The diminution of mortality has been most pronounced in the large cities. For instance, in 190o the tuberculosis death-rate for New York city was 39% in excess of that for the general popula tion of the country (death registration area). By 1925 this dis parity had fallen to 7% and exhaustive analysis will show that it represents a general phenomenon. There is no longer any doubt that tuberculosis is declining more rapidly in the cities than in the country districts of the United States.
It is also declining most at the earlier ages of life; that is, more among infants under two years of age than among children, and more among the latter than among the general population. In New York city the death-rate for infants in 1923 was only one-sixth that of 1898 (94 in 1923 and 6o9 in 1898), while for children under 15 the decline was from 136 to 33; meanwhile the rate for the general population was cut in three.
The forces that are combining to bring tuberculosis under con trol in the United States are by no means clear. They are, no doubt, numerous and complex. That the sanatoria are playing their part can hardly be questioned. These institutions annually remove tens of thousands of the ill from active life and thus inter rupt innumerable infectious contacts between the sick and the healthy. They, meanwhile, train the patients in habits of better health and return them to the community as living object-lessons of the benefits of a hygienic regimen. That the American people have accepted the sanatorium movement is evidenced by the tens of millions of dollars that they are providing out of public funds for the founding and maintenance of sanatoria.
The sanatorium movement in the United States is the out growth of organized propaganda set in motion by the National Tuberculosis Association established in 1904. The efforts of this organization, working through its affiliated local societies, entered into every hamlet. For 25 years it has exhorted the people con tinuously on practices designed to avoid and treat tuberculosis, maintaining services and agencies to be applied to every phase of the disease. Its funds are recruited through the unique man ner of selling, every year at Christmas-time, the so-called "Christ mas Seals," stamps to be affixed to postal matter but not for postage. Their sale has become so enormous as to bring an annual gross return of over $5,000,000 though they cost but a cent each.
Working toward the reduction of tuberculosis must also be regarded the amelioration of existence and the rise of the stand ards of living that have characterized our era and which have, in turn, flowed from the extraordinary multiplication of national and personal wealth in the United States. These resultants of the industrial age have served to cut down tuberculosis; organized endeavour has been alive to their influence and for its own pur poses has moulded them to greater effectiveness.
In the United States sanatorium regimen is synonymous with treatment of the disease to a degree that is unmatched elsewhere in the world. The attitude of the medical profession toward newer and more special modes of therapy has been, in general, more conservative than that of their European confreres. However, artificial pneumothorax and the more radical surgical measures (thoracoplasty, phrenicotomy, pneumolysis, etc.) have become standard procedures in selected cases of pulmonary tuberculosis and are in general usage. Heliotherapy and other forms of light treatment are universally employed in non-pulmonary disease; their utility in phthisis has not won the same general approval and at present the weight of opinion advises awaiting more tan gible results before expressing final judgment. Specific treatment (tuberculin), valuable only in expert hands, holds its own; its most settled field embraces certain forms of ocular tuberculosis. Chemotherapy has made no headway.
The X-ray is universally recognized as indispensable in diag nosis, but each succeeding year strengthens the conviction that rontgenography cannot supplant tried and standard methods of physical examination, but, on the contrary, gains in utility only as it is brought into co-ordination with the latter. Of the many specific and laboratory tests only the long-recognized demonstration of tubercle bacilli in tissue products is regarded as decisive in diagnosis.
The spirit of study and research of the disease has developed enormously. It was given great impetus by The American Review of Tuberculosis, a monthly scientific periodical, founded in 1917 by the National Tuberculosis Association. Among the more promi nent centres of research in tuberculosis are the Trudeau Founda tion at Saranac Lake, the Henry Phipps institute at Philadelphia, the Kenneth Dows laboratories of the Johns Hopkins university at Baltimore, the National Jewish hospital at Denver, the munici pal sanatorium at Chicago, the Lymanhurst School for Children at Minneapolis and the Colorado foundation at Colorado Springs, all of which were established since 191o. (A. K. K.) Research Council, Special Report No. 18. "Epidemiology of Phthisis in Great Britain and Ireland," parts 1 and 2 (1918) ; Special Report No. 33, "Pulmonary Tuberculosis; Mortality after Sanatorium Treatment" (1919) ; Special Report No. 46, "Epide miology of Phthisis in Great Britain and Ireland," part 3, H.M. Station ery Office, London (192o) ; Special Report No. 67, "Report on Artificial Pneumothorax," H.M. Stationery Office, London (1922). See also Sir A. Newsholme, The Prevention of Tuberculosis, 2nd ed. (Iwo) ; Sir J. K. Fowler, Pulmonary Tuberculosis (1921) ; C. Riviere, The Early Diag nosis of Tubercle, 3rd ed. (Oxford 1921) ; id., Problems in Tubercu losis: Administration, Diagnosis, Employment, Settlements (Oxford, 1923).