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The dispensary treatment of phthisis. What it may achieve
February, 1920]
219
TUBERCLE
cases of apical tuberculosis. During the last decade Freund's hypothesis found a certain number of supporters who advocated the operation arid who have also in some cases put it into practice. The evidence of the accuracy of the premises did not seem to me to ~ conclusive, and for this reason I investigated, in 1913, specimens from 201 autopsies, 100 radiograms of the upper thoracic opening which had pl"eviously been taken for other purposes, and the thoracic skeleton and contents from 17 monkeys. The results were published in full in the Driti.~k Journal of Surgery. I It is sufficient here to quote the summary. "(1) Neither abnormal shortage nor ossification of the first cartilage predisposes to apical pulmonary tuberculosis. II (2) Abnormal shortness of the first costal cartilage does not encourage ossification in that cartilage. H (3) Ossification of the first costal cartilages is dependent on age and sex and probably on occupation. '" (4) With increasing age, there is increase in limitation of movement of the sternal angle. .. (5) Limitation of movement of the sternal angle does not predispose to apical pulmonary tuberculosis. .. (G) The presence of a groove in the posterior external aspect of the lung below the apex (Schmod) is not the result of abnormal shortage of the costal cartilage, but probably of emphysema. .. (7) The formation of a false joint in the rigid cartilage does not tend to lead to the cure of apical tuberculosis; and therefore II (8) The balance of evidence. is against the probability of the operation {or division of the first costal cartilage in cases of apical tuberculosis producing. any material improvement."
has
THE DISPENSARY TREATMENT OF PHTHISIS. :MAY ACHIEVE. By HENRY A.
ELLIS,
\VHAT IT
M.B., B.S.
Late Tuberculo8ill Medical Officer JOT Middle,brough. WIlEN considering the results available after a four years' study of the problem of ,the treatment of tuberculosis in a. County Borough, one asks ones elC the question "·What definite views have been arrived at?" .. ,Vhat are the outstanding advantages in the present method of handling the tuberculosis problem?" and .. What are the most apparent defects whose reform should be aimed at?" The first most outstanding point is the enormous value and capacity of the Dispensary over all other methods for observation and treatment, whether this is considered from the results achieved or the costs at which those results are obtained. It must be remembered that costs are still a. roost material factor in the tuberculosis problem. Funds nre still limited, and if the best use is not bein~ made of the available money, success has not 'been achieved, and waste has occurred. I .. A Consideration of the Influence of the First Costal Cartilage toeill," DTiti8h Journal of Surgery, vol. i, No.1, 1913.
011
Apical Tubercu.
220
TUBERCLE
. [February. 1920
Originally a sanatorium man. I recognised ere long the liinita:tion ana failure of the sanatorium in the control of tuberculosis, though its value in a. general scheme is undoubted. THE DISPENSARY SYSTEM.
Dispensary treatment IS the main factor in the Middlesbrough scheme. and the keynote of that dispensary treatment i:i1 that, when once a case has been reported, it is kept under observation, directly or indirectly. till death has occurred or the individual may be considered safe; by which latter is meant· two years of ordinary life, with ordinary strains and ailments, without the display of any tendency to the increase of the tuberculosis incidence. Nurses are the keynote of this successful system, and the' question arises, How many nurses are necessary to achieve definite results? I think there should be one dispensary nurse to every 30,000 population in Count1" . Boroughs, and at least one doctor to every 60,000. That this method of controlling pulmonary tubercle is on the right lines must be admitted, when the diminished death-rate from adult male lunt< tubercle in Middlesbrough is realised. Lung tubercle is the variety of tubercle about which, at present, the most complete information. exists and is also the most carefully treated class. During the five .years ~ question it has achieved a fall in the death-rate, as shown in the report of adult males over 16, from 95 deaths in 1914, to 88 in 1915,81 in 1916 ~nd 1017, and 69 in 1918, or a total fall of 27 per cent., and that in face of a large increase in the population. But, furthermore, and what is even more interesting, advanced cases, as shown in the report. have been reduced amongst the insured, from 97 cases Class III, or 48 per cent. on the roll of 1916, to 26 cases, or ] 0 per cent. on the roll of 1919, which latter figure includes all the Poor Law cases which have been insured, which were no\ ·included'in the 97 cases of the 191G roll. The present roll suggests a further great improvement in the pulmonary death rate of the present :year 1919, in spite of the diminished .resistance produced by the grave influenza epidemics we have passed through. That such ,an improvement can be achieved without a. Pulmona~_ Hospital-for Middlesbrough does not possess one, having only a sanatorium of twenty-'eight beds, used for early cases-':"'suggests that the whole view of the treatment for advanced cases demands reconsideration. and the question arises in the face of such successful results, U Are the main theories correct on which the treatment of advanced tuberculosis is based?" .After-care is of course considered an essential part of dispensary treatment, and by its means occasional holidays are given; free from financial strain, when the resistance is threatened. The total costs of the administration of the dispensary should work out at'somewhere between £3 and £5 per case treated. In Middlesbrough the cost; worked out roughly. is under £3 per head, so it is highly economic as well as' successful.' . . After the dispensary in value comes the sanatorium for the treatment of early cases. This roughly costs five times as much, which means that only one c~se ca~ b~ tre3:ted for the B~me amo~mt as fhe ~n the dispensary -a materIal pomt If funds are defiCIent. StIll, on the whole results are
February, 1920J.
TUBERCLE
221
good, but it does not compare pound for pound with the value of dispensary treatment, and therefore until full dispensary requirements are satisfied sanatoriums should occupy a distinctly second place as a comparatively unremunerative undertaking. The treatment of children of school age threatened with tuberculosis is also an essential portion of the dispensary treatment, and is probably the most remunerative of all tuberculEl3is expenditure. In the Middlesbrough plan, infection is considered to be so universal that the raising of tile resistance of those in danger of breakdown has replace~ its oonsideration as a main objective in a modern tuberculosis campaign. PRESENT DEFECTS IN ADMINISTRATION.
The next consideration in looking back over the four years under review is, ""Vhat are the main errors outstanding at present? Undoubtedly the most discordant note is the enormous proportion revealed by the report of cases dying within six months of notification. The figures are staggering, and, as the other County Boroughs investil{ated appear no better, the whole question demands most earnest consideration. Take the years 1914, 1915, 1916, the figures read 164, 170, and 153 dying within t~e first six months after noti?cation, as al{ainst 24, 24, 25 in the second SIX months, and 22,26 and 20 10 the whole of the following or second year. This, of course, contains two corollaries: one, that tubercle in the main may be much more rapidly fatal than we are in the habit of considering, and secondly, that those who survive two years, or even one in the.· mass, do not die in anything like the supposed proportion. Th~ natural criticism that presents itself is, that very young cases, under 10, who die usually from the acu.te forms of the disease are included, and, as all figures Bre generally mixed together, an erroneous impression is - produced. . ]3ut, even eliminating those under 15 years, as shown in the report, the 6n'ures still remain a discouragement and general admission of failure. The deaths within six months of notifica.tion in those over 15 years for Middlesbrough are, for the years .1914, 1015, 1916-100, 00, 100, as an'ainst 21, 21, 21, for the next SIX months, and 19, 22, 16, for the 6~b5equent twelve months. This should not be, and demands investigation as to w.heth~r it is due to a failing of recognition of early cases, or failure of notificatIOn, or the presence of much more acute tuberculosis than is suspected, as is suggested by Dr. Brownlee's investigations. That this latter point is probably a much greater cause of early death after notification than is generally recognised,.1 have no doubt. In the 31 deaths investigated with a view' to ascertaining the amount existing in Middlesbrough, 14, or nearly half, came under the heading of acnte, as dying with!n one year of the first symptom of ill-health appearing. Curiously, in confirmation of Dr." Brownlee's hypothesis, they were divided between persons between th~ ages of 17 and 22, and above the age of 43, no acute deaths occurring between 22 and 43, suggesting that Dr. Brownlee's deduction may Qe correct, that the young and old variety may be one strain and the intermediate another. This should be investigated as it easily can be by keeping an accurate record of all acute cases ie' cases dying within a year of the first symptoms.'. ' .' " II
222
TUBERCLE
[February, 1920
This brings me to what is possibly the worst error of the present tuberculosis administration, that is, the way the statistics are compiled. They are so massed together and mixed up that no reasonable information can be obtained. First, male and female figures are not kept separately, which is absurd, considering that the difference in the acre incidence of deaths of men and women from tuberculosis is one of the outstanding features of the disease. Then, cases above and below 15 are mixed together, although acute meningeal tuberculosis is a twenty-one day disease, and usually occurs under 10 years of age. Again, tuberCUlosis of the bones and joints is another inherently different proposition. : The neglect of this treatment of b~ne and)oint d~sease is one of 'the great scandals of the whole tuberculOSIS questlOn, as It causes at least half the' permanent cripples. There i~ no greater scandal existing at the present day than the indifference in this country to the question. of the - Unnecessary occurrence of tuberculosis cripples. To sum up the whole question, from a four years' study of tuberCUlosis in the County Borough of Middlesbrough, with its popUlation of: about 125,000 people, I should say the main deductions arrived at are : (1) The dispensary system, properly carried out, should be Our 'lIlain first line of defence against tuberculosis, as being both essentially efficien~ and economic. (2) Sanatoriums for early cases are both valuable and necessary as lit direct aid to dispensary treatment. I (3) The whole question 'of the theories of advanced tuberculosis shOUld be reconsidered. (4) An effort should be made to find out how much acute pulmonan tuberculosis exists (an almost incurable condition, killing usually 'Witbiil twelve months of first symptoms). (5) The reason for the failure of early notification should be investigated . (6) The present form of statistics should be revised; as at .presenL published they are useless for comparison purpo!?es. ·As a tentative classification, to focus discussion, might I suggest that statistics be divided into male, female and children under 15. The following differentiation might then be adopted : Pulmonary. (1) Acute, death under one year from onset of first symptoms. (2) Intermediate, death between one and· two years of onset.. (3) Chronic, patient alive after two years from onset of symptoms. Non-P.ulmonary. (1) . Meningeal or general. (2) Abdominal. Surgical. (1) Superficial-cutaneous and glandular, eyes. &c.
(2) Deep-osseous, bones and joints. . . So may we be able. to arrive at an· answer to the vital. question_ " Are we making 'any progress' or not.in the control of tuberculosis, and if progress is being made, in what direction are we progressing? ..
219
TUBERCLE
cases of apical tuberculosis. During the last decade Freund's hypothesis found a certain number of supporters who advocated the operation arid who have also in some cases put it into practice. The evidence of the accuracy of the premises did not seem to me to ~ conclusive, and for this reason I investigated, in 1913, specimens from 201 autopsies, 100 radiograms of the upper thoracic opening which had pl"eviously been taken for other purposes, and the thoracic skeleton and contents from 17 monkeys. The results were published in full in the Driti.~k Journal of Surgery. I It is sufficient here to quote the summary. "(1) Neither abnormal shortage nor ossification of the first cartilage predisposes to apical pulmonary tuberculosis. II (2) Abnormal shortness of the first costal cartilage does not encourage ossification in that cartilage. H (3) Ossification of the first costal cartilages is dependent on age and sex and probably on occupation. '" (4) With increasing age, there is increase in limitation of movement of the sternal angle. .. (5) Limitation of movement of the sternal angle does not predispose to apical pulmonary tuberculosis. .. (G) The presence of a groove in the posterior external aspect of the lung below the apex (Schmod) is not the result of abnormal shortage of the costal cartilage, but probably of emphysema. .. (7) The formation of a false joint in the rigid cartilage does not tend to lead to the cure of apical tuberculosis; and therefore II (8) The balance of evidence. is against the probability of the operation {or division of the first costal cartilage in cases of apical tuberculosis producing. any material improvement."
has
THE DISPENSARY TREATMENT OF PHTHISIS. :MAY ACHIEVE. By HENRY A.
ELLIS,
\VHAT IT
M.B., B.S.
Late Tuberculo8ill Medical Officer JOT Middle,brough. WIlEN considering the results available after a four years' study of the problem of ,the treatment of tuberculosis in a. County Borough, one asks ones elC the question "·What definite views have been arrived at?" .. ,Vhat are the outstanding advantages in the present method of handling the tuberculosis problem?" and .. What are the most apparent defects whose reform should be aimed at?" The first most outstanding point is the enormous value and capacity of the Dispensary over all other methods for observation and treatment, whether this is considered from the results achieved or the costs at which those results are obtained. It must be remembered that costs are still a. roost material factor in the tuberculosis problem. Funds nre still limited, and if the best use is not bein~ made of the available money, success has not 'been achieved, and waste has occurred. I .. A Consideration of the Influence of the First Costal Cartilage toeill," DTiti8h Journal of Surgery, vol. i, No.1, 1913.
011
Apical Tubercu.
220
TUBERCLE
. [February. 1920
Originally a sanatorium man. I recognised ere long the liinita:tion ana failure of the sanatorium in the control of tuberculosis, though its value in a. general scheme is undoubted. THE DISPENSARY SYSTEM.
Dispensary treatment IS the main factor in the Middlesbrough scheme. and the keynote of that dispensary treatment i:i1 that, when once a case has been reported, it is kept under observation, directly or indirectly. till death has occurred or the individual may be considered safe; by which latter is meant· two years of ordinary life, with ordinary strains and ailments, without the display of any tendency to the increase of the tuberculosis incidence. Nurses are the keynote of this successful system, and the' question arises, How many nurses are necessary to achieve definite results? I think there should be one dispensary nurse to every 30,000 population in Count1" . Boroughs, and at least one doctor to every 60,000. That this method of controlling pulmonary tubercle is on the right lines must be admitted, when the diminished death-rate from adult male lunt< tubercle in Middlesbrough is realised. Lung tubercle is the variety of tubercle about which, at present, the most complete information. exists and is also the most carefully treated class. During the five .years ~ question it has achieved a fall in the death-rate, as shown in the report of adult males over 16, from 95 deaths in 1914, to 88 in 1915,81 in 1916 ~nd 1017, and 69 in 1918, or a total fall of 27 per cent., and that in face of a large increase in the population. But, furthermore, and what is even more interesting, advanced cases, as shown in the report. have been reduced amongst the insured, from 97 cases Class III, or 48 per cent. on the roll of 1916, to 26 cases, or ] 0 per cent. on the roll of 1919, which latter figure includes all the Poor Law cases which have been insured, which were no\ ·included'in the 97 cases of the 191G roll. The present roll suggests a further great improvement in the pulmonary death rate of the present :year 1919, in spite of the diminished .resistance produced by the grave influenza epidemics we have passed through. That such ,an improvement can be achieved without a. Pulmona~_ Hospital-for Middlesbrough does not possess one, having only a sanatorium of twenty-'eight beds, used for early cases-':"'suggests that the whole view of the treatment for advanced cases demands reconsideration. and the question arises in the face of such successful results, U Are the main theories correct on which the treatment of advanced tuberculosis is based?" .After-care is of course considered an essential part of dispensary treatment, and by its means occasional holidays are given; free from financial strain, when the resistance is threatened. The total costs of the administration of the dispensary should work out at'somewhere between £3 and £5 per case treated. In Middlesbrough the cost; worked out roughly. is under £3 per head, so it is highly economic as well as' successful.' . . After the dispensary in value comes the sanatorium for the treatment of early cases. This roughly costs five times as much, which means that only one c~se ca~ b~ tre3:ted for the B~me amo~mt as fhe ~n the dispensary -a materIal pomt If funds are defiCIent. StIll, on the whole results are
February, 1920J.
TUBERCLE
221
good, but it does not compare pound for pound with the value of dispensary treatment, and therefore until full dispensary requirements are satisfied sanatoriums should occupy a distinctly second place as a comparatively unremunerative undertaking. The treatment of children of school age threatened with tuberculosis is also an essential portion of the dispensary treatment, and is probably the most remunerative of all tuberculEl3is expenditure. In the Middlesbrough plan, infection is considered to be so universal that the raising of tile resistance of those in danger of breakdown has replace~ its oonsideration as a main objective in a modern tuberculosis campaign. PRESENT DEFECTS IN ADMINISTRATION.
The next consideration in looking back over the four years under review is, ""Vhat are the main errors outstanding at present? Undoubtedly the most discordant note is the enormous proportion revealed by the report of cases dying within six months of notification. The figures are staggering, and, as the other County Boroughs investil{ated appear no better, the whole question demands most earnest consideration. Take the years 1914, 1915, 1916, the figures read 164, 170, and 153 dying within t~e first six months after noti?cation, as al{ainst 24, 24, 25 in the second SIX months, and 22,26 and 20 10 the whole of the following or second year. This, of course, contains two corollaries: one, that tubercle in the main may be much more rapidly fatal than we are in the habit of considering, and secondly, that those who survive two years, or even one in the.· mass, do not die in anything like the supposed proportion. Th~ natural criticism that presents itself is, that very young cases, under 10, who die usually from the acu.te forms of the disease are included, and, as all figures Bre generally mixed together, an erroneous impression is - produced. . ]3ut, even eliminating those under 15 years, as shown in the report, the 6n'ures still remain a discouragement and general admission of failure. The deaths within six months of notifica.tion in those over 15 years for Middlesbrough are, for the years .1914, 1015, 1916-100, 00, 100, as an'ainst 21, 21, 21, for the next SIX months, and 19, 22, 16, for the 6~b5equent twelve months. This should not be, and demands investigation as to w.heth~r it is due to a failing of recognition of early cases, or failure of notificatIOn, or the presence of much more acute tuberculosis than is suspected, as is suggested by Dr. Brownlee's investigations. That this latter point is probably a much greater cause of early death after notification than is generally recognised,.1 have no doubt. In the 31 deaths investigated with a view' to ascertaining the amount existing in Middlesbrough, 14, or nearly half, came under the heading of acnte, as dying with!n one year of the first symptom of ill-health appearing. Curiously, in confirmation of Dr." Brownlee's hypothesis, they were divided between persons between th~ ages of 17 and 22, and above the age of 43, no acute deaths occurring between 22 and 43, suggesting that Dr. Brownlee's deduction may Qe correct, that the young and old variety may be one strain and the intermediate another. This should be investigated as it easily can be by keeping an accurate record of all acute cases ie' cases dying within a year of the first symptoms.'. ' .' " II
222
TUBERCLE
[February, 1920
This brings me to what is possibly the worst error of the present tuberculosis administration, that is, the way the statistics are compiled. They are so massed together and mixed up that no reasonable information can be obtained. First, male and female figures are not kept separately, which is absurd, considering that the difference in the acre incidence of deaths of men and women from tuberculosis is one of the outstanding features of the disease. Then, cases above and below 15 are mixed together, although acute meningeal tuberculosis is a twenty-one day disease, and usually occurs under 10 years of age. Again, tuberCUlosis of the bones and joints is another inherently different proposition. : The neglect of this treatment of b~ne and)oint d~sease is one of 'the great scandals of the whole tuberculOSIS questlOn, as It causes at least half the' permanent cripples. There i~ no greater scandal existing at the present day than the indifference in this country to the question. of the - Unnecessary occurrence of tuberculosis cripples. To sum up the whole question, from a four years' study of tuberCUlosis in the County Borough of Middlesbrough, with its popUlation of: about 125,000 people, I should say the main deductions arrived at are : (1) The dispensary system, properly carried out, should be Our 'lIlain first line of defence against tuberculosis, as being both essentially efficien~ and economic. (2) Sanatoriums for early cases are both valuable and necessary as lit direct aid to dispensary treatment. I (3) The whole question 'of the theories of advanced tuberculosis shOUld be reconsidered. (4) An effort should be made to find out how much acute pulmonan tuberculosis exists (an almost incurable condition, killing usually 'Witbiil twelve months of first symptoms). (5) The reason for the failure of early notification should be investigated . (6) The present form of statistics should be revised; as at .presenL published they are useless for comparison purpo!?es. ·As a tentative classification, to focus discussion, might I suggest that statistics be divided into male, female and children under 15. The following differentiation might then be adopted : Pulmonary. (1) Acute, death under one year from onset of first symptoms. (2) Intermediate, death between one and· two years of onset.. (3) Chronic, patient alive after two years from onset of symptoms. Non-P.ulmonary. (1) . Meningeal or general. (2) Abdominal. Surgical. (1) Superficial-cutaneous and glandular, eyes. &c.
(2) Deep-osseous, bones and joints. . . So may we be able. to arrive at an· answer to the vital. question_ " Are we making 'any progress' or not.in the control of tuberculosis, and if progress is being made, in what direction are we progressing? ..