Respiratory tuberculosis in East London

August 1956

233

Respiratory Tuberculosis in East London By M A X W E L L CAPLIN, J. J. G R I F F I T H S and C. P. S I L V E R from the Tuberculosis Dispensary, London Chest Hospital Before I949 mortality from tuberculosis in this country had been falling steadily for a century. Since i949 the rate of fall had increased sharply, a change coinciding with the introduction of antibacterial treatment. In London the mortality from respiratory tuberculosis has fallen from o.71 per I,OOO living in I937 to o.6 in 1947 and o.I8 in 1954. This recent dramatic fall was not preceded by a fall in newly notified cases, and therefore can only be due to a sudden improvement in the prognosis of the disease. However, total mortality statistics only dimly reflect this change in prognosis. They give no clear indication whether there has been a general improvement throughout the whole range of respiratory tuberculosis, or whether the change is limited to certain types of the disease. To show the patterri of tuberculosis and the changes that have recently befallen it, we have made a detailed study of the fate of every case of respiratory tuberculosis notified in each of the years ~949 and 1951 in an East London area where mortality and notification rates have followed the same trends as those for the County of London. The two series differed in the antibacterial treatment that they were given. By comparing them over a three-year period the effect of these differences could be estimated. By continuing the follow-up of the T949 series for a further two years, making five in all, it has been possible to compare the prognosis of these patients with some published accounts of surveys. Finally, basing these series on the whole tuberculous population of an area has allowed the effect of age on prognosis to be studied. Definitions Notified patients have been classified on the basis of sputum state, radiographic extent of disease, and age. The patients have been divided according to ~putum state into: negative ('N' cases) where no record is available of tubercle bacilli being discovered on smear or culture within eight weeks of notification; and positive ('P' cases) where tubercle bacilli were discovered within eight weeks of notification. The sputum state quoted throughout refers to the initial sputum state ('N' or 'P'); so that if bacilli were not discovered within eight weeks of notification the case has remained classified as 'N' even though tubercle bacilli were found subsequently. The radiographic grouping used is as follows: Group I.-Radiographic change present in only one zone: hilar adenitis or pleural effusion with no lung involvement or lung involvement limited to one zone. Group 2. - Radiographic change present in two or three zones. Group 3. - Radiog/"aphie change present in four or more zones. The patients have been divided into three age groups: o-I 4 years; 15-44 years; 45 years and over. B

234

August I956

TUBERCLE

T h e t e r m 'quiescent' has b e e n used to i n d i c a t e t h a t the state o f clinical a n d r a d i o g r a p h i c recover)- was such t h a t the p a t i e n t could be considered non-infectious a n d fit to r e t u r n to light work. I n the investigation a p e r i o d o f at least eight m o n t h s w i t h o u t a r e c o r d o f a positive s p u t u m was r e q u i r e d for the p a t i e n t to b e r e g a r d e d as non-infectious. 'Aclh'e' cases were those not quiescent. Methods Ever), notification of tuberculosis m a d e in this a r e a d u r i n g the years 1949 a n d 195I was reviewed. A l r e a d y notified p a t i e n t s w h o m o v e d into the a r e a d u r i n g these two years were excluded, b u t all those w h o left the a r e a after notification were followed u p t h r o u g h the kindness o f the physicians u n d e r whose care t h e y subsequently came. T h e reports a n d r a d i o g r a p h s o f those not t r e a t e d d i r e c t l y b y this clinic were e x a m i n e d a n d , w h e t h e r t r e a t e d here o r elsew.here, the salient clinical features a n d t r e a t m e n t were r e c o r d e d , a n d a y e a r l y assessment o f the patients state m a d e as n e a r the a n n i v e r s a r y o f notification as possible. Both" groups were followed for three y e a r s from the d a t e o f notification. T h e 1949 series was then followed for a f u r t h e r two years, m a k i n g five in all. The Area and its Pattern of Tuberculosis T h e a r e a served b y this clinic consists o f the b o r o u g h o f B e t h n a l G r e e n a n d the s o u t h e r n h a l f o f H a c k n e y , with a c o m b i n e d p o p u l a t i o n o f I43,ooo persons. A l m o s t all belong to social g r a d e s I I I , I V , a n d V a n d m a k e their living in light industries in the district, p a r t i c u l a r l y furniture m a k i n g a n d t a i l o r i n g . . T h e m a j o r i t y o f m a r r i e d w o m e n are at work, m a i n l y as packers a n d machinists. H o u s i n g conditions a r e g e n e r a l l y poor. O n l y 55 p e r cent o f patients notified in the a r e a were d i a g n o s e d at this clinic. T h e r e m a i n d e r were d i a g n o s e d at o t h e r hospitals a n d b y g e n e r a l practitioners, t h o u g h most s u b s e q u e n t l y a t t e n d e d here. I n - p a t i e n t t r e a t m e n t was given in a w i d e v a r i e t y o f hospitals r a n g i n g from w e l l - e q u i p p e d chest units to a few lacking a d e q u a t e facilities. A small n u m b e r o f m e n t a l patients received t r e a t m e n t for their tuberculosis TABLE I . - AGE AND SEX DISTRIBUTION OF THE 1949 AND 1951 SERIES XVITInN TIIE INITIAL DISEASE CLASSIFICATIONS

I949

195I

Age (years) Initial °-14 classification* Total ~I F

I5-44

Age ( y c r s ) 45+

°-I4

2tl

F

M

F

Total .~f

I5-44

45+

F

M

F

M

F

1'4I N2 N3

68 39 _'2

13 o o

I8 o o

15 13 I

18 16 I

3 lO o

I n o

49 28 I

9 I o

13 o o

I3 3 o

13 n3 o

I n I

o I o

PI P2 P3

15 44 25

o o o

o o o

7 x2 6

7 I2 3

I 15 12

o 5 4

I2 42 12

2 o o

o o o

4 20 I

6 7 3

o I2 6

o 3 2

193

13

18

52

57

41

I~

I44

I2

13

41

5°

22

6

Total

* N = Sputum negative. P = sputum positive. 1 = radiographic change present in only one zone; hilar adenltls or pleural effusion with no lung involvement or lung involvement limited to one zone. 2 = radiographic change present in two or three zones. 3 = radiographic change present in four or more zones.

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TUBERCULOSIS IN LONDON

235

in inental hospitals. Nearly a third of all patients notified in these two years left the district during the period of observation. In 1949 2I 7 respirator), and 19 nonrespiratory cases of tuberculosis were notified, and in z95 z there were 168 respiratory and z8 non-respiratory. T h e non-respiratory cases have not been followed further. From the respiratory cases of both series three groups have been excluded, consisting of those whose notification was incorrect (I I), those who could not be traced or would not attend (3~), and those notified posthumously (5)- This has left I93 patients in the ;949 series and I44 in the I951 series. These 337 patients are the subjects of the investigation. Their classification is given in Table I. The total n u m b e r of patients in the i95 I series was smaller, but apart from relatively fewer over 45 the age distribution was similar. 23 of the ' N ' cases of the 1949 series and 7 of the I951 series subsequently proved bacteriologically positive. O f these 3° cases 24 remained negative for more than six months from diagnosis. There were 56 patients under I5 years of age and all had primary tuberculosis, either hilar adenitis with or without segmental lesions, or pleural effusions; in only 2 was bacteriological proof of the diagnosis obtained. T h e majority of patients, forming a large group of 2oo cases, were aged 15 t o 4 4 years. i8 of these had pleural effusions without obvious lung disease on diagnosis. T h e r e were 81 patients over 45 years of age; these had the more severe types of disease, and men predominated. Diabetes was a complication in 7 patients.

Comparison of the 1949 and 1951 Series Antibacterial therapy T h e z95I series is distinguished from t h e 1949 by earlier, more frequent and slightly longer administration of antibacterial therapy (Table. I I ) . In both series the patients with a positive sputum received drug treatment more frequently than those without. I n the I95I series 91 per cent of 'P' cases were given antibacterial treatment and of these four-fifths received it within a month of diagnosis. For the purpose of this investigation antibacterial treatment refers to the use of streptomycin, p-aminosalicylic acid (PAS) and isoniazid alone or in combination. In the 1949 series all antibacterial treatment during the first year was given in hospital. A 'course' usually lasted three months; in half the patients a combination of streptomycin and PAS was used, and in half one or other drug alone. Where a combination had been given PAS was often continued for a further three months. I n the I951 series 3 ° per cent of all patients with a positive sputum receiving antibacterial treatment started their 'course' at homb within three months of diagnosis. Streptomycin and PAS were now nearly always given together, and only 2 per cent received a single drug for their initial course. Combined courses were generally a little longer and were more freqfiently follow6d by a course of PAS alone.

TABLE I I . - - T H E PROPORTIONS OF TtIE I949 AND 195I PATIENTS ~VIIO RECEIVED ANTIBACTERIAL TREATMENT

Year notified

I949

I95I

Initial sputum state

Proportion (per cent) receiving drugs withhz Total

Negative io 9 Positive 84 Total 193 Negative Positive Total

78 66 144

I month 3 months 6 months

o 5

~ zo 2

28 73

4 18 5

4z 66 49

8 3t zo

46 89 62

z year

18 5[ 9z

66

3years

17 5I 32 55 9r

69

72

236

August I956

TUBERCLE

TABLE III. -

COLLAPSE TIIERAPY AND SURGICAL TREATMENT IN TIIE

1949

AND

' 9 5 I SERIES (ADULTS ONLY)

"earperformed T.)pe of proce&tre Pneumothorax

~`ear notified .-

Pneumoperitoneum

..

Phrenic crush . . . .

I949 x95I I949 I951 I949

Ist x7

Resection

-. . . . .

O t h e r operations Total procedures Total patients . . . .

.. -.

x

I~

5 I

1949 I951

41

~949 i95i

--

I

2

I

7

I

2

i

I I I3

2

5

o

2

7 I8

~ --

Io 2

o

I 47

12

9 2

o

o

I8 I6

I

3

I

24 II

x

3 IO

4

22 o

3

12

Total

2 3

7

1949 I95X I949 I95i 1949 195I

3rd

3 2I

I95I

Thoracoplasty

2rid

6~ 6

~ ~

7I I62

__

ii 9

Isoniazid, introduced into general use in April I952 , was used alone or in combination with either streptomycin or PAS in subsequent 'courses' in both series. O n l y 5 per cent of the i95I series received a 'course' of treatment lasting less than ten weeks c o m p a r e d with x3 per cent for tile i949 series.

Hospital Admission T h e waiting period before admission was longer in the I949 series than in the x951 series, since the years I95o and I951 saw an expansion in the n u m b e r of beds available. I n the whole area served by the N o r t h East Metropolitan Hospital Regional Board the n u m b e r o f beds increased by 27 per cent and the waiting list decreased bY 3 o per cent between D e c e m b e r 1949 and D e c e m b e r 195i. O f all patients admitted within one year of diagnosis half the z95x series entered hospital within the first m o n t h whereas the c o m p a r a b l e . f i g u r e for the x949 series is less than one third. W i t h i n three years fi'om diagnosis 89 per cent of the i95i series had received hospital treatment c o m p a r e d with 70 per cent o f the 1949 series. T h e r e was little difference between the series in the average duration o f hospital treatment. I n both series, o f those patients surviving three years, the ' N ' cases s p e n t s e v e n months in hospital and the ' P ' cases a b o u t a year.

Collapse Therapy and Surgical Treatment Collapse t h e r a p y (artificial pneumothorax, p n e u m o p e r i t o n e u m , and phrenic crush) and surgical treatment (thoracoplasty, resection and other major procedures) were confined to adults, a p a r t from one child treated by phrenic crush and another b y removal of caseous hilar nodes. T h e remarks that follow deal only with the adult patients receiving collapse therapy or surgical treatment, the great majority of w h o m were aged 15 to 44. I n the i9~ 9 series there were I62 adults; 20 per cent o f these were treated b y collapse therapy alone, 5 per cent b y surgery alone and 2 per cent by a combination. I n the i95x series there were I ~9 adults; 3 ° per cent o f these were treated by collapse therapy alone, 9 per cent b y surgery alone and

August t956

TUBERCULOSIS IN LONDON

237

5 per cent by a combination. Thus only 27 per cent of the adults of the I949 series received collapse therapy or surgical treatment compared with 44 per cent of the i951 series. Surgical treatment alone or in combination was used in only a small proportion of patients; yet this was in an area where ihe surgical facilities were excellent. The types of collapse measures and surgical treatments employed are shown in Table III, which gives the actual number of procedures. It disregards any collapse measures maintained for less than six months. Frequently a patient was treated with more than one procedure. In both series most collapse therapy was induced in the first year, less in the second year, and least in the third, but surgical treatment tended to be spread more evenly throughout the years. Artificial pneumothorax was the most commonly employed measure, though pneumoperitoneum became popular in the i951 series. Thoracoplasty was the commonest surgical procedure.

After-History Mortality At the end o f three years 15 per cent o f the 1949 patients were dead, comp a r e d with Io per cent o f the I95I series. I n the I949 series there were 26 deaths directly due to respiratory tuberculosis, one indirectly (cor pulmonale) and two to u n r e l a t e d causes. A m o n g the i951 patients there were i2 deaths directly due to respiratory tuberculosis, none indirectly, a n d 3 to u n r e l a t e d causes. Active respiratory tuberculosis was present in 4 o f the 5 dying from u n r e l a t e d causes, a n d only I o f these deaths o c c u r r e d in a patient u n d e r 45 years o f age. I t is clear that as the prognosis o f tuberculosis improves so d e a t h will increasingly be a t t r i b u t a b l e to u n r e l a t e d causes. T h e m a j o r i t y o f deaths directly due to tuberculosis o c c u r r e d in elderly men. T h e deaths a m o n g those over 45 are discussed more fully in a later section. O n l y 7 deaths o c c u r r e d in females in the 1949 series, a n d 3 in the I95I series. O n l y I child died, a b o y aged 8 who, after being u n d e r observation for hilar adenitis, d e v e l o p e d tuberculous meningitis from which he subsequently died. O n e d e a t h was due to pialmonary embolism following a thoracoplasty, the only d e a t h a t t r i b u t a b l e to surgery. Most deaths o c c u r r e d within the first y e a r in b o t h series ( T a b l e IV). I n the TABLE I V . - DEATIIS ~VITItIN TItREE YEARS OF NOTIFICATION DIRECTLY DUE TO RESPIRATORY TUBERCULOSIS AMONG. TIlE I949 AND 1951 SERIES

Deaths Age when diagnosed (.)'ears) o-I 4 I5-44 45 and over Total

Tear Total notified patients i949 I95I i949 I951 I949 i95r

31 IO9

i949 x95I

i93

25 91 53 28 144

Total t (3%) o (o%) 6 (6%) 3 (3%) I9 (36%) 9 (32%) 26 (13%) I2 (8%)

During ist year 2ndyear 3rdyear I

o o

4

o o

2 2

9

o

7 6

14

I

3 o

9 8

o o 3 3

o

4

238

August 1956

TUBERCLE

TABLE \ r . _ DEATttS ~VITttIN TttREE YEARS OF NOTIFICATION DIRECTLY DUE TO RESPIRATORY TUBERCULOUS RELATED TO AGE, SPUTU.Xl STATE AND RADIOGRAPIIIC EXTENT OF DISEASE (ADULTS ONLY)

Age i 5-44years

Age 45 years or more

Notified in

Notified in

Classification i949 on diagnosis* Total Deaths

1951

I949

I951

Total Deaths

Total Deaths

Total Deaths

NI N2

33 27

o o

26 24

o I

4 12

o o

I 3

o o

N3

")

I

O

O

O

0

I

O

62

I

5°

I

16

o

5

o

PI

14

o

Io

o

I

o

o

o

P2 P3

24 9

I 4

~7 4

.o o

2o 16

5 14

I5 8

5 4

47

5

41

o

37

19

23

9

Total N

Total P

*For explanation of classification s e e footnote to Table I.

second year there were fewer deaths in the I949 series and none in the I951. By the third year the deaths in the 1949 series were again reduced; but they were once more high in the i95i series, suggesting that some whose death had been delayed had now succumbed. A three year follow-up period is, of course, insufficient to do more than indicate such a tendency. Table V shows the increase in mortality which goes with age, an initial positive sputum and increasing extent of disease. ' Oddescence' 'Quiescence' occurred earlier and more frequently in the I95I series both for 'N' and 'P' cases. By the end of the first year in the I949 series 5 ° per cent of 'N' cases and five per cent of 'P' cases rdached 'quiescence' compared with 62 per cent and 9 per cent for the I95I series. By the end of three years only 36 per cent o f ' P ' cases in the z949 series had reached 'quiescence' compared with 58 per cent for the 1951 series. The good prognosis of patients without a positive sputum in both series is in part due to the inclusion of patients under 15 years of age, nearly all of whom were in class 'NI'. By the end of the third year almost all were 'quiescent' in both series: few had received antibacterial treatment. Taking adults alone, in the 1949 series 76 per cent o f ' N ' cases under 45 years of age on diagnosis, and 5 ° per cent over this age reached 'quiescence' by tile third year. For the I95I series the percentages were increased to 86 and 8o. For the 'P' cases results were less favourable, and in the I949 series only 57 per cent under 45 years of age on diagnosis and 8 per cent over this age became quiescent by the third year. In the i951 series the F.ercentages were increased to 76 and 22.

August i956

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239

Breakdown after 'quiescence' Once 'quiescence' had been attained breakdown was uncommon in both series, but tile periods of observation were short. Only one breakdown occurred in a child. Taking adults only, 9 (6 per cent) of those who became quiescent in the i949 series broke down in the second or third year from diagnosis. In the I951 series only 4 patients (3 per cent) broke down.

Five-.yearfollow-up of the z949 Series The 1949 series was followed for two years longer than the I95I series- to a total of five years. In the last two years treatment continued on the same lines as before. Antibacterial treatment was given for the first time to a further 14 per cent of the 'N' cases and to 3 per cent of the 'P' cases~ while very few were admitted to hospital for. the first time. Collapse measures were not often employed, but surgical treatment was used alone or in combination in a further 6 patients so that in the whole five years 33 of the total of I62 adults were treated surgically. T h e more even spread of surgical treatment throughout the five years was a contrast to the waning frequency of other collapse measures. There were only ~ deaths in the fourth and fifth years directly due to respiratory tuberculosis and these were both of patients over 45 years of age. One indirectly related death occurred from cor pulmonale. Nearly all deaths in the series therefore occurred in the first three years of observation. 83 per cent of the patients first notified in I949 survived five years. The number of patients 'quiescent' at five years was also very similar to that at three. O f the 'N' cases about the same proportion was 'quiescent' at the end of the fourth and fifth years as at the end of the third, but rather more 'P' cases became 'quiescent'. Breakdowns were rather common, i I patients broke down i n the fourth and fifth years compared with 9 in the previous three; and 8 of the 78 'N' patients became sputum positive for the first time. None of these had received antibacterial treatment within a year of diagnosis. The Effect of Age While initial sputum state and initial extent of disease as seen radiographically are known as important prognostic factors, the effect of age has received less attention, for most series are selected and the older age groups frequently unrepresented. The unselected population of our series allows the effect of age itself to be analysed. There were 53 patients over the age of 45 years in the 1949 series and 28 in the 1951 series - a total of SI. Their treatment was very similar to that of adults under 45 though there was a tendency in both series for older patients to be less frequently admitted to hospital and less frequently given'drug treatment. While age did not preclude active collapse measures these were also less often employed. 5 patients were treated by pneumoperitoneum, but none by artificial pneumothorax. Thoracoplasty was performed on 8 patients, and resection on 2. No collapse or surgical measures were carried out over the age of 55. J u d g e d by age alone patients over 45 years had a mortality rate seven times that of those under this age. In the two series combined there were in three years 37 adult deaths directly due to tuberculosis; 28 (76 per cent) of these were of patients over the age of 45 , yet these represented only 29 per cent of all adults. I f the largest group of patients, Group o, is considered, mortality is found to

~4o

August z956

TUBERCLE

TABLE V I . - - A D U L T PATIENTS NOTIFIED IN i949 AND 1951 XVITtt RADIOGRAPHIC CtIANGE LIMITED TO T 1 v o OR TttREE ZONES. DEATtIS AND 'OuIESCENCE' ~,VITttlN TtIREE YEARS RELATED TO INITIAL SPUTUM STATE AND AGE ON DIAGNOSIS

Classification on diagnosis*

Total patients

N2 age I5-44 N2 age 45-?

51 I5

I (e%) o (0%)

37 (73%) 8 (53%)

P2'age I5-44 P~ age 45-?

51 35

3 (6%) IO (-o9%)

3 r (6r%) 6 (17%)

14 (9%)

82 (54%)

Total

i52

Dead

'Quiescent'

*For explanation of classification s e e footnote to Table I,

vary with sputum state and age (Table VI). The mortality rate for all adults was 9 per cent. This was reduced to 2 per cent for 'N' cases and 6 per cent for 'P' cases under the age of 45 years, but for patients with a positive sputum over that age it was 29 per cent. In G r o u p 3 patients the sputum is nearly always positive and a negative result should cast doubt upon the diagnosis. For the whole of this group the mortality rate was 58 per cent, 33 per cent for those under 45 and 72 per cent for those over that age. O f the 'P3' cases over 45 in the I949 series 88 per cent were dead in three years - a mortality worse than that of treated carcinoma of the bronchus. Even with earlier drug treatment in the I95I series 5 ° per cent were de~id. Group I contained only 7 per cent of adults over 45 years of age, and here age and sputum state did not appear to modify the low mortality. Posthumous notifications were excluded from our series. During the years I949 and I951 there were I3 deaths attributed to tuberculosis where the patmnts were never notified, or only notified posthumously. All but 2 were over 45 years of age. H a d they been included in. the series the grave prognosis of tuberculosis in the older age groups would have been even more apparent. The effect of age on 'quiescence' was similar to that on mortality. Fewer patients over the age of 45 became 'quiescent' than those under this age in all groups. Table VI shows the percentage reaching 'quiescence' in Group 2. The fewest of any group to become 'quiescent' were 'P3' cases over the age of 45 (8 per cent only). Discussion

This investigation is unusual in that it takes into account every case of respiratory tuberculosis diagnosed and notified in an east London area. By choosing the years 1949 and i95I for study an attempt has been made to show the influence of earlier and more widespread use of antibacterial treatment, but in no other way have the patients been specially selected.

August i956

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241

Comparison with the most nearly comparable published accounts shows a much higher five-year survival rate in this series. Lowe (x954) in Birmingham found rates of 3o per cent for patients notified in I93 % 34 per cent for I935 and 45 per cent for those notified in 1945- Acker (I95I) reported a five-year survival rate in Edinburgh of 54 per cent for patients notified between I936 and I944. But 83 per cent of the patients notified in I949 in this area of east London were alive five years later. The survival rate for sputum-positive patients is also much higher. Before the introduction of antibacterial treatment Thompson (I943) found that only 25 per cent of such cases in County D u r h a m survived five years; Tattersall (I947) only 32 per cent in Reading; and Fraser (I947) only 45 per cent in Aberdeen. The five-year survival rate for the initially positive patients in our i949 series is 69 per cent, or 73 per cent for those positive at any time. These survival rates represent a dramatic improvement in prognosis and must be due to the initial impact of antibacterial treatment. The I95I series has been followed for only three years, but it seems likely that a longer follow-up would show results superior to those of the I949 series. This further, though less pronounced, improvement is probably due to t h e earlier and wider use of antibacterial drugs. The study of prognosis has been hindered for lack of a simple yet adequate classification of cases. In our investigation the radiological classification that we have employed is essentially that of Foster-Carter and others (I952) . We have combined this with sputum state and age on diagnosis. While no classification is entirely satisfactory the one employed here proved easy to use and an effective guide to prognosis. It appears much more satisfactory than the standard classification of the Ministry of Health, which in our view requires revision. Children accounted for one-sixth of the total notifications, and, apart from one child with hilar adenitis who subsequently died from tuberculous meningitis, all attained 'quiescence' within two years. However, much bigger surveys than this are required to demonstrate the occasional grave sequelae of primary infection which offset the generally benign character of the disease. In childhood most of the deaths occur amongst the non-respiratory notifications, particularly tuberculous meningitis and miliary tuberculosis. Adults under 45 years of age accounted for most of those notified. Collapse therapy and surgical treatment were almost confined to this group. Surgery played a relatively minor part in both series; but like collapse therapy had increased in the i95i group. There can be no doubt that the increased use of antibacterial treatment made more patients suitable for these measures. Improvement in prognosis was most marked at this age, and was reflected by a fall in the number of deaths, earlier attainment of 'quiescence', and reduced liability to breakdown. Taking both series together, by the end of three years 6 per cent were dead, 74 per cent were quiescent, and 2o per cent remained active. This still leaves room for considerable improvement. O f particular interest is the difference in mortality between the sexes at this age. The commonly described preponderance of deaths in young adult females was not demonstrated. The figures are small, but in each five-year period a higher proportion of deaths occurred amongst males. A partial explanation o f this change may be the lessening of the hazards of pregnancy since the introduction of antibacterial treatment.

242

TUBERCLE

August i956

Adults over 45 years of age showed the worst prognosis. Only 7 per cent had Group I disease, and the prognosis of the remainder was worse than that of younger patients with the same extent of disease. Over 75 per cent of the patients were men. This poor prognosis in older patients is usually not apparent, since most accounts of treatment deal with adults under 45 years of age. The results for the I95I series were only slightly less unfavourable than those for I949. Taking both series together, within three years 41 per cent were dead, only 25 per cent were 'quiescent', and 34 per cent remained 'active' cases most of whom were unamenable to further treatment. Antibacterial treatment used in both series had a less dramatic effect in the elderly, and the large number of patients who failed to attain 'quiescence' will form an important source of infection for the future. This problem is a serious and an increasing one. Antibacterial treatment cannot be given much earlier after diagnosis than it was in the i95i series; and with the drugs at present available the best hope for improved results in the future appears to be centred upon earlier diagnosis and more prolonged treatment. Summary An account is given of respiratory tuberculosis in an arca of East London where an attempt has been made to follow cvcry patient notified in thc ycars 1949 and 1951. A satisfactory follow up was obtained in 193 notified in I949 and 144 notified in 1951. The rcsults in tcrms of survival were much better than in any unselected group of notified paticnts previously recorded. In both series hospital trcatment, collapse measures and surgical treatment differed only slightly, but there was a great difference in the antibacterial treatment given. In the i95I series a larger number received it, and a larger number received it early. In terms of survival, 'quiescence' and liability to break down the prognosis over a three-year pcriod was better for the 1951 series than for the 1949. The group most fiavourabty affected was that of adults under 45 ),ears of age. Over 45 ),ears the prognosis was still poor in both series. In assessing prognosis at the time of diagnosis the clearest picture was gained if account was taken of the age of the patient and the sputum state as well as the radiographic extent of the disease. A simple classification including these factors has been described. We wish to thank Mr B. Benjamin, Chief Statistician to the General Register Office; Mr J. R. Belcher, Surgeon to the London Chest Hospital; and Dr ~V. Hartston, Principal ~Iedical Officer (Tuberculosis), London County Council, for their help. ~Ve also thank those physicians who kindly supplied us with information about their patients, and Miss E. Hcwison for secretarial assistance. References

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