March 1953 81

A Broadcast and its Repercussions By GEORGE DAY

From Mundesley Sanatorium

About two years go, in response to a chal- lenge by some patients, I drafted with their help a broadcast script on 'Adjusting to Tuberculosis'. This was recorded on a Scophony-Baird tape-recorder, and the re- cording has bccn played over our internal broadcasting system to all patients' head- phones once every four or five months. Thus the average patient has been hearing it twice during his stay. The advantage of putting it over in this way is that different groups of patients at different times have bccn exposed to exactly the same st imulus- not only the same words but the same emphases, hesitancies, inflexions and similar grace notes. The comparatively long inter- vals betwcen exposures obviates any dulling of interest from over-t2tmiliarity.

I f after each playing, one goes about with one's eyes and ears open, much can be learned quite unsolicited about its effect on individual patients and on the community as a whole.

What follows is (a) The Script of 'Ad- justing to Tuberculosis', and (b) Reactions Observcd Fol!owing Its Broadcast.

(a) Adjusting to Tuberculosis For the next few minutes I am going to talk to you about Being a Patient in a Sanatorium; about some of the problems and difficulties you are likely to meet, and about the adjustments you will have to make: adjustments you will have to make if you are to get well, to be as happy and content as possible while .getting well, and, eventually, to remain well.

The framework of my little sermon con- cerns three major adjustments: adjustment to yourself, adjustment to the medical staff and their funny little ways, and adjustment to your fellow paticnts and their funny little ways.

First of all, adjustment to yourself- That 's an odd idea. What does it mean?

Well, while we are enjoying perfect health we are apt to take our own good health for granted. Other people may get serious illnesses, but that sort of thing doesn't happen to its. We arc a l l - each one of u s - rather special. And then something serious does happen to us: and that's a frightful come down. Wc feel tlmt our bodies have betrayed our trust in them, have let us down, and we are inclined to view them less in sorrow than in anger. Then a lot of us are pretty important figures in our own little worlds- the bread- winner of the family, the mothcr, or the indispensable member in the firm. At one blow we are brought low, and we find we aren't so indispensable after all: people manage to jog along without us. Then, possibly worst of all, we may have prided ourselves that we have always stood on our own two f c e t - a n d now we are dependent upon others. Somebody else has got to do our job; we cease to be boss in the family lifc; and other people have to attend to our simplest needs -even to washing our faces and bands. Our little world looks very different: we are viewing it from the hori- zontal instead of the vertical.

All this is a most fcarfid come down, and wc have got to accept it. And some of us find this acceptance, this adjustment to ourselves as we are at the moment, pretty difficult.

How did you react when the diagnosis was frst made? I expect you reccivcd the news with mixed feelings. I f the bottom didn' t seem to drop right out of your world, it probably slipped down several fcct with a nasty jar. You may have been frankly incredulous: you felt so wcll and it was so unexpected. You may have felt angry: Life or at least someone else was to blame. Maybe it awakened in you an illogical sense of guilt and you asked, 'What lmve I done to deserve this?' This deep feeling

82 T U B E R C L E March 1953

that pain, suffering, and disease are punish- ments for sin is as old as religion. And even the National Health Act won't eradi- cate it. Maybe you had an odd feeling of relief: relief that tile diagnosis was no worse; relief that it marked the end of uncertainty; relief even that it at an t . rate afforded respite from a world which was becoming intolerable. You ahnost certainly had wind-up to some extent because tubcr- losis can be a fatal disease. But then you comforted )'ourself with the sure knowicdge that in most cascs people recovered from it complctcly. All the same it is an uneasy sort of bedfellow - to bc treated with a certain amount of respect. ; :

On the whole you are a bit angry and impatient about the whole business. In- evitably it produces other worries: financial worries; the possibility of losing tile job; the family getting out of hand in )'our absence; the bflsiness running less efficiently. Like war it brings separation from loved ones, the fear of drifting apart, of becoming strangers. It is absolutely useless, I know, to tell you not to worry. I might just as well tell you to stop.feeling pain or hunger. It would have to be reinforced with powerful hypnosis. And so I am afraid yo u may have spells of anxiety antl depression-especial ly round about bedtime: that lonely hour. Well, if it's any comfort, nearly everybody is in the same boat and you'll find there's always something encouraging to cling to. A friend of mine, torpedoed in the Adriatic Sea on a pitch black night, swam round for six hours. He kept going by saying to lfimself, 'Well, it's all right so thr'.

You have come to a sanatorium because it is a more convenient and a more Certain way of taking the cure than at home. The cure is rest, and it is easier to rest when you are surrounded by lots of other people who are also resting, than it is when you try to lie a b e d at home surrounded by loved ones who have to work all tile harder in order to keep you comfor table- and loved ones who can be cxcc.,sivcly tiresome with their occasional domestic crises. You dodge these crises: they are filtered off bcforc the)' reach

you here by letter. Here you should find, as the hymn says, 'Peace, perfect peace, with lovcd ones far away'.

One of your predominant emotions will be hnpatiencc. Naturally enough you want to get well as quickly as possible. But days may pass, weeks may pass, and you'll be complaining to, or of, the d o c t o r s - ' W h y don't they do something? When am I going to be given some treatment?' The answer is that you are already having the most important part of your t r e a t m e n t - t h e unavoidable part: bed rest, more bed rest, and still more bed rest. You have got to take this disease lying down. All the other special treatments are secondary. They have their right place anti their right momeut; but they are not effective on their own. T h e weedkillers we give you don't kill the weeds outright and rid you of them. For a few weeks or months they check them from flourishing and s p r e a d i n g - b u t they don't so to speak get down to their roo t s - i t ' s your body has to do that; but during their action they do make it easier for )'our body to perform this extermination.

T h e A.P.s, ptlrenics, thoras and s!milar operations don't cure. They are like the stitches put into a badly cut hand: they may bring tile raw edges together, but it is

you who have to do the healing. It is no use saying as one might of a painfully inflamed appendix, 'Please take the nasty thing away'. Only very rarely is the trouble so localized that we can nip it out c l ean ly - and feel confident that we are leaving nothing behind which may not presently burst into full bloom elsewhere.

No. You have at first to live with tlle disease, come to terms with it, get on top of it and keep it under control. It is a slow passive business. You fight it by taking it lying down. Then in course of time y o u will be able safely to regard the trouble as 'arrested' or even 'cured', and your expecta- tion of life will be actually longer than it would be if you had never had this trouble. I'll explain this curious paradox presently.

So at the beginning you have to accept weeks and perhaps months of rcst; being

March 1953 T U B E R C L E 83

dependent upon others for everything; perhaps feeling fitter and more bursting with energy than you have for months - but still resting: feeling too that the doctors are not bothering about you because they aren't doing things to you and because they volunteer so little day by day as to how you are getting o n - a n d precious little from month to month. (So it seems to you, and yet I assure you that if a doctor is away only three or four days you would be amazed at the amount of overtime he has to put in to catch up with all that has been happening to you during his absence.)

Now a word about your doctors, and your nurses; and your adjustment to them.

When we are ill we tend to regress- t o slip backwards - towards childhood, and for a time our doctors may then become what the psychologists call Father Figures, and our nurses become Mother Figures. This may happen even when the patient is himself a d o c t o r - e v e n when he is a psychologist! The Father Figure represents authority: he wants us to be good, obedient, co-operative: he seems to be able to reward or punish us. He is the quintessence of father, school- master, parson, policeman, the law and the State. The Mother Figure of course has authority but her authority is more maternal and she represents food, loving attention, and comfort when we hurt ourselves. History is apt to repeat itself and so is your Family Pattern. I f you had 'parent trouble' or 'schoohnaster trouble' as a child you are certainly going to have a'little difficulty with some doctor or nurse.

Similarly your fellow patients are like brothers and sisters--or classmates. How did you get on with other children? Did you have jealousies, rivalries, strong likes and hatreds? The same situation will arise again like echoes of the past. But by understanding and remembering your childish tendencies you can make your life far more tolerable, and may avoid letting your feelings get on top of you. You may even catch yourself out making yourself a little ridiculous - and you may even be able to laugh at yourself.

To return to your d o c t o r s . . . It would be

lovely if we doctors were anything like the magic doctors who used to come and See us when we were children. Do you remember? How they came in, unbent, tickled o u r tummies, twinkled knowingly at us, pre- scribed magic medicines and made us well again? It was so obvious that in their hands a cure was guaranteed. No need to worry. They were rather like royalty, such a lot of filss d id their visits produce in the house- h o l d . . . I t would be nice once again to throw the whole responsibility on such a grand person t o d a y - ' D o things to me and make me w e l l ' . . . Alas, w e can only reply: 'We will show you how you can get yourself well, and teach you how to keep well.'

To get the best out of us, regard us as guides, counsellors and - if possible - friends, who in their past experiences have led many others over the same rocky road you are now treading; and can see rather farther ahead than you can, and can guess better what to expect round the next corner.

And don' t forget that they and tile nurses are human. They have their own worries, headaches and disappointments. Sometimes they too get out of bed the wrong side. But

. I

the rule with them - as with actors - is 'The show must go on'; so you mustn't be surprised if sometimes when they are a bit under the weather they don't put up such a good performance as at others.

Some time or another you will notice with dismay that some other patient, who was a new boy the same t i m e as you were, is outstripping you, going ahead with 'up to meals' and walking exercise while you arc still condemned to lie in bed; and this may cause alarm and despondency. 'What's gone wrong with me? Why don't I keep up with him?' You want to ask, 'I don't like the look of this at all. Am I w o r s e than him?' The answer i s - It's all in the luck of the game. In the first place you may have been dealt a poor hand, or one more difficultto play; and then, to change the metaphor, the other chap may have a run of double sixes while you plod along only shaking ones or twos. In the game there are both Snakes and Ladders but these are ahvays on the move,

84 T U B E R C L E March 1953

and crop up at different places for each individual patient. Should your bedroom, so to speak, be infested with snakes, which .you cannot see, but the doctors may sense, the doctors will keep you in bed until the danger has passed. Accept these long weeks when you lie in the doldrums as a temporary phase, and reassure yourself that in the long run a lull of a few weeks makes very little difference.

Sooner or l a t e r - a n d usually later than you e x p e c t e d - a n d just when you are get- ting used to bed-life, the doctors will start ordering you up and about. A t first your exertions will be prescribed in microscopic doses. It will seem absurd, when you feel so well, to be out of bed only from 2 to 4 and walking a few score yards. Why! you will feel you could do six times as much without harm. But don't try it. You may not be caught out; you may get away with it with- out doing any physical harm; but you are nevertheless weakening your self-discipline. You are proclaiming to the world and to yourself that you lack self-control: that when 'What You Want To Do' conflicts with 'What You Ought To Do', you haven't the guts io hold yourself back. Without self- discipline nobody has ever recovered from this disease. Here, at this sanatorium, we encourage you to exercise and to develop your self-discipline. We don't ring warning bells or blow whistles, and very rarely do we snoop round to see that our prescriptions are being followcd~ Such regimentation or enforced discipline would end on the d a y you left the sanatorium. The self-discipline you develop by practice here will stand you in good stead after you have got back into the world with all its problems and compli- cations.

How are you going to spend your time while you are here? It's a golden oppor- lunity to d o all sorts of things. Maybe for some harsh reason or another you had to leave school at an early age and plunge straight into making a living - with no time, energy or opportunity for the many rich things in this world that are of no immediate use, no monetary value but nevertheless the

greatest fun: books, music, art, handicrafts. Perhaps you have a feeling that you have missed a lot which luckier people could take in their stride - indeed had handed them on a plate. Now's your chance. There are twenty-four hours in the day. Subtract eight or nine for sleep, and two rest hours, and some more for meals, and you still have a dickens of a lot left. How are you going to spend them? Let me make a suggestion. Break fresh g r o u n d . . . Are you interested in music? Would you like to be interested in music? Then plan to listen purposefully. You can, for example, hear all the Beethoven Symphonies not only once but several times, if you watch the British and Continental broadcasting programmes. Take any one of the great classical composers and saturate yourself in him. The rest will follow. You might find that you prefer modern music on the Third Programme. Give it a trial. The same applies to poetry. There must be something in it because poets have existed ever since mankind first developed speech. What about finding out what that something is? Devote just one evening to one of Masefield's racy narrative poems. Listen to some of the superb poetry readers on the B.B.C. Explore. Break new ground. Bird watching? Equipment: a pair of field glasses and an illustrated bird book from the Library.

These are all passive pleasures and their chief snag is that you have to sustahz a high degree of concentration. I f your attention wanders, you lose the thread: the music becomes 'background music', the eves reach the bottom of the page without having registered more than a vague impression of what you think you are reading.

So what about something creative? What about that novel you always meant to write? A course of study? A foreign language? Have you ever tried sketching or painting? Tapestry or embroidery? Creative pastimes have two great advantages of the passive variety: one is that while you are doing them you concentrate on them and forget everything else, even the passage of t ime ; the other is that no day need go by without

March 1953 T U B E R C L E 85

the glorious satisfaction of having done something, brought something nearer to completion; and there's also the attractive prospect of getting on a tilt 'forrader' to- morrow.

Now if you feel you want to embark on something cultural or creative, get cracking at o n c e - b e f o r e you fall into a routine of just passing the time. It is so fatally easy to get so busy doing nothing that you cannot make time even to write letters home. You know how it is. After breakfast the mail; then the newspapers; and then it's not worth while starting on anything because the doctors or nurses or orderlies will be in at any moment; then after lunch you snooze perhaps, start the crossword, see what's on the radio, pick up tile detective n o v e l . . , and it's teatime, and so the hours bleed away. And once you've got into this way it's very difficult to get out of it.

While on this subject I'll make one further observation. You may have had such a gruelling time before you knew you were ill that the best thing in the world for you is to lie f a l l o w - a n d revel in the more trMal amusement of detective stories, cross-words, jigsaw, patience and the more rollicking B.B.C. programmes. This may be the very best sort ofchange for you and yott must not allow ),ourself to feel guilty because you seem to be neglecting the opportunity for widening your experience. To each man according to his needs.

Now a word about adjusting to your fellow patients here. You will find various types: first you will probably meet the patient who talks endlessly about tubercu- losis and particularly about his own case. Why does he do so? Is it because tubercu- losis is the biggest thing that has ever happened to him and he can't get over it? Is he, i n an odd sort of way, seeking re- assurance against his f e a r s ? - a sort of whistling in the dark? These are only part truths. I think the real truth lies deeper.

There appear to be three main types ot" personality each of which reacts differently when meeting with misfortune. There's the predominantly restless, muscular, bull-at-a-

gate type who wants to fight - to take some sort of action. In a crisis he is apt to say, 'Don't stand there, do something'; and it goes very much against his grain to take this trouble lying down. Then there's tile quiet brain-controlled chap who when he gets hurt tends to crawl into a corner and lick his wounds in private. Possibly, indeed probably, he suffers more than the others, but he keeps it strictly to himself. Last of all there's the ' tummy type' so called because the pleasures of the larder and the cellar, conviviality and company mean so much to him: when he is in trouble his mastering impulse is to talk about it to everyone. It undoubtedly does bring him relief and satisfaction. The tummy type is the most difficult chap to live with, unless you are a tummy type yourself. Then, I imagine, you can have a whale of a time together. But suppose you're not? What are you to do? Well, live and let live is a very good rule and you can avoid the bores up to a point; but they are apt to be clingers especially if you have once been a polite listener to their woes. I am afraid the only action is the snub direct. 'Can' t you talk about something else? I 'm getting a bit bored with all this.' Bores don't want to be bores; and, poor dears, they don't realize that they are bores, and on correction they do try to mend their ways. It may sound bnltal, but it's kindest in the long rim.

Every now and then we have a dis- gruntlcd patient here, a rebel, a barrack- room lawyer. W e l l . . . We are all dis- gruntlcd at times, have our rebellious moments. But very occasionally - and, thank goodness - only very occasionally do we have a type who glories in breaking rules and getting away with it; glories in 'scoring off the doctors' just as some years earlier he gloried in 'scoring off the schoohnaster' by breaking school rules; and maybe gaining some intoxicating notoriety among his class- mates thereby. Earlier still you can bet there was parent t r o u b l e . . . Hc has never grown u p . . . l"ou can help him grow u p . . . Show him that he is held in far less esteem for his bravado and his deeds of d a r i n g - t h a n he

86 T U B E R C L E March 1953

would be if he had the guts to behave sensibly. Thus treated he quickly crumples u p - then he sulks a b i t - a n d then he toes the line with the rest. ~/'bu-his c lassmates-can succeed with him, where w e - h i s doctors, his despised schoolmasters- fail so ignom- inously.

All the time you are here you will be learning-absorbing both consciously and unconsciously a lot about tuberculosis, about the problems of sickness and health, about yourself, and about your fellow creatures-~ possibly you've never had the time, leisure or. opportunity before to look around, to take stock, face things, to exchange views, to make friends.

Your values will change insensibly and by the time you leave you'll be a somewhat different person from what you were before you took ill. "You will have got into a moderate way of life, and a different rhythm of l iv ing- l iv ing with fresh air eating leisurely meals, taking rest hours: getting a full night' s sleep, avoiding fatigue. When you get back into the world there's going to be some difficulty about continuing this regime, but you'll find that you like it, it suits you, and won't w a n t to give it up. The Greek ideal, 'Moderation in all things' will become your life motto. In another four to five years your tuberculosis should be a thing of the past; but the habit of not burning yourself up will persist; and so you will live l o n g e r - a n d more than make up for the months or years you had to step on o n e side.

An elderly ex-patient said to me quite recently: 'The year I spent in the Sanatorium in z9o 3 was my best investment.'

How shall I end this talk? It takes a Churchill to quote poetry in peroration and get away with it: but I should like to quote just two lines of Shakespeare. They are:

'Our remedies oft in ourselves do lie V~rhich we ascribe to Heaven.'

(b) Reactions Observed Following Its Broadcast

Individual The Enthusiast#.- T h e r e a r e a l w a y s o n e

or two patients whose beatific demeanour the next day suggests that they have been Born Again. It was just what they needed, and it came at just the right moment. Life is now going to be different. A thousand thanks. This is the worst sort of reaction. I t spells emotional instability, and earmarks those patients who are destined to suffer periods of anxiety, depression, reckless euphoria and want-to-go-home-ishness be- fore they have served their full sentence.

The Intellectual.- She grasps the letter all t o o clearly and critically, and entirely misses the s p i r i t - o r the sp!rit misses her. Although not necessarily unpopular or unsociable, She is an: 'isolate'. What applies so neatly to her neighbours does not apply to her, for she is different.

The Delayed Reaction. - A few patients mull it ovcr and will unexpcctcdly bring it up a few days, weeks, or even months later, very often carrying the ideas touched upon a few steps further. For them the talk breaks the ice a n d eases the unloading and discussion of their personal worries.

At the final heart-to-heart chat on the e v e of departure, reference is very often made to the broadcast. On these occasions one is encouraged to feel that t h e whole business has been worth while after all.

The Mass Reaction This is something quite different from,

and independent of, the individualresponses. As in a l l communities judgment remains suspended until a lead has been given by the Leading Authorities. (All we like sheep have gone astray, when our political bell- wethers have misled us; and should there be two conflicting views, we shout with the largest party, as advised by Mr. Pickwick. Thus is Public Opinion born.) O n one occasion there was 'universal.

indignation and scorn' at the idea of Regression and Father-and-Mother Identifi- cation of the medical a n d nursing staff. Another time there was a cheerful little epidemic of calling nurses 'Mummy' .

Only once was the whole talk 'generally Conth2ued at foot of page 8o

80 T U B E R C L E March 1953

logical findings. Gross, mucosal, tuberculous disease was demonstra ted histologically in a major i ty of the normal bronchoscopies.

Though not statistically significant, there was a higher mortal i ty and complication rate in those patients undergoing resection who had abnormal bronchoscopic findings. Such complications appeared to increase with the severity of disease found .]fistologically.

A c k n o w l e d g m e n t s

We would like to acknowledge the work done by the participants in the s tudy and to thank the Physician Superintendents, Phy- sicians and Surgeons at the Hospitals where the investigations were carried out, for their co-operation.

Dr Har ley Stevens read the proofs of this ioaper and made valuable suggestions on its presentation.

APPENDIX Histological Definitions

( I ) "Florid Tuberculosis.-- Cases showing clas- sical epithe!ioid tubercles in the bronchial mucosa.

(2) Severe Disease . - Gases of severe in- f lammatory reaction with the presence of tuberculous granulat ion tissue, ulceration, severe fibrosis, etc.

(3) Moderate Disease. - Cases with definite evidence of tuberculous bronchitis and acute inf lammatory reaction or marked oedema.

(4) .P(o Disease. - It is very much doubted if any specimen submit ted was entirely normal, but the changes in this group were so small that it was considered wiser to regard them as falling within normal limits.

Bacteriological Classifications" Early in the course of the investigation it was found exceedingly difficult to demonstrate acid-filst organisms in the sections and, in con- sequence, animal inoculation was adopted, in a high proportion of the cases, to determine the presence or absence of tubercle bacilli. The injection material used was that portion of the bronchus muti la ted at operation by the bronchial clamp. Elaborate precautions

were taken to wash the mucosal surface very thoroughly, in tri-sodium phosphate, for at least two days, in several changes of solution. The tissue was then macerated and injected into guinea-pigs.

Names and Titles of the Participants I |. M. Siddons, v.R.e.s., Consultant Thoracic Surgeon to

Surgeon, Regional

Surgeon, Board. Surgeon, Regional

A. St George's Hospital, London, W.I.

E. F. Chin, r.R.c.s., Consultant Thoracic Western Area, South-West Metropolitan Hospital Board.

C. A..Jackson, F.R.e.S., Consultant Thoracic South-West Metropolitan Regional Hospital

K. S. Mullard, r.R.e.s., Consultant Thoracic tIarefiekl Hospital, North-West Metropolitan I [ospltal Board.

S. J. MacHale, V.R.e.S., Consultant Thoracic Surgeon, Birmlngl,am Regional I Iospital Board.

G. C. Laurie Pile, V.R.C.S., Consultant Thoracic Surgeon, Radcliffe Infirmary, Oxford and Oxford Regional Hospital Board.

F. Hodgkiss, sf.u., cH.n., Deputy Physician Superintendent, Preston Hall Hospital, Maidstone.

B. Benjamin, D.sc., v.nA., Statistical Member of British Tuberculosis Association Research Committee.

J. w. Clegg, st.R.c.s., L.R.C.P., D.C.P., Co~lsultant Patholo- gist, Institute of Chest Diseases, Brompton I [ospital.

L. E. Houghton, .~s.~., Consultant Physician, Harefield Hospital, North-West Metropolitan Regional Hospital Board.

F. E.Joules, s~.D., M.R.C.P., Consultant Physician, Peppard Chest tlospital, Oxford Regional IIospital Board.

A Broadcast and its Repercussions Continued from page 86

regarded' as being too frighteningly de- pressing. At other times it was voted en- couraging. Certain individuals are always identified as those whom I was so obviously getting at with my ' T u m m y Types ' and 'Barrack Room Lawyers ' . Towards the vagaries of the latter a helpfill and salutary a t t i tude usually develops.

The broadcast is invariably followed by a definite if short-lived rise in the demands for occupational therapy, and the Music- listening and Art Groups receive a slight fillip. Indeed it may be wishful observation, but my impression is that general morale shows signs of having been boosted, judg ing by the diminished incidence of disciplinary problems. But the talk has never had the slightest effect on the inescapability of pu lmonary tuberculosis as a topic of con- versation.

Our grateful acknowledgments are due to Dr Harry Wilmer of Stanford University, San Francisco, whose series of canned pep-talks put ideas into our heads.