Tuberculosis yesterday and today

September 1953

251

Tuberculosis Yesterday and Today By G. LISSANT COX and H. F. HUGHES

Introduction 'I cannot so properly say that he died of one disease for there were m a n y that had consented and laid down their heads together to bring him to his end. He was dropsical, he was consumptive, he was surfeited, was gouty, and, as some say, had a tang of the pox in his bowels. Yet the Captain of all these men of death was the consumption, for 'twas that that brought him down to his grave.' Thus J o h n Bunyan in the Life and Death of Mr Badman. What of today? A recent visit to the County Palatine of Lancaster after a seven years' interval, and a review of many annual reports of medical officers of health, together with the annual reports of regional hospital boards, has stimulated enquiry into some results of present-day methods of prevention and treatment. As ever, the clifficulty is to see the wood for the trees, and a further complication arises, for here and there the forest is encumbered with fallen timber or with growth of young trees. To cover the same geographical areas, there are, for example, annual reports of the Lancashire Administrative County, the cities of Liverpool and Manchester, but also reports including these areas of two regional hospital boards. These several reports emphasize the administrative break in what should be a unified service having unified and Comprehensive annual reports. We note an effort in the Manchester city report (z95z) to combine some small measure of prevention with treatment. The Liverpool city report (z95z) is, by contrast, a meagre one for tubercle. The reports of the Manchester and Liverpool Regional Hospital Boards cover limited - too limited ground: Manchester R.H.B. give statistics from I 9 4 2 - the peak war-year (and regard the declining death-rate as the best indication of progress against tubercle) - and Liverpool R.H.B. from I948. The County report gives valuable tables dealing with morbidity and mortality and, most im-

portant, the information covers many years. Too many annual reports give figures fi)r one year, and the largest public health department in the Midlands, asked to help with previous records replies that it is too busy and suggests a visit to the distant city library! And so from isolation, bed-rest, good food, and too much moving air before the first World W a r - a n d a f t e r - w e progress by collapse therapy (major and minor), and since World War II by wide use of the new antibiotics or 'wonder drugs'. Through the last-named has followed a greater success with surgical measures for both respiratory and non-respiratory, and a far-reaching control of secondary infection. Thus, at our old Wrightington Hospital, we find the turnover of the non-respiratory patients is three times greater and the waiting list reduced to single figures. The same happy results were confirmed at the Lord Mayor Trcloar's Orthopaedic Hospital, Alton, Hants, with replacement of cmpty children's beds by adult patients. What arc the present-day results for respiratory tuberculosis? Arc we to conclude, as is imagined in some cloud-capped towers in Whitehall, that all is nearly over? Wc have tried to answer this bricily in the pages that follow. T h e Tuberculosis Picture in Figures To aid a quick, general appreciation of the position of tuberculosis, we give under a few main heads figures, to"show the increase or decrease 'today', compared with 'yesterday' (represented by the pre-war z938 , and for mass radiography, i946 ). Several of the items in this statement invite discussion, and they are dealt with in the remainder of the article.

Mortality and Morbidity In recent years, the steady, and of late alm~3t dramatic, fall in the deaths and death-rates is welcome; but what of the stationary

252

September 1953

TUBERCLE

position, or even increase, in the notifications o f respiratory tuberculosis? T a b l e I I shows a few examples a m o n g the larger local health authorities, along with the experience in E n g l a n d and Wales.

a d v a n c e d f r o m 223,856 in 1949 to in 195o , a n d to 250,889 at the end For the same years, Liverpool numbers are 11,29% 12,53o a n d M a n c h e s t e r R.H.B. (with twice the

237,350 o f 1951. R.H.B. i3,o77; popula-

TABLE I . - COMPARISON OF ~[AIN TUBERCULOSIS STATISTICS; ENGLAND AND X,VALES

(a) No. in

( b) No. in

I938

1951

. . . . . . . . . . . . .

21,93 o 4,246

I2,O 31 1,775

~o - - 45" I _ 58.1

. . . . . . . . . . . . .

37,879 12,8IO

42,696 6,744

+ i2. 7 -- 47"3

1,867 1,223

2,067 539

+IO "6 - - 53"9

i38,483 49,773

250,889 44,198

+ 8I'I -- I I'2

i9,o75 5,986 1946 571,697 3"5

26,397 3,Ol I

+ 38.3 - - 49"7

2,254,4I x 2"9

+ 294"3 -- 17"1

Item

I. DEATHS from:

Respiratory tuberculosis . Non-respiratory . . . . 2. N E W CASE NOTIFICATION: Respiratory tuberculosis . Non-respiratory . . . . 3- NoN-NoTIFIED FATALCASES: Respiratory tuberculosis . Non-respiratory . . . .

. . . . . . . . . . . . . 4- NOTIFIED CASES ON CIIEST CLINIC: REGISTERS: Respiratory tuberculosis . . . . . . . . Non-respiratory . . . . . . . . . . 5. BEDSIN TUBERCULOSISHOSPITALSoccupied at year-end: Respiratory tuberculosis . . . . . . . . Non-respiratory . . . . . . . . . . 6. h'[ASS RADIOGRAI~nY:

Persons examined . . . . . . . . . . Active cases per I,ooo . . . . . . . .

Increase or decrease

TABLE I I . - COMPARISON OF (a) NEW CASE NOTIFICATIONS OF RESPIRATORY TUBERCULOSIS in 1936-38 (AvERAOE), x.VITII I95I ; AND (b) NO. OF DEATHS IN I936--38 (AvERAOE) WITH I95I

Respiratory tuberculosis (a) aVew notifications I951 Rise or (av.) fall

1936-38

Authority

%

Birmingham .... Middlesex . . . . . . Lancashire .... England and "Wales

..

913 1,938 1,263 (I937-38) .38,754

(b) No. of deaths I936-38

195i

Rise or fall

382 528 529

_ 47. o -- 49.1 -- 37"1

(av.)

i,x84 2,416 1,838

+ 29.6 + 24"6 + 45"3

74 ° I,O38 84I

42,696

+ IO.I

23,234

N e w cases thus persist in the count W in greater n u m b e r than pre-war, whereas the deaths are considerably down. Prevention has manifestly not kept pace with treatment. Does tills illustrate the present-day t e n d e n c y to consider a case o f tuberculosis as a disease o f the individual r a t h e r t h a n a source o f potential infection? It is significant that the Ministry report ( C m d . 8655 ) the n u m b e r o f notified cases o f r e p i r a t o r y tuberculosis on the chest clinic registers in the c o u n t r y has

%

i2,o31

-- 48.2

tion) are 19,399, 2O,Ol 4 a n d 2o,578. T h e r e p o r t to the Liverpool R . H . B . (i952) states: ' T h e r e is no cause for c o m p l a c e n c y . . . T h e notification rate continues to show no d o w n w a r d trend at all.' I t is interesting to c o m p a r e an example o f A m e r i c a n m o r b i d i t y and m o r t a l i t y in the medium-sized State of C o n n e c t i c u t which has a tuberculosis service o f accepted efficiency: ' N e w l y reported cases in the last ten years r e m a i n almost u n c h a n g e d , applica-

September 1953

TUBERCLE

tions to State Sanatoria have increased slightly, although the n u m b e r of deaths and death-rates have dropped rapidly and significantly in the ten years 194o-5 o' (Connecticut State Med. ffl., xvi, 322), and from C a n a d a we read of a record low deathrate, great advances in case-finding, but: 'However, new cases continue to arrive at a rate that shows very little tendency to d e c r e a s e . . . ' ( C a n a d i a n T u b . Assoc., report, I95z). aVon-respiratory Tuberculosis. - For one or two years after the change-over in J u l y 1948, the responsibility of the chest physicians in regard to this form of the disease was insufficiently defined, a n d action from the chest clinic deteriorated. It is likely that the period of uncertainty resulted in a falling off of statutory notification a n d with it a slackening of prevention. Under-notification still persists, a n d reduces the satisfaction at the improvement as measured by notifications. Non-Notified

Fatal

Cases

An i m p o r t a n t criterion of the efficacy of tuberculosis control is the proportion of

253

patients escaping case-notification d u r i n g life. T h e practice in Lancashire was to investigate the circumstances of each nonnotified death in a n endeavour to secure the greatest possible proportion of notification. Thus, all sources of infection could be supervised, that is, brought u n d e r Public H e a l t h control. T h e d i c h o t o m y of prevention a n d treatm e n t by the 1946 A c t - as expected by m a n y of u s - has produced less efficient notification, as will be seen from the following statement o f the experience of local health authorities whose reports are available to us: T h e Chief Medical Officer of the Ministry, reporting in i95o , said: 'Scrupulous attention to the statutory d u t y of notification is essential; the increasing n u m b e r of deaths o f tuberculous persons whose cases have not been notified before death and who m a y have been a large and unrecognized reservoir of infection is deplorable.' A n d later: ' M a n y such cases occur in hospital practice.' A similar statement is m a d e by the C o u n t y Medical Officer of Lancashire• Again, the consultant chest physician of a northern city writes: 'Surgeons are particularly casual

TABLE III

Proportion of deaths not notified as cases during life

.. ••

~"ear i933-35 (av.) 1949 195o I951 I938 I951 I951 I951

Respiratory Per cent 4"2 I I "o I4"8 I2.1 Io'8 23"2 I5"5 7"3

Non-respiratory Per cent 16"5 25"4 37"6 32"9 35"4 3o'4 32-4 27"9

. . ..

I95I 1951

IO" 5 2o'6

I I'I

Authority Lancashire ..

..

London

..

..

h'Ianchester Liverpool Cardiff Hampshire Birmingham

.. .. .. ..

.•

I938 3"3 21-O I951 IO"5 55"6 Sheffield .... I942 4"3 33"3 x952 I3"7 63"6* England and Wales.. 1938 8"5 28"8 195 x 17"I 26"0 • Calculated on a smalI number ofdeaths. [Information obtained from the Health reports of tile autboritles named and from Report of Min. of Health, Cmd. 8787.]

254

TUBERCLE

about notifying any form of tuberculosis which they happen to treat.' The Chief Medical Officer of the Ministry also states that it is the duty of seniors to ensure that their juniors appreciate this obligation to notify cases of tuberculosis (Cmd. 8582 , p. 79). It will be interesting to hear what action (if an),) has been taken to remedy the nonnotification position: hospital medical staff are a part of the N.H. Service personnel and ought to be available for a 'reminder' at the least; general practitioners can be invited to say how notification came to be missed. A medical officer of health cannot be satisfied until he knows that every source of infection has been investigated, contacts examined, environmental conditions reported on, the source of infection (including milk) ascertained. But the key to the position is the chest physician who deals with the individual household in his local health authority duty. Some chest physicians and medical officers do enquire (e.g. in Sheffield, Essex, Cardiff); but what of those who do not? Who prompts them? 'Pastoral visiting' by an adviser without power is not the answer. One detects here a serious weakness in initiative, stinmlation and co-ordination. We know from the Ministry's report (Cmd. 8787) that in I95I some 2,6oo persons died without being notified to the medical officers of heahh. Is not this an acid test of effective tuberculosis control and does it not show how much, in spite of the new drugs, is still to be done?

Tuberculosis Among Children In searching for the age-groups in which the increased incidence of respiratory tuberculosis has occurred, one hears of the 'shift' towards the younger ages. In the pre-sanocrysin era, prevention among children was g o v e r n e d - i n Lancashire, at any r a t e - b y the rule: Find, isolate, educate, treat and rehabilitate the adult positive case. It is a very different picture today: Mass x-ray surveys, Mantoux testing, BCG, en-

September 1953

thusiastic work by paediatricians, differing standards of diagnosis, and above all a more intense examination of contacts, have produced changes in incidence and treatment. Dr Metcalfe Brown, in his Annual Report for Manchester for i95i , warned us that the incidence of pulmonary tubercnlosis among children aged o - 5 years is increasing several fold. H e believes the reason can only be that 'infectious cases are still not being admitted to sanatoria quickly enough and in consequence young children with poor immunity are contracting the disease in increasing numbers'. Let us look at the Manchester figures and also of several other authorities whose reports happen to be available to us: The rise in cases among the o - 4 years group appears heavy but the numbers are relatively small. We used to find that notification of young children was greater in the south, but that difference is disappearing. If in the north cases were not so readily diagnosed and notified as in the south one would have expected the children to return with the disease manifest in early adult age, but in Lancashire our investigations of new young adult patients did not disclose that they had been rejected at the chest clinic in childhood. Dr Midgley Turner (Sheffield), in a personal communication, states that his notifications of young children are much smaller than they used to be; he believes that a factor in the country as a whole is the skin testing in connexion with BCG which is leading in some parts to the discovery of hilar tuberculosig with 'segmental collapse' lesions; such cases require treatment and, in his opinion, should be notified. In the absence of generally accepted criteria for the notification of children with respiratory tuberculosis, it is not surprising that there should be wide variations. The case mortality is low. Combining the figures for Manchester, Lancashire and Middlesex, one finds that age-group 0-4, with 592 cases and 22 deaths, has a case mortality of 3"9

.September 1953 TABLE

T U BERC L E

I~,[. - - N O T I F I E D

255

CASES OF RESPIRATORY TUBERCULOSIS AMONG C t n L D R E N

P e r c e n t a g e of C h i l d r e n to T o t a l Notifications (All Ages) o f R e s p i r a t o r y Tuberculosis; a n d M o r t a l i t y from R e s p i r a t o r y Tuberculosis a m o n g C h i l d r e n in C e r t a i n L a r g e A u t h o r i t i e s a n d E n g l a n d a n d Wales

Range of.years Average Authority, population, age-groups and percentage Manchester (7o3,175) CASES

O- 4 . . . . 5--14 . . . . C h i l d r e n to all ages % . . DEATIIS

O-- 4 5-14

193 I -35

I936 -4 °

1941 -45

1946

1947

1948

1949

I95O

I95I

I952

14 63 7"2

IO 43 5"7 4 8

15 35 5"5 5 5

17 44 7.6 3 3

27 60 11. 7 9 I

37 42 9"1 7 3

36 62 lO. 9 5

38 48 IX.6 3

49 48 x3.6 2

46 78 17- 3 3 I

8 44 4 .0 6 11

14 39 3 .6 7 8

20 56 4"5 6 9

28 64 6"6 ii 4

37 69 6" 9 9 9

36 80 7"I 4 4

51 89 8"6 3 I4

75 98 9"4 i 3

Io 4 6.6 6 13

35 95 6.i 8 ii

73 135 8.i 12 8

87 179 9"9 6 7

96 200 IO'9 i6 I1

126 200 II'5 7 6

lO2 i74 IO.O 3 --

lO 3 129 9"3 3 3

io2 i48 lO"3 8 2

54 254 5.2 31 47

72 181 5"0 22 22

Iz6 234 7"I 24 17

I86 352 8" 5 25 12

2o 4 361 IO"4 25 17

273 329 II'O 15 8

279 341 10"8 7 5

278 28I 10" 7 7 3

28o 27o ll'I 8 3

93 6" 4

99 6"8

I35 9"5

I23 9 .0

I48 IO"7

I24 9 "t

. . . . . . . .

IO 13

- -

2

- -

Lancashire (2,o46,457) CASES

O-- 4

. . . .

12

5-14

. . . .

61

C h i l d r e n to all ages, % . . DEATHS O- 4 . . . . 5--I4 . . . . Middlesex (2,268,ooo) CASES

O--

4

. . . .

5-I4 . . . . C h i l d r e n to all ages, % . . DEATHS O- 4 . . . . 5--14 . . . . London (3,358,ooo) CASES O-- 4 . . . . 5-I4

. . . .

C h i l d r e n to all ages, % . . DEATHS O-- 4 . . . . 5--I4 . . . .

5-2 5 19 (I935) 17

85 128 I°'°

io 3

73 lO 9 ----

Essex (I,6OO,9OO) CASES

O-I 4

. . . .

C h i l d r e n to all ages, ~/o . .

--

--

m

--

England and I Vales (43,744,924) CASES O--I4 . . . . C h i l d r e n to all ages, % . . D E A T H S

O-I 4

. . . .

----

(1938 -4o) 2,546 2,876 3,595 4,195 4,719 4,641 4,798 4,911 -7"o 6"9 8"5 9"7 lO'7 lO. 4 11.3 i1-5 -.~ __ __ __ 331 205 I83 154 -[Compiled from information in Annual Reports of the M.O'sH. of the Authorities named, and from Min. of ttealth Reports, C.M.O. i938 , 1949-5o-51. ]

per cent for 1949-5i ; twenty years ago, on 43 cases a n d 21 d e a t h s , it w a s 48"8 p e r cent. W i t h r e g a r d to t h e 5 - 1 4 a g e : g r 0 u p , t h e c a s e m o r t a l i t y i n 1949-51 w a s 3"2 p e r c e n t (877 cases, 28 d e a t h s ) , w h e r e a s t w e n t y y e a r s a g o it w a s 19. 7 p e r c e n t (228 cases, 45 deaths). T a k i n g all c h i l d r e n o - 1 4 , t h e n o t i f i c a t i o n s a r e g o i n g u p a n d n o w a c c o u n t for a b o u t I I

to 12 p e r c e n t o f a l l r e s p i r a t o r y n o t i f i c a t i o n s , a g a i n s t 6 to 7 i n t h e e a r l y i93os. In the Newcastle Region there has been a r e m a r k a b l e d r o p as b e t w e e n 1952 a n d i 9 5 I . T h e rise i n t h e o--4 a g e n o t i f i c a t i o n s h a s not seriously aggravated the tuberculosis p r o b l e m a n d t h e r e a s o n s for t h e i n c r e a s e i n children of all ages are:probably: Mantoux t e s t i n g for B C G , g r e a t e r s e a r c h for c o n t a c t s ,

256

T U BERC L E

September 1953

one, better than the alternative, an independent service, which has been tried out, e.g. in Nottingham. The Welsh R.H.B. have carried out their experimental survey in the Little R h o n d d a Valley. The Manchester R.H.B. are carrying out a survey, comMass X-rays and Miniature Radiography-- menced early in I953, by six units of the A Ten Years' Research whole of the City of Salford (though not so A bright report presented to the Manchester grandiose as the American mass attack by Regional Hospital Board (in May x952 ) some twenty units), an example of initiative reminds us that it was in t943 that the which should produce valuable data. Lancashire County Council was allotted the Here are some examples of the results of first local authority mass x-ray plant. There surveys measured by the number found are now some sixty at work. Have they with active respiratory tuberculosis per t,ooo justified, on the whole, their expense and examined: Lancashire (I943-45), industrial l a b o u r - m e d i c a l and lay? In 1943, we groups, 3"2, and (t946-48), 2"9; Manchester expressed the opinion that mass x-ray (i95i), general population, x.65, and should be considered a new research in the National Service recruits, 1.85; Liverpool tuberculosis field, always flexible, never (z95i), general population, 3"2, National stereotyped. There is, happily, no uniformity Service recruits, 2.I7, and doctors' request in present use; most units now are really cases, 30.5; Essex (195o), general and mobile (not just movable). Others are static, industrial, 1.8; the four Metropolitan and cater for the 'request' cases from the Boards working in London, general populageneral practitioners, so well described and tion, 3"4 (approximate); London County, used by Dr Toussaint, D r Nash and others National Service recruits, IO.6 ('apparently (B.M.J., 7.2.53, and The Aled. Officer, active lung tuberculosis'); Ministry of Health 25.1o.52), followed by a critical corres- unit in London, civil servants, 4.15; Welsh pondence with two medical directors of R.H.B. and Pneumoconiosis Research Unit, units (The Med. Officer, 6.i2.52 and 27.i2.52 ). survey in Little Rhondda Valley, 7.1 But this is miniature radiography and should females and 6-2 males; Middlesex, general not be confused with mass radiography. population, 1.7; England and Wales, all The mass x-ray service has to its benefit surveys, x943-5 I, 3"5. a national standardization for its statistics. From the surveys, it can be estimated One is glad to notice that these are corre- roughly that there is an undiscovered lated with the different kinds of field work reservoir of over 5o,ooo active respiratory (e.g. routine examinations of industrial cases (nearly 2%ooo with positive sputum) workers, general public, doctors' request at large in the country. Clearly there is cases, National Service recruits). plenty of scope for radiography to be used The Liverpool R.H.B. advocate, from in further experimental ways to reduce the their experience with the static unit in the large and dangerous sources of infection. city, that their two other units should Summary similarly offer facilities to the general practitioners. The Manchester R.H.B. are Tuberculosis morbidity and mortality of considering their policy 'in relation to the yesterday and today are contrasted. Reducmost productive groups to be examined'. tion in mortality following extensive use of The Newcastle R.H.B. are to place their antibiotics is not matched by reduction in five units under the administrative control morbidity. of the consultant chest physician in whose Statutory notification and deaths from area they are based. This policy is the right respiratory tuberculosis of children are better and more numerous x-ray pictures, paediatricians' clinics, and the greater tendency for present-day chest physicians to give the child the benefit of treatment if there is a degree of doubt in the diagnosis.

September 1953

T U BERC L E

257

reviewed. T h e figures are taken from different administrative areas a n d analysed in different age-groups and different years. Geographical variations are considerable but are tending now towards uniformity. T h e rise in recent years in the n u m b e r of deaths of non-notified respiratory cases is illustrated by examples and the causes discussed. Methods to achieve a more effcctive enforcement of statutory notification are dealt with. Some a n n u a l reports of medical offÉcers of health a n d regional hospital boards are reviewed a n d their often f r a g m e n t a r y information criticized. Mass r a d i o g r a p h y is dealt with in relation to research. It gives us an estimate of the large reservoir of infectious tuberculous persons awaiting discovery. A new measure of progress in the fight against tubercle is needed, for death-rate deceives: we need a 'live' register of infectious cases for local health authority areas. Wider a n d greater use of Public Health measures to discover a n d control sources of infection, together with regained unity of administration, is the urgent need of today.

modifications' of the classification which he has in mind. Further, has a 'nationally approved terminology'; and the 'M.R.C. morbidity code' been published, and if so, where? And what is meant by the 'occupation classification' used by me, which cannot be compared with that used by the Registrar-General? Is there so much room for different interpretation of the pathological findings on which the classification is based, that this can reasonably be described as an 'inherent defect'? Is it not rather the surest basis of classification open to us? It is on this basis that it has been described by some well-informed observers as being 'sound and logical'. I regret to have to trouble your reviewer with these questions , but as these particular comments are quite obscure to me, it is possible that they may not be clear to many ofyour readers. I hope that he will help me in my attempts to clarify a subject which all of us have found so difficult. Yours faithfully,

Acknowledgments

I953 September 25: Manson House, 26, Portland Place, London, ~V.I. 5.o p.m. ORDINARY MEETING D r F. A. H. Simmonds, Presidential Address, 'Tubcrculosis, the Prospect Before Us'. Dr Stephen Hall, 'Local Epidemiology'. November 20: ]k'lanson House, 26, Portland Place, London, ~V. r. 5.0 p.m. ORDINARY h{EETING Mr Geoffrey Flavell and Dr ~,V. iX{. Macleod, 'The Problem of Round Foci in the Lung'. I954 February 19: Manson House, 26, Portland Place, London, W.I. 5.0 p.m. ORDINARY~,'IEETING. 'A Symposium on Tuberculin and Tuberculin Testing.' April 23: PROVINCIAL h[EETING - - King Edward VII Sanatorium, Midhurst (One Day).

We-have used the reports published by many authorities, as indicated in the article; in addition, we are indebted to the following for personal communications: Dr H. K. Cowan (Essex C.C.), Dr A. C. T. Perkins (Middlesex C.C.), Dr J. A. Scott (London C.C.), Dr Midgley Turner (Sheffield No. 3 H.M.C.), Dr Greenwood Wilson (Cardiff), Dr F. L. ~,Vollaston (Newcastle R.H.B.), Dr R. J. Gourlay (NAV. Metrop. R.H.B.), M r J . Dobson (Wrightington Hospital), and Dr S. C. Gawne (Lancashire).

Correspondence The E d i t o r - 'Tubercle'. SIR, - I am grateful for the favourable comments made by your reviewer of my book on 'The Classification of Pulmonary Tuberculosis', although I am a little puzzled by some of his remarks. As I am now engaged in further study of the practical application of my classification, I would be most grateful if your reviewer would give me more information on the 'simple

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London, W. IV.8. ffuly 24, I953.

The British Tuberculosis Association 16, Grosvenor Place, London, S.~V. z (Sloane 2115)

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