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tween 1910 and 1920 and 55% between 1900 and 1920. In 1900 the New York City rate was 29% in excess of the rate for the United States; in 1910 it was 24% higher; but by 1920 conditions had so improved that it was only 9 % higher. The chance of dy- ing from tuberculosis in New York City in 1920 was about one- third that in 1900 and a little more than half that in 1910. Such a remarkable improvement in so crowded a city is unparalleled in the history of tuberculosis.

During the decade 1910-20 the fall in the death-rate was by no means uniform. Between 1912 and 1915 the mortality from tuberculosis throughout the country was almost stationary (150 in 1912 and 146 in 1915), while between 1916 and 1918, the pe- riod of the World War and the epidemic of influenza, the rate rose from 142 to 150. Virtually the same conditions obtained in New York City (201 in 1912, 196 in 1915, 182 in 1916 and 188 in 1917). The greatest decline was after 1918: from 184 in 1918 to 126 in 1920 for New York City and, during the same period, from 150 to 114 for the United States.

TUBERCULOSIS* DEATH-RATE OF NEW YORK CITY AND OF THE UNITED STATESf I9OO TO 1920

ISO

100

New York City 280 264 243 246 250 240 246 238 227 214 210 210 201 199 200 196 112 188 184 152 126

United States 202 197 185 189 201 192 180 179 168 161 160 159 150 148 147 146 142 147 150 126 114

N.r.RateEcess78 67 58 57 49 48 66 59 59 53 50 51 51 51 53 50 40 41 34 26 12

Pet Cent Excess 39 34 31 30 24 25 37 33 35 33 31 32 34 35 36 34 23 28 23 17 11

the population or 87,486,713 inhabitants. G. J. DROLET, Statistician
 * All forms of tuberculosis, f U.S. Registration area which in 1020 included 82% of

New York Tuberculosis Association.

The registration of deaths became more exact and complete. A consideration of the conditions described on page 358 of Vol. XXVII. as being widespread late in the igth century shows how much registration had been needed. Registration, the creation of state, not Federal, legislation was provided for only gradually by the necessary state laws. In 1910 the Registra- tion Area of the United States covered 58-3% of the popu- lation; by 1920 nearly three-fourths of the states, with about 80% of the population of the country. The fact, therefore, that the tuberculosis death-rate shows a marked decline at the same time that the reporting of deaths has come under better control accentuates the great improvement. As has always been the case, pulmonary tuberculosis accounts for about seven-eighths of the deaths from tuberculosis of all forms. In 1920 the rate (pulmonary tuberculosis) for large cities ranged from 54 per 100,000 for Portland, Oregon, to 281 for Denver, to which city many tuberculosis patients have resorted. Chicago's rate was 83 and Philadelphia's 121; Boston's was 126, the same as that of New York City.

The decline in mortality was due to many factors, which in 1921 could not be formulated and estimated. The influenza epi- demic played its part, but in a manner not definitely understood. The great wave of this disease swept the country in the autumn of 1918. It is significant that for the first time on record there was in that year a marked autumnal increase of tuberculosis deaths above the normal. For example, in Oct. 1917, the deaths from tuberculosis in New York State were 1,089, a rate of 122-2. This was an average incidence which had been maintained for years. In Oct. 1918, the month of the influenza epidemic, 1,520 deaths from tuberculosis were reported an increase of about 50%. Oct. 1919 showed only 813 deaths, and Oct. 1920 726 deaths. It is conceivable that influenza carried off thousands of consumptives who would have contributed to the tuberculosis

mortality later; and, that these potential deaths for later years, thus compressed into 1918, reduced the rate during the succeed- ing years. Nevertheless, influenza can have been only one of several or many factors. Economic and social movements played their part. It seems certain that tuberculosis to no small extent has yielded to the remarkable organized efforts! directed against it in the United States.

The keynote of the American struggle against the disease has been organization. Founded in 1904, the National Tuberculosis; Association developed into probably the most effective public health body in the United States. With its subsidiary state andi local societies it reaches into every hamlet. Few men and women,' interested actively in tuberculosis, are working otherwise thaw in connexion with the National Association. Perhaps its great-' est achievement is that it calls the attention of a vast proportion! of the population to tuberculosis and educates them in it through' its unique way of raising funds tp carry on its work. Every year.j during the month of Dec. its subsidiary societies sell, at one cent 1 each, stamps called Christmas seals, which may be used (not as] postage) to fasten and embellish envelopes. Their sale in 192 1 had! reached the enormous yearly total of more than 500,000,000 and! yielded more than $4,000,000 for the work of the Association.!

Treatment. The elements of the routine treatment of tuber- culosis changed but little during 1910-20, but therapeutic re4 sources expanded greatly. In 1920 there were more than 6ooi sanatoria for the treatment of pulmonary tuberculosis in the! United States. These were maintained by states, cities, counties, private individuals and corporations, and by endowments. Under N.Y. State law every county must erect and maintain an institution for the care of its tuberculous population. Some trade unions and fraternal organizations established sanatoria for their members. The Metropolitan Life Insurance Co. of New York built for its employees one of the best sanatoria in the country. The trend away from sanatorium treatment which is to be observed on the continent of Europe has not been mani- fest in the United States. Artificial pneumothorax is the only surgical measure which has gained anything like a vogue: Amer- ican observers are unanimous as to its usefulness in selected cases. Heliotherapy and phototherapy for surgical tuberculosis were used, but only sporadically, and very few reports as to their results appeared in American medical literature. Chemotherapy was under extensive experimentation at the Phipps Institute in Philadelphia and at the University of Chicago: results have not warranted its application to human tuberculosis. Tuberculin treatment is practised with more discrimination than formerly.

The decade was notable for the use and development of the X-ray in the diagnosis of pulmonary tuberculosis. As an aid to! diagnosis it became indispensable in routine tuberculosis prac- tice. It is the better American opinion that the roentgenologist must work hand in hand with the practitioner and that good diagnostic judgment is attained only by the proper analysis and! evaluation of information yielded by physical examination, lab- ! oratory procedures and X-ray observation together: no single) one of these will alone suffice in routine diagnosis. Diagnosis of I tuberculosis by tuberculin was practically abandoned, few cases ; having proved amenable to this method.

The practitioner of 1920 regarded tuberculosis from a point of view quite different from that of 1910. The relatively recent disclosure that tuberculosis exists as a latent infection in almost all people and that infection confers a measure of specific immu- nity to reinfection gave rise to the almost necessary presumption that adult pulmonary tuberculosis develops from infection ac- quired in childhood and that the adult is insusceptible to expo- sure to infection from without. By 1915 this opinion had become almost a dogma. But during 1918-20 opinion became less posi- tive; an increasing number of studies by American authorities showed that conditions are only relative. Although early infec- tion and immunity therefrom are conceded, it is maintained that infection is capable of complete healing and that immunity may greatly diminish or even disappear; and that, therefore, there is 'every likelihood that reinfections and active disease from them are possible at any period of life.