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The results of re-housing tuberculous patients
THE RESULTS OF RE..HOUSING TUBERCULOUS PATIENTS. By J. A. GRANT KEDDIE, M.D.St.And., D.P.H.Camb., D.P.A.Lond. Deputy Medical O,fficer of Health and Clinical T'uberculosis Officer, County Borough of West Bromwich.
THERE is a general consensus of. opinion that in the anti-tuberculosis campaign it is desirable to deal with the family of the tuberculous patient as a unit, and not solely with the patient himself. To many, the problem of dealing with the tuberculous patients and their families in a comprehensive manner resolves itself in large part into a consideration of the question of re-housing. The local authorities of a few towns, such as those of Leeds [1J, Sheffield [2J, Hull [3J, N ewcastleon-Tyne [4J, Walsall [5J, Middlesbrough and Dudley [6J, impressed by the importance of the housing factor in the control and treatment of tuberculosis, have made a definite attempt to secure that patients returning from residential institutions shall live under housing conditions which will safeguard their families from infection and enable the patients to live under conditions calcuiated to minimise the risk of relapse. The above-named authorities, during the past three to six years, have undertaken the re-housing of a proportion of the families of patients with pulmonary tuberculosis who are living in unhygienic homes. As has been pointed out by COX [7J, one must not regard the matter of re-housing as quite an innovation in tuberculosis schemes, for the Boards of Guardians, as far back as sixty years ago, provided accommodation for the badlyhoused infectious cases on quite a large scale, but the schemes abovementioned are the first attempts to deal with the problem in a more or less systematic and organised manner. In the majority of instances these special housing schemes have been in operation for far too short a time for a definite assessment of preventive results to be made, or for the probable lessened frequency of relapse to be measured, although the opinion of Turner [8J, of Sheffield, where the scheme has been in, operation for a period of about five years, is that his observations lead him to believe that the work is on "lines which will later be generally accepted as the rational lines along which work for the prevention of tuberculosis in the community should proceed in the future." It is generally taken for granted that expenditure on re-housing of the tuberculous is bound to lead to a dividend in positive health result. While the assumption may be warranted so far as the family contacts are concerned, I, personally, was for long of the opinion that the position in regard to the actual sufferers themselves was definitely problematical. I could not find, by a search of the literature, concrete evidence which made the position more certainly clear. The object of this paper is to outline the results of an investigation, conducted in the County Borough of West Bromwich, to ascertain the value to sufferers from pUlmonary tuberculosis of transfer from unhygienic and, commonly, overcrowded housing to more sanitary and more roomy conditions. West Bromwich, a town largely industrial in character, has a popula22
338
[May, 1934
TUBERCLE
tion of 81,281 (1931 Census). Since 1920 about 4,000 houses have been built, 3,500 with State assistance, the Local Authority having been responsible for 3,000 of that number. The bulk of the Council houses have been built on two new Housing Estates on the outskirts of the town near open country. Although the Housing Committee have not specified that a fixed percentage of houses be allotted to tuberculous patients and their families, yet in 36 such cases re-housing has actually been secured on one or other of the two estates above-mentioned, from 1928, when the first of these families were transferred, to the end of 1931. Soon after this the list of applicants was temporarily closed to enable the large number of outstanding approved cases, of which but a few were tubercular, to be dealt with. Of the 36 patients only 20 were suitable for detailed investigation, the remaining 16 being excluded from the series for the following reasons : (1) In two cases, with advanced disease, there was death soon after transfer. (2) Eight cases were admitted to sanatorium at about the same time as new housing was secured for their families, and after return from sanatorium they were resident in their new homes for a period less than twelve months when this survey was completed. (3) Six cases, at the time of completion of the survey, had been residing in the new houses for less than twelve months. CASES INVESTIGATED.
This investigation thus comprised 20 patients with pulmonary tuberculosis, 16 being initially sputum-positive and four sputum-negative. All had enjoyed, shortly before the initial observation, a period of sanatorium treatment varying in duration from two to six months (the average being 4'2 months). Response to treatment was good in nine and fair in 11 cases. Upon completion of institutional treatment all the patients made a return to unsatisfactory housing conditions. Thereafter a period of from three to six months (the average being 3'9 months) elapsed before re-housing was carried out. Just prior to transfer the first detailed observations were recorded. Of the 20 cases, 16 being males and 4 females, classification according to clinical type of the disease was as outlined below, this classification being based upon ponderable factors together with clinical impressions at the time of initial observation as well as upon their case-records immediately prec~ding sanatorium treatment. Fibroid (F.) .. .. Chronic fibro-caseous (F. C.) .. Early localised fibre-caseous (F.C.e)
4 cases 12 cases 4 cases
METHOD OF INVESTIGATION.
The observations recorded were made in my capacity as Clinical Tuberculosis Officer either at the Dispensary or in the homes of the patients. During the course of the investigation none of the patients received further institutional treatment. The periods of observation ranged from twelve to thirty months, the
May, 1934]
RESULTS OF RE-HOUSING TUBERCULOUS PATIENTS
majority being observed for a period of at least eighteen months after re-housing, as may be seen from the table appended herewith :Period of observation
30 24 18 12
months months months months
No. of cases
6 3 6 5
Investigation embraced a large number of points, which are outlined below. (A) Environmental Influences. An attempt was made to assess the various environmental influences to which the patient was exposed, those prior to re-housing being differentiated from those present throughout the whole, or the greater part, of the period following transfer and up to the time of the final observation. The influences to which particular attention was paid were the following :(1) Sanitary condition of housing-whether good, fair or poor. In classifying houses under one or other of these heads factors such as site, construction and plan of house were considered, especial attention being directed to questions of dryness or dampness, state of repair, lighting, ventilation, facilities for storing and for cooking food and the condition of thp sanitary fittings. (2) Overcrowding in the house as a whole-the observations being recorded as follows : Absence of overcrowding .. .. .. .. .. Overcrowding of a minor degree (1'5 to 2 persons per livinR room) Overcrowding of a marked degree (over 2 persons per living room)
0 1 2
(3) Overcrowding in the bedroom of the patient-as estimated in a general manner by consideration of the number of occupants and their ages, in relation to the cubic capacity and height of the room. Absence of such overcrowding (e.g., bedroom solely for patient) .. Overcrowding of a minor degree (eg., bed in small room shared by consort) .. Overcrowding of a marked degree (e.g., bed in small room shared by two others). .
0 1 2
(4) The district in which the house was situated-whether open or congested and industrial. (5) The position in which the patient was actually placed in regard to the question of work-the following being considered to be the possibilities :A. Patient fit for hard work. 1. Regular hard work. 2. Regular light work only obtainable. 3. Long way to work. 4. Unsatisfactory conditions of work. 5. Irregular light work. 6. Irregular hard work. 7. Unemployed. 8. Suitable domestic duties. 9. Unsuitable domestic duties. B. Patient fit for light work. 1. Regular light work. 2. Regular hard work only attainable.
340
TUBERCLE
[May, 1934
3. Long way to work. 4. Unsatisfactory conditions of work. 5. Irregular light work. 6. Irregular hard work. 7. Unemployed. 8. Suitable domestic duties. 9. Unsuitable domestic duties C. Patient unfit for work. 1. Regular hard work. 2. Regular light work. 3. Long way to work. 4. Unsatisfactory conditions of work. 5. Irregular hard work. 6. Irregular light work. 7. Unemployed. 8. Suitable domestic duties. 9. Unsuitable domestic duties. (6) Food-as to adequacy or inadequacy. Conclusion was here based upon a consideration of one's own observations, those of the 'ruberculosis Visitors, the opinion of the patient, and the total income of the household and the rent paid. (7) Financial position of the family-whether good, fair or poor. Opinion was here based, where possible, upon a consideration of the following scheme :The amount of rent was deducted from the total income of the household, the figure thus obtained being then divided by the number of persons in the family, counting each child under the age of 5 years as one-half. Where the final figure lay under 7s. per head, the position was considered to be poor, if between 7s. and lIs. per head, to be fair, and if over 11s. per head, to be good. (8) Mental anxiety on the part of the patient with regard to the welfare of the family-as to its absence or presence. (An influence psychical rather than environmental, here included largely for convenience.) (B) Habits of the Patients. Note was made of an endeavour to follow a satisfactory mode of life both (9) In the home, and (10) Outside. Points to which particular heed was paid were the following :Attention to personal hygiene. Attention to ventilation and lighting of the room. Extent of indulgence in alcohol and tobacco. Evidence of vicious habits. Number of hours spent in the home daily. Use of leisure time. Exercise, its amount and nature. Presence of a hobby, such as gardening and poultry-keeping. Rest, its amount per day.
May, 1934J
RESULTS OF RE-HOUSING TUBERCULOUS PATIENTS
341
In addition, in order that an opinion at the end of the period of observation might be formed as to any change in the general outlook of the patient, the presence or absence of the following points was noted at each six-monthly period :Oscillating mood, restless agitation, apprehensiveness, hypersensitiveness, irritability, depression, discontent, lack of keenness for work, dependence, low degree of self-respect, morbid outlook, unwillingness to postpone marriage, and unwillingness to limit family numbers. (C) Cond-ition of the Patient. The clinical condition of each patient was noted throughout the whole period of observation, the state immediately prior to transfer, and at sixmonthly intervals thereafter, being recorded in detail. In this paper, for reasons of space, I shall, in Tables I and II, which follow on later pages, outline the position which existed just before removal as well as that present at the time of the final examination. As to the classification of the stage of the disease which was adopted, an endeavour was made to follow lines akin to those of Philip, as outlined in Price's" Textbook of Medicine" [9J. Classification of patients suffering from pulmonary tuberculosis is admittedly difficult, and most efforts are open to criticism, yet I have endeavoured to assess the condition upon a consideration not only of clinical impressions but also, so far as was practicable, of ponderable factors, the position as to the systemic state of the patient being based upon a review of the following factors :(1) The temperature-as to whether the patient was ambulant aferbile or ambulant febrile. (2) The weight (in pounds)-as to whether it was rising steadily, falling slowly or tending to remain stationary. (3) General characters, such as the following :Lassitude-as to whether it was absent siight .• moderate or marked .. Appetite-as to whether it was good, fair or poor.
+
++ +++
The presence and character of the following were also recorded : Coughing-as to whether it was slight .. of moderate degree markedly troublesome Dyspncea on exertion--as to whether it was slight of moderate degree of marked degree.. Night sweats-as to whether occasional or frequent Staining or hremoptysis-as to whether it was occasional and slight . • .. or frequent and marked .,
C+ C++ C+++ D+ D++ D+++ NS+ NS++ St+ St++
In addition a record was made of the amount of expectoration, as well as of the presence or absence of tubercle bacilli therein. (D) The Physical Capacity
jar Work.
This problem was considered at each six-monthly period, it being estimated whether there was capacityFor hard work light work or for no work
A
B C
..
..
.. ..
.. __ ..
..
•. ..
.. ..
.. ..
.. .. .. .. .. .. .. .. ..
..
..
.. ..
..
.. ..
Stage of disease .. .. .. Duration of quiescence (months) .. Maximum weight before treatment.. Weight in pounds.. •. .. Sputum-Amount (ozs.) in 24 hours Sputum~ Positive or negative Temperature-Ambulant febrile or afebrile Pulse-rate .. .. .. Lassitude .. .. ..
Clinical condition immediately before l'emoval--
9. In the home 10. Outside
Sanat. life led-
Sanitary condition of hOUSlllg .. Overcrowding in house •. Overcrowding in bedroom of patient District-Open or industrial " Position in regard to work .. Food-Adequate or inadequate .. Financial position-Good, fair, poor Mental anxiety re family ..
Habits.
1. 2. 3. 4. 5. 6. 7. 8.
Envi,-onmetd and habits after removal-
9. In the home 10. Outside
Sanat. life led-
Sanitary condition of housing . . Overcrowding in house.. Overcrowding in bedroom of patient District- Open or industrial .. Position in regard to work .. Food-Adequate or inadequate Fiuancial position-Good, fair, poor l\Iental anxiety re family ..
Habits.
1. 2. 3. 4. 5. 6. 7. 8.
..
.... .. .. .. .. observation .. .. .. ..
Environment and habits before removal-
Initials .. Sex .. .. .. Age at time of first observation Type of tuberculosis at time of first Response to sanatorium treatment Sputum-Positive at any time
Group No. ..
++
84
Af
+
L 2s 154 141 1
Yes Yes
Gd 0 0 Op Bl Ad F No
No No
Fr 2 2 Op 07 Ad F No
+
O. W. M 47 F Gd
1
+
+
Af 84
Af 76
+
!
Los 108 86 3
Yes Yes
Gd 0 0 Op 88 Ad F No
Yes Yes
Pr 2 2 In 07 Ad P Yes
+
R. R. F 43 F Fr
3
L 2s 164 150
No No
Gd 0 0 Op 07 Ad F No
No No
Pr 1 1 In B1 Ad F No
+
D. B. M 55 F Fr
2
I
++
F 88
3
+
WO
192
LaS
Yes Yes
Gd 0 0 In 07 Ad F No
Yes Yes
Fr 1 1 In 07 Ad F No
-
Af 72
-
L1 6 138 135
Yes Yes
Gd 0 0 In Al Ad F No
Yes Yes
Pr 0 0 In Bl Ad F No
+
W. O. M 30 FO Gd
F. E. M 47 F Gd
+
5
4
~
TABLE I.-Nos. 1-10 OF THE 20 OASES WHO WERE RE-HOUSED.
+
F 88
+
Los 132 123 2
Yes Yes
Gd 0 0 Op Bl Ad F Yes
Yes Yes
Pr 0 0 In Bl Ad F Yes
+
G. G. M 37 FO Gd
6
I
++
F 88
+
L 2s 140 128 3
No Yes
Gd 1 0 Op 07 Ad F No
No Yes
Pr 2 2 In 07 Ad F Yes
+
37 FO Fr
:M
W. F.
7
++
F 90
+
L 2s 189 166 3
Yes Yes
Gd 0 0 Op Bl Ad G No
Yes Yes
Pr 0 0 In C7 Ad G No
+
A. A. M 49 Fe Fr
8
I
++
F 90
+
L"s 126 107 2
Yes Yes
Gd 0 0 In B7 Ad F No
Yes Yes
Pr 1 2 In 07 Ad F No
+
9 G. W. M 45 FO Gd
(For signs used refer to text.)
+
:F 90
+
L.,s ..:. 118 112 2
Yes No
Gd 0 0 Op 08 Ad F Yes
Yes Yes
Pr 1 0 In 08 Ad G Yes
+
H. F. F 47 FO Fr
10
~
c.:
0
'~ -
';; """
~
a
~
OJ
q
H
~~
Capacity for work. .
..
.,
.. .. .. .. ..
.. 30
..
.. 2 2
:2
I
"I C-B ..
..
..
B
..
G 0+ D+
-
..
9. In the home
Contin1J,at~~oj
.. ..
.. •.
.. ..
Table II on nextJage.
Habits-- Banat. life led-
Sanitary condition of housing .. Overcrowding of house .. .. Overcrowding in bedroom of patient District-Open or industrial .. Position in regard to work .. Food-Adequate or inadequate Financial position-Good, fair, poor Mental anxiety re family ..
.. ..
.... .. .. .. .. .. .. observation .. .. ..
Environment and habits before removal-
10. Outside
-
+++ P 0+++ D++ NS++ C
72
18 4 2 2 C-B
30 8 8 8 B-U
B
G C+ D+
D+++
-
0-U
12 4 4 4
C
G C++ D++
78
Al
174 1
A
L 3s
St+ U
P 0++
B-A
30 1 1 1
A
-
G
70 -
Af
-
141
L1 Qt
B
F C+
~
25 FO Fr
25 FC Fr
No No
In F No No Yes
,_.
No No
Yes
08 Ad
C8
No
Op
In
2 In C7 In
G
2
2
o
Pr
+
Fr
PC
31
M
13 P. C.
p
Fr 2
Pr 2
+
+
H.A. F
L. E. F
12
11
'---
Yes Yes
No
F
Ad
C7
In
o
1
Fr
+
M 29 FC Fr
14 W.R.
'
Yes Yes
2 In C8 Ad F No
o
Pr
+
FC Fr
44
~'
B-B
30 4 2 2
B
G C+ D+
-
70
Af
-
i-
125
A
Los
B
P 0++ D-r
I
C-C
30 4 4 4
C
+ G C+ D+
80
+ Af
128 2
Los A
P C++ D+ NS+ C
-
24 4 2 2 C-B
B
G C+ D+
76
+ Af
i-
1'13
A
Los
C
D++
P C++
I
_
Yes Yes
In p No
U7
2 In
1
Pr
+
~'r
~'U
25
M
16 B. H.
I
No Yes
In P No
£7
Fr 2 2 In
Gd
~'('e
M 30
17 M.S.
Yes Yes
In Bl Ad F No
:2
Pr 2
FCe Gd
I
------_.
Yes Yes
No
p
Pr 2 2 In Bl In
FCe Gd
F
16
M
19 R. D.
C-B
24 4 2 2
B
G 0+ D+
19
18 B. J.
Af
76 -
P
--.
Yes Yes
Yes
F
Ad
B2
In
o o
Fr
FCe Gd
42
M
20 J. F.
5 5 5 C-C
U 18
C++ D+
++
96
+F
3
-
t
A
LoS
o
104
I
P C++ D+ NS+
107
Los A
O~+
D+ NS+ C
(For signs used refer to text.)
__ 1
15 S. R.
TABLE 11.- Nos. 11-20 OF THE 20 CASES WHO WERE RE·HOUSED.
Group No. .. Initials.. .. Sex .. .. .. Age at time of first observation Type of tuberculosis at time of first Response to sanatorium treatment Sputum-Positive at any time..
1. 2. 3. 4. 5. 6. 7. 8.
Af
74
84
Af
..
Number of months observed after removal Doctor's opiaion 1"e health. 1-8 Patient's feelings re health. 1-8 .. General outlook of patient. 1-8 .. Change in capacity for work. 1-8 ..
Capacity for work ..
..
+ F
-
86 1
141 4
146
i
Los A
0
P c++ D+ St+
L3s A
B
"
F C+ D+
Los A
.. ..
Stage of disease .. .. Active or quiescent .. Weight in pounds .. .. Sputum-Amount (ozs.) in 24 hours Sputum-Positive or negative •• Temperature-Ambulant febrile or afebrile .. Pulse. rate .. Lassitude .. .. .. .. .. Appetite-Good, fair or poor .. " Other symptoms .. .. .. ..
..
Clinical condition end oj period-
+ '-'T+ St+ C
P
~
;,>
::J,;
H::-
Cl:l
en
~
Z
::trJ
"'d
en
oq
t"
o q
::0
trJ
tJj
q
~
Z Q
en .....
q
~ o
~
trJ
ttj
o
en
8~
en ......
trJ
L.......I
~
<:l:l
to
......
:.<
~
Il>
..
--"-
..
--
----
..
..
..
..
.. ..
.. ..
"
.. ..
..
..
..
..
..
.. .. .. ..
..
..
..
..
"
..
..
Oapacity for work. . .. .. Number of months observed after removal 1-8 .. Doctor's opinion re health. 1-8 .. Patient's feelings re health. .. General outlook of patient. 1-8 .. Change in capacity for wQrk. 1-8
..
..
.. ..
.. ..
..
.. .. Stage of disease .. .. .. .. .. Active or quiescent .. .. Weight (in pounds) .. Sputum-Amount (ozs.) ill 24 hours Sputum-Positive or negative Temperature-Ambulant febrile or afebrile .. .. .. .. .. Pulse-rate .. Lassitude .. " .. .. Appetite-Good, fair or poor .. .. Other symptoms ..
Clinical condition end of period-
Capacity for work ..
Stage of disease . . .. .. .. .. Duration of quiescence (Maximum weight before treatment) .. Weight (in pounds) Sputum-Amount (ozs.) in 24 hours .. Sputum-I'ositive or negative Temperature-Ambulant febrile or aferbrile .. .. .. Pulse-rate .. .. Lassitude .. .. Appetite-Good, fair, or poor .. .. Other symptoms ..
.. .. .. .. Clinical condition immediately before re11loval-
9. In the home 10. Outside
..
Sanitary condition of housing .. Overcrowding of house .. .. Overcrowding in bedroom of patient District-Open or industrial Position in regard to work Food-Adequate or inadequate .. Financial position-Good, fair, poor .. Mental anxiety re family
Habits-Banal. life leil-
1. 2. 3. 4. 5. 6. 7. 8.
Environment and habits after removal-
..
II-cont'inned.
Group No.-contd.
TABLE
I
I
--
C+
S
0-0
II
18 7 6
C
118 2 + F 94 ++ P 0+ D+ NS+
A
12
I
I
8 0-0
6
18 7
L"S A 128 4 + F 96 ++ P 0++ D++ NSt+
140 138 3 + F 92 + F U+ D+ NS+ 0
o-t
B 12 4
G C+ D+
-
0-0
4
12 4 4
C
113 1 + At 76 + G C+ D+
132 1 + Af 76
L 2s
LoS 132 112 1 + F 84 ++ F U++ D+ NS++ 0 A
I
I
Yes Yes
Gd 0 0 Op 07 Ad F Yes
14
A
Los
0
146 130 2 + F 84 + P U++ D+
-
Los
L 2S
L2S 132 126 2 + F 90 + P
-
Yes Yes
Gd 0 0 Op 07 Ad F Yes
13
No Yes
Gd 1 0 Op C8 Ad G No
12
No No
Gd 0 1 Op 08 In F No
I
----
11
D-iNS+ C
---
p
90 ++
.I<'
98 2 +
?
Los -
Yes Yes
4 4 4 O-U
U
0
Af 80 + G 0+ U+
"2' -j-
I
100
A
L 2s
C
D+
I U++
I
i
I
I
Gd 0 0 Op C8 Ad F No
15
I
2 O-B
:J I
30 4 1 1 B-A
A
G
G C+ D+ B 12 4
-
At 72
-
L1 Qt 121
B
Af 72 + P c+
A 24 4 1 1 B-A
G
-
68
,.If
-
L1 Qt 174 -
B
-
1 1 B-A
4
A 24
G
-
Af 76
.-
-
L1 Qt 119
B
F C+
--
F
--
-
116 -
?
L1 4
Yes Yes
Ad F No
Al
Gd 0 0 Op
19
Af 80
I
I
I
I
Af 70
I
-
4
-
154
?
L1 3
Yes Yes
Gd 0 0 Op Al Ad F No
18
1
-
152 1 + F 8)
A
L 2s
0
0++ D+
p
88 ++
.I<"
?
168 150 3 + 114
L1 3
No Yes
Gd 0 1 Op A7 In P No
i I
--
17
Los
-
Yes Yes
0 In B7 In P No
0
Gd
16
I
I
I
,
I
I
A 18 4 1 1 B-A
G
-
Af 64
-
L1 Qt 142 -
B
-
P
-
At 68
-
L1 4 144 137 -
Y.es Yes
No
~'
Gd 0 0 Op Al Ad
20
.....
::N
~
I-'
~
~
~
,.......,
t>;j
a t-<
t>;j ~
>-3
d O:J
CJ.:i ..... .....
May, HJ34]
RI£SULTS OF RE-HOUSING TUBERCULOUS PATIENTS
345
ABRIDGED ANALYSES OF CASES INVESTIGATED.
There is given above, in Tables I and II, a review of the environment and habits of each patient before and after transfer, and of his or her clinical condition immediately prior to removal as well as that existing at the end of the period of observation. RESULTS.
At the foot of each case-record outlined above reference is made to a surrimation of the results. It may be observed that there is consideration of four points. We have (A) my own opinion as to the health of the patient since transfer. This I considered could be supplemented usefully by a record of (B) the feeling of the patient as to any change in well·being, as well as by reference to (0) any change in his general outlook which was observed by me or claimed by the patient to be present. Finally any change in (D) the physical capacity for work throughout the period of observation was noted. Considering the group of 20 cases as a whole from these four angles, I now append the results, which are given in conjunction with the various possibilities under each heading. (A) My opinion as to the health of the patient. Group Nos.
No. of cases
1. 2. 3. 4.
Good position maintained .. Marked improvement Fair position maintained .. }Ioderate improvement
5. 6. 7. 8.
Improvement at first; worse later •. Poor position unchanged .. Worse .. 'Much worse
1 1
14
5 1
3, 4, 6, 7, 8, 9, 13, 14, 15, 16, 17, 18, 19, 20
1
10
2
11, 12 2
1
(B) Patients' feelings as to well-being. No. of cases
1. 2. 3. 4. 5.
Feelinf{ of well-being throughout .. Definitely greater feeling of well-being "Moderate degree of well-being throughout " Moderately greater feeling of well-being Greater feeling of well-being at first, not mainta.ined .. 6. La.ck of feeling of well- being throughon t 7. Feeling of well-being somewha.t less 8. Feeling of well. being definitely less
Group No•.
5
5, 17, 18, 19, 20
7
1, 3, 6, 8, 9, 13, 16
4
4, 7, 14, 15
1 2
10 11, 12
1
:2
(C) General outlook of the patients. No. of cases
1. 2. 3. 4. 5. 6. 7. 8.
Bright throughout Definitely brighter ontlook }[oderately bright outlook .. Moderately brighter outlook Brighter at first, less bright later Ahsence of bright ontlook throughout Outlook somewhat less bright Ontlook definitely less bright
Group
No~.
5 7
5, 17, 18, 19, 20 1, 3, 6, 8, 9, 13, 16
4
1
4, 7, 14, 15 10
3
2, 11, 12
(D) Physical capacity of the patients for work. Increased capacity
1. Light to hard 2. Nil to light Retention of capacity Light Loss of capacity Light to nil .. Absent capacity throughout ..
No. of cases
5 6 1 1
7
Gronp Nos.
5, 17, 18, 19, 20 1, 3, 8, 9, 13, 16 6 2 4, 7, 10, 11, 12, 14, 15
346
[May, 1934
TUBERCLE
It should be noted, however, that of the seven patients unfit throughout for work, four (Group Nos. 4, 7,14 and 15) showed a moderate degree of improvement in the state of their health. DISCUSSION OF THE RESULTS.
Consideration of 'rabIes I and II shows that all patients, prior to re-housing, had been subject to undesirable housing conditions. On transfer all patients were in a decidedly better position. In the case of 12 the housing conditions fulfilled all requirements, while the remaining 8 occupied accommodation in regard to which not more than one defect existed. As to other adverse environmental influences to which there was exposure before removal, these were present in 10 cases, the details being as follows ; Group No<.
No. of cases
Inadequate food .. Mental anxiety regarding family Poor, with inadequate food .. Poor, with anxiety regarding family .. .. At hard work, while only fit for light, with anxiety regarding family .. .. Poor, with inadequate food and anxiety regarding family .. Unable to secure light work, poor, wi~h inadequate f(lod
1 3 2 1
11 6, 7, 10 16, 19 3
1
20
1
13
1
17
After removal the position as to these adverse environmental influences was somewhat more satisfactory, eight cases being affected, and in the case of four of them anxiety regarding the family was alone present. No. of cases
Inadequate food .. Mental anxiety regarding family Unable to obtain light work .. .. Unable to obtain light work, poor, with inadequate food .. .. .. .. At light work only while fit for hard work, poor, with inadequate food
Group Nos.
1 4
11 6, 10, 13. 14
1
9
1
16
1
17
In passing, it should be noted that the change in housing, with consequent improvement in the condition of most patients, brought with it, in an indirect manner, a reduction in the number of adverse influences, Group Nos. 3, 7, 19 and 20 not figuring in the second of the above lists, though on the other hand Group Nos. 9 and 14 now appear, the former becoming fit for light work for which he previously had not the capacity, while the latter came to realise more fully his family responsibilities. The question of habits before and after removal will now be noted. Before removal the position was as follows ; No. of cases
Unsatisfactory habits in the home only Unsatisfactory habits both in the home and outside ..
Group Nos.
3
7, 12, 17
4
1, 2, 11, 13
After removal the position was thus ; No. of cases
Unsatisfactory habits in the home only Unsatisfactory habits outside only .. .. Unsatisfactory habits both in the home and outside
Group Nos.
3 1
7, 12, 17 10
2
2, 11
May, 1934]
RESULTS OF BE-HOUSING TUBERCULOUS PATIENTS
347
It is of interest to llotethat the numbers unsatisfactory in respect to habits thus showed a reduction from 7 to 6; no change in habits followed removal in 5 of the 7 affected before removal, while one case (Group No. 10) showed deterioration in habits after removal. In the light of these analyses let us study the group of 20 cases, dealing with them in two distinct lists, the first that of the 16 who showed at the end of the respective periods of observation an improvement in health, or the maintenance of a satisfactory state of health, and the second that of the four who failed to show improvement or who lost ground steadily, using in this survey, for convenience, the numbers 1 to 10, indicative of the various adverse influences recorded and which have been defined above, where record is made of the method of investigation.
Dist of 16 cases-impTOved or otherwise satisfactory. Ad verse influences after removal
Group No.
,-------'----------, HOllstug
othert~~~~~~~~ental
Habits
1
3 4
4
5 6 7 8 9
4
8
2
9
4
5 8 8
16
4
5, 6, 7
17
3
5, 6, 7
13 14
15 9
18 19 20
List of 4 cases-wot'se. 2
10 11
12
8
6
9, 10 10 9, 10 9
Even if we exclude Group Nos. 17 to 20, all early sputum-negative cases, with quiescence of disease present on removal to new housing, and in the case of which it was only reasonable to expect the maintenance of quiescence, we still have left, out of the new total of 16 cases, 12 which evidently benefited greatly by the change, and this in spite of the fact that in a number of cases counteracting adverse influences were present throughout the whole, or the greater part, of their stay. Had these influences not been present, there is hardly any doubt, in my opinion, that improvement in certain of the cases would have been more pronounced. In passing, one should note. however, that anxiety with regard to the family welfare cannot always be regarded as an adverse factor of marked degree, as its presence in certain cases may act rather as a stimulus and incentive to maintain health so far as it lies in the power of the patients to do so. It appears to me to be a point of great importance that on studying the
34tl
TUBERCLE
[May, 1934
above two lists of cases side by side, a definite impression is received that the failure to improve or to maintain a satisfactory position as to health appears to be closely associated with the inability or unwillingness to lead a life of care, in the home, outside the home, or both. There was some evidence, at the time of transfer, that restless agitation, apprehensiveness and irritability were fairly common characteristics. In such cases I did observe a decided tendency, as the activity of the disease slowed down, for a change in temperamental expression to occur, restlessness becoming less with replacement of a somewhat calmer frame of mind, irritability altering to a spirit more akin to one of cheerfulness, a morbid attitude to the disease becoming changed to a more intelligent one, and the standard of life and ideals tending to become higher. SUMMARY AND CONCLUSIONS.
This investigation comprised 20 patients with pulmonary tuberculosis, who, with their families, were transferred during the years 1928 to 1931, from unhygienic and, commonly, overcrowded housing tv more sanitary and more roomy conditions. At the time of the transfer 15 of the patients had active pulmonary tuberculosis, the remaining 5 being cases in whom quiescence of disease had recently been secured as a result of sanatorium treatment, which all cases observed had enjoyed prior to re-housing, return being made to the bad conditions after treatment in sanatorium and for a period of a varying number of months before transfer. The initial detailed observation of each patient was made immediately prior to re-housing, and thereafter at six-monthly intervals. 'l'he majority were observed for a period of at least eighteen months after re-housing. The main results were as follows : (1) Out of the 20 cases there was in 15 a definite improvement in health, and in one other case the maintenance of a satisfactory position. If we exclude the four initially quiescent (and at no time sputum-positive) cases, there was a definite improvement in 12 cases out of the 16. (2) From the angle of the patients' own feelings, all those considered by me on clinical grounds to have improved were of the opinion that the change in housing had proved of definite benefit to them. (3) In outlook the same group showed a satisfactory response to their new environment, it appearing in several cases that the lessening activity of the lesion, and consequent diminution of the toxffimia, brought with it a tendency to greater balance of temperamental expression. (4) As to capacity for work, 11 of the 20 showed increased physical capacity, and one retained a capacity for light work, while four others, though unfit for work throughout the period observed had, nevertheless, improved in health. (5) Fact appen,red to agree with theory in that there was definite evidence of a close link between the presence of bad habits and deterioration in health on the one hand, and between the presence of a careful manner of life and improvement on the other. In only one of the improved cases were bad habits considered to exist, while in the four cases who were worse all showed definite evidence of bad habits.
May, 1934]
RESULTS OF RE-HOUSING TUBERCULOUS PATIENTS
349
(6) Change in housing conditions produced in two cases a change for the better in habits, though in one other case laxity of habits appeared for the first time. (7) Improvement in housing tended, indirectly, to lessen the number of other adverse environmental influences to which the patient was exposed, especially when he or she definitely improved in health and so gained an increased physical capacity for work. On the other hand, where fitness for light work, but inability to secure work, was an indirect result of improvement in health, previous incapacity for work having been present, an added adverse psychical factor was judged to follow as a consequence. (8) With regard to infectivity, of the 15 cases, 10 became, with a reduction in the amount of sputum, potentially less dangerous, two cases becoming sputum-negative over the latter part of their respective periods of observation, in one case for the last twelve months, and in the other for the last eighteen months. (9) The juvenile contacts examined appeared to have gained markedly in health, there being increased vigour and the development of a more healthy colour, while no fresh cases of gross infection were noted. It may, therefore, be reasonably inferred that there had been an increase of the resistance to infection of the contacts. To sum up, it may therefore be claimed, though rigid conclusions are to be deprecated because of the smallness of the numbers on which my opinions are based, that the results noted are sufficient to justify an organised attempt, on the part of the Local Authority, to secure for other suitable tuberculous patients and their families, at present living in unhealthy homes, removal to good conditions. Further, the question of rent-assistance would appear to be a justifiable consideration in view of the benefit, not only to contacts, but to the health of the actual patients themselves, the majority of the latter who were observed having showed a slowing up of the activity of the disease, a gain in feeling of well-being, an improvement in outlook and an increased physical capacity for work. To increase the proportion of cases who go to new housing with a willingness to lead a life, both in and out of the home, based on sanatorium principles, I consider that special conditions of tenancy are advisable, not only to secure the control of infection but also to make certain the regular attendance at the anti-tuberculosis Dispensary of all patients re-housed and who are under public medical treatment. In addition, I feel it would be beneficial were some scheme of housing management in operation, whereby, in appropriate cases, the tenants were to receive suitable instruction before removal so as to prepare them to enjoy and to appreciate the great change in their mode of living. It is my belief that many present anti-tuberculosis schemes could be amended advantageously by the payment of a greater degree of attention to the question of re-housing of the patients and their families, especially if prior selection were made of those patients in whom the lesion is tending towards quiescence or chronicity, and particularly of those whose temperament and character are such that there is a likelihood of home treatment being carried out successfully.
350
[lJ [2J [3J [4J [5J [6J [7J [81 [9J
TUBERCLE
[May, 1934
REFERENCES. TOMSON, W. B. "The Housing Problem in its Relation to the Tuberculous and Tuberculosis Care Committees," 1930, p. 18. TURNER, H, M. Report on the Prevention and Treatment of Tuberculosis. In the Annual Report on the Health of Sheffield, 1931, pp. 122-124. FRAZER, W. M. Annual Report, Medical Officer of Health, Hull, 1931, pp. 104-105. HURRELL, G. Journ. Roy. San. Inst., 1928, 48, 571. CLARK, J. A. M. Annual Report, Medical Officer of Health, Wallsall, 1931, pp. 100-101. NEWMAN, G. Report of C.M.O. Ministry of Health, 1931, p. 84. Cox, G. L. Public Health, 1932, 45, 206. TURNER, H. M. Lac. cit., p. 124. PRICE, F. W. "A Textbook of the Practice of Medicine," 3rd edit., p. 1103.
PULMONARY CONSOLIDATIONS IN CASES OF TUBERCULOSIS. By S. S. JAIKARAN, M.R.C.S.Eng., L.R.C.P.Lond. PULMONARY tuberculosis is a disease in which it is notoriously difficult to give a definite prognosis. No matter how severe the symptollls, the illness may settle down within a comparatively short time, and thereafter pursue a chronic and rather benign course. A case with trivial symptoms and slight fever to start with may run a steady downhill course and lead to death within a few months. Extensive consolidations may eventually end in fibrosis with some calcification and, within recent years, the possibility of the absorption of tuberculous exudates has been widely discussed. Small consolidations, as often as not, lead to caseation and cavitation. A consideration of certain tuberculous lesions, for example: (a) epituberculosis, (b) extensive pulmonary consolidations, lobar in distribution, in adults, and (c) acute infra-clavicular lesions, may help to explain the apparently contradictory behaviour of many tuberculous processes.
1.-EPITUBERCULOUS CONSOLIDATIONS. Some patients suffering from tuberculous disease are found, at their first physical examination, to present signs of extensive pulmonary consolidation, and to produce a sputum containing tubercle bacilli. Until quite recently, such cases were almost invariably given a poor prognosis. X-ray pictures of these patients' chests, when showing large areas of opacity involving one lobe of a lung or more, were usually described as indicating advanced disease. The onset of illness often bore a striking resemblance to that of lobar pneumonia. Such cases were labelled as tuberculous pneumonia, a condition regarded as leading to death in a matter of weeks. So fatal was tuberculous pneumonia thought to be that whenever, as happened sometimes, a case so diagnosed recovered, the diagnosis used to be re-considered and declared to have been mistaken. Non-tuberculous pneumonia was then blamed for the illness, and the prevailing view of such a case was that
THERE is a general consensus of. opinion that in the anti-tuberculosis campaign it is desirable to deal with the family of the tuberculous patient as a unit, and not solely with the patient himself. To many, the problem of dealing with the tuberculous patients and their families in a comprehensive manner resolves itself in large part into a consideration of the question of re-housing. The local authorities of a few towns, such as those of Leeds [1J, Sheffield [2J, Hull [3J, N ewcastleon-Tyne [4J, Walsall [5J, Middlesbrough and Dudley [6J, impressed by the importance of the housing factor in the control and treatment of tuberculosis, have made a definite attempt to secure that patients returning from residential institutions shall live under housing conditions which will safeguard their families from infection and enable the patients to live under conditions calcuiated to minimise the risk of relapse. The above-named authorities, during the past three to six years, have undertaken the re-housing of a proportion of the families of patients with pulmonary tuberculosis who are living in unhygienic homes. As has been pointed out by COX [7J, one must not regard the matter of re-housing as quite an innovation in tuberculosis schemes, for the Boards of Guardians, as far back as sixty years ago, provided accommodation for the badlyhoused infectious cases on quite a large scale, but the schemes abovementioned are the first attempts to deal with the problem in a more or less systematic and organised manner. In the majority of instances these special housing schemes have been in operation for far too short a time for a definite assessment of preventive results to be made, or for the probable lessened frequency of relapse to be measured, although the opinion of Turner [8J, of Sheffield, where the scheme has been in, operation for a period of about five years, is that his observations lead him to believe that the work is on "lines which will later be generally accepted as the rational lines along which work for the prevention of tuberculosis in the community should proceed in the future." It is generally taken for granted that expenditure on re-housing of the tuberculous is bound to lead to a dividend in positive health result. While the assumption may be warranted so far as the family contacts are concerned, I, personally, was for long of the opinion that the position in regard to the actual sufferers themselves was definitely problematical. I could not find, by a search of the literature, concrete evidence which made the position more certainly clear. The object of this paper is to outline the results of an investigation, conducted in the County Borough of West Bromwich, to ascertain the value to sufferers from pUlmonary tuberculosis of transfer from unhygienic and, commonly, overcrowded housing to more sanitary and more roomy conditions. West Bromwich, a town largely industrial in character, has a popula22
338
[May, 1934
TUBERCLE
tion of 81,281 (1931 Census). Since 1920 about 4,000 houses have been built, 3,500 with State assistance, the Local Authority having been responsible for 3,000 of that number. The bulk of the Council houses have been built on two new Housing Estates on the outskirts of the town near open country. Although the Housing Committee have not specified that a fixed percentage of houses be allotted to tuberculous patients and their families, yet in 36 such cases re-housing has actually been secured on one or other of the two estates above-mentioned, from 1928, when the first of these families were transferred, to the end of 1931. Soon after this the list of applicants was temporarily closed to enable the large number of outstanding approved cases, of which but a few were tubercular, to be dealt with. Of the 36 patients only 20 were suitable for detailed investigation, the remaining 16 being excluded from the series for the following reasons : (1) In two cases, with advanced disease, there was death soon after transfer. (2) Eight cases were admitted to sanatorium at about the same time as new housing was secured for their families, and after return from sanatorium they were resident in their new homes for a period less than twelve months when this survey was completed. (3) Six cases, at the time of completion of the survey, had been residing in the new houses for less than twelve months. CASES INVESTIGATED.
This investigation thus comprised 20 patients with pulmonary tuberculosis, 16 being initially sputum-positive and four sputum-negative. All had enjoyed, shortly before the initial observation, a period of sanatorium treatment varying in duration from two to six months (the average being 4'2 months). Response to treatment was good in nine and fair in 11 cases. Upon completion of institutional treatment all the patients made a return to unsatisfactory housing conditions. Thereafter a period of from three to six months (the average being 3'9 months) elapsed before re-housing was carried out. Just prior to transfer the first detailed observations were recorded. Of the 20 cases, 16 being males and 4 females, classification according to clinical type of the disease was as outlined below, this classification being based upon ponderable factors together with clinical impressions at the time of initial observation as well as upon their case-records immediately prec~ding sanatorium treatment. Fibroid (F.) .. .. Chronic fibro-caseous (F. C.) .. Early localised fibre-caseous (F.C.e)
4 cases 12 cases 4 cases
METHOD OF INVESTIGATION.
The observations recorded were made in my capacity as Clinical Tuberculosis Officer either at the Dispensary or in the homes of the patients. During the course of the investigation none of the patients received further institutional treatment. The periods of observation ranged from twelve to thirty months, the
May, 1934]
RESULTS OF RE-HOUSING TUBERCULOUS PATIENTS
majority being observed for a period of at least eighteen months after re-housing, as may be seen from the table appended herewith :Period of observation
30 24 18 12
months months months months
No. of cases
6 3 6 5
Investigation embraced a large number of points, which are outlined below. (A) Environmental Influences. An attempt was made to assess the various environmental influences to which the patient was exposed, those prior to re-housing being differentiated from those present throughout the whole, or the greater part, of the period following transfer and up to the time of the final observation. The influences to which particular attention was paid were the following :(1) Sanitary condition of housing-whether good, fair or poor. In classifying houses under one or other of these heads factors such as site, construction and plan of house were considered, especial attention being directed to questions of dryness or dampness, state of repair, lighting, ventilation, facilities for storing and for cooking food and the condition of thp sanitary fittings. (2) Overcrowding in the house as a whole-the observations being recorded as follows : Absence of overcrowding .. .. .. .. .. Overcrowding of a minor degree (1'5 to 2 persons per livinR room) Overcrowding of a marked degree (over 2 persons per living room)
0 1 2
(3) Overcrowding in the bedroom of the patient-as estimated in a general manner by consideration of the number of occupants and their ages, in relation to the cubic capacity and height of the room. Absence of such overcrowding (e.g., bedroom solely for patient) .. Overcrowding of a minor degree (eg., bed in small room shared by consort) .. Overcrowding of a marked degree (e.g., bed in small room shared by two others). .
0 1 2
(4) The district in which the house was situated-whether open or congested and industrial. (5) The position in which the patient was actually placed in regard to the question of work-the following being considered to be the possibilities :A. Patient fit for hard work. 1. Regular hard work. 2. Regular light work only obtainable. 3. Long way to work. 4. Unsatisfactory conditions of work. 5. Irregular light work. 6. Irregular hard work. 7. Unemployed. 8. Suitable domestic duties. 9. Unsuitable domestic duties. B. Patient fit for light work. 1. Regular light work. 2. Regular hard work only attainable.
340
TUBERCLE
[May, 1934
3. Long way to work. 4. Unsatisfactory conditions of work. 5. Irregular light work. 6. Irregular hard work. 7. Unemployed. 8. Suitable domestic duties. 9. Unsuitable domestic duties C. Patient unfit for work. 1. Regular hard work. 2. Regular light work. 3. Long way to work. 4. Unsatisfactory conditions of work. 5. Irregular hard work. 6. Irregular light work. 7. Unemployed. 8. Suitable domestic duties. 9. Unsuitable domestic duties. (6) Food-as to adequacy or inadequacy. Conclusion was here based upon a consideration of one's own observations, those of the 'ruberculosis Visitors, the opinion of the patient, and the total income of the household and the rent paid. (7) Financial position of the family-whether good, fair or poor. Opinion was here based, where possible, upon a consideration of the following scheme :The amount of rent was deducted from the total income of the household, the figure thus obtained being then divided by the number of persons in the family, counting each child under the age of 5 years as one-half. Where the final figure lay under 7s. per head, the position was considered to be poor, if between 7s. and lIs. per head, to be fair, and if over 11s. per head, to be good. (8) Mental anxiety on the part of the patient with regard to the welfare of the family-as to its absence or presence. (An influence psychical rather than environmental, here included largely for convenience.) (B) Habits of the Patients. Note was made of an endeavour to follow a satisfactory mode of life both (9) In the home, and (10) Outside. Points to which particular heed was paid were the following :Attention to personal hygiene. Attention to ventilation and lighting of the room. Extent of indulgence in alcohol and tobacco. Evidence of vicious habits. Number of hours spent in the home daily. Use of leisure time. Exercise, its amount and nature. Presence of a hobby, such as gardening and poultry-keeping. Rest, its amount per day.
May, 1934J
RESULTS OF RE-HOUSING TUBERCULOUS PATIENTS
341
In addition, in order that an opinion at the end of the period of observation might be formed as to any change in the general outlook of the patient, the presence or absence of the following points was noted at each six-monthly period :Oscillating mood, restless agitation, apprehensiveness, hypersensitiveness, irritability, depression, discontent, lack of keenness for work, dependence, low degree of self-respect, morbid outlook, unwillingness to postpone marriage, and unwillingness to limit family numbers. (C) Cond-ition of the Patient. The clinical condition of each patient was noted throughout the whole period of observation, the state immediately prior to transfer, and at sixmonthly intervals thereafter, being recorded in detail. In this paper, for reasons of space, I shall, in Tables I and II, which follow on later pages, outline the position which existed just before removal as well as that present at the time of the final examination. As to the classification of the stage of the disease which was adopted, an endeavour was made to follow lines akin to those of Philip, as outlined in Price's" Textbook of Medicine" [9J. Classification of patients suffering from pulmonary tuberculosis is admittedly difficult, and most efforts are open to criticism, yet I have endeavoured to assess the condition upon a consideration not only of clinical impressions but also, so far as was practicable, of ponderable factors, the position as to the systemic state of the patient being based upon a review of the following factors :(1) The temperature-as to whether the patient was ambulant aferbile or ambulant febrile. (2) The weight (in pounds)-as to whether it was rising steadily, falling slowly or tending to remain stationary. (3) General characters, such as the following :Lassitude-as to whether it was absent siight .• moderate or marked .. Appetite-as to whether it was good, fair or poor.
+
++ +++
The presence and character of the following were also recorded : Coughing-as to whether it was slight .. of moderate degree markedly troublesome Dyspncea on exertion--as to whether it was slight of moderate degree of marked degree.. Night sweats-as to whether occasional or frequent Staining or hremoptysis-as to whether it was occasional and slight . • .. or frequent and marked .,
C+ C++ C+++ D+ D++ D+++ NS+ NS++ St+ St++
In addition a record was made of the amount of expectoration, as well as of the presence or absence of tubercle bacilli therein. (D) The Physical Capacity
jar Work.
This problem was considered at each six-monthly period, it being estimated whether there was capacityFor hard work light work or for no work
A
B C
..
..
.. ..
.. __ ..
..
•. ..
.. ..
.. ..
.. .. .. .. .. .. .. .. ..
..
..
.. ..
..
.. ..
Stage of disease .. .. .. Duration of quiescence (months) .. Maximum weight before treatment.. Weight in pounds.. •. .. Sputum-Amount (ozs.) in 24 hours Sputum~ Positive or negative Temperature-Ambulant febrile or afebrile Pulse-rate .. .. .. Lassitude .. .. ..
Clinical condition immediately before l'emoval--
9. In the home 10. Outside
Sanat. life led-
Sanitary condition of hOUSlllg .. Overcrowding in house •. Overcrowding in bedroom of patient District-Open or industrial " Position in regard to work .. Food-Adequate or inadequate .. Financial position-Good, fair, poor Mental anxiety re family ..
Habits.
1. 2. 3. 4. 5. 6. 7. 8.
Envi,-onmetd and habits after removal-
9. In the home 10. Outside
Sanat. life led-
Sanitary condition of housing . . Overcrowding in house.. Overcrowding in bedroom of patient District- Open or industrial .. Position in regard to work .. Food-Adequate or inadequate Fiuancial position-Good, fair, poor l\Iental anxiety re family ..
Habits.
1. 2. 3. 4. 5. 6. 7. 8.
..
.... .. .. .. .. observation .. .. .. ..
Environment and habits before removal-
Initials .. Sex .. .. .. Age at time of first observation Type of tuberculosis at time of first Response to sanatorium treatment Sputum-Positive at any time
Group No. ..
++
84
Af
+
L 2s 154 141 1
Yes Yes
Gd 0 0 Op Bl Ad F No
No No
Fr 2 2 Op 07 Ad F No
+
O. W. M 47 F Gd
1
+
+
Af 84
Af 76
+
!
Los 108 86 3
Yes Yes
Gd 0 0 Op 88 Ad F No
Yes Yes
Pr 2 2 In 07 Ad P Yes
+
R. R. F 43 F Fr
3
L 2s 164 150
No No
Gd 0 0 Op 07 Ad F No
No No
Pr 1 1 In B1 Ad F No
+
D. B. M 55 F Fr
2
I
++
F 88
3
+
WO
192
LaS
Yes Yes
Gd 0 0 In 07 Ad F No
Yes Yes
Fr 1 1 In 07 Ad F No
-
Af 72
-
L1 6 138 135
Yes Yes
Gd 0 0 In Al Ad F No
Yes Yes
Pr 0 0 In Bl Ad F No
+
W. O. M 30 FO Gd
F. E. M 47 F Gd
+
5
4
~
TABLE I.-Nos. 1-10 OF THE 20 OASES WHO WERE RE-HOUSED.
+
F 88
+
Los 132 123 2
Yes Yes
Gd 0 0 Op Bl Ad F Yes
Yes Yes
Pr 0 0 In Bl Ad F Yes
+
G. G. M 37 FO Gd
6
I
++
F 88
+
L 2s 140 128 3
No Yes
Gd 1 0 Op 07 Ad F No
No Yes
Pr 2 2 In 07 Ad F Yes
+
37 FO Fr
:M
W. F.
7
++
F 90
+
L 2s 189 166 3
Yes Yes
Gd 0 0 Op Bl Ad G No
Yes Yes
Pr 0 0 In C7 Ad G No
+
A. A. M 49 Fe Fr
8
I
++
F 90
+
L"s 126 107 2
Yes Yes
Gd 0 0 In B7 Ad F No
Yes Yes
Pr 1 2 In 07 Ad F No
+
9 G. W. M 45 FO Gd
(For signs used refer to text.)
+
:F 90
+
L.,s ..:. 118 112 2
Yes No
Gd 0 0 Op 08 Ad F Yes
Yes Yes
Pr 1 0 In 08 Ad G Yes
+
H. F. F 47 FO Fr
10
~
c.:
0
'~ -
';; """
~
a
~
OJ
q
H
~~
Capacity for work. .
..
.,
.. .. .. .. ..
.. 30
..
.. 2 2
:2
I
"I C-B ..
..
..
B
..
G 0+ D+
-
..
9. In the home
Contin1J,at~~oj
.. ..
.. •.
.. ..
Table II on nextJage.
Habits-- Banat. life led-
Sanitary condition of housing .. Overcrowding of house .. .. Overcrowding in bedroom of patient District-Open or industrial .. Position in regard to work .. Food-Adequate or inadequate Financial position-Good, fair, poor Mental anxiety re family ..
.. ..
.... .. .. .. .. .. .. observation .. .. ..
Environment and habits before removal-
10. Outside
-
+++ P 0+++ D++ NS++ C
72
18 4 2 2 C-B
30 8 8 8 B-U
B
G C+ D+
D+++
-
0-U
12 4 4 4
C
G C++ D++
78
Al
174 1
A
L 3s
St+ U
P 0++
B-A
30 1 1 1
A
-
G
70 -
Af
-
141
L1 Qt
B
F C+
~
25 FO Fr
25 FC Fr
No No
In F No No Yes
,_.
No No
Yes
08 Ad
C8
No
Op
In
2 In C7 In
G
2
2
o
Pr
+
Fr
PC
31
M
13 P. C.
p
Fr 2
Pr 2
+
+
H.A. F
L. E. F
12
11
'---
Yes Yes
No
F
Ad
C7
In
o
1
Fr
+
M 29 FC Fr
14 W.R.
'
Yes Yes
2 In C8 Ad F No
o
Pr
+
FC Fr
44
~'
B-B
30 4 2 2
B
G C+ D+
-
70
Af
-
i-
125
A
Los
B
P 0++ D-r
I
C-C
30 4 4 4
C
+ G C+ D+
80
+ Af
128 2
Los A
P C++ D+ NS+ C
-
24 4 2 2 C-B
B
G C+ D+
76
+ Af
i-
1'13
A
Los
C
D++
P C++
I
_
Yes Yes
In p No
U7
2 In
1
Pr
+
~'r
~'U
25
M
16 B. H.
I
No Yes
In P No
£7
Fr 2 2 In
Gd
~'('e
M 30
17 M.S.
Yes Yes
In Bl Ad F No
:2
Pr 2
FCe Gd
I
------_.
Yes Yes
No
p
Pr 2 2 In Bl In
FCe Gd
F
16
M
19 R. D.
C-B
24 4 2 2
B
G 0+ D+
19
18 B. J.
Af
76 -
P
--.
Yes Yes
Yes
F
Ad
B2
In
o o
Fr
FCe Gd
42
M
20 J. F.
5 5 5 C-C
U 18
C++ D+
++
96
+F
3
-
t
A
LoS
o
104
I
P C++ D+ NS+
107
Los A
O~+
D+ NS+ C
(For signs used refer to text.)
__ 1
15 S. R.
TABLE 11.- Nos. 11-20 OF THE 20 CASES WHO WERE RE·HOUSED.
Group No. .. Initials.. .. Sex .. .. .. Age at time of first observation Type of tuberculosis at time of first Response to sanatorium treatment Sputum-Positive at any time..
1. 2. 3. 4. 5. 6. 7. 8.
Af
74
84
Af
..
Number of months observed after removal Doctor's opiaion 1"e health. 1-8 Patient's feelings re health. 1-8 .. General outlook of patient. 1-8 .. Change in capacity for work. 1-8 ..
Capacity for work ..
..
+ F
-
86 1
141 4
146
i
Los A
0
P c++ D+ St+
L3s A
B
"
F C+ D+
Los A
.. ..
Stage of disease .. .. Active or quiescent .. Weight in pounds .. .. Sputum-Amount (ozs.) in 24 hours Sputum-Positive or negative •• Temperature-Ambulant febrile or afebrile .. Pulse. rate .. Lassitude .. .. .. .. .. Appetite-Good, fair or poor .. " Other symptoms .. .. .. ..
..
Clinical condition end oj period-
+ '-'T+ St+ C
P
~
;,>
::J,;
H::-
Cl:l
en
~
Z
::trJ
"'d
en
oq
t"
o q
::0
trJ
tJj
q
~
Z Q
en .....
q
~ o
~
trJ
ttj
o
en
8~
en ......
trJ
L.......I
~
<:l:l
to
......
:.<
~
Il>
..
--"-
..
--
----
..
..
..
..
.. ..
.. ..
"
.. ..
..
..
..
..
..
.. .. .. ..
..
..
..
..
"
..
..
Oapacity for work. . .. .. Number of months observed after removal 1-8 .. Doctor's opinion re health. 1-8 .. Patient's feelings re health. .. General outlook of patient. 1-8 .. Change in capacity for wQrk. 1-8
..
..
.. ..
.. ..
..
.. .. Stage of disease .. .. .. .. .. Active or quiescent .. .. Weight (in pounds) .. Sputum-Amount (ozs.) ill 24 hours Sputum-Positive or negative Temperature-Ambulant febrile or afebrile .. .. .. .. .. Pulse-rate .. Lassitude .. " .. .. Appetite-Good, fair or poor .. .. Other symptoms ..
Clinical condition end of period-
Capacity for work ..
Stage of disease . . .. .. .. .. Duration of quiescence (Maximum weight before treatment) .. Weight (in pounds) Sputum-Amount (ozs.) in 24 hours .. Sputum-I'ositive or negative Temperature-Ambulant febrile or aferbrile .. .. .. Pulse-rate .. .. Lassitude .. .. Appetite-Good, fair, or poor .. .. Other symptoms ..
.. .. .. .. Clinical condition immediately before re11loval-
9. In the home 10. Outside
..
Sanitary condition of housing .. Overcrowding of house .. .. Overcrowding in bedroom of patient District-Open or industrial Position in regard to work Food-Adequate or inadequate .. Financial position-Good, fair, poor .. Mental anxiety re family
Habits-Banal. life leil-
1. 2. 3. 4. 5. 6. 7. 8.
Environment and habits after removal-
..
II-cont'inned.
Group No.-contd.
TABLE
I
I
--
C+
S
0-0
II
18 7 6
C
118 2 + F 94 ++ P 0+ D+ NS+
A
12
I
I
8 0-0
6
18 7
L"S A 128 4 + F 96 ++ P 0++ D++ NSt+
140 138 3 + F 92 + F U+ D+ NS+ 0
o-t
B 12 4
G C+ D+
-
0-0
4
12 4 4
C
113 1 + At 76 + G C+ D+
132 1 + Af 76
L 2s
LoS 132 112 1 + F 84 ++ F U++ D+ NS++ 0 A
I
I
Yes Yes
Gd 0 0 Op 07 Ad F Yes
14
A
Los
0
146 130 2 + F 84 + P U++ D+
-
Los
L 2S
L2S 132 126 2 + F 90 + P
-
Yes Yes
Gd 0 0 Op 07 Ad F Yes
13
No Yes
Gd 1 0 Op C8 Ad G No
12
No No
Gd 0 1 Op 08 In F No
I
----
11
D-iNS+ C
---
p
90 ++
.I<'
98 2 +
?
Los -
Yes Yes
4 4 4 O-U
U
0
Af 80 + G 0+ U+
"2' -j-
I
100
A
L 2s
C
D+
I U++
I
i
I
I
Gd 0 0 Op C8 Ad F No
15
I
2 O-B
:J I
30 4 1 1 B-A
A
G
G C+ D+ B 12 4
-
At 72
-
L1 Qt 121
B
Af 72 + P c+
A 24 4 1 1 B-A
G
-
68
,.If
-
L1 Qt 174 -
B
-
1 1 B-A
4
A 24
G
-
Af 76
.-
-
L1 Qt 119
B
F C+
--
F
--
-
116 -
?
L1 4
Yes Yes
Ad F No
Al
Gd 0 0 Op
19
Af 80
I
I
I
I
Af 70
I
-
4
-
154
?
L1 3
Yes Yes
Gd 0 0 Op Al Ad F No
18
1
-
152 1 + F 8)
A
L 2s
0
0++ D+
p
88 ++
.I<"
?
168 150 3 + 114
L1 3
No Yes
Gd 0 1 Op A7 In P No
i I
--
17
Los
-
Yes Yes
0 In B7 In P No
0
Gd
16
I
I
I
,
I
I
A 18 4 1 1 B-A
G
-
Af 64
-
L1 Qt 142 -
B
-
P
-
At 68
-
L1 4 144 137 -
Y.es Yes
No
~'
Gd 0 0 Op Al Ad
20
.....
::N
~
I-'
~
~
~
,.......,
t>;j
a t-<
t>;j ~
>-3
d O:J
CJ.:i ..... .....
May, HJ34]
RI£SULTS OF RE-HOUSING TUBERCULOUS PATIENTS
345
ABRIDGED ANALYSES OF CASES INVESTIGATED.
There is given above, in Tables I and II, a review of the environment and habits of each patient before and after transfer, and of his or her clinical condition immediately prior to removal as well as that existing at the end of the period of observation. RESULTS.
At the foot of each case-record outlined above reference is made to a surrimation of the results. It may be observed that there is consideration of four points. We have (A) my own opinion as to the health of the patient since transfer. This I considered could be supplemented usefully by a record of (B) the feeling of the patient as to any change in well·being, as well as by reference to (0) any change in his general outlook which was observed by me or claimed by the patient to be present. Finally any change in (D) the physical capacity for work throughout the period of observation was noted. Considering the group of 20 cases as a whole from these four angles, I now append the results, which are given in conjunction with the various possibilities under each heading. (A) My opinion as to the health of the patient. Group Nos.
No. of cases
1. 2. 3. 4.
Good position maintained .. Marked improvement Fair position maintained .. }Ioderate improvement
5. 6. 7. 8.
Improvement at first; worse later •. Poor position unchanged .. Worse .. 'Much worse
1 1
14
5 1
3, 4, 6, 7, 8, 9, 13, 14, 15, 16, 17, 18, 19, 20
1
10
2
11, 12 2
1
(B) Patients' feelings as to well-being. No. of cases
1. 2. 3. 4. 5.
Feelinf{ of well-being throughout .. Definitely greater feeling of well-being "Moderate degree of well-being throughout " Moderately greater feeling of well-being Greater feeling of well-being at first, not mainta.ined .. 6. La.ck of feeling of well- being throughon t 7. Feeling of well-being somewha.t less 8. Feeling of well. being definitely less
Group No•.
5
5, 17, 18, 19, 20
7
1, 3, 6, 8, 9, 13, 16
4
4, 7, 14, 15
1 2
10 11, 12
1
:2
(C) General outlook of the patients. No. of cases
1. 2. 3. 4. 5. 6. 7. 8.
Bright throughout Definitely brighter ontlook }[oderately bright outlook .. Moderately brighter outlook Brighter at first, less bright later Ahsence of bright ontlook throughout Outlook somewhat less bright Ontlook definitely less bright
Group
No~.
5 7
5, 17, 18, 19, 20 1, 3, 6, 8, 9, 13, 16
4
1
4, 7, 14, 15 10
3
2, 11, 12
(D) Physical capacity of the patients for work. Increased capacity
1. Light to hard 2. Nil to light Retention of capacity Light Loss of capacity Light to nil .. Absent capacity throughout ..
No. of cases
5 6 1 1
7
Gronp Nos.
5, 17, 18, 19, 20 1, 3, 8, 9, 13, 16 6 2 4, 7, 10, 11, 12, 14, 15
346
[May, 1934
TUBERCLE
It should be noted, however, that of the seven patients unfit throughout for work, four (Group Nos. 4, 7,14 and 15) showed a moderate degree of improvement in the state of their health. DISCUSSION OF THE RESULTS.
Consideration of 'rabIes I and II shows that all patients, prior to re-housing, had been subject to undesirable housing conditions. On transfer all patients were in a decidedly better position. In the case of 12 the housing conditions fulfilled all requirements, while the remaining 8 occupied accommodation in regard to which not more than one defect existed. As to other adverse environmental influences to which there was exposure before removal, these were present in 10 cases, the details being as follows ; Group No<.
No. of cases
Inadequate food .. Mental anxiety regarding family Poor, with inadequate food .. Poor, with anxiety regarding family .. .. At hard work, while only fit for light, with anxiety regarding family .. .. Poor, with inadequate food and anxiety regarding family .. Unable to secure light work, poor, wi~h inadequate f(lod
1 3 2 1
11 6, 7, 10 16, 19 3
1
20
1
13
1
17
After removal the position as to these adverse environmental influences was somewhat more satisfactory, eight cases being affected, and in the case of four of them anxiety regarding the family was alone present. No. of cases
Inadequate food .. Mental anxiety regarding family Unable to obtain light work .. .. Unable to obtain light work, poor, with inadequate food .. .. .. .. At light work only while fit for hard work, poor, with inadequate food
Group Nos.
1 4
11 6, 10, 13. 14
1
9
1
16
1
17
In passing, it should be noted that the change in housing, with consequent improvement in the condition of most patients, brought with it, in an indirect manner, a reduction in the number of adverse influences, Group Nos. 3, 7, 19 and 20 not figuring in the second of the above lists, though on the other hand Group Nos. 9 and 14 now appear, the former becoming fit for light work for which he previously had not the capacity, while the latter came to realise more fully his family responsibilities. The question of habits before and after removal will now be noted. Before removal the position was as follows ; No. of cases
Unsatisfactory habits in the home only Unsatisfactory habits both in the home and outside ..
Group Nos.
3
7, 12, 17
4
1, 2, 11, 13
After removal the position was thus ; No. of cases
Unsatisfactory habits in the home only Unsatisfactory habits outside only .. .. Unsatisfactory habits both in the home and outside
Group Nos.
3 1
7, 12, 17 10
2
2, 11
May, 1934]
RESULTS OF BE-HOUSING TUBERCULOUS PATIENTS
347
It is of interest to llotethat the numbers unsatisfactory in respect to habits thus showed a reduction from 7 to 6; no change in habits followed removal in 5 of the 7 affected before removal, while one case (Group No. 10) showed deterioration in habits after removal. In the light of these analyses let us study the group of 20 cases, dealing with them in two distinct lists, the first that of the 16 who showed at the end of the respective periods of observation an improvement in health, or the maintenance of a satisfactory state of health, and the second that of the four who failed to show improvement or who lost ground steadily, using in this survey, for convenience, the numbers 1 to 10, indicative of the various adverse influences recorded and which have been defined above, where record is made of the method of investigation.
Dist of 16 cases-impTOved or otherwise satisfactory. Ad verse influences after removal
Group No.
,-------'----------, HOllstug
othert~~~~~~~~ental
Habits
1
3 4
4
5 6 7 8 9
4
8
2
9
4
5 8 8
16
4
5, 6, 7
17
3
5, 6, 7
13 14
15 9
18 19 20
List of 4 cases-wot'se. 2
10 11
12
8
6
9, 10 10 9, 10 9
Even if we exclude Group Nos. 17 to 20, all early sputum-negative cases, with quiescence of disease present on removal to new housing, and in the case of which it was only reasonable to expect the maintenance of quiescence, we still have left, out of the new total of 16 cases, 12 which evidently benefited greatly by the change, and this in spite of the fact that in a number of cases counteracting adverse influences were present throughout the whole, or the greater part, of their stay. Had these influences not been present, there is hardly any doubt, in my opinion, that improvement in certain of the cases would have been more pronounced. In passing, one should note. however, that anxiety with regard to the family welfare cannot always be regarded as an adverse factor of marked degree, as its presence in certain cases may act rather as a stimulus and incentive to maintain health so far as it lies in the power of the patients to do so. It appears to me to be a point of great importance that on studying the
34tl
TUBERCLE
[May, 1934
above two lists of cases side by side, a definite impression is received that the failure to improve or to maintain a satisfactory position as to health appears to be closely associated with the inability or unwillingness to lead a life of care, in the home, outside the home, or both. There was some evidence, at the time of transfer, that restless agitation, apprehensiveness and irritability were fairly common characteristics. In such cases I did observe a decided tendency, as the activity of the disease slowed down, for a change in temperamental expression to occur, restlessness becoming less with replacement of a somewhat calmer frame of mind, irritability altering to a spirit more akin to one of cheerfulness, a morbid attitude to the disease becoming changed to a more intelligent one, and the standard of life and ideals tending to become higher. SUMMARY AND CONCLUSIONS.
This investigation comprised 20 patients with pulmonary tuberculosis, who, with their families, were transferred during the years 1928 to 1931, from unhygienic and, commonly, overcrowded housing tv more sanitary and more roomy conditions. At the time of the transfer 15 of the patients had active pulmonary tuberculosis, the remaining 5 being cases in whom quiescence of disease had recently been secured as a result of sanatorium treatment, which all cases observed had enjoyed prior to re-housing, return being made to the bad conditions after treatment in sanatorium and for a period of a varying number of months before transfer. The initial detailed observation of each patient was made immediately prior to re-housing, and thereafter at six-monthly intervals. 'l'he majority were observed for a period of at least eighteen months after re-housing. The main results were as follows : (1) Out of the 20 cases there was in 15 a definite improvement in health, and in one other case the maintenance of a satisfactory position. If we exclude the four initially quiescent (and at no time sputum-positive) cases, there was a definite improvement in 12 cases out of the 16. (2) From the angle of the patients' own feelings, all those considered by me on clinical grounds to have improved were of the opinion that the change in housing had proved of definite benefit to them. (3) In outlook the same group showed a satisfactory response to their new environment, it appearing in several cases that the lessening activity of the lesion, and consequent diminution of the toxffimia, brought with it a tendency to greater balance of temperamental expression. (4) As to capacity for work, 11 of the 20 showed increased physical capacity, and one retained a capacity for light work, while four others, though unfit for work throughout the period observed had, nevertheless, improved in health. (5) Fact appen,red to agree with theory in that there was definite evidence of a close link between the presence of bad habits and deterioration in health on the one hand, and between the presence of a careful manner of life and improvement on the other. In only one of the improved cases were bad habits considered to exist, while in the four cases who were worse all showed definite evidence of bad habits.
May, 1934]
RESULTS OF RE-HOUSING TUBERCULOUS PATIENTS
349
(6) Change in housing conditions produced in two cases a change for the better in habits, though in one other case laxity of habits appeared for the first time. (7) Improvement in housing tended, indirectly, to lessen the number of other adverse environmental influences to which the patient was exposed, especially when he or she definitely improved in health and so gained an increased physical capacity for work. On the other hand, where fitness for light work, but inability to secure work, was an indirect result of improvement in health, previous incapacity for work having been present, an added adverse psychical factor was judged to follow as a consequence. (8) With regard to infectivity, of the 15 cases, 10 became, with a reduction in the amount of sputum, potentially less dangerous, two cases becoming sputum-negative over the latter part of their respective periods of observation, in one case for the last twelve months, and in the other for the last eighteen months. (9) The juvenile contacts examined appeared to have gained markedly in health, there being increased vigour and the development of a more healthy colour, while no fresh cases of gross infection were noted. It may, therefore, be reasonably inferred that there had been an increase of the resistance to infection of the contacts. To sum up, it may therefore be claimed, though rigid conclusions are to be deprecated because of the smallness of the numbers on which my opinions are based, that the results noted are sufficient to justify an organised attempt, on the part of the Local Authority, to secure for other suitable tuberculous patients and their families, at present living in unhealthy homes, removal to good conditions. Further, the question of rent-assistance would appear to be a justifiable consideration in view of the benefit, not only to contacts, but to the health of the actual patients themselves, the majority of the latter who were observed having showed a slowing up of the activity of the disease, a gain in feeling of well-being, an improvement in outlook and an increased physical capacity for work. To increase the proportion of cases who go to new housing with a willingness to lead a life, both in and out of the home, based on sanatorium principles, I consider that special conditions of tenancy are advisable, not only to secure the control of infection but also to make certain the regular attendance at the anti-tuberculosis Dispensary of all patients re-housed and who are under public medical treatment. In addition, I feel it would be beneficial were some scheme of housing management in operation, whereby, in appropriate cases, the tenants were to receive suitable instruction before removal so as to prepare them to enjoy and to appreciate the great change in their mode of living. It is my belief that many present anti-tuberculosis schemes could be amended advantageously by the payment of a greater degree of attention to the question of re-housing of the patients and their families, especially if prior selection were made of those patients in whom the lesion is tending towards quiescence or chronicity, and particularly of those whose temperament and character are such that there is a likelihood of home treatment being carried out successfully.
350
[lJ [2J [3J [4J [5J [6J [7J [81 [9J
TUBERCLE
[May, 1934
REFERENCES. TOMSON, W. B. "The Housing Problem in its Relation to the Tuberculous and Tuberculosis Care Committees," 1930, p. 18. TURNER, H, M. Report on the Prevention and Treatment of Tuberculosis. In the Annual Report on the Health of Sheffield, 1931, pp. 122-124. FRAZER, W. M. Annual Report, Medical Officer of Health, Hull, 1931, pp. 104-105. HURRELL, G. Journ. Roy. San. Inst., 1928, 48, 571. CLARK, J. A. M. Annual Report, Medical Officer of Health, Wallsall, 1931, pp. 100-101. NEWMAN, G. Report of C.M.O. Ministry of Health, 1931, p. 84. Cox, G. L. Public Health, 1932, 45, 206. TURNER, H. M. Lac. cit., p. 124. PRICE, F. W. "A Textbook of the Practice of Medicine," 3rd edit., p. 1103.
PULMONARY CONSOLIDATIONS IN CASES OF TUBERCULOSIS. By S. S. JAIKARAN, M.R.C.S.Eng., L.R.C.P.Lond. PULMONARY tuberculosis is a disease in which it is notoriously difficult to give a definite prognosis. No matter how severe the symptollls, the illness may settle down within a comparatively short time, and thereafter pursue a chronic and rather benign course. A case with trivial symptoms and slight fever to start with may run a steady downhill course and lead to death within a few months. Extensive consolidations may eventually end in fibrosis with some calcification and, within recent years, the possibility of the absorption of tuberculous exudates has been widely discussed. Small consolidations, as often as not, lead to caseation and cavitation. A consideration of certain tuberculous lesions, for example: (a) epituberculosis, (b) extensive pulmonary consolidations, lobar in distribution, in adults, and (c) acute infra-clavicular lesions, may help to explain the apparently contradictory behaviour of many tuberculous processes.
1.-EPITUBERCULOUS CONSOLIDATIONS. Some patients suffering from tuberculous disease are found, at their first physical examination, to present signs of extensive pulmonary consolidation, and to produce a sputum containing tubercle bacilli. Until quite recently, such cases were almost invariably given a poor prognosis. X-ray pictures of these patients' chests, when showing large areas of opacity involving one lobe of a lung or more, were usually described as indicating advanced disease. The onset of illness often bore a striking resemblance to that of lobar pneumonia. Such cases were labelled as tuberculous pneumonia, a condition regarded as leading to death in a matter of weeks. So fatal was tuberculous pneumonia thought to be that whenever, as happened sometimes, a case so diagnosed recovered, the diagnosis used to be re-considered and declared to have been mistaken. Non-tuberculous pneumonia was then blamed for the illness, and the prevailing view of such a case was that