- Email: [email protected]
The Public's View of Tuberculosis
661 ’
established the quantitative measurements sound on a basis, DONALD and his colleagues then data from which the effect of nursing provided cardiac output could be determined. positions upon to see It is pleasing published data from which the own conclusions and compare can draw his reader of the authors-a practice which with those them be more frequently followed. with advantage might effect of posture on the cardiac found that the They some was variable. In subjects cardiac output output in some it rose, and in some it remained unchanged, fell. In the whole group there was a mean decrease of 0’36 litre per min. : this decrease was statistically significant, but the authors consider it to be so small The 36 people studied as to be probably unimportant. included 10 normal subjects, 6 with a high resting cardiac index and 6 with a low cardiac index, 6 patients with mitral stenosis, and 8 with either cardiac or respiratory disorders. In a heterogeneous clinical group the mean results may bear little relation to the clinical significance of the findings in the various subgroups ; and, in selecting their subjects to cover all variables, DONALD et al. have necessarily had some difficulty in expressing their results, even though none of these subgroups behaved differently from the whole group. It is conceivable, for example, that in the group of patients who had lately been in congestive cardiac failure the work of pumping 0-36 litre per minute extra-500 litres per day-might be quite sufficient to cause, the death of a patient on the borderline of congestive failure, if he was nursed flat-an unlikely event. The renal tubules excrete excess sodium before long changes can be detected in the plasma, and life is sustained on one or two microgrammes of vitamin B12 daily. It would not be surprising, therefore, if the body’s homoeostatic mechanisms in the cardiovascular system were more sensitive than the present means of measuring them. If this is so, then it is unlikely that statistical analysis in a heterogeneous group can reflect the true state of affairs unless the number of subjects in the subgroups is greatly increased. This, in the matter investigated by DONALD et al., would entail Herculean work out of proportion to the importance of the question posed-and these observations are applicable to many aspects of clinical research. DONALD and his colleagues have appreciated the difficulties, and they have been conservative in interpreting their findings concerning cardiac output in direct relation to clinical problems. That the measurement of cardiac output is at present rather crude is also suggested by the more consistent findings with pulmonary-artery pressures and pulsepressures-measurements that are subject to smaller error. DONALD et al. found that in the sitting position the pulmonary-artery pressures, in people with a high initial pressure, and the pulse-pressures, in the whole group, fell. While it is readily understandable, though by no means proven, that symptoms are relieved by a fall in pulmonary-artery pressures and by the consequent decrease in the demands on the heart, it is hard to understand the teleological reason for the fall of pulse-pressure in the sitting position in normal subjects, seeing that most of us sleep flat. No doubt much more evidence will be forthcoming to answer these questions, but meanwhile the clinician may be relieved to know that it is justifiable to nurse his patients in the position they find most comfortable.
Having
The Public’s View of Tuberculosis SURVEYS of public opinion, ranging from the housewife’s view of foaming detergents to the mother’s estimate of child-welfare clinics, are as popular as ever. GORE and HARTSTON1 have now given the results of a survey, made during the first quarter of 1952 by health visitors, of 1080 mothers of children born in the administrative county of London and in Tottenham during the fortnight ended Sept. 1, 1951. The aim was to measure the extent of the public’s knowledge of pulmonary tuberculosis and to see whether people were aware of the facilities for the diagnosis and treatment of this disease. The inquiry was made among a readily accessible group of women, who were to some extent selected in that they were the mothers of six-month-old babies and represented, therefore, only a small proportion of the whole female population. An earlier survey, carried out in the London area in 1950, was partly based on a questionary about tuberculosis, which was put to 432 adults, a carefully selected " random " sample. This inquiry was also used to compare the reliability of those interviewers who were fully experienced in the technique of interviews with that of interviewers new to the work. An analysis showed that the responses obtained were sufficiently close to justify the use of amateur interviewers when these
were
easier to
come
by.2 This finding is of importance when judging the results of the surveys made by students from the teaching hospitals as part of their public-health training-for example, a recent survey to assess the value of antenatal instruction and child-welfare clinics. The tuberculosis questionary used in 1950 was used again by the health visitors in 1952. The first question dealt with the relative mortality of tuberculosis and cancer ; 44% of those interviewed thought that tuberculosis killed most people in this country, and 35% considered cancer to be the chief cause of death. At the time of the survey, 41 % thought more about tuberculosis than about any other disease-nearly twice as many as those whose thoughts were more often on cancer. It should be noted that the early part of 1952 was not a time when poliomyelitis The confusion was prominently in the public mind. about tuberculosis is indicated by the fact that while 43% thought that the disease was hereditary, 44% believed it was not ; and of those who said that it was not, or did not know, 42% had no idea how the infection could be conveyed. Contrariwise, when asked if the disease was catching or contagious, 71% said " yes " and 22% said " no." Of the 1080 women interviewed, 66 said that there was somebody with tuberculosis in their family at the time, but 30% of this contact group did not think that the disease was infectious. This figure makes it clear that the instruction given by tuberculosis health visitors. and chest physicians is not getting across or is being misunderstood by patients and their families. But 80% of the 66 women who were family contacts said that their chests had been radiographed, which indicates very efficient supervision of contacts either by mass X-ray units
or
by
chest
clinics, though 80%
is
probably
Mon. Bull. Minist. Hlth Lab. Serv. 1. Gore, A. T., Hartston, W. 1953, 12, 131. 2. Durbin, J., Stuart, A. J. R. statist. Soc. 1951, 114, part II.
662
higher than the proportion in the whole contact population. Few physicians at chest clinics would claim a supervision-rate as high as this. The failure to examine all contacts may be partly explained by the fact that 69% of the women questioned thought that many people were afraid to be examined in case they had tuberculosis. The sketchiness of the public’s knowledge of tuberculosis was also shown by the fi -nding that 54% of women knew nothing about the causes of extrapulmonary tuberculosis, and only 4% suggested that milk had something to do with it. In
several other ways the survey disclosed lack of information or failure to absorb it : 80 % had never heard of B.C.G. vaccine ; more than half realised that hospitals and sanatoria were provided for treatment, but only a quarter knew that priority food and milk were available for tuberculous patients. On the other hand, 72% said that the present number of hospitals and sanatoria was insufficient to deal with a disease which 91 % considered to be a serious problem and which 61% thought was more serious than poliomyelitis. These results are very similar to those obtained by DAVID3 in his analysis of the 1950 survey, with one curious exception in the answers to the question about symptoms. Frequent cough was thought to be a symptom by 63% of the mothers and by only 35% of those in DAVID’s analysis ; 19% mentioned blood in the sputum, as compared with 8% in 1950 ; and 28% included loss of weight, as against 18% in the earlier figures. Perhaps this difference was the result of direct questions at the antenatal clinic, but it may also be attributable to the valuable health teaching given by certain women’s magazines. When, as the survey suggests, 80% of this adult population know where to go for an X-ray examination of the chest which 98% feel should be done regularly to combat a disease which 80% think is curable, which 91 % believe is a serious problem to the country, and which 71 % know to be contagious, it is disappointing that the spread of the disease has not been checked more rapidly. Can it be because of the 69% who are afraid to be examined in case they have the disease ? Or is there some error in the survey-not in the sampling, but in the method of interview ? There is now some evidence from the interviewers, both amateur and professional, that the much-interviewed public, especially the housewife, is at last beginning to show some " interviewer resistance." No longer are questions answered with a’simple spontaneity, but with some hesitation as if the speaker was considering whether or not the answer would please the interviewer, or weighing any indirect repercussions that might arise from the reply. So it is becoming increasingly difficult to be sure that figures obtained in this way accurately reflect public knowledge and opinion. But these latest results emphasise the importance of vigorous propaganda ; and the best keynote in the campaign is the cheerful one that patients can be made well and restored to a normal life. Using all the well-tried methods of advertising, backed by instruction through the press, radio, television, and cinema, the methods of prevention and the importance of early treatment can be driven home. Although modern chemotherapy has greatly improved the chances of successful treatment, it has not detracted from the importance of knowledge as a means of prevention. 3.
David, S. T.
Tubercle, Lond. 1952, 33, 78.
Annotations THE MEANING OF EDUCATION THE hours we spent with dogfish and club-mosses,
nerve-muscle preparations, test-tubes, cultures, and microscope slides laid down in us patterns as lasting as those in Pavlov’s dogs. Even if we have since been exponents of the art, rather than of the science, of medicine our training has preserved in us some lingering sense of proportion and discrimination when the scientific aspects of our calling are discussed. This is something; but as a preparation for life was it enough ? Was it Dr. even thorough enough, let alone wide enough ? A. T. Macqueen1 thinks not ; and he urges the value of philosophy as a mind-widening discipline for students. " Despite the lip service paid to the concept of treating the patient as a whole," he says, " too many medical students graduate with the idea-which their teachers do little to correct by philosophical teaching-that man is little more than a collection of basic particles, built up into cells and organs, which needs occasional technical repair and a lot of humouring." There is no coherent theory of medical philosophy ; yet (as academic philo. sophers are always trying to point out) all men are applied philosophers, none more so than doctors ; and every decision, every word of advice given by doctors, implies a philosophy, an attitude to man, to human rights and duties, and to the universe as a whole. If doctors themselves have no clear notion of their philosophy what diverse and random impressions must they leave upon their patients, and what vast tracts of their patients’ minds and natures they leave unexplored. The idea of learning philosophy-and its sworn companion, logic-does not readily commend itself to doctors. Scientific method, we are apt to think, is-or should be-a better training for the mind than logic ever was. As for the relations of man to God and the universe and all that, the attitude proper to a scientist is agnostiIn modern education, however, and especially cism. perhaps in medical education, the opportunities for hearing what great minds in the past have thought about such topics are so few that our attitude of agnosticism might strike an informed observer as one of agnosia. Medical ethics are no more self-evident than any other kind of ethics. What is a " right " or a " wrong " human (or professional) act?’? This is a problem in applied philosophy, yet our universities seem to assume that the medical student can solve it without formal lectures or any encouragement to consult published work. Certainly many doctors (like many other university students) cannot distinguish between a primary and a secondary cause ; and here Dr. Macqueen refers us for examples to The Lost Tools of Learning,2 a paper read by Miss Dorothy Sayers to a vacation course in education a few years ago. She illustrates not only such failures in discrimination, but also the common trick of assuming the thing we set out to prove. Modern education, she argues, does not teach us how to learn : we remember what we have learnt, but forget altogether how we learned it ; and she believes that medieval schemes of education did the job rather better. For the syllabus was divided into two parts, the trivium and the quadrivium;; and the whole of the first part (the trivium) was concerned with teaching the pupil how to think and how to learnhow to use his tools, in fact. The trivium consisted of grammar, dialectic, and rhetoric, in that order ; which fitted themselves very well, she says, to three stages of childhood-the " pollparrot," the " pert," and the " poetic." Grammar meant learning (at an age when glib learning is easy) the structure of a language-usually Latin-and later how 1. Universities Quarterly, May, 1953, p. 298 2. London : Methuen. 1948. Pp. 30. 1s.
established the quantitative measurements sound on a basis, DONALD and his colleagues then data from which the effect of nursing provided cardiac output could be determined. positions upon to see It is pleasing published data from which the own conclusions and compare can draw his reader of the authors-a practice which with those them be more frequently followed. with advantage might effect of posture on the cardiac found that the They some was variable. In subjects cardiac output output in some it rose, and in some it remained unchanged, fell. In the whole group there was a mean decrease of 0’36 litre per min. : this decrease was statistically significant, but the authors consider it to be so small The 36 people studied as to be probably unimportant. included 10 normal subjects, 6 with a high resting cardiac index and 6 with a low cardiac index, 6 patients with mitral stenosis, and 8 with either cardiac or respiratory disorders. In a heterogeneous clinical group the mean results may bear little relation to the clinical significance of the findings in the various subgroups ; and, in selecting their subjects to cover all variables, DONALD et al. have necessarily had some difficulty in expressing their results, even though none of these subgroups behaved differently from the whole group. It is conceivable, for example, that in the group of patients who had lately been in congestive cardiac failure the work of pumping 0-36 litre per minute extra-500 litres per day-might be quite sufficient to cause, the death of a patient on the borderline of congestive failure, if he was nursed flat-an unlikely event. The renal tubules excrete excess sodium before long changes can be detected in the plasma, and life is sustained on one or two microgrammes of vitamin B12 daily. It would not be surprising, therefore, if the body’s homoeostatic mechanisms in the cardiovascular system were more sensitive than the present means of measuring them. If this is so, then it is unlikely that statistical analysis in a heterogeneous group can reflect the true state of affairs unless the number of subjects in the subgroups is greatly increased. This, in the matter investigated by DONALD et al., would entail Herculean work out of proportion to the importance of the question posed-and these observations are applicable to many aspects of clinical research. DONALD and his colleagues have appreciated the difficulties, and they have been conservative in interpreting their findings concerning cardiac output in direct relation to clinical problems. That the measurement of cardiac output is at present rather crude is also suggested by the more consistent findings with pulmonary-artery pressures and pulsepressures-measurements that are subject to smaller error. DONALD et al. found that in the sitting position the pulmonary-artery pressures, in people with a high initial pressure, and the pulse-pressures, in the whole group, fell. While it is readily understandable, though by no means proven, that symptoms are relieved by a fall in pulmonary-artery pressures and by the consequent decrease in the demands on the heart, it is hard to understand the teleological reason for the fall of pulse-pressure in the sitting position in normal subjects, seeing that most of us sleep flat. No doubt much more evidence will be forthcoming to answer these questions, but meanwhile the clinician may be relieved to know that it is justifiable to nurse his patients in the position they find most comfortable.
Having
The Public’s View of Tuberculosis SURVEYS of public opinion, ranging from the housewife’s view of foaming detergents to the mother’s estimate of child-welfare clinics, are as popular as ever. GORE and HARTSTON1 have now given the results of a survey, made during the first quarter of 1952 by health visitors, of 1080 mothers of children born in the administrative county of London and in Tottenham during the fortnight ended Sept. 1, 1951. The aim was to measure the extent of the public’s knowledge of pulmonary tuberculosis and to see whether people were aware of the facilities for the diagnosis and treatment of this disease. The inquiry was made among a readily accessible group of women, who were to some extent selected in that they were the mothers of six-month-old babies and represented, therefore, only a small proportion of the whole female population. An earlier survey, carried out in the London area in 1950, was partly based on a questionary about tuberculosis, which was put to 432 adults, a carefully selected " random " sample. This inquiry was also used to compare the reliability of those interviewers who were fully experienced in the technique of interviews with that of interviewers new to the work. An analysis showed that the responses obtained were sufficiently close to justify the use of amateur interviewers when these
were
easier to
come
by.2 This finding is of importance when judging the results of the surveys made by students from the teaching hospitals as part of their public-health training-for example, a recent survey to assess the value of antenatal instruction and child-welfare clinics. The tuberculosis questionary used in 1950 was used again by the health visitors in 1952. The first question dealt with the relative mortality of tuberculosis and cancer ; 44% of those interviewed thought that tuberculosis killed most people in this country, and 35% considered cancer to be the chief cause of death. At the time of the survey, 41 % thought more about tuberculosis than about any other disease-nearly twice as many as those whose thoughts were more often on cancer. It should be noted that the early part of 1952 was not a time when poliomyelitis The confusion was prominently in the public mind. about tuberculosis is indicated by the fact that while 43% thought that the disease was hereditary, 44% believed it was not ; and of those who said that it was not, or did not know, 42% had no idea how the infection could be conveyed. Contrariwise, when asked if the disease was catching or contagious, 71% said " yes " and 22% said " no." Of the 1080 women interviewed, 66 said that there was somebody with tuberculosis in their family at the time, but 30% of this contact group did not think that the disease was infectious. This figure makes it clear that the instruction given by tuberculosis health visitors. and chest physicians is not getting across or is being misunderstood by patients and their families. But 80% of the 66 women who were family contacts said that their chests had been radiographed, which indicates very efficient supervision of contacts either by mass X-ray units
or
by
chest
clinics, though 80%
is
probably
Mon. Bull. Minist. Hlth Lab. Serv. 1. Gore, A. T., Hartston, W. 1953, 12, 131. 2. Durbin, J., Stuart, A. J. R. statist. Soc. 1951, 114, part II.
662
higher than the proportion in the whole contact population. Few physicians at chest clinics would claim a supervision-rate as high as this. The failure to examine all contacts may be partly explained by the fact that 69% of the women questioned thought that many people were afraid to be examined in case they had tuberculosis. The sketchiness of the public’s knowledge of tuberculosis was also shown by the fi -nding that 54% of women knew nothing about the causes of extrapulmonary tuberculosis, and only 4% suggested that milk had something to do with it. In
several other ways the survey disclosed lack of information or failure to absorb it : 80 % had never heard of B.C.G. vaccine ; more than half realised that hospitals and sanatoria were provided for treatment, but only a quarter knew that priority food and milk were available for tuberculous patients. On the other hand, 72% said that the present number of hospitals and sanatoria was insufficient to deal with a disease which 91 % considered to be a serious problem and which 61% thought was more serious than poliomyelitis. These results are very similar to those obtained by DAVID3 in his analysis of the 1950 survey, with one curious exception in the answers to the question about symptoms. Frequent cough was thought to be a symptom by 63% of the mothers and by only 35% of those in DAVID’s analysis ; 19% mentioned blood in the sputum, as compared with 8% in 1950 ; and 28% included loss of weight, as against 18% in the earlier figures. Perhaps this difference was the result of direct questions at the antenatal clinic, but it may also be attributable to the valuable health teaching given by certain women’s magazines. When, as the survey suggests, 80% of this adult population know where to go for an X-ray examination of the chest which 98% feel should be done regularly to combat a disease which 80% think is curable, which 91 % believe is a serious problem to the country, and which 71 % know to be contagious, it is disappointing that the spread of the disease has not been checked more rapidly. Can it be because of the 69% who are afraid to be examined in case they have the disease ? Or is there some error in the survey-not in the sampling, but in the method of interview ? There is now some evidence from the interviewers, both amateur and professional, that the much-interviewed public, especially the housewife, is at last beginning to show some " interviewer resistance." No longer are questions answered with a’simple spontaneity, but with some hesitation as if the speaker was considering whether or not the answer would please the interviewer, or weighing any indirect repercussions that might arise from the reply. So it is becoming increasingly difficult to be sure that figures obtained in this way accurately reflect public knowledge and opinion. But these latest results emphasise the importance of vigorous propaganda ; and the best keynote in the campaign is the cheerful one that patients can be made well and restored to a normal life. Using all the well-tried methods of advertising, backed by instruction through the press, radio, television, and cinema, the methods of prevention and the importance of early treatment can be driven home. Although modern chemotherapy has greatly improved the chances of successful treatment, it has not detracted from the importance of knowledge as a means of prevention. 3.
David, S. T.
Tubercle, Lond. 1952, 33, 78.
Annotations THE MEANING OF EDUCATION THE hours we spent with dogfish and club-mosses,
nerve-muscle preparations, test-tubes, cultures, and microscope slides laid down in us patterns as lasting as those in Pavlov’s dogs. Even if we have since been exponents of the art, rather than of the science, of medicine our training has preserved in us some lingering sense of proportion and discrimination when the scientific aspects of our calling are discussed. This is something; but as a preparation for life was it enough ? Was it Dr. even thorough enough, let alone wide enough ? A. T. Macqueen1 thinks not ; and he urges the value of philosophy as a mind-widening discipline for students. " Despite the lip service paid to the concept of treating the patient as a whole," he says, " too many medical students graduate with the idea-which their teachers do little to correct by philosophical teaching-that man is little more than a collection of basic particles, built up into cells and organs, which needs occasional technical repair and a lot of humouring." There is no coherent theory of medical philosophy ; yet (as academic philo. sophers are always trying to point out) all men are applied philosophers, none more so than doctors ; and every decision, every word of advice given by doctors, implies a philosophy, an attitude to man, to human rights and duties, and to the universe as a whole. If doctors themselves have no clear notion of their philosophy what diverse and random impressions must they leave upon their patients, and what vast tracts of their patients’ minds and natures they leave unexplored. The idea of learning philosophy-and its sworn companion, logic-does not readily commend itself to doctors. Scientific method, we are apt to think, is-or should be-a better training for the mind than logic ever was. As for the relations of man to God and the universe and all that, the attitude proper to a scientist is agnostiIn modern education, however, and especially cism. perhaps in medical education, the opportunities for hearing what great minds in the past have thought about such topics are so few that our attitude of agnosticism might strike an informed observer as one of agnosia. Medical ethics are no more self-evident than any other kind of ethics. What is a " right " or a " wrong " human (or professional) act?’? This is a problem in applied philosophy, yet our universities seem to assume that the medical student can solve it without formal lectures or any encouragement to consult published work. Certainly many doctors (like many other university students) cannot distinguish between a primary and a secondary cause ; and here Dr. Macqueen refers us for examples to The Lost Tools of Learning,2 a paper read by Miss Dorothy Sayers to a vacation course in education a few years ago. She illustrates not only such failures in discrimination, but also the common trick of assuming the thing we set out to prove. Modern education, she argues, does not teach us how to learn : we remember what we have learnt, but forget altogether how we learned it ; and she believes that medieval schemes of education did the job rather better. For the syllabus was divided into two parts, the trivium and the quadrivium;; and the whole of the first part (the trivium) was concerned with teaching the pupil how to think and how to learnhow to use his tools, in fact. The trivium consisted of grammar, dialectic, and rhetoric, in that order ; which fitted themselves very well, she says, to three stages of childhood-the " pollparrot," the " pert," and the " poetic." Grammar meant learning (at an age when glib learning is easy) the structure of a language-usually Latin-and later how 1. Universities Quarterly, May, 1953, p. 298 2. London : Methuen. 1948. Pp. 30. 1s.