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Influences adverse to tuberculous patients
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tions against the spread of infection. T h e rainfall is heavy and the valley villages receive little sunshine. T h e general mode of living does not tend to raise the resistance of the individual to infection, while pride and fatalism form a bar to early diagnosis a n d successful treatment. Small rooms, damp walls a n d primitive sanitation, together with the presence of dusty industries, are further c o n t r i b u t o r y factors. It has been argued that there are m a n y villages in E n g l a n d where the people live under very unsatisfactory conditions, and yet do not suffer from tuberculosis to an a b n o r m a l extent. This is u n d o u b t e d l y t r u e ; but there can be few villages or districts in which the adverse influences of housing, sanitation and diet, habits and customs, climate and occupation, are so marked as they are in certain parts of North Wales. It must also be borne in m i n d that the people who live in these districts have been bequeathed a legacy of poverty and malnutrition by their forebears. T h e y have a low n a t u r a l resistance to infection, and to such a people a high s t a n d a r d of living a n d a changed outlook are of p a r a m o u n t importance. A n intensive anti-tuberculosis campaign is being launched, and the Memorial Association is playing its part by providing tuberculosis health visitors, shelters for t u b e r c u lous families, dietaries for the working classes, etc. It r e m a i n s for the people themselves to co-operate to the utmost, for without their support little will be achieved. REFERENCES. I B~OWNLEE, J. : " An Investigation into the Epidemiology of Phthisis in Great Britain, i918 and I92o." London : H.M. Stationery Office. 2 BOWEN, EMRYS: "The Incidence of Phthisis in Relation to Race Type and Environment in South and South-West Wales." [ourn. Roy. Auth. I~st.. lviii., 1928. 3 CHALKE,H. D. : " Report of an Investigation into the Causes of the Continued High Death-Rate from Tuberculosis in Certain Parts of North Wales°" Welsh Nat. Mere. Assoc., Cardiff, I933.
INFLUENCES ADVERSE T O TUBERCULOUS PATIENTS. BY J. A. GRANT KEDDIE M.D. (ST. AND.}, D.P.H. (CAMB.), D.P;A. (LOND.). Deputy Medical Officer of Health and Clinical Tuberculosis Officer, County Borough of West Bromwich. IT has recently been urged by Sir George N e w m a n 1 that each local authority should, in a periodic survey of its health services, note, a m o n g other things, the particular i n f l u e n c e s which appear to be of m a i n importance in leading to mortality from various diseases of public t Newman, G.: Rep. of Chief Medical Officer to the Ministry of Health for I93I, p. 2t7.
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health importance. I n this connection, and with special reference to p u l m o n a r y tuberculosis, it has a p p e a r e d worth while to a d o p t a suggestion of Toussaint. 1 I t is his opinion t h a t if every tuberculosis worker were to c o n d u c t a p r i v a t e " i n q u e s t " on each p a t i e n t who dies, we would find r e a d y answers to the question of how a n d why our tuberculosis schemes fail. I n conducting the investigation which is here recorded, a line of action similar to this was pursued. I n an endeavour to ascertain as e x a c t l y as possible the most c o m m o n factors which are, in the c o u n t y borough of W e s t B r o m w i c h , a d v e r s e to the tuberculous, and w h i c h p r e s u m a b l y lead to a hastening of mortality, I dealt, however, w i t h patients who are still alive as well as with those who have died. T h e p r i m a r y object of the investigation was t h u s to determine with more or less precision, the more c o m m o n l y o c c u r r i n g factors which have exerted, a n d still continue to exert, an a d v e r s e influence on the patient, and which may, p r e s u m a b l y , b r i n g a b o u t his earlier demise. Method of Investigation.
Informzttion on the points r e q u i r e d was obtained by consideration of my o w n clinical and e n v i r o n m e n t a l notes and by a s t u d y of the initial and subsequent e n v i r o n m e n t a l reports of the tuberculosis visitors. I n addition, to check points in doubt or to ascertain p a r t i c u l a r s not otherwise available, a special consultation was made in the case of m a n y patients, while the relatives of some of the deceased were i n t e r viewed either in the home or at the dispensary. T h e influences o b s e r v e d were briefly as follows : (~) N o t i f i c a t i o n - - w h e t h e r early or late. (b) R e s i d e n t i a l t r e a t m e n t - - a d e q u a c y or inadequacy. (c) E n v i r o n m e n t a l i n f l u e n c e s - - i n c l u d i n g housing conditions, position as to work, a d e q u a c y of food, and the financial standing of the family. (d) H a b i t s - - i n the home and outside. (e) M e n t a l a n x i e t y as to the -welfare of the f a m i l y - - i t s presence or absence. A t the end of each case record an a t t e m p t was made to assess the relative i m p o r t a n c e of the adverse factors with which the patient had to contend up to the time of death or up to the end of I932, if still alive. I t should be observed t h a t for the s a k e of completeness of record all p a r t i c u l a r s in regard to e n v i r o n m e n t a l c i r c u m s t a n c e s and habits were noted, but t h a t in the final a s s e s s m e n t only those to which there was definite exposure from time o f notification were considered. T h u s a patient m a y have had v e r y unhygienic home s u r r o u n d i n g s and have been himself of careless habits, b u t if moved at once to a 1 Toussaint, C. H. C. : BRIT. J. TUBERC., I932, xxvi. I6 3.
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residential institution, in which he remained up .to time of death, obviously such bad housing and habits should be omitted from the final assessment. On the other hand, it should be noted that in regard to cases in a sanatorium at the end of t932 , factors likely to be prejudicial to them on return from the sanatorium were taken into account in the final assessment. In such a study as this it is well-nigh impossible in most cases to state with any certainty the order of importance of the adverse factors which were present, and besides, were the attempt to be made, personal bias would be likely to lead one astray. However, I have attempted a rough division into which I have considered to be the main, as opposed to the less important, factors, and the principles followed I have outlined below in order that any tendency to persona/ bias may be noted and the necessary allowances made. Factors
considered
to b e o f M a i n
Importance.
A. Treatment so,~tght late by the patient. That is to say, at a considerable interval after the onset of symptoms. 13. Diagnosis made late by the doctor. T h a t is to say, at a considerable interval after the first consultation, and without an attempt throughot~_t to seek the opinion of the tuberculosis officer and the benefit of the facilities in regard to X-ray examination, etc., available to the latter. C. Treatmej# so~g~t early a~d diagnosis made ear@, yet di~ea.~'e ~eii established or far advanced on notification. D. No residential treatmen~ obtained; E. Co~siderable delay in entering residential ins~it~tio~z. T h a t is to say, over two months from the time of notification, only.
This factor is general
Iv. I~.zsu~cient length of stay in residential institz#ion. This in general only, special consideration, however, being paid to the first period of sanatorium or hospital treatment, and more particularly when the response to treatment was fair or good, six months' stay being regarded as a reasonable minimum standard for earIy sputum-negative cases or for chronic fibro-caseous cases, and three months reasonable for sputum negative fibroid cases. G. insanitary condition of ho~sing. !n c!as~ifying houses as of good, fair or poor sanitary condition, factors such as site, construction and plan of house were considered, especiaI attention being directed to questions of dryness or d a m p n e s s / s t a t e of repair, lighting, ventilation, facilities for storing and for cooking food, and the conditio~ of the sanitary fittings. H. Marked degree of overcro~uding in the hoarse as a whole. T h a t i~ to say, to the extent of over two persons pe~ toum. I. Overcrowding of any degree i~ tier bedroo~n ,af t]~e/,a/,/e~¢l~ Es!i;r, at ....
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was m a d e by consideration of the n u m b e r of the o c c u p a n t s and their ages in relation to the cubic capacity and height of the room. K. Position in regard to work unsatisfactory. T h a t is to say, where the patient was fit for work, but u n a b l e to obtain it, food being i n a d e q u a t e in consequence. Also in cases where the p a t i e n t was at work, b u t exposed to unsatisfactory conditions of work or at w o r k beyond his physical capacity. L. Food inadequate. Conclusion was here based upon a consideration of one's own observations, those of the t u b e r c u l o s i s visitors, the opinion of the patient, the total income of the household, a n d the rent to be paid. M. t)oor financial circumstances. Opinion was here based, where possible, upon a consideration of the following scheme : T h e a m o u n t of rent was d e d u c t e d from the total income of household, the figure thus obtained b e i n g then divided by n u m b e r of p e r s o n s in the family, counting each child under the of five years as one-half. W h e r e the final figure lay u n d e r 7 s. head, the position was considered to be poor.
the the age per
N. Habits in the home unsatisfactory. O. Habits outside the home unsatisfactory.
T h a t is to say, there was an a b s e n c e of e n d e a v o u r to lead a life on s a n a t o r i u m principles in the home or outside respectively. In coming to a decision in r e g a r d to these two matters, p a r t i c u l a r a t t e n t i o n was paid to the following points : Attention to personal hygiene. Attention to ventilation and lighting of the room. E x t e n t of indulgence in alcohol and tobacco. E v i d e n c e of vicious habits. N u m b e r of hours spent in the home daily. Use of leisure time. E x e r c i s e : its a m o u n t and nature. Presence of a hobby, such as g a r d e n i n g or p o u l t r y - k e e p i n g . R e s t : its a m o u n t per day. Factors
considered
to be of Relatively
Less
Importance.
H. Overcrowding of a minor degree in the house as a whole.
T h a t is to
say, to the extent of i" 5 to 2 persons p e r living room.
j. Congested industrial area. K. Inability to secure work for which there is physical capacity, adequacy of food being obtained. T h e adverse influence would be l a r g e l y psychical. I t will be readily understood t h a t adequacy of food may result in such a case t h r o u g h the presence of a pension or the earnings of the children. P. Mental ankiety with regard to the welfare of the family. T h i s influence is psychical rather than e n v i r o n m e n t a l , but its inclusion a p p e a r s to be of importance. Rist, ~ in his a d d r e s s at the F i f t e e n t h Annual t Rist, E. : Trans. Nat. Ass. Prey. Tuberc., I5th Ann. Conf., 1929, p. 45.
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Tuberculosis Conference at Newcastle, in discussing the psychic factors that play a part in determining pulmonary tuberculosis, emphasized worry, sorrow~ moral pain or anxiety, especially when it is prolonged. Whether one agrees or not that such factors are likely to play a very important part in determination of the disease, it can hardly be doubted that mental stress and anxiety for the welfare of his family is a thing from which the patient should be protected whenever possible. Cases
Investigated.
The total number of cases of pulmonary tuberculosis dealt with is 262, all having been notified during the years 1927 to 1932. At the end of ~932 the death of 134 had taken place, while the remaining 128 were alive with the disease quiescent or in various stages of activity. In the table which follows the cases are grouped according to the year of notification and as to whether now dead or alive, and if alive as to whether quiescence or activity is present.
Year of Notification Condition o f Patients at end of 1932.
Dead .., Alive disease active A l i v e d i s e a s e a c t i v e , b u t witi~ p r e v i o u s q u i e s c e n c e for o v e r twelve months Alive with disease quiescent
Totals
...
I927 .
1928.
1929.
193o.
~93 I.
I932.
Totals.
26
33
27
29
--
i
6
24
I4 39
5 36
134 lO6
--
--
---
2
--
2
6
2
7
28
42
35
60
2
3
56
20
41
262
A further classification, according to the type of disease present at time of notification, is here outlined : Year o f Notilicaliou Type o f Disease,
_ 1927.
_
1928.
1929.
193o.
I931 .
~932.
Totals.
I 42
4 X9
19 I7I 3° 4z
.A
Acute caseous
...... Chronic fibro-caseous Early localized fibro-caseous Fibroid ......
Totals VOL. XXVlIl.
......
4 19 2 3
28
'
4 29 i 8
4 24 3 4
2 38
42
35
6o
7
56
41
262
9
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I t should be noted t h a t cases notified prior to 1927 a r e not included in this survey, no m a t t e r w h e t h e r they were alive at the end of 1932, or w h e t h e r t h e y h a d died in a n y of the y e a r s 1927 to 1932. D u r i n g the six y e a r s i927 to 1932 the t o t a l n u m b e r of new cases of p u l m o n a r y t u b e r c u l o s i s notified was 535. A s I deal in this s u r v e y with only 262 cases, it would a p p e a r at first sight as if there was not a consideration of the whole of the problem. T h e reasons w h y 273 cases are excluded from s u r v e y are given below. Class of Case.
No. of Cases.
A. N o t notified until after death ...... B. D e a t h in institutions or while on d o m i c i l i a r y visitation within three months of notification ... C. N o t a c c e p t e d b y tuberculosis officer as cases of p u l m o n a r y tuberculosis ...... D. N o t in receipt of p u b l i c medical t r e a t m e n t E. Insufficient d a t a a v a i l a b l e for i n v e s t i g a t i o n
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Total
. . . . . . . . .
68 75 35 61 273
G r o u p s A a n d B, with 34 and 68 cases respectively, are obviously i m p o r t a n t from t h e angle of lateness of notification, a n d reference will be m a d e later to them. M e a n w h i l e , it is to be seen that I shall in this s u r v e y cover the v a s t m a j o r i t y of the cases of p u l m o n a r y tuberculosis notified during the y e a r s in question, and a c c e p t e d as definite cases, so t h a t a n y conclusions formed as a result of this investigation will a p p l y equally to all cases of p u l m o n a r y tuberculosis occurring in the c o u n t y borough of W e s t B r o m w i c h . Summary and Conclusions. T h e m a i n results of the investigation were as follows :
i. Of the 262 cases surveyed, 87 sought t r e a t m e n t at a c o n s i d e r a b l e interval after the onset of s y m p t o m s , 58 sought t r e a t m e n t early, but a diagnosis of p u l m o n a r y t u b e r c u l o s i s was m a d e only after a considerable interval, while in the case of 22 t r e a t m e n t was sought late and diagnosis was m a d e after a longer i n t e r v a l than w a s r e a s o n a b l e . T h e r e was thus r e s u l t a n t late notification in 167 cases, or 63"8 per cent. of all dealt with. 2. F a i l u r e on the p a r t of the medical practitioner to co-operate with the t u b e r c u l o s i s officer, or to t a k e a d v a n t a g e of the diagnostic facilities a v a i l a b l e to the latter, was considered to be of very g r e a t m o m e n t in cases in which the docfor was responsible for lateness of notification. W h e r e patients were p r i m a r i l y or solely at fault, l a x i t y was a d j u d g e d to be the main factor a t work, although e c o n o m i c fears were considered to be causal in a certain p r o p o r t i o n of cases.
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3. A p a r t from the 262 cases of t h e group which is studied in detail, ~o2 were notified either after death (34 cases), or within three m o n t h s ~f death (68 cases). F u r t h e r evidence was thus o b t a i n e d for the con,clusion t h a t the doctor, t h e patient, a n d s o m e t i m e s both, were frequently responsible for notification only when the disease was far advanced. 4. A l t h o u g h there was no delay on the part of the patient in seekm g medical advice, and of s u b s e q u e n t p r o m p t diagnosis of tuberculosis ~n the p a r t of the doctor, 33 cases, or I2"6 p e r cent., had a lesion w h i c h was well established or far a d v a n c e d on notification. Of these, o n l y i i were considered to be of an a c u t e caseous type, so that in the m a j o r i t y of cases it was a p p a r e n t that s y m p t o m s in the early stage h a d been so mild as to a p p e a r to the patient to be consistent with n o r m a l health. I t is obvious, therefore, t h a t in spite of all p r a c t i c a b l e m e a s u r e s to secure cases of p u l m o n a r y t u b e r c u l o s i s at an early stage of the disease, a group will a l w a y s r e m a i n with a w e l l - e s t a b l i s h e d lesion at time of notification. 5. I t is satisfactory to be able to record that 62 cases, or 23'6 per cent., p r e s e n t e d a definitely early lesion, there h a v i n g been an early recourse to medical advice and p r o m p t correct diagnosis. Of this g r o u p , 35 were s p u t u m - p o s i t i v e cases and 27 sputum-negative. 6. Cases receiving no residential t r e a t m e n t n u m b e r e d 46. In 4 of t h e s e cases only was a b s e n c e of such t r e a t m e n t r e g a r d e d as not a c t i n g a d v e r s e l y on the patient, b u t in 27 instances it is possible t h a t a definitely d e t r i m e n t a l effect was occasioned, I n a further 27 cases t h e r e was considerable delay in e n t e r i n g a residential institution, and in I6 instances this delay was held to have been a factor of m a j o r importance. 7. Of the causes which led to failure to secure residential t r e a t m e n t , o r to delay in entering an institution, t e m p e r a m e n t a l u n s u i t a b i l i t y for residence on the p a r t of the patient took first place, domestic difficulties b e i n g second in importance. 8. In those cases where patients availed t h e m s e l v e s of the first o p p o r t u n i t y offered for residential t r e a t m e n t , the period of residence w a s too short in i i 6 cases, in 99, indeed, of s u c h brief duration as p r o b a b l y to be quite ineffective. 9. A s t u d y of the duration of the first periods of residential treat° m e n t shows t h a t out of i72 cases, 92, or 53"4 p e r cent., were in r e s i d e n c e for t h r e e m o n t h s or less. I n 31 cases only were patients resident for six months or more, and in Io instances only were the c a s e s such t h a t u l t i m a t e benefit was likely to ensue from such prolonged treatment. (In this p a r t i c u l a r s u m m a t i o n t h e r e have been e x c l u d e d from consideration those cases in which death took place on the first occasion of
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residential treatment , as well as those notified in 1932 and in sanatorium or hospital at the end of the year.) io. Of these 172 cases, which had been resident in sanatorium or hospital for the first time, in 79, or 40"7 pe r cent., the reason for discharg e was more or less beyond the control Of the individual patient, being due most commonly to domestic difficulties. The most frequent of these obstacles was the desire of the patient to return to work because of family need. In 67 cases, or 38.9 per cent., the reason for discharge was attributable directly to the fault of the patient. There was either temperamental unsuitability for residence or, less commonlyi-the presence of a false Sense of well-being. In only 13 cases, or o'75 per cent., was quiescence of disease the reason for discharge, 1i~ As additional proof of the great need for early and adequate residential treatment in order to secure and to maintain thereafter quiescence of disease we have the fact that out of the 1927-1931 group of patients, in number 52, who sought advice promptly and were diagnosed immediately as having an early tubercular lesion, 36 failed to reach quiescence by the end of 1932. Of these 36 cases, 5 had had no sanatorium or hospital treatment, while 25 had received insufficient initial residential treatment. To judge by frequency of occurrence, this absence Or inadequacy of residential treatment was the most important factor at work. Other important influences adverse to these particular patients were, in order of frequency, insanitary housing, an unsatisfactory position with regard to work, and overcrowding in the bedroom. 12. There was occupancy of overcrowded or otherwise unhygienic housing by 144 patients, or 57"3 per cent. of all who, after notification, had lived at home for any appreciable period. The most important adverse factor in connection with housing was the presence of overcrowding in the bedroom of the patient, this being observed in marked degree in 83 cases. On the assumption that the patient was solely or largely responsible where such marked overcrowding of the be&6om existed in conjunction with absence of overcrowding of the house as a whole, in 43 cases of the 83 the patient was at fault. In the remaining 40 cases there was the association with overcrowding of the house as a whole; and more roomy accommodation was necessary for correction of the crowded state of the bedroom. 13 . Environmental influences, other than those of housing, were seen to be of definite adverse importance. Inadequacy of food, associated in practically all cases wit'h marked financial embarrassment, was :present in 45 cases. Such a position was commonly a direct consequence of inability on the part of the patient to secure Work for which there was physical capacity, Many patients also were faced with work of too arduous a nature or the conditions of work were otherwise unsatisfactory. As a result oflthese and other influences, as many as 8x
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patients were definitely concerned about the welfare of their families, who were; as a rule, dependent upon the afflicted. 14. In the case of 7 ~ p a t i e n t s , unsatisfactory habits in the home, outside; or both, were noted. In practically all of these cases an ad~zerse effect upon health was considered a probable resultant. O f the 7 I, those who had had no residential treatment n u m b e r e d I6, or 34"8 per cent. of those of the 262 cases in which such treatment had been obtained. On the o t h e r hand, those who had been resident for a period in sanatorium or hospital numbered 55, or 31'8 per cent. of those who took advantage of residential treatment. The latter percentage, rela. tively high in proportion to that shown by those who received no in-patient treatment, was adjudged to be so for two reasons. T h e first and main cause was an insufficient l e n g t h of stay in sanatorium or ~hospital, as m a n y as 39 being resident for three months or less. T h e second reason was the difficulty encountered-by the patient in carryihg out s a n a t o r i u m principles under the unsatisfactory home conditions to which return was c o m m o n l y made. .i To sum up, it has been shown that a very ]urge proportion of the cases of pulmonary tuberculosis are notified to the Public Health Authority when the disease is well established or far advanced, and that, therefore, in comparatively few instances can one expect ultimate permanent arrest of the lesion to be secured. Not only is this so, but the majority of all cases, whether early or advanced in type, fail to secure adequate initial residential treatment. While the medical practitioner is partly responsible for so m a n y patients presenting themselves for public medical treatment at a late stage of the disease, the patient i% on balance, more at fault. T h e patient is also primarily responsible in a large n u m b e r of cases for the absence of residential- treatment or its insufficiency. T h o u g h lack of education in regard to the n e e d for early and adequate treatment is commonly the factor at work, yet domestic difficulties, especially the desire for the patient to remain at work or to return to work because of family need, are n o t infrequently the important causal influences. On return from residential ~rgatment the patient has in many cases t o face housing conditidns which are almost certaim to be deleterious to h i s health. Many, too, :have to endure inadequacy of food a n d are tortured by anxiety with regard to the family welfare, both of these ~adv~rse influences being usually present as a result of the inabiIity to secure suitable work for which there is physical capacity. It is little wonder that the~conditions to which return is made on discharge f£om sanatorium or hospital are usually deterrent to the .practice of the sanatorium creed, i ,: T h e results of this investigation make more apfiarent the extent of
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the local problem with which we have to deal, and we should be in a stronger position in regard to the suggestion of the adoption of measures which should ensure a more successful result in the fight with pulmonary tuberculosis than we are securing at the present time. In particular, I am of the opinion that in order to secure the amelioration of the conditions under which tuberculous patients and their families so commonly live, conditions which undoubtedly cause the patients to relapse or hasten their deaths, and which are practically certain to lower markedly the resistance to infection of the house contacts, there is urgent need for the rehousing of many cases and for the establishment of a care and aftercare organization. With the latter in existence, there could be secured for many cases earlier and more prolonged residential treatment by the removal or amelioration of domestic obstacles to the securing of such treatment. Abundance of nourishing food and a sufficiency of clothing for the families as well as for the patients would be made more certain. Further, in spite of obvious difficulties~ there is little doubt that suitable work would be found for a number of unemployed but employable patients, and for others .already at work an improvement in the conditions of work.
NOTES ON ALPINE CLIMATE IN CONNECTION WITH LARYNGEAL TUBERCULOSIS. BY T H . R 1 J E D I , M.D,~ Laryngologist, Davos-Platz, Switzerland ; AND
BERNARD HUDSON, M.A., M.D. (CANTAB.), M.R.G.P. (LOND.), Swiss Federal Diploma, Medical Superintendent, Victoria British Sanatorium, Davos-Platz, Switzerland.
THE climate to be discussed in this relation is one of an altitude of 5,ooo to 6,ooo feet above the sea, situated in the eastern part of Switzerland (the Rhmtian Alps). For long, even as far back as in Galen's time, attention had been drawn by medical men to the beneficial and curative effect of dry mountain air on pulmonary tuberculosis. Dr. Lucius Rtiedi, the district physician at Davos, was the first to open an establishment for "scrofulous and consumptive" patients at Davos in the year i84i. He was followed by Dr. Alexander Spengler, a German physician,
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tions against the spread of infection. T h e rainfall is heavy and the valley villages receive little sunshine. T h e general mode of living does not tend to raise the resistance of the individual to infection, while pride and fatalism form a bar to early diagnosis a n d successful treatment. Small rooms, damp walls a n d primitive sanitation, together with the presence of dusty industries, are further c o n t r i b u t o r y factors. It has been argued that there are m a n y villages in E n g l a n d where the people live under very unsatisfactory conditions, and yet do not suffer from tuberculosis to an a b n o r m a l extent. This is u n d o u b t e d l y t r u e ; but there can be few villages or districts in which the adverse influences of housing, sanitation and diet, habits and customs, climate and occupation, are so marked as they are in certain parts of North Wales. It must also be borne in m i n d that the people who live in these districts have been bequeathed a legacy of poverty and malnutrition by their forebears. T h e y have a low n a t u r a l resistance to infection, and to such a people a high s t a n d a r d of living a n d a changed outlook are of p a r a m o u n t importance. A n intensive anti-tuberculosis campaign is being launched, and the Memorial Association is playing its part by providing tuberculosis health visitors, shelters for t u b e r c u lous families, dietaries for the working classes, etc. It r e m a i n s for the people themselves to co-operate to the utmost, for without their support little will be achieved. REFERENCES. I B~OWNLEE, J. : " An Investigation into the Epidemiology of Phthisis in Great Britain, i918 and I92o." London : H.M. Stationery Office. 2 BOWEN, EMRYS: "The Incidence of Phthisis in Relation to Race Type and Environment in South and South-West Wales." [ourn. Roy. Auth. I~st.. lviii., 1928. 3 CHALKE,H. D. : " Report of an Investigation into the Causes of the Continued High Death-Rate from Tuberculosis in Certain Parts of North Wales°" Welsh Nat. Mere. Assoc., Cardiff, I933.
INFLUENCES ADVERSE T O TUBERCULOUS PATIENTS. BY J. A. GRANT KEDDIE M.D. (ST. AND.}, D.P.H. (CAMB.), D.P;A. (LOND.). Deputy Medical Officer of Health and Clinical Tuberculosis Officer, County Borough of West Bromwich. IT has recently been urged by Sir George N e w m a n 1 that each local authority should, in a periodic survey of its health services, note, a m o n g other things, the particular i n f l u e n c e s which appear to be of m a i n importance in leading to mortality from various diseases of public t Newman, G.: Rep. of Chief Medical Officer to the Ministry of Health for I93I, p. 2t7.
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health importance. I n this connection, and with special reference to p u l m o n a r y tuberculosis, it has a p p e a r e d worth while to a d o p t a suggestion of Toussaint. 1 I t is his opinion t h a t if every tuberculosis worker were to c o n d u c t a p r i v a t e " i n q u e s t " on each p a t i e n t who dies, we would find r e a d y answers to the question of how a n d why our tuberculosis schemes fail. I n conducting the investigation which is here recorded, a line of action similar to this was pursued. I n an endeavour to ascertain as e x a c t l y as possible the most c o m m o n factors which are, in the c o u n t y borough of W e s t B r o m w i c h , a d v e r s e to the tuberculous, and w h i c h p r e s u m a b l y lead to a hastening of mortality, I dealt, however, w i t h patients who are still alive as well as with those who have died. T h e p r i m a r y object of the investigation was t h u s to determine with more or less precision, the more c o m m o n l y o c c u r r i n g factors which have exerted, a n d still continue to exert, an a d v e r s e influence on the patient, and which may, p r e s u m a b l y , b r i n g a b o u t his earlier demise. Method of Investigation.
Informzttion on the points r e q u i r e d was obtained by consideration of my o w n clinical and e n v i r o n m e n t a l notes and by a s t u d y of the initial and subsequent e n v i r o n m e n t a l reports of the tuberculosis visitors. I n addition, to check points in doubt or to ascertain p a r t i c u l a r s not otherwise available, a special consultation was made in the case of m a n y patients, while the relatives of some of the deceased were i n t e r viewed either in the home or at the dispensary. T h e influences o b s e r v e d were briefly as follows : (~) N o t i f i c a t i o n - - w h e t h e r early or late. (b) R e s i d e n t i a l t r e a t m e n t - - a d e q u a c y or inadequacy. (c) E n v i r o n m e n t a l i n f l u e n c e s - - i n c l u d i n g housing conditions, position as to work, a d e q u a c y of food, and the financial standing of the family. (d) H a b i t s - - i n the home and outside. (e) M e n t a l a n x i e t y as to the -welfare of the f a m i l y - - i t s presence or absence. A t the end of each case record an a t t e m p t was made to assess the relative i m p o r t a n c e of the adverse factors with which the patient had to contend up to the time of death or up to the end of I932, if still alive. I t should be observed t h a t for the s a k e of completeness of record all p a r t i c u l a r s in regard to e n v i r o n m e n t a l c i r c u m s t a n c e s and habits were noted, but t h a t in the final a s s e s s m e n t only those to which there was definite exposure from time o f notification were considered. T h u s a patient m a y have had v e r y unhygienic home s u r r o u n d i n g s and have been himself of careless habits, b u t if moved at once to a 1 Toussaint, C. H. C. : BRIT. J. TUBERC., I932, xxvi. I6 3.
INFLUENCES
ADVERSE
TO
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II 9
residential institution, in which he remained up .to time of death, obviously such bad housing and habits should be omitted from the final assessment. On the other hand, it should be noted that in regard to cases in a sanatorium at the end of t932 , factors likely to be prejudicial to them on return from the sanatorium were taken into account in the final assessment. In such a study as this it is well-nigh impossible in most cases to state with any certainty the order of importance of the adverse factors which were present, and besides, were the attempt to be made, personal bias would be likely to lead one astray. However, I have attempted a rough division into which I have considered to be the main, as opposed to the less important, factors, and the principles followed I have outlined below in order that any tendency to persona/ bias may be noted and the necessary allowances made. Factors
considered
to b e o f M a i n
Importance.
A. Treatment so,~tght late by the patient. That is to say, at a considerable interval after the onset of symptoms. 13. Diagnosis made late by the doctor. T h a t is to say, at a considerable interval after the first consultation, and without an attempt throughot~_t to seek the opinion of the tuberculosis officer and the benefit of the facilities in regard to X-ray examination, etc., available to the latter. C. Treatmej# so~g~t early a~d diagnosis made ear@, yet di~ea.~'e ~eii established or far advanced on notification. D. No residential treatmen~ obtained; E. Co~siderable delay in entering residential ins~it~tio~z. T h a t is to say, over two months from the time of notification, only.
This factor is general
Iv. I~.zsu~cient length of stay in residential institz#ion. This in general only, special consideration, however, being paid to the first period of sanatorium or hospital treatment, and more particularly when the response to treatment was fair or good, six months' stay being regarded as a reasonable minimum standard for earIy sputum-negative cases or for chronic fibro-caseous cases, and three months reasonable for sputum negative fibroid cases. G. insanitary condition of ho~sing. !n c!as~ifying houses as of good, fair or poor sanitary condition, factors such as site, construction and plan of house were considered, especiaI attention being directed to questions of dryness or d a m p n e s s / s t a t e of repair, lighting, ventilation, facilities for storing and for cooking food, and the conditio~ of the sanitary fittings. H. Marked degree of overcro~uding in the hoarse as a whole. T h a t i~ to say, to the extent of over two persons pe~ toum. I. Overcrowding of any degree i~ tier bedroo~n ,af t]~e/,a/,/e~¢l~ Es!i;r, at ....
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was m a d e by consideration of the n u m b e r of the o c c u p a n t s and their ages in relation to the cubic capacity and height of the room. K. Position in regard to work unsatisfactory. T h a t is to say, where the patient was fit for work, but u n a b l e to obtain it, food being i n a d e q u a t e in consequence. Also in cases where the p a t i e n t was at work, b u t exposed to unsatisfactory conditions of work or at w o r k beyond his physical capacity. L. Food inadequate. Conclusion was here based upon a consideration of one's own observations, those of the t u b e r c u l o s i s visitors, the opinion of the patient, the total income of the household, a n d the rent to be paid. M. t)oor financial circumstances. Opinion was here based, where possible, upon a consideration of the following scheme : T h e a m o u n t of rent was d e d u c t e d from the total income of household, the figure thus obtained b e i n g then divided by n u m b e r of p e r s o n s in the family, counting each child under the of five years as one-half. W h e r e the final figure lay u n d e r 7 s. head, the position was considered to be poor.
the the age per
N. Habits in the home unsatisfactory. O. Habits outside the home unsatisfactory.
T h a t is to say, there was an a b s e n c e of e n d e a v o u r to lead a life on s a n a t o r i u m principles in the home or outside respectively. In coming to a decision in r e g a r d to these two matters, p a r t i c u l a r a t t e n t i o n was paid to the following points : Attention to personal hygiene. Attention to ventilation and lighting of the room. E x t e n t of indulgence in alcohol and tobacco. E v i d e n c e of vicious habits. N u m b e r of hours spent in the home daily. Use of leisure time. E x e r c i s e : its a m o u n t and nature. Presence of a hobby, such as g a r d e n i n g or p o u l t r y - k e e p i n g . R e s t : its a m o u n t per day. Factors
considered
to be of Relatively
Less
Importance.
H. Overcrowding of a minor degree in the house as a whole.
T h a t is to
say, to the extent of i" 5 to 2 persons p e r living room.
j. Congested industrial area. K. Inability to secure work for which there is physical capacity, adequacy of food being obtained. T h e adverse influence would be l a r g e l y psychical. I t will be readily understood t h a t adequacy of food may result in such a case t h r o u g h the presence of a pension or the earnings of the children. P. Mental ankiety with regard to the welfare of the family. T h i s influence is psychical rather than e n v i r o n m e n t a l , but its inclusion a p p e a r s to be of importance. Rist, ~ in his a d d r e s s at the F i f t e e n t h Annual t Rist, E. : Trans. Nat. Ass. Prey. Tuberc., I5th Ann. Conf., 1929, p. 45.
INFLUENCES
ADVERSE
TO PATIENTS
~2I
Tuberculosis Conference at Newcastle, in discussing the psychic factors that play a part in determining pulmonary tuberculosis, emphasized worry, sorrow~ moral pain or anxiety, especially when it is prolonged. Whether one agrees or not that such factors are likely to play a very important part in determination of the disease, it can hardly be doubted that mental stress and anxiety for the welfare of his family is a thing from which the patient should be protected whenever possible. Cases
Investigated.
The total number of cases of pulmonary tuberculosis dealt with is 262, all having been notified during the years 1927 to 1932. At the end of ~932 the death of 134 had taken place, while the remaining 128 were alive with the disease quiescent or in various stages of activity. In the table which follows the cases are grouped according to the year of notification and as to whether now dead or alive, and if alive as to whether quiescence or activity is present.
Year of Notification Condition o f Patients at end of 1932.
Dead .., Alive disease active A l i v e d i s e a s e a c t i v e , b u t witi~ p r e v i o u s q u i e s c e n c e for o v e r twelve months Alive with disease quiescent
Totals
...
I927 .
1928.
1929.
193o.
~93 I.
I932.
Totals.
26
33
27
29
--
i
6
24
I4 39
5 36
134 lO6
--
--
---
2
--
2
6
2
7
28
42
35
60
2
3
56
20
41
262
A further classification, according to the type of disease present at time of notification, is here outlined : Year o f Notilicaliou Type o f Disease,
_ 1927.
_
1928.
1929.
193o.
I931 .
~932.
Totals.
I 42
4 X9
19 I7I 3° 4z
.A
Acute caseous
...... Chronic fibro-caseous Early localized fibro-caseous Fibroid ......
Totals VOL. XXVlIl.
......
4 19 2 3
28
'
4 29 i 8
4 24 3 4
2 38
42
35
6o
7
56
41
262
9
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I t should be noted t h a t cases notified prior to 1927 a r e not included in this survey, no m a t t e r w h e t h e r they were alive at the end of 1932, or w h e t h e r t h e y h a d died in a n y of the y e a r s 1927 to 1932. D u r i n g the six y e a r s i927 to 1932 the t o t a l n u m b e r of new cases of p u l m o n a r y t u b e r c u l o s i s notified was 535. A s I deal in this s u r v e y with only 262 cases, it would a p p e a r at first sight as if there was not a consideration of the whole of the problem. T h e reasons w h y 273 cases are excluded from s u r v e y are given below. Class of Case.
No. of Cases.
A. N o t notified until after death ...... B. D e a t h in institutions or while on d o m i c i l i a r y visitation within three months of notification ... C. N o t a c c e p t e d b y tuberculosis officer as cases of p u l m o n a r y tuberculosis ...... D. N o t in receipt of p u b l i c medical t r e a t m e n t E. Insufficient d a t a a v a i l a b l e for i n v e s t i g a t i o n
34
Total
. . . . . . . . .
68 75 35 61 273
G r o u p s A a n d B, with 34 and 68 cases respectively, are obviously i m p o r t a n t from t h e angle of lateness of notification, a n d reference will be m a d e later to them. M e a n w h i l e , it is to be seen that I shall in this s u r v e y cover the v a s t m a j o r i t y of the cases of p u l m o n a r y tuberculosis notified during the y e a r s in question, and a c c e p t e d as definite cases, so t h a t a n y conclusions formed as a result of this investigation will a p p l y equally to all cases of p u l m o n a r y tuberculosis occurring in the c o u n t y borough of W e s t B r o m w i c h . Summary and Conclusions. T h e m a i n results of the investigation were as follows :
i. Of the 262 cases surveyed, 87 sought t r e a t m e n t at a c o n s i d e r a b l e interval after the onset of s y m p t o m s , 58 sought t r e a t m e n t early, but a diagnosis of p u l m o n a r y t u b e r c u l o s i s was m a d e only after a considerable interval, while in the case of 22 t r e a t m e n t was sought late and diagnosis was m a d e after a longer i n t e r v a l than w a s r e a s o n a b l e . T h e r e was thus r e s u l t a n t late notification in 167 cases, or 63"8 per cent. of all dealt with. 2. F a i l u r e on the p a r t of the medical practitioner to co-operate with the t u b e r c u l o s i s officer, or to t a k e a d v a n t a g e of the diagnostic facilities a v a i l a b l e to the latter, was considered to be of very g r e a t m o m e n t in cases in which the docfor was responsible for lateness of notification. W h e r e patients were p r i m a r i l y or solely at fault, l a x i t y was a d j u d g e d to be the main factor a t work, although e c o n o m i c fears were considered to be causal in a certain p r o p o r t i o n of cases.
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I23
3. A p a r t from the 262 cases of t h e group which is studied in detail, ~o2 were notified either after death (34 cases), or within three m o n t h s ~f death (68 cases). F u r t h e r evidence was thus o b t a i n e d for the con,clusion t h a t the doctor, t h e patient, a n d s o m e t i m e s both, were frequently responsible for notification only when the disease was far advanced. 4. A l t h o u g h there was no delay on the part of the patient in seekm g medical advice, and of s u b s e q u e n t p r o m p t diagnosis of tuberculosis ~n the p a r t of the doctor, 33 cases, or I2"6 p e r cent., had a lesion w h i c h was well established or far a d v a n c e d on notification. Of these, o n l y i i were considered to be of an a c u t e caseous type, so that in the m a j o r i t y of cases it was a p p a r e n t that s y m p t o m s in the early stage h a d been so mild as to a p p e a r to the patient to be consistent with n o r m a l health. I t is obvious, therefore, t h a t in spite of all p r a c t i c a b l e m e a s u r e s to secure cases of p u l m o n a r y t u b e r c u l o s i s at an early stage of the disease, a group will a l w a y s r e m a i n with a w e l l - e s t a b l i s h e d lesion at time of notification. 5. I t is satisfactory to be able to record that 62 cases, or 23'6 per cent., p r e s e n t e d a definitely early lesion, there h a v i n g been an early recourse to medical advice and p r o m p t correct diagnosis. Of this g r o u p , 35 were s p u t u m - p o s i t i v e cases and 27 sputum-negative. 6. Cases receiving no residential t r e a t m e n t n u m b e r e d 46. In 4 of t h e s e cases only was a b s e n c e of such t r e a t m e n t r e g a r d e d as not a c t i n g a d v e r s e l y on the patient, b u t in 27 instances it is possible t h a t a definitely d e t r i m e n t a l effect was occasioned, I n a further 27 cases t h e r e was considerable delay in e n t e r i n g a residential institution, and in I6 instances this delay was held to have been a factor of m a j o r importance. 7. Of the causes which led to failure to secure residential t r e a t m e n t , o r to delay in entering an institution, t e m p e r a m e n t a l u n s u i t a b i l i t y for residence on the p a r t of the patient took first place, domestic difficulties b e i n g second in importance. 8. In those cases where patients availed t h e m s e l v e s of the first o p p o r t u n i t y offered for residential t r e a t m e n t , the period of residence w a s too short in i i 6 cases, in 99, indeed, of s u c h brief duration as p r o b a b l y to be quite ineffective. 9. A s t u d y of the duration of the first periods of residential treat° m e n t shows t h a t out of i72 cases, 92, or 53"4 p e r cent., were in r e s i d e n c e for t h r e e m o n t h s or less. I n 31 cases only were patients resident for six months or more, and in Io instances only were the c a s e s such t h a t u l t i m a t e benefit was likely to ensue from such prolonged treatment. (In this p a r t i c u l a r s u m m a t i o n t h e r e have been e x c l u d e d from consideration those cases in which death took place on the first occasion of
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residential treatment , as well as those notified in 1932 and in sanatorium or hospital at the end of the year.) io. Of these 172 cases, which had been resident in sanatorium or hospital for the first time, in 79, or 40"7 pe r cent., the reason for discharg e was more or less beyond the control Of the individual patient, being due most commonly to domestic difficulties. The most frequent of these obstacles was the desire of the patient to return to work because of family need. In 67 cases, or 38.9 per cent., the reason for discharge was attributable directly to the fault of the patient. There was either temperamental unsuitability for residence or, less commonlyi-the presence of a false Sense of well-being. In only 13 cases, or o'75 per cent., was quiescence of disease the reason for discharge, 1i~ As additional proof of the great need for early and adequate residential treatment in order to secure and to maintain thereafter quiescence of disease we have the fact that out of the 1927-1931 group of patients, in number 52, who sought advice promptly and were diagnosed immediately as having an early tubercular lesion, 36 failed to reach quiescence by the end of 1932. Of these 36 cases, 5 had had no sanatorium or hospital treatment, while 25 had received insufficient initial residential treatment. To judge by frequency of occurrence, this absence Or inadequacy of residential treatment was the most important factor at work. Other important influences adverse to these particular patients were, in order of frequency, insanitary housing, an unsatisfactory position with regard to work, and overcrowding in the bedroom. 12. There was occupancy of overcrowded or otherwise unhygienic housing by 144 patients, or 57"3 per cent. of all who, after notification, had lived at home for any appreciable period. The most important adverse factor in connection with housing was the presence of overcrowding in the bedroom of the patient, this being observed in marked degree in 83 cases. On the assumption that the patient was solely or largely responsible where such marked overcrowding of the be&6om existed in conjunction with absence of overcrowding of the house as a whole, in 43 cases of the 83 the patient was at fault. In the remaining 40 cases there was the association with overcrowding of the house as a whole; and more roomy accommodation was necessary for correction of the crowded state of the bedroom. 13 . Environmental influences, other than those of housing, were seen to be of definite adverse importance. Inadequacy of food, associated in practically all cases wit'h marked financial embarrassment, was :present in 45 cases. Such a position was commonly a direct consequence of inability on the part of the patient to secure Work for which there was physical capacity, Many patients also were faced with work of too arduous a nature or the conditions of work were otherwise unsatisfactory. As a result oflthese and other influences, as many as 8x
INFLUENCES
ADVERSE
TO PATIENTS
I~ 5
patients were definitely concerned about the welfare of their families, who were; as a rule, dependent upon the afflicted. 14. In the case of 7 ~ p a t i e n t s , unsatisfactory habits in the home, outside; or both, were noted. In practically all of these cases an ad~zerse effect upon health was considered a probable resultant. O f the 7 I, those who had had no residential treatment n u m b e r e d I6, or 34"8 per cent. of those of the 262 cases in which such treatment had been obtained. On the o t h e r hand, those who had been resident for a period in sanatorium or hospital numbered 55, or 31'8 per cent. of those who took advantage of residential treatment. The latter percentage, rela. tively high in proportion to that shown by those who received no in-patient treatment, was adjudged to be so for two reasons. T h e first and main cause was an insufficient l e n g t h of stay in sanatorium or ~hospital, as m a n y as 39 being resident for three months or less. T h e second reason was the difficulty encountered-by the patient in carryihg out s a n a t o r i u m principles under the unsatisfactory home conditions to which return was c o m m o n l y made. .i To sum up, it has been shown that a very ]urge proportion of the cases of pulmonary tuberculosis are notified to the Public Health Authority when the disease is well established or far advanced, and that, therefore, in comparatively few instances can one expect ultimate permanent arrest of the lesion to be secured. Not only is this so, but the majority of all cases, whether early or advanced in type, fail to secure adequate initial residential treatment. While the medical practitioner is partly responsible for so m a n y patients presenting themselves for public medical treatment at a late stage of the disease, the patient i% on balance, more at fault. T h e patient is also primarily responsible in a large n u m b e r of cases for the absence of residential- treatment or its insufficiency. T h o u g h lack of education in regard to the n e e d for early and adequate treatment is commonly the factor at work, yet domestic difficulties, especially the desire for the patient to remain at work or to return to work because of family need, are n o t infrequently the important causal influences. On return from residential ~rgatment the patient has in many cases t o face housing conditidns which are almost certaim to be deleterious to h i s health. Many, too, :have to endure inadequacy of food a n d are tortured by anxiety with regard to the family welfare, both of these ~adv~rse influences being usually present as a result of the inabiIity to secure suitable work for which there is physical capacity. It is little wonder that the~conditions to which return is made on discharge f£om sanatorium or hospital are usually deterrent to the .practice of the sanatorium creed, i ,: T h e results of this investigation make more apfiarent the extent of
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the local problem with which we have to deal, and we should be in a stronger position in regard to the suggestion of the adoption of measures which should ensure a more successful result in the fight with pulmonary tuberculosis than we are securing at the present time. In particular, I am of the opinion that in order to secure the amelioration of the conditions under which tuberculous patients and their families so commonly live, conditions which undoubtedly cause the patients to relapse or hasten their deaths, and which are practically certain to lower markedly the resistance to infection of the house contacts, there is urgent need for the rehousing of many cases and for the establishment of a care and aftercare organization. With the latter in existence, there could be secured for many cases earlier and more prolonged residential treatment by the removal or amelioration of domestic obstacles to the securing of such treatment. Abundance of nourishing food and a sufficiency of clothing for the families as well as for the patients would be made more certain. Further, in spite of obvious difficulties~ there is little doubt that suitable work would be found for a number of unemployed but employable patients, and for others .already at work an improvement in the conditions of work.
NOTES ON ALPINE CLIMATE IN CONNECTION WITH LARYNGEAL TUBERCULOSIS. BY T H . R 1 J E D I , M.D,~ Laryngologist, Davos-Platz, Switzerland ; AND
BERNARD HUDSON, M.A., M.D. (CANTAB.), M.R.G.P. (LOND.), Swiss Federal Diploma, Medical Superintendent, Victoria British Sanatorium, Davos-Platz, Switzerland.
THE climate to be discussed in this relation is one of an altitude of 5,ooo to 6,ooo feet above the sea, situated in the eastern part of Switzerland (the Rhmtian Alps). For long, even as far back as in Galen's time, attention had been drawn by medical men to the beneficial and curative effect of dry mountain air on pulmonary tuberculosis. Dr. Lucius Rtiedi, the district physician at Davos, was the first to open an establishment for "scrofulous and consumptive" patients at Davos in the year i84i. He was followed by Dr. Alexander Spengler, a German physician,