croom Helm, 1988. 2. Hogbin B, Fallowfield L. Getting it taped: the "bad news" consultation with cancer patients. Br J Hosp Med 1989; 41: 330-33. 3. Ellis DA, Hopkin JM, Leitch AG, Crofton J. "Doctors’ orders"; controlled trial of supplementary, written information for patients. Br Med J 1979; 1: 456. 4. Reynolds PM, Sanson-Fisher RW, Poole AD, Harker J, Byrne MJ. Cancer and communication: information-giving in an oncology clinic. Br Med J 1981; 282: 1449-51. 5. Tattersall RB. Informing patients. Lancet 1989; ii: 280. 6. Tattersall RB. Writing to and for patients. Diabetic Medicine 1990; 7: 917-19. 7. Wilcoxon F. Individual
comparisons by ranking methods. Biometrics 1945; i: 80-83. 8. Lunn D, McNeil D. SPIDA Users’ Manual. Sydney: Southward Press, 1988. 9. 10.
George CF, Waters WE, Nicholas JA. Prescription information leaflets: a pilot study in general practice. Br Med J 1983; 287: 1193-96. Cassileth BR, Zupkis RV, Sutton-Smith K, March V. Information and participation preferences among cancer patients. Ann Intern Med 1980; 92: 832-36.
From The Lancet Out of this world?
Amongst the many ingenious hypotheses put forward to account for the origin and spread of influenza, it is interesting to observe one which approximates to a certain extent to the doctrines of those early Italian physicians who assigned a name which has the merit of vagueness and nescience-a name for which even now we are not prepared to find a better substitute. It would appear, however, that there is something still to be said for an extra-mundane origin of this mysterious affection; and the case has been well put by Mr G. H. Willis, who adduces facts from Dr Parsons’ report to prove not only that the spread of the disease is unaffected by aerial currents, but in opposition also to Parsons’ contention that it is mainly propagated along the lines of human intercourse. Willis suggests (Times, July 10) that the disease which visits so suddenly and simultaneously so many parts of the earth may take its rise in the intrusion into the atmosphere of some poisonous gas of such density as to penetrate, in spite of the law of diffusion, to the surface of the earth, over which it would necessarily tend to travel, in the main, in a westward direction, modified variously by the lower currents of the atmosphere.... [perhaps] when sanitation has banished all specific fevers, the human race will still be prone to infection (if that term is permissible in this relation) on the large scale from sources beyond the limits of terrestrial activity!
(July 18, 1891)
CLINICAL PRACTICE
Letters to
patients: improving communication in cancer care
Numerous studies have shown that patients are usually dissatisfied with the information they receive during clinical consultations with medical specialists. Therefore, a randomised study design has been used to assess the role of personal letters to patients outlining their cancer consultation. Compared with the control group, patients receiving letters were more satisfied with the amount of information given, and tended to have greater and more accurate recall of the consultation. A survey of referring doctors revealed general support for the idea of sending to cancer patients letters that outline the substance of their consultations. The study shows that letters to patients are a useful method of improving patient satisfaction and recall in clinical consultations. They also provide a permanent record of the consultation, which can be kept for future reference, and encourage greater patient involvement in their care. Introduction
Despite increasing recognition of the need for effective doctor-patient communication, numerous reports show that patients are still less than satisfied with the information they receive.’1 Dissatisfaction may arise when too little information is given, when it is not presented clearly enough, or when it is not registered or remembered by the patient. Adequate understanding and recall enables patients to be more actively involved in their management. Attempts to improve doctor-patient communication and patient understanding have included the provision of printed information. Although pamphlets, posters, and information sheets are often useful, material specifically adapted for individual patients can be more comprehensive and helpful, without the inclusion of irrelevant and potentially confusing details. Such "tailor-made" information may be provided-in various ways. In a study by Hogbin and Fallowfield,2patients with cancer found that audiotapes of their initial visits to a surgeon were very useful, even when the tapes contained distressing information. The use of short notes outlining diagnosis, management, prognosis, and follow-up arrangements has also been found in one study to substantially improve patients’ understanding and recalJ,3 but not in another.4 Tattersa1l5,6
reported that his practice of sending his general medical patients letters summarising their consultations (ie, copies of the usual correspondence with general practitioners [GPs]) has been very well received by both patients and their families. We here report a randomised study to see whether letters to patients outlining the oncology consultation influence their satisfaction and recall of information and whether they are useful to cancer patients and their families. We have also sought the views of referring doctors about this approach to improving doctor-patient communication.
Patients and methods Patients attending a general oncology outpatient clinic for a follow-up consultation were eligible for the study. Those presenting for "check-ups" only (no discussion of treatment strategies, change in disease status, or intercurrent disorders) were excluded from the study (38 patients). Patients who did not speak English (14) or who were considered too ill or disabled to be interviewed (7) were also excluded. A total of 48 patients were eligible for the study, and all agreed to take part. Table i shows the demographic and medical characteristics of these patients. All patients had met with the consultant previously (median number of previous consultations 6; range 1-20). At the end of the consultation, patients were randomised to either receive or not receive a letter outlining their consultation. Assignment of patients to experimental (letter) or control (no letter) groups was done by the use of pre-randomised forms numbered to correspond with the patients’ order of entry into the study. After each clinic, the consultant noted the salient points raised in the consultation for all patients, and dictated letters to those in the letter group. The 24 letters were written specifically for each patient and were not copies of reports sent to their referring doctors. Use of medical terminology was reduced to a minimum; none of the patients said that they had difficulty understanding the letters. All subjects were later followed up with a structured telephone interview. These interviews were conducted by one of us (D. D., who was present at all consultations), and it was emphasised to patients that they would remain anonymous. Patients were asked to indicate how satisfied they were with eight aspects of the consultation (table I:). Satisfaction was assessed by a ADDRESSES: Department of Cancer Medicine, University of Sydney (D Damian) and Department of Medical Oncology, Royal Prince Alfred Hospital (Prof M. H. N. Tattersall, FRCP), Australia. Correspondence to Prof M. H. N Tattersall, Department of Cancer Medicine, Blackburn Building, University of Sydney, 2006 Australia.
924
TABLE II-REPORTED SATISFACTION AT FOLLOW-UP
TABLE I-DEMOGRAPHIC AND MEDICAL CHARACTERISTICS OF PATIENTS
Data
are
median
(range)
*p=0014
5-point scale, with scores of 1 ("completely dissatisfied") to 5 ("completely satisfied"). Patients’ recall of the consultation was also assessed (both unprompted and prompted) and any misunderstanding was recorded. Patients in the control group were then asked if they thought that a letter outlining their consultation would be useful or distressing to them. Patients in the letter group were asked a series of open-ended questions about the letter they had received, and were asked to indicate their attitude to the letter by a 5-point scale, with values of 1 ("not at all") to 5 ("completely")
(table in). 42 of the 48 patients had one or more referring doctors who involved in their cancer care and who were receiving correspondence from the oncologist (M. H. N. T.). This group consisted of 45 GPs and 26 specialists (surgeons, gynaecologists, and psychiatrists). All were sent questionnaires (with sample letters enclosed) seeking their views on the use of such letters in cancer care. Responders were told that they would remain anonymous. Statistical analysis of the patient and letter satisfaction scales was done with the Wilcoxon rank sum test to compare responses of the two groups.’ Linear regression analysis of correlation between recall and time from consultation to interview was carried out with the SPIDA statistical package.8 Student’s t test was used for the remainder of the comparisons made. were
Results Structured interviews with patients took place within 3 to 19 days of the consultation (median 8 days for the letter group, 7 days for the control group). All patients were asked if they felt that the consultation had differed in any way from with the oncologist. Only 6 patients believed the consultation to be substantially different: 4 thought that it was longer and more informative than usual, and 2 felt that the doctor had been especially honest with them this time. An additional 7 patients noted the presence of a medical student (D. D.) but did not think that this affected the consultation. The oncologist (M. H. N. T.) did not believe the study to have altered his usual manner of consultation. Although content of the letters varied with each consultation, most included details of treatment choices and strategies (83%), test results (71%), current disease status (67%), clinical findings (63%), and follow-up/referral arrangements (54%). Other areas commonly mentioned were prognosis (33%), side-effects of treatment (33%), further investigations required (29%), and explanation of symptoms (29%). Patients were generally very satisfied with their consultations (table 11). Compared with the control group, patients in the letter group were more satisfied with the amount of information given to them (p 0-014) and the median total scores were higher (p 0-014). In particular, 13
previous meetings
patients in the letter group reported "complete satisfaction" with the consultation overall compared with only 4 control patients. There was no significant difference in percentage of items recalled by the two groups, although patients receiving a letter were given more items to remember than the control group. Median (range) number of recorded points per patient was 6 (3-13) in the letter group and 5 (4-9) in the control group. Amount of information recalled was 85% (50-100) and 75% (50-100), respectively. There was no significant relation between recall and interval from consultation to follow-up. Patients who wrongly remembered items were more likely to be in the control group than in the letter group (7 control patients recalled at least one piece of wrong information compared with 2 in the letter 16
group). patients in the control group (67%) thought that a letter outlining their consultation would be useful, especially as a reminder of what was said during the consultation. Most patients said that they would like a letter even if it contained "bad news"; 3 said that they would only want to see "good news" in writing. Of the patients receiving a letter, 20 (83%) had found it useful. Reasons given included the letter’s ability to clarify, improve understanding, and provide a permanent record of the consultation. 4 patients did not find the letter useful; 3 said that they already knew and remembered all the important points in the consultation, and 1 preferred "not to know about it unless it was good news". Patients receiving letters were also asked to classsify their consultation as either good news or bad news. Most of those with bad news consultations were pleased to have received the letter (83%), although 5 (42%) reported that it had been distressing. The letter satisfaction scale revealed that patients who had received bad news found the letter significantly more useful in helping them to understand and remember what they had been told during the consultation than did patients receiving good news (table III). As we TABLE III-REPORTED USEFULNESS OF THE LETTER
=
=
Data
are
shown
as
median
score
(range).
*p < 0 001, tp - 0 016, tp = 0 002.
925
TABLE IV-ATTITUDES OF REFERRING DOCTORS TO QUESTION, "DO YOU FEELTHAT A LETTER OUTLINING THE ONCOLOGY CONSULTATION WOULD BE USEFUL TO PATIENTS?"
expected, letters outlining bad news consultations made patients significantly more anxious than did those outlining good news (p 0 002), although fewer of those receiving bad news thought that the letter "seemed useless". Patients read their letters an average of 2-6 times (range 1 to 8), and 20 of =
spouse
(13 patients),
to at least 1 other person--eg, their friends (7), other family members (7),
their doctor (5). 62 (87%) of the 71 referring doctors completed a questionnaire about the use of letters to cancer patients (40/45 GPs and 22/26 specialists). Most responders welcomed the idea (table iv). The questionnaire also asked whether there were any circumstances in which a letter would be either especially helpful or best not sent. Answers to the former included situations in which patients would be most likely to misunderstand or forget information-for example, after the initial consultation (37%) or when a consultation contained distressing news (13%). 11 responders (35%) considered it best not to send a letter when there was potential for causing distress. By contrast, 14 (22%) felt that there were no situations in which a letter should not be sent, and that even bad news must be faced realistically. The reponses also reflected the viewpoint that a letter must not be sent at the expense of supervision by the referring doctor. 75% of GPs (30/40) and 86% of specialists (19/22) thought that copies of the letters should be sent to the patients’ medical advisers. or
Discussion
Although most patients were highly satisfied with their consultations, total satisfaction scores were higher in the group randomised to receive a letter, with more of these patients reporting complete satisfaction with the consultation overall. Patients who received a letter were also satisfied with the amount of information given to them. These fmdings contrast with those of Reynolds et al,4 who found no significant difference between a control group and patients receiving supplementary written information. However, George et al9 noted that general practice patients given information leaflets about their medication were more satisfied with their treatment,overall. Whilst patients receiving bad news found the letter more useful in helping them to understand and remember what they had been told at the consultation, such benefits should be balanced against broader questions of patient welfare. Letters may be distressing to patients, especially when they contain bad news. Cassileth et all in a study of 256 cancer patients, investigated this possibility in relation to those who more
their illness by avoiding or denying distressing information. Although the provision of detailed information helped many patients to sustain hopeful attitudes, this will not be so in all cases. In our study, almost half the patients receiving bad news found their letter distressing to some extent; however, with 1 exception, all patients were pleased to have received it. A few patients (most of whom were in the control group) said that they would prefer not to see bad news in writing, but would welcome seeing any good news "in black and white". To ensure a satisfactory balance between recall, understanding, and patient wellbeing, supplementary information may be most beneficial when provided on an individual basis. We thank Dr Phyllis Butow, Dr Stewart Dunn, and Ms Jenny Taylor for their assistance in planning this study, and we are most grateful for the statistical advice of Prof Alan Coates.
GP=general practitioner
the 24 had shown it
coped with
REFERENCES 1. Ley P. Communicating with patients: improving communication, satisfaction and compliance. New York: Croom Helm, 1988. 2. Hogbin B, Fallowfield L. Getting it taped: the "bad news" consultation with cancer patients. Br J Hosp Med 1989; 41: 330-33. 3. Ellis DA, Hopkin JM, Leitch AG, Crofton J. "Doctors’ orders"; controlled trial of supplementary, written information for patients. Br Med J 1979; 1: 456. 4. Reynolds PM, Sanson-Fisher RW, Poole AD, Harker J, Byrne MJ. Cancer and communication: information-giving in an oncology clinic. Br Med J 1981; 282: 1449-51. 5. Tattersall RB. Informing patients. Lancet 1989; ii: 280. 6. Tattersall RB. Writing to and for patients. Diabetic Medicine 1990; 7: 917-19. 7. Wilcoxon F. Individual
comparisons by ranking methods. Biometrics 1945; i: 80-83. 8. Lunn D, McNeil D. SPIDA Users’ Manual. Sydney: Southward Press, 1988. 9. 10.
George CF, Waters WE, Nicholas JA. Prescription information leaflets: a pilot study in general practice. Br Med J 1983; 287: 1193-96. Cassileth BR, Zupkis RV, Sutton-Smith K, March V. Information and participation preferences among cancer patients. Ann Intern Med 1980; 92: 832-36.
From The Lancet Out of this world?
Amongst the many ingenious hypotheses put forward to account for the origin and spread of influenza, it is interesting to observe one which approximates to a certain extent to the doctrines of those early Italian physicians who assigned a name which has the merit of vagueness and nescience-a name for which even now we are not prepared to find a better substitute. It would appear, however, that there is something still to be said for an extra-mundane origin of this mysterious affection; and the case has been well put by Mr G. H. Willis, who adduces facts from Dr Parsons’ report to prove not only that the spread of the disease is unaffected by aerial currents, but in opposition also to Parsons’ contention that it is mainly propagated along the lines of human intercourse. Willis suggests (Times, July 10) that the disease which visits so suddenly and simultaneously so many parts of the earth may take its rise in the intrusion into the atmosphere of some poisonous gas of such density as to penetrate, in spite of the law of diffusion, to the surface of the earth, over which it would necessarily tend to travel, in the main, in a westward direction, modified variously by the lower currents of the atmosphere.... [perhaps] when sanitation has banished all specific fevers, the human race will still be prone to infection (if that term is permissible in this relation) on the large scale from sources beyond the limits of terrestrial activity!
(July 18, 1891)
