- Email: [email protected]
Post-war prospects in tuberculosis
PUBLIC HEALTH, November, 1945 with a director loaned b y the M e d i c a l R e s e a r c h C o u n c i l to t h e Welleome Foundation, Ltd. T h e m e t h o d of m a n u f a c t u r e r e q u i r e d t h e use of large n u m b e r s of cotton-rats. T h e y are i h d i g e n o u s in t h e s o u t h e r n states o f N o r t h A m e r i c a (Louisiana, etc.), a n d in o r d e r to establish b r e e d i n g colonies in tiffs c o u n t r y a n d get sufficient animals for t h e p r o d u c t i o n of t h e first b a t c h e s of vaccine cotton-rats h a d to b e o b t a i n e d f r o m t h e U n i t e d States. W e e k l y s h i p m e n t s of a n i m a l s w e r e sent b y air across t h e A t l a n t i c in specially h e a t e d aircraft, these c o n s i g n m e n t s h a v i n g t h e h i g h e s t priority. T h e rats o n arrival in this c o u n t r y w e r e b r o u g h t d o w n i m m e d i a t e l y to Sussex, s o m e t i m e s b y air b u t in m o s t cases by Service t r a n s p o r t . I n o r d e r to p r o v i d e p e r s o n n e l for t h e a n i m a l h o u s e s a n d l a b o r a t o r y work, A . T . S . a n d R . A . M . C . workers w e r e selected a n d t r a i n e d in t h e work w h i c h t h e y h a d to carry out. Scientific officers were r e c r u i t e d f r o m t h e R . A . M . C . a n d scientific b o d i e s in this c o u n t r y . I n v i e w of t h e h i g h risk to w h i c h all p e r s o n n e l w o u l d b e exposed in t h e p r e p a r a t i o n of s c r u b t y p h u s v a c c i n e , g r e a t p r e c a u t i o n s w e r e t a k e n to r e d u c e t h i s risk to a m i n i m u m . Special e q u i p m e n t w a s d e s i g n e d a n d built, i n c o r p o r a t i n g n e w p r i n c i p l e s o f air sterilisation. I n addition, all engaged o n t h e work w e r e i m m u n i s e d a n d strict control was exercised o v e r t h e disposal of i n f e c t e d material. As a result of t h e c o - o r d i n a t i o n o f all c o n c e r n e d it has b e e n f o u n d possible to p r e p a r e 100,000 doses of t h e vaccine for s h i p m e n t to t h e F a r East at t h e t i m e r e q u i r e d b y t h e A r m y authorities.
The Wellcome Foundation announce that they have appointed Dr. E. Ashworth Underwood as Director of the Wellcome Historical Medical Museum and the Wellcome Historical Medical Library, and that he will take up his new duties as soon as he can be released from his present post of Medical Officer of Health and Chief School Medical Officer of the County Borough of West Ham. Dr. Underwood has held his present post for the past eight years. Before that he had been Medical Officer of Health of the Metropolitan Borough of Shoreditch, Deputy Medical Officer of Health of the City of Leeds, and Lecturer in Public Health in Leeds University. In this field he has written widely on tuberculosis, on epidemiology, and allied subjects. Dr. Underwood is well known for his activities in the sphere of the History of Medicine. During the past five years he has been Hon. Secretary of the History of Medicine Section of the Royal Society of Medicine. He has contributed to the Proceedings of that Society, and to other journals, studies on the history of certain infectious diseases, on the medical importance of Lavoisier and the French chemists, on the earlier anatomists and on other subjects. He has for some time been collaborating with Prof. Charles Singer in work on Vesalins. The Government Of Northern Ireland has introduced a Bill providing for financial assistance to local authorities or statutory water undertakings in connection with water supply or sewerage schemes. It places upon local authorities the duty of providing a supply of water for domestic purposes in all parts of their districts, and enables them to make water supplies available for non-domestic purposes. The Bill also seeks to ensure that new houses and existing occupied houses are provided with an adequate water supply, The Ministry of Health and Local Government is given certain powers in the event of default by a local authority or statutory water undertaking in carrying out its duties. T h a t Ministry is also empowered to vary by order the district of supply of a local authority or statutory water undertaking, and also to authorise a statntory water undertaking to construct or acquire and maintain waterworks and ancillary works, or to borrow money for capital expenditure. The Bill also places a statutory water undertaking in the same position as a sanitary authority in regard to the compulsory acquisition of land, by applying the machinery of the Local Government Act (Northern Ireland), 1934, for that purpose. The Ulster Housing Trust, which was set up by the Government in February, 1945, to tackle the serious housing problem, now has plans under which orders could be placed next summer for upwards of 4,000 dwellings. Since its appointment, the Trust has procured sites for over 1,800 houses, and in the near future acquisition of land for a further 2,500 is expected. Road and site works have begun on three estates capable of accommodating 1,100 houses.
1.5 POST-WAR
PROSPECTS
IN
TUBERCULOSIS
WILLIAMS,M.D., Secretary-General, N A P T
B y HARLEY
I W a l k i n g to t h e city of Cork a pair of tourists e n q u i r e d of a local p e a s a n t w h a t distance t h e y still h a d to cover, a n d t h e reply w a s : " N i n e miles." A few miles f u r t h e r o n towards t h e i r objective t h e v~alkers asked a second local w o r t h y h o w far t h e y were f r o m t h e city, a n d received t h e same ~eassuring " a b o u t n i n e m i l e s . " Feeling weary a n d impatient, it so h a p p e n e d t h a t t h e y p u t t h e identical q u e s t i o n to a t h i r d w a y f a r e r still some w a y on, a n d were confidently a n s w e r e d " a b o u t n i n e m i l e s . " " V ~ l l , " said o n e walker to his fOotsore c o m p a n i o n , " w e ' r e h o l d i n g o u r o w n . " Similar feelings o c c u r to t h e s t u d e n t of t u b e r c u l o s i s as h e c o n t e m p l a t e s the p r e s e n t stage r e a c h e d in o u r campaign, c o m p a r e d w i t h o u r u l t i m a t e objective, a n d also w i t h t h e situation in 1939. Feelings are m i x e d . A t m o m e n t s , s o m e t h i n g of t h e m e n t a l d e p r e s s i o n characteristic of this disease steals o v e r e v e r y o n e c o n c e r n e d w i t h it as, a l t h o u g h h i m s e l f mercifully free f r o m tuberculosis, h e takes o n t e m p o r a r i l y t h e fatigued outlook o f o n e o f his patients. Y e t looking squarely at o u r a n t i - t u b e r c u l o s i s work we h a v e reasons for solid satisfaction. T h e a c h i e v e m e n t s of t h e past few years h a v e b e e n , in t h e i r limited sphere, as r e m a r k a b l e as t h e n a t i o n a l resistance to t h e e n e m i e s a r o u n d o u r coasts. T h e t u b e r c u l o s i s f r o n t has b e e n m a i n t a i n e d . W e h a v e m o r e t h a n h e l d o u r own. W e h a v e advanced, as yet w i t h o u t fully realising h o w far. Statistically, t h e w a r - t i m e setback in t h e d e a t h - r a t e is b e i n g overcome,, a n d t h e w a r h a s b r o u g h t into b e i n g two excellent w e a p o n s w h i c h in 1939 were h a r d l y h e a r d of. T h e y are m a s s radiography, a n d t r e a t m e n t allowances. II F o r years t u b e r c u l o s i s physicians h a v e d e p l o r e d t h e fact t h a t t h e i r p a t i e n t s paid t h e i r first visit to t h e d i s p e n s a r y whe~a t h e disease was often in its last stage. W e h a v e tried to educate t h e p u b l i c t h a t cough, loss of weight, etc., are d a n g e r signals, p r o m p t i n g an e x a m i n a t i o n of the chest. N o w in mass radiograph)" w e h a v e t h e c h a n c e of picking o u t of t h e great haystack of t h e n o r m a l t h e s e few needles of early, a n d often symptomless, cases. F o r long we h a v e asked p a t i e n t s to come early, a n d n o w t h e y c o m e before we are ready, before t h e r e are b e d s e n o u g h to treat t h e m all. T h i s great revolution in p r e v e n t i v e m e d i c i n e has revealed t h e reality b e h i n d t h o s e t u b e r c u l i n - p o s i t i v e i n d i v i d u a l s w h o show n o physical signs of disease, a n d are n o t conscious of feeling ill, yet w h o are in t h e first stages of t h e i r conflict w i t h K o c h ' s bacillus a n d its toxins. M a n y of t h e m require n o t r e a t m e n t b u t clinical expectancy, a n d it is o b v i o u s t h a t a v e r y p o w e r f u l m e t h o d of case-finding has c o m e into o u r h a n d s . T h e p u b l i c has s h o w n m o r e e n t h u s i a s m for m a s s radiogral3hy t h a n m a n y m e m b e r s o f t h e m e d i c a l profession. T h e m a n in t h e s t r e e t exaggerates t h e c e r t i t u d e of x - r a y diagnosis, a n d u n d e r estimates t h e p o w e r of o t h e r m e t h o d s w h i c h t h e clinician uses. H e also fails to realise t h a t o n e m a s s r a d i o g r a p h y u n i t c a n n o t h a n d l e m o r e t h a n 50,000 people a year, a n d t h a t t h e s u p p l y of b o t h m e n a n d m a c h i n e s for this p u r p o s e is still very limited. T h e r e is n o d o u b t , however, t h a t large n u m b e r s of p o t e n t i a l p a t i e n t s are n o w as keen to s t a n d before t h e mass r a d i o g r a p h y screen as t h e y w o u l d b e opposed to a p r e c a u t i o n a r y visit to t h e t u b e r c u l o s i s officer. T h e only ones w h o s h r i n k f r o m mass r a d i o g r a p h y are those w i t h s y m p t o m s , or suspicions, or past history, b u t these i n d i v i d u a l s we h o p e will b e picked u p a n d c o m e to t h e d i s p e n s a r y in o t h e r ways. T h e a m o u n t of tuberculosis revealed b y mass r a d i o g r a p h y is a b o u t w h a t w a s expected. T e n i n d i v i d u a l s o u t of every original t h o u s a n d h a v e to b e r e - e x a m i n e d , a n d a b o u t h a l f of t h e m n e e d active t r e a t m e n t . M a s s r a d i o g r a p h y has given u s n e w u n d e r s t a n d ing o f t h e p r i m a r y f o r m of tuberculosis, a n d in t h e e n d will create a fresh p a t h o l o g y of t h e living chest. III I n a social disease like this, e v e n early diagnosis is n o t the only t h i n g we require a n d a second t i m e w a r has p r o d u c e d t h e
16 miracle. English administrative procedure moves crabwise to its objective. I n a L a t i n country, once it has been decided to provide relief to help the tuberculous, a law m i g h t be passed declaring that every such patient was forthwith entitled to so m u c h of a pension. Probably in practice only a fraction would ever receive the pension, owing to various slips between the administrative cup and the patient's thirsty lips, b u t the theory would be established that a tuberculous patient possessed certain rights. In Britain we m o v e more soberly, and towards a m o r e limited objective. I n this country the theory is that the present treatment allowances are not m e a n t to benefit the patient. Oh, n o ! T r e a t m e n t allowances are intended to aid the national effort by getting the tuberculous person back to work as soon as nossible. T h e allowance is social, not personal in aim. I n principle they are not doles or pensions ; they are part of treatment. Yet o u t of this indirect legal conception a m o s t useful scheme of social welfare has evolved. A t present, 50% w o u l d be an overgenerous estimate of the n u m b e r of patients w h o actually draw treatment allowances. A n d unfortunately the exclusion of " chronic " and n o n - p u l m o n a r y patients has been required by legislative expediency. Different tuberculosis officers may take different views of w h e t h e r an individual patient is qualified for the allowance by his inherent chances of recovery. Nevertheless, the treatment allowances have m a d e medical history as the first attempt to replace wages in order that the victims of a chronic disease inay be induced to complete their treatment, and no one doubts that the whole system will be overhauled and amplified w h e n the Ministry of National Insurance begins its gigantic operations. T o carry out the ideas behind Circular 2 6 6 / T m a n y authorities have appointed almoners, and in the long run this m a y turn out to be the most valuable part of that much-discussed by-proddct of the E m e r g e n c y Powers Act. IV W h e n we examine the treatment of p u l m o n a r y tuberculosis we face the extraordinary fact that, on the one hand, it has become m o r e refined and exact, and, on the other, treatment is m u c h m o r e difficult to get owing to a cause which few people would have foreseen seven years ago. Clinical methods have extended beyond recognition; yet there are not nurses enough to provide the fundamental necessities of bed care. W h e n we probe into the shortage of sanatorium nurses we find things are not entirely w h a t they seem on the surface. T h e shortage of nurses turns out to be in part a deficiency of domestics. W h e n we look further into the shortage both of nurses and domestics it becomes a lack of living accommodation. Nurses' quarters are invariably too small. N o new sanatorium building ever seems to be planned with an eye to inevitable increases of staff. So we have a vicious chain of circumstances. Beds are d o s e d d o w n because poor living conditions cannot be greatly i m p r o v e d until nurses' homes are rebuilt and enlarged. Meanwhile labour is needed to build houses so that tuberculous patients m a y not require so many sanatorium beds. O u r sanatorium treatment, which is now more than ever the best chance of cure open to tuberculous patients, has become a chance which only a minority can obtain, and that only after an undesirably long wait before admission. V But the majority of tuberculous people live at h o m e and not in sanatoria. W e are in danger of forgetting that for the average case sanatorium care can only be one episode in the long drama of progress towards arrest, and this winter the housing shortage will be even m o r e trying than the bed shortage. T h e supervision of the tuberculosis officer and family doctor will be the m e t h o d of necessity this w i n t e r for a great n u m b e r of patients, rich and poor, even t h o u g h they may be on waiting lists for sanatorium admission. E v e n m o r e responsibility will fall on the tuberculosis officer. H e a l t h visitors wilt have extra opportunities to practise the gospel of preventive medicine ; care of contacts, h o m e disinfection, domestic hygiene, will be of more tangible benefit for the patient than the uncertain prospect that he may go into a sanatorium later
PUBLIC HEALTH, November, 1945 on. I f we were in any danger of forgetting that prolonged rest and care u n d e r congenial surroundings are fundamental, and that surgery to close a lung cavity is only one part o f treatment, this i m m e d i a t e post-war period will remind us. H o m e care of tuberculous patients will be complicated by the new rights w h i c h they have u n d e r the Disabled Persons ( E m p l o y m e n t ) Act. It is astonishing what wide opportunities of re-training are now open to them. A tuberculous patient has the choice of a large n u m b e r of courses of all kinds, and the ingenious and determined ones m a y turn the m o n o t o n y of illness to their own advantage. L a t e r on workshops and factories will cater for the m o r e seriously disabled patients (e.g., sputum-positive), and w h e n c o m b i n e d with the " N i g h t Sanatorium " they will help the patient less well endowed with education and initiative. W h i c h patients can benefit f r o m re-training, and how m u c h work can they do ? T h e doctor's responsibility here is to use his clinical j u d g m e n t to replace the non-existent science of psychophysical adaptation to work. So far, we have no means of measuring accurately what reserve of energy a patient has, and how far he is likely to be able to stand a six-hour, or even a f o u r - h o u r working day. T h i s new knowledge of reablement will be a fascinating field for the tuberculosis physician, w h o can now call on the D.R.O. (Disablement and Rehabilitation Officer) of the Local E m p l o y m e n t Exchange to help h i m in finding the right job for each patient. L a t e r on, the D.R.O. will be able to use the quota system as a lever to get tuberculous patients into the larger industries, where there are jobs enough for t h e m once the first resistance has been broken down. It seems as though we have now reached the conception of a tuberculous m a n as m e r e l y a normal m a n so m u c h p e r cent. disabled and, once the acute stage of his disease is over, capable of being fitted back into a working life. W h a t a difference from the older idea of necessary m o n t h s and years of enforced idleness! T h e whole success of this new industrial reablement will depend on placing the patient at the right work. T h e r e is room for personal flair. S o m e tuberculosis officers have great success in placing their patients, and it is always a good thing to handle the individual as though he were the only man in the world suffering from tuberculosis. If a man is bent on becoming a cinema operator it is no use sending h i m on a practical course in watch repairing. A p r e d e t e r m i n e d artist will not be h a p p y if required to learn horticulture. T h e T . O . and health visitor are used to this kind of problem, and the n e w opportunities they have o f helping their dispensary patients will be a w e l c o m e stimulus in the routine of their average day. VI T h e further post-war prospects in tuberculosis are good. W e can look forward to the m o m e n t w h e n i t w i l l be possible to offer every patient the right kind of medical treatment and social care, but how far.this can be achieved in practice will depend a good deal on whether the n e w ideas take root in people's imagination. All these changes and developments have to be explained to tuberculous patients and their friends. W e have to show t h e m how the war has changed o u r outlook on tuberculosis. T h e war has shown b o t h the p o w e r and the i m p o t e n c e of propaganda. It is best used to p u t over into practice ideas w h i c h are already latent in people's imagination. But propaganda has to keep in relation to popular ideas and contemporary tastes. T h e N A P T has carried on health education for 45 years, and since the war its methods have evolved in a satisfactory way. T h e technique of this health educational work is based nowadays, m u c h more than formerly, upon knowledge of what people are thinking. Propaganda in the old days was a matter of generalities and platitudes such as " keep y o u r windows o p e n . " T o - d a y it is m o r e personal and realistic. T h e old leaflets and cinema films which seemed quite adequate in 1939 appear very feeble to-day compared with w h a t has replaced them. M e m b e r s h i p - - w h i c h represents the n u m b e r of those w h o are willing to pay a small fee for being kept in touch with the latest d e v e l o p m e n t s - - h a s quintupled. T h e r e is an immense latent anxiety about tuberculosis, and
PUBLIC HEALTH, November, 1945
17
the task of propaganda is to harness this and make it produce action--both personal a n d communal. Anti-tuberculosis propaganda should be based on a twoway traffic of ideas. It helpe the public, and it should teach something to the authorities and their officers. Letters from every type of tuberculous patient reveal that anti-tuberculosis measures fail to give confidence to a large number of people who come up against the realities of the situation by personal experience. These letters show that for one reason and another people are still not able to make full use of the manysided powers which exist to treat the tuberculous and give them hope for the future. I believe that health authorities can make it easier for their patients and their own staff by adapting their policy and bringing the tuberculosis service nearer the patient. T h e efficiency of case-finding can be immensely improved if it is properly explained to people and their co-operation invited. VII Never in 25 years has the anti-tuberculosis front been so lively or so interesting as to-day. T h e war has accelerated progress, and if we were given a few thousand sanatorium beds and some new homes for our patients the pioneer work of the past would yield more rapid results. To-morrow, some new compound of benzene rings and hydrogen ions may be able to seal off the tubercles ; the juice of a fungus or extract of some insignificant mould m a y paralyse the tubercle bacillus, toxins and all. But even such spectacular achievements would not lessen the need for prompt diagnosis and patient after-care. In the control of tuberculosis we still need energy and forethought : big ideas rather than big institutions : m o r e leadership and less " administration."
TEETH
AND
THE
SCHOOL
DOCTOR
~
By E. H. WILKINS, M.B., D.P.H.,
Assistant School Medical Officer, Birmingham Unless school doctors take careful notice of the teeth, gums, and jaws we cannot claim to make a true assessment of the health and physical condition of the child as a whole. And unless we show concern about these organs and give advice as to the treatment they need and about how to keep them healthy, the present appalling neglect and abuse of the teeth is likely to continue or get worse. Medical duty in this respect is the greater in view of the extremely high incidence of oral defect of one kind or another, to say nothing of its possible long-term relation to disease of other parts. Medical men cannot afford to ignore the teeth simply because they are treated by another profession. School doctors~should keep certain standardised records as a measure of the prevalence of dental disease, and show as much conceru about it as about any other malady. The Temporary Teeth At the age of five plus there should be a routine recording of the T . C . F . or " total caries figure." In official reports we often see statements of the number of children with " sound teeth " or " n o t requiring treatment." Such statements are meaningless as a measure of the incidence of caries, as such categories may include cases with fillings and/or extractions but without actually untreated caries. T h e only figure that tells us anything definite is the total of filled, carious, and extracted teeth for each mouth. T h e average of this per head gives a useful basis for comparison between different groups or between similar groups at different times. T h e proportion of children not requiring treatment is, of course, accidental, depending on the extent and promptness of treatment by the dental service. T o illustrate the value of this T . C . F . - - i n the years 1936-37, in five-year-old elementary school children in my area I found an average of 6.5 defective teeth per head and roughly 6% of children with perfect sets of teeth. I found later that these figures corresponded fairly, closely with the
* Presidential address to Medical Group of the Society.
Birmingham
and
District School
published findings of various school dentists. Dividing these children into two groups of schools--poorer and better-off-and comparing them with a third group of professional class children attending private schools in London, the average T . C . F . s for the three groups of five-year-olds were respectively 6"9, 6.5 and 1.16; and the percentages with complete sets of naturally sound teeth were 5.9, 7.6 and over 70. T h e r e is something in the mode of life of the well-to-do that favours freedom from caries Of the temporary teeth. Lady Mellanby and others have been recording a much better state of the temporaries in five-year-olds during the war years--presumably the result of the admittedly better feeding. My findings in 1944-45, for the same groups of elementary schools as in 1936-37, support this : 2-8 T.C.F. compared with over 6.5 in the earlier investigation, and 34~o of children, compared with 6~o, with all their temporaries naturally sound. Such figures give the school doctor a valuable lever in discussing the cause of dental caries. This T . C . F . in five-yearolds is already showing signs of .being accepted as a standard measure of dental well-being. The Permanent Teeth Because of the transition between the temporary and the permanent dentitions and the varying ages of eruption of individual teeth of the permanent set, a complete total caries count in older children cannot have the same value as that in the five-year-old. T h e condition of the four first permanent molars, however, provides some measure of the tendency to decay of the permanent set. Also, by reason of their time of eruption, their size and position, these molars are functionally the most important teeth in the m o u t h ; and they are very susceptible to decay. A record of their condition can be made at any age, but is specially valuable at, say, 12 or 14 years, when the child will soon be leaving school. T h e progress of decay in these sixth-year molars is well iUustrated in a Scottish investigation of nearly 9,000 children: the proportion of molars that were sound (that is an aggregate of teeth, not children) was 82% at six years and dropped steadily to 20% at 13 years. My findings in Birmingham elementary school children of 12 to 14 years in 1940-41 showed 45% of the aggregate of first permanent molars to be apparently sound. Only 16% of these children had all four molars sound; at the other extreme, 25% of the children had all four molars either carious, filled or extracted. T h e condition of these sixth-year molars at a stated age~-say, 13 plus--provides a valuable measure of the vitality of the second dentition: I suggest that this might become the second accepted measure of dental well-belng. But there are snags in deciding whether a molar one is looking at in a 12- to 14, year-old is really a sixth-year molar, or, on the other hand, whether the sixth-year molar has been extracted at an early age and its place taken by the second molar which has erupted somewhat earlier and moved forward, leaving no appreciable gap. With practice one becomes cute on this question : the doubtful molar may be tipped forward more than usual, or it may be noticed that the bicuspids are slightly spaced backwards; or, again, the gum behind the doubtful molar may appear empty through not containing a second molar "about to erupt. T h e r e are sometimes other diagnostic points. I merely mention this deceptive appearance to put would-be investigators on their guard. I have known even a dentist to be in error in this matter. Particularly deceptive is a mouth with all four first permanent molars extracted at an early age and their plac*es taken symmetrically by the four second molars, with no appreciable gaps. Such a mouth is likely to be recorded as having all four first permanent molars sound, whereas the whole four had really paid the full penalty. These two total caries figures--for the whole temporary set at five, and for the four first permanent molars at, say, 13 or 14 years--enable the school doctor to know something of what is happening in the matter of dental caries in the children under his care. The Gums T h e seriousness of marginal gingivitis in children has been stressed by many dental authorities. As a cause of loss of
The Wellcome Foundation announce that they have appointed Dr. E. Ashworth Underwood as Director of the Wellcome Historical Medical Museum and the Wellcome Historical Medical Library, and that he will take up his new duties as soon as he can be released from his present post of Medical Officer of Health and Chief School Medical Officer of the County Borough of West Ham. Dr. Underwood has held his present post for the past eight years. Before that he had been Medical Officer of Health of the Metropolitan Borough of Shoreditch, Deputy Medical Officer of Health of the City of Leeds, and Lecturer in Public Health in Leeds University. In this field he has written widely on tuberculosis, on epidemiology, and allied subjects. Dr. Underwood is well known for his activities in the sphere of the History of Medicine. During the past five years he has been Hon. Secretary of the History of Medicine Section of the Royal Society of Medicine. He has contributed to the Proceedings of that Society, and to other journals, studies on the history of certain infectious diseases, on the medical importance of Lavoisier and the French chemists, on the earlier anatomists and on other subjects. He has for some time been collaborating with Prof. Charles Singer in work on Vesalins. The Government Of Northern Ireland has introduced a Bill providing for financial assistance to local authorities or statutory water undertakings in connection with water supply or sewerage schemes. It places upon local authorities the duty of providing a supply of water for domestic purposes in all parts of their districts, and enables them to make water supplies available for non-domestic purposes. The Bill also seeks to ensure that new houses and existing occupied houses are provided with an adequate water supply, The Ministry of Health and Local Government is given certain powers in the event of default by a local authority or statutory water undertaking in carrying out its duties. T h a t Ministry is also empowered to vary by order the district of supply of a local authority or statutory water undertaking, and also to authorise a statntory water undertaking to construct or acquire and maintain waterworks and ancillary works, or to borrow money for capital expenditure. The Bill also places a statutory water undertaking in the same position as a sanitary authority in regard to the compulsory acquisition of land, by applying the machinery of the Local Government Act (Northern Ireland), 1934, for that purpose. The Ulster Housing Trust, which was set up by the Government in February, 1945, to tackle the serious housing problem, now has plans under which orders could be placed next summer for upwards of 4,000 dwellings. Since its appointment, the Trust has procured sites for over 1,800 houses, and in the near future acquisition of land for a further 2,500 is expected. Road and site works have begun on three estates capable of accommodating 1,100 houses.
1.5 POST-WAR
PROSPECTS
IN
TUBERCULOSIS
WILLIAMS,M.D., Secretary-General, N A P T
B y HARLEY
I W a l k i n g to t h e city of Cork a pair of tourists e n q u i r e d of a local p e a s a n t w h a t distance t h e y still h a d to cover, a n d t h e reply w a s : " N i n e miles." A few miles f u r t h e r o n towards t h e i r objective t h e v~alkers asked a second local w o r t h y h o w far t h e y were f r o m t h e city, a n d received t h e same ~eassuring " a b o u t n i n e m i l e s . " Feeling weary a n d impatient, it so h a p p e n e d t h a t t h e y p u t t h e identical q u e s t i o n to a t h i r d w a y f a r e r still some w a y on, a n d were confidently a n s w e r e d " a b o u t n i n e m i l e s . " " V ~ l l , " said o n e walker to his fOotsore c o m p a n i o n , " w e ' r e h o l d i n g o u r o w n . " Similar feelings o c c u r to t h e s t u d e n t of t u b e r c u l o s i s as h e c o n t e m p l a t e s the p r e s e n t stage r e a c h e d in o u r campaign, c o m p a r e d w i t h o u r u l t i m a t e objective, a n d also w i t h t h e situation in 1939. Feelings are m i x e d . A t m o m e n t s , s o m e t h i n g of t h e m e n t a l d e p r e s s i o n characteristic of this disease steals o v e r e v e r y o n e c o n c e r n e d w i t h it as, a l t h o u g h h i m s e l f mercifully free f r o m tuberculosis, h e takes o n t e m p o r a r i l y t h e fatigued outlook o f o n e o f his patients. Y e t looking squarely at o u r a n t i - t u b e r c u l o s i s work we h a v e reasons for solid satisfaction. T h e a c h i e v e m e n t s of t h e past few years h a v e b e e n , in t h e i r limited sphere, as r e m a r k a b l e as t h e n a t i o n a l resistance to t h e e n e m i e s a r o u n d o u r coasts. T h e t u b e r c u l o s i s f r o n t has b e e n m a i n t a i n e d . W e h a v e m o r e t h a n h e l d o u r own. W e h a v e advanced, as yet w i t h o u t fully realising h o w far. Statistically, t h e w a r - t i m e setback in t h e d e a t h - r a t e is b e i n g overcome,, a n d t h e w a r h a s b r o u g h t into b e i n g two excellent w e a p o n s w h i c h in 1939 were h a r d l y h e a r d of. T h e y are m a s s radiography, a n d t r e a t m e n t allowances. II F o r years t u b e r c u l o s i s physicians h a v e d e p l o r e d t h e fact t h a t t h e i r p a t i e n t s paid t h e i r first visit to t h e d i s p e n s a r y whe~a t h e disease was often in its last stage. W e h a v e tried to educate t h e p u b l i c t h a t cough, loss of weight, etc., are d a n g e r signals, p r o m p t i n g an e x a m i n a t i o n of the chest. N o w in mass radiograph)" w e h a v e t h e c h a n c e of picking o u t of t h e great haystack of t h e n o r m a l t h e s e few needles of early, a n d often symptomless, cases. F o r long we h a v e asked p a t i e n t s to come early, a n d n o w t h e y c o m e before we are ready, before t h e r e are b e d s e n o u g h to treat t h e m all. T h i s great revolution in p r e v e n t i v e m e d i c i n e has revealed t h e reality b e h i n d t h o s e t u b e r c u l i n - p o s i t i v e i n d i v i d u a l s w h o show n o physical signs of disease, a n d are n o t conscious of feeling ill, yet w h o are in t h e first stages of t h e i r conflict w i t h K o c h ' s bacillus a n d its toxins. M a n y of t h e m require n o t r e a t m e n t b u t clinical expectancy, a n d it is o b v i o u s t h a t a v e r y p o w e r f u l m e t h o d of case-finding has c o m e into o u r h a n d s . T h e p u b l i c has s h o w n m o r e e n t h u s i a s m for m a s s radiogral3hy t h a n m a n y m e m b e r s o f t h e m e d i c a l profession. T h e m a n in t h e s t r e e t exaggerates t h e c e r t i t u d e of x - r a y diagnosis, a n d u n d e r estimates t h e p o w e r of o t h e r m e t h o d s w h i c h t h e clinician uses. H e also fails to realise t h a t o n e m a s s r a d i o g r a p h y u n i t c a n n o t h a n d l e m o r e t h a n 50,000 people a year, a n d t h a t t h e s u p p l y of b o t h m e n a n d m a c h i n e s for this p u r p o s e is still very limited. T h e r e is n o d o u b t , however, t h a t large n u m b e r s of p o t e n t i a l p a t i e n t s are n o w as keen to s t a n d before t h e mass r a d i o g r a p h y screen as t h e y w o u l d b e opposed to a p r e c a u t i o n a r y visit to t h e t u b e r c u l o s i s officer. T h e only ones w h o s h r i n k f r o m mass r a d i o g r a p h y are those w i t h s y m p t o m s , or suspicions, or past history, b u t these i n d i v i d u a l s we h o p e will b e picked u p a n d c o m e to t h e d i s p e n s a r y in o t h e r ways. T h e a m o u n t of tuberculosis revealed b y mass r a d i o g r a p h y is a b o u t w h a t w a s expected. T e n i n d i v i d u a l s o u t of every original t h o u s a n d h a v e to b e r e - e x a m i n e d , a n d a b o u t h a l f of t h e m n e e d active t r e a t m e n t . M a s s r a d i o g r a p h y has given u s n e w u n d e r s t a n d ing o f t h e p r i m a r y f o r m of tuberculosis, a n d in t h e e n d will create a fresh p a t h o l o g y of t h e living chest. III I n a social disease like this, e v e n early diagnosis is n o t the only t h i n g we require a n d a second t i m e w a r has p r o d u c e d t h e
16 miracle. English administrative procedure moves crabwise to its objective. I n a L a t i n country, once it has been decided to provide relief to help the tuberculous, a law m i g h t be passed declaring that every such patient was forthwith entitled to so m u c h of a pension. Probably in practice only a fraction would ever receive the pension, owing to various slips between the administrative cup and the patient's thirsty lips, b u t the theory would be established that a tuberculous patient possessed certain rights. In Britain we m o v e more soberly, and towards a m o r e limited objective. I n this country the theory is that the present treatment allowances are not m e a n t to benefit the patient. Oh, n o ! T r e a t m e n t allowances are intended to aid the national effort by getting the tuberculous person back to work as soon as nossible. T h e allowance is social, not personal in aim. I n principle they are not doles or pensions ; they are part of treatment. Yet o u t of this indirect legal conception a m o s t useful scheme of social welfare has evolved. A t present, 50% w o u l d be an overgenerous estimate of the n u m b e r of patients w h o actually draw treatment allowances. A n d unfortunately the exclusion of " chronic " and n o n - p u l m o n a r y patients has been required by legislative expediency. Different tuberculosis officers may take different views of w h e t h e r an individual patient is qualified for the allowance by his inherent chances of recovery. Nevertheless, the treatment allowances have m a d e medical history as the first attempt to replace wages in order that the victims of a chronic disease inay be induced to complete their treatment, and no one doubts that the whole system will be overhauled and amplified w h e n the Ministry of National Insurance begins its gigantic operations. T o carry out the ideas behind Circular 2 6 6 / T m a n y authorities have appointed almoners, and in the long run this m a y turn out to be the most valuable part of that much-discussed by-proddct of the E m e r g e n c y Powers Act. IV W h e n we examine the treatment of p u l m o n a r y tuberculosis we face the extraordinary fact that, on the one hand, it has become m o r e refined and exact, and, on the other, treatment is m u c h m o r e difficult to get owing to a cause which few people would have foreseen seven years ago. Clinical methods have extended beyond recognition; yet there are not nurses enough to provide the fundamental necessities of bed care. W h e n we probe into the shortage of sanatorium nurses we find things are not entirely w h a t they seem on the surface. T h e shortage of nurses turns out to be in part a deficiency of domestics. W h e n we look further into the shortage both of nurses and domestics it becomes a lack of living accommodation. Nurses' quarters are invariably too small. N o new sanatorium building ever seems to be planned with an eye to inevitable increases of staff. So we have a vicious chain of circumstances. Beds are d o s e d d o w n because poor living conditions cannot be greatly i m p r o v e d until nurses' homes are rebuilt and enlarged. Meanwhile labour is needed to build houses so that tuberculous patients m a y not require so many sanatorium beds. O u r sanatorium treatment, which is now more than ever the best chance of cure open to tuberculous patients, has become a chance which only a minority can obtain, and that only after an undesirably long wait before admission. V But the majority of tuberculous people live at h o m e and not in sanatoria. W e are in danger of forgetting that for the average case sanatorium care can only be one episode in the long drama of progress towards arrest, and this winter the housing shortage will be even m o r e trying than the bed shortage. T h e supervision of the tuberculosis officer and family doctor will be the m e t h o d of necessity this w i n t e r for a great n u m b e r of patients, rich and poor, even t h o u g h they may be on waiting lists for sanatorium admission. E v e n m o r e responsibility will fall on the tuberculosis officer. H e a l t h visitors wilt have extra opportunities to practise the gospel of preventive medicine ; care of contacts, h o m e disinfection, domestic hygiene, will be of more tangible benefit for the patient than the uncertain prospect that he may go into a sanatorium later
PUBLIC HEALTH, November, 1945 on. I f we were in any danger of forgetting that prolonged rest and care u n d e r congenial surroundings are fundamental, and that surgery to close a lung cavity is only one part o f treatment, this i m m e d i a t e post-war period will remind us. H o m e care of tuberculous patients will be complicated by the new rights w h i c h they have u n d e r the Disabled Persons ( E m p l o y m e n t ) Act. It is astonishing what wide opportunities of re-training are now open to them. A tuberculous patient has the choice of a large n u m b e r of courses of all kinds, and the ingenious and determined ones m a y turn the m o n o t o n y of illness to their own advantage. L a t e r on workshops and factories will cater for the m o r e seriously disabled patients (e.g., sputum-positive), and w h e n c o m b i n e d with the " N i g h t Sanatorium " they will help the patient less well endowed with education and initiative. W h i c h patients can benefit f r o m re-training, and how m u c h work can they do ? T h e doctor's responsibility here is to use his clinical j u d g m e n t to replace the non-existent science of psychophysical adaptation to work. So far, we have no means of measuring accurately what reserve of energy a patient has, and how far he is likely to be able to stand a six-hour, or even a f o u r - h o u r working day. T h i s new knowledge of reablement will be a fascinating field for the tuberculosis physician, w h o can now call on the D.R.O. (Disablement and Rehabilitation Officer) of the Local E m p l o y m e n t Exchange to help h i m in finding the right job for each patient. L a t e r on, the D.R.O. will be able to use the quota system as a lever to get tuberculous patients into the larger industries, where there are jobs enough for t h e m once the first resistance has been broken down. It seems as though we have now reached the conception of a tuberculous m a n as m e r e l y a normal m a n so m u c h p e r cent. disabled and, once the acute stage of his disease is over, capable of being fitted back into a working life. W h a t a difference from the older idea of necessary m o n t h s and years of enforced idleness! T h e whole success of this new industrial reablement will depend on placing the patient at the right work. T h e r e is room for personal flair. S o m e tuberculosis officers have great success in placing their patients, and it is always a good thing to handle the individual as though he were the only man in the world suffering from tuberculosis. If a man is bent on becoming a cinema operator it is no use sending h i m on a practical course in watch repairing. A p r e d e t e r m i n e d artist will not be h a p p y if required to learn horticulture. T h e T . O . and health visitor are used to this kind of problem, and the n e w opportunities they have o f helping their dispensary patients will be a w e l c o m e stimulus in the routine of their average day. VI T h e further post-war prospects in tuberculosis are good. W e can look forward to the m o m e n t w h e n i t w i l l be possible to offer every patient the right kind of medical treatment and social care, but how far.this can be achieved in practice will depend a good deal on whether the n e w ideas take root in people's imagination. All these changes and developments have to be explained to tuberculous patients and their friends. W e have to show t h e m how the war has changed o u r outlook on tuberculosis. T h e war has shown b o t h the p o w e r and the i m p o t e n c e of propaganda. It is best used to p u t over into practice ideas w h i c h are already latent in people's imagination. But propaganda has to keep in relation to popular ideas and contemporary tastes. T h e N A P T has carried on health education for 45 years, and since the war its methods have evolved in a satisfactory way. T h e technique of this health educational work is based nowadays, m u c h more than formerly, upon knowledge of what people are thinking. Propaganda in the old days was a matter of generalities and platitudes such as " keep y o u r windows o p e n . " T o - d a y it is m o r e personal and realistic. T h e old leaflets and cinema films which seemed quite adequate in 1939 appear very feeble to-day compared with w h a t has replaced them. M e m b e r s h i p - - w h i c h represents the n u m b e r of those w h o are willing to pay a small fee for being kept in touch with the latest d e v e l o p m e n t s - - h a s quintupled. T h e r e is an immense latent anxiety about tuberculosis, and
PUBLIC HEALTH, November, 1945
17
the task of propaganda is to harness this and make it produce action--both personal a n d communal. Anti-tuberculosis propaganda should be based on a twoway traffic of ideas. It helpe the public, and it should teach something to the authorities and their officers. Letters from every type of tuberculous patient reveal that anti-tuberculosis measures fail to give confidence to a large number of people who come up against the realities of the situation by personal experience. These letters show that for one reason and another people are still not able to make full use of the manysided powers which exist to treat the tuberculous and give them hope for the future. I believe that health authorities can make it easier for their patients and their own staff by adapting their policy and bringing the tuberculosis service nearer the patient. T h e efficiency of case-finding can be immensely improved if it is properly explained to people and their co-operation invited. VII Never in 25 years has the anti-tuberculosis front been so lively or so interesting as to-day. T h e war has accelerated progress, and if we were given a few thousand sanatorium beds and some new homes for our patients the pioneer work of the past would yield more rapid results. To-morrow, some new compound of benzene rings and hydrogen ions may be able to seal off the tubercles ; the juice of a fungus or extract of some insignificant mould m a y paralyse the tubercle bacillus, toxins and all. But even such spectacular achievements would not lessen the need for prompt diagnosis and patient after-care. In the control of tuberculosis we still need energy and forethought : big ideas rather than big institutions : m o r e leadership and less " administration."
TEETH
AND
THE
SCHOOL
DOCTOR
~
By E. H. WILKINS, M.B., D.P.H.,
Assistant School Medical Officer, Birmingham Unless school doctors take careful notice of the teeth, gums, and jaws we cannot claim to make a true assessment of the health and physical condition of the child as a whole. And unless we show concern about these organs and give advice as to the treatment they need and about how to keep them healthy, the present appalling neglect and abuse of the teeth is likely to continue or get worse. Medical duty in this respect is the greater in view of the extremely high incidence of oral defect of one kind or another, to say nothing of its possible long-term relation to disease of other parts. Medical men cannot afford to ignore the teeth simply because they are treated by another profession. School doctors~should keep certain standardised records as a measure of the prevalence of dental disease, and show as much conceru about it as about any other malady. The Temporary Teeth At the age of five plus there should be a routine recording of the T . C . F . or " total caries figure." In official reports we often see statements of the number of children with " sound teeth " or " n o t requiring treatment." Such statements are meaningless as a measure of the incidence of caries, as such categories may include cases with fillings and/or extractions but without actually untreated caries. T h e only figure that tells us anything definite is the total of filled, carious, and extracted teeth for each mouth. T h e average of this per head gives a useful basis for comparison between different groups or between similar groups at different times. T h e proportion of children not requiring treatment is, of course, accidental, depending on the extent and promptness of treatment by the dental service. T o illustrate the value of this T . C . F . - - i n the years 1936-37, in five-year-old elementary school children in my area I found an average of 6.5 defective teeth per head and roughly 6% of children with perfect sets of teeth. I found later that these figures corresponded fairly, closely with the
* Presidential address to Medical Group of the Society.
Birmingham
and
District School
published findings of various school dentists. Dividing these children into two groups of schools--poorer and better-off-and comparing them with a third group of professional class children attending private schools in London, the average T . C . F . s for the three groups of five-year-olds were respectively 6"9, 6.5 and 1.16; and the percentages with complete sets of naturally sound teeth were 5.9, 7.6 and over 70. T h e r e is something in the mode of life of the well-to-do that favours freedom from caries Of the temporary teeth. Lady Mellanby and others have been recording a much better state of the temporaries in five-year-olds during the war years--presumably the result of the admittedly better feeding. My findings in 1944-45, for the same groups of elementary schools as in 1936-37, support this : 2-8 T.C.F. compared with over 6.5 in the earlier investigation, and 34~o of children, compared with 6~o, with all their temporaries naturally sound. Such figures give the school doctor a valuable lever in discussing the cause of dental caries. This T . C . F . in five-yearolds is already showing signs of .being accepted as a standard measure of dental well-being. The Permanent Teeth Because of the transition between the temporary and the permanent dentitions and the varying ages of eruption of individual teeth of the permanent set, a complete total caries count in older children cannot have the same value as that in the five-year-old. T h e condition of the four first permanent molars, however, provides some measure of the tendency to decay of the permanent set. Also, by reason of their time of eruption, their size and position, these molars are functionally the most important teeth in the m o u t h ; and they are very susceptible to decay. A record of their condition can be made at any age, but is specially valuable at, say, 12 or 14 years, when the child will soon be leaving school. T h e progress of decay in these sixth-year molars is well iUustrated in a Scottish investigation of nearly 9,000 children: the proportion of molars that were sound (that is an aggregate of teeth, not children) was 82% at six years and dropped steadily to 20% at 13 years. My findings in Birmingham elementary school children of 12 to 14 years in 1940-41 showed 45% of the aggregate of first permanent molars to be apparently sound. Only 16% of these children had all four molars sound; at the other extreme, 25% of the children had all four molars either carious, filled or extracted. T h e condition of these sixth-year molars at a stated age~-say, 13 plus--provides a valuable measure of the vitality of the second dentition: I suggest that this might become the second accepted measure of dental well-belng. But there are snags in deciding whether a molar one is looking at in a 12- to 14, year-old is really a sixth-year molar, or, on the other hand, whether the sixth-year molar has been extracted at an early age and its place taken by the second molar which has erupted somewhat earlier and moved forward, leaving no appreciable gap. With practice one becomes cute on this question : the doubtful molar may be tipped forward more than usual, or it may be noticed that the bicuspids are slightly spaced backwards; or, again, the gum behind the doubtful molar may appear empty through not containing a second molar "about to erupt. T h e r e are sometimes other diagnostic points. I merely mention this deceptive appearance to put would-be investigators on their guard. I have known even a dentist to be in error in this matter. Particularly deceptive is a mouth with all four first permanent molars extracted at an early age and their plac*es taken symmetrically by the four second molars, with no appreciable gaps. Such a mouth is likely to be recorded as having all four first permanent molars sound, whereas the whole four had really paid the full penalty. These two total caries figures--for the whole temporary set at five, and for the four first permanent molars at, say, 13 or 14 years--enable the school doctor to know something of what is happening in the matter of dental caries in the children under his care. The Gums T h e seriousness of marginal gingivitis in children has been stressed by many dental authorities. As a cause of loss of