Trends in Tuberculosis

21

produced by oxygen-enriched air, but unfortunately it is still impossible to estimate plasma-oxygen levels directly-they

can

only

be

et awl. think that the infants

calculated. are

GRAHAM

mainly suffering

In England and Wales, the deathpulmonary tuberculosis fell from 56 per 100,000 population in 1940 to 44 in 1948, but the morbidity-rate rose from III to 121. Actually the notification-rate is not a very satisfactory figure to go by, because not all the cases notified prove to have

not identical.

rate from

from a defect in oxygen exchange from blood to tissues. Providentially, newborn mammals can survive the disease ; but we also know that the number of anoxia much longer than they can later, and the cases on the dispensary registers has risen almost less mature they are at birth the longer their survival steadily, from 188,752 in 1939 to 271,552 in 1949. time. The two main reasons for this are their low (These totals may be swollen by some recovered cases cerebral metabolic rate and their faculty of anaerobic whose names have accidentally been left on the metabolism which is characteristic of foetal life and registers ; but relatively they are comparable, and a persists for a short time after birth. The fcetus and rise of over 80,000 can hardly be without significance.) newborn use less oxygen per unit of energy than older During the past eight or ten years, then, here as in mammals do, because their metabolism has an end- America, the mortality-rate has been declining but breakdown short of carbon the incidence of new infections apparently has not. point in carbohydrate dioxide and water.44 Nevertheless, those who suffer In both countries the cases under treatment have from prolonged anoxia may sustain permanent tissue increased ; the sanatorium waiting-lists are lengthendamage if they survive. The central nervous system ing ; poor housing and overcrowding are helping the is the most vulnerable part of the body to anoxia, spread of infection, and the pool of active cases and its vital processes cannot withstand oxygen lack in the community is almost certainly growing larger. for longer than five or six minutes without harm. The falling death-rate may, in fact, be misleading ; The mechanism of the pathological changes produced is for, though it must depend partly on modern methods a complex one, involving functional, metabolic, and of treatment, it also partly is a legacy from the days, structural factors, and capillary haemorrhage may 15 or 20 years ago, when beds and nurses were better also become serious in some situations. A consider- matched to the number of patients, and when on the able proportion of cases of cerebral palsy, personality whole there was probably less overcrowding of houses. disorder, and mental defect are now thought to be In another 15 and 20 years’ time we may possibly sequelse of foetal or neonatal anoxia. For the great pay with a rising death-rate for our present failure majority, however, nature has provided adequate to control infection. To cope with the new cases clinics are working safeguards against this hazard of birth. harder than ever before. In New York, field visits paid by health-department nurses to patients or their Trends in Tuberculosis families in their homes fell by a third between 1945 A GRAPH of the mortality from tuberculosis for and 1948, largely because the clinic staffs were so the past century is agreeable to contemplate, so steady that less time could be spared for visiting. has been the decline ; but does it give an accurate busy The New York Tuberculosis Association comment picture of what is going on ? Dr. HERBERT R. that " it is impossible to avoid thinking of a possible EDwARDS and Mr. GODIAS J. DROLET7 think it time link between this reduced amount of home superwe turned our eyes from the cemeteries and prevision and the spread and increase of tuberculosis mature graves and considered the living tuberculous ; in New York City in the past few years." The load for, unless the incidence of new cases is also falling, we on our own clinics is hard to estimate accurately. cannot regard the disease as under control. They Their number has not increased greatly to meet the say that between 1940 and 1947, though the growing demands on them: there were 4711 in tuberculosis death-rate in the United States fell in 1938, and 492 in 1947. Graphs made at from 45-8 to 33-5 per 100,000 population, the number England a typical clinic show that, between 1939 and 1949, of new cases registered (the morbidity-rate) rose the number of patients systematically examined by from 76-4 to 93-3 per 100,000. Some of this rise the physician nearly doubled, and so did the total is of course due to better ascertainment-especially while examinations became more attendances, of early cases-by mass radiography ; but it cannot than six times as X-ray numerous, and refill attendances of all be explained in this way. Thus in New York in patients with artificial pneumothorax rose from 1947 mass radiography accounted for only 3-4% 877 to 3024. The clinics in fact are doing a great of the new cases registered, whereas 66% were in the deal of work which was formerly done by the sanasecond or third stage and diagnosed by other methods. and their routine work will become even In Los Angeles in 1948 nearly 87 % of cases were toria ; heavier if B.C.G. is used on a wide scale. All this already " advanced " when notified.8 Admittedly the means that there is less opportunity for home visiting morbidity-rate is no direct measure of the amount of or follow-up. tuberculosis in a community ; for tuberculosis is a Weaknesses in our tuberculosis scheme have always long disease, and the yearly increment of new cases been evident. In the days before the war, standards merely swells an existing tuberculous population of in different areas varied with the keenness of the uncertain dimensions. But the fact that the local authorities and the amount of money at their is morbidity-rate rising suggests that this population disposal. In some areas the care offered was firstmay be growing, despite the benefits of modern rate ; in others it was The National very poor. treatment. Health Service Act, by reducing financial differences, In our own country the picture is similar though has removed some of this inequality ; but it has not, 7. Amer. Rev. Tuberc. 1950, 61, 39. of course, been able to create staff, conjure up new 8. Tuberculosis Reference Statistical Year Book, 1948. New York Tuberculosis and Health Association. 1949. hospital buildings, or solve the country’s housing

22 as Dr. F. HALL puts it in the clearly deserves. As a rule we are rightly anxious June issue of the N.A.P.T. B1l11etin, it has produced to treat quickly the patient whose life is threatened, a state of administrative divorcement between the even though the chances of cure may be small and curative and preventive branches of medicine." the risk is to the patient alone. Yet we turn a Dr. W. L. BURGESS points out that the local health curiously blind eye to the tuberculous, whose life authority is handicapped in preventive work by the may be threatened as gravely, whose chances of cure loss of the dispensaries, which now come under are often good, and whose infection, untreated, will the hospital authorities. There is a danger that the spread and spread and spread. dispensaries, formerly the very centres of preventive education and aftercare, may become purely clinical Annotations institutions or outpatient-departments. Undoubtedly the service might gain much if advisory committees SAMPLE SURVEYS were established to integrate the tuberculosis work of THE sample survey as a tool in medicosocial research each region. At present, as Dr. F. A. H. SIMMONDS has come to stay, and P.E.P. has done a thoroughly says, we are " fighting with two armies who not only useful job in issuing two broadsheetsdescribing in fair have no unified command, but have no joint plan for detail the present position, both as to techniques and the common task." What has been gained on the organisations in the field. The essence of the sample differs in no essential from the familiar technique hospital side (and thanks to advances in thoracic survey of the blood-count. In each, a tiny fraction only of surgery, and the better- deployment of thoracic the whole is examined, and from this deductions about surgeons, this has been much) is offset by a decline the whole are made. In each, a measurement is made, on the preventive side. Moreover, the economic while the vast multitude to whom it applies, whether position of patients, though in theory as good as it human or cellular, swirls by unaware that it has been was before, now requires an unpopular appeal to the measured. The process of sampling, though to the Assistance Board. outsider the most fallible part of the job, is in fact the Some means of limiting the spread of infection more least chancy of all the stages, since, provided wellauthenticated rules are followed, the precise margin of effectually are already being tried. Domiciliary error is known. The analysis of results, using the treatment, used in conjunction with hospital care, or clipped card technique, can also be rendered punched has already enabled many patients to become sputumautomatic, though special precautions are entirely negative-and therefore safe companions for their necessary since the high speeds of work tend greatly to families-within a few weeks or months of diagnosis. human error. magnify But this does not mean that domiciliary care is the The key to successful sample survey work lies in the ideal treatment for every patient, or even for most, design of the questionary and the conduct of the interand it should be regarded mainly as an expedient view. A careful pilot inquiry, using the free-interview capable of helping us through a difficult phase. A method, is a usual first step in any new field of investigasecond measure now widely recognised as necessary tion ; for nothing is harder than to judge, in vacuo as it is that the general and teaching hospitals should were, what questions a sample of the public can or cannot answer. Inability to answer relates mainly to memory reserve a proportion of their beds for tuberculous or lack of experience. For example, it is of little use to This could at one stroke provide beds for all cases. out what people think of heating or lighting methods find early cases, and would have the additional advantage of which they have had no personal experience, or products of making all student nurses and future doctors which they have never tried. On the other hand, it familiar with a widespread disease of which they are seems that when faced with an investigator, questionary nowadays too often ignorant. The difficulty that in hand, the large majority of people tell the truth. some of the nurses in these hospitals may object to In most situations, the Law of Least Energy operates : looking after patients diagnosed as tuberculous can that is to say, it is easier to speak the truth than to make be overcome--as Dr. HORACE JOULES is showing at up a lie. Where social prestige operates, this does not the Central Middlesex Hospital-when proper preapply. For example, the question, "Do you go to invariably produces an inflated cautions are taken for the care of their health. In church regularly this hospital all patients in the general wards who are answer. To get at the true facts, all mention of church can be excluded from the questions ; every alternative suspected of tuberculosis are transferred at once to a Sunday occupation is checked over, and then the crucial tuberculosis unit in a separate building, and only is " And did question popped : you do anything else ?" Mantoux-positive nurses are allowed to look after In the medicosocial field, the Government Social them. The health of all the nurses is carefully superSurvey, now a permanent institution, has been making vised, and the incidence of tuberculosis among them history since 1945 with its monthly Health Index for is lower than in any of the hospitals studied in the the Registrar-General. At present Britain is the only Prophit investigation9 : indeed Dr. JOULEShopes to country in the world to collect a complete picture of be able to show in a year or so that it is no higher national morbidity, though the United States intends than the incidence of tuberculosis in young women shortly to follow our example. Ad-hoc medicosocial sample surveys include such notable efforts as the of the same age-group in the general population. maternity-services investigation made by the Royal He warns all prospective students and their parents of Obstetricians and Gynaecologists and College will be to nurse that they tuberculous the expected Committee. This was Population Investigation patients, and he has never had a refusal. As the care in fact a census of all women giving birth to of the nurses could perfectly well be of this standard in children in a single week in March, 1946. Its success all hospitals, there seems to be no adequate reason (13,687 women cooperating out of 15,130) was due to why those who control our hospital resources should the efforts of nearly all the local health authorities in the country. The investigators-medical officers of go on denying tuberculosis the larger share it so

problem. Moreover, "

"

-.

9. Tuberculosis in London, 1948.

Young Adults.

Prophit Report, 1935-44.

May 15 and June 5, 1950. From Political and Economic Planning, 16, Queen Anne’s Gate, London, S.W.1.

1. Planning.