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TABLE 2. Mortality in England and Wales from Tuberculosis (all forms] Per Million Poi>. 1012-4. JO/7, and 1018

Males

Females

Persons

1912 to 1914

1917 (Civilians only)

1918 (Civilians only)

1912 to 1914

1917

1918

1912 to 1914

1917 (Civilians only)

1918 (Civilians only)

All crude ages standardized

j L569 I 1,546

2,072 2,334

2,153 2,518

1,167 1,168

1,303 l,3H

1,373 1,378

1,361 1.347

1,624 1,801

1,694 1,924

o. ..

5

2,063 566

1,915 662

1,741 632

1,701

572

1,631 694

1,417' 682

1,883 569

1.774 678

1,580 657

JO. .

442

573

611

685

892

920

564

733

766

15 . ..

927

?

?

1,214

,719

1,789

1,071

?

?

20 . ..

1,478

?

?

1,326

,643

1,888

1,398

?

?

25 ..

1,774

?

?

1,369

,489

1,723

1,561

?

?

35

2,233

?

?

1.405

>523

1,613

1,804

?

?

15-45

1, 68 1

3,240

3, 68 1

1,342

,570

1.733

1.505

2,104

2,328

45

2,437

2,590

2,592

1,208

,249

1,321

1,798

1,892

1,924

55

2,283

2,316

2,192

1,004

,018

1,050

' I, 608

1,649

1,604

65 ..

1,421

1,540

1,484

767

798

1,057

1,129

791

1,057

1,129

1,102

75 85 and upwards.

'649 260

649

527

740 295

496 246

490

218

464 233

558 251

554 328

574 255

Provisional death-rate per million living from ( i.) all causes 1920

(ii.) all forms of tuberculosis 1920

12,360 1,128

In April 1919 an important inter-departmental committee was appointed jointly by the Local Government Board and Ministry of Pensions, " to consider and report upon the immediate practical steps which should be taken for the provision of residential treat- ment for discharged soldiers and sailors suffering from tuberculosis and for their reintroduction into employment, especially on the land." The report of the committee laid stress on the fact that "the problem of the tuberculous ex-soldier or sailor is only one aspect of the national problem of dealing with tuberculosis," and considered that " the best interests, both of the country and of the ex-service man, will be served first by making the best possible use of all existing means of treatment, and then by expanding, improv- ing, and increasing these means as rapidly as possible." It reported that existing accommodation was most seriously inadequate in quantity, and advocated in addition to the development of schemes for the institutional treatment of tuberculosis, provision of facilities for the training, both occupational and vocational, of sanatorium patients in suitable industrial and other occupations, and also for their permanent settlement, after training, in village communities where they could earn a livelihood under sheltered conditions. Owing to considerations of economy, the recommendations of this committee as to developments on the lines of training colonies, village and industrial settlements, were temporarily hampered, but doubtless are destined to fructify as economic conditions improve. Valuable information as to the development of Public Health schemes for the treatment of tuberculosis is in the annual reports of the Chief Medical Officer of the Ministry of Health and other Government publications.

While the above records official encouragement and exhortation in the measures calculated to assist in the eradication and treatment of tuberculosis, tribute should be paid to philanthropic and other agencies which have been at work, and which have afforded valuable information on the lines on which policy should be directed. By progressive legislation voluntary work has tended to become more and more subsidized by the state. An instance of such combined activity on a large scale is afforded by the King Edward VII. Welsh National Memorial Association, which was founded in 1910 for the prevention and eradication of tuberculosis and other diseases in Wales. For the furtherance of this aim Wales (with Monmouth- shire) is divided into 14 dispensary areas with a tuberculosis physi-
 * ian having a central dispensary in each area. In each area there

ire a number of visiting stations at which patients are seen and
 * xamined at frequent intervals. There were 90 of such visiting

stations in 1921. In addition, hospital beds and sanatoria are pro- vide 1 for the treatment of all forms of tuberculosis. From its incep-

i ;ion up to 1921 the association's officers had examined 76,500 patients.

i Df these 7,800 were treated at sanatoria and 14,200 at its hospitals.

i FABLE 3. Notification of Tuberculosis in England and Wales (from

the 1920 Report of the chief medical officer of the

Ministry of Health, Cmd. 1.307).

Pulmonary

Non-pulmonary

Total All forms

Notifi- cations

Cases

Notifi- cations

Cases

Notifi- cations

Cases

1913 1914

1915 1916 1917 1918 1919

1920

91,866 86,081 73,359 75,796 76,183 79,025 67,123 63,732

80,788 76,109 68,309 68,109 68,801 71,631 61,154 57,844

38,583 25,237 22,573 24,521 22,514 20,215

17-775 16,694

36,351 23,388 22,283 22,799 20,884 18,942

16,357 15,488

130,449 111,318

95,932 100,317

98,697 99,240 84,898 80,426

177-139 99,497 90,592 90,908 89,685

90,573 77,616 73,332

TABLE 4. Mortality from Tuberculosis (England and Wales).

Deaths from Pulmonary

Deaths from other forms

Tuberculosis

of Tuberculosis

Males

Females

Total

Males

Females

Total

1911

21,985

17,247

39,232

7,242

6,646

13,888

1912

21,568

16,515

38,083

6,238

5,730

1 1 ,968

1913

21,034

16,021

37,055

6,623

5,798

12,421

1914

21,812

16,825

38,637

6,264

5,397

11,661

1915

23,630

18,046

41,676

6,715

5,904

12,619

1916

23,238

18,307

41,545

6,488

5,825

12,313

1917

23,670

19,443

43,H3

6,689

6,132

12,821

1918

24,756

21,321

46,077

6,271

5,725

1 1 ,996

1919

I9,58l

17,081

36,662

4,969

4,681

9,650

1920

18,184

15,285

33,469

4,734

4,342

9,076

Tables 2 (by courtesy of the Ministry of Health), 3 and 4 give details as to the incidence of tuberculosis in. Great Britain. Com- menting on these tables, Sir George Newman remarks on the con- siderable decline in the number of new cases, of both pulmonary and non-pulmonary tuberculosis in 1919; in 1920 there were 3,310 fewer new cases of pulmonary tuberculosis than in 1919. Regarding Table 3 he states that the causes of increase of tuberculosis mor- tality during the war are generally ascribed to underfeeding or lack of particular varieties of food materials, greater industrial employ- ment of women (often in unfavourable conditions and under much stress and strain), exposure and fatigue, and the great outbreak of influenza. Similar increases were observed in other countries, both neutral and those directly engaged in the war. It is significant that the increase during the war was particularly great in lunatic asylums and among women aged 20-25 years many of whom were employed in munition works. Sir George Newman further adds: " The past history of the decline of tuberculosis is full of instruction as to the future." He suggests that we should (i) fortify the powers of resistance of the individual to disease; (ii) prevent the spread of infection; (iii) undertake all the general health reform which is necessary; (iv) educate and lastly we must revise and apply in a proper and effectual way the particular methods with which we have made a substantial beginning notification, domiciliary and dispen- sary treatment, the sanatorium, the training colony, the village set- tlement and the proper means of after-care. The local administra- tion of these matters should be unified under the local authority and its medical officer of health.

REFERENCES. Sir R. D. Powell and P. H. Hartley, Diseases of the Lungs and Pleurae (6th ed., 1921); Sir W. Osier, Principles, Practice of Medicine (gth ed., 1920) ; Sir T. Clifford Allbutt, System of Medicine (1905-11); G. E. Bushnell, Epidemiology of Tubercu- losis (1920); Louis Cobbett, Causes of Tuberculosis (Public Health Series, 1913); a series of international studies by many authors, The Control and Eradication of Tuberculosis (1911); also various official publications from the Ministry of Health and elsewhere.

(H. J. G.) UNITED STATES

An extraordinary decline in the mortality from tuberculosis in the United States decreased the rate for the whole .country from 202 per 100,000 inhabitants in IQOO to 160 in 1910, 21% less, and to 114 in 1920, 29% less than in IQIO and 43-5% less than in 1900. In New York City the decline was even more notable, the rate being 280 for 1900, 210 for 1910 and 126 for 1920; this was a fall of 25% between 1900 and 1910, 40% be-