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TUBERCULOSIS.--SOME OBSEt~VATIONS AND REFLECTIONS. By W. H. DICKINSON, O.B.E., ~/[.D., M.R.C.P.Ed., D.P.H. Part-Time Tt~berc~dosis Pkysicia~z, Ncwc~stle.on-Ty~w. IT is commonly said that we learn more from our failures than from our successes; in the fight against tuberculosis the deaths constitute our failures, and I have selected a review of the fatal cases of tuberculosis, and the mortality rates in Newcastle, for the subject of my address this evening. In the words of the great Sydenham, " The thing I endeavour is to show, by the assistance of a few years' observation, how this matter stood lately with respect to ---- the city wherein I live." Since 1913 a special record of the deaths from tuberculosis has been kept at the Dispensary, and in the sixteen years up to December 31, 1928, a total of 7,540 residents of Newcastle have died from some form or other of the disease. Tuberculosis of the lungs accounted for 5,663 or 75 per cent., whilst deaths from " other forms " of the disease amounted to 1,877 or 25 per cent. For convenience sake I have always classified all below 16 years, the age at which young persons become eligible for " National Health Insurance," as children, and on looking into the figures it is found that only 10 per cent. of the deaths from phthisis as contrasted with 71 per cent. from other forms occurred before the sixteenth birthday. While the non-pulmonary deaths were fairly evenly divided between the two sexes at all ages (989 males, 888 females) it is interesting to note that in pulmonary tuberculosis, although in the aggregate there were more " male " than " female" deaths (3,208 to 2,455), below the age of 25 years there were actually more deaths amongst females (910) than males (794) ; and this was especially noticeable at ages below 16 years (334 and 240). Above the age of 45 years the male deaths were more than double the female deaths. The carefully compiled records in our Dispensaries contain an enormous amount of valuable information, which I fear none of us has had leisure to assimilate completely, but each year I have been able to get certain details extracted concerning the fatal cases of pulmonary tuberculosis, and some of these I propose to bring to your notice. DURATIO~ OF InLN~SS. Considerable interest attaches to the duration of the illness in fatal cases of pulmonary tuberculosis, and the estimates given by different authorities vary greatly ; e.g., Louis was of opinion that the average length ' Paper read at the Meeting of the North of England Tuberculosis Society ol~ April 26th, 1929. 35

Tuberculosis.—some observations and reflections

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Page 1: Tuberculosis.—some observations and reflections

T U B E R C U L O S I S . - - S O M E OBSEt~VATIONS AND

R E F L E C T I O N S .

By W. H. DICKINSON, O.B.E., ~/[.D., M.R.C.P.Ed., D.P .H.

Part-Time Tt~berc~dosis Pkysicia~z, Ncwc~stle.on-Ty~w.

IT is commonly said that we learn more from our failures than from our successes; in the fight against tuberculosis the deaths consti tute our failures, and I have selected a review of the fatal cases of tuberculosis, and the mor ta l i ty rates in Newcastle, for the subject of my address this evening. In the words of the great Sydenham, " The thing I endeavour is to show, by the assistance of a few years' observation, how this mat ter stood lately with respect to - - - - the city wherein I live."

Since 1913 a special record of the deaths from tuberculosis has been kept at the Dispensary, and in the sixteen years up to December 31, 1928, a total of 7,540 residents of Newcastle have died from some form or other of the disease.

Tuberculosis of the lungs accounted for 5,663 or 75 per cent., whilst deaths from " o ther forms " of the disease amounted to 1,877 or 25 per cent.

For convenience sake I have always classified all below 16 years, the age at which young persons become eligible for " National Hea l th Insurance ," as children, and on looking into the figures it is found that only 10 per cent. of the deaths from phthisis as contrasted with 71 per cent. from o ther forms occurred before the sixteenth birthday.

While the non-pulmonary deaths were fairly evenly divided between the two sexes at all ages (989 males, 888 females) it is interesting to note that in pulmonary tuberculosis, al though in the aggregate there were more " male " than " f e m a l e " deaths (3,208 to 2,455), below the age of 25 years there were actually more deaths amongst females (910) than males (794) ; and this was especially noticeable at ages below 16 years (334 and 240). Above the age of 45 years the male deaths were more than double the female deaths.

The carefully compiled records in our Dispensaries contain an enormous amount of valuable information, which I fear none of us has had leisure to assimilate completely, but each year I have been able to get certain details extracted concerning the fatal cases of pulmonary tuberculosis, and some of these I propose to bring to your notice.

DURATIO~ OF InLN~SS.

Considerable interest attaches to the duration of the illness in fatal cases of pu lmonary tuberculosis, and the estimates given by different authorities vary greatly ; e.g., Louis was of opinion that the average length

' Paper read at the Meeting of the North of England Tuberculosis Society ol~ April 26th, 1929.

35

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546 TU~ERCL~ [September, 1929

of illness was two years, while Williams estimated the duration (amongst private patients, however) at eight years.

In Newcastle careful histories have been taken of all patients with a view to determining the duration of the illness prior to notification and subsequently; in fatal cases the sum of the two items gives the total length of illness from the first appearance of symptoms till death.

Two groups of material hare been utilised for all these investigations, namely (1) all the fatal cases of pulmonary tuberculosis registered each year ; (2) only the known sputum positive cases dying in each year.

The results of the analysis of the two sets of figures have been found to correspond very closely from year to year, but most of the figures given refer to sputum-positive cases only. A noticeable difference is evident between the earlier and the later figures, but that is readily accounted for by the fact that notification was only introduced in 1912, and that latterly the Dispensary staff has been in touch with the cases from a relatively earlier stage of the illness; the increased insti tutional accommodation Provided must also have played an important part.

Thus the average duration of illness recorded in 1913 for sputum positive cases was 21"6 months for adult males and 15"6 for adult females, whereas in 1928 the corresponding figures were 61"0 and 44'0, while the averages for the sixteen years are 40"1 months and 29"4 months respectively.

The statistics relating to children are apt to be misleading, for many of the more chronic cases live to be classed as " adults " ; but generally speaking the disease runs a much more rapid course in childhood, and this is especially true below the age of 10 years.

The average duration of the fatal illness for a l l c a s e s , male and female, adults and children, for the year 1928, was forty-six months ; the interval between notification and death was twenty-five months, so that on the average each patient presented symptoms of pulmonary tuberculosis twenty-one months before notification.

Taking all the figures available into consideration, I have come to the conclusion that although the duration of the illness in fatal cases varies very much, a fair average for the industrial classes is four years for men, three years for women and about eighteen months for " children " aged less than 16 years, excluding cases of acute miliary and broncho-pneumonic tuberculosis in the earlier years of life.

The longer duration of illness in males coupled with the greater incidence of the disease among men accounts for the large excess of male patients (five males to two females) on the " live " files in the dispensary.

FAMILY HISTORY.

W h i l e this is very important as regards meningeal and glandular tuberculosis in children, it is of the greatest significance in respect to tuberculosis of the lungs.

Reginald Thompson in his book " :Family :Phthisis" stated that 50 per cent. of the offspring of a phthisical union died of tuberculosis.

Although a great deal has been writ ten on the subiect it must be observed that concerning it there is much that is not clearly understood. For

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September, ]9291 SOME OBSERVATIONS ON T U B E R C U L O S I S 547

example, in the vast majori ty of cases the phthisical parent and children all develop the disease within the space of a few years, and hence it is difficult to believe that the child has been infected in its infancy by the parent who at that t ime presented no symptoms of the disease; on the other hand, we now know that infection is almost universal in densely populated areas.

The suggestion is, rather, that some common predisposing cause or procatarctic factor has. operated on parent and offspring at about the same time.

As an example of what is meant the history of one family will be given. James McA., aged 62, was notified as a case of pulmonary tuberculosis in

August, 1917 ; he never visited the dispensary at that t ime ; when examined in January, 1923, he was found to have signs of " quiescent " or " arrested " disease, and died on April 3, 1926, of senility (no reference to tuberculosis). In September, 1920, a granddaughter, Sheila M., aged 2~, who was living with him, died of tuberculous meningitis.

The next victim was Mary M., aged 33, daughter of the first mentioned case and mother of the second ; she was notified on January 21, 1921, and died of phthisis on June 27, 1921.

Towards the end of 1922, three more sputum-positive cases were found among the contacts, namely, Bernard McA., aged 23, and :Lawrence McA., aged 31, sons of James McA., and Catherine McA., aged 31, wife of Lawrence McA.

Another son of James McA. has been examined and was under suspicion for some time, but has now left the district.

The first James McA. stated that he had had no symptoms of chest trouble before 1915.

This is perhaps an extreme case, but it illustrates the terrible t o l l exacted by tuberculosis from one family within the space of a few years.

An interesting feature is that the nature and situation of the lung lesions were very similar in the blood relations, points which I have frequently noticed in other families, and which suggest the existence of a hereditary " locus resistenti~e minoris."

For some reason or other, e.g., owing to deaths in institutions, deaths of residents outside the area, full details of all the 5,663 cases were not available, but of 4,819 investigated it was found that some near relative was suffering from or had died of pulmonary tuberculosis in 1,824 instances, i.e., 37"5 per cent.

Analysis of the 3,301 sputum-positive cases revealed a family history in 1,252 instances, i.e., 37"9 per cent., or practically an identical proportion.

A parental history was given in 13 per cent. of all cases, but it is found that the proportion of female patients giving such a history is higher than males, naraely, 16"7 per cent. as compared with 10"7 per cent.

An interesting point which I have not seen previously mentioned is that patients with a parental history of the disease die at a relatively earlier age, on the average, than those with no such history ; in this series of case it means a difference of about seven years in favour of those without a parental history.

Below the age of 40 years a history of a parental phthisis was given in 17 per cent. of the cases as opposed to 6"9 of those over 40 years of age (5"1 of males only.)

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548 TUBERCI~E [September, 1929

Below the age of 16 years the difference was still more striking, as 27 per cent. of the sputmn-positive " children " gave a history of parental phthisis.

C O:NJUGAL STATUS.

3,301 sputum-positive cases were investigated, and it was found that 1,635 were married (985 males, 650 females), 1,474 were single (841 males, 683 females), and 192 were widowed (97 males and 95 females).

In no fewer than 141 instances was there a history that a deceased's wife or husband had suffered from pulmonary tuberculosis (66 men, 75 women).

I t would therefore appear that conjugal tuberculosis is not so infrequent as is commonly stated.

Wi th the accurate information now available through notification, &c., it is surprising to find in how many cases the spouse of a phthisical patient dies of tuberculosis--often after a lapse of several years however--and we now have records of 272 instances in which both partners to a marriage have suffered from pulmonary tuberculosis; in some cases both husband and wife are dead ; in others, one or both are still alive with the disease.

I t is wor thy of special note that in only eleven instances out of all the female deaths which form the material of this inquiry did pregnancy occur after the finding of tubercle bacilli in the sputum, and therefore pregnancy

~per se cannot be regarded as a common cause of hastening the fatal issue in women previously known to suffer from pulmonary tuberculosis.

While active disease frequently reveals itself shortly after childbirth, it is very uncommon in my experience for a woman known to have " open" phthisis to become pregnant.

This paucity of material (though not generally recognised) possibly accounts for the very conflicting views of different authors on the effects of pregnancy on the course of pulmonary tuberculosis.

Incidental ly only two cases have come within my experience o f " sputum- posi t ive" pregnant women dying before giving bir th to their children.

CLINICAL ~NTOTE S.

Only brief mention will be made of some of the outstanding features. Thus h~emoptysis and pleurisy with effusion were more frequently given

as the mode of onset in males than females, whereas among the latter an insidious onset with anaemia was more common.

l~leurisy with effusion, as the late Sir V~illiam Osler said, puts the stamp ~f chronicity on pulmonary tuberculosis, and it is significant tha t most of the patients (almost exclusively males) who developed bony lesions, e.g., spinal caries or hip-ioint disease, after the establishment of the lung condition, dated their illness from an at tack of pleurisy with effusion.

:Fistula-in-ano was recorded much more frequently in the males than in the females (rates 7 to 1), and was usually found associated with disease of a very chronic type.

Although the throat is examined as a routine at the dispensary, definite hypertrophy of the faucial tonsils was very rarely detected, and where this was present the type of disease was again inclined to be chronic.

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September, 1929] SOME OBSERVATIONS ON T U B E R C U L O S I S 549

Enlargement of the tonsils predisposes to catarrhal conditions, e.g., bronchitis, and I believe that there is a definite antagonism between these and tuberculosis of the lungs; on the other hand, when tuberculosis of the lungs heals, emphysema and chronic bronchitis develop as a sequela.

My final observations are in connection with the site of the lesions in the lungs. Some, e.g., La~nnec, have maintained that the right lung is first affected more commonly than the left, and others, e.g., Louis and Cotton, the reverse.

The location of the disease was noted in 1,232 positive cases, and each year it was noticed that the male cases presented more advanced lesions on the right side, as a rule, whereas the females were more " left sided " ; when the indefinite or indeterminate cases were eliminated, 59 per cent. of the males showed more advanced disease on the right side when first examined, and 61 per cent. of the females more advanced disease on the left side.

The figures are too large to suggest coincidence, and have been found similar year after year ; no satisfactory explanation can be given, but possibly the extra use of the right arm by men may render the right lung more susceptible to the spread of the disease.

Dr. Alexander James has stated that the lesions of the left upper lobe advance more rapidly than those of the right lung, and that may give some clue, for the female cases usually came first under observation with more extensive disease than the men.

REVIEW OF THE DEATH-I~ATES.

So far I have only discussed deaths, but what of the death-rates ? In 1884, the first year for which we have accurate figures, the death-

rate from all forms of tuberculosis in Newcastle was 3'20 per 1,000, and remained about this figure till 1891, when it rose to 3"52 per mille.

F rom 1891 onwards there was a steady decline till 1913, when it stood at 1"76 per thousand.

During the war the tuberculosis death-rate rose, especially in the years 1916-17, but it is important to note that the increase was exclusively due to pulmonary tuberculosis; the decline in the death-rate from non- pulmonary tuberculosis continued practically without interruption.

After the Armistice the mortali ty from phthisis again showed a pro- gressive reduction and the latest return (1928) is the lowest death-rate from tuberculosis ever recorded in the city, namely, 1"32 per thousand.

Thus, in forty-five years; the tuberculosis death-rate has been reduced by 60 per cent.

The decrease has been most striking in respect of the non-pulmonary forms of the disease, namely 75 per cent.

The steady decline in the number of deaths and the death-rate is a very hopeful feature and extremely encouraging to those engaged in anti- tuberculosis work.

THE FUTURE.

However, it is up to us to consider by what means we can accelerate the improvement noted in fhe past few years, and there are two methods

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550 TU]3ERCLF. [September, 1929

for us to adopt, namely, t rea tment of the affected individual and prevention, i.e., protection of the public as a whole.

Treatment . - -The sanatorium method of complete rest during the period or periods of activity, wish gradually increasing exercise once the activity of the disease has been subdued, has stood the test of time, and it is the best at our disposal.

In selected cases collapse therapy has given good results, and artificial pneumothorax therapy should be available in all sanatoriums and hospitals dealing with pulmonary cases. I have seen numerous patients who have been cured by thoracoplasty, and I feel sure that this method will be practised to a greater extent in this country in the next few years, but it requires very special experience and skill, and I think that it is likely to remain as a " speciality " in the hands of a very limited number of surgeons.

Fur ther , there is a great deal of prejudice to be overcome, for at the present time patients have a great horror of what they call the " rib operation."

Wi th regard to complete cure of established and definite pulmonary tuberculosis the sanatorium physician is apt to be unduly optimistic after seeing the remarkable improvement which usually occurs after even a short period of treatment, while the Dispensary Medical Officer is usually de- pressed and unduly pessimistic when he sees case after case relapse sooner .or later after a term of institutional t reatment . There is, however, a happy mean, and I have seen too many definite " c u r e s " in the past few years to doubt for one nmment that permanent arrest of the disease is possible.

The first essential is to get the cases early. Our ideas on the pathology of pulmonary tuberculosis have been revolutionised in the last ten or fifteen years, and I believe the prognosis is largely determined by the severity of the initial outbreak of the disease in the lungs. These remarks .do not apply, of course, to the so-called " pr imary focus " of early childhood.

During the first few years after compulsory notification was introduced a very large proportion of the fatal cases of phthisis (approximately 25 per cent.) were not notified before death; latterly, however, things have improved very greatly, and in the year 1928 the percentaae was only 7"1.

Pat ients are, however, still reported for the first t ime at a very late stage of their illness, and there is room for very considerable improvement in this respect.

The official tuberculosis service must make itself more efficient as a whole, so that the body of general practitioners can rely upon getting a sound and reliable opinion upon their patients.

In practice amongst the industrial classes I hold tha t it is the duty of all private and " panel " practitioners to send every " suspect " case to the Tuberculosis Dispensary, and thus lay the onus for early diagnosis upon the Tuberculosis Officer.

Diagnosis must, however, only be made on adequate grounds and not on symptoms alone.

Some definite standards are essential, and I believe that " t h e five cardinal points," as enunciated by Lawrason :Brown of the Trudeau Sanatorium, admirably fulfil our requirements. As these standards are not generally adopted I do not hesitate to enumerate them.

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September, 1929] SOME OBSE~WtTmNS ON TUBERCULOSIS 551

(1) A history of hmmoptysis. (2) A history of pleurisy with effusion. (3) The presenc%of persistent crepitations in the upper third of the chest. (4) X-ray evidence of consolidation in the upper third of the chest. (5) Finding of tubercle bacilli in the sputum. The last mentioned, if above suspicion, is the only definite single

criterion, but if any two of the other points are present in any case it can fairly safely be regarded as a case of tubercle of the lungs.

Any patient presenting symptoms such as cough, lack of energy, loss of weight, night sweats, &c., in addition to one of the first four " cardinal points," is to be regarded as a " suspect," and requires careful investiga- tion, preferably in an insti tution where accurate temperature records can be obtained.

I t must be noted that in this connection h~emoptysis does not mean " streaking " or " staining " of the sputum, but denotes the coughing up of bright blood in an amount of not less than a teaspoonful.

The value of the X-ray examination is still far from being assessed at its true importance.

I have never yet seen an undoubted case of pulmonary tuberculosis wi th bacilli in the sputum which failed to show quite definite lesions radio- graphically, and I hold that every department dealing with diseases of the chest should have adequate radiological facilities.

Were it not that it is so frequently neglected it would be unnecessary to emphasise the necessity of repeated examinations of the sputum in all doubtful cases.

In my experience every patient with lesions in the lung, excluding cases of miliary tuberculosis, coughs up bacilliferous sputum in periods of activity. During intervals of quiescence of whatever duration, it may prove very difficul~ or impossible to demonstrate bacilli ia the expectoration.

La te notification of " lung " cases has already been mentioned, but the position is much worse in respect of non-pulmonary tuberculosis, for something like 40 per cent. of the cases were not reported before death. This is probably due to the fact that the facilities provided by the municipality for the t reatment of these cases are not nearly so compre- hensive as for the lung cases, but when the large and well-equipped Poor Law hospitals come under the control of the Local Authority next year it is hoped that a complete scheme of t reatment of all cases will be possible.

PREVENTION.

This is a very large subiect , and I can only deal with it briefly. We know tha t infection is almost universal in urban communities, but much can be done to prevent the outbreak of active or actual disease by improving the general standard of health of the working classes.

:By means of earlier diagnosis and the "speeding u p " of notification we are getting a firmer hold on the situation.

:By increased t rea tment of the less advanced cases in sanatoriums and the more advanced cases in hospitals we are enabling our patients to learn and put into practice a right and proper method of living. At the same t ime each admission to an institution means the removal of a grave source

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552 TUBERCLE [September, 1929

of danger to young children, and also saves the impoverished family from squandering its financial and physical resources on the nursing of the invalid.

Overcrowding is gradually being overcome, and industrial conditions, which presumably account for the excess of male over female deaths, are being improved all round.

The milk supply is purer and the public is surely taking an increasing interest in the general principles of heal thy living and dietetics, and we all hope that better times and better wages for all will come in the near future.

The portents are good, and we have reason to expect further success in the campaign against tuberculosis.

In conclusion, I would just like to add that a great responsibili ty rests upon all of us, the members of the tuberculosis service. I have emphasised the importance of some standards of diagnosis-- i t is our duty to see that the public funds devoted to the t rea tment of tuberculosis are not dissipated upon individuals who are not suffering from the disease.

ANTI-TU:BEI~CULOSIS P R O P A G A N D A .

By FREDERICK I~EAF, M.D.

Medical Superintendent of the Warwickshire King Edward VIL ,~[emorial Sanator~iu~l, Hertford Hill, ~zea.r Warwick.

AT the Meeting of the Tuberculosis Association held last January , Dr. Brand read an able paper on " The Educat ion of the Public in the Prevent ion of Tuberculosis." The ideas put forth in that paper gave much food for thought, which was reflected in the discussion which followed. Many who were privileged to hear Dr. :Brand's views on this important subject must have been st imulated to consider the problem in more detail. I therefore make no apology in presentin~ the following views which have occurred to me, but ra ther hope that others will give their opinions so that all may benefit by free criticism and discussion.

The aim of propaganda is to proclaim and spread amongst the public certain facts and precepts which will guide and induce them to act in such a manner as to effect a definite result in accordance with the plan of the propagandist. In the particular case under discussion, this plan is to reduce the incidence and ult imately to eliminate the disease known as tuberculosis. But before discussing methods of propaganda let u s consider the field of action, and the forces at our disposal.

:Firstly, we have the public, particularly the labouring and artisan classes, constituting the material upon which the energies of the public health services must act for the benefit of the country. These masses of people have one or two general characteristics which are most important to the health propagandist. :Firstly they invariably place pleasure and comfort before health; secondly they have a great dislike for intellectual