tion can be safely immunized against tuberculosis and the
infected population cured by specific measures, the laborious
and often complicated methods now employed, constantly im-
proved and elaborated, will constitute both our means of
prophylaxis and of attempted cure. Tuberculosis is protean
in its manifestations and the methods directed against the dis-
ease are of corresponding variety. Certain general principles in
treatment may, however, be laid down. These comprise the
adoption of all those measures calculated to increase the patient's
power of resistance and preserve and restore the part or parts
attacked. Life in the open air under suitable climatic and



7 8 4



TUBERCULOSIS



good hygienic conditions, with ample and easily assimilated
food, rest while the disease is acute, absence of worry or fatigue,
graduated exercise later, and education in the mode of life to
be followed are details of first importance. Drugs are chiefly
of value in the treatment of symptoms and complications.
The introduction of tuberculin by Koch raised vast hopes
which have not been fulfilled. Numerous varieties of tuberculin
have since been manufactured and employed which still fall
short of the anticipations of their originators. Sir Almroth
Wright placed tuberculin therapy on a more scientific basis:
his opsonic theory giving promise of a means of scientific ad-
ministration and control. In 1887 Sir Robert Philip introduced
the scheme known as the Edinburgh system for the coordination
of efforts, applicable to all phases of the tuberculosis problem.
It has the tuberculosis dispensary as the centre of its activities,
with trained physicians and nurses for educating, treating and
directing the patient, examination of contacts, distribution of
patients requiring institutional care to the tuberculosis hospital
or sanatorium where advanced cases can be segregated, and early
cases receive curative treatment. Later, facilities are given for
continued aftercare or treatment and training in a farm colony.
The scheme is a practical and comprehensive one and has been
the pioneer of other analogous efforts elsewhere. The value of
this coordination of methods cannot be sufficiently emphasized.

Marcus Paterson by graduated exercise has shown how
much may be safely and advantageously done by auto-inocula-
tion of the patient by his own tuberculin. Varrier-Jones at
Papworth has demonstrated the value of the tuberculous colony
with facilities for treatment of pulmonary tubercle in all stages
of the disease, and where prolonged segregation in village
settlements is encouraged under reasonable conditions. The
patient is trained and his labour subsidized. The value of
rest in the treatment of all forms of acute tuberculous disease
has inspired surgical interference for securing more complete
rest to the diseased and damaged lung in the hope of procuring
cure. Forlanini demonstrated the feasibility of introducing by
injection gas into the chest to secure the collapse and rest of a
tuberculous lung. This manoeuvre, introduced into Great Britain
by Lillingston and others, has proved of considerable value in
carefully selected cases. This method of treatment is known as
the induction of artificial pneumothorax and has proved of
dramatic value in the treatment of many patients who were in
an apparently hopeless condition.

In non-pulmonary conditions such as tuberculous disease of
the bones, joints and glands, for long the condition was regarded
as a local disease, comparable to a malignant tumour. This
" tuberculome " conception, aided by the discovery of anaes-
thetics and antiseptics led often to extensive operations being
undertaken with a view to the extirpation of infected tissues.
The results in the more severe conditions were frequently
unsatisfactory, the mortality both direct and indirect high,
deplorable orthopaedic results frequent, sinus formation and
subsequent secondary infection common. The present trend
of surgical opinion is avoidance where possible of severe radical
measures and the adoption of conservative treatment. While
the disease is acute the patient is kept at rest, the part affected
immobilized, orthopaedic measures are employed to prevent
or correct the severe deformities which are frequent in tuber-
culous lesions of the bones and joints, tuberculous abscesses
are evacuated, preferably by aspiration. Later, when ambulatory
treatment is permissible the lesions are suitably immobilized
in appropriate splints. Institutions for these cases should be
specially designed and staffed and situated in suitable localities
at the seaside or in the country. Auxiliary methods of treatment
such as heliotherapy (sun treatment), X-ray treatment, etc.,
play an important part. As treatment is necessarily lengthy it
should be associated with education for children, technical
training for adolescents, and occupation for adults. In this way
the monotony of long enforced recumbency is relieved and the
moral of the patient preserved. The value and low mortality of
such treatment may be illustrated by Table i. showing the
results achieved at the Treloar Cripples' Hospital, at Alton.



TABLE i. Analysis of results of treatment of patients suffering froi
surgical tuberculosis at the Lord Mayor Treloar Cripples'


Hospital, Alton, Hants., from the opening of the


Hospital in Sept. 1908 to Jan. 31 IQ2I.












T
P


7




<n




J


1


0>T3
(ft O

S to


1

o


1


s


"S


rtj"*


Lesion




6


* &

ss


c

a


_g

*s


>^z

is


s


||t












>


H




(0


Spine .


920


810


674


22


24


68


27


503-2


Hip .


880


768


710


18


2


25


13


413-1


Knee .


333


34


282


7





II


7


334-7


Other .


354


315


265


16


5


19


9


259-8




2487


2197


1931


63


3i


123


56


382-5



During the decade 1910-20 greatly increased public interesi
was manifested in serious and organized endeavours to dea
with the tuberculosis problem. In England and Wales prioi
to the passing of the National Insurance Act, 1911, it wa;
competent to sanitary authorities, under the powers of sectior
131 of the Public Health Act, 1875, to provide dispensaries am
residential institutions for the treatment of persons suffer in;;
from tuberculosis, and some authorities had initiated a campaign
of prevention and treatment. At the beginning of 1912, 1,500
beds in institutions had thus been provided by British sanitary
authorities for treatment of tuberculosis; 57 sanitary authorities
also had contracted for use of beds in private sanatoria; 30
tuberculosis dispensaries had been established by local author-
ities; and 50 by voluntary effort. The need for a national
campaign assisted by. contributions from the British Exchequer
became evident. This heed was recognized by the National!
Insurance Act, 1911, which included provision for " sanatorium
benefit " of insured persons. Under this Act and the Financei
Act, 1911, a capital sum of 1,500,000 was made available ini
the United Kingdom for the treatment of tuberculosis. After:
the passing of the National Insurance Act ' a departmental
committee on tuberculosis was appointed to report upon the
consideration of the problem in its preventive, curative and
other aspects. The recommendations of this committee had
an important influence on subsequent policy. Compulsory
notification of pulmonary tuberculosis was enforced in 1912,
and of all forms the following year. In July 1912 domiciliary
treatment of insured patients suffering from tuberculosis was
approved by the Local Government Board. Schemes for the
institutional treatment of tuberculosis became gradually formu-j
lated. The extent to which official schemes had been brought
into operation in England and Wales may be gathered from the
following figures. On April i 1921, the number of approved;
dispensaries was 41 1 ; officers and assistant officers for tubercu-
losis, 341; residential institutions, 418; the number of beds
available in these institutions was 17,352; the total gross main-
tenance cost of tuberculosis schemes for 1919-20 was i,953)99 2 -
The amount of Government grant for 1919-20 was 619,941.
All this was accomplished notwithstanding the severe setback
to anti-tuberculosis endeavour which was an inseparable effect
of the World War.

On July I 1919 the powers of the Local Government Board in rela-
tion to the tuberculosis schemes of local public-health authorities
and of the Insurance Commissioners in relation to the administra-
tion by the Insurance Committees of the sanatorium benefit of
insured persons under the National Insurance Act 1911 devolved
upon the Minister of Health, and one central department was made
responsible for the guidance and supervision of the work of the two
classes of local bodies principally concerned (apart from Poor L
authorities) in the conduct of measures for the prevention and treat-
ment of tuberculosis. The National Health Insurance Act, 1920,
was further designed to simplify administration by providing for
the discontinuance of sanatorium benefit within 12 months of the
passing of the Act, and insurance patients needing institution
treatment for tuberculosis may obtain it at the hands of the local
authorities under the schemes undertaken for the provision of such
treatment for the population generally of their respective areas.
This transfer of authority came into force on May I 1921. .
Tuberculosis Act 1921 carried this legislation a step further by
enabling local authorities to provide approved schemes for t
treatment of all patients suffering from all forms of tuberculosis,
and on their failing to do so empowered the Ministry of Health to
deal with the matter, debiting the cost to the authorities concerned.



TUBERCULOSIS



785



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-



786



TUBERCULOSIS



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



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

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