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Chest diseases in China
OHEST
DlSF.A~ES
IN eRWA
certain diseases, such as emphysema, is elegantly demonstrated by this technique. Moreover, a series of results may have serious prognostic significance jf it shows a general tendency towards a diminution of diffusing capacity. A 'single breath' technique for carrying out the test has also been elaborated and may replace the 'steady-state' method; but the analysis ofthe experimental results is a good deal more complicated and probably the figure arrived at means little more than that obtained from the 'steady-state' method. Other pulmonary function tests are available which analyse in greater detail abnormalities shown up by one or other of these simple tests; but they all require complicated apparatus and skilled technical work and should be reserved for cases in which full investigation is required for purposes other than purely clinical study. The most important is the analysis of the arterial blood gases; for this it is necessary to be able to use the Van Slyke manometric apparatus and measure blood pH. Both of these techniques are difficult and subject to considerable error. They therefore require a degree of expertness which a busy physician has little opportunity to acquire. Nevertheless, this investigation provides the most convincing and absolute proof of the functional efficiency of the whole respiratory system, the function of which is to oxygenate the mixed venous blood. Measurement of the elastic properties of the lungs and of the resistance to gas Row offered by their airways is sometimes helpful in elucidating the mechanism underlying breathlessness; study of intra-oeaophageal pressure changes during breathing gives this information rather precisely, but some of the findings may be inferred, though not measured, by careful consideration of the form of the tracing afforced vital capacity mentioned above. Finally, the importance of clinical observation in analysing the nature of disability from pulmonary disease should need no emphasis; such information often leads to correct diagnosis without the help of the laboratory. Reference.. lKennedy, M. C. S., Thorax, 1953, 8,73. lilates, D. V., KnOll, J. M. S., and Christie, R. V., Quart.
J. u«, N.S.,
1956, illS, 137.
HERE AND THERE CHEST DISEASES IN CHINA A medical research worker is so accustomed to taking every conceivable step to prevent bias creeping into a scientific paper that 11e feels rather unwilling to generalize about the medical care of 600,000,000 people after a visit lasting less than a month to a country whose language he does not understand. In addition, the political situation was at least conducive to bias; and there were no obvious means of avoiding it. However, the facilities put at our disposal by our Chinese hosts, the high percentage of them that spoke English and the excellent service provided by the interpreters justify, I think, a few generalizations, Personal bias is unavoidable. All I can say is that I liked the Chinese very much indeed and disliked many aspects of Communism. It is very important, before dealing with one aspect of the medical services in China, to get the whole medical situation into perspective. The simplest way is to stress the fact that in China there are only about the same number of doctors practising 'Western' medicine as there are in this country. In addition, there are about 500,000 'traditional doctors' who do not practise 'Western' medicine, the value of whose work has never been assessed scientifically, though it undoubtedly has a considerable psychological effect. As a result of this scarcity of doctors trained in
43 0
'rUBERCLE
'Western' methods, the Chinese Government had to make important decisions about priorities, and the general decision seems to have been made to concentrate their best doctors in teaching hospitals in order to keep up the standards of medicine in a few centres and to produce as many adequately trained new doctors as quickly as possible. The standards in the hospitals at such centres as Peking and Shanghai are consequently very high indeed and in most ways comparable with our own ; but as we moved into the provinces they fell ofTsharply and I believe that had we been able to see more centres, particularly in the agricultural areas, they would have been lower still. In addition to this type of priority, decisions have had to be made as to which diseases should be attacked first. My impression was that the main drive for the moment is against the common infectious diseases such as malaria, typhus, typhoid, 'plague and schistosomiasis. Tuberculosis does not seem to be getting very great priority at present, and, considering how serious some of the other problems such as schistosomiasis are, this is understandable.
Tuberculosis The administrative plan [or tuberculosis control is similar to our own, i.e. tuberculosis clinics and hospitals. The idea is to have a tuberculosis clinic for each 'district' (about 300,000 people). The system seemed well developed in Peking and Shanghai and less so in smaller centres. I was unable to investigate the set-up in the countryside but I understood that it was practically undeveloped. My Chinese hosts were kind enough to show me what they described as the best and worst clinics in Peking. The best was very similar to our own in practice, though the setting in an old temple made it appear unusual. They used small films for screening the people coming to the clinic and large films of all those tholLght to be abnormal. Approximately go per cent of those diagnosed as suffering from active tuberculosis received domiciliary treatment which consisted usually of PAS and isoniazid - streptomycin is very scarce in China. The duration of treatment was short by British standards and no figures were available about relapse after treatment. Contact work seemed poorly developed. The worst clinic proved to be small and dark, equipped only for fluoroscopy. It was, however, clean and the staff seemed hardworking and enthusiastic. One of the two MlvIR mobile units in Peking was stationed at the best clinic. Community surveys, I was told, gave a prevalence of 3 - 4 per cent of active tilberculosis requiring treatment. These figures are somewhat lower than those of Gilmour (t947) (quoted by McDougall in Tuberculosis: A Global SllUry in Social Pathology) but are high enough. This was the usual prevalence figure given to me in the various parts of China that I visited. The highest prevalence I found was at a cement factory with I,800 workers in Canton. All the workers there had been x-rayed and a prevalence of 9' 2 per cent of active tuberculosis found; but I thought that this was due to an associated silica risk. Treatment is free for students and members of most trade unions although there is usually some payment for the food in hospital. Agricultural workers, who make up such a large proportion of the population, have to pay for their treatment. BCG is given orally to all newborn children, mainly through the maternity and child welfare clinics. It is also given at the tuberculosis clinic to those of other age groups found to be Mantoux negative. There was an odd difficulty about discovering the number of tuberculosis hospital beds for the population of Peking, arising from the use of the word 'sanatorium' in two senses, one to mean a tuberculosis sanatorium and the other a rest home. For this reason the estimates I got varied from place to place and the final figure of 1,400 beds is possibly rather high. This would mean that for Peking, which has probably more hospital beds than the other parts of China, there were 0'4 hospital beds for tubercu-
GH:EST lJISEASES IN CHINA
losis per T,000 of the pop ulation. The figure for England and Wales is approximately 0·8 per I .ooo, The I' eking Chest Hospital must be one of the best chest hospitals in the world from the point of vlew of buildings, equipment, research facilities and, as far as I could make out, standards of treatment. It is divided into medical and surgical sections which are further divided into tuberculosis and non-tuberculous sections. There is also a complete department of anaesthetics. The hospital is clearly designed to see that there is one centre in the country where the standards are as high or higher than anywhere else in the world; and I felt that they were achieving their aim. It was of interest that the commonest operation in the non-tuberculous section was for carcinoma of the oesophagus. This is much commoner than carcinoma of the lung in the whole of Northern China and presents a very serious problem. The cause of this high carcinoma risk is unknown. It is worth stressing that the death-rate, as far as it is known, for carcinoma of the nasopharynx is also higher than that of carcinoma of the lung. I saw two other tuberculosis sanatoria in the provinces and the standards were much lower. They 'were usually very short of streptomycin and were frequently using isoniazid alone. Pneumoperitoneum was still being used on a relatively large scale and one occasionally saw pneumothoraces. ' Some figures for the tuberculosis death-rate were available in Peking and Shanghai. I was told that the death-rate was now approximately 60 per IOO,OOO but the doctors stated that it was probably an underestimate. On the whole, I think it improbable that the death-rate is as low as this. For instance, in Hong Kong the prevalence rate from surveys is about 2 per cent, definitely lower than in Peking and they still have a death-rate of over 100 per roo,ooo. Yet their chemotherapy is better and their death certification is also probably more accurate than in Peking. I also discussed the treatment of tuberculosis with two 'traditional' Chinese doctors, They stated that they relied chiefly on acupuncture in the fifth dorsal segment but, in addition, gave ox bile by mouth, They believed that this type of therapy was at least as effective as pneumothorax or bed-rest but confessed that they had seen little of the effects of modern chemotherapy. Dust Diseases
Before I left lor my Chinese trip I had heard indirectly from a Chinese doctor in this country that there was no dust disease in China. I was therefore surprised to find that there was a considerable prevalence of many different types of dust disease in most of the areas I visited. In the area around Shengyang, where I visited several mines, I saw a large number of chest films of miners with simple and complicated pneumoconiosis indistinguishable from the types we are so accustomed to see in South Wales, Their investigations so far have been somewhat limited by the shortage of x-ray equipment and x-ray films, and it was impossible to obtain an accurate picture of the prevalence of the condition. My impression, however, was that it was considerably lower than in South Wales. The modern mines I visited were well equipped and steps were already being taken to reduce dust concentrations. Methods of measuring dust were, however, ill-developed. The Chinese attach great importance to ultra-violet radiation of miners after the shift. They claim that this prevents upper respiratory infection; but they had no figures available to substantiate this. In the North I was also shown films of shale workers with x-ray appearances similar to those of coal miners. Unfortunately, it is very difficult to obtain post-mortems at present in China so one cannot be certain how this condition should be classified pathologically - as a silicosis or as a relatively inert pneumoconiosis. In most of the big cities I was shown several cases of classical silicosis. They were chiefly from quartz workers in glass factories. Some had died after less than five years' exposure to the dust. They were working hard to suppress such hazards but are somewhat lacking in technical know-how. I was also told about a tungsten mine and was shown some of the films where there appeared to be a high prevalence of classical
43-2
TUllERCLE
silicosis. In addition, there was the cement factory in Canton with a high prevalence of tuberculosis where there was almost certainly a concealed silicotic risk. In Tientsin I was shown many films from an asbestos factor}' showing the typical appearances of asbestosis. Some had been followed up for several years and it was striking that so far they had found no cases of carcinoma. I was also told in Tientsin that there was a remarkably high absentee rate for bronchitis in the cotton factories and that the absentees chiefly worked in the carding' rooms. It seemed reasonable to conclude that they were probably suffering from byssinosis. China is industrializing rapidly and one must expect a certain amount of pneuma· coniosis, The medical services at present lack experience of the disease and the engineers lack know-how as regards dust measurement and suppression.
OtherChest Diseases The doctors with whom J talked seemed convinced that there was no histoplasmosis or coccidiomycosis in China, and another notable absentee was sarcoidosis. As far as I could make out it had only been diagnosed twice in China, and one of these patients was not Chinese. In discussion I was convinced that this was not due to lack of interest in the condition nor to inability to diagnose it. It does appear to be a true epidemiological difference. It would be discourteous to conclude this article without expressing my gratitude
to all my colleagues in China who treated me 'with such kindliness and talked to me so freely. I sincerely hope that the two-way medical traffic between this country and China, which has sunk to such a low level in recent years, will increase rapidly in the future. A. L. COCHRANE.
JOHN ARCHER'S 'SECRETS DISCLOSED' Old medical books are usually interesting for one of three reasons. Sometimes they are 'classics'; sometimes they are merely representative of their time; but often they only survive because of their curiosity value, rarely emerging from the limbo of catalogues and bibliographies. Such seventeenth century works as Bennet's' Theatrum Tnbidorum' and Morton's 'Phihisiologia' are outstanding in the literary history of 'consumption' . But in addition to these books, which are founded on personal observation and to some extent record pathological findings, several other works were published during the cen tury, Many of these we now regard only as curiosities; but they have some value, for they are examples of a common form of medical writing against which the more enduring achievements of the few can be judged. One such book, written by a man very different from Bennet or Morton, was the 'Secrets Disclosed, of Consumptions, Slwwing How to Prevent and Cure the Fistula by Chymical Drops, without Cutting; Also Piles, Haemorrhoids, arid other DISEASES, By John Archer Author of the Book called Every Man his own Doctor; to be Sold by the Booksellers, and also to be had/rom the Authors House at Knightsbridge, or at the Saddlers against the Mews by Charingcross, London, r 684, Printedfor the Author.' Littlebiographical information is recorded about Archer, most of what we know about him being derived from internal evidence of his works. Payne (188S) summarizes this information, and tells us that Archer was possibly an Irishman as he was in practice at Dublin about 1660. The first edition of his 'Every Man his own Doctor' was published at London in 1671. A second edition (,Compleated with an Herbal') appeared in 1673 bearing a portrait of the author, and his '11 Compendious Herbal' was published in the same year. From an examination of his works it is clear that Archer was a fair example of the advertising quack, a type that abounded in
DlSF.A~ES
IN eRWA
certain diseases, such as emphysema, is elegantly demonstrated by this technique. Moreover, a series of results may have serious prognostic significance jf it shows a general tendency towards a diminution of diffusing capacity. A 'single breath' technique for carrying out the test has also been elaborated and may replace the 'steady-state' method; but the analysis ofthe experimental results is a good deal more complicated and probably the figure arrived at means little more than that obtained from the 'steady-state' method. Other pulmonary function tests are available which analyse in greater detail abnormalities shown up by one or other of these simple tests; but they all require complicated apparatus and skilled technical work and should be reserved for cases in which full investigation is required for purposes other than purely clinical study. The most important is the analysis of the arterial blood gases; for this it is necessary to be able to use the Van Slyke manometric apparatus and measure blood pH. Both of these techniques are difficult and subject to considerable error. They therefore require a degree of expertness which a busy physician has little opportunity to acquire. Nevertheless, this investigation provides the most convincing and absolute proof of the functional efficiency of the whole respiratory system, the function of which is to oxygenate the mixed venous blood. Measurement of the elastic properties of the lungs and of the resistance to gas Row offered by their airways is sometimes helpful in elucidating the mechanism underlying breathlessness; study of intra-oeaophageal pressure changes during breathing gives this information rather precisely, but some of the findings may be inferred, though not measured, by careful consideration of the form of the tracing afforced vital capacity mentioned above. Finally, the importance of clinical observation in analysing the nature of disability from pulmonary disease should need no emphasis; such information often leads to correct diagnosis without the help of the laboratory. Reference.. lKennedy, M. C. S., Thorax, 1953, 8,73. lilates, D. V., KnOll, J. M. S., and Christie, R. V., Quart.
J. u«, N.S.,
1956, illS, 137.
HERE AND THERE CHEST DISEASES IN CHINA A medical research worker is so accustomed to taking every conceivable step to prevent bias creeping into a scientific paper that 11e feels rather unwilling to generalize about the medical care of 600,000,000 people after a visit lasting less than a month to a country whose language he does not understand. In addition, the political situation was at least conducive to bias; and there were no obvious means of avoiding it. However, the facilities put at our disposal by our Chinese hosts, the high percentage of them that spoke English and the excellent service provided by the interpreters justify, I think, a few generalizations, Personal bias is unavoidable. All I can say is that I liked the Chinese very much indeed and disliked many aspects of Communism. It is very important, before dealing with one aspect of the medical services in China, to get the whole medical situation into perspective. The simplest way is to stress the fact that in China there are only about the same number of doctors practising 'Western' medicine as there are in this country. In addition, there are about 500,000 'traditional doctors' who do not practise 'Western' medicine, the value of whose work has never been assessed scientifically, though it undoubtedly has a considerable psychological effect. As a result of this scarcity of doctors trained in
43 0
'rUBERCLE
'Western' methods, the Chinese Government had to make important decisions about priorities, and the general decision seems to have been made to concentrate their best doctors in teaching hospitals in order to keep up the standards of medicine in a few centres and to produce as many adequately trained new doctors as quickly as possible. The standards in the hospitals at such centres as Peking and Shanghai are consequently very high indeed and in most ways comparable with our own ; but as we moved into the provinces they fell ofTsharply and I believe that had we been able to see more centres, particularly in the agricultural areas, they would have been lower still. In addition to this type of priority, decisions have had to be made as to which diseases should be attacked first. My impression was that the main drive for the moment is against the common infectious diseases such as malaria, typhus, typhoid, 'plague and schistosomiasis. Tuberculosis does not seem to be getting very great priority at present, and, considering how serious some of the other problems such as schistosomiasis are, this is understandable.
Tuberculosis The administrative plan [or tuberculosis control is similar to our own, i.e. tuberculosis clinics and hospitals. The idea is to have a tuberculosis clinic for each 'district' (about 300,000 people). The system seemed well developed in Peking and Shanghai and less so in smaller centres. I was unable to investigate the set-up in the countryside but I understood that it was practically undeveloped. My Chinese hosts were kind enough to show me what they described as the best and worst clinics in Peking. The best was very similar to our own in practice, though the setting in an old temple made it appear unusual. They used small films for screening the people coming to the clinic and large films of all those tholLght to be abnormal. Approximately go per cent of those diagnosed as suffering from active tuberculosis received domiciliary treatment which consisted usually of PAS and isoniazid - streptomycin is very scarce in China. The duration of treatment was short by British standards and no figures were available about relapse after treatment. Contact work seemed poorly developed. The worst clinic proved to be small and dark, equipped only for fluoroscopy. It was, however, clean and the staff seemed hardworking and enthusiastic. One of the two MlvIR mobile units in Peking was stationed at the best clinic. Community surveys, I was told, gave a prevalence of 3 - 4 per cent of active tilberculosis requiring treatment. These figures are somewhat lower than those of Gilmour (t947) (quoted by McDougall in Tuberculosis: A Global SllUry in Social Pathology) but are high enough. This was the usual prevalence figure given to me in the various parts of China that I visited. The highest prevalence I found was at a cement factory with I,800 workers in Canton. All the workers there had been x-rayed and a prevalence of 9' 2 per cent of active tuberculosis found; but I thought that this was due to an associated silica risk. Treatment is free for students and members of most trade unions although there is usually some payment for the food in hospital. Agricultural workers, who make up such a large proportion of the population, have to pay for their treatment. BCG is given orally to all newborn children, mainly through the maternity and child welfare clinics. It is also given at the tuberculosis clinic to those of other age groups found to be Mantoux negative. There was an odd difficulty about discovering the number of tuberculosis hospital beds for the population of Peking, arising from the use of the word 'sanatorium' in two senses, one to mean a tuberculosis sanatorium and the other a rest home. For this reason the estimates I got varied from place to place and the final figure of 1,400 beds is possibly rather high. This would mean that for Peking, which has probably more hospital beds than the other parts of China, there were 0'4 hospital beds for tubercu-
GH:EST lJISEASES IN CHINA
losis per T,000 of the pop ulation. The figure for England and Wales is approximately 0·8 per I .ooo, The I' eking Chest Hospital must be one of the best chest hospitals in the world from the point of vlew of buildings, equipment, research facilities and, as far as I could make out, standards of treatment. It is divided into medical and surgical sections which are further divided into tuberculosis and non-tuberculous sections. There is also a complete department of anaesthetics. The hospital is clearly designed to see that there is one centre in the country where the standards are as high or higher than anywhere else in the world; and I felt that they were achieving their aim. It was of interest that the commonest operation in the non-tuberculous section was for carcinoma of the oesophagus. This is much commoner than carcinoma of the lung in the whole of Northern China and presents a very serious problem. The cause of this high carcinoma risk is unknown. It is worth stressing that the death-rate, as far as it is known, for carcinoma of the nasopharynx is also higher than that of carcinoma of the lung. I saw two other tuberculosis sanatoria in the provinces and the standards were much lower. They 'were usually very short of streptomycin and were frequently using isoniazid alone. Pneumoperitoneum was still being used on a relatively large scale and one occasionally saw pneumothoraces. ' Some figures for the tuberculosis death-rate were available in Peking and Shanghai. I was told that the death-rate was now approximately 60 per IOO,OOO but the doctors stated that it was probably an underestimate. On the whole, I think it improbable that the death-rate is as low as this. For instance, in Hong Kong the prevalence rate from surveys is about 2 per cent, definitely lower than in Peking and they still have a death-rate of over 100 per roo,ooo. Yet their chemotherapy is better and their death certification is also probably more accurate than in Peking. I also discussed the treatment of tuberculosis with two 'traditional' Chinese doctors, They stated that they relied chiefly on acupuncture in the fifth dorsal segment but, in addition, gave ox bile by mouth, They believed that this type of therapy was at least as effective as pneumothorax or bed-rest but confessed that they had seen little of the effects of modern chemotherapy. Dust Diseases
Before I left lor my Chinese trip I had heard indirectly from a Chinese doctor in this country that there was no dust disease in China. I was therefore surprised to find that there was a considerable prevalence of many different types of dust disease in most of the areas I visited. In the area around Shengyang, where I visited several mines, I saw a large number of chest films of miners with simple and complicated pneumoconiosis indistinguishable from the types we are so accustomed to see in South Wales, Their investigations so far have been somewhat limited by the shortage of x-ray equipment and x-ray films, and it was impossible to obtain an accurate picture of the prevalence of the condition. My impression, however, was that it was considerably lower than in South Wales. The modern mines I visited were well equipped and steps were already being taken to reduce dust concentrations. Methods of measuring dust were, however, ill-developed. The Chinese attach great importance to ultra-violet radiation of miners after the shift. They claim that this prevents upper respiratory infection; but they had no figures available to substantiate this. In the North I was also shown films of shale workers with x-ray appearances similar to those of coal miners. Unfortunately, it is very difficult to obtain post-mortems at present in China so one cannot be certain how this condition should be classified pathologically - as a silicosis or as a relatively inert pneumoconiosis. In most of the big cities I was shown several cases of classical silicosis. They were chiefly from quartz workers in glass factories. Some had died after less than five years' exposure to the dust. They were working hard to suppress such hazards but are somewhat lacking in technical know-how. I was also told about a tungsten mine and was shown some of the films where there appeared to be a high prevalence of classical
43-2
TUllERCLE
silicosis. In addition, there was the cement factory in Canton with a high prevalence of tuberculosis where there was almost certainly a concealed silicotic risk. In Tientsin I was shown many films from an asbestos factor}' showing the typical appearances of asbestosis. Some had been followed up for several years and it was striking that so far they had found no cases of carcinoma. I was also told in Tientsin that there was a remarkably high absentee rate for bronchitis in the cotton factories and that the absentees chiefly worked in the carding' rooms. It seemed reasonable to conclude that they were probably suffering from byssinosis. China is industrializing rapidly and one must expect a certain amount of pneuma· coniosis, The medical services at present lack experience of the disease and the engineers lack know-how as regards dust measurement and suppression.
OtherChest Diseases The doctors with whom J talked seemed convinced that there was no histoplasmosis or coccidiomycosis in China, and another notable absentee was sarcoidosis. As far as I could make out it had only been diagnosed twice in China, and one of these patients was not Chinese. In discussion I was convinced that this was not due to lack of interest in the condition nor to inability to diagnose it. It does appear to be a true epidemiological difference. It would be discourteous to conclude this article without expressing my gratitude
to all my colleagues in China who treated me 'with such kindliness and talked to me so freely. I sincerely hope that the two-way medical traffic between this country and China, which has sunk to such a low level in recent years, will increase rapidly in the future. A. L. COCHRANE.
JOHN ARCHER'S 'SECRETS DISCLOSED' Old medical books are usually interesting for one of three reasons. Sometimes they are 'classics'; sometimes they are merely representative of their time; but often they only survive because of their curiosity value, rarely emerging from the limbo of catalogues and bibliographies. Such seventeenth century works as Bennet's' Theatrum Tnbidorum' and Morton's 'Phihisiologia' are outstanding in the literary history of 'consumption' . But in addition to these books, which are founded on personal observation and to some extent record pathological findings, several other works were published during the cen tury, Many of these we now regard only as curiosities; but they have some value, for they are examples of a common form of medical writing against which the more enduring achievements of the few can be judged. One such book, written by a man very different from Bennet or Morton, was the 'Secrets Disclosed, of Consumptions, Slwwing How to Prevent and Cure the Fistula by Chymical Drops, without Cutting; Also Piles, Haemorrhoids, arid other DISEASES, By John Archer Author of the Book called Every Man his own Doctor; to be Sold by the Booksellers, and also to be had/rom the Authors House at Knightsbridge, or at the Saddlers against the Mews by Charingcross, London, r 684, Printedfor the Author.' Littlebiographical information is recorded about Archer, most of what we know about him being derived from internal evidence of his works. Payne (188S) summarizes this information, and tells us that Archer was possibly an Irishman as he was in practice at Dublin about 1660. The first edition of his 'Every Man his own Doctor' was published at London in 1671. A second edition (,Compleated with an Herbal') appeared in 1673 bearing a portrait of the author, and his '11 Compendious Herbal' was published in the same year. From an examination of his works it is clear that Archer was a fair example of the advertising quack, a type that abounded in