The growth, of anti-tuberculosis work in England since the passing of the Insurance Act may be gathered from the steady increase in expenditure shown in the table in next column which is quoted from Dr. Coutts' pamphlet.
Large as these figures may seem, there is still a vast field to cover if tuberculosis is to be dealt with adequately on the present lines. The actual notifications, amounting for England and Wales to 57,737 persons in 1924, or 1.47 per i,000 of population, are admittedly an under-estimate of the known cases, while the undiagnosed carriers of infection must be more numerous still. If the isolation of infective persons is to become effective—and the Public Health Act, 1925, contains clauses providing for the compulsory hospitalization of infective cases—it will be neces sary to face the public maintenance of their dependants while patients remain in residential institutions. And there is an ur gent need for further expenditure to provide accommodation and treatment for cases of surgical tuberculosis. The best chance of ultimate economy would seem to lie in the endowment of research directed towards preventive measures and curative treatment. (S. L. C.) United States.—During the present century tuberculosis has been a declining disease in all industrialized nations. A moderate though rather steady fall in its death-rate was interrupted by the World War, when all countries involved experienced increases of mortality that were roughly proportionate to the stresses and deprivations (as of food and shelter) incident to the conflict. After 1918 the decline in mortality reappeared at an accelerated pace and to an unprecedented degree.
This universal recession of the age-long principal cause of death was most pronounced in the United States. Here its outstanding features may be summarized as follows: (I) a drop in the tuber culosis death-rate from 202 per ioo,000 population in 1900 to 80.7 in 1927. (2) An estimated total of 102,000 deaths among a population of approximately 117,000,000 in 1927 as compared with upward of 154,000 deaths among only 76,000,00o people in 1900. (3) Almost a million and a half fewer deaths from tuber culosis during 1900-25 than if the old high rate of 1900 had con tinued throughout the period. (4) The retreat of tuberculosis from first to fifth place as a cause of death. Until 1912 it had always been the most mortal of all diseases; in 1914 it yielded up this position permanently; and since 1924 it has been out ranked by the classifications Diseases of the Heart, Pneumonia (all forms), Cancer and either Cerebral Haemorrhage or Nephritis.
This unexampled diminution of a formerly entrenched prin cipal disease has attended a development and perfection of sana toria for its treatment that have far outstripped similar efforts in any other country. Thirty-four of these institutions, with 4,485 beds, in 190o, had by 1910 grown to 145 with 20,195 beds and by 1925 to over 600, with facilities for 73,715 patients (in cluding 13,401 under the auspices of the Federal Government). At present about 15o,000 new patients with tuberculosis are being admitted to sanatoria annually, and Drolet has estimated that, up to 1926, a total of 1,234,00o individual patients had received treatment in the tuberculosis sanatoria of the United States.
As between the several States the disease varies widely in both mortality and morbidity. Colorado, to which sufferers resort for climatic treatment, has long had the highest death-rate, while Utah, adjoining it, has reported the lowest rate (39 for In general, tuberculosis mortality is normally highest in the South ern States as a group, particularly those with relatively larger urban population (Kentucky, Maryland, Tennessee, Louisiana, Virginia). The high rates of these States are the direct result of the exaggerated toll of tuberculosis among their city negroes, for whom the disease is two to three times as deadly as for the whites. Nevertheless, encouragement is to be found in the fact that the tuberculosis mortality of the negro is also declining markedly.
The recent radical restriction of immigration has not been in effect long enough to disclose its influence on the nation's tuber culosis. In former times of unrestrained immigration, the pour ing of new thousands of young and vigorous members of Eurc pean stocks into the great Atlantic ports probably operated toward a reduction of local mortality by dilution of population. In general, the Russian Jews appeared to weather American urban life best, so far as tuberculosis was concerned, and in New York city would consistently show death-rates for the disease below those of the general community. Next usually came Italians, French (many from Canada), Germans and English, with rates not much higher than those for native American stock. The Irish have been notably prey to tuberculosis on American soil, while the Finns, whose numbers are small, have had rates almost as high as the negroes in New York city. Any attempts to explain these national (rather than racial) differences must no doubt take into consideration such a prime factor as relative adaptability to American life.