31/ Cornell University Library RC 311.A93 Report on tuberculosis. 3 1924 000 347 686 The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000347686 1916. ^ COMMONWEALTH OF AUSTKALIA. DEPARTMENT OF TEADE AND CUSTOMS. / COMMITTEE CONCERNINa CAUSES OF DEATH AND INVALIDITY IN THE COMMONWEALTH. REPORT ON TUBERCULOSIS. ISSUED UNDER THE AUTHORITY OP THE HCNISTER FOR TRADE AND CUSTOMS. Printed and Published for the Government of the Commonwealth of Aostealu by Aibebt J. Muilett, Government Printer for~ the State of Victoria. REPORT ON TUBERCULOSIS. 19th September, 1916. The Htmofoble the Mimsler of Trade etrd CtMf&ms, Sir, The Commifctee appcanted to considei? and teport on the Causes of Death and Invalidity in the Commonwealth has the honour to submit the following Report on 'FttbercUlosis : — INTRODUCTORY. Before eateMng on ft sttidy of [the statistics of tttberoulosis in Au'stfalia, ii is advisable to nOte the main features of the Mstctfy Of the disease in England afi.d W^ks. Ik his Rep(«t foif 1906 the Regiigtrsee^Getiieral stated that m the 40 years from! 1866 to 1905 the mortality had fallen to just one-balfy afid that there had been a singnlttr uniformity in the fall. In 1865 YillemiiBi's experiments on the inoeul»tion of tubercle from human sources into laboratory animals gained earnest attention, but they were not entirely satisfactory, and many investigators Stated that tubercle was not due to a specific virus. It was not till 1882 that Koch pubUshed his discovery of the tubercle bacilus,- and proved that the bacillus was the essential cause of the (£^ease. Without th^ bacillus there is nO tubercle. For many years this new frruth. How ttciversally accepted, was doubted, or only believed in part, so that it was not till a later date that the public, or even the administrators of pubhc health, grasped the full> meaning and importance of the faotff which Koch had so completely demonstrated. Hence we may say that d-omtg: the first half of the period in which the twbercle rates^ were falling in' Ehgland and Wales, there was no active general belief that tubercle is an infective disease, always deilived from some pre-existing case. Nevertheless, as wilt be shown- later, some impor- taait factors in the diminished psevalefice of tubercle depended on segregation of the sick and lessened exposure of the healthy. The whole sti^y of tubercle, however, must be of twofold character — firstly, in relation to exposure to infection with the baciUus,and, secondly, in relation to the resistance of the individual. Dr. Newsholme> in Ms Report as Medical Offider ©f the Local Government Board for 1910-11, summarizing the history of the fall of tubercle mortality in England and Wales, wrote as follows :— " It is evident that this decline has been asuofeisted with an impfo'Wia^ social and sanitary co&dition of ther people- III addition to rkOre efficient medical attendaince than inr the past, these improvements have nieant better housing, less unhealthy conditions of occupation, more whole- some and more abundant rood and clotMng". These influences in the aggregate have insured increased resistance to the infection of tuberculosis. They have probably even more insured diminished facilities for infectioa. The close association' between bad housing and excessive tubet-titdosis is well known. Hence /the importance attaching to the work of the Board and of local authorities under th€ Housing Acta . . . ; to the efforts to prevent overcrowding" in houses, to remedy defective lighting and ventilation, to prevMit permanent dampness in houses, and to diminish and prevent future congestion of houses on area. Improved housing, doubtless increases the resistance to tubercidosis ; still more it implies diminished opportunities- for infection." Br. Newaholme proceeds to analyze three ways in which opportunities for infection are being diminished in the homes of the people : — 1st. — The provision of better houses implies more room and more rooms, enabling separate sleeping accommodation for adults and children, and for the weakly and the healthy, to be obtained to a greater extent. 2nd. — The habits of the people have immensely improved in two important respects. Spitting is seldom indulged in at home. The spittoon has disappeared from privatej^houses. The average worker's house is kept cleaner than in the past, and the harboring and transmission of infection are thus prevented. 3rd. — ^A much more completely separate treatment of the sick is now secured than has ever been practised in the past. In London, in 1910, over 56 per cent, of the total male deaths^from phthisis, and over 46 per cent, of the total female deaths from phthisis, occurred in public institutions, the average aggregate stay in these institutions of each patient covering the most serious period of his sickness. Hence the towns share in the general improvement in the tubercle rate, and the average urban rate is approaching closely to the average rural rate. Dr. Newsholme lays stress on the general conclusion that, apart from infected food, tubercle baciUi in elective dos&,ge are present chiefly in the ipamediate vicinity of consumptive patients who are careless in their habits. The following table sets out in detail the death rates from phthisis and other tubercular diseases in England and Wales since 1870 : — * 1871-80. 1881-90. 1891-1900. 1901-10. 1910. 1911. ' 1912. 1913. England and Wales — * Pulmonary Tuberculosis 219 178 139 117 (1901-09) 101 106 101 98 Other Tuberculosis 67 65 ~ 62 50 , „ , 41 40 34 35 London — Pulmonary Tuberculosis 251 208 179 145 122 132 128 123 The graphs illustrating these figures show an uninterrupted dechne in the, phthisis death rate from 1871 till the present day — ^the death rate having fallen from 240 per 100,000 in 1871 to 98 per 100,^00 in 1913, a faU of ,' approximately, 60 per cent. The death rate from " other tubercular diseases " fell concurrently with that from phthisis, and exhibits the same uniformity in dechne. (Graph 1.) TUBERCULOSIS IN THE COMMONWEALTH. During 1914, there were 3,574 deaths from aU forms of tuberculosis within the Commonwealth, or 72*6 per 100,000 of population. The deaths from pulmonary tuberculosis were 3,lllj or 63*2 per 100,000 of population. The following table shows the record for the last ten years. The corresponding New Zealand figures are given for purposes of comparison : — Death Rates pek 100,000 from all Forms oe Tuberculosis. Year. Commonwealth. Kew Zealand. Year. Commonwealtb. Kew Zealand. 1905 101 77-9 1910 83 73-6 1906 99 80-4 1911 83 72-7 1907 92 93-1 1912 79 68-9 1908 .. .. 94 88-7 1913 79 76-0 1909 86 82-3 1914 73 66-7 The Austrahan rate for all forms of tuberculosis for 1914 is 45*1 per cent, lower, and the New Zealand rate nearly 49" 8 per cent, lower than the rate for England and Wales in 1913. • Viie Local Government Board Eeport 1910-11. , The Australian rate for 1914 is 27 "7 per cent, lower than that for 1905. The New Zealand rate, though lower than the Australian, has not improved in the same degree or with the same regularity. The Australian rate fell by nearly 7 per cent, from 1905 to 1908 ; by 11-7 per cent, from 1908. to 1911 ; and by 12-04 per cent, from 1911 to 1914. These results, taken by themselves, are highly satisfactory. If the total fall of 27 "7 per cent, in the last ten years were repeated in the next decade, the rate for Australia in 1925 would be 52 '7. The question, however, which should properly be asked is whether the existing tubercle rate of Australia is as low as it ought to be in comparison with that of England and Wales, or that of the United Kingdom as a whole. Dr. P. C. Cowan, Inspector of the Local Government Board, lecturing at the College of Science, Dublin, early in 1916, said that about 8,000,000 men were engaged in regular occupations in the United Kingdom, and that about 1,000,000 had wages of less than 21s. a week. In 1911, 3*2 per cent, of families lived in single rooms in England and Wales, 6" 4 per cent, in Ireland, and 12*5 per cent, in Scotland. In certain areas the wages are lower and the housing conditions worse than these figures would "indicate. The interactions of poverty and sickness, however, are not easily comprehended. Mr. Burns, President of the Local Government Board, in an address in 1911, said that, in his opinion, 30 per cent, of the total pauperism, on which the country spent fifteen and a half millions per annum, was due to sickness alone. When they grappled with sickness, ill-health, and invahdity, the bed-rock of pauperism was reached. He held that it was a sickness rather than a wages question. However this may be, your Committee is of opinion that the existing tubercle rates of Australia are unsatisfactory, in view of the ample spaces available, the separate housing of families, and the high wages current. The detailed study of tubercle rates in the various States reveals great irregularity in incidence of the disease, and great inequality of progress towards better conditions. The metropolis of a State may be improving rapidly, while the extra-metropohtan districts are comparatively stationary ; or, on the contrary, the metropolis may have high rates while the extra- metropolitan districts have very low rates. Further investigation is urgently needed, so that these inequalities may be levelled down, and that tubercle in Australia, if not abolished, may be brought down to the rate that would correspond with the excellence of our opportunity. MOETALITY DISTRIBUTION AMONG THE STATES. The distribution of the deaths as amongst the various States for 1914 gives the following figures : — Mean FopnUtion. Deaths. Kate per 100,000. Lungs. other. lungs. other. Total. New South Wales Victoria . . Queensland South Australia Western Australia Tasmania 1,852,506 1,423,513 674,932 440,012 323,462 198,372 1,178 1,031 289 280 227 89 180 199 46 57 24 26 63-6 72-4 42-8 63' -6 70-1 44-8 9-7 14-0 6-8 12-9 Y-4 13-1 73-3 86-4 49-6 76-5 77-5 57-9 This table shows that Victoria and Western Australia have the highest death rates from pulmonary tuberculosis. Queensland and Tasmania have the lowest death rates, while New South Wales and South Austraha occupy an intermediate position, the rates being equal in these States. It is interesting to note that the order of magnitude for tubercular diseases other than pulmonary tuberculosis is different from the above, Victoria being highest with 14 '0 per 100,000, South Australia and Tasmania next, then New South Wales, with Western Australia and Queensland far below. The question why Victoria should have a total rate of 86 '4, while Queensland has a total rate of only 49 '6, derpands serious consideration, but it cannot be discussed with advantage till the history and peculiar features of the disease in each State have been set forth, however imperfectly. All rates given are per 100,000 of population. Tubercle in New South Wales. The general history may be learnt from the following table Xear, 1875 1880 1885 1890 1895 Tobercle Eate.. Pqlmojiary. Other, lOB 108 116 93 81 48 31 41 33 27 Total. 153 149 157 126 108 Year. 1900 1905 1910 1914 Tuljerole Hate Pulmonary, Other. 79 18 71 14 65 11 63 9 Iptal. 97 85 76 72 The total rate was high till 1885, and has fallen from 157 to 72. Pulmonary tubercle has fallen from 105 to 63, but other tubercle has fallen far more, i^om 48 to 9. Since 1906 the pulmonary rate has only falleix from 68 to 63, while other tubercle has continued to decline rapidly. The striking features of the tubercle-curves in New South Wales, however, appear in the graph showing the annual death rates among persons of>ll ages from all forms of tubercle, distinguislung the sexes in the metropolitan district from the sexes in the extra-metropolitan districts. (Graphs 4 and 5.) For the metropolis in 1885 the male rate per 100,000 was nearly 308, and the female rate about 248. In 1896 the male rate was 148 and the^female nearly 122, In 1907 the male rate was 95 and the female 94. i In 1914 the male rate was 88 and the female 55. For the extra-metropolitan districts in 1876 the male rate was 100 and the female 85. The male rate rose to 134 in 1881 and again to nearly 133 in 1886, while the female rate reached nearly 108 in 1885. Then the rates fell in an irregular way to their former level, which they maintained till 1903 (male, nearly 109 ; female, 91), after which the rates both feU, the male rate crossing the female rate in 1908 (male, 73 ; female, 76). Since then the male rate has increased and the female rate has fallen, the rates in 1914 having been respectively 91 and 54. The metropolitan rates, which were formerly far the higher, have become the lower» the improvement being marked in both sexes. The extra-metropolitan rates have not improved in anything like the same degree, the female rate being less favorably afiected than the male. For the last ten years there has been very little improvement. The contrast is still more striking if we limit our attention to pulmonary tubercle. Phthisis Bates per 100,000. — Phthisis Hates per 100,000. Metropolis. 102-6 100-3 78-9 Eztra- MetropoUtan. New South ■Wales. Metropolis. Extra-fl Metropolitan. New South Wales. 1894-1898 .. 1899^1903 .. 1904-1908 ,. 69 -9 f 71-8 1 64-0 .i 81-5 82-1 69-6 1909-1913 ' . . 1914 67-0 58-3 64-5 67-1 65-5 63-6 - Tubercle in Victoria. ruberole Eate, Tuhercle Eate Year. Year. Pulmonary. Other. Total. Puhnonary. Other. Total. 1870 . . 124 35 159 1895 .'. 132 29 161 1875 . . 130 47 177 1900 . . 116 31 147 1880 . . 138 37 175 1905 . . 101 28 129 1885 . . 144 36 180 1910 . . 83 17 100 1890 . . 145 39 184 1914 . . 72 14 86 The maximum rates in Victoria were attained in 1887, the pulmonary rate being 153 ; other tubercle, 38 ; total rate, 191. The maximum in New South Wales was two years earlier, in 1885, but with definitely lower rates — ^pulmonary, 116; other tubercle, 41 ; total rate, 157. In 1914 the rates in Victoria were still higher than those in New South Wales, but the improvement in Victoria had been greater than that in New South Wales, especially in recent years. The piilmonary rate in New South Wales from 1906 to 1914 moved from 68 to 63, but in Victoria it fell fron^ 98 to 72. Afl we have seen, the tubercle rate for the extra-metropolitan districts of New South Wales is now higher than the rate of the metropolis. In 1914, the pulmonary rates were as follow : — For the State of New South Wales, 63* 6 ; for the metropolitan district of Sydney, 54" 7 ; for the extra-metropolitan districts, 69 • 1. In Victoria, for the same year, the rates were as follow : — For the State, 72 ; for the metropolitan district of Melbourne, 89 ; for the extra-metropolitan districts, 56. While the phthisis rate for Sydney is far below that for Melbourne, the extra-metropolitan districts of New South Wales compare unfavorably in this respect with those of Victoria. The Sydney rate is very slightly below the extra-metropolitan rate of Victoria. It must not be thought that the extra-metropolitan districts of Victoria have a rate uniformly lower than that of the metropolis. Bendigo, including its suburbs, has always shown a much higher pulmonary rate than Melbourne and its suburbs, as the following table shows : — Melbourne and Subuibs. Bendigo and Subuibs. Melbourne and Suburbs. Bendigo and Suburbs. 1891-1900 . . 1901-1905 . . 1906 1909 167 139 115 97 241 227 ,217 1229 1912 1913 1914 100 S8 89 177 200 118 The contrast between the high rates prevaihng in Bendigo even in 1913 and the relatively low rate of 1914 is astonishing, and its cause is not apparent. Ballarat and its suburbs have as a rule had a rate slightly above that of Melbourne, but in 1913 and 1914 Melbourne has shown improvement, while Ballarat has shown higher rates. In 1914 the Ballarat rate of 112 was only slightly below that of Bendigo. Geelong and its suburbs show far less phthisis than Melbourne or Ballarat, and the rest of the State shows much less than Geelong. Tubercle in Queensland. Year Tubercle Rate. Year. Tubercle Bate. Pulmonary. Otber. Total. Pulmonary. other. Total. 1873 . . 1875 . . 1880 . . 1885 . . 1890 . . 1895 . . 1900 . . ■i08 141 144 191 133 96 87 26 32 16 71 53 32 32 134 173 160 262 186 128 119 1905 . . 1910 . . 1911 . . 1912 . . 1913 . . 1914 . . 75 50 55 51 53 42 15 8 10 10 6 5 90 58 65 , 61 59 48 This extraordinary record shows that the rates, both pulmonaiy and " other," rapidly rose from 1873 tiU 1885, till they were high above any record in New South Wales, while subsequently there was a fairly steady fall, so that the rates fell below those of New South Wales in 1906, and continued to fall absolutely and relatively tiU 1910, becoming decidedly the lowest rates obtaining in any Australian State. Since 1910, however, there was no further improvement until 1914, when a further decided reduction was recorded. The fall in the total tuberclejrate from 262 to 49 within 30 years is phenomenal. In Queensland, however, there is still a striking difference between the tubercle rates of the metropolitan district (10-mile radius) and the extra-metropolitan districts. In 1914, the pulmonary rate for Brisbane and its suburbs was 71, while that for the TBxtra-metropolitan districts was 35, the rate for the whole State being 42, so that the phthisis rate for Brisbane is slightly above that of Sydney, while the extra-metropolitan districts of Queensland have a rate less than half that of the extra-metropolitan districts of New South Wales. Tubercle in South Australia. * Tubercle Bate. Tubercle Bate. Tear. Pulmonary. other. Total. Pulmonary. other. Total. 1870 . . 97 1*7 114 1900 . . 82 15 97 1875 . . 100 20 120 1905 . . 77 11 88 1880 . : 101 24 125 1908 . . 100 11 111 1882 . . 117 21 138 1910 . . 81 18 99 1885 . . 99 19 118 1913 .. 73 16 89 1890 . . 95 18 113 1914 . . ■ 63 12 75 1895 . . 95 20 115 8 Here the rates have never been high, reaching a maximum of 138 for total tuberde in 1882 ; but improvement has been slow, and interrupted by a rise in 1908 above the rates of 1870. The rates are now not far below those of Victoria and are higher than those of New South Wales. Victoria and even New South Wales had formerly much worse records. TUBEECLE IN WESTERN AUSTRALIA. Tubercle Bate. Year. Tnbeicle Bate. Year. Pulmonary. other. Total. Fnlmonary. other. Total. 1888 . . 1890 . . 1895 . . 1900 . . 93 91 62 78 11 10 15 15 114 101 77 93 1905 1910'.. 1913 . . 1914 . . 65 74 63 70 11 11 10 7 76 85 73 77 -4 Here again the rates have never been high, but for twenty years there has been no improvement. The pulmonary rate is now higher than that of New South Wales. Concerning districts, the pulmonary rates for 1911 were as follow: — Metropolitan . . . . Central and Eastern (mining) North and North- West . . South- Western (agricultural) 91 90 61 25 The rates for the mining district were almost exactly identical with those of the metropolis. Those for the agricultural districts were only 28 per cent, of the foregoing. Tubercle in Tasmania. Year. Tubercle Bate, Year. Tubercle Bate. Pulmonary. other. Total. Pulmonary. other. Total. 1881 .. 1885 . . 1890 .. 1895 . . 1900 98. Ill 96 75 61 5 4 13 20 20 103 115 109 95 81 1905 . . 1910 . . 1913 . . 1914' .. 72 67' ■ 54 44 17 13 19 13 89 80 73 57 What has been said of Western Australia applies to Tasmania also, years Tasmania has shown a lower pulmonary rate and a higher " other ' Western Austraha. In recent rate than The position may be briefly stated by saying that New South Wales, Victoria, and Queensland have in that ascending order of relative magnitude shown marked improvement in their tuberculosis condition, while South Australia, Tasmania, and Western Australia have remained practically stationary, or have shown relatively slight improvement within the last twenty years. If some fundamental explanation of the reduction of tuberculosis in Queensland could be obtained, it would go far towards elucidating many of the problems in the control ofj^the disease. STATISTICS OF TUBEECLE AMONG THE LIVING. The preceding records apply only to the facts known concerning deaths from pulmonary tuberculosis. Of the number of persons still living afEected with this disease not so much is known. Payment op Pensions. During the period 18th November, 1910, to 27th August, 1915, a total of 3,381 pensions were paid on account of tuberculosis, and of these 2,532 were tuberculosis of lungs. The pensions represent only those persons permanently incapable of earning their livelihood, which means, in all probability, that the 2,532 persons were advanced cases of tuberculosis, and therefore infectious. Cases op Phthisis Notified. As the disease has not been notifiable in all of the States for any lengthy period, it is not possible to give very complete information concerning the distribution of the disease. The following information is, however, available. New South Wales. Tuberculosis of the lungs was made notifiable within the metropolis of Sydney in 1904. By the Public Health Act Amendment Act 1915, the disease was made notifiable in any district of the State which might be proclaimed for the purpose. For the year 1913 there were 656 cases of pulmonary tuberculosis notified in the city of Sydney. Victoria. Pulmonary tuberculosis was made notifiable in the metropolitan area in 1903, in the principal cities and towns in 1905, and in the remainder of the State in 1909. The following table shows the number of cases notified under the above provisions : — Year. Metropolitan. • Extra Metropolitan. Whole State. Bate per 100,000 Whole State. 1904 413 1 1905 .. 603 .. .. 1906 .. 780 , _ , , , , 1907 .. 841 , , , , 1908 .. 972 380 1,352 108-1 1909 .. 754 529 1,283 101-0 1910 .. 928 529 1,457 112-0 1911 .. 879 528 1,407 105-8 1912 .. 803 524 1,327 96-1 1913 .. 780 596 1,376 97-6 1914 .. 856 554 1,410 98-6 1915 .. 972 537 1,509 An interesting analysis of the data accumulated during two and a half years ended June, 1911, has been made' by the Government Statist of Victoria {Victorian Year-Booh 1913-14, p. 389). These data are based upon the notifications received under the Health Act. During the period under review, 1,912 residents of Greater Melbourne, 137^of BaUarat and suburbs, 347 of Bendigo and suburbs, 71 of Geelong and suburbs, and^731 of the "rest ofjthe State]^"t contracted the disease. The annual notifications of cases of pulmonary tuberculosis and the annual deaths therefrom per 10,000 of the population of each of the' five divisions referred to and of the whole State are compared in the following table : — Rates per 10,000 ow the Popttlation. Cases notified Deaths Melbourne. Ballaiat. Bendigo. Oeelong. B«Btofthe State. 13-1 9-5 11-6 9-9 31-6 21-8 10-2 7-2 4-9 6-1 The Whole State. 9-8 8-3 The report rate exceeded the death rate by 38 per cent, in the metropolis, by 17 per cent, in Ballarat, by 45 per cent, in Bendigo, by 42 per cent, in Geelong, and by 18 per cent, in the whole State. From the deficiency in the report or notification rate for the " rest of the State " it would appear that numerous cases occurring therein have not been reported to the Board of Health, or that many residents of the metropolis and'of the three other large cities referred to, who contract phthisis, leave these areas and'reside in country districts, where some of them subsequently die from the disease. The latter is true to some extent, but it accounts for only a portion of the discrepancy mentioned. If all cases occurring in the rural areas were notified, it is probable that the report rate would slightly exceed the death rate. 10 Tuberculosis of the ]pngs was made notifiable from 1st July, 1905, since which date^the following notifications have been received : — Year. 1.7.04 to 30.6.05 1.7.05 to 30.6.06 1.7.06 to 30.6.07 1.7.07 to 30.6.08 1.7.08 to 30.6.09 1.7.09 to 30.6.10 1.7.10 to 30.6.11 1.7.11 to 30.6.12 1.7.12 to 30.6.13 1.7.13 to 30.6.14 1.7.14 to '30.6.15 Number. 295 261 369 288 273 345 462 474 473 471 402 Bate pet 100,000. 8 55 48-6 68-0 52-0 47 58 75 75 72 ■9 •3 •2 •1 •5 69-6 Tasmania. The following are the annual numbers of cases reported in Tasmania Tear. 1913 1914 1915 Ifumber. 268 257 231 Bate per 100,000. 133-3 127-8 South Australia. Pulmonary tuberculosis has been notifiable in South Australia since 1898. following table gives a record of the numbers of cases notified since that date : — The Bate Bate Year. Caaea. per 100,000. Year. Cases. per 100,000. 1899 225 63-0. 1908 426 112-8 1900 216 59 8 1909 397 102-2 1901 356 90 9 1910 360 93-0 1902 330 92 7 1911 467 113-5 1903 341 95 9 1912 550 130-5. 1904 320 89 6 1913 667 153-8 1905 324 90 1914 548 124-5 1906 330 90 8 1915 554 1907 426 115-8 1902. Western Australia. Pulmonary tuberculosis has been nominally notifiable in Western Australia since but no figuies are available prior to 1909. The information subsequently available is as follows : — Year. Cases ITotiSed. Bate per 100,000 of Population. Year. Cases Notifled. Rate per 100,000 ol Population. 1909 1910 1911 190 202 259 71-7 73-1 ■ 88-9 1912 1913 1914 429 424 363 140-1 132-5 109-2 It will be obvious that these figures, representing as they do only the notifications received during the years concerned, cannot be accepted as representing the total number of cases in the community during any one year. Cases will still be alive which had been notified during the preceding year, cases will escape notification, and other such causes combine to render the total incomplete as an estimate of the total numbers of phthisical persons alive during any one year. The most complete estimate on these lines was made in South Australia, where it was estimated from carefully compiled records that 457 persons suffering fiom phthisis were alive on 31st December, 1910. If this estimate be applied to the total population of the Commonwealth, it will be found that on this ratio there would be in 1914 about 5,677 persons in the Commonwealth suffering from pulmonary tuberculosis. In the five States, Victoria, South Australia, Queensland, Tasmania, and Western Australia, a total of 3,049 notifications was received in 1914 amongst a population of 3,073,498. 11 Applying this proportion to the total population of the Commonwealth, 4,940,952, an estimated total of 4,901 is obtained as the number of notifications which would have been received if the proportion in these four States had obtained throughout the Commonwealth. On the evidence thus available, and having regard to the usual duration of life in phthisical patients, we believe that the number of living consimiptive patients in the Commonwealth may be estimated as at least 6,000. AGE DISTRIBUTION. As regards Invalidity Pensions, the actual numl^pr of persons affected at different ages inmost important. But in an inquiry into the causes of the disease, much more accurate information is obtained by a study of the numbers affected at any age in proportion to the number of persons living at that age. These two aspects will be considered separately. The only reliable figures in each case are those concerning actual mortalities. The following table is taken from the Bulletin No. 32 of the Conamonwealth Bureau of Census and Statistics on Population and Vital, Statistics. Pulmonary tubercle here includes laryngeal, bronchial, acute milia,ry tuberculosis, and pleural tubercle, and the various forms of tuberculous pneumonia : — ^ Deaths from Tubkeole IN THE Commonwealth in 1914 k other lubeide. Total Tobetide. Male. Female. Total. Per- centage. Male. Total. Male. Female. Total. Under 5 20 16 36 1-2 100 69 159 120 75 195 5-9 6 10 16 0-5 23 19 42 29 29 58 10-14 13 16 29 0-9 19 6 25 32 22 64 15-19 59 95 154 5-0 20 16 36 79 111 190 20-24 159 191 350 11-3 14 23 37 173 214 387 25-29 211 223 434 14-0 19 17 36 230 240 470 30-34 217 165 382 12-2 8 11 19 225 176 401 35-39 223 155 378 12-1 13 7 20 236 162 398 40-44 185 116 301 9-7 13 7 20 198 123 321 45-49 199 '84 283 9-1 6 5 11 205 89 294 50-54 203 W5 57 260 8-4 12 9 21 215 66 281 55-59 50 185 5-9 9 3 12 144 53 197 60-64 98 30 128 4-1 6 7 13 104 37 141 65-69 67 28 95 3-0 4 4 8 71 32 . 103 70-74 • . 29 11 40 1-3 2 2 31 11 42 75-79 17 9 26 0-8 1 1 2 18 10 28 80 and over . 7 1 8 0-3 , , , , 7 1 8 Unspecified . 5 1 6 0-2 •• 5 1 6 m ■ 1,853 1,258 3,111 100-0 269 194 463 2,122 1,452 3,574 • ■• The number of deaths from tubercle in the Commonwealth may be stated more shortly as follows without distinction of sex : — * Number of Deaths from Tubercle in the Commonwealth in 1914. Age Period. Pulmonary Tubercle. Other Tubercle. Total Tubercle. Age Period. Pulmonary Tubercle. other luberole. Tubercle. Under 10 52 201 253 50-59 .. 445 33 478 10^19 .. 183 61 244 60-69 .. 223 21 244 20-29 .. 784 73 857 70-79 .. 66 4 70 30-39 .. 760 39 799 80 and over 8 , , 8 40-49 .. .. 584 31 615 Unspecified 6 6 From these tables it appears that the number of deaths is greatest between 20 and 40, the maximum being attained between 25 and 29. Though the number of deaths diminishes from the age of 40 onwards, 615*lives are lost between 40 and 49, 478 between 50 and 59, and 328 after 60. ' 12 A different picture is obtained by comparing the numbers of deaths per 100,000 Kving at each age period. The age distribution of the population is far more certain in the census years than in intermediate periods, and for this reason we have used the statistics of 1911. Average Mortality Rates (1909-1913) prom all Forms oe Tubercle per 100,000 Living at each Age Period in the Commonwealth in 1911. Age Period. Male. Female, Total. Age Period. Male. Female. Total. Under 5 48 43 46 "45-49 .. 168 94 131 5-9 .. 13 13 13 50-54 .. 171 73 122 10-14 .. 14 20 * 17 55-59 .. 185 82 133 15-19 .. 37 68 52 . 60-64 .. 179 91 • 135 20-24 73 113 93 65-69 .. 157 91 124 25-29 .. 111 135 123 70-74 .. 137 73 105 30-34 .. 126 121 123 75-79 .. 74 41 57 35-39 . . 140 120 130 80 and over 41 39 40 40-44 .. 148 103 125 This table shows that the total mortality from tubercle per 100,000 living at each age period rises till 35-39, then fluctuates till it attains a slightly higher point between 60 and 64, the rate being higher from 70 to 74 than between 20 and 24. The full meaning of these figures, however, cannot be grasped until the sex distribution has been studied. According to Dr. John Brownlee (Society of Medical Officers of Health, 14th January, 1916) there are three types of pulmonary phthisis — one specially afiecting young adults and attaining its maximum between 20 and 30 ; a second affecting chiefly persons of middle age, with its maximum between 40 and 50 ; and a third affecting persons in more advanced age, with its maximum between 60 and 70. Shetland and Ireland give the first type almost pure, London gives the middle' type. The curve of the coal miners gives the third type. As a rule, the general curve is made up of the three types in varying proportion, but there are curious exceptions in addition to those above mentioned. South Wales has no middle-age phthisis, while Lancashire has practically nothing but the middle-age type. In England as a whole there has been a rapid and continued fall in young adult phthisis since 1860. Probably there had been an increase from 1840 to 1860. In Ireland, phthisis among persons between 20 and 30 years has steadily increased since 1851-60, and it would appear that a decline is now setting in. (Graphs 6 and 7.) ^ The explanation of these variations is mor'g problematical. Brownlee finds that the young adult type spreads equally in healthy and unhesibhy districts, while the middle-age tjrpe is, more deadly in proportion as general health is depressed. He thinks that -early and late phthisis may be one disease and middle-age phthisis another disease. Some such distinctions of type are, in our opinion, essential to the understanding of tubercle in the Commonwealth, but we regard Dr. Brownlee's explanations as unproved hypotheses. In our opinion, pulmonary tuberculosis is probably one disease, but with varying incidence and prevalence according to the amount of exposure to infection, and the surrounding conditions making for increased or diminished resistance. Tubercle other than pulmonary will be discu|^ed in a separate section of this Eeport. Pulmonary tubercle in the Commonwealth probably includes all the three types, and we shall consider the subject farther in connexion with sex distribution. Phthisis in elderly persons usually runs a very chronic course. In the young it is often rapid, and even when slower in its evolution it often presents marked exacerbations during which progress is accelerated. In considering relative mortalities therefore, it must be remembered that the number of patients in middle and advanced hfe 18 relatively larger than the number of deaths would indicate. Age Distribution of Human Cases amongst the Living. Pensions. During approximately five years, 1910-1915, pensions were paid on account of phthisis to 2,532 persons. These were distributed as follows :— 16-20. 20-30 30-40 40-50 BO-60 60-70 70-80 Total. Total Cases . . ... . . 87 448 534 656 651 153 3 2,532 Percentage of Total . . '\ c '■ 3-4 17-6 21-0 25-9 25-7 6-0 0-1 99-7 13 Cases Notified. Tte only information available concerning the ages ' of cases notified under various Health Acts is that for Western AustraUa. In that State 353 cases were notified during the year 1914, and these were distributed as follows : — 0-6. 6 1-7 6-10. 3 0-8 10-15. 15-20. 20-25. 26-30. 30-35. 36-40. 40-45. 45-50. Over 50. rnspecifled. Total. Total Cases . . 6 21 42 45 40 49 13-8 41 35 44 ' 21 353 Percentage of total 1-7 5-9 11-9 12-7 11-3 11-6 9-9 12-4 5-9 99-6 SEX DISTEIBUTION. The following table shows the sex distribution of deaths from tubercle in the Commonwealth in 1914 : — Pulmonary Tutercle. other Tubercle. Total Tuberde. Males . . . . Females 1,853 1,258 269 194 2,122 1,452 Per 100,000 of each sex, the rates for total tubercle in the last census year (1911) were- and in 1913— Males, 88; females, 78; Males, 85 ; females, 73. For the several States in 1913 the total death rates from tubercle per 100,000 of mean population were as follows : — Males. T, ,„ Male Bate in Females. percentage of Female. New South Wales . . 88 67 131 Victoria 89 85 104 Queensland.. 69 49 141 South Australia 86 94 91 West Australia 89 54 165 Tasmania 68 80 85 The female rate exceeded the male decidedly in Tasmania, and to a less degree in South Austraha. The male rate exceeded the female shghtly in Victoria, decidedly in New South Wales, stiU more in Queensland, and even more in Western Austraha. In Queensland, startling results are obtained by comparing the tubercle mortahty rates per 100,000 of each sex in 1914, as the following table shows : — Pulmonary Tubercle. other Tubercle. Total Tubercle. Male. ' Female. Male. Female. Male. Female. State of Queensland Metropolitan District (10-mile radius) Extra-metropolitan Districts *57-3 98-2 46-6 27-9 45-7 21-8 5-5 9-2 4-5 5-4 10-1 3-8 62-8, 107-4 51-1 33-1 55-8 25-6 Malea. Females. The respective populations are as follow : — State of Queensland .. .. 364,526 .. 312,181 Metropolitan District . •• . . 75,295 . . 78,716 Extra-metropohtan Districts . . 289,231 . . 233,465 It must be remembered that the extra-metropohtan districts include such centres of population as Eockhampton, Maryborough, Toowoomba, and Townsville. In Queensland, therefore, the female rate throughout is only half the male rate. The male and the female rates are twice as high in the metropohtan districts as in the extra-metropohtan districts. In the latter the female rates are as follows : — Pulmonary, 21 • 8 ; other tubercle, 3 ' 8 ; total tubercle, 25 • 6. 14 The history of the mortality rates in the sexes is shown in the following tables for New South Wales and Victoria : — New South Waha. MoulAMt^ Eitsa Pbs 100,000 O* BiraaB SB*. Pulmonary Phthisis. other lubeicle. Year. Pulmonarr Phthisis. other Xuhercle. Year, Male. Female. Male. retnale. Male. Female. Male. remale. 1875 .. 1885 .. 1895 .. 113 123 97 95 107 62 ~ 45 41 27 52 40 27 1905 . . ' 1914 .. 84 77 57 48 15 12 14 6 other In 1908 the male and female phthisis rates were nearly equal. For tubercle " the male and female rates were practically equal from 1885 to 1905. We have already shown that in the mettopohtan district of Sydney there has been marked improvement both in males ^nd in f emales^ the sexes now aufiering equally ; whereas in the extra-metropolitan districts there has been relatively httle improv^eme&t^ especially in females. Victoria. Mortality Rates Per 100,000 of Either Sex. Pulmonary Phthisis. 1860-68. 1870-72. 1880-82. 1890-92. 1900-«2. 1910-12. Male . . Female 133 144 129 106 153 127 157 118 135 , 97 90 76 In New South Wales the rates have improved much more rapidly in females than in m^lks. In Victoria the rates for both sexes are relatively^high, butj, asjin New South Wales, the female rate has shown greater decrease than the male. AGE DISTRIBtJTION OF TUBERCLE MORTALITY IN MALES AND FEMALES. We have already given a table (page 12) showing the rates of death per 100,000 living at each age period in the Commonwealth for males and females (1909-13) from all forms of tubercle (page 12). The graph corresponding (Graph 2) shows in striking fashion the contrast between the sexes. Disregarding cases under 15, we find that both male and female rates rise rapidly from 15 to 30, but in this fteriod the female rate is much the higher. The male rate continues to rise till 40, while the female rate falls slightly. Subsequently the male rate rises high above the female to reach its maximum of 185 between 55 and 6&, while the female rate, which reached its maximum of 135-5 between S5 and 29, falls to a temporary minimum of 73-6 between 50 and 54. Subsequently the male rate falls, but more rapidly after 70 than before, while the female rate rises to 91 between 60^;and 70, the male and female rates coming close together after 80 at a level of about 40. These facts may be Sitated shortly with some degree of probability in terms of Dr. BrOWnlee*s classification. In females, there is a high early wave of tubercle, reaching its maximum about 30 ; the wave of middle life is oiJy feebly marked ; and the wave of later life, though very definite, is much less strong than the early wave. In men all three waves are strongly marked. The early wave is less high than that in femalea ; but the middle and late Waves combine to give a high maximum between 55 and 59! Over 80, male and female curves are close together at a relatively low level.. A few age periods may be selected for contrast of the rates : — Total Tuberclb Mortality per 100,000 Living is bach Age Period. Agd A:AM. 15-19 50-54 Male Rttte. 37 111 171 Female Bate. 68 135 '5 73-6 Age Pettea. 55-59 65-69 80«ftlid over Mjd0ihtt«. 185 1S7 41 Female Rate. 82-5 91 39 The tendeney to tubercle is governed by exposure to the bacilius and by individuaJ reaistance to inle&tion. In the period 15-30, woman suffers much more than nuka. After 30 men begin to fall victims more than women. At 60-54 the death tax is falling 15 heavily on the males, while it haa receded in the females. The male maximum is f cached at 55-59, the female rate now rising slightly-i During the next ten y^ars the male rate is falling, while the female is rising or Btationary. After 70 both, rates fall. The great contrast is between the female rate of 73- 6 at 50-54, and the male rate of 185 at 55-59. If we review the history of tubercle for 50 years, We find that peat Changes have occurred in the age incidence in the two sexes. For this purpose, we take the statistics of pulmonary phthisis in Victoria as given in the Victorian Year-Book for 1914-15, page 393. At the end of this Report, graphs are given showing the rates for males and females in age periods at the last six Census years. It must be remembered that the general male rate for phthisis rose to a maximum in 1881-1891, and then fell, while the general female rate has fallen since 1861, the steady fall being broken only by a more marked drop in 1871. The history of phthisis in Victoria is in sum as follows : — In 1861 females suffered more than males. Women had their maximum from 25 to 55, while men reached their maximum more slowly at 55 to 65 . Women had a strong early and middle Wave and only a weak late wave, while men had a strong middle and late wave. In 1871 the rates for both men and women had fallen, but the male rate had passed above the female. The early wave was increasing in intensity in both sexes, but the middle and late waves were falling rapidly in women and the late wave was accentuated in men. In 1881 the female rate was above that of 1871, but below that of 1861. The male rate showed a decided rise even above 1861. The early wave had become still more dominant in women, while all three waves were marked in men, with two maxima at 25-35 and at 55-65. In 1891 the female rate was falling, but the male rate still rising. In females the early and middle waves were dominant, the early wave being less abrupt. In males the! middle and late waves increased, and with a dimimshing early wave brought a majd- mum of nearly 365 per 100,000 between 55 and 65. In 1901 the male rate was falling, but was 135 as compared with the female rate of 97. The female curve was more homogeneous, with a high middle part, the maximum lasting from 25 to 45, with a slight increase in the second of these decades, The male caught the female at 25, and then soared up to 357 at 65-65, while the female rate was dying away. In 1911 both rates had fallen. The early female wave showed only slight improve- ment, the rate between 20 and 25 being practically unchanged ; but the middle and late waves were falling away. The female maximum of 140 lay between 25 and 35. The early male wave was disappearing, but the middle and late waves, though Vastly improved, were still relatively marked, the maximum of nearly 189 lying between 65 and 65, while the female rate at that age period was only 74*7. The Victorian phthisis rates are still too high (male, nearly 90 ; female, 76), but Victoria has reason to be thankful for the great change from the conditions of 1891 to those of 1911. Special attention, however, should be paid to the conditions of life affecting the young women in that State. (Graph 3.) OCCUPATIONAL DISTRIBUTION. The occupations of the male persons who died from tuberculosis of the lungs in the Commonwealth are classified for the year 1914 as follows : — Professional Domestic . . Mercantile pursuits . . Transport and Communication Industrial — Manufacturing . . Building and construction . . Others . . It^is evident that the incidence of tuberculosis is not limited to any one occupation — ^meicantile pursuits and general industrial work providing the greatest numbers of deaths, while mining is fourth in order of magnitude. As the total numbers of males engaged in these pursuits is not known, the degree of distribution of this disease amongst the various trades Cannot be stated. 93 Primary producers — 90 Agricultural . 128 306 Pastoral 48 155 Mining and quarrying . 193 Other .. 9 212 Independent' means 18 101 Dependent 79 340 Unapecified . . 37 Total . 1,804 16 This distribution does not quite correspond with the distribution obtained by arranging the death rates in order of magnitude. As 1911 is the only year in which the populations engaged in the various occupations are known, the death rates can l^e given for this year only, and as the pubhshed figures specify occupational distribution for males only, this sex alone can be dealt with. The following table gives the rates per 100,000 in the different groups of occupations : — Total Population Number of Deaths Death Bate per Occupation. Employed. from laberculoBls, 100,000. Independent Means . . 13,939 31 222 Mining and Quarrying 105,726 212 200 Domestic . . * 48,235 87 180 Industrial ^ . 453,743 695 153 Professional 91,638 112 122 Commercial . 236,499 280 118 Engaged in Transport and Communication 152,554 160 104 Unspecified . . 39,386 31 78 Agricultural 277,232 142. 51 Dependent . . 706,773 259 36 Pastoral 143,-591 35 24 Other Primary Producers . . . . . . 43,719 . 11 25 Total 2,313,035 2,055 88 An interesting return has been supphed by the Health Department of Victoria showing the occupations of male persons suffering from pulmonary tuberculosis who applied to the Public Health Department for admission to a State Sanatoriuna during the period January, 1912, to December, 1915 : — Males. Factory hand . 15 Potter 3 Actor 4 Farmer . 30 Printer . 30 Agent . . ' . 24 Farm labourer . 42 Prospector . , 2 Artist 2 Fireman . 14 Quarryman . . 6 Baker . 13 Fitter 7 Railway employee 14 Barman . 12 Frenchpolisher 4 Railway guard 1 Billiard-marker 6 Gardener . 20 Railway signalman 3 Blacksmitli .. . 21 Gasfitter 4 Railway shunter 2 Boilermaker 8 General . 67 Railway train examine r 2 Bookbinder . . 2 Glassworker 7 Rubber-worker 7 Bookmaker .. 2 Greengrocer . . 4 Salesman . 24 Bootmaker . . . 72 Grocer 12 S.A. officer . . 6 Boundary rider 2 Groom . 22 Sawmaker . . 5 Brassfinisher 2 Hairdresser . . . 25 Saw-mill hand 3 Bricklayer . . . 19 Hawker 9 School 6 Butcher 19 Harnessmaker . 10 Seaman . 32 Cab-driver . . 6 Hardware employee . 2 Ship steward 10 Cabinetmaker 12 Horse-trainer 7 Shop assistant . 11 Canvasser 6 Ironworker . . 6 Sign writer . . 6 Caretaker 7 Ironmoulder 5 • Slaughterman 2 Carpenter . 86 Jeweller 8 Soldier 51 Carriage-cleaner 4 Journalist . . 4 Stableboy 6 Carrier 7 Labourer . 399 Steelworker 2 Casemaker . . 3 Laundryman 4 Stoker 10 ChaufEeur . 18 Leadworker . . 3 Stonemason .. 3 Chemist . . 4 Machinist 3 Storekeeper 5 Cigarette-maker 3 Mechanic 17 Storeman 9 Circus rider . . 2 Medical student 3 Tailor 16 Clerk . 140 Messenger . . . 10 Tailor's pressor 7 Coachbuilder 4 Miner . 99 Tentmaker . . 5 Compositor . . 6 Musician 7 Tinsmith lb Confectioner 4 News agent . . 3 Tobacconist . . 1 Cook . 20 Orchardist . . 6 Tobacco-worker 17 Cooper . . 4 Packer 2 Tram conductor • 3 Dairyman . . 7 Painter . 31 Tram employee 4 Dealer 4 Pensioner — Traveller 23 Draughtsman 5 Invalid 7 Waiter 9 Draper . 17 Old-age 4 Wardsman . . 7 DriUer . 3 Photographer 4 Warehouseman 6 Driver (engine) . 29 Piano tuner . . 5 Watchmaker 2 Driver . 59 Plasterer 5 Woodturner 13 Drover 9 Plumber . 15 Woolworker 5 Electrician . . . 14 Police constable 3 Electroplater 3 Porter . 15 Total .. . 2,067 Engineer 9 Postman . . 7 It is noticeable that the two groups principally affected are clerks and labourers and that the number of miners who applied was also comparatively large. 17 TUBEECULAE DISEASE OTHEE THAN PULMONAEY TUBEECULOSIS. The following table shows the number of deaths recorded in the Commonwealth during the last eight years :— Year. Meningeal Tubeiole. other Sites. Total. Tear. Meningeal Tubercle. other Sites. Total. 1907 . . 1908 . . 1909 . . 1910 .. 237 205 220 215 415 352 332 343 652 557 552 558 1911 .. 1912 . . 1913 . . 1914 . . 269 215 252 207 303 327 296 349 572 542 548 556 The following table shows the detailed causes of death of the 556 cases in 1914 : — ' Male. Female. Total. fAcute tuberculosis . . Group I. < Miliary tuberculosis . . (^Disseminated tuberculosis Group II. Tubercular meningitis 1 Group III. Abdominal tuberculosis ("Tubercle of spine Group IV. -j Tubercle of hip . . ... (^Tubercle of other bones and joints Tubercle of kidneys . . Other forms 27 22 25 130 55 23 14 4 10 8 29 15 27 77 53 18 6 1 9 3 56"! 37 U45 52 207 108 4n 20 U6 5 19 11 Totrfils . 318 238 656 * The age and sex distribution of the 556 cases in 1914 was as follows : — — Under 5. B-9. lO-U. 16-10. ao-24. 25-20. 30-31. astsi. 10-44. 46-40. 50-64. 65-50. eo-64. 65-69. 70-74. 76-79. Total. Males Females 105 64 24 21 23 7 26 20 18 31 26 25 13 14 19 12 14 9 8 9 15 10 12 3 8 7 4 4 2 1 2 318 238 Total . , 169 45 30 46 49 51 27 31 23 17 25 15 15 8 2 3 556 The statistics concerning total tubercle are more rehable than those concerning the difEerentiation of pulmonary tuberculosis and other tuberculosis ; for cases certified simply " tuberculosis " are officially counted in pulmonary tuberculosis, and number no less than 797 in the total of 3,018. Tubercular -meningitis is chiefly a disease of early life. Of the 207 deaths from this cause, 113 occurred in children under five. Of the 108 deaths attributed to abdominal tubercle, 35 were in children under five. The remaining forms of " other tubercle " were widely distributed over the age periods. For the Commonwealth as a whole there has been no diminution in the number of deaths ascribed to " other tubercle " during the past seven years. The history in the States has. varied greatly. In New South Wales, since 1875, the " other tubercle " rate has fallen steadily, far more rapidly than the pulmonary rate, so that in 1914 it was 9 instead of 48. In Victoria, the fall has been similar, but less yapid, from 47 to 14. In Queensland, since the enormous rise to 71 in 1885, the rate has fallen to 6. South Australia has lost groimd recently, the rates being 24 in 1880, 11 in 1905 and 1908, 18 in 1910, and 16 in 1913. Western Austmha has always had low rates, but the 10 of 1913 is substantially the same as the 11 of 1905. Tasmania had formerly a very low rate of 4 or 5 ; but in 1895 and 1900 the rate was 20, and in 1913 it was 19. ' F.11958.— B 18 In brief, New South Wales, Victoria, and Queensland show great improvement in their "other tubercle" rates, decidedly greater than the improvement in the pulmonary rates. The other States show little or no improvement in " other tubercle." Special reference must, be made to tuberculosis in children under five, for this is mainly tubercle other than pulmonary, the chief causes of death being tuberculous meningitis, abdominal tuberculosis, and generalized tuberculosis. In 1914 the total number of deaths from tubercle in the Commonwealth in children under five was 195. In 1886 there were 428 such deaths in New South Wales alone. In New South Wales, the deaths increased greatly from 1876 to 1886, when the Dairies Supervision Act was passed. Since then there has been a progressive fall, with only slight interruptions, from 427 deaths in 1888 to 85 deaths in 1915. The fall has been great both in the metropohs and in the extra-metropohtan districts ; but, in proportion to the number of children exposed to infection, the fall in the metropohs has been far greater. All forms of tubercle show improvement, but the greatest change in this age-period is in abdominal tubercidosis, the deaths from which from 1905 to 1908 were only 18 per cent, of the deaths from 1883 to 1886, and this, too, without considering that the annual number of births in New South Wales increased from 15,267 in 1883 to 20,853 in 1908. These facts stand out as a bright record of progress in the campaign against tuberculosis. Invalid Pensions. Pulmonary tubercle was responsible for 11 per cent, of all invahd pensions, and tubercle of bones and joints for 3 per cent. Of invahd pensions paid to persons under 40, 16-7 per cent, were in respect of pulmonary tubercle, and 7*8 per cent, in respect of other tubercle, or a total of 24-5 per cent, in respect of tubercle in any -form. SUMMAEY OF STATISTICAL DATA. In respect of tubercle, the Commonwealth compares favorably with the United Kingdom, but not so favorably as it shoxjld. In its own records there has been marked improvement, but in some of the States the tendency to improvement has recently diminished or disappeared. The most remarkable progress is seen in the tubercle of children under five. Great discrepancies are still present. Victoria has the highest rates, but is showing progressive improvement. In New South Wales there has been great progress in the metropohtan district, but very little durii^ recent years in the remainder of the State. In Queensland the rates, which were once very high, have become decidedly the lowest in the Commonwealth ; but the rates in Brisbane are as high as those in Sydney, while those in the extra-metropohtan districts of Queensland are very low. South Austraha, Western Austraha, and Tasmania show httle recent progress. The number of deaths from tubercle is greatest between the ages of 20 and 40, but in proportion to the number of persons hving at each age-period the rates are highest between 55 and 59, and are higher between 70 and 74 than between 20 and 24. In the old the disease lasts much longer than in the young. The prevalence and importance of tubercle in middle life and commencing old age is seriously imderestimated. There is a striking difierence between the incidence of tubercle in males and females. In the Commonwealth as a whole the male rate per 100,000 in 1913 was 85, and the female rate 73 ; but taking the female rate as 100, the male rate varies from 165 in Western Austraha to 85 in Tasmania. In the Commonwealth the stress comes earher in women than in men, and the early stress is more severe. The maximum mortality per 100,000 Hving at any age- period is reached in women between 25 and 29, after which the rate recedes. But in man the maximum is not reached till between 55 and 59, when the male rate is more than double the female, in spite of a shght late rise in women. Special attention must be given to the early high rise in women, and to the persistent increase in men far above the female rates in the middle and later periods of life. It must not be thought that early stress is absent in men, but it is relatively less severe. Women show evidences of late stress, but not in any degree comparable with that seen in men. Concerning occupation, it is curious to note that those of " independent means " sufier most ; those engaged ih mining and quarrying head the list of workers, while it is surprising to note that the "domestic' rate considerably exceeds the industrial. Pastoral and agricultural pursuits show low rates. It must be remembered that the information is available for males only. 19 The death rate for the Commonwealth for all forms of tuberculosis is 726 pet ttiillion of population, and that for pulmonary tuberculosis 613 per million. The number of deaths from tubercle in 1914 was 3,574, including 3,018 from pulmonary tubercle, A reasonable estimate on which to base practical action would be that there are at least 6,000 persons living in the Commonwealth suffering from pulmonary phthisis. Tubercidosis is still far too prevalent. The avoidable excess represents a great loss of life and widespread invahdity. It also causes financial loss to the Commonwealth, not only indirectly in many ways, but directly by the payment of invaUd pensions. Eleven per cent, of aU pensions, and nearly one-fourth of all pensions paid to persons under 40 years of age, were made necessary by tuberculosis. A total of 3,381 pensions was paid on account hi tuberculosis between 1910 and 1915. If pensions were paid to each individual on an average for six months (which is probably less than the average period), it appears that this disease has in five years cost the Commonwealth Government, in this way alone, approximately £44,000., In view of these facts, your Committee submits that a campaign should be inaugurated to secure a great reduction in the mortaUty and invalidity caused by tubercle in the Commonwealth. Your Committee is of opinion that the ideal of complete eradi- cation of tubercle should be taken into serious consideration. It is often said that tuberculosis discharges a useful function in weeding out the, unfit. Such sayings are idle and mischievous. The incidence of tubercle is not confined to the weakly and the unfit. The strong are not exempt if the dose of infection is^sufB,ciently large. Great numbers of the most promising young folk are swept away. The tax on early woman- hood and on men in middle fife is very severe. The incidence on children should be still further reduced, and the large measure of success already attained in connexion with tuberculosis of children should encourage us to aim at equal results in aU periods of life, and at the nearest possible approach to complete ehnaination of the disease. THE TUBERCULOSIS PROBLEM. The tuberculosis problem has within recent years received much careful study by authoritative bodies. The principal reports which directly concern Austraha are — 1. Report by the Conference of Principal Medical Officers on Uniform Measures for the Control of Consumption in the States of Austraha, 24th April, 1911. 2. Final Report of the Departmental Committee on Tuberculosis in the United Kingdom, March, 1913. . 3. Report of the Advisory Board as to the best methods of dealing with Tuberculosis, New South Wales, 10th June, 1913. These three reports deal very completely with the whole question in its theoretical and practical aspects, and your Conamittee does not consider that any advantage would result from considering in detail the ground already so adequately covered. No attempt wiU therefore be made in this Report to do more than present a summary of the principal aspects, and indicate certain directions in which further efforts might usefully be made. Introduction from other Communities. The Commonwealth is in an especially favorable situation for accurate information on this subject. During the year 1914, 3,574 deaths were registered as being due to tuberculosis in all forms. These may be classified as follows : — ■ Born in the Commonwealth . . . . 2,582 or 72 • 2 per cent. Resident in Commonwealth — 20 years or over 483 or 13-5 jj 15-20 years 31 or '8 j> 10-15 „ 40 or 1-1 >> 5-10 „ 62 or 1-7 )) 2-5 „ 121 or 3-3 99 Under 2 years 106 or 2-9 n B 2 20 These figures are sufficient to estabHsh the fact that immigration has not witMn recent years at any rate played an important pait in the production of tuberculosis in the Commonwealth. . . . . Your Committee recognises that already certain administrative machinery is in operation by medical inspection in England and on arrival at all ports of the Common- wealth to prevent the further introduction of infective tubercular individuals, but as your Committee considers that the idea of the complete eradication of the disease should be contemplated as Bfeing not entirely visionary, it is urged that these admimstrative measures be made as efiective as possible for the prevention of the immigration of consumptives. Any stimulus of migration consequent upon the return to peaceful international relationships wiU necessitate care in this direction. Inheritance. Tuberculosis is very seldom transmitted directly from either parent to the child at any stage before birth. The notion of direct inheritance of actual tubercular disease is one which has long been popularly entertainfed, but precise experience and investigation have shown that cases of children having been born with the disease actually present at the time of birth are very rare. In an investigation in Copenhagen it was shown by tests that of 317 new-born infants not one was tubercular. Only 51 cases of undoubted congenital tuberculosis are on record ; all occurred with mothers who showed exacerba- tions of tuberculosis during the last months of pregnancy. The popular conception of inherited infection has its origin in the numerous instances of family incidence, i.e., several members of a family developing the disease. It is well known that some species of animals have a much greater resisting power than others. Certain human beings are endowed with a low resisting power against tuber- culosis, and it may be that they transmit this low resistance to their duldren. This hypothesis has frequently been advanced, but no reliable evidence either in support or otherwise is known to your Committee. Inherited low resistance must be considered as a possible factor, and one which should be made the subject of further study. A second explanation of special family incidence consists in unfavorable family environment, which doubtless accounts for much that is attributed to inheritance. A third and far-reaching explanation of family incidence is that of direct personal infection. The members of a family in which a case occurs are exposed to infection from that case to a much greater extent than other persons ; and clearly the probability of " family infection " is great. An infant in arms being nursed by a tubercular mother is in very great danger of becoming infected by that mother — ^the danger amounts in practice to certainty. An investigation in HoUand^into a large number of actual cases of tuberculosis showed that amongst 1,510 patients — (a) The actual source of infection was undiscovered in 488. (6) In 823 (54*5 per cent.) the infection was acquired beneath the parental roof, (c) In 199 the source of infection was said to be the husband or wife, feUow- workers, friends, servants, boarders, persons nursed, or, in 30 cases, residence in an infected house. The very high percentage of family infection is especially notable. The factor of inherited resistance should be further investigated, but, as a matter of practical reform, steps should be taken to reduce family infection to a miniTmiTn, The importance of such infection in relation to the total numbers of cases of tuberculosis and the measures that should be adopted to deal with it are indicated at a later stage in this Report. Infection from Animals. Undoubtedly infection of human beings from animal sources has been very common, and still is more prevalent than it should be. Bovine animals infect through milk and imperfectly cooked beef, while pigs infect through imperfectly cooked pork. These phases of the tuberculosis problem have been very thoroughly discussed in many official reports, and the principal facts are now well understood. Reference has already been made in this Report to the improvement in New South Wales in the years following on the introduction of the Dairies Supervision Act, and similar experiences have been 21 recorded elsewhere. One of the important facts recorded by the British Eoyal Com- mission on Tuberculosis was that, not only does a cow showing visible external lesions of the udder secrete tubercle bacilli in the rmlk, but a cow which is afEected by internal generalized tuberculosis may also, and frequently does, secrete tubercle bacilli in the milk. This was experimentally shown by the inoculation of a cow with tubercle bacilli. The bacilli were injected into the neck, and at the end of the first week the milk was infected enough to produce tubercle in guinea-pigs, and at the end of 30 days the cow died with generalized tuberculosis. Professor Delepine, of Manchester, working on the basis that examination of the milk supply of the city would afiord a valuable indication of the presence of tubercular danger, obtained very interesting results. By careful examination of the milk supply in Manchester, and adequate steps on the discovery of any infected source of supply, the percentage of mixed milk samples {i.e., milk as supplied to the public) found infected with tubercle bacilli in Manchester has been reduced in ten years from 17-2 to 5 "14. The bovine type of bacilli is especially responsible for tubercular affections of the glands, the bones, and the joints. In Edinburgh 20 per cent, of samples of nulk infected guinea-pigs with tuberculosis, and in Edinbxirgh the bovine type of bacilli has been found to be abundant in tubercle of the cervical glands. In the investigations carried out on behalf of the British Eoyal Commission, 20 per cent, of tubercular bones and joints were found to be due to tubercle bacilli of the bovine type. There can be no doubt concerning the damage done, especially to young chUdren, by tubercular infection of the bovine type from milk, and these childhood infections are of the kind which renders them in their early life cripples or chronic invalids, living many years dependent upon charity or upon pensions for their existence. The methods of control are well enough defined, and it is not necessary to rehearse them in detail. Your Committee strongly urges that all sources of milk supply should be thoroughly investigated, and that all recognised methods of control should be brought into operation without *delay. That a great deal can be done in the direction of reducing bovine tuberculosis is evidenced jby the decrease in the amount of tuberculosis in cattle slaughtered in Melbourne. In the Melbourne City Abattoirs careful notes of the numbers of cattle afiected with tuberculosis in 1884r-5 were kept for the Board appointed to inquire into Tubercu- losis in Cattle, and it was fotmd that 5*6 per cent, were so afiected. In the same abattoirs in the years 1912, 1913, 1914, 1915, the following total figures were recorded : — Cattle. Calves. PtgS. Tear. Total Examined. Tabeiculai. Total Examined. lubeiculai. Total Tubercular. 1912 1913 1914 1915 79,370 92,890 102,425 79,961 875 899 1,187 650 14,682 16,197 16,930 17,181 6 5 5 4 25,883 15,255 11,765 17,522 237 132 98 339 Totals 354,646 3,611 64,990 20 70,425 806 Percentage 1-01 ■03 1-14 It is satisfactory that the total percentage of tubercular cattle (and this includes all cases of tuberculosis in any degree) has fallen within the 30 years from 5"6 per cent, to 1*01 per cent. It should be possible to reduce the amount to a fraction of that now prevaUing. The low percentage of tuberculosis amongst calves is especially noteworthy. It would appear that in New Zealand, no such improvement has been recorded. Dr. Gilruth reported in 1906 for the three years ending March, 1905, that the percentage of animals found tuberculous was as follows : — ^Fat bullocks and heifers, 3 -7 ; cows, over 10 ;■ pigs, nearly 4. Yet the human rates in New Zealand are lower than those in Australia. 22 Relative Importance op Human and Bovine Infections. The Britisli Royal Commission on Tuberculosis, which published its Final Report in 1911, examined very carefully the question of the relative importance of human and bovine infection in the production of various forms of human tuberculosis. Their results may be analyzed as follows : — • rorm. Hnman. BoTiue, Mijted Bovine and Human. Total. Pulmonary tuberculosis Generalized tuberculosis . . Tuberculous Meningitis Bronobial gland tuberculosis ■ Cervical gland tuberculosis Primary abdominal tuberculosis Joint and bone tuberculosis Tuberculosis of tbe — Testicle Kidney Suprarenal capsule 40 3 3 3 6 13 13 1 1 1 2 3 14 2 2 1 42 3 !3 FB f9 29 , 14 1 1 1 ■ 84 19 5 108 It is thus seen that of the total of 108 cases of human tuberculosis investigated 84 yielded human tubercle bacilli only, nineteen jdelded bovine tubercle bacilli only, and five both bovine and human tubercle bacilli. Of 60 cases of human tuberculosis (not pulmonary phthisis) fourteen, or nearly one in four, gave the bovine type. Considering the cases other than pulmonary tuberculosis, the distribution is as follows :— Human origin . . . . . . 44 * Bovine origin . . . . . . 17 Mixed origin . . . . . . 5 Ot 28 alimentary cases in children exactly half gave the bovine type. Concerning tubercle of bones and joints, Eastwood and GrrifS.th recently reported that out of 261 cases, 196 gave the human type of bacilli,f55 gave the bovine type, and 16 gave atypical forms. fJcmrnal of Hygiene, XV., 257.) The lesson to be learned from the results of careful scientific research, extending over ten years, is that most of the tuberculosis affecting parts of the body other than the lungs is due to infection from a human source. But a considerable proportion is, nevertheless, due to infection from bovines, and the principal vehicle for the infective material is milk consumed in childhood. From the point of view of the payment of pensions by the Commonwealth, it is of some practical importance to note that tuberculosis of the lungs, and tuberculosis of bones and joints formed the only important tubercular groups amongst the causes of invahdity. The findings of the Royal Commission indicate that infection of human origin is the only form of infection that needs practical consideration in connexion with tubercle of the lungs, and is the most common form in tubercle of bones and joints.^ / ' *But it must be remembered that the minimum age for receipt of pensions is sixteen years, and the damage done by bovine infection is mostly accomplished before that age is reached. ^ "^' In 212 specimens of phthisical sputum Dr. A. S. Griffiths found standard human bacilli in 205, atypical human in four, and standard bovine in three. In 736 cases tested by foreign observers only three gave bovine bacilli, and in two of the three human bacilli greatiy preponderated. ' '\ '^f pOr. A. Ghon, from fost-mortem examinations of babies and children in Vienna, found that a primary infection of the lungs represents the usual form of tuberculous infection in Vienna, even in the young. Evidences of Widespread Infection with Recovery. Various observers have demonstrated the very ^reat frequency of small tubercular deposits which have occurred in persons with sufficient resisting power to overcome these incipient infections, and to so surround the deposits of tubercle bacilli with healing tissue that they are rendered innocuous. When the widespread probability of tubercular 23 infection is considered, it ia not surprising that many persons receive the infection, although this infection does not, fortunately, in the majority, progress to manifest disease. The Germans have a sort of proverb to the effect that " Every man has eventually a trifle of tuberculosis." Naegeli found that 98 per cent, of the persons on whom he made fost-martem examinations showed some sign of old or present tuberculosis. The cutaneous test introduced by Von Pirquet has been used to demonstrate that a very large proportion of persons are infected in slight degrees in early childhood. A s imil ar test has been employed with the conjunctiva of the eye. In Vienna, Hamburger and Monti showed that 95 per cent, of children who attained the age of eleven to sixteen years had been infected. Dr. Albrecht, in Vienna, made carefu post-mortem examinations in 3,213 children, and found evidences of tubercular infection in 1,060, or 33 per cent. Sir Harry AUen, in his experience as Pathologist to the Melbourne Hospital, has found that in a large proportion of the patients dying from other causes there are evidences of old slight tuberculous infections, such as local adhesions at the apex of the lung, or pigmented thickenings in and beneath the pleura near the apex, or definite apical scars with or without encapsuled dry caseous or calcified relics beneath the scar, or traces of calcification in bronchial glands. Calcified mesenteric glands are relatively unconunon. It is possible that in overcoming these slight infections, a sort of vaccination takes place, so that the power of the system to react against tubercle is increased. While there is no direct evidence available, apart from the results of the skin and conjunctiva tests, to indicate whether these minor and healed infections are mainly contracted in early life or widely distributed throughout the years of life, yet from the various facts, such as that recorded by Albrecht, that children show not more than 33 per cent., the curves of age-incidence given by Brownlee and quoted above, and the varying ages of onset of symptoms, it may be presumed that these infections occur frequently throughout the years of life. TTie two alternative means of preventing such infections are (a) so to deal with the sources of infection as to render them non-infective ; (b) so to treat all persons that their resistance is raised to such a point as to prevent infection occurring. The various aspects of these two alternatives wiU be dealt with in some detail later in this Report, but an indication may be given of one possible field of research which may be found to give good results. Protection by prophylactic vaccina- tion has now been foimd to afford a very complete measure of protection against many of the infectious diseases, and although a satisfactory vaccine for tuberculosis has not yet been discovered, there is no reason why such should not be discovered in the near futirce, and used particularly for the protection of those'whose family ties or daily duties involve'their exposure to infection. Control of Humai^SoubcesTop Infection. It is universally agreed that the person with an " open " focus of tubercular infection in the lung, who disseminates massive quantities of tubercle bacilli during coughing and expectoration, is the most serious element of danger in the spread of tuberculosis. This has been so abundantly demonstrated that it can be accepted without reservation. A very careful study of groups of families with and without a known tubercular member was made in Minneapolis, TJ.S.A. The results of this investigation are very striking, and they are the more striking in that they are not only not unique, but are typical of the results of similar investigations in many other places. They are recorded by the investigator, Dr. H. T. Lampson, as follows : — " I conclude from the above studies, first, that the spread of tuberculous infection in families where open cases of tuberculosis exist is greater than it is generally understood to be. Sixty-seven per cent, of the individuals of these families, excluding the centre cases, show evidence of tuberculous infection. In no case where there has been definite proven exposure of a family to an open case of tuberculosis, no matter what precautions have been taken, have I failed to find a spread of infection. In at least ten cases investigated, the infection has spread to the limit of available material. Every member of these \en families shows evidence of tuberculous infection. 24 Second, that in families where no cases of tuberculosis have been found, no matter what the home life or living conditions were, the number of individuals showing evidence of tuberculous infection was small, namely 2^ per cent. Third, that in families where cases of latent tuberculosis exist, the spread of infection is not as great as in families where open cases of tuberculosis are found — 22 per cent, against 67 per cent. Fourth, that in families where healed cases of tuberculosis are present, the spread of infection is less than in families where open cases exist — 33 per cent, against 67 per cent. Fifth, that in families where no tuberculosis is found, the number of individuals showing evidence of infection is very small (2^ per cent.) in comparison with the families in . which open, latent, or healed tuberculosis exists." The British Departmental Committee in its Final Report states the position as follows : — " One of the priacipal sources of danger at the present .time is the existence of a number of persons in the more acute and advanced stage of the disease living in the intimate contact with their families and neighbours which is necessitated by -the ordinary conditions of, their lives." The results of the investigation in Holland should also be recalled in this relation {see page 20). These summarized results of a particular investigation in a limited field may weU be taken as a summarized statement of the whole tuberculosis position. Milk and meat do produce tuberculosis — ^principally of the glands, bones, and joints — but the amount of tubercidosis so produced, as compared with the direct transmission by infection from man to man, is relatively of minor importance. The International Congress on Tuberculosis heldj)at Washington, U.S.A., in 1908, adopted the following resolution : — " That the utmost efforts should be continued in the struggle against tubercu- losis to prevent the conveyance of tuberculous infection from man to man as the most important source of the disease." We have therefore the fundamental fact, that infection from man to man is the principal method of spread of the disease. Not only is this true, but the general deduc- tions from the Minneapolis investigation are also true in general. They may be broadly stated as follow : — 1. Where there is not much expectoration and not much excretion of tubercle bacilli there is not much infection of surrounding persons. 2. Where there is greater dissemination of tubercle baciUi in expectoration there is much greater amount of infection. This spread of infection is seen at its maximum in such instances as those ten families m which every member was infected. When these two generalizations are considered along with these other two, viz., (1) that in families where there is no tubercular focus a very small amount of infection is found, and (2) that in no case where there has been definite proven exposure of a family to an open case of tuberculosis, no matter what precautions have been taken, did the investigator fail to find a spread of infection, it is clear that while bovine control should be strictly observed, yet the spread of tuberculosis is dependent upon infection of one person by another principally at short range, and that the elimination of tuberculosis is primarily a question of the discovery and control of these infective persons ; and it is also clear that protective treatment of those who are constantly in contact with the infective persons is essential to success. In 1902 an investigation was carried out by Dr. W. P. Norris and Dr. E. Robert- son,Sof the Victorian Health Department, into the conditions associated with the cases of tuberculosis whose deaths were reported during 1902. It was found during thidiin- vestigation that in 30 per cent. ,of the cases, a history of intimacy or relationship with^an already infected person was obtained, the great majority of these cases being those of females wbo had assisted in tending and nursing persons suffering from pulmonary tuberculosis. In Melbourne City during 1915, investigation was made into 179 cases of tubercu- losis reported during the year — A history of previous consumption in members of the family was obtained in . . . . . . 23 or 12 ■ 8 per cent. There had been a history of previous consumption in the house in which the patient was living at the time of investigation in . . . . . . 4 or 2*2 per cent. There was a history of having lived with a consump- tive in . . . . . . . . . . 17 or 9 • 5 per cent. There was a history of having been associated with a case of tuberculosis at the place of employment in 4 or 2*2 per cent. Total in which there was an admitted possibility of direct personal infection .. .. .. 48 or 26*7 per cent. In 1909 all cases of pulmonary tuberculosis reported during that year to the Central Board of Health in Western Australia were investigated as carefully as possible. It was shown that in 34 per cent, of the cases there was sufficient evidence to justify the conclusion that the disease originated by direct exposure to infection from another case. < During an examination of miners in Western Australia in 1910, 65 cases of tubercu- losis came imder notice. In these cases 50 per cent, gave a clear history of close contact with cases of tuberculosis. At this point it might be well to recall that infection may be acquired not only in the home, but in the factory or office, the lodginghouse, or in the mine. Above all other sources, infection is acquired in the home. Necessity for Notification. A knowledge of the existence of infective foci is an essential to any organized attempt to reduce the amount of tuberculosis in any community. Notification indicates where danger of infection exists and where measures of control should be brought into operation. Notification is the fire-alarm of sanitation. In the control of tuberculosis the notification of a case should at once be followed by (a) effective precautions to prevent further infection spreading from the patient ; (6) minute examination of all contacts to detect early infection in any person, and appropriate measures for the cure of any early infections so detected. While notification is essential, it is necessary in order that it should be successful that it should be regular, systematic, and rigidly eniorced. It would not be unreasonable to extend existing legislation so far as to require all registrars of death to report deaths from tuberculosis (and the same provisions might apply to other infectious diseases) to the health authority, so that the completeness of notification during life might be checked, and, incidentally, the necessary precautionary measures of disinfection and cleansing. It is also advisable that all forms of tuberculosis should be notified, as cases of non-pulmonary tuberculosis are often the first danger signal indicating an open case in the family. Isolation of Infective Persons. The first step of importance to be taken after the discovery of the infective person is to render the spread of infection impossible. No objective less comprehensive than this should be contemplated. The patient in the early stage, who has few bacilli in his expectoration, may be dealt with along the lines of scrupulous personal cleanliness— lines which are now well established for the tubercular person, such for example as the careful collection and disinfection of all sputum, coughing into paper handkerchiefs, and so on. These measures are very generally adopted, and may succeed; but, in view of the results of the Minneapohs inquiry, where it was found that infection occurred in every instance of exposure to an open case of tuberculosis, no matter what precautions were taken, the success of these measures^ — thitherto accepted as reliable — ^might well be carefully investigated. It would, in any event, be safer to insure, in every instance where it is possible, that the patient be removed to an institution where trained supervision is constant and leliable. 26 The more advanced cases, emitting massive doses of infection at every paroxysm of coushing, are the real fans et arigo malorum of tuberculosis. The unanimity of opimon as to the desirability of insuring the segregation of such persons is evidenced by tHe following expressions of opinion by very authoritative bodies :— The Conference of Principal Medical Officers resolved— " Legal power should be given to the Central Health Authority to remove dangerous consumptives into segregation on the order of a police magistrate, given after private hearing, on application of the Central Health Authority." The British Departmental Committee expresses itself unnaistakeably— " The Committee desire, therefore, to recommend, as an effective means of preventing the spread of the disease, the compulsory isolation of certain cases which are in a state of high infeotivity, particularly in those instances where the patients' surroundings are such as to increase the risk of other persons becoming infected." The New South Wales Advisory Board expressed the same conclusion — "In cases of tubercular phthisis, where the surroundings of the patient, owing to poverty or other reasons, cause home nursmg to_ be against the interest of the patient or" the community, the medical practitioner under whose care he may be shall cause to be sent to the Board of Health a specimen or specimens of the sputum of such patient, and if the presence of tubercle bacilli in the sputum be demonstrated, shall notify him as being in an infectious state, and that home nursing in the interest of the patient and community cannot be efficiently carried out. The Board recommended that legal power should be given to remove such cases for efficient care and treatment on the order of a magistrate." It has been repeatedly affirmed by the most reliable authorities that no one immediately practicable measure ofiers so great promise of material reduction in the tuberculosis rate of a community as that of the provision of hospital accommodation for advanced cases. Such provision offers not omy the definite advantages presented by segregation as limiting the extent of infection, . but there is additional value to be. gained by the education of patients in matters of personal hygiene and in methods for preventing the spread of infection. Provision foe Cueativb Treatment also Necessary, The isolation of advanced cases is essential, but experience has shown that it is iiot desirable to mix those early cases who offer a reasonable prospect of cure with those whose disease has so far advanced that the prospect of cure is remote. Many cases in the early stages will be notified by the medical attendant, and a large proportion of these will be so circumstanced that they could not obtain the necessary institutional treatment except at the public expense. The investigation which should automatically follow upon notification will reveal in many families incipient cases of tuberculosis of the lungs, of the glands, and of the bones and joints. Many of these also will require institutional treatment. For this large group the type of institution now familiarly known as sanatoria ia required. The functions of these institutions may be summarized by stating that in them the patients are taught how to regulate their personal habits of food, clothing, general habits, and cleanliness, so that their resisting and recuperative powers are built up and they are placed under the best conditions for nature to effect a cure. They go to sanatoria for cure and for education, and the cure rests mainly upon education. So true is this that it is practicable to discharge many before the cure ia effected, theic education having progresaed to a stage at which they may be trusted to continue their own cure and prevent the infection of others. They are taught what to eat and what not to eat ; what form and amount of exercise to take ; when and how to bathe ; to avoid alcohol and tobacco ; what clothing to wear ; what undesirable habits to give up and what desirable habits to cultivate ; and above all what precautions to take so that ptherg may not suffer infection by their carelessness. 27 Kesults of Sanatobium Treatment. Dr. Kinghorn, of the famous Saranac Lake Sanatottmn, stated that " any patient, taken in time, is practically sure of being cured." That such complete optimism is not justified is shown by the results obtained under very good conditions at the i'rimi.ey Sanatorium in England. The Frimley Sanatorium was associated with the well-known Brompton Hospital, in Loi].don. The cases at this sanatorium were all transferred after examination at the Brompton Hospital. The cases were not chosen at random, still less was every case at Brompton passed on to the Frimley Sanatorium. On the contrary, the cases sent were carefully selected, only those patients being chosen who were free from fever or other serious constitutional symptoms, who possessed considerable vitality and had already begun to show signs of improvement. So far as possible, also, patients with signs of limited disease were preferred, although it was found that patients with disease extensive, but of a quiescent type, often did remarkably well. Another important point borne in mind, in selecting cases at Brompton to be sent to the sanatorium, has been the UkeUhood of the patient obtaining work upon his discharge from the institution — since it early became apparent that if the patient had no work to return to after leaving the sanatorium, he Would almost certainly relapse quickly through inabUity to obtain adequate nourishment. These circumstances, therefore, combined to afford conditions such that the sanatorium should achieve the best results |)0Ssible. What were the results obtained ? The period of investigation was from March, 1905, to December, 1910, and cases were followed up after their discharge. Anaong 690 patients 55 • 9 per cent, were well and able to work at the end of the fourth year following that in which they were discharged. At the end of the fifth year 48 • 4 per cent, were in the same condition. " These results compare not unfavorably with those relating to the German Sanatoria in which patients are treated under the provisions of the Invalidity Insurance Law. Nevertheless, in view of the jjareful selection of cases for the Frimley Sanatorium, it was hoped that a larger percentage would have retained their health. It must be remembered, however, that in many cases the patients have not had work to return to after leaving the sanatorium, and too often this has meant a return to unsatisfactory home conditions and insufficient food, with consequent relapse. " There can be no doubt that to insure the maximum benefit from sanatorium treatment, efficient after-care and supervision are essential," It was also found that lasting benefit is more likely to follow when the patient comes under treatment in an early stage of his disease than when large areas of lung are already involved. Sanatoria then, while accomplishing much good, are yet so far from perfect and complete in their results that more attention should be paid to measures of prevention than to those of treatment. Sanatoria fail fou the reasons that the cases enter when the disease is advanced, and that cases cured or materially improved must frequently return to ap unhealthy environment, and often find themselves unable to earn a sufficient income, Farm Colonies, Dr. A. A. Brown has quite recently drawn attention to the fact that this difficidty is encountered in Victoria also. He expresses the results of his oWn experience at the Gte^ttirare Sanatorium ^ aS'l f oUows :— " The care and treatment by the State of consumptives, especially early cases, is a praiseworthy undertaking, but the present method stops far too short of securing permanent benefit to the afflicted. Whatever gdod results have been achieved at Sanatoria, it is quite possible that a great many cases will again relapse, because the surroundings to which the patients return on leaving the Sanatorium are quite unsuitable towards fostering and maintaining the cure or benefit received during residence at the institutions. To continue the benefits of treatment received at Sanatoria and to train patients in country work, a farm colony* in association with a guiding institution is an indispensable factor." Such farm colonies, carefully designed, and under wise direction, have beeOi very valuable adjuncts to the other means for treating tubercular patients. 28 Australian Experience. With these facts before us it is of interest to ascertain with regard to Australia- (1) What special institutional accommodation exists for— (a) segregation of advanced cases; (6) treatment of early cases. (2) The results of treatment in sanatoria. New South Wales. Accommodation — Waterfall State Sanatorium— (a) Division for males . . . . 230 beds. (6) Division for females . . . . 120 beds. Queen Victoria Homes for Consumptives — Wentworth Falls, for males . . . . 54 beds. Thirlmere, for females .. .. 54 beds. E. T. Hall Sanatorium . . . . . . 16 beds. Results of treatment : — State Sanatorium at Waterfall, for the year ending 30th June, 1911— Disease arrested . . • • 39 Much improved . . . . ■ • • • 52 Slight improvement . . . . . . 55 No apparent benefit . . . . ■ • 29 ^\ ■ ' 175 Died 108 Total 283 Victoria. Accommodation — {a) For early cases — Greenvale Sanatorium . . . . 100 beds (70 male, 30 female). Amherst Sanatorium (female cases only are taken here) . . . . . . 62 beds. (&) For advanced cases — Heatherton Sanatorium . . . . 90 beds (60 male, 30 female). Austin Hospital . . . . . . 120 beds. ' It is interesting to note that experience shows that the institutions for advanced cases are always full, whereas the sanatoria for early cases frequently have empty beds. There are also some private sanatoria concerning which information is not available. Results of treatment : — No statistics are of great value for Victoria, as it is the 'practice to keep patients in the sanatoria for periods of three mionths only, largely for educational purposes. The average duration of stay is about 70 days. The value of the education is largely discounted by the fact that patients have, in many cases, to return to very unsatisfactory surroundings. With these reservations the following figures are given for the years 1913-1914 :— Total sanatorium cases . . . . . . 940 At time of discharge — Regarded as cured . . . . . . 52 Improved No apparent benefit Disease progressed Died 199 146 164 357 29 South Australia. Accommodation — For early cases — Kalyra Sanatorium . . . . 52 beds For advanced cases — North. Terrace Consumptive Home, ad- ministered in connexion with the Adelaide Hospital . . . . . 68 beds Results of treatment at Kalyra Sanatorium for the years 1914-1915 : — Remaining on 1st July, 1913 . . 46 Condition on discharge : — Admitted up to 30th June, 1915 .. 262 Disease arrestedj. ., 46 .Improved . . 146 Unimproved] . . 80 Died .. ..Nil Remaining on 30th June 36 "308 "308 Tasmania. Accommodation — For early cases — New Town Sanatorium . . . . 37 beds For advanced cases — Consumptives' Home, New Town . . 15 beds Particulars of cases at New Town Sanatorium for the years 1915 and 1916 : — Remaining ia hospital at beginning of Discharged . . . . 68 year . . . . . . . . 16 Remaining . - . . 32 Admitted during year . . . . 84 100 100 Results of treatment : — • Arrested • . . 38 Greatly improved Unimproved Left for other reasons .. »8 12 10 Queensland. Accomm odation — For early cases — Dalby Sanatorium 62 beds For advanced cases — Diamantina Hospital . . Dunwich 60 beds ... 35 beds Results of treatment Dalby Sanatorium for year ended 30th June, 1916 : — Arrested . . . . . . 12 Improved . . . . . . 39 Condition Unaltered . . . . 45 Total .. .. .. 96 Western Australia. Wooroloo Sanatorium has 300 beds for both early and advanced cases. The results obtained from treatment are not immediately available. The total number of beds available in Australia specially for tubercular cases is 1483, It is not practicable to divide this accommodation specifically into tha,t for early cases, and that for advanced cases, as some institutions — e.g., Wooroloo Sanatorium, inJWestem Australia --admit both classes without reserving any special number of beds for either class. No account is taken of beds which may be available in general hospitals and other similar institutions, but even allowing for this factor, it is clear that the accommodation available in Australia for tubercular cases falls far short of requirements, and at least twice the present accommodation should b^ provided. Probably even this would be insufficient. so Dispensaries. It is clear from what has been said above that in the campaign against tuberculosis the foremost place miist be given to early detection of sources of infection (which implies notification rigidly enforced), effective measures to prevent further infection from such persons (which implies segregation or in other cases adequate precautions), and careful search amongst contacts for incipient cases (which implies a dispensary system). The dispensary system was instituted by Sir Robert Philp, of Edinburgh, with the object of providing a cleariag houscj as it were, for cases of tuberculosis. The principal functions of such a dispensary are — (1) Cases of tuberculosis are seen and divided into groups. Those requiring sanatorium treatment are sent to sanatoria ; those requiring surgical treatment in hospital sent to hospital ; some are treated in their own homes ; while provision is made for advanced cases in hospitals and other institutions. (2) Advice on all matters connected with tuberculosis is freely given to any appUcant. (3) Very careful instructions, suited to the needs of each individual case, are given concerning all the precautions that should be taken both for their own health and for the safety of those around them. (4) The home of each patient is visited to see whether the house is healthy and the methods of family hfe hygienic. Where unhealthy conditions , are found the health authorities are notified. (5) Not only does the dispensary be^n the supervision of the treatment of the consumptive, but it continues its supervision over them after improvement or cure — ^preventing relapses, finding suitable employ- ment in farm colonies specially instituted for the purpose, and doing any other similar action to encourage and maintain the improvement resulting from the treatment. (6) The dispensary concerns itself also with the financial status of the patients, and uses its influence to provide material relief for those whom illness has brought to poverty. (7) It acts in conjunction with the educational authorities, removing children found to be infected from school, and taking them away from conditions of school life which are detrimental to Siem. It. also arranges for open-air schools for consumptive children. (8) The principal function of the dispensary may, however, be said to be its prospecting work. From the centre-point of the patient who presents himself for advice and treatment the dispensary authorities start investigating his contacts— in the family, in the school, in the factory or office— but principally in the family. In this way they discover the early cases — ^the curable cases. Every such case removed from his environment and treated represents not only a case probably cured, but the removal of a person who at a later stage would develop into an active focus of infection. It would not be out of place to have a law requiring that when a case of tubercu- losis is notified every member of that patient's family must be examined, and the results of the examination reported to the health authorities. A necessary corollary to this would be the provision of suitable treatment for those found to be infected. But all countries are now coming to recognise the absolute necessity for providing means for suph treatment. Such a dispensary organization would require the necessary hospital accommoda- tion, necessary sanatorium accommodation, suitable centres for examiuation at which all patients could get the advantage of skilled advice. In order to enable all persons to have the advantage of the advice, evening chnics on one or two evenings weekly would be necessary. Visitiiig nurses to visit patients' " contacts " in their homes would be an essential part of the organization, and complete co-operation with the health authorities alone can produce the sanitary improvements which will inevitably be found to be necessary. Co-operation with the registrars of death is also necessary in order to secure information concerning persons who have died from tuberculosis and whos» tubercular condition was not previously known to the authorities. 31 Bureau for Co-ordination of Administrative Measures and for the Promotion OP Research. Tixe provision of sanatoria for the treatment of those whose condition offers prospect of cure ; the necessity for taking such measures as will prevent the spread of infection from advanced cases ;* the very valuable part played by tubejjculosis dis- pensaries in any tuberculosis campaign, particularly by the detection of early cases, have aU been indicated. But the vital part of any scheme against tuberculosis is the central control and co-ordination of all these various activities. Each local centre should be made aware of the experience gained in any direction by other local centres ; it should carry out investigations into special subjects of interest ; and it should act as the centre for all educational movements in connexion with the attempt to eradicate tuberculosis. In other countries private or semi-private agencies have established such dispensaries and central bureaux, but in Australia the most suitable arrangement would be for the Health Departments to establish the Central Bureau as a branch of their own organization and for them to co-ordinate and direct this work. Unfortunately, however, it must be admitted that too often the oflScers in Health Departments do not fetthe encouragement and financial assistance necessary to preserve the enthusiastic ^sire to improve the health of the people with which they often start their administrative career. No campaign against tuberculosis, or any other disease, can hope to be successful unless the responsible Governments are prepared to set aside the necessary money, and are prepared to support whole-heartedly the efforts of their officers to inaugurate and successfully carry out a systematic scheme of operation. What may be done is evidenced by the work of two institutions. The Tuberculosis Dispensary in Edinburgh begun by Sir Robert Philp in 1887 has had a striking success in the reduction of the tuberculosis death rate in Edinburgh. The Henry Phipps Institute was founded by Mr. Phipps in 1903 to carry on " the study of the cause, treatment, and prevention of tuberculosis and the dissemination of knowledge on these subjepts ; the treatment and the cure of consumptives." The work done by this institute is not only administrative in character along the lines of a tuberculosis dispensary, but there is carried out also a scheme of research of that intensive variety which is most productive of valuable results. In Melbourne the Health Department has a Tuberculosis Bureau, which has a somewhat limited sphere of application. A nurse is attached to this Bureau, which is open every day, and patients attend to the number of from four to ten daily. Patients are not seen by a medical man at the Bureau, but are directed to certain hospitals or medical men for examination and certification. This Bureau could, doubtless, be extended in scope with advantage. In Sydney several tuberculosis bureaux are in operation or are projected. Tuberculosis and the Invalid Pensions Act. In an earlier portion of this Report reference has been made to the number of persons brought by tuberculosis to a condition in which they are permanently incapable of earning their own living. Cases are known to your Committee in which other members of the family have become infected from the pensioner. The receipt of the pension may be sufficient to prevent the sufferer entering an institution, thus retaining him as a permanent focus of infection within the home. In this way the payment of pensions may actually be the payment of premiums for the spread of tuberculosis. Those infected by the pensioner may be an ever-increasing liability upon the finances of the Commonwealth, as it is probable that some, if not all, of the children so exposed to infection will ultimately become claimants for pensions in their turn if they do not die before reaching the minimum pension age. Such a condition of things is economically unsound, and it would be wise, policy for the Commonwealth Government to consider means for the removal of the infective persons to an environment in which they could do no further harm. Segregation. You^ Committee suggest that it would be economical as well as humane for the "Comnionwealth Government to provide or arrange for the provision of sufficient hospital accommodation in the various large centres of population for the treatment of advanced cases of phthisis who are in receipt of pensions. 32 Your Committee is of opinion that legal power should be given to order the removal to hospital of any such case, as it is obvious that any claimant for pension will be m such financial circumstances as to render adequate precautionary measures impossible. _ Your Committee, however, is strongly of the opinion that payment of the pension to the invalid should] continue notwithstanding the maintenance provided by the Governmeht in the shape of hospital accommodation. Even if legal power of isolation is not taken by the Commonwealth Government, your Committee still would recommend strongly that adequate hospital accommodation be provided, and^that phthisical persons in receipt of invalid pensions be induced to take advantage of this provision. In addition to such provision by the Commonwealth Government, it is recom- mended that other Governments responsible erect hospital accommodation for advanced cases, so that there may be available a bed for every advanced case of tuberculosis in the State concerned. Such institutions could be widely distributed in small units, and experience has shown in Australia that there is no necessity to build costly structures, comparatively inexpensive buildings having been found to be quite satisfactory. It has been repeatedly afi&rmed by the most reliable authorities that no one immediately practicable measure offers so great promise of material reduction in the tuberculosis rate of a community as this one of the provision of hospital accommodation for advanced cases. Quite apart from the definite advantages presented by segregation as limiting the extent of infection, there is a great value obtained by the education of patients in matters of personal hygiene and in methods for preventing the spread of infection. The existing provision in Australia falls very far short of the requirements necessary at this moment, and your Committee urges that such hospital accommodation should be immediately provided. The Obligations of the Pensioner. The Invalid Pensions Act at present involves no recognition by the pensioner of any duty to the community in return for the care the community gives him. It would surely not be unreasonable for the community to demand that the patient should exercise proper precautions to prevent the infection of others. The Common- wealth Government might well consider the advisability of making the payment of pensions conditional upon the observance by the patient of at least the more important of the precautions recognised as necessary, as, for example, sleeping by himself, using proper sputum cups, &c. Inquiry into Hygienic Conditions. Before, however, practical restrictions based upon rational principles can be imposed, it is necessary that full information be obtained concerning the conditions under which, as a rule, pensioners are living, and the extent to which they are infecting others. A preliminary investigation by competent inquirers into the circumstances associated with each of the cases dealt with under the Invalid Pensions Act for one year would form a useful commencement, and would, without doubt, indicate the directions in which further inquiries should be made. Infection prom Inanimate Objects. Before the infection of any person from inanimate objects, e.g., clothes, dust, bedding, &c., can occur, a necessary condition is that such objects must themselves have become in some way contaminated. Tubercular material cannot originate de novo, it must have originated from some living creature infected with the tubercle bacillus. Such creature may be either human or animal. It is probably correct to say that the animal hosts may in this connexion be ignored, and for all practical purposes it may be assmned that the contamination of inanimate objects, excluding meat and milk, is the direct result of the presence of some infective tubercular person in the environment concerned. If this person is not constantly present, but is a casual and unknown distributor of tubercular infection, then we have to deal with a -wide variety of circum- stances, some of which were indicated in the Report of the New South Wales Advisory Committee, e.g. : — {a) The handling of food in the course of manufacture, preparation, and packing by hunfan carriers of the disease. (6) Contamination of hotel rooms and bedding by casual occupants, (c) Contamination of pubUc vehicles in a similar way. {d) Contamination of a house which remains undisinfected whfii the tuber- cular person ceases to occupy, and acts as a source of infection for subsequent tenants. These matters involve two principal considerations — (1) The identification of the infective individual and the application of measures necessary to preveiat his continuing to act as a focus of infection. (2) The application of such routine administrative measures as wiU reduce to a minimum the chance of the persistence of the infectivity of inanimate objects contaminated by a casual unidentifiable infective person. The first of these resolves itself into identification (which is compulsory notifica- tion, combined with systematic examination in the case of certain industries) and isolation, either in his own home or in an institution, or employment in a way involving only minimum risks. The second includes in practice the whole range of sanitary administration, proper construction of houses, routine cleanliness in dwelling houses and houses for public accoromodation, routine disinfection of pubHc vehicles, of houses in which tubercular persons live or have lived, and so on. These are matters which have received so much attention that improvement can only be obtained by the perfection of the application of existing powers. In one respect, however, an advance on present practice might well be made. In New York the systematic medical examination of persons engaged in the handling ■of foodstuffs at any stage in the course of their preparation and distribution has recently been inaugurated, and this practice could be adopted with great profit in the larger towns in Australia. There is one very important aspect of this question. Tubercular persons are quite frequently carried on ship board as passengers, and are placed in the same cabin with other passengers, the cabin being used for further passengers without any measure of disinfection. This is a matter which your Committee considers should receive prompt and effective attention. Factors affecting the Progress op, or the successful Resistance to, the Disease in a Person who has received Infection. An indication has been given above of the extensive occurrence of healed early tubercular infections. The obvious interpretation is that many persons are infected at some stage in their life-history, but their resistance is sufficient for them to overcome the infection. Others, of course, have not sufficient resistance, and become tubercular patients. The two principal^factors concerned in the determination of the results for infection are — (1) Personal resistance of individual infected ; (2) Effect of environment on the health of the person. With regard to the comparative importance of either of these two factors very little can be said in the present state of scientific knowledge. An accurate study of the importance of either inherited or acquired predisposition in controlling or favouring the disease should be begun as soon as practicable. The. effect of environment is conceivably as manifold as the variations of environment experienced by different individuals. The principal features of environ- ment may, however, be discussed imder two principal headingST-Housing, and Social or Economic. " Generally speaking, a healthy, sober, weU-fed, weU-clothed, and well-housed community is far less liable to tubercular diseases than one in which disease and drinking habits are prevalent, whose members are inadequately fed and clothed, and in which houses are crowded and insanitary. It may be broadly stated that an advance in material prosperity of the commimity as a whole will be reflected in a decreased incidence of tuberculosis," (Report of British Departmental Committee on Tuberculosis, page 8.) F.11968.— 34 f It is clear that no complete consideration of all the aspects of so extensive a subject can be attempted in a Report such as this. Certain passages may, however, be quoted from the Report of the British Departmental Committee on Tuberculosis : — " Housing.— The Committee believes that much may be done to assist in preventing tuberculosis by improvement of the housing conditions in this country. There is no doubt that dirty, ill-ventilated, dark, damp, and otherwise insanitary houses are provocative of the disease. There is equally no doubt that the incidence of the disease is greater where famihes are crowded into one or two dirty, ill-ventilated rooms than where better conditions are obtainable, or where the rooms are kept clean and ventilated. The Committee fully realize the diflaculties surrounding the housing question, but they consider improvement in the present state of affairs both desirable and possible." Newsholme also produces evidence to show that the index • of total poverty agrees closely with the index of tubercle. Your Committee is of the opinion that there is no need in this Report to discuss this aspect further. The methods of rectification of structural defects or of overcrowding are established both from legal and constructional points of view. Your Conamittee, however, strongly urges that more complete legal power should be provided for, and greater freedom of action allowed to executive ofl&cers of local authorities to require minor structural alterations in dwelling houses where such are necessary to remove conditions of defective hygiene. Overcrowding is one of the most important factors in the tuberculosis problem. It is, however, not merely a question of the Umitation of the numbers of persons inhabiting a given space. It is entirely involved with, and dependent upon, economic conditions. Upon this phase of the tuberculosis question, the British Departmental Committee expressed itself as follows : — | " There is great need for research work in connexion with the social and " economic causes of tuberculosis. The present knowledge on the subject, though increasing rapidly, is inadequate, and it is highly desirable that more information should be obtained, and that the iniormation when obtained shovdd be sifted and co-ordinated so as to serve as a reliable basis for the preparation of remedial measures. Inquiries should be made into the causes which operate so as to give rise to the existing occupational incidence of tuberculosis, and into local and other factors which have a bearing on the problem of the distribution of the disease." As, an illustration of the difficulties existing at present in assessing the relative values of economic factors may be cited the interesting fact ehcited during the inquiry by Dr. Norris and Dr. Robertson above referred to. During this inquiry the financial condition of the families concerned was ascertained, and it is recorded that " in 50 per cent, the barest dietetic necessities were available, and the possibility of even relative isolation practically nil. In a large proportion of these cases the assistance of charity alone enabled the patient to be maintained at home." Interesting as this is, it leaves undetermined the question whether the tuberculosis was determined by the poverty or the poverty by the tuberculosis. A great deal of investigation is necessary along these lines, and your Conunittee considers that very valuable work can be done by systematic investigation of these various economic aspects. The machinery of administration of the Invalid Pensions Act offers exceptional facilities for the conduct of such an inquiry, as one of the greatest difl&culties usually met with in such an investigation of tubercular persons, viz., migration of individuals with loss of continuity, would not be experienced — ^the regular payment of pensions enabling the investigator to keep constantly in touch with the persons under supervision. Such an investigation is immediately necessary in order to determine the direct relationship between tuberculosis and social economic conditions. There is, however, another field of inquiry. Any worker who is obliged to perform his daily duties under conditions of improper ventilation, Hghting, heating, or in the presence of any other departure from adequately hygienic environment, will suffer by some departure from normal health. While such depression of general health has definite relationship to tuberculosis, it has also a very important bearing in other forms of invalidity. 35 It appears to your Committee, therefore, very necessary that an organized scientific study of the various phases, of industrial hygiene should be commenced, and that the study of this subject should be continued and extended as industries develop and the ' directions of useful extension come to be indicated. One phase of the economic question has received a great deal of attention within recent years, the amount of tuberculosis amongst persons engaged in certain trades, especially mining and metallurgical operations. The figures quoted in an earlier portion of this Eeport show clearly the excessive amount of tuberculosis in the Bendigo District of Victoria. This is naturally attributed to the efiects of mining. But it is interesting ' to find that the Victorian Government Statist, from an analysis of the cases of pulmonary tuberculosis notified under the Health Act between 1909-1911, concluded that the incidence of the disease among females in Bendigo was somewhat heavier at most age- groups than that for the metropolitan area, while among males it was considerably heavier, especially at older ages^ In Bendigo, many miners past middle|life, sufiering irom chronic respiratory diseases, subsequently die from tuberculosis. It has been weU determined that the " chronic respiratory diseases " referred to are directly associated with and may almost be said to be to some extent an integral part of the occupation of mining, but it has not yet been satisfactorily determined to what extent tuberculosis may be regarded as the concomitant or the direct consequent of such " chronic respiratory disease." This is also a matter to which further attention might well be given. The Strain on Young Adult Females and on Males at Later Periods of Lieb. The statistical evidence in the earlier portion of this Report shows clearly the great incidence of tuberculosis upon the young woman and on the man whose powers should be ripening to their fuU in early middle-age and on the man in later Kfe. The Victorian Government Statist explains the greater frequency of attack in young women by the fact of the increased proportion of females engaged in manufacturing industries. Your Committee is not prepared to accept this hypothesis without reservation upon the evidence available ; but it is clear that tuberculosis is attacking an unduly large pro- portion of young women and of men in middle and later life. This fact is of the utmost importance to the Commonwealth, and aU factors contributing to this result, whether industrial or otherwise, should be carefully and closely investigated. Nutrition in the School-life Period. An inquiry concerning the health of London school children was summarized in The Lancet of 9th January, 1915, page 85. On entry to the schools, 10*8 per cent, of the boys and 9 • 8 per cent, of the girls showed poor and bad nutrition. On leaving the school the rates were decidedly worse, being 14*7 per cent, of the boys and 14-3 per cent, of the girls. The statistics varied greatly in different districts even among those containing great numbers of poor people. Even in the same district, the figures might be very (Afferent for boys and girls. In Bermondsey the percentage of ill nutrition on entering school was 5 '6 for boys and 5*0 for girls ; but at leaving time it was 28*5 for boys and 29 '6 for girls. In Hammersmith the percentages for entrant boys and girls were identical — 5 • 6 ; but at leaving school the rates were — ^f or boys, 7 • ; for girls, 12-0. It would be well if the medical inspectors of school children in Australia were supplied with definite standards of nutrition, and if a watch were kept on the changes in nutritional percentages during the period of school life. Of 2,000,000 children examined by school doctors in Great Britain in 1910, 1 per cent., and in some districts 4 per cent., had tuberculosis in a readily recognisable form. 36 RECOMMENDATIONS. 1. There are many factors associated with the occurrence and spread of tubercu- losis that require careful, study — (a) The reasons for the marked variation in death rates from year ^ year, as between the different States, and between the sexes, should be sought for, and any evidence likely to throw light on the special ■ features of tuberculosis in Australia should be carefully examined. (6) An attempt should be made to ascertain whether heredity, ?)er se, plays any part in the actual transmission of tuberculosis, or whether it has any large effect in the production of lowered resistance. (c) Careful scientific investigation of the extent of the occurrence of bovine infection of humans in the Australian community should be under- taken by the laboratory examination of material from actual cases of tuberculosis. (d) Laboratory examination of public milk supplies, on lines similar to those adopted in Manchester to determine the extent of infection dis- seminated by this means amongst the commimity, could profitably be undertaken. (e) Carefully recorded results of fost-mortem examinations noight well be kept, so that very definite evidence should be available as to the amormt of healed minor tubercular infections which occur amongst the Australian community. (f) There is a wide range of bacteriological, pathological, and personal phenomena which require investigation. Such investigation could only be carried out in prtfperly-equipped laboratories. The above aspects of this important question should be -made the subject of research ; but this research should not be haphazard. It should be co-ordinated ; it should be thoroughly well-equipped financially ; and every inducement should be offered to suitable graduates to devote their career to these fields of research, which often produce practical results of the most far-reaching importance to the community. While these aspects are important, there are two other phases which are 6i equal and, perhaps, of more immediate importance — ' (g) It is vitally necessary that accurate information, carefully compiled, concerning the cases actually occurring in the Commonwealth should be obtained and studied. Administrative action may be based upon the experience of other communities, and this may be successful ; but it is obviously more reasonable to expect success from measures based upon knowledge of what actually is occurring among our own people. It is important to ascertain how our tubercular cases become infected, to what extent they are infecting others, what economical or social factors have assisted towards the development of their disease. This is the only way to obtain that accurate knowledge which is the indispensable foundation of successful action. {h) Industrial factors should be very carefully studied. One pertinent question might be put to illustrate the importance of this phase of the problem : Can quartz-mining be carried on without tuberculosis ? This question is not yet settled ; but there is reason for believing that by the exclusion of tubercular patients from mines, mining can be carried on without any associated tuberculosis. This might well be carefully investigated. The amount of tuberculosis associated with other industries also requires study, with the object of determining whether such association is merely a matter of coincidence or is definitely an attribute of the industry. In the latter case remedies should be sought. The hypothesis of the Victorian Goyernment Statist that factory employ- ment is responsible for tuberculosis amongst young girls should be very carefully examined — ^as it is, if well-founded, of the greatest importance. 37 V n ^.®f ^s^*y f?^ careful study of these two groups of questions is self-evident, lour Lommittee considers, However, that in the present conditions of national stress too much should not at first be attempted. Such a study should proceed carefully and gradually along well-ordered lines. J i^ J A preliminary investigation by competent inquirers into the circumstances associated with each of the cases that are dealt with under the Invalid Pensions Act would ±orm a useful beginmng for such an inquiry, and the results of such inquiries during one year would, without doubt, point out the directions in which further inquiries should be made. 2. Administrative measures should be adapted to the knowledge and experience already available. It can hardly be said that advantage is being taken of all those methods of control which have been found to be valuable. These can be adopted more widely than at present, can be tested to determine the suitability of old-world methods to Australian conditions, and can be modified and improved in the light of the experience so gained. (a) Bovine Tuberculosis. — The system of inspection of dairy cattle already in operation in certain districts in some of t)ie States can be extended and improved. Municipal and city milk supplies merit a very great deal more attention than they receive at present, and advantage might well be taken of the Manchester method to examine these public supplies with special reference to tuberculosis, and to effect a decided improvement in this direction. (&) A considerable extension of the machinery for the control of human infection is necessary. The number of beds available for advanced (i.e., infectious) cases is very inadequate, and it is probable that an early increase in the number available would result in a definite and rapid decrease in the numbers of new cases arising. Considerable extension of the dispensary system is required, with the object especially of detecting the early cases before they reach the stage when they are infective for others. A necessary corollary to this is the provision of sufficient sanatoriuin and hospital accommodation to afEorda bed for every early case, not only of pulmonary tuberculosis, but also of the crippling bone, joint, and gland infections. The close investigation of the hygienic conditions of the home and of the place of education or employment are of the utmost importance in any campaign against tuberculosis, and stiU more important is the necessity for executive powers to effect immediate rectification of such defects as are discovered. Such investigation and such new powers would produce great results throughout the whole range of sanitary work, and would exercise a profound influence in the control of tuberculosis. SUMMAEY. The above recommendations may be summarized briefly as follows : — 1. Greater need for co-ordinated investigation both in the laboratory and in the field concerning the many phases of tuberculosis as yet undeter- mined ia Australia, but particularly concerning the modes of spread of the disease. 2. Necessity for making fuller use of those methods already proved valuable, particularly — (1) Milk control. (2) Segregiation of advanced cases. (3) Sanatoria for early cases. • (4) Dispensaries for investigational and local co-ordination, (5) Central bureau for co-ordination and direction of]'(l), (2), (3) and (4). 3. Necessity for strict enforcement of ordinary sanitary principles in the home, in the school, in the office, in the factory, in the mine, and everywhere. 38 The Coimnonwealtli Government has an extensive financial responsibility on account of tuberculosis under the Invalid Pensions Act, and it would be an economical, as well as a humane, policy for the Commonwealth Government to consider any means of efEectively assisting towards the ultimate ideal of the eradication of the disease in Australia. Accordingly your Committee makes the following suggestion : — That the Commonwealth Government co-operate with the State Government concerned in a vigorous campaign against tuberculosis in a selected locality in which it is more than ordinarily prevalent. The mining centre of Bendigo offers an exceptionally suitable field for such a cam- paign, affording as it does opportunities for attacking not only the general problem of tuberculosis in a municipal community, but also the special problem of tuberculosis in mines. The Commonwealth and the State working in co-operation could put into operation all those methods of control known to be useful elsewhere, and could establish their general value or discover modifications necessary for the conditions encountered in Australia. An attempt might with quite reasonable hope of success be made to reduce the tuberculosis death rate in that district by half within five years. It would be necessary to provide a laboratory for examination of sputum and minor investigational work, a hospital into which advanced cases should be encouraged to go, a sanatorimn for early cases, a dispensary for consultations and as the centre of administration for the campaign, a small staff of visiting nurses and two or perha/ps three supervising medical o£S.cers. The active assistance of the city health staff would be required. Such a scheme, the details of which could be easily elaborated, would serve many useful purposes ; but it would particularly serve as a practical experiment on a large scale, and would indicate the measures which might usefully be applied elsewhere in Australia. Provision for financial assistance to families while the breadwinners were receiving treatment might also be found necessary. The lack of medical men might cause some difficulty in bringing such a scheme into full operation during the war, but a commencement might well be made at once in certain essential directions. We have the honour to be, Sir, \ Your obedient Servants, H. B. ALLEN, Kt., M.D. J. H. L. CUMPSTON, M.D. A. JEFFEEYS WOOD, M.D. JAMES MATHEWS, M.P. (Chanman). 39 APPENDICES. Tuberculosis— Death Rate per 100,000. England and Wales. New South Wales. Victoria. Queensland. South Australia. Western Australia. Tasmania, • Year. rf bi &i >.4 >.■§ d bl flu S si 2J . 3"^ « S'B S 4"^ S §"3 U « O M °i 11 5 2 o S ^ Q § g ^ a IS s% § g ^ S O g :3 M ^-S Sxi ® § 9 K o i I.S o i SS °i S s o i i£ o 3 Is %& Is ^S fiS gg h ■ %i II 4 is g| Is 5l 1870 241 74 124 ■. 5 35 •1 .. 97- J 17 •4 .. 1871 234 71 114- I 31 •6 .. . 83- 3 10 •1 .. 1872 223 70 116 •, 3 32 •1 .. 76- 1 16 •8 .. 1873 220 71 123 •' I 34 •5 108 •0 26 ■0 78-. 5 16 •9 .. , , 1874 209 70 130 •( ) 37 •2 110 •7 24 •4 89 ■( ) 26 •3 .. 1875 220 79 105 48 •4 130 •' 1 47 •6 140 •9 32 ■7 100-' 1 20 •2 .. 1876 211 9 74 101 ■4 42 •9 126 -i i 41 ■9 148 •0 22 •2 105 •. 3 17 •4 .. 1877 207 9 76 93 ■0 42 •5 134 •( 3 38 •6 119 ■0 31 •7 87- 1 '19 •0 .. , , 1878 211 1 81 97 •8 38 •3 136 -f 3 34 ■2 132 •7 18 ■1 109- J 21 •6 .. , , 1879 202' 1 74 106 •6 34 •3 126- 3 29 •7 138 •5 20 •7 104 -i 3 23 •9 ^.. , . 1880 186 9 83 108 •0 31 ■7 138 •. 2 37 •5 144 •6 16 •8 101 ■. 5 24 \. , . 1881 182 5 70 5 113 •2 32 •0 138 •( ) 33 •0 134 •9 23 •1 97-' t 22 •7 .. 98- 8 5 ■1 1882 185 73 114 8 28 •2 143 -i 2 33 174 35 •3 117- d 21 •1 .. 103- 2 9 •2 1883 188 71 1 112 •3 32 •1 133 -i 2 30 ■1 180 •1 48 ■5 105 •. 3 20 •2 .. 112- i 11 •4 1884 182 7 74 7 113 6 35 •7 145 •' J 32 •3 196 4 49 •1 105 -i 3 22 5 .. 114- 4 5 ■6 1885 177 66 3 116 •3 41 144 ■( 3 36 •4 191 8 71 •1 99-. 3 19 .. 111- 1 4 •6 1886 173 9 73 7 108 •4 46 •3 139 •( 3 36 •2 152 2 61 •6 113 •( ) 16 9 .. 101- 5 8 •4 1887 161 5 67 1 97 2 41 •3 153- I 38 •3 128 •9 68 •6 112 -i 2 12 6108- 9 16'"- 5115- 4 7 •4 1888 156 8 65 6 100 •9 45 144 •( i 35 •3 136 •8 59 •8 117 -f 3 15 4 93- 5 11- 4 84- 2 12 •4 1889 157 3 68 8 96 •1 40 •2 144- I 40 •5 125 •5 55 •8 92 •( 3 18 2 87- 1 2- 2 86- 5 20 ■7 1890 168 2 69 6 93 ■4 33 •3 145 •( i 39 133 ■1 53 •2 95 •< ) 18 ■9 91- 3 10- 6 96- 3 13 •9 1891 159 9 70 4 92 •2 35 •0 129 •. J 41 •8 126 •4 44 •4 102 \ 2 20 5 96- 3 3- 9 90- 5 11 •4 1892 146 8 67 1 86 •5 28 •8 135 •' ) 33 •6 104 4 43 •9 93 •( ) 21 5 84- 2 7- 1 85- 6 19 •9 1893 146 6 67 7 88 •8 31 3 134- I 29 114 •8 46 •8 99-, 3 20 •5 71- 2 11- 3 91- 1 17 •9 1894 138 3 58 8 84 •9 29 •9 131 •. } 27 ■3 105 41 •9 102 •( 3 17 ■8 72- 3 8- 1 93- 7 9 •2 1895 139 5 66 7 81 •2 27 •1 132 •. 3 29 •6 96 •2 32 •7 95 •( 5 20 •2 62- 6 15- 3 75- 4 20 •1 1896 130 3 58 7 80 •8 27 •8 120 •' r 30 •2 99 ■1 36 •1 87-' t 21 69' 9 13- 4 71- 9 15 •9 1897 133 6 59 74 •7 22 •5 116 ■' 1 30 ■8 91 ■2 30 ■3 87-' t 15 58- 5 14- 1 83- 5 21 •6 1898 131 1 59 •9 82 •9 26 •1 128 •; ) 34 ■5 89 ■7 35 •1 89 •( 3 14 1 69- 13- 4 75- 2 31 •2 1899 133 57 4 80 •2 24 ■5 112 •' 3 30 ■7 84 6 37 •4 87- I 18 7 67- 6 15- 4 59- 2 28 •1 1900 133 3 56 •9 79 ■5 18 •1 116 -i 2 31 1 87 1 32 4 82 -f 3 15 5 78- 2 15- 4 61- 9 20 •3 1901 126 4 54 ■3 85 •8 17 •1 117 •( 3 31 5 85 1 36 6 84-^ t 12 5 80- 2 5- 8 58- 5 15 ■0 1902 123 4 50 8 83 •0 18 •9 116 •( 5 25 9 89 7 31 7 82 •{ ) 14 6 71- 3 17- 3 59- 3 31 •3 1903 120 6 54 1 90 •6 18 •6 110-' ) 29 78 1 27 4 83-5 2 14 9 65- 5 12- 7 62 •( 3 14 •9 1904 124 1 54 3 82 ■2 15 •0 111-] L 31 1. 78 5 17 8 81 •( ) 14 2 84- S 7- 5 62- 2 23 •4 1905 114 6 49 3 71 ■3 14 8 101 •! ) 28 2 75 15 3 77 -f ) 11 1 65- S 11- 3 72- 3 17 •3 1906 115 7 49 7 68 7 15 8 98 ■{ i 27 3 67 3 13 2 84 ■{ ) 15 1 83- 7 ■ 8- 2 64-. 5 11 •9 1907 114 8 46 9 64 3 17 95 •{ i 20 9 64 4 7 9 81 •{ 3 17 9 85- 3 13- 3 62-, 2 21 •6 1908 112 3 47 2 66 16 5 95 •£ ) 20 62 4 9 5 100 -C ) 11 9 84- 1 13-. 5 77 -f 3 14 9 1909 109 1 44 6 67 3 12 9 84 -J J 19 2 58 7 8 2 89 -C ) 12 6 75- 5 12-, 5 66-' J 16 2 1910 101 5 41 9 65 4 11 9 83 •( ) 17 6 50 8 7 81-4 t 18 3 74- 3 11 •( ) 67". 5 13 6 1911 106 2 40 6 66 10 5 83 ■< ) 18 6 55 6 10 9 68 -C ) 17 9 63 •! 3 14 •( 5 62 •( ) 23 6 1912 101 7 34 9 62 10 80-; 5 15 4 51 6 10- 7 74-5 ! 15 4 71-. 3 13-: 2 59-' ) 19 8 1913 98 35 9 66 9 12 9 75 -f ) 15 6 53 6 5 73-: i 16 3 63 ■( 3 10- I 54 •{ ) 19 4 1914 63-6 9-7 72-4 [ 14- 42- 8 6- 8 63-f 12- 9 70- I T' I 44 -f 3 13-1 4D Deaths from Tubercular Diseases. England and Wales. New South Wales. Victoria. Queensland. South Australia. Western Australia. Tasmania. Year. Is ll OS ^1 ii 11 i PhEH is' li d ID i 1 1 1870 54,231 16,694 * * 888 250 * * 179 32 * * * * 1871- 53,376 16,266 , * * 841 233 * * 156 19 * * * * 1872 52,589 16,256 * * 876 242 * * 146 32 * * * * 1873 51,355 16,496 * * 945 264 145 35 153 33 * * * * 1874 49,379 16,596 * * 1,011 289 163 36 179 53 * * * * 1875 52,943 19,042 614 283 1,027 375 228 53 208 42 * * * * 1876 51,775 18,036 616 259 1,010 334 260 39 229 38 * * * * 1877 51,353 18,850 585 267 1,088 312 225 60 203 44 * * * * 1878 52,856 20,321 643 252 1,124 281 263 36 269 53 * * * * 1879 51,272 18,788 736 237 1,058 248 281 42 271 62 * * * * 1880 48,201 21,427 787 231 1,175 319 301 35 275 65 * * * * 1881 47,541 18,363 866 245 1,199 287 292 50 274 64 .* * 115 6 1882 48,715 19,309 917 225 1,274 294 404 82 341 61 * * 123 11 1883 50,053 19,009 941 269 1,212 274 471 127 313 60 * * 137 14 1884 49,325 20,157 1,003 315 1,359 301 572 143 323 69 * * 143 7 1885 48,175 18,046 1,078 380 1,384 348 593 220 307 59 * * 142 6 1886 47,872 20,276 1,051 449 1,375 357 494 200 339 52 * * 142 11 1887 44,935 18,661 977 415 1,557 389 441 235 343 39 46 7 154 10 1888 44,248 18,514 1,045 466 1,528 372 492 215 365 48 42 5 116 17 1889 44,738 19,567 1,025 429 1,571 442 470 209 289 57 39 1 121 29 1890 48,366 19,833 1,029 367 1,631 436 515 206 304 60 43 5 1.38 20 1891 46,515 20,475 1,053 400 1,483 479 501 176 329 66 49 2 134 17 1892 43,323 19,770 1,018 339 1,581 391 423 178 307 71 47 4 129 30 1893 43,632 20,167 1,069 377 1,572 340 476 194 338 70 44 7 137 27 1894 41,641 17,722 1,042 367 1,548 322 446 178 356 62 53 6 142 14 1895 42,490 20,287 1,016 339 1,567 350 420 143 335 71 57 14 116 31 1896 40,251 18,106 1,027 353 1,428 357 444 162 308 74 83 16 113 25 1897 41,642 18,353 964 290 1,375 364 418 139 308 53 87 21 135 35 1898 41,335 18,857 1,088 342 1,520 408 421 165 317 50 113 22^ 125 52 1899 42,408 18,312 1,069 327 1,339 364 407 180 312 67 114 26 101 48 1900 42,987 18,369 1,077 245 1,387 371 427 159 299 56 137 27 107 35 1901 41,224 17,706 1,173 234 1,416 379 427 184 302 45 151 11 101 26 1902 40,671 16,725 1,152. 263 1,412 314 458 162 292 52 146 35 104 55 1903 40,132 17,975 1,275 262 1,341 350 402 141 296 53 144 28 113 27 1904 41,851 18,354 1,174 215 1,342 376 410 93 289 51 198 18 114 43 1905 38,950 16,809 1,037 215 1,235 342 397 81- 279 40 162 28 134 32 1906 39,746 17,095 1,020 234 1,213 335 361 71 307 55 213 21 119 22 1907 39,839 16,262 976 258 1,195 261< 350 43 301 66 218 35 115 40 1908 , . . 39,499 16,581 1,021 255 1,209 253 346 53 378 45 217 35 146 28 1909 ~ 38,639 15,786 1,062 203 1,087 246 335 47 346 49 199 33 127 31 1910 36,334 14,983 1,057 193 1,078 229' 296 52 325 73 203 30 129 26 1911 39,232 13,856 1,099 175 1,108 246 342 67 280 74 183 42 118 45 1912 38,083 11,961 1,078 174 1,087 209 326 68 313 65 215 40 115 38 1913 37,055 12,409 1,210 234 1,052 217 346 43 318 71 200 32 107 38 1914 * * 1,178 180 1,031 199 289 46 280 57 227 24 89 26 Information not available. Printed and Published for the Government of the Commonwealth of Australia bv Albfrt t MtTrr^™ Governmenl Printer fnr thi- Stnf. «^f Vi,.f„r;- '■ ■>" ™"LLETT, GoTeinment Printer for the State of Victoria. Graph 1. 1914 1914 Death-rates from Tuberculosis per 100,000 of population for each year from 1870-1914. Pulmonary Tuberculosis . . Other Forms of Tuberculosis Graph 2. ^^ 1^ d >^ 00 /' .' CO o oo"-* «= oo oo o o o X >^ "^ \ ^.y^ ^^ ■ [f^ ) 1 ' \ u \ ^•>. ^ >^ ' •* -^. •^ »^ *>. ^ "N -^ *>. '\ , ■■ .' - ■ < s \ \ / \ / K , l\ J / V "* ' , / / / \ ' ^ - \ ■• / / • / \ \ * / • \ \ \ \ \ . ^ \ \ / \ / \ ' r 1 y 1 y^ ' / 1 > / / / / / / / ^ / •■ ^^^^^ y ^^^^ y ^ "^ ^ ^^^^^ ^ ■ • • ^^ ^ N . 1 ■ Death-rates for the Commonwealth from all forms of Tuberculosis per 100,000 of population at various ages for the years 1909-1913. MALES .. \ FEMALES .. Graph 3. 25 20 15 10 5 25 20 15 10 5 30 25 20 15 10 :\ 5 35 30 25 20 15 10 5 35 30 25 20 15 10 5 20 15 10 5 0-15 15-20 20-25 25-35 35-45 45-55 55-65 OVER 65 ,-' ^^ "'— , -^ "-. 4f / ■*-.s • ^ CEN! 5US YE AR 186' 3-2 jj^S.^.'-^ \. / y/ ^^— -< /' Z,,.''^ CEN SUS Y ;AR 187 0-2 z ^^ ^ / /'' "■•■■ --- \. / * / CENS US YE, ^R I88C -2 ^ ^ - j^ V \ . .^^ ^ \ ^^. o .;>^ CENSV JS YEfl ' Y ' .^ rrr ^^^^ ^ :^ ■^ ■ '--. ^ENSU 3 YEAF I900- 2 ,--;; xr ~-*^ - ^ c ENSUJ YEAR I9IO-1 .^ 1-1 cvi CM en <* in g Tuberculosis in Victoria in Census Years. Death-rates per 10,000 of population for each sex in Age Groups. MALES FEMALES Graph 4. ALL FORMS OF TUBERCULOSIS. . ^-i Annual Death-rates among ' Persons of all Ages in N.S.W. V" '■ 1876 78 9801 2348567 89901 S849567 890012840667 8910128 415 1.9 : , 1.9 1878 78 9801 2848667 89901 284 96 67 89001 234 06 6 7 8910128 416 MALES FEMALES TOTAL ^^y^^y-y-y^^^^V^^J-yt^^^^ ii.t.tt. GoaernmenI Statislieian. Graph 5. ALL FORMS OF TUBERCULOSIS. Annual Dea^h-rates among Persons of all Ages. METROPOLIS AND COUNTRY. 1876 78 9801 2848567 89901 3349567 800012340567 89 10 123 4 15 U76 78 9801 2348667 89901 2 849667 890012340687 8910123 415 Metropolis— MALES „ FEMALES Country— MALES FEMALES Government Statistician. ii.a.16. , Graph 6. LowooN tuRwey VfewKSHiRe LawcashiRe NottTM Walcs South Wales Cogrinv/»n.L * Graph 7. SHgTCAWO 1880 » 1900 ■ 1880-1890 ■» LOWPOW W80-