COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX0003051 1 1 BUREAU OF THE CENSUS S. N. D. NORTH ^ DIRECTOR TUBERCULOSIS IN THE UNITED STATES PREPARED FOR THE INTERNATIONAL CONGRESS ON TUBER- CULOSIS, WASHINGTON, SEPTEMBER 21 TO OCTOBER 12,1908 DEPARTMENT OF COMMERCE AND LABOR liiMifliLiltiittiillliik^MMlM Columbia Wini\}tv&itp N^O in ttje Citp of J^etn gorfe College of l^i)v^itian^ anb burgeons ^titvtmt llihvavp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/tuberculosisinunOOunit PROPORTION OF DEATHS FROM EACH SPECIFIED CAUSE IN THE REGISTRATION AREA 1907 PhOI0-t.'IMOGR*PHE0S WASMiNGTON D < BUREAU OF THE CENSUS S. N. D. NORTH ^ DIRECTOR 1 UBERCULOSIS IS THE UNITED STATES ^ PREPARED FOR THE INTERNATIONAL CONGRESS ON TUBER- CULOSIS, WASHINGTON, SEPTEMBER 21 TO OCTOBER 12, 190S DEPARTMENT OF COMMERCE AND LABOR 8—1413. V. 8. No. 109. CENSUS PUBLICATIONS ON MORTALITY STATISTICS SINCE 1900. TWELFTH CENSUS. Vital Statistics, Part I — Analysis and Ratio Tables. Vital Statistics, Part II — Statistics of Deaths. Bulletin No. 15. A discussion of the Vital Statistics of the Twelfth Census. [The last of the series of decennial reports. The data are for the census year end- ing May 31, 1900, and are based upon enumerators' returns from the nonregistration area and upon transcripts of deaths from the registration records, chiefly, for the registration area. Succeeding reports are for the calendar years and relate to the registration area only.] PERMANENT CENSUS. Mortality Statistics, 1900 to 1904. Five years in one volume. Mortality Statistics, 1905. Sixth Annual Report. Mortality Statistics, 1906. Seventh Annual Report. Mortality Statistics, 1907. Eighth Annual Report. In preparation. PAMPHLETS. No. 71. (Circular) Registration of Deaths. No. 100. Legislative Requirements for Registration of Vital Statistics. [Out of print See Nos. 71 and 104.] No. 101. Practical Registration Methods. No. 102. Relation of Physicians to Mortality Statistics. No. 103. Medical Education in Vital Statistics. [Out of print.] No. 104. Registration of Births and Deaths. No. 105. Statistical Treatment of Causes of Death. No. 106. Extension of the Registration Area for Births and Deaths. No. 107. Modes of Statement of Cause of Death and Duration of Illness upon Certifi- cates of Death. No. 108. Legal Importance of Registration of Buths and Deaths. No. 109. Tuberculosis in the United States. Manual of International Classification of Causes of Death. NOTE.-Any publications now in print may be obtained upon application to the Director of the Census. fiufaeniment Prtetlng mSut u^?, CONTENTS. Page. Letter of transmittal — 7 Vital statistics are the foundation of sanitary science 8 Letter from President Roosevelt accepting the presidency of the International Congress on Tuberculosis 9 Introductory H Purpose of tlie Census H Vital statistics dependent upon enumeration of population 11 The beginning of vital statistics 11 Success and failure of state registration laws 12 Present constitution of registration area for deaths 12 No registration area for births 14 Attempted national mortality statistics 14 Extension of the registration area 15 How the Census aids 15 L— Some Facts in Regard to Tuberculosis in the United States from THE Mortality Statistics op the Census 16-36 Mortality statistics of the Census indispensable 16 Sources of tables 16 Statistics for 1907 16 The nature of tuberculosis 17 Tuberculosis (all forms) 17 Mortality of the United States from tuberculosis 17 No exact statement possible 18 The President's estimate 18 High mortality of the colored race from tuberculosis 19 Sparsely settled areas 20 Understatement of tuberculosis in returns of deaths 20 Difficulty of securing correct statements of deaths from tuberculosis 21 discussion op tables. Decreasing death rates from tuberculosis 22 Overstatement of tuberculosis in early statistics 22 "Proportional deaths " 23 Need of fully comparable international statistics of causes of death 23 Death rates of foreign countries 24 How tuberculosis kills 24 Various forms of tuberculosis 24 Comparison of statistical classifications 25 Influence of sex 25 City and country 26 Death rates at certain age periods 27 Age distribution of deaths from various forms of tuberculosis 27 Economic loss from tuberculosis 28 Estimates of pecuniary loss - 28 (3) 4 CONTENTS. Page. I. — Some Facts ix Regasd to Tubeecclosis ix the Uxixed States frou THE MoRTALiTT STATISTICS OF THE CENSUS — Continued. Economic value of life 29 Average age at death. 30 Incidence of tuberculosis upon the most productive ages 31 Westergaard's life table, excluding tuberculosis 31 Relative importance of tuberculosis and other diseases 32 Relative frequency of deaths fi-om tuberculosis by states 34 Color 34 Conjugal condition 34 Relative prcA'alence of tuberculosis by classes of occupations 35 Rates of tuberculosis for specified occupations 35 Occupations most subject to tuberculosis 35 Death rates from tuberculosis i^all foiTos) by states and cities, 1907 36 II. — The Work of the Bureau of the Cexsus ix Vital Statistics 36-41 Relation of the Census to registration 36 Duty of undertaker, relative, and attending physician 37 Duty of local registrar 37 Duty of state registrar 38 Transcripts for the Census 38 Compilation by the Census 38 Requisites for accui'ate mortality statistics 39 Chief difficulties in obtaining statistics of tuberculosis 39 Cooperation for extension of registration area 40 Resolution by the Congress of the United States 40 UnifoiTQ certificate of death to be adopted 41 UnifoiTii nomenclatui'e of diseases in prepai-ation 41 III. — Hovr THE IXTERXATIOXAl COXGEESS OX TUBERCULOSIS CaX PrOMOTE the Prevextiox of Tuberculosis bt Ixsistixg upox the Xecesstty for Complete Registratiox of Deaths Throughout the Uxited States : 41-45 Statistics of tuberculosis a part of general mortality statistics 42 COLLECTIOX OF STATISTICS OF TUBEECrXOSIS. Registration of deaths and notification of sickness fi-om tuberculosis 42 Complete statistics are essential 43 A. Indispensable importance of registration of sickness and deaths from tuberculosis 43 Preliminary' draft of resolutions proposed 43 Accurate and internationally comparable statistics of tuberculosis required. 44 B. Necessity for uniform statistical classification and accurate reporting of tuberculosis 44 Preliminary^ draft of resolutions proposed 44 REFERENCE TABLES. Table 1. — Death rates and proportional deaths (to all causes) from all forms of tuberculosis in the United States, Massachusetts, and England and Wales, for each, year since the middle of the last centmy 49 Table 2. — Death rates from tuberculosis of lungs in the registration area of the United States and in certain foreign coimtries (dui-ing recent years) : 1902 to 1906 52 Table 8. — Deaths, death i-ates, and per cent of deaths from the various forms of tuberculosis (International Classification) in the registration area of the United States (during recent years): 1902 to 1907 52 CONTENTS. 5 Page. Table 4. — Death rates, by sex, and as urban and rural, from tuberculosis of lungs for the registration states: 1900 and 1890 53 Table 5. — Death rates, by sex, for the registration area and registration states (aggregate, urban, and rural) from tuberculosis of lungs: 1900 and 1890 55 Table 6. — Proportional deaths from each form of tuberculosis (International Classification) at certain age periods for the registration area: 1900 to 1904 55 Table 7. — Relative importance of tuberculosis as a cause of death at specified age periods in the registration area, 1907 : {A) At all ages 56 (B) Under 15 years of age 56 (C) From 15 to 29 years, inclusive 57 (Z)) From 30 to 44 years, inclusive 57 (E) From 45 to 59 years, inclusive 58 (F) From 60 to 74 years, inclusive 58 (G) Over 75 years of age 59 Table 8. — Relative importance of tuberculosis as a cause of death in the regis- tration states: 1907 59 Table 9. — Death rates from tuberculosis of lungs of white and colored, by sex, for the registration area and registration states (aggregate, urban, and rural): 1900 and 1890 60 Table 10.— Death rates from tuberculosis of lungs, by conjugal condition, at certain age periods in the registration area: 1900 60 Table 11. — Death rates from tuberculosis of lungs and other important causes of death, by classes of occupations, in the registration states: 1900 60 Table 12. — Death rates from tuberculosis of lungs, for certain occupations of each sex iu the registration states: 1900 65 Table 13. — Death rates from all forms of tuberculosis in the registration area, its main subdivisions, the registration states, and cities of 100,000 population or over in 1900, for each year since the beginning of the annual reports on mortality statistics: 1900 to 1907 66 DIAGRAMS AND ILLUSTRATIONS. Page. Proportion of deaths from each specified cause in the registration area: 1907, colored diagram Frontispiece. Increase in the number of registration states: 1880, 1890, 1900, 1907, cartogram. 13 Standard certificate of death Facing 38 Facsimile of punched mortality card Facing 38 Death rates and proportional deaths (to all causes) from all forms of tubercu- losis in the United States, Massachusetts, and England and Wales for each year since the middle of the last century, colored diagram Facing 47 Consumption — Number of deaths per 100,000 of population for cities and rural districts in the registration states: 1900 and 1890, diagram 54 Consumption — Number of deaths per 100,000 of population, bj^- color and sex: 1900 and 1890, diagram 61 Consumption — Number of deaths per 100,000 of population by conjugal condi- tion and age periods, registration area: 1900, diagram 62 Number of deaths per 100,000 of population from specified causes in the principal occupation groups: 1900, diagram 63 Consumption — Number of deaths per 100,000 of population among persons 10 years of age and upward in specified occupations: 1900, diagram 64 LETTER OF TRANSMITTAL. Department of Commerce and Labor, Bureau of the Census, Washington, D. C, July 80, 1908. Sir: This pamphlet, the contents of which will form a part of the eighth annual report on mortality statistics for the year 1907, is published in advance of the complete preparation of that report in order that it may be of use to the International Congress on Tuberculosis at its session in this city from September 21 to October 12, 1908. No more important service can be rendered by mortality statistics than the compilation of data which will prove of practical assistance to those actively engaged in the prevention of disease. With the awak- ening interest of the public in sanitation there is arising an urgent demand, which should be met, that our mortality statistics shall be fully adequate for this important purpose. This pamphlet has been prepared by Dr. Cressy L. Wilbur, chief statistician for vital statistics of the Bureau of the Census. The diagrams, together with others contained in the Census exhibit, but not reproduced here, were constructed under the direction of Mr. C. S. Sloane, geographer of the Census. Very respectfully. Director. Hon. Oscar S. Straus, Secretary of Commerce and Labor. VITAL STATISTICS ARE THE FOUNDATION OF SANITARY SCIENCE AND ABSOLUTELY NECESSARY FOR THE PREVEN- TION OF TUBERCULOSIS. ^^Our Absurd Vital Statistics. — ^Vital statistics in this country are an infant science. Yet they are the very basis and foundation of any attempt to better the general health. Knowledge of what is killing us before our time is the first step toward saving our lives. The Census Bureau does its best to acquire this essential information." — Samuel Hopkins Adams in McClure's, July, 1908. '^Resolved, That the achievement of the registration of all deaths, with their causes, immediately after their occurrence, and the prompt retiirn of certificates from local registrars to the central bureau of "vital statistics, thereby giAdng the sanitary authori- ties of the state timely information of the exact prevalence and distribution of disease, IS THE MOST IMPORTANT OP ALL SANITARY MEASURES, AND SHOULD BE UNREMITTINGLY URGED UNTIL SUCCESSFULLY CARRIED OUT IN EVERY STATE OP THE UNION." — Associ- ated Health Authorities and Sanitarians of Pennsylvania, 1904- "Public hygiene is built upon, is controlled and directed by, and is everlastingly in debt to vital statistics. The might and the right to dnect the future of preventive medicine, to make and to terminate contracts, to approve and reject risks, to test materials and methods, to invest means and to distribute profits, these things belong inalienably to vital statistics. Eveiy wheel that turns in the service of public health must be belted to this shaft, otherwise preventive medicine must remain invertebrate and unable to realize the profits available from the magnificent offering of collateral sciences. If the unborn historian of hygiene in the twentieth centurj^ shall find one anomaly more curious than any other, it will be that the twentieth century, opening with prodigious resources, immediately available, ran a third or half its course before these resources became so standardized that each unit of power might be accounted for in a definite scheme of ^ital statistics." — Dr. John S. Fulton, then Secretary of the State Board of Health of Maryland, now Secretary-General of the International Congress on Tuberculosis, in an address, "Vital Statistics: A Plea for Actuarial Administration and Control of the Great Resources of Preventive Medicine," before the American Public Health Association, 1902. (8) THE INTERNATIONAL CONGRESS ON TUBERCULOSIS. LETTER FROM PRESIDENT ROOSEVELT. The White House, Wasliington, May 12, 1908. To Dr. Lawrence F. Flick, Ohairman, Committee on International Congress on Tuberculosis: Sir: It is with great pleasure that I accept the presidency of the ''International Congress on Tuberculosis" which is to meet in this city on September 21, 1908, and extend its session to October 12, 1908. Official duties, however, may prevent my presiding at the initial meeting of the Congress, in which case I will deputize Secretary Cortelyou. The importance of the crusade against tuberculosis, in the interest of which this Congress convenes, can not be overestimated when it is realized that tuberculosis costs our country two hundred thousand lives a year, and the entire world a million lives a year, besides con- stituting a most serious handicap to material progress, prosperity, and happiness, and being an enormous expense to society, most often in those walks of life where the burden is least bearable. Science has demonstrated that this disease can be stamped out, but the rapidity and completeness with which this can be accomplished depend upon the promptness with which the new doctrines about tuberculosis can be inculcated into the minds of the people and engrafted upon our customs, habits, and laws. The presence m our midst of representatives of world-wide workers in this magnificent cause gives an unusual opportunity for accelerating the educational part of the program. The modern crusade against tuberculosis brings hope and bright prospects of recovery to hundreds and thousands of victims of the dis- ease, who under old teachings were abandoned to despair. The work of this Congress will bring the results of the latest studies and mvesti- gations before the profession at large, and place in the hands of our physicians all of the newest and most approved methods of treating the disease — a knowledge which will add many years of valuable life to our people and will thereby mcrease our public wealth and hap- piness. (9) 10 TUBERCULOSIS IN THE UNITED STATES. The International Congress on Tuberculosis is in the interest of universal peace. By joining in such a warfare against a common foe the peoples of the world are brought closer together and made to better realize the brotherhood of man; for a united interest against a com- mon foe fosters universal friendship. Our country, which is honored this year as the host of other nations in this great gathering of leaders and experts, and as the custodian of the magnificent exhibit which will be set up by the entire world, should manifest its appreciation by giving the Congress a setting worthy of the cause, of our guests, and of ourselves. We should endeavor to make it the greatest and the most fruitful Congress which has yet been held, and I assure you of my interest and services to that end. With expressions of appreciation for the comphment conferred in extending the invitation to become president of the Congress, Very respectfully, Theodore Roosevelt. TUBERCULOSIS IN THE UNITED STATES. INTRODUCTORY. The Census of the United States was primarily constituted for the purpose of making a decennial enumeration of population so that the representation of the various states in the lower house of Congress might be apportioned properly. The First Census was taken in 1790, and a decennial census has been taken every tenth year since that time; the last, for the year 1900, was the Twelfth Census, and the next one, the Thir- teenth Census, for which plans are already being made, will be for the year 1910. A correct enumeration of population, at sufficiently frequent intervals, is absolutely essential to the proper presentation of vital statistics, and hence the ^"^^ ''''''''":' ^^^P^^deat , .. ,i,.i 11 11 upon enumeration of popula- constitutional provision that the people should ^j^^ be counted every ten years may be considered to have laid a part of the foundation of vital statistics, and therefore of modem preventive medicine, in the United States. It was not enough, however, merely to enumerate the population at regular intervals, but at an early date the importance of vital statistics to the people of . . ^ egmnmg o yi a s a- the United States was realized, and an effort was made to secure such statistics in connection with the other Census inquiries. England began a comprehensive series of "Annual Reports of the Registrar-General of Births, Deaths, and Marriages" in 1837, from which period dates the beginning of modem sanitation. Other European countries soon followed her example, until, at the present time, there is scarcely a civilized nation upon the globe — except the United States of America — but possesses a complete official registry of the vital events of its people. The movement was felt in the United States. The "First Annual Report of the Secre- tary of the Commonwealth to the Legislature: Under the Act of March, 1842, relating to the Registry and Returns of Births, Mar- riages, and Deaths in Massachusetts" was published in 1843, and the annual volumes have been continued regularly down to the present time. Every citizen of the United States, as well as every citizen of Massachusetts, should take interest and pride in these reports, for they are nearly all that we have in the way of a continuous history of (11) 12 TUBERCULOSIS IN THE UNITED STATES. the movement of population and the variations in the vital statistics of any considerable portion of the American people for the last half of the nineteenth century. Other states attempted to follow the example Success and failure of state n -kit i i_. •i',i,,i registration laws. ^f Massachusetts, as summarized m the tenth annual report of that state: As observed above, the law in this state was passed in 1842. This law was modified and improved by the act of March 16, 1844, and still further by the act of May 2, 1849. The state of New York followed with a registration law, passed, April 28, 1847, and made their first report in April, 1848. New Jersey passed a law on the subject March, 1848, and remodeled it with improvements by the act of March 19, 1851. Their report before us bears date of February, 1852. The registration law of Connecticut passed, June 24, 1848. We have their three reports; the last is dated May, 1852. New Hampshire passed a less efllcient law, July 7, 1849, and altered it without much improvement, July 4, 1851. The act in Pennsylvania on this subject passed the legis- lature of that state, April 14, 1851, and became a law without the signatm'e of the governor, as certified by the proper authorities, January 12, 1852. Dming the last session of the legislature that body manifested their approbation of it by appropriating $4,500 to put the law into operation. On the 9th of January, 1852, the legislatm'e of Kentucky passed a registration law, and the subject will come from influential sources before the next legislature of South Carolina. This was the somewhat hopeful condition of the movement for registration of vital statistics in the United States over half a century ago, but the results were not commensurate with the expectations entertained at that time. The original New York law was a total failure, and no other effort was made in that state until nearly forty years later when the excellent system planned by Dr. Elisha Harris went into effect. Massachusetts and New Jersey were the only states of the original ''registration area" as constituted for the mortality statistics of the Tenth Census, 1880. All of the New England states are now included, the last to be admitted being Maine, whose law dates from 1891. The early Pennsylvania law was a dead letter, and later attempts at registration were futile until the enactment of the excellent law of 1905, whose results justified the admission of the state to the registration area in 1906. During the session of 1908 the legis- lature of Kentucky failed to act upon a registration bill, and no effective law for tliis purpose yet exists in any Southern state. The net results of the unassisted efforts of the states to secure the adoption and enforcement of adequate regis- Present constitution of tratiou laws may be seen in the Hst of those registration area tor deaths. i c i • • i« i accepted for the registration area or the Twelfth Census, 1900, as having at least fairly complete (90 per cent) registration of deaths: Connecticut. New Jersey. Maine. New York. Massachusetts. Rhode Island. Michigan. Vermont. New Hampshire. 14 TUBERCULOSIS IN THE UNITED STATES. To this limited list Indiana was added in the year 1900, and in 1906 the states of California, Colorado, Maryland, Pennsylvania, and South Dakota were accepted, so that at present there are fifteen of the forty-six states of the Union included therein. The District of Co- lumbia, which is coterminous with the city of Washington, is regarded as a registration city rather than as a registration state, and with 76 other registration cities in nonregistration states helps to raise the total population of the registration area, according to the estimate for 1907, to 41,758,037, or 48.8 per cent of the total population of the United States. The above statements relate to the registration of deaths. There is as yet no registration area for births, because No registration area for j^ jg j^q^ ^^^ knOWn that any Statc in this births. -^ -11. • • country has succeeded m registermg even 90 per cent of the births that actually occur within its limits. The rea- sons for this are stated in the Census Report on Mortality Statistics, 1906 (page 16), and also in the pamphlet on the ''Legal Importance of Registration of Births and Deaths," copies of which will be dis- tributed at the International Congress on Tuberculosis in connection with the present publication. It should be remembered that on account of the entire absence of effective registration of births in this country, valuable data that would be of service to the Congress and to all who are concerned in the prevention of tuberculosis and other diseases are entirely wanting. It is impossible to present any state- ment of infant mortality from tuberculosis, some forms of which are especially fatal to infants and young children, because there is no total number of living births upon which to base the ratio. The success of some of the systems of state registration and the increasing reahzation of the importance of a Attempted national kj^owlcdge of mortality statistics with respect to mortality statistics- . ° . ^ -' ^ ^ their practical sanitary uses led to the incorpora- tion of tliis subject as one of the inquiries of the Seventh Census (1850). It has been retained in each of the decennial enumerations since that time. The method adopted was unfortunate, namely, the enumeration of deaths after the close of the year by the Census enumerators. It was well understood by the Census authorities that satisfactory results could not be obtained by such means. As stated by Gen. Francis A. Walker, Superintendent of the Tenth Census, 1880 (Compendium, Part I, page xxxiii), "In truth, however, the statistics of mortality obtained through the census have always been defective, and often grossly misleading." This was to be expected, because the ordinary census method of enumeration, which is properly used for population which can be counted at a given time, is totally inapplicable to the collection of data concerning vital events, such as births, deaths, and marriages. If accurate statistics are to be obtained, these events TUBERCULOSIS IN THE UNITED STATES. 15 must be registered immediately after their occurrence, and under laws which provide penalties for neglect. The true mortality statistics of the United States began with the establishment of the "registration area/' at first consisting only of two states and twenty cities, in . Extension of the registra- ® ♦^ , . tion area. 1880. It has progressed so far that we are qmte justified in recommending that the futile attempt at a decennial enumeration of deaths be discontinued, and that sole dependence be placed upon the results of immediate registration of deaths under proper state laws effectively enforced. A very important part of the duty of the Bureau of the Census since its permanent organization in 1902 — such work was quite out of the question under the old system whereby the Census Office was completely disorganized or nonexistent during the interdecennial years — is extension work; that is, cooper- ation with the sanitary authorities of nonregistration states, and with such great national organizations as the American Medical Associa- tion, the American Public Health Association, and the Conference of Commissioners on Uniform State Laws, for the purpose of securing adequate registration laws. A model bill for this purpose, indorsed by the national associations and by the Bureau of the Census, will be presented to the legislatures of nonregistration states at their next sessions. In addition to the new registration states added in 1906, several other states, namely, Minnesota, Montana, Nebraska, North Dakota, Ohio, Utah, Washington, and Wisconsin, have recently adopted laws whose results are now under observation. How the Census aids in this work may be learned from some of the pamphlets found in the list of publications / r.\ rrn -J "j. it How the Census aids. (page 2) . 1 he more rapid its progress the sooner will come the time when Americans will possess vital statistics which cover the entire country, and of which they need no longer be ashamed in comparison with those of other nations. For no amount of devoted work on the part of those immediately in charge of the subject of mortality statistics in the Census — and the names of Dr. Edward Jarvis, Dr. John S. Billings, and Mr. William A. King are honored among the vital-statisticians of the world — can make up for the absence of materials for their labors. So long as present conditions continue the United States must stand in the eyes of the world as practically a nonregistration country — a country having only par- tial registration. The Census can do nothing directly to remedy this; the registration of births and deaths is entirely dependent upon state and city laws. When the people, who are affected by the failure or absence of such laws, shall come to see their importance, there will be a rapid extension of effective registration, and the United States will no longer be compelled to confess failure in one of the requisites of modem government, the proper registration of vital statistics. 16 TUBEKCULOSIS IN THE UNITED STATES. I. — Some Facts in Regard to Tuberculosis in the United States FROM the Mortality Statistics of the Census. Incomplete as they are, the mortahty statistics of the Census form the only source of information in regard to the Mortality statistics of the act.ual prevalence of tuberculosis and other Census indispensable. -^.^^^..^ .. diseases m the united States or any consider- able portion of it, apart from the data presented for individual states and cities in their annual registration reports. These reports vary greatly in their quality, and present such marked differences in the methods of compilation that it is extremely difficult for any person except a statistical expert to prepare comparable tables from them. For a general examination of the occurrence of tuberculosis, even as restricted to the states of the registration area, it is therefore neces- sary to resort to the compilations made by the Bureau of the Census, which present the data with absolute uniformity so far as method of compilation is concerned, and with all of the accuracy that is obtainable from the original returns. The tables themselves, for the most part, will be presented at the end of the pamphlet, where they may be ources o ta as. referred to conveniently in connection with the present brief text, which is intended only to point out some salient features. Their sources are chiefly the two volumes on Vital Statistics of the Twelfth Census, 1900, which present comparative figures for the census years ending in 1900 and 1890, and the last pub- lished volume of the series of annual reports, which began with the calendar year 1900. The tables in the latter (Mortality Statistics, 1906) give comparative rates for several recent years (1902 to 1905) and a quinquennial average (1901 to 1905) for the purpose of con- venient reference. It is not worth while, as a rule, to make any com- parison with the rates for the registration area of the Tenth Census, 1880, because this area was so small and so largely urban in character that it can not be taken as fairly comparable with the registration areas of 1890, 1900, and later years. Statistics for 1907 from the annual report which is now in prepara- tion and will be published very shortly, have or 1907. been introduced in many of the tables. It should be remembered that the present text and the illustrative diagrams were necessarily prepared some time before the meeting of the International Congress on Tuberculosis, and hence it was neces- sary to use the data at hand at that time, the latest published being those contained in the annual report for 1906. Tuberculosis does not as a rule show marked fluctuations from year to year, and hence the statistics for the year 1906 may be taken equally with those for 1907 as representing present conditions. TUBERCULOSIS IN THE UNITED STATES. 17 The first question that naturally presents itself is, What is tuber- culosis? The word " tuberculosis" is of com- paratively recent vogue in vital statistics and ^J^" "^^"'« ^^ '"^"'="" in general medical and popular usage. As re- cently as the Twelfth Census, 1900, the official term employed in the mortality statistics for tuberculosis of the lungs was "consumption." In the earlier statistics "consumption," or "phthisis," was regarded as a local disease of the lungs, and other forms of tuberculosis were elsewhere classified in connection with the organs or parts of the body affected. The present conception of tuberculosis is that of a general infectious disease, capable of affecting all parts of the human body, but, in whatever situation found, caused by the Bacillus tuberculosis, the "germ" which was discovered by Robert Koch in 1882. It is a general disease, because it may affect the entire organism; and it is an infectious, or infective, disease, because it may be communicated, either directly or indirectly, from a person ill with it to a healthy person, by means of the bacillus that causes it. But it is not a con- tagious disease, in the sense that smallpox and scarlet fever are actively contagious or transmissible by mere contact; and it is a cruel injustice to tuberculous persons who take proper precautions in regard to the destruction or disinfection of their sputa, to treat them with the abhorrence that is usually associated with leprosy and smallpox. The present tendency in mortality statistics is to deal with the total nunaber of deaths from tuberculosis, so far as obtainable, and it is therefore necessary in Tuberculosis (all employing the older statistical tables to con- solidate the deaths compiled under the various forms formerly in use, such as "consumption" (tuberculosis of lungs), "scrofula and tabes" {tuberculosis of lymphatic glands and abdominal tuberculosisO , and "hydrocephalus" (tuberculous meningitis), in order to obtain the number of deaths from tuberculosis {all forms), which is stated when- ever possible. The International Classification of Causes of Death, which was adopted by the Census beginning with the statistics for the calendar year 1900, brings many of the forms of tuberculosis together, but even yet does not include "scrofula;" the number of deaths thus returned, however, is insignificant; and the title will prob- ably be abolished at the decennial revision which occurs next year. The next question that would naturally occur to a person interested ,n the prevention of tuberculosis in this coun- try is. What is the mortality— the total number ^ Mortality in the United J, -, -, -,-,_ ^ ^ . States from tuberculosis. rf deaths ana the death rate — -from tuberculosis n the United States? This knowledge is very needful, because it * Title No. 29, Tuberculose abdominale, of the International Classification; itself an »bjectionable term, for which tuberculous peritonitis could perhaps preferably be ubstituted. 53046—08 2 18 TUBERCULOSIS IX THE UNITED STATES. would inform us of the importance of the disease at the present time and enable us to know, by means of future comparisons, whether the restrictive work inaugurated by the International Congress on Tuber- culosis is bearing practical fruit in lives saved from this disease. It is necessary to confess frankly that an exact answer can not be given to this question. Neither the total No exact statement possi- n^niber of deaths in the United States from Die. tuberculosis (or any other disease) can be stated for any year, nor can the death rate, which is dependent upon an exact registry of all deaths from this cause, be given. Until the United States shall possess an effective system of registration of vital statistics such absolutely necessary data can not be obtained. In the absence of facts, and only in the absence of facts, estimates may be permissible. In his letter accepting The President's estimate. ,i • ^ i> l^ -r , , • i/^ the presidency or the International Congress on Tuberculosis the President of the United States has referred tc« the loss of two hundred thousand lives a year in our country from^ this cause. The statement is a reasonable one and probably well within the limits of precision attaching to any estimate. For the year 1907 there were registered and returned to the Bureau of the Census from the states and cities of the registration area, having an estimated population of 41,758,037, or 48.8 per cent of the total population of continental United States, 76,650 deaths from the various forms of tuberculosis recognized by the International Classi- fication. If it is assumed that the death rate from tuberculosis for that part of the country not covered by registration returns was equal to that ascertained for the registration area, then the number of deaths that occurred in the entire United States in 1907 would be about double the number reported, or approximately 153,000. But it is reasonable to suppose that the death rate from tuberculosis for the nonregistration area may have been higher than that for the registration area. The map^ showing the relative proportion of deaths from consumption during the census year 1900 in cUfferent state groups per 1,000 deaths from kno^^^l causes does not present £> maximum mortality, as indicated by the heaviest coloring employed^ for any portion of the present registration area except Cahfornia, western and central South Dakota (very sparse population and high Indian tuberculosis rate), eastern Colorado, and the Ohio River belt of counties in Indiana. For the nonregistration area, on the other hand, we find maximum relative prevalence of tuberculosis in Nevada, Arizona, northern jMissouri, the Gulf counties of Alabama and Mississippi, the central counties of North Carolina and South Carohna, and all of the states of Kentucky, Tennessee, Virginia, and West Virginia. Moreover the mortality of the colored population is much 1 Vital Statistics, Twelfth Census, Plate No. 18. TUBEECULOSIS IN THE UNITED STATES. 19 higher than that of the white population from this disease, as indi- cated by Table 9 (page 60), and also by the subjoined table from Mortahty Statistics, 1907: NUMHER OF DEATFTS FROM TUBERCULOSIS OF LUNGS PER 100,000 OF population: 1907. White. Colored. Maryland, rural. . Washington, D. C Louisville, Ky New Orleans, La. Baltimore, Md Kansas City, Mo. . Memphis, Tenn . . . 106. r> 153. 6 161.0 231.6 182.2 129.3 118.3 2.30. 2 448.0 328. 1 498.0 498.2 679.8 249.7 The rates given above indicate that the negro death rate fi'om tuberculosis of the lungs is markedly higher than ,,. , ,. , , , . . . °, High mortahty of the the white death rate, not only m cities but also colored race from tubercu- in rural districts, of which Maryland affords the ^°^'^' only example. It is probable, moreover, that the registration of deaths is somewhat incomplete in rural Maryland; it is known to be practically worthless in certain counties of that state, while in all of them the registration of the deaths of negroes is probably not so thorough as the registration of the deaths of white persons. Hence a higher mortality from pulmonary tuberculosis may fairly be assumed for all of the negro population than that for the corresponding white population. There were in the registration area as constituted in the census year 1900 only 1,180,546 negroes, or 4.1 per cent of the total population. Subtracting these from the 8,833,994 negroes in con- tinental United States in 1900, we have 7,653,448 negroes in the non- registration area in 1900. No notable addition of negro population has been made to the registration area since that date, except Maryland exclusive of Baltimore, Annapolis, and Frederick, representing a net increase of 131,862 negro population as enumerated in 1900. The death rate of the total white and colored population of the registration area from tuberculosis of the lungs was 158.9 per 100,000 for the year 1907. If we subtract this rate from the rate shown for the colored inhabitants of the mral part of Maryland (230.2 per 100,000), and apply the difference (71.3 per 100,000) to the negroes of the nonregis- tration area enumerated in 1900, we shall find a probable increase of about 5,500 deaths a year from pulmonary tuberculosis alone. Con- sidering the imperfect registration of deaths in rural Maiyland, the additional deaths from other forms of tuberculosis, and the increase of the negro population since 1900, perhaps from 10,000 to 15,000 more deaths of colored persons from all forms of tuberculosis would 20 TUBERCULOSIS loST THE UNITED STATES. be added to the returns on account of the greater relative negro mor- tahty from tuberculosis if we had effective registration in the South. This is in addition to the number corresponding to the average death rate (white and colored) of the registration area (183.6 per 100,000). The chief objection that can be urged against the view that the number of deaths from tuberculosis in the non- Sparsely settled areas. -ij.' •iii ijijr registration area considerably exceeds that of the registration area is that the former contains much sparsely settled territory, and that it is well known that the mortality from tubercu- losis increases with the crowding together of people. On the other hand, the inhabitants of sparsely settled regions form a comparatively small aggregate of population, and in many localities of this class, as in Arizona, New Mexico, Florida, and Texas, there is a considerable influx from other states of invalids suffering from tuberculosis, whose deaths, when they occur, are not charged to the states in which the disease originated. Finally, there is a large margin of possible error and probably of understatement in the recorded deaths from Understatement of tuber- tuberculosis cvcu in the registration area. How culosis m returns or deaths. tip i i i • i many deaths from pulmonary tuberculosis have been reported as due to "heart failure," " congestion of lungs," " debil- ity," "inanition," "marasmus," and the like? Many deaths from ''chronic bronchitis" and "bronchopneumonia" are really due to tuberculous infection. A majority of the cases of acute serofibrinous pleurisy are tuberculous (Osier), and many of the deaths reported from "hemorrhage" — practically all of those from "hemorrhage of the lungs" — are those of tuberculous persons. Keports of deaths from "lung trouble," "heart disease," and in fact any form of disease, may, either through ignorance or intention, conceal deaths from tuberculosis. At least the proportional number (11.2 per cent) of deaths from tuberculosis to deaths from all Icnovjn causes would also apply to the ill-defmed or unspecified causes. Dr. J. W. Irwin, phy- sician to the Henry Pliipps Institute ^ of Philadelphia, gives a long list of causes of death registered in Philadelphia that he considers to be "probably tuberculosis." Among these are: Abscess of chest, hip, lungs; iliac, lumbar, pleural, and psoas abscess; asthma; congestion of brain, chest, lungs; debility; disease of brain, chest, hip, lungs; drops}^ of brain, chest, lungs; empyema; brain fever; inflammation of brain, hip, larynx; marasmus; tabes mesenterica, etc. Among the "possibly tuberculosis" are: Cachexia; cerebro-spinal meningitis; cholera infantum ; convulsions; cyanosis; diarrhea; diseases of spine; typhoid fever [a certain proportion] ; inflammation of bronchi, chest, ^ First annual report, page 89. TUBERCULOSIS IN TUE UNITED STATES. 21 lungs, peritoneum, pleura, spine, stomach, and bowels; influenza; teething; whooping cough. Does the list seem extreme ? Is it possible that physicians legally authorized to practice medicine Avill make such _._ , • p 1 ^ 1 J^ p ji !• Difficulty of securing cor- retums m cases or actual death ti'om tuberculosis, rect statements of deaths from and that the registration officials will gravely tuberculosis. accept such certificates and compile them as official statistics? In regard to the latter point, most registration offices are compelled to accept what they can get; the attending pliysician is the sole arbiter as to what shall be said or not be said upon the certificate of death. And the absence of any standard nomenclature of diseases in this country renders it difficult for even the careful and intelligent physi- cian to know how to report the cause of death in many cases. Add to this the protean forms of tuberculosis, the difficulty of its diagnosis in some cases, the unwillingness of the attending phj^^sician to sign the certificate of death of a patient whose illness from this disease he may have failed to report as required by law, and perhaps the fact that the occurrence of the death from this cause may be thought undesirable as a matter of record by the friends or relatives, or may, perchance, conflict with representations made in applications for policies of insurance — there are reasons enough why many deaths from tuber- culosis should not be reported and hence not be compiled under this cause. Every registrar is familiar with such cases. A careful and fairly conservative estimate worked out along this line on the basis of the total number of deaths registered in the registration area and enumerated in the nonregistration area during the last decennial census year — with allowance for increase of population and incom- plete total number of deaths — showed that about 190,000 deaths might fairly be considered to have occurred in the United States dar- ing the year 1907 from tuberculosis or from causes that might be considered, in the proportion assigned, as "probably tuberculosis." DISCUSSION OF TABLES. Only the most important general indications relating to the incidence of tuberculosis are shown in the brief series of tables presented. For more Reference tables beginning . . . '^^ P3ge 49- detailed data, and especially for statistics relating to individual localities, reference should be made to the original reports, which are, chiefly, the Vital Statistics of the Twelfth Census, 1900, and the annual reports on Mortality Statistics, 1900 to 1904 (published in one volume), 1905, and 1906. Mortality Statis- tics, 1907, is in preparation and Avill be issued soon after the close of the Cono-ress. 22 TUBERCULOSIS IN THE UisITED STATES. Tuberculosis has been more or less steadily decreasing both in its absolute and in its relative importance as a Decreasing death from tuberculosis. Table 1, page 49. cause of death for many years. The death rates per 100,000 of population from all forms of tuberculosis declined, as follows, in the registration area of the United States from 1880 to 1907: Death rate. Per cent of decrease. 1S80 (census year) . . 1890 (census year) . . 1900 (calendar year) 1907 (calendar year) 326.2 267.4 201.2 183.6 18.0 24.8 8.7 The registration area of 1880 represented only a comparatively small portion of continental United States and was largely urban, so that the decrease from 1880 to 1890 may be partly due to the addition of rural population in the registration states admitted in 1890. Moreover, comparisons in which single years are concerned are not so satisfactory as those based upon a series of consecutive years, as in the following table, sho\^dng the decrease in the death rates from all forms of tuberculosis in Massachusetts and in England and Wales : 1851-1860. 1861-1870. 1871-1880. 1881-1890. 1891-1900. 1901-1906 1 MASSACHUSETTS. Death rate per 100,000 of popu- lation. 469.9 410.9 391.5 364.3 283.2 218.3 Per cent of decrease from pre- ceding decade. 12.6 4.7 6.9 22.3 22.9 ENGLAND AND WALES, Death rate per 100,000 of popu- lation. 348.7 327.0 287.8 242.9 200.9 172.2 Per cent of decrease from pre- ceding decade. 6.2 12.0 15.6 17.3 14.3 1 Six-year period. The decline has been especially marked in Massachusetts during , , the past six years, the per cent of decrease of Overstatement of tubercu- ^. .' ' j. i i i n losis in early statistics. the SIX ycars 1901-1906 trom the decade 1891- Tabiei, page49. igQO (22.9) already exceeding that shown from 1881-1890 to 1891-1900 (22.3). The decline in the Enghsh death rate from tuberculosis has been remarkably uniform. Concerning this Doctor Tatham remarks that "there has been an almost steady and not a slow decline in the aggregate mortahty from tuberculosis, the rate in the last year being less than half that in the earher years, and, further, that the decHne has been greater in females than in TUBERCULOSIS IN THE UNITED STATES. 23 males," although he is careful to note, and the fact should be taken into consideration in comparing all extended series of death rates from this disease, that "with respect to the aggregate mortality from all forms of tuberculosis, although, as previously mentioned, the earlier records hardly warrant a definite conclusion, it is at least probable that in the fifties and sixties of last century mortality was to some extent overstated." About that time in Massachusetts Hon. John G. Palfrey, secretary of state, declared in the third annual registration report for the year ending May 1, 1844, that "consump- tion is the grand receptacle for all lingering diseases, of whatever nature, which prove fatal." It is probable that the present tendency is to understatement, rather than to overstatement, in the returns of deaths from the various forms of tuberculosis. "Proportional deaths" showing the ratio from tuberculosis per 1,000 deaths from all causes have some degree -proportional deaths." of usefulness, because they indicate the relative Tabid, page 49. importance of this cause of death as compared with others. They do not show the incidence of mortality upon a fixed and comparable basis, and the figures fluctuate inversely with the excessive prevalence of other disease. It is significant, however, that in Massachusetts, for the period 1851-1860, over a quarter of the deaths at all ages (257.5 per 1,000) were from tuberculosis, while now, 1901-1906, less than one-seventh (131 per 1,000) are from this cause. The regis- tration area gives a proportion of 117.9 per 1,000 for the last six years, which is curiously close to the ratio shown by the returns of the Seventh Census, 1850 (116.6 per 1,000), although no safe deduc- tions can be drawn from the very imperfect older statistics. In order to appreciate the condition of the United States as com- pared with other parts of the world with respect ^^^^ ^^ f^^n^ comparable to the mortality from tuberculosis, comparison international statistics of of the death rates from this disease may be made ""^^^ ° on the basis of the statistics contained in the international tables printed each year by the Registrar-General of England and Wales. Unfortunately all of the countries do not tabulate total deaths from tuberculosis, so that it is necessary to restrict the comparison to tuberculosis of the lungs ; and there may be some considerable element of doubt even as regards the deaths thus returned as a result of differences in statistical methods and the customs followed by physi- cians in the various countries in making the original returns. The paucity of fully comparable data concerning this, the most important of all diseases, shows the crying need for a universal system of noso- logical classification, and the desirability that the medical profession in all lands be induced to give greater attention to the requirements incident to the proper reporting of causes of death. 24 TUBERCULOSIS IN THE UNITED STATES. The annual average death rate of the United States (169.9 per _ , r r • 100,000 of population) for a short series of recent Death rates or foreign ' ^ ^ • t countries. jears (1901 to 1905) as indicated by the returns Table 2, page 52. froHi the registration area, places this country in a fairly favorable light as compared with others for which data are available. Much higher rates are shown for Austria (334.8) and Servia (279.7), while the rates for Norway (196.4), Switzerland (188.6), and Germany (185.8) slightly exceed the American rate. Italy (114.9), Belgium (118.2), Netherlands (133.4), the United Kingdom (133.8), Japan (146.3), and Spain (147.8) fall below it. The rate for England and Wales in particular is much below (121.5), but Ireland, with an abnormal age distribution of its population, shows a higher rate (215.3). The extremely low mortality of the Australasian states is very remarkable, ranging from 111.6 for Victoria to only 63.3 for Tasmania. Tuberculosis may seize upon any organ or part of the body. It may remain localized for years, as in a kneejoint. How tuberculosis kills. ., ijiji i • • , i or it may attack the entire organism at once and with the virulence of an acute infectious disease, as in acute miliary tuberculosis. It is not yet settled in statistical practice whether the seat of the initial infection should be reported, if known, or whether the organ upon which the most serious inroads are made should determine the classification of the disease. Probably the latter plan is preferable; it is more important to know the whole number of deaths that resulted from tuberculosis of the lungs than to attempt to separate the comparatively small number supposed to have resulted from primary laryngeal infection. But if the true source of infection could be determined — whether through the food and so on indirectly to the lungs, or directly from the air — it would be a matter of supreme importance. As it is, the mortality statistics measure only the results and the primary causes remain obscure. Among the multitude of forms of tuberculosis recognized by the • , . , , , Nomenclature of Diseases of the Royal College Various forms of tubercu- . . ,i /• ii • losis. or Physicians or London are the rollowmg: Table 3, page 52. Tubcrculosis of adrcuals, arteries, bladder, bones, brain, bronchi, conjunctiva, fauces, gums, intestines, kidneys, joints, larynx, liver, lungs, lymphatic glands, middle ear, mouth, naso- pharynx, nerves, nose, pancreas, pericardium, peritoneum, pharynx, pleura, skin, spleen, stomach, tongue, and of other organs and parts of the body. It is needless to say that such an extended list would not be practicable for the purposes of a general statistical report, and hence all statistical classifications attempt to reduce the most im- portant forms in which tuberculosis causes death into more condensed lists. For example, in accordance with the International Classifica- tion of Causes of Death, the following forms of tuberculosis were TUBERCULOSIS IN THE UNITED STATES. 25 compiled for the registration area of the United States for the year 1907: FORM OF TUBEECULOaiS. Number of deaths. Tuberculosis (all forms) Tuberculosis of lungs Tuberculosis of larynx Tuberculous meningitis Abdominal tuberculosis Pott's disease Tuberculous abscess White swelling Tuberculosis of otber organs General tuberculosis 76,660 66,374 090 4,0C2 2,029 594 05 209 713 1,254 Nearly nine-tenths of all of the deaths from tuberculosis are due to tuberculosis of the lungs. Some of the forms given are of very minor importance, and perhaps ciass'St'onT °^ ^f^'"'^'"' it might be desirable to give greater detail in regard to the more fatal forms of the disease. Does this mode of presentation of the mortality statistics best answer the purpose of sanitarians and of practical clinicians and does it meet the demand for complete information in regard to all features of this disease that will surely arise from the present concentration of attention upon it through the International Congress on Tuberculosis? If not, imme- diate steps should be taken to suggest the necessary changes so that they may be incorporated in the second decennial revision of the International Classification which will be held in 1909. For the purpose of comparison with the above statement of the methods by which tuberculosis kills, we may submit the corresponding English figures for 1906 according to the classification used by the Registrar-General : FORM OF TUBERCULOSIS. Tuberculosis (all forms) . Pulmonary tuberculosis (tuberculous phthisis) . Phthisis (not otherwise deflned) ' Tuberculous meningitis Tuberculous peritonitis Tabes mesenienca i Lupus Tubercle of other organs General tuberculosis Scrofula ' Number of deaths. 50,841 18,384 21,302 6,104 3,857 1,238 84 1,809 3, 954 49 1 Terma in italics are regarded as indefinite and unsatisfactory by the Registrar-General. Sex is apparently an influential factor in determining differences in mortality from tuberculosis. For the states influence of ses. of the registration area during the census year Table 4, page 53. 1900 the death rate of males from tuberculosis of the lungs was 188.4 per 100,000 of male population, while the corresponding death rate of 26 TUBERCULOSIS IN THE UNITED STATES. females was only 163.3. The mortality of males exceeded that of females from this disease by 15.4 per cent. The corresponding rates for 1890 were, for males, 257.7 per 100,000 of male population; for females, 240.4; relative male mortality in excess of female mortality from "consumption," 7.2 per cent. So the disproportionate excess of male mortality from tuberculosis of the lungs more than doubled during the ten years that elapsed from 1890 to 1900. In Massachu- setts the male mortality from this disease began to exceed the female mortality about 1894. A similar change has been in progress in England and Wales. In the earlier years of registration in England the mortality of females from "phthisis" invariably exceeded that of males. About 1856 the curve representing the male death rate rose slightly above the curve for the female rate, and the difference has increased in a fairly regular way from year to year since that time. During the decade 1861 to 1870 the death rate of males was 253.8 and of females 255.2, while in the last decade, 1891 to 1900, the rates were 158.0 and 121.4, respectively. Certainly such changes are very significant, and perhaps are due, to some extent, to a progressive tendency among women to Hve more in the open air than formerly. The "athletic girl" is not the sort that "goes into a decHne" in the interesting way common to fiction of the first half of the last century, but there must be an additional reason, first, why under the extremely bad hygienic conditions of the old days, when woman was considered a hothouse plant and treated accordingly, female mortality from tuberculosis was not vastly liigher, not merely considerably higher, than male mortality; and, second, why under present conditions the female death rate is now so markedly lower, although men are still, on the whole, more com- monly engaged in outdoor occupations than women. ^ Crowding into dense city quarters means increased mortality from City and country. tuberculosis, although there may be some tend- Tabie4, page53. cncy to report correctly a larger proportion of deaths from tuberculosis in the city than in the country. Following are the death rates from tuberculosis of lungs per 100,000 of urban and of rural population in the registration states during the last two decennial census years and the last year contained in the series of annual reports: Cities. Country. 1906 (calendar year) . 1900 (census year) . . . 1890 (census year) . . . 181.5 204.8 293.5 121.9 134.1 181.0 ^ Tuberculosis affects nutrition. Women are perhaps more resistant to conditions affecting nutrition than are men. In India, according to Sir J. A. Baines, "-women appear to succumb to famine less than the other sex.-' TUBEECULOSIS IN THE UNITED STATES. 27 The rural rate in 1900 was only about two-thirds (07.1 ])cr cent) of the urban rate, although the decrease in the urban rate during the period of sixteen years (.38.2 per cent) was slightly larger than the decrease in the rural rate (32.7 per cent). States with a large pro- portion of urban population will tend to have higher death rates from tuberculosis of lungs than those chiefly rural in constitution; thus in 1907 the rates for New York (171.0), New Jersey (170.0), and Rhode Island (103.0) exceeded those for Indiana (140.2), Maine (134.3), and Michigan (88.7). Other factors must be considered, however, in addition to the mere density of population; for instance, the younger age distributions of some urban populations would tend to lower mortalities. In England in 1900 the urban counties showed a death rate from phthisis of 149.3 per 100,000 of population while the corresponding rate for rural counties was 129.2, the excess of urban mortality being 15.0 per cent. One of the influences always to be reckoned with in the analysis of mortality statistics is age distribution of the ^ , , p ., , , ^, Death rates at certain age deaths and or the people among whom they periods. occurred. As a result of the difficulties attend- ^^^^'^ ^' p^s'' ^3- ant upon estimating the age distribution of the population during postcensal years comparisons are most conveniently made of the death rates at certain ages during the last two census years, 1900 and 1890. The aggregate death rate at all ages from tuberculosis of the lungs (pulmonary ''consumption") in the registration states declined from 249 per 100,000 of population in 1890 to 175.9 in 1900, or 29.4 per cent; for the thirty-year period of life from 15 to 44 years of age, it fell from 324.8 per 100,000 of population at that age period in 1890 to 239.8 in 1900, or 20.2 percent; for the twenty-year period of life from 45 to 04 years, it fell from 310.2 to 208.4, or 32.8 1 p , 1 1 , Table 5, page 55. per cent ; and tor the older ages, 05 years and over, it fell from 300.5 to 240.0, or 31.0 per cent. Roughly spealdng, during the ten years from 1890 to 1900 the death rate from "consumption" decreased one-fourth of its amount for young and middle-aged adults up to 44 years of age, and nearly one-tliird for those of more advanced ages. The highest rate shown for 1900, by sex, age, and locahty, is for males aged 45 to 04 years living in cities (337.2 per 100,000 of popula- tion), and the lowest rate is for females of the same age period living in the country (141.0 per 100,000). The different forms of tuberculosis vary considerably wath refer- ence to the periods of life chiefly afi"ected. . • , 1 ^^ J £ ±1 T •^ £ Aee distribution of deaths Approximately 28 per cent ot the deaths from ^^^^ various forms of tuber- tuberculosis of the lungs occur between the ages cuiosis. of 25 to 34 years; 21 per cent, from 15 to 24 Table g, page 55. years; and 20 per cent, from 35 to 44 years. Over two-thirds (67.4 28 TUBERCULOSIS IN THE UNITED STATES. per cent) of the deaths from tuberculous meningitis are those of children under five years of age. The value of a human life can not be measured in dollars and cents. The world is forever poorer on account of the Economic loss from tuber- untimclv death of Robcit Louis Stevenson, culosis. " , ' though richer for the record of his brave fight against the unrelenting foe — tuberculosis — that harried him to the islands of the great "South Sea " he loved, and slew him there. What would have been the value to literature of a few more years of this single Kfe? And how many are now dying from tuberculosis who, were they but permitted a few more years of healthful life, would, by their works of genius, add immensely to the treasures of humanity! Tuberculosis kills men and women chiefly in the most active, most productive period of life, when their work is worth the most to them- selves, to their families, and to the world. While such loss can not be stated in money, for it transcends all symbols of value, we may consider Avith amaze- Estimates of pecuniary ment some of the results that havc been obtained loss. . . . , by conservative writers m the attempt to find some clue to the economic injury resulting from this single disease. In an article on ''The Statistical Laws of Tuberculosis,"^ ^Ir. Freder- ick L. Hoffman, statistician of the Prudential Life Insurance Com- pany, says: Tubercxilosis causes annually more than 150,000 deatlis in the United States at the average age of thirty-five years. At this age the normal after-lifetime is about thirty- two years, so that the real loss of life covered, measured in time, is represented by 4,800,000 years per annum. If we assume that the net value of a year of human life after age thMy-five is at least $50, the real loss to the nation resulting from the disease (a large proportion of which is known to be needless) may be estimated at §240,000,000 per annum. These astounding and almost incomprehensible figures are far from being an exaggeration, but let us assume that only one-half cf this mortality is pre- ventable, and we have a net possible saving to the nation of $120,000,000 per annum. This estimate does not take into account the social, moral, and sentimental value of at least 100,000 lives, which, under different conditions, might reasonably hope to continue for many years. The mortality from tuberculosis is, therefore, a problem compared with which all other social problems of a medical character sink into insig- nificance, and it is safe to say that the possible prevention of a large portion of the mortality from this disease is justly desersdng of the solicitude, the active personal interest, and liberal pecuniary support of all who have the real welfare of the people of this nation at theu* heart. Collier's (July 25, 1908), in an editorial under the title '"'Expressed in Money," puts it higher: ''Now put it into money, this same saving to the race through intelligent observation. Hunter has estimated the average cost of preparing a man for usefulness at SI, 500. * * * If we could master tuberculosis, the saving in money to the United ^Maryland Medical Journal, Februarj', 1904. TUBERCULOSIS IN TUE UNITED STATES. 29 States would be $330,000,000 per year. Is it any wonder, then, that the best physicians are heart and soul in the study of prevention ?" In another very valuable paper,^ from which several paragrapha may be quoted at length, Mr. Hoffman endeavors . j^ 1 !• 1 ii ' • - p • 1 Economic value of life. to establish the approximate measure of social and economic value of life : Life period of industrial activity. — The period of industrial activity of wage-earners generally, but chiefly of men employed in mechanical and manufacturing industries, it may be assumed, should properly commence with the age of fifteen and terminate at sixty-five. This gives fifty years of labor and life, during which, as the result of individual effort, primarily, of course, for self-maintenance and the support of others, some net addition is annually made to the accumulated wealth of the nation. The large variety of employments, which is so characteristic of modern nations, and the increasing subdivision of labor and the development of special ability, precludes more than an approximate estimate of what normally constitutes the economic gain to society during the period of industrial activity of a wage-earner. Economic and social value of life. — The usual method has been to confuse cause and effect and to estimate the present value of a workingman's life merely upon the basis of his future earnings after deducting the cost of future maintenance. This method, however, does not establish the economic value of men to society, but rather the social value of a man to himself and his family or survivors. The economic gain to society, as I view it, is rather the value of the product over and above wages, cost of supervision, cost of material, and miscellaneous expenses, necessarily incurred to carry on any particular process of manufacture or industry. A fairly accurate basis for an esti- mate of this kind is furnished by the census returns of our manufacturing industries, which give employment to some seven million persons. While any calculation of this character must necessarily be merely approximate, it, however, will prove useful for the present purpose, to establish the principle that there is an economic value inherent in every year of a workman's life, and that every gain in human longevity above the age of fifteen and below the age of sixty-five represents a corresponding gain to the nation at large and a distinct contribution to the accumulated wealth and capital of the nation. Variations in industrial efficiency. — It is probably safe to assume that the net gain to society is at least equivalent to about three hundred dollars per annum in the case of male wage-earners employed in American manufactiu'ing and mechanical industries. The return is higher, among others, in the manufacture of food and kindred products, also in the manufacture of metal ware, paper, printing, and chemicals. It is lower, among others, in the manufacture of textiles, leather, clay, glass, stoneware, and tobacco. Making allowance also for the lower wages of women and the relatively small earnings of children below the age of fifteen in industries, which are included in the census returns, the average of three hundred dollars, assumed for the present purpose, would appear to fairly correspond to the facts of actual experience. Of course, the gain is less at the younger ages and probably remains fairly the same or level during the ages of thirty to fifty, when the normal physical strength is enhanced by practical trade education and experience. After the age of fifty a natural decline in physical strength and possibly brain weariness gradually decreases the industrial efficiency, which in the case of wage-earners may be held to come practically to an end by about the age of sixty-five to seventy. There are, of course, always some excep- tions in every trade and industry, where men continue to work, sound in body and mind, to the close of a long life. ' "Physical and Medical Aspects of Labor and Industry," Annals of the American Academy of Political and Social Science, May, 190G. 30 TUBERCULOSIS IN THE UNITED STATES. Economic loss by premature mortality. — Upon the assumption of an average annual net gain to society of three hundred dollars as the result of individual labor applied to American industry under normal conditions, the degree of variation in value may be placed between the minimum of seventy-five dollars at the age of fifteen and a maxi- mum of four hundred dollars at the age of thirty-two. The value is then assumed to remain about the same, or level, until the age of forty-eight, when industrial efficiency gradually declines as the result of decreasing strength and mental aptitude and inclina- tion. The minimum value at the end of industrial life is assumed to be one hundred and seventy dollars. By means of this estimate, which, of course, is purely theoretical, in that there are no wage statistics by ages, or useful observations of employers of labor respecting the industrial efficiency of employees at different periods of life, it is pos- sible to calculate with approximate accuracy the economic loss due to premature death or impaired physical efficiency as the result of illness. If, upon the basis of an average net gain to society of three hundred dollars per annum, the fifty active years of a work- ingman's life represent a total of fifteen thousand dollars, then if death should occur at the age of twenty-five, the economic loss to society would be thirteen thousand six hundred and ninety-five dollars; if at the age of thirty-five it would be ten thousand three hundred and ninety-five dollars; if at the age of fifty, four thousand four hundred and five dollars; and, finally, at the age of sixty, the loss would still l^e one thousand and ninety dollars. Of course, the values would vary considerably in different employments, but the broad principle is fairly well illustrated and with approximate accuracy in this calculation. Now, the approximate average age at death of the persons dying from tuberculosis of the lungs (pulmonary '' con- sumption") in the United States is practically about thirty-five years, a figure which has been curiously stationary for each year for which the statistics are available since 1860, although the average age at death from all causes has increased from 22.7 years in 1860 to 38.1 years in 1907. Approxi- mate aver- 1 Approxi- age age at ' mate aver- deatli from I age age at tuberculo- jdeath from sis of j all causes, lungs. United States: Census year 1860 1 . Census year 1870.. Census year 1880.. Registration area: Census year 1890. . Census year 1900 . . Calendar year 1900 Calendar year 1901 Calendar year 1902 Calendar year 1903 Calendar year 1904 Calendar year 1905 Calendar year 1906 Calendar year 1907 349 36,7 35.^ 35.3 35.3 35.3 35.5 35.5 35.3 35.1 35.3 35.5 35.9 22.7 25.2 36.9 31.1 35.2 35.1 37.0 36.3 37.2 37.5 37.5 36.8 3&1 i j PER CENT OF DEATHS UNDER 5 l-EAES OF AGE. Tuberculo- sis of All causes. ! lungs. ! 7.9 42.7 6.4 40.2 5.2 37.9 3.9 34.6 3.6 30.0 a5 30.4 a2 27.3 3.0 28.2 ai 26.7 2.9 26.5 2.8 27.0 3.1 28.4 ai 26.7 Approxi- mate medi- an age at death from tuberculo- sis of limgs. 30.9 32.7 31.2 31.6 32.5 31.8 32.0 32.1 32.0 31.8 32.1 32.3 32.8 1 Estimate based on ten-year periods from 30 years to 90 years. As the average age at death is a ver}^ doubtful ratio, depending chiefly upon the average age of the population or special class sus- ceptible to an individual disease, the figures given in the above table TUBERCULOSIS IN THE UNITED STATES. 31 must be cautiously used; subsidiary columns are given for the ])er- centages of deaths under five years of age as affecting pulmonary tuberculosis and deaths from all causes, and also the approximate median age at death from tuberculosis of the lungs, which is the age for which one-half of the persons dpng from this disease are older and one-half younger. The latter ratio is somewhat lower than the average age at death, and likewise shows only a slight variation during the series of years. As age at last birthday forms the basis of the compilation, one-half year may be added to show the true approximate average or median age at death. Of the 42,734 deaths of males from all forms of tuberculosis in the registration area of the United States during y ., , , , . ° '^ Incidence or tuberculosis 1907, 12,035, or 28.2 per cent, were at the ages upon the most productive 15 to 29 years, both mclusive; 14,423, or 33.8 ^s"' per cent, at the ages 30 to 44 years; and 9,679, or 22.6 per cent, at the ages 45 to 64 years. During the younger and probably most efficient period of industrial activity, from 15 to 44 years, occurred 26,458, or 61.9 per cent (nearly two-thirds), of all of the male deaths from tuberculosis. And for the entire "fifty years of labor and life," as expressed by Mr. Hoffman, there were 36,137 deaths of men, or 84.6 per cent of the total male deaths from all forms of tuberculosis. So at least four-fifths of all of the deaths of males from this disease mean direct loss of earning power in men who are productively employed. If we take the 26,458 deaths of men aged from 15 to 44 years in the registration area, 1907, and assume that their average age at death was about 35 years or somewhat less (from tuberculosis of lungs it was 31 years), then consider the economic loss to society, according to Mr. Hoffman's computation, to be $10,395 at the age of 35, we shall have a total economic loss, in the registration area alone, from the deaths of this limited most productive age class of males only, dur- ing a single year of experience amounting to $275,030,910. The registration area includes less than one-half of the population of the United States, It is not profitable to press such estimates too closely, but it is easy to see that there is a tremendous waste dis- tributed throughout society, and pressing with the greatest cruelty upon the weakest dependent members of the families from which tuberculosis has removed the means of support. For a thorough analysis of the effects of tuberculosis in limiting the productive capacity of man a life table must 1 1 ix-ij^i' T-»i« TXT Westereaard's life table, be employed. Jbor this purpose rrofessor Wes- excluding tuberculosis. tergaard^ has computed the effect upon the life ^"The Horoscope of the Population of the Twentieth Century," Bulletin de rinstitut Internationale de Statistique, 1907, xvii, 103. 32 TUBERCULOSIS IIST THE UNITED STATES. table of England, 1881-1891, upon the assumption that tuberculous diseases can be eliminated: Oy^ars. 5 years. 15 years 25 years 35 years 45 years 55 years 65 years 75 years 85 years 95 years ENGLISH LIFE- TABLE, 1881-1891. Males. 10,000 7,515 7,262 6,938 6,396 5,644 4,630 3,225 1,539 299 Females. 10,000 7,832 7,591 7,248 6,710 6,040 5,164 3,855 2,042 481 21 TTJBEECTTLOTTS DIS- EASES ELIMI- NATED. Males. 10,000 7,629 7,410 7,209 6,873 6,304 5,381 3,889 1,911 378 11 Females. 10,000 7,928 7,730 7,535 7,195 6,668 5,837 4,439 i 2,387 I 568 ] 27 GAIN FEOM ELIMI- NATION OF TU- BEECULOTJS DIS- EASES. Males. Females. 114 % 148 139 271 287 477 485 660 628 751 673 664 584 372 345 79 87 3 6 Out of 10,000 newborn children of each sex, 6,873 males and 7,195 females would reach the age of 35 provided tuberculous diseases could be done away with, as against 6,396 males and 6,710 females who would reach that age under present conditions. This represents a gain to the community of 477 males and 485 females at this single age period. The probabihty that a man aged 25 would reach the age of 35 under the conditions of the Enghsh life-table employed is 92.1 per cent; with tuberculosis eliminated it would be 95.3 per cent. In the course of human life from infancy to old age each period has its peculiar perils. All over the world the Relative importance of tu- i , . -, . . i p bercuiosis and other dis- babics are dying lu unneccssarj^ numbers from ^^ses. filth, foul milk, and the various causes of e /, page o . diarrhea and enteritis. After the ordeal of early infancy, the gantlet of measles, whooping cough, and scarlet fever must be run. Then come the comparatively immune days of early youth, when the death rate falls to its lowest ebb during the entire period of existence, and then the tide of death begins to rise, with the Bacillus tuberculosis as the chief causative agent, until, with advancing years, the degenerative changes, due chiefly to improper or unwise living, become of chief importance, and even tuberculosis must play a secondary role. In the practical everyday conflict with disease that is being waged by sanitary authorities, it is of importance to know just where to direct the attack — what causes of sickness and death are of the greatest relative importance, both at all ages and at the various special periods of life. For all ages, according to the mortality statistics of the registration All ages. area of the United States during the year 1907, (4), page 56. 11.2 per cent of the deaths from all causes were from some form of tuberculosis. Tuberculosis of the lunss alone was TUBERCULOSIS IN THE UNITED STATES. 33 responsible for 9.7 per cent of the total deaths of the year. Pneu- monia, including bronchopneumonia, came next to tuberculosis as a cause of death, with a percentage of 9.8, then heart disease (8.6 per cent), violence (7.6 per cent), and diarrhea and enteritis (7.1 per cent). For infants and children under 15 years of age, the percentage of deaths from all forms of tuberculosis {according infants and children. to the returns) is low (4 per cent). But many (5), page so. of the deaths from meningitis (unqualified), "convulsions," and from diarrhea and enteritis are probably due to tuberculous infection. The story of the dealings of tuberculosis with infancy and childhood is not yet told in the statistics, nor will it be until physicians are much more careful in their certificates of cause of death, and, indeed, until science has rendered it less difficult to obtain precise information in many instances. For youth and early manhood and womanhood (15 to 29 years of age), nearly a third (33.2 per cent) of all of v .u j . u j '^ ' > 'J ^ ■[ _ ' Youth and early manhood the deaths are due to tuberculosis in some of its and womanhood. forms. For females the proportion is even (c^), pages?. higher (38.3 per cent). The mortality from no other cause ap- proaches that from this disease, the nearest being violence (16.8 per cent), typhoid fever (7.4 per cent), pneumonia (6.7 per cent), and heart disease (4.3 per cent). Here is where the most immedi- ately beneficial results of the active campaign against tubercidosis should first be perceived. For mature manhood and womanhood (30 to 44 years) over a quarter (25.6 per cent) of all of the deaths are j^^^^^^ ^^^^^^ ^^^ from tuberculosis, but the relative importance womanhood. of the disease as a cause of death is less because (-D). page 57. of the increased fatality of other diseases. Violence (13.1 per cent), pneumonia (8.8 per cent), Bright's disease (7.5 per cent), and heart disease (7.1 per cent) are the next most important causes, and cancer (4.5 per cent) now makes its appearance as a considerable cause of death. The period from 45 to 59 years is hard to designate; perhaps we may call it the harvest time of life, as it should The harvest time of life, be, after the exertions of mature manhood and (S),page58. womanhood and before the shadows of advancing years become too pronounced. Here tuberculosis ceases to be the most important cause of death; its proportion of the total (12.1 per cent) is reduced to one-half of that of the preceding period. This is because the degenerative diseases begin at these ages rapidly to increase in their efi'ect upon the death rate. Violence declines (8.5 per cent) because the days of most active labor are over, but heart disease (12.5 per cent) now exceeds tuberculosis and becomes the leading cause of death; nephritis and Bright's disease (11 per cent) is close behind; and cancer (10.5 per cent) is almost equally important. 53046—08 3 34 TUBEECXJLOSIS IN THE UNITED STATES. Advancing age yields fewer deaths in proportion from tuberculosis Advancing age. (4-6 per Cent), wliile heart disease (17.4 per cent), (i^),pageo8. nephritis and Bright's disease (11.5 per cent), apoplexy (10.5 per cent), and other organic affections absorb the lion's share. The death rate from tuberculosis is also diminishing, and in the final period of life, from 75 years of age upwards, the proportion of deaths from tuberculosis is less than in any of the preceding age periods. The relative frequency of deaths from tuberculosis as compared with other causes varies among the different deaths from tuberculosis by statcs of the registration area. The deaths states. necessarily include those of nonresidents, many of whom are invalids who have resorted to the states in which their deaths occurred in search of health, and hence the relative proportion of deaths from tuberculosis or even the absolute death rate does not gage the natural healthfulness of the state with re- spect to tuberculosis. In California no less than 15 per cent of all deaths that occurred during the year 1907 were from tuberculosis; in Colorado even more, 16.4 per cent; while ^Michigan showed only 7.4 per cent, Vermont 8. 1 per cent, and New Hampshire 7.6 per cent. But consumptives go from ]\Iichigan, Vermont, and New Hampshire to California and Colorado, and there is no systematic plan yet accepted whereby their deaths, should they occur in the latter states, may be charged back to the states in which the disease originated. For some valuable data on this point reference may be made to the recent registration reports published by the state board of health of California. The time mil undoubtedly come, -with, the more general extension of the registration area, when it will be possible to establish equitable rules for this purpose. The influence of color has aheady been referred to, although it is Color. difficult to dissociate the influences of race and Table 9, page 60. Conditions of hfe as related to the production of an excessive mortahty from tuberculosis. According to the returns from the registration area of 1900, the colored death rate from pulmonary tuberculosis (490.6 per 100,000 of colored population) exceeded the white death rate (173.5) by 182 per cent. Death rates of the colored included chiefly the residents of the nonregistration cities of the South. Until the admission of Maryland in 1906 as a registration state, there existed no appreciable amount of returns from rural colored population, so that all of the comparative death rates of white and colored must be taken with much caution. According to the mortahty statistics of the census 3^ear 1900, the Conjugal condition. death rate of unmarried males aged 15 years or Table 10, page 60. ovcr from tubcTculosis of the lungs (309.8 per 100,000 persons of this class in the population) was considerably TUBERCULOSIS IN THE UNITED STATES. 35 higher than that of unmarried females of the same ages (225.2), The death rates of married males and married females were practically tho same (215.5 and 216.4, respectively), but ^vith the widowed again, the male rate (465) considerably exceeded that of the female (2.35.1). For the three age periods shown, the highest death rate from pulmo- nary tuberculosis was that of widowers aged from 15 to 44 years (667), while the lowest rate was that of married women aged from 45 to 64 years. The incidence of tuberculosis of lungs (pulmonary "consumption") as compared with other diseases upon the gen- Relative prevalence of tu- eral classes of occupations may serve to draw bercuios's by classes of occu- some broad lines of distinction, but the groups Table ii, page oo. of occupations are hardly sufficiently definite to yield results of much value. Moreover, the fact must be considered that they difler con- siderably in age distribution, and this is a very important factor of the death rate. Tuberculosis of lungs caused 376.8 deaths per 100,000 of the laboring and servant class in 1900, being the maximum rate shown for any class of occupations, and the lowest rate for tuber- culosis of lungs, 147.2 per 100,000, was among those engaged in agri- culture, transportation, and other outdoor employment. More specific, and hence generally more valuable, information is obtainable from the examination of the death ^^^^^ ^^ tuberculosis for rates from tuberculosis of certain listed occupa- specified occupations. tions of each sex, the statistics being hmited to "^^^'^ ^^' p*^® ^^• persons over 10 years of age employed in gainful occupations in the registration states during the census year 1900. Here again the difference in age constitution of the persons employed must be con- sidered, and data upon this point are available for the most important occupations shown in the volume on Vital Statistics, Part I, of the Twelfth Census reports, to which reference should be made. The highest death rate from tuberculosis of the lungs per 100,000 of persons of specified occupation in the popu- lation in 1900 was that of marble and stone cut- ^^ tuberculoses. ™°^' ^" ''"^ ters (540.5), followed by that of cigarmakers and tobacco workers (476.9), compositors, printers, and pressmen (435.9), servants (430.3), and bookkeepers, clerks, and copyists (398). Laborers (not agricultural) showed a high rate (370.7), but farmers, planters, and farm laborers had one of the lowest rates for males in the list (111.7). Occupational mortahty is one of the most important features in vital statistics, but it is subject to many practical diffi- culties in the collection of the data, which come from two sources, namely, the enumerators' returns of population and the registration returns of deaths. Unless the statement of occupation is identical for the population and for the deaths, there is much risk of overstatement or understatement of the mortahty from a given occupation. Hence 36 TUBERCULOSIS IN THE UNITED STATES. special caution is recommended in employing comparative occupa- tional rates of mortality. The death rates due to all forms of tuberculosis may be studied for Death rates from tubercu- the jesLTs for which the aimual reports on mor- losis (aU forms) by states and taKty statistics havc bccu Compiled, but it Table 13, page 66. should be remembered that a considerable addi- tion was made to the registration area in 1906, and that in con- sequence thereof some of the relations between its main subdivisions are disturbed. Comparisons between the years 1907 and 1906 need no correction, nor are corrections required in examining the rates for the individual states and cities. The total death rate of the registration area from all forms of tuber- culosis in 1907 (183.6 per 100,000 of population) was sHghtly less than in 1906 (184.2), and all of the main subdivisions showed a decrease except the rural part of registration states, which increased from 140.4 to 142.5. Six of the fifteen registration states showed increased mortahty from tuberculosis, but the changes are well within the hmits of the ordinary annual fluctuations. The highest death rates, by states, in 1907, were those of Colorado (289.4) and California (278.9), both favorite resorts for the tuberculous; Rhode Island (200.9), very densely populated and largely urban; and Maryland (200.2), with its large colored population. The lowest rates were in Mchigan (103.5), South Dakota (105.1), New Hampshire (130.5), and Vermont (131.2). For San Francisco recent rates can not be given because of the difficulty in estimating population since the earthquake of 1906. The immensely high mortaHty of Denver (486.6) is due to the inclusion of the deaths of nonresident tuberculous invahds, as is also that of the Bronx borough (512.6), which includes hospitals receiving patients from Manhattan and other boroughs of Greater New York. For a fuller study of the variations of mortaHty in the individual cities reference should be made to the detailed data in the annual reports. 11. — The Work of the Bureau of the Census in Vital Statistics. In order to obtain a correct idea of the relation of the Bureau of the Census to the registration of vital statistics, Relation of the Census to ^ ^^ incidcntaUy to cast somc Hght upon the registration. "^ o jt vaHdity of the results obtained and to suggest means of improvement, the mechanism of the registration and com- pilation of vital statistics must be studied. The working force of the Bureau of the Census, formerly, and still informally, known as the "Census Office," is divided into four princi- TUBERCULOSIS I^: THE UNITED STATES. 37 pal "divisions" in accordance with the chief Hnes of statistical inquiry. These are : (1) Division of Population. (2) Division of Manufactures. (3) Division of Agriculture. (4) Division of Vital Statistics. Before the organization of the permanent Census Office in 1002, the work of the Census was necessarily confined to the compilation of data collected by or during the decennial enumerations. Wliile the material necessary for statistics of population, manufactures, and agriculture, can be so obtained, it was recognized at a very early date that vital statistics could not be collected satisfactorily by enumera- tion, and, beginning with the Tenth Census, 1880, an effort was made to obtain better returns of deaths by substituting the results of imme- diate registration, under laws requiring burial permits, as conducted by certain states and cities. The registration area thus instituted has increased until at present it comprises nearly one-half (48.8 per cent in 1907) of the total population of continental United States; and with the effective enforcement of new laws already in operation or Hkely to be passed in 1909, it is possible that it will embrace nearly two-thirds of the entire population at the date of the Thirteenth Census, 1910. Taking a tyjiical state of the registration area as an example, the following processes would occur in the registration and compilation of a death : 1. The undertaker or, in the absence of an undertaker, the person in charge of the interment, removal, or other disposition of the body, takes a blank certificate . ^"'^ °^^ undertaker, reia- ^ '' ' . . tive, and attending physician. of death provided him by the state registration office, (1) has it filled out with the name, sex, age, color, conjugal con- dition, occupation, and other personal particulars concerning the decedent and signed by a relative, friend, or other person acquainted with the facts; then (2) presents the certificate thus far filled out to the attending physician, or coroner in certain cases of violent death, who fills out the medical certificate of cause of death; and finally (3) delivers it to the local registrar of death hefore the interment, removal, or other disposition of the body. 2. The local registrar receives and examines the certificate dehvered to him by the undertaker, and if it is properly _ , , , . Z' . 1 . 1 • 1 I^ufy °^ ^°'^^ registrar. executed, issues a burial permit or a removal permit to the undertaker, which authorizes liim to proceed with the interment or removal of the body. 3. The local registrar should record the death in his register before issuing a permit, as he is thus more apt to detect omissions. He may 38 TUBERCULOSIS IN THE UNITED STATES. index the local register for convenient reference, and in cities he fre- quently makes a weekly, monthly, or annual compilation of mortality statistics for local sanitary purposes. Soon after the close of the month (e. g., on the fourth day of the following month in Mchigan, on the fifth in Pennsylvania) he sends to the state registrar all of the original certificates of death registered with him for the month or, if no deaths occurred, makes a postal card report of "no deaths." 4. The state registrar receives monthly the prompt returns of deaths from each local registration oflB.ce, and aeregisrar. ^^ mcans of the reports of "no deaths" is enabled to know that each district of the state has reported all of the deaths that have occurred. He examines the returns, obtains neces- sary corrections for items imperfectly filled out, and in general sees that the law is uniformly and effectively enforced throughout the state. The returns are indexed and such statistical compilations are made and pubhshed in monthly bulletins and annual reports as may be required for state use. 5. Under the census law, the Director is authorized to obtain tran- scripts of certificates of death from such states Transcripts for the Census. i-,. // • ,i t ,• i> ,i -r\' and cities as m the discretion of the Director possess records affording satisfactory data in necessary detail," and these transcripts are made out for each death upon an individual blank in the exact form of the Standard Certificate. Formerly these transcripts were sent in annually or semiannually, but an effort is being made to secure prompt monthly returns to Washington of the transcripts from the registration states and cities, so that the annual report on MortaHty Statistics may be compiled and pubhshed at an earHer date. 6. On arrival at the Census OflSce the transcripts are examined, and corrections of imperfect data are obtained Compilation by the Census. - ., , ,i , • , ji so far as possible; the transcripts are then "edited," that is, the numbers corresponding to the classification of causes of death, occupations, etc., are inserted in readiness for the next process of compilation. 7. From the perfected transcript of a death all of the statistical information required for compilation is transferred to a card by means of a punch. The punched cards are then compiled by means of electric tabulating machines, which record on many dials the various items necessary for the statistical tables. The resulting tables, arranged and edited, constitute the annual report on Mortahty Statistics, which is distributed to state and cit}' sanitary authorities, physicians, foreign governments, etc., and is for the use of all persons interested in the condition of the public health of the United States. Uuq SB S PLACE C County of — Townsiiip of- or Village of DEli City of \ [If dsath occurs away fj USUAL RESIDENC give facts called for un " Special information. rJEIiSONAJj SEX Maid DATE OF BIRTH 24 .._.t/i SINGLE, MARRIED, WSDOWED, OR Dive BIRTHPLACE (State or country) NAME OF FATHER BIRTHPLACE OF FATHER (State or country) MAIDEN NAME OF MOTHER BIRTHPLACE OF MOTHER (State or country) OCCUPATION THE ABOVE STATED BEST OF MY KNO' (Informant) (Address) Filed .190 PLACE OF DEATH County of -....-J)EN.VER«.__ Township of Village of ^./'", DENVER, ,„„ City of. -" 'No^ [If death occurs away from USUAL RESIDENCE ""Speclalfnfoma'tlon""]" FULL NAME ._. 3436 STANDARD CERXIFICAXE COLORADO 1127 W. Cedar -St.; Ward) a Hospital or Institution, givo its NAME Instead of street and numberil FEUBON^L ^ > STATISTICAL FAJBTICUJiAjaS '"°try) Missouri (Slutour country) (Informant) (Address) . MEDtOJ-L OBnTIFICATE OF HJSATJI DATE OF DEATH Dec. 9, 1907. jgO- "{Monih")"'"" "(D^y)"" (ToaV) I HEREBY CERTIFY, That I attended deceased from .J90-. -to- that I last saw h.. — alive on and that dt.ath occurred, on the date stated abov< M. The CAUSE OF DEATH was as follows -Pti^^m&tm-yy-T u bercttl-^g-ig-- ..^, 'SyrsV -190 (Addri SPECIAL INFORMATION only for HosplUls, Inslltiillons, Transients, r Rocent Resldonts, UNDERTAKER TT^rln'.iiy \ s :- r >.'i;'.-4 j". o C3 r^ CO 4 o o ^03 P hH m r^ r-t Cl %. .^ t> ir o w J:3 A, _^_5f^__ H K ^■3 CO m Cl '3 :^m ,t2 - o ■5 -J a CO t' '■■' ■VD '■-'O o H »H CI '^ 1 ' ^ A o :o o P i-'W I-) 'r-\^ CO Cl Cl eg f 1 l^# ^; H Vi |p^^ h 1 J o^^ Cl _ "-^ C) Cl 1 CO CI 3 ^^ '•J •i f.' } r^ CO 10 I> CJ> -U d S ^2 .-5 o o C-1 ^. o^ n '1 -, .^ iL „ r-- 10 CI CO o o LI Cl n CO CO o o o o ^^ ^. o ^. r- ^"^ L- o o o I-* Cl (.i ■J' i" o tc < o lO o n CI CO o rH CO -:< 1' '■5 o o '-' CJ CO >1< 'C* ^^ ^ ^^ o o l*! cW ■r; w CO Cl r-t O m o CO wj Cl^^ fl -H^^ w CJ CO S;! ■3< o i.O 3 .« rH Cl O o ■D ■" ■"* '■' '^ Ol CO CO J^ 3 2 -( >-' o O o CO ^ 1 "^ '■3 :i CI CO ■Tj '"^ -A o o A^V o CO r^ M W ft CD p^ rH o U3 ;^ pj _^ ^J) »^~ IH ji p!, ,o t^ en LO CO CO < ^ ^' o r-t CO CO 1.0 X g| •3< " *^%^^ ■r'^ ' "J o ^ A n LO I> o ■0 .-, .a ^ ^^ n ^ o ji» - o ^1 1-5 ■p __ r^._ _.^__. Cl lO u # Of4 02 o^ ,-. 22_ '» !-•? ■n r- n n # ^# riP^ -M o__^"_ rt CI o _ o t- ro CO^ 70 # o^ rH CI o •^ L? '^ r- ^ 01 coc TUBERCULOSIS IN Tlili UNITED STATES. 89 It is evident from the foregoing outline, that accurate mortahty statistics are dependent upon the faithful service and cooperation of many individuals. Requ'S'tes for accurate ^ 1111 mortality statistics. It is necessary that there should be — 1. Obedience to the law on the part of the undertaker. 2. Care in filling out the statement of age, occupation, etc., by a relative or friend of the deceased person. 3. Care and special knowledge on the part of the attending physi- cian or coroner in stating the cause of death. 4. Interest and care on the part of the local registrar in seeing that the certificates of death filed with him are completely and properly filled out and that all deaths that occur in his jurisdiction are promptly registered and returned by him to the state office.^ 5. Alert supervision by the state registrar so that the law will be thoroughly enforced in all parts of the state, with the will and power to compel obedience on the part of undertakers, physicians, and local registrars when necessary. 6. Careful examination of returns by the state registrar and prompt securing of missing data or correction of imperfect statements of cause of death. 7. Accurate copying (which implies comparison) of the original certificates upon the transcripts sent to the Bureau of the Census. 8. Prompt examination of transcripts upon receipt by the Bureau of the Census, and correspondence for corrections. 9. Careful "editing," especially for classification of causes of death, by expert compilers thoroughly acquainted with the International Classification and with the use of medical terms. 10. Accurate transferal of data to the punched tabulation card. These are "compared back" with the original transcripts to insure correctness. 11. Careful tabulation of punched cards. Electrical tabulating machinery has reduced this to a mechanical basis and thus largely eliminated the "personal equation." 12. Lastly, the editorial work proper, or the analysis of the figures presented in a registration report. The analysis is subject to error, but the figures themselves stand as witnesses of their own significance. The chief difficulties in obtaining accurate statistics of the mor- tality from tuberculosis (or any other disease) for the United States are due to the following .^"^^SSfZl^^Si:^. causes : 1. Adequate laws, with the requirement of compulsory burial per- mits, do not yet exist in a large portion of the United States. At- tempts to collect data concerning deaths by assessors, or through 1 See Census pamphlet No. 101, "Practical Registration Methods," which is de- signed to aid the local registrar in his work. 40 TUBERCULOSIS IN THE UNITED STATES. county officers, or by direct reports from physicians or undertakers, without the rigid requirement of burial permits issued by a local registrar, are futile and worse than useless so far as reliable mortality statistics are concerned. The remedy for this lies in the passage and enforcement of ade- quate laws, and the American Medical Asso- Cooperation for extension ciatiou, the Conference of Commissioners on or registration area. • r-i Uniform State Laws, and the American Public Health Association have united with the Bureau of the Census in recommending a model bill for the consideration of state legisla- tures at their approaching sessions. The Bureau of the Census has been earnestly engaged in this work — the extension of the registra- tion area — ever since its establishment on a permanent basis enabled it to plan for the future, instead of being concerned alone with the tabulation of past results. Its efforts in this respect have been attended with signal success in Pennsylvania^ and other states, and Congress has especially commended the movement in the following joint resolution: JOINT RESOLUTION REQUESTING STATE AUTHORITIES TO COOPERATE "WITH CENSUS OFFICE IN SECURING A UNIFORM SYSTEM OF BIRTH AND DEATH REGISTRATION. Whereas the registration of births and deaths at the Resolution by the Con- ,- j-ji- j -i rc-i j • t x- c ^u TT -f. J c. tune of their occurrence furnishes oincial record inf ormation gress of the United States. of much value to individuals; and Whereas the registration of deaths, with information upon certain points, is essential to the progress of medical and sanitary science in preventing and restricting disease and in devising and applying remedial agencies ; and "\^Tiereas all of the principal countries of the civilized •world recognize the necessity for such registration and enforce the same by general laws; and "WTiereas registration in the United States is now confined to a few states, as a whole, and the larger cities, under local laws and ordinances which differ widely in their requirements; and WTiereas it is most important that registration should be conducted under laws that will insure a practical uniformity in the character and amount of information avail- able from the records ; and Whereas the American Public Health Association and the United States Census Ofl&ce are now cooperating in an effort to extend the benefits of registration and to promote its efhciency by indicating the essential requirements of legislative enact- ments designed to secure the proper registration of all deaths and births and the col- lection of accurate vital statistics, to be presented to the attention of the legislative authorities in nonregistration States, with the suggestion that such legislation be adopted: Now, therefore, Resolved by the Senate and House of Representatives of the United States of America in Congress assembled, That the Senate and House of Representatives of the United States hereby expresses approval of this movement and requests the favorable consideration and action of the State authorities, to the end that the United States may attain a complete and uniform system of registration. Approved February 11, 1903. ^ See Census pamphlet No. 106, "Extension of the Registration Area for Births and Deaths." See also Census pamphlet No. 108, ''Legal Importance of Registration of Births and Deaths," copies of which are obtainable at the Census exhibit of the International Congress on Tuberculosis. TUBERCULOSIS IN THE UNITED STATES. 41 2. Where fairly efficient laws exist there is frequent difficulty in obtaining from physicians correct statements of the causes of death. This is due to two reasons: (1) Lack of a uniform and plainly com- prehensible blank for the medical statement of cause of death, with expHcit instructions for its use;^ (2) lack of uniform nomenclature^ of diseases, which results in a difficulty in understanding just what the physician meant in his statement. The question of the form of blank has been solved, to a considerable extent, by the adoption of the Standard Certifi- cate by many states and cities. Unfortunately , Uniform certificate of dea.h '^ , , . *' to be adopted. all do not use it, and the Section on Vital Statis- tics of the American Public Health Association has rendered a great service by recommending, at its recent meeting at Winnipeg, August, 1908, the exclusive use of an improved form of the Standard Certifi- cate byall registration offices in the United States after January 1, 1910. The question of nomenclature of diseases has also been taken up in a practical way by a committee of the Ameri- can Medical Association, whose chairman is Dr. Uniform nomenclature of ' _ ^ diseases m preparation. Frank P. Foster, of New York. This committee is cooperating with special committees appointed by other national medical organizations, and with the Government medical services (Army, Navy, and Public Health and Marine-Hospital Service), and with the Bureau of the Census. As a result of its labors, it will be possible for the physicians of the United States to have a standard of reference for the use of medical terms, and for the Bureau of the Census to cooperate with state and city officials in recommending the use of authorized terms to report causes of death.^ The vital statis- tics of the future must be statistics of greater precision, for they are to be the working tools of an aggressive scientific public health ad- ministration. III. — How THE International Congress on Tuberculosis Can Promote the Prevention of Tuberculosis by Insisting upon THE Necessity for Complete Registration of Deaths through- out THE United States. Une statistique generale de la tuberculose ne peut etre etablie convenablement qii'au moyen d'une statistique generale des causes de decfes Etablie selon une nomenclature comparable de pays a pays et sp^cifiant les principales maladies qui peuvent etre con- fondues avec la tuberculose (bronchite clironique, m^ningite, etc.). La nomencla- ture dite ' ' internationale " est particuli^rement recommandable. — Dr. Jacques Bertillon. ' See Census pamphlet No. 107, "Modes of Statement of Causes of Death and Dura- tion of Illness upon Certificates of Death." - The International Classification of Causes of Death is not a complete nomenclature of diseases. ^ As by Census pamphlet No. 102, "Tlelation of Physicians to Mortality Statistics,'^ a new edition of which will be prepared. 42 TUBERCULOSIS IX THE UNITED STATES. The above quotation from Doctor Bertillon's valuable paper on „ . . , , , . ' ^Comment doivent etre etablies les statistiques Statistics of tuberculosis a . ^ ^ part of general mortality sta- relatives a la tuberculose dans les viUes, dans lea *^'^"- campagnes, dans les hopitaux, dans les sanato- riums," read before the International Institute of Statistics at its session held at Copenhagen in 1907, is presented for its direct bear- ing upon the proper method of obtaining general statistics of tuber- culosis. Such statistics are a part of general mortaUty statistics, and the whole Hst of causes of death must be studied in connection with them. Moreover, in the United States we must first obtain our gen- eral mortality statistics for a considerable part of the country, since it is useless to expect statistics for an individual disease unless all deaths are registered as they occur. The following abstract of the address of the chief statistician for vital statistics of the Bureau of the Census as chairman of the Sub- section on "Collection of Statistics" of Section VI, ''State and Municipal Control of Tuberculosis," of the International Congress on Tuberculosis, contains a preUminary draft of certain resolutions whose sanction by the Congress, and whose practical recognition by the sanitary agencies now interested in the control of tuberculosis, would be of the utmost service in securing adequate mortality statistics for the United States, and thus providing the means by which the warfare against tuberculosis, and against all other diseases which may be controlled by man, will be vitally aided : COLLECTION OF STATISTICS OF TUBERCULOSIS. [Abstract.] In efforts for the "State and Mimicipal Control of Tuberculosis," „ . r , , , the first and most obvious step is to ascertain Registration of deaths and <. i i • notification of sickness from the amouut of tubcrculosis present m a given tuberculosis. countrv, statc, or city; the forms and conditions of its occurrence; its natural fluctuations; and thus to be enabled to measure the value of procedures undertaken for its prevention and restriction. This imphes — (a) Registration (notification) of all cases of tuberculoeis. (b) Registration of all deaths from tuberculosis. Subdix^ded by character of area, ve have — 1. National registration of tuberculosis — (a) Sickness. (b) Deaths. 2. State registration of tuberculoeis — (a) Sickness. (6) Deaths. 3. Municipal registration of tuberculosis — (a) Sickness. (6) Deaths. TUBERCULOSIS IN THE UNITED STATES. 43 The registration of sickness and deaths from tuberculosis is of value to a sanitary administration not only for the statistical informa- tion afforded but as an administrative means whereby the health officer may come into close touch with cases of tuberculosis, as soon as they are recognized by the attending physicians, and thus be enabled to instruct the patients, their families, friends, and neighbors in regard to the necessary precautions to prevent infection of other persons, and to give helpful general advice. It is not worth while to attempt anything less than complete regis- tration of all cases of sickness and death from tuberculosis. This is especially true from the 3e„^°a7'''' '*"''''" "■' "' point of view of the statistical data collected. Imperfect statistics based upon incomplete returns may be misleading and worse than useless. Accurate registration of sickness from tuber- culosis should be of much greater value to a sanitary administration than the accurate registration of deaths, and is of particular impor- tance to the tuberculous sick. For the individual the accounts are closed when it comes to the mortality statistics. The registration of all cases of sickness from tuberculosis or from any other disease pre- sents extreme difficulties, however, especially in the Unifed States; it is futile to expect even approximately correct returns of sickness when the deaths themselves are not recorded, as is the case in a large portion of the United States. The first and absolutely necessary step is, therefore, to insure the complete registration of all deaths, including those of tuberculosis, and the Congress on Tuberculosis should com- mend, and its members in the United States should earnestly support, the organized efforts made to secure the extension of the registration area in this country. The following resolutions may be submitted under this head: A. INDISPENSABLE IMPORTANCE OF REGISTRATION OF SICKNESS AND DEATHS FROM TUBERCULOSIS. 1. The registration of sickness and deaths from tuberculosis is of indispensable impor- tance to a sanitary administration which undertakes to com- bat this disease, and the registration (notification) of sickness ■ . ^^ •^'"^0' r^ from tuberculosis should be of special benefit to the tuber- culous sick, to their medical attendants, and to theh families and friends. For its full value, especially for administrative and statistical purposes, such registration ought to be complete; and it should be considered a paramount duty by legislators, sanitary officials, the medical profession, and the press and public, to bring about such complete and effective registration of all deaths and sickness from tuberculosis. 2. The first step, in the United States, must be to secure the proper registration of all deaths, from whatever cause; the registration of deaths from tuberculosis is merely a part, although a very important one, of the general problem. It is useless to attempt adequate registration of sickness when deaths are not registered . The organized efforts and cooperation of the American Medical Association, the American Public Health Association, the Conference of Commissioners on Uniform State Laws, the United 44 TUBERCULOSIS IN THE UNITED STATES. States Public Health and Marine-Hospital Service, and tlie United States Bureau of the Census, to secure the adoption and enforcement of adequate laws for the proper registration of deaths and the extension of the registration area of the United States,'are, therefore, most cordially commended by the Congress on Tuberculosis as affording the first and absolutely indispensable means for the control and final suppression of tuber- culosis in this country, and all who are interested in the movement for its control are earnestly requested to help to secui-e the necessaiy legislation, and to support it when secured and to seek to educate public sentiment on this subject, to the end that the United States may attain a complete and uniform system of registration. The comparability of international statistics of tuberculosis should Accurate and internation- ^6 assured. This requires a knowledge of the ally comparable statistics of various systcms of classification ia use, and also tuberculosis required. ^^ ^^^ tendcncj amoug phjsicians to report deaths under terms that may be classified under titles having no apparent relation to tuberculosis. The use of the International Classification should be indorsed/ as its general acceptance will re- move many of the difficulties now inherent in comparing the statis- tics of one country with those of another. The International Com- mission for regular decennial revision of the International Classi- fication will meet in 1909, and the Congress on Tuberculosis should make specific recoimnendations relative to the form in which the statistics of morbidity and mortality from tuberculosis should be presented, so that they may show most satisfactorily the true inci- dence of the disease upon the various classes of population, and under different environments, and may be more closely in harmony with practical clinical classifications. The medical profession should be educated to present, and the people to demand the TRUTH about the occurrence of this disease; the failure to report tuberculosis as a cause of sickness or death, when such reports are required by law, or the making of a false report to conceal the presence of this disease, should consequently be considered a dishonorable professional act on the part of any medical attendant; and any regulations of insur- ance companies or other institutions tending to the falsification of the reports of tuberculosis should be considered as contrary to public policy. The following resolutions are proposed: B. NECESSITY FOR UNIFORM STATISTICAL CLASSIFICATION AND ACCURATE REPORTING OF TUBERCULOSIS. 1. All Statistics of tuberculosis, whether national, state, or municipal, and also sta- tistics of hospitals and institutions, should be thoroughly Preliminar)' draft of reso- (^oj^pa^able, both for the statistics of sickness and of deaths. lutions proposed. _..,,, ,^1 i t Physicians should confine themselves to the accepted terms of the standard classification, and doubtful reports ("possibly tuberculous") should be systematically investigated by sanitary and registration authorities. A penalty ^ At the recent meeting of the American Medical Association at Chicago, June, 1908, the House of Delegates imanimously resolved "that the International Classification of Diseases and Causes of Death be recommended for all official morbidity and mortality statistical reports." TUBERCULOSIS IN THE UNITED STATES. 45 should be provided for false statements intended to conceal the presence of tubercu- losis, the making of which should be considered a matter of professional and personal dishonor; and all legal requirements relative to insurance and other matters tending to falsification of official statements of causes of illness or death should be held contrary to public policy. 2. The Congress on Tuberculosis should endeavor to secure the adoption in all sta- tistical classifications of a standard classification of tuberculosis, and for this purpose should appoint a Committee to consider the various forms now in use and to present its recommendations to the International Commission for the Revision of the Inter- national Classification of Causes of Death and Sickness, which meets in 1909, and also to the registration authorities of the governments employing other systems of classifi- cation, to the end that as soon as possible a uniform classification of tuberculosis may be used by all of the countries of the world. SlXry VEAKS O? tuberculosis Call forms) DEATH RATES PER 100,000 Of POPUUA.T10W i^ Annual r "P " z z - - = = = ~ Z ~ ~ — — *•' Ill % \ 1 S ^ ■, 1 / p \ _ 1 111 / \ ^ Ss, Ui /, ^ 1 '' lA^ «. ^ _ „ _ " — J 1^ tc H - _J ^-j L — - — — - s — — — — - — _ ^ — _ _ — — _ — — ... — — - - p n^ - — — — — =^ ^ s '. ■', ^'^ *^ ■ a s :"mj ^ 1 *< % ^ ~ Is ^' \ rt ts •J ^ "'f , s ] '6 :1 T • s* / s ** *, , "« ,,1 *s ^ N > , '\ ri , 'UJ Uc " S. « v\ ■"' < p« V % ',0 s ""■!» — ■« at iL -J r? -f^ £ti L_ _ r^ _- _ « ;* ^ _ 9t ^ !» ■J >B 1^ N ^ Jt '« % rA u s, _, ^ N, V _ _ _ __ _ >■• — n ^ -^ Vl — — — — - — — — — i* pi3 ■T — »5 fi - __ — — — — 1 - "^i s> ^" — -J — — — rR(«lWraHn>Area,rirM(bir t T5 "0 = 2 i Extension of the RegistraHon Area of the Unil-cA 51- It- cs means Increasei Power ouer Tuberculosis i REFERENCE TABLES. (47) TUBERCULOSIS IN THE UNITED STATES. 49 Oj O (0 M C8 E'^StJ « 3 •"P.O'^ c^oo COb-t^t^OCM»raiOr^Oi "^OOCC CO,''-< >o 1-t '^ t .-( 05 CD CO CO <3 CO lO .-H -«J» Ci r COC)C4COC^COCOOOr-« CO CO CO CO CO CO CO CO CO CO °S2S§5.! lOCO*O^OC^itMt--C iC O *VX> O h- t~» CO lO lO Tp lO ?0 CO cocDt^OiXicOcDcDcDcO pot— OiOCNi-tt 5 to CD O t— t- I> c go gogogooooo '^gggggSSSSS **"* lO CO CO'co'-^'^CD'arci't^r-rt-^co" a^-r-^':S-^^-«S t^t^ i>^o6"ocroo"oc oT of oToTor o'crToo't-H'^i-Hr-rN'c^ !••« 53c 03 p . 00 CO CO CO CO CO ■* -^ "O lO O >0 S Tf CO O 1-H CO 00 S^ 5 S gt3g» — — - — ■ — ■ — — -— J;^ gj 4J ts go OOOOOOOOOQ OOQOOOOOOO <^ S3 S 2 oo oooooooooo ooo<5oooooo flt]®B COOJ (N -^ t^ O CO lO l:^ OJ ^ CO cO'5'ioScO O^S-tnto " •" . T) 0>0> OOO^i-lrt^rtC^lCM (N(N(NC^(?gcOC0CO'*n< "'(BoB 1-1 r-( rl r-l rt .-H rH ,-1 ,-H r-H rt r-l tH >-l r-l t-H ■-! i-H >-l rt „ ^ j, W •§» 'S'lH iH iH 00 OS IM IN O «0 1-1 M ^ CO >-l N CT> "3 (N -^ rH >-l Oil— IQiOoO^eOi-ib-iO (NCNOa>0 CO - -- jioioio _ _ . — ^^.- coco 00 00 CO oo 00 00 00 00 CO CO CO 00 00 00 00 00 oo 00 00 00 O CO CD to CD CD CD 3:^g5 o m g-" ■"So 2 c| ~ g £ (0 5 33 n > boba <1'5bSS - d"^ " 53046—08- 50 TUBERCULOSIS IN THE UN'ITED STATES. 1 •13 w 3 '-S'S „• c3 p ffi ^ ^ P-^5"S >" Q.O'O Q CD M 3 ^-^ cc d 00 r^ t^ oc !0 ^ '— I c^ c ic 05 00 w r^ t* t>- c; ic ooo occi W t- t^cic^co icci(^iOi-<:Dc4iocc'-i ■^•—i^occcDoic^ccT-* c^c^t--c-- lOirsiOLO-^-- OC^MOCSW^OOCCi-1 I TT r>^ lO oi (N o o o (N CO CO ■^ 1— < OJ O 00 CS Ci 05 OS C0C^CN(MCMC^o5o"r-rcro'co"ocr ict^co^cTcrcd'coc^-^oo' ^^^'co'co^cTc^otrorocri-r CO S ;c X: r^cc c^iv t^o to o ooo coo co :oo ooo lOO GSoo oo >iC3 oooooooooc csoooooocoo OwOw — ooocc o :d" cT lO lo o o CO ■n-TrsT t^o-^r^ocot^ocoi^- c^cococo'^"^'5ro»o>o COQOOOCOOO OOOOOOCJOOO OC3000CO oooooooc:;oo o c; c c o o oooccooooo T-H ^oTco 00 otri-H"or CO O»OOiC.-^00'^ t^ t-H -^r 00 1— I »-'5 OC' M OC^-^l>-OrCt^T-i "^CO(NCNCNCNOJC0'»ic;(Moo»J^oc3'^ i oi CO -c. co^»■^OlO■^T-lt^cOt-^ OOt-Hci'^COOOOOJidoO CS^CiCDT-(rj. Hoct-coiot-' 05 00 00 r- 1^ o CO »o CO CM iOOOOOOO"*OOCOOO> c- IC »-H CO t-* 1-i CO CI Ci 00 CM CM CM lO U5 CD O I>- t* 05 -^ IV lO Cft S O !>■ t-» CO - i-l t-h C^ i-H CO CO "^ "^ CM CO »-l CO CO CM CM CO i-l OS OS O lo CO CO CO «o CO CO o CO CO ^-^*^-t*t>-t t^t^l>-l:^t^t^£-«.cOOt^ §000000000 OOOOOOOOOO OQOOOOOOOO OOOOCOOOO OOOOOOOOOO OQOOOOOOOO OOOOOOOOO OOOOOOOOOO OOOOOOOOOO TjTcM'T-rr-rcM't^co'crco'co" ■^ic't^cTcM o6~co ic'co" cT oTo CM"co"croo'"oo"o --TiO O5C0t>.— iidt^OCMOOO ■^"«'t»O-n'CiOwl>.C0 cc^Ci-voo^r^-^o '^ lO lO CD CD CD 1> !>■ t-- t^ 00 00 00 O OS O O T-' 1-H CM CM CO CO '^ IC lO O O t^ 00 T^T^T^r^r-^r-^-r^T^T^r^ r^r^T^ r^ -^ ^ ^<^ ^C^ CM*'cM*'cm"cm'~Cm"cM*"cm'~Cm'" Cm'cm"" I— iCMCO-^^Ot^CCCiO T-tCQCO-^iOcOt^oOOSO i-HCMCO'*OOt^OOOsO t^ t^ r* t^ J>. t— !>■ h* t>. 00 OC OC CO 00 OC 00 00 OC 00 CS OS CI OS OS OS OS OS OS 03 o 00 00 00 00 00 00 OC 00 00 00 00 oo 00 00 00 OC 00 OC 00 00 00 00 00 00 00 00 00 00 00^ TUBERCULOSIS IN THE UNITED STATES. 51 OO'-H ooo 00 lO iX> QO IC fO to -^ Tji cr^ o CO »0 '^ CC C^l -^ O U5 I^ OS T-l O L'J c5 CO cc 00 cv? '^ t^ O 00 Oi c; c^ 00 r-^ r-^ cj o (>j cc CO CM c^^<^^ t-t »o -^ »n oi o> r <£> C^ '* CO 1-- " 00 CC O i-H ^' c co't>^o.'5 UD O L 'Tl' as r- 1 04 O r-t C CI I--* 'O O 00 c5 OS o> to"i-rh-r CO ;C to CD ^ lO oooooo oooooo oooooo CI C. ^ i-H (M CO CO O 1-H CO CO CO CO CO "^ ■^ CO 'S* lO CO l>- 00 CO CO(N CO(N (M LO O OS OS 00 o t>^ C1 -^ C^ CO (N O i-H T-H i-H Coo<: 300 300 >oo J'tjTio" 00 00OSO5OO cmcm^cTcm" co^co" ■^ 00 CM CD O"^ oooooo OOOOOO OOOOOO CO 1— I ^ OS CO ni rH coco OSLO OS i-T T-T T-T i-T cf cf OOOOOCD CD t^CO OS OO 00 00 op 00 OS OS ooc5oooo Loor^oooso OS OS OS OS CS OS OS 00 CO 00 00 00 OS ^o5 g8 t^ p^ ^ 03 5< a 03" cc 03 M CO o C ^ O £^ bDoJ^'" s ;^ 3 ^ ftoS ^ 03 u F-< ^Q-^ 2 SA >> J^-^ ■- a; «^ O p, ~T3 oS m H PS— © gpd 0-l-> ; ca OQ-X** 03 2 « g o a __ en ■- ■ C o _r ^ 0_- o3 ""^ ; a.: -M ^ £ ^ o 9.^ +^ ® f>>"S o; ,„ S iJ « ,1:! te ° n ojTi .>o3 03.2 " ■? '"' • £^ ^.2^ o3'3 tr t! ■" p! tr''3 -r TS c ' a i< -^ > S (D - O o3 to 4J •- ja Ts 3 .12 <^ o3 ptH Eh S fto2 ^ 'Ow « -2 o — ftp, P^ o 52 TUBERCULOSIS IN THE UNITED STATES. Table 2. — Death rai-es from tuberculosis of lungs in the registration area of the United States and ni certain foreign countries {during recent years): 1902 to 1906. j NUMBEE OF DEATHS FEOM TXTBEECULOSIS OF LUXGS PEE ! 100,000 OF POPCLATIOK. 1^^- United States (registration area Anstralasia Australian Commonwealth . . New South Wales Queensland South Australia Tasmania Victoria Western Australia ■ • New Zealand Austria Belgium Cevlon Chile German Empire Italys Jamaica Japan Netherlands Norway Servia Spain Switzerland United Kingdom —-.-'England and Wales Scotland .Jreland Annual '. average: • 1901 to ■ 1902 1903 1904 1903 1906 1905. 169.9 1 163.2 165.7 177.3 168.2 159.4 85.6 89.1 86.8 85.9 76.5 75.7 SS.9 91.5 90.4 89.2 80.8 7&7 80.2 ; 80.6 86.8 81.2 70.1 66. a 81.3 89.2 7a 4 79.0 75.5 67.8 80.4 ; 81.1 81.8 79.0 75.2 81.6 63.3 58.0 63.1 63.2 74.8 65.9 111.6 116.6 110.9 111.1 101.9 9^9 72.6 71.0 65.1 83.7 64.7 82.6 69.9 ; 77.3 69.5 70.8 57.0 62.1 334 8 ■ 337.4 336.2 331.4 0) (1) 11&2 i 131.6 108.6 109.1 107.5 (•) 93.0 : 90.8 91.3 92.6 95.7 104. « (?) i 0) 245.1 (1) 201.7 (») 185.8 I 187.7 187.3 182.6 179.3 (•) 114.9 1 10&8 111.6 117.4 iia2 148.8 153.7 1 147.7 155.2 163.0 152.2 160.4 14a 3 143.4 144.9 U46.4 <159.5 « 133.4 132.0 132.0 129.4 135.7 133.7 196.4 188.5 198.2 197.4 203.5 0) 279.7 1 265.6 277.5 277.0 332.5 287.4 147.8 : 186.0 144.0 % a a a o c3 =3 3 O o All causes 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Typhoid fever 1.8 3.6 1.2 98 1.1 2.5 7 1 6 7 1 1 1 2 3 1 6 2 0.7 0,9 Whooping cough 0.5 0.4 0.8 0.5 0.6 0.7 0.6 0.6 0.9 0.6 0.5 1.1 0.9 2.9 Diphtheria and croup. 1.2 1.2 1.5 1.0 1.0 1.0 1.4 1.1 1.3 1.9 1.7 1.8 1.4 1.7 0.6 Tuberculosis (all forms) 15.0 16.4 9.8 13.2 10.2 12.4 10.5 7.4 7.6 11.8 11.3 9.3 11.2 10,8 8,1 Cancer 6.2 3.1 4.7 4.6 6.1 3.8 5.4 4.8 5.6 3.9 4.5 3.8 5.1 4 6,1 Meningitis 2.0 1.9 2.0 1.4 2.2 1.4 2.1 1.3 2.2 1.8 1.4 1.1 1.4 1.5 1.1 Apoplexy 4.3 2.6 6.2 4.3 6.7 4.0 5.7 4.7 6.7 5.5 4.9 4.6 5.3 2,7 7,5 Paralysis 1.2 0.9 0.7 2.1 1 6 2 2 9 2 2 1 9 1 "^ 7 1 2 7 1 "^ 0.9 0.1 "Convulsions " 0.4 0.4 0.8 0.6 0.7 1.4 0.8 1.4 0.7 1.1 0,6 i.'r, n 4 2 1 Heart disease 10,9 5,7 9 S 9 f) 10 5 7.7 10 5 in 9 11 6 7.5 9.2 8.0 9.4 4.9 12.1 Broncliitis 1.3 0.9 2.0 1.3 1.6 1.8 2.2 2.1 2.4 1,7 1 9 1 7 ?, 1 n 2.4 Pneumonia (all forms) 7.9 10.2 9.2 7.5 9.5 8.5 9.2 7.7 7.9 in.9 11,8 9.3 10 8 3 10.4 Diarrhea and enteritis 3.4 6.0 7.9 6.2 4.1 7.9 7.3 4.9 4.9 8.0 7.6 8,6 8 9 6 9 4 6 Cirrhosis of liver 1.3 0.6 1.0 0.8 0.5 0.6 0.6 0.9 0.7 1,1 ^.?, 0,8 9 n 4 0.7 Nephritis and Bright's disease 5.6 4.8 6.0 5.6 6.1 7 5 5 2 4 6 5 6 7 1 7 9 5 6 8 3.7 1.4 6.0 2 7 Premature birth 1.5 2.2 2.5 2.5 1.8 2.4 2.5 2.0 2.7 2,1 ?..?. ?..n 2 X Congenital deoihty 1.4 1.6 2.2 2.1 2.0 3. 6 2. 7 2.6 2.6 2.2 1.9 2..i 1.6 ,3.1 0.9 Old age 1.9 1.9 1.7 2.5 4.4 2.5 2.1 3.6 4.1 1.4 1.5 1.4 1.S 4 3 3 7 Violence 10.8 10.5 7.2 7.1 5.3 5.8 6.1 7.5 5.2 7.3 6.9 9.4 6.8 8.9 5,4 Ill-defined causes 1.7 1 2 1.5 1.6 3.6 4.1 2.2 3.1 2.7 2.4 1.0 2.6 1.3 6.S 1 8 All other causes 20.7 23.6 21.4 23.6 20.5 18.2 21.0 24.9 22.0 19.4 19.9 20.2 20.2 21.3 23.2 Note.— This table is based upon the returns of the deaths that actually occurred in the several states, includmg deaths of nonresidei'is. Many of xhe deatns from tuberculosis reported from certain states were those of invalids whose illness originated elsewhere. 60 TUBEKCULOSIS IN THE UNITED STATES. Table 9. — Death rates from tuberculosis of lungs,^ of white and colored, by sex, for the registration area and registration states {aggregate, urban, and rural): 1900 and 1890. Registration area 1900. . 1890.. Registration states 1900. . 1890. . Cities 1900. . 1890.. Rural 1900. . 1890.. NUMBEE OF DEATHS FEOM TUBEKCULOSIS OF LUNGS PEE 100,000 OF POPULATION. White. Total. 173.5 230.0 170.5 242.4 197.8 285.1 131.6 177.7 Males. 188.3 240.1 182.8 250.1 226.8 308.1 122.4 165.1 Females. 158.8 220.0 158.3 234.9 169.9 263.2 141.2 190.6 Colored. Total. 490.6 546.1 431.9 529.2 471.0 600.1 322.7 365.2 Males. 527. 578. 463. 589. 525.8 302. 364. Females. 455.1 515.0 401.6 471.9 420.2 513.7 345.2 366.1 1 Identical with consumption as shown in the diagram; the latter term was employed in the Mor- tality Statistics of the Census up to the close of the census year 1899-1900. Table 10. — Death rates from tuberculosis of lungs,^ by conjugal condition, at certain age periods in the registration area: 1900. NXJMBEE OF DEATHS FEOM TU^EECULOSIS OF LUNGS (IN THE EEGISTEATION AEEA) PEE 100,000 OF POPULATION. CONJUGAL CONDI- TION. 15 years and over. 15 to 44 years. 45 to 64 years. 65 years and over. Males. Females. Males. Females. Males. Females. Males. Females. Single 309.8 215.5 225.2 216.4 292.2 208.3 667.0 223.4 237.6 356.7 565.3 223.1 487.4 235.6 153.7 189.3 604.1 244.2 312.0 296.0 236.1 Widowed 465.0 1 235.1 213.2 1 Identical with consumption as shown in the diagram; the latter term was employed in the Mor- tality Statistics of the Census up to the close of the census year 1899-1900. Table 11. — Death rates from tuberculosis of lungs ^ and other important causes of death, by classes of occupations, in the registration states: 1900. NUMBEE OF DEATHS PEE 100,000 OF POPULATION, OP OCCXTPIED MALES, 10 YEARS OF AGE AND OVEE (IN THE EEGISTEATION STATES), BY CLASS OF OCCUPATION. Agri- Per- Manu- culture, PEINCIPAL CAUSE OF DEATH. Mer- Public enter- tain- ment. sonal Labor- ing and serv- ant. factur- trans- Profes- sional. Clerical and official. cantile and trad- service, police, and ing and me- chan- porta- tion, and ing. mili- ical in- other tary. dustry. out- door. Malarial fever 6.9 37.9 7.4 182.2 22.2 263.4 3.8 46.6 7.5 304.2 18.1 154.0 3.4 28.3 5.5 165.8 19.4 17L5 3.4 27.3 10.2 268.5 15.9 192.3 8.7 38.2 6.7 254.8 8.7 144.8 5.4 51.1 6.6 376.8 7.9 199.9 4.7 29.4 6.8 262.1 11.2 172.6 4.5 32.8 9.0 Tuberculosis of lungs 147.2 13.3 Diseases of nervous system 221.3 176.8 143.8 94.0 134.7 138.7 94.2 145.5 133.4 85.9 143.4 166.1 184.3 126.0 148.2 76.5 192.5 249.2 110.2 150.0 138.9 75.5 211.1 140.0 Diseases of digestive system 91.0 Diseases of urinary system ioa4 138.0 140.9 172.9 145.5 167.3 134.6 145.5 Diseases of bones and joints 4.9 3.5 2.2 2.3 2.7 6.0 3.2 3.6 Violence ... 77.3 51.7 79.8 37.7 66.2 52.0 88.8 35.3 111.3 42.9 240.8 66.5 108.8 53.3 158.6 69.2 1 Identical with consumption as shown in the diagram; the latter term was employed in the Mor- tality Statistics of the Census up to the close of the census year 1899-1900. z o Q. 3 CO z o O z o p < J D a o Q. ii. o o o o o o UJ 0., CO X < hi O tj. o q: D Z O 00 Q Z < o o X u 0^ CO o z < o -I o o >- 00 '^^^r.':^^H'^~S'"'-'- 'H:'>'''^l' ' ''-' ^■■■^ HI Hi m m U :|~. ■1 : ■- o o o o o o o o o 09 0> CO 0> 00 a> 00 ^ *~ •" •" z 2 o o 5< 111 -J < oruj al- k-q: H< 1- C0< toH ~~ CO o o qOT 111 Ul q: on CONSUMPTION NUMBER OF DEATHS PER 100,000 OF POPULATION BY CONJUGAL CONDITION AND AGE PERIODS REGISTRATION AREA: I900 15 YEARS AND OVER MALES FEMALES TOO eOO 50O 400 300 200 100 O 100 200 300 400 500_ 600__700 SINGLE MARRIED WIDOWED SINGLE MARRIED WIDOWED SINGLE MARRIED WIDOWED SINGLE MARRIED WIDOWED 65 YEARS AND OVER 45 TO 64 YEARS 15 TO 44 YEARS IsStt 1 1 i 1 1 i . 1 1 1 1 z g < -i O U. -, Q- O ? D o < z g o 2 CD D Z Q. ?Oz lO « q: -I < J-M-BirtM# liiilil£:i*lil ■ i ■ I ■ ■ ■ _l ° u-Li in at* ■2LJ I I I Mi — , ■iiiia'-i'si 1. <^ 2 o> O «« H ^(Q Q. :Sf3 S too 3 Q> CO o: Z Ui O z o .— Ijj tiJ 111 <0 l- < U-CO Q 5> < ± tij q: tli H (0 IL>- < ow o <^ X 111. 3 oJO UJ liJ Z 2 OL O UI O Z u -1 o > ill O Z < tt: ill > 111 ii. o o X CL > I- co u »- 111 ID < 5 CO < 111 I CO '^ 2 111 ~ ill lL-> < 2< Ct coco < Olil J Z < o S ID CONSUMPTION NUMBER OF DEATHS PER lOO.OQO OF POPULATION AMONG PERSONS 10 YEARS OF AGE AND UPWARD IN SPECIFIED QCCyPATiONS: 1300 OCCUPATION MARBLE AND STONE CUTTERS CIOARMAKERS AND TOBACCO WOgKERO COMPOSITORS, PRINTERS, AMD PfSESSMEK SERVANTS BOOKKEEPERS, CLERKS, AND COPYISTS LASORERS (NOT ACRICULTURAU TIWNERS and TINWARE MAKERS CABINETMAKERS AND UPHOLSTERERS musicians AND TEACHERS OF MUSIC BARBERS AND HAIRDRESSERS SAILORS. PILOTS, FISHERMEN,. AND OYSTERkIeM PAINTERS, GLAZIERS, AND VARNISHER3 LEATHER MAKERS APOTHECARIES. PHARMACISTS, ETC COOPERS PLUMBERS AND CAS AND STEAM FITTERS MASONS IBRICK AND STONE) BUTCHERS SALOON AND RESTAURANT KEEPERS LIVERY STABLE KEEPERS AND HOSTLERS DRAYMEN, HACKMEN, TEAMSTERS, ETC. BOATMEN AND CANALMEN BREWERS, DISTILLERS, AND RECTIFE.SS JANITORS AND SEXTONS HUCKSTERS ANP PEDDLERS BAKERS AND CONFECTIONERS- IRON AND STEEL WORKE!^ CARPENTERS AND JOINERS ENGINEERS AND FIREMEI* LEATHER WORKERS TAILORS BLACKSMITHS HOTEL 'AND BOARDING HOUSE KEEPEHS MILL AND FACTORY OPERATIVES ITEXTILESt MILLERS IFLOUR AND GRIST)- MACHINISTS ARCHITECTS. ARTISTS, TEACHERS OF ART, ETO, JOURNALISTS GARDENERS. FLORISTS. AND NURSERYMEN PHYSICIANS ANT) SURGEONS MERCHANTS AND DEALERS SCHOOL TEACHERS LAWYERS POUCEMEN, WATCHMEN, AND OETECtfvES BOOT AND SHOE MAKERS COLLECTORS, AUCTIONEERS. AND AGENTS STEAM RAILROAD EMPLOYEES CLERGYMEN MINERS AND QUARRYMEN FARMERS, PLANTERS. AND FARM LABORERS tUMBERMEN AND RAFTSMEN BANKERS, BROKERS. «iid OFFICIALS t>< COMPANIES SERVANTS TELEGRAPH AND TELEPHONE OPERATOftS BOOKKEEPERS. CLERKS, AND COPYISTS MILL AND FACTORY OPERATIVES (TEXTILES) DRESSMAKERS A.ND SEAMSTRESSES SCHOOL TEACHERS MURSES AND MIONVIVES LAUNDRESSES MALE TUBEECULOSIS IN THE UNITED STATES. 65 Table 12. — Death rates from tuberculosis of lungs ^for certain occupations of each sex, in the registration states: 1900. OCCUPATION. MALES. Marble and stone cutters Cigannakers and tobacco workers Compositors, printers, and pressmen Servants Bookkeepers, clerks, and copyists Laborers (not agricultural) Tinners and tinware makers Cabinetmakers and upholsterers Musicians and teachers of music Barbers and hairdressers Sailors, pilots, fishermen, and oystermen Painters, glaziers, and varnishers Leather makers Apothecaries, pharmacists, etc Coopers Plumbers, and gas and steam fitters Masons (brick and stone) Butchers Saloon and restaurant keepers Livery stable keepers and hostlers Draymen, hackmen, teamsters, etc Boatmen and canalinen Brewers, distillers, and rectifiers Janitors and sextons Hucksters and peddlers Bakers and confectioners All occupied males Iron and steel workers Carpenters and joiners Engineers and firemen (not locomotive) Leather workers Tailors Blacksmiths Hotel and boarding house beepers Mill and factory operatives(textiles) Millers (flour and grist) Machinists Architects, artists, teachers of art, etc Journalists Gardeners, florists, nurserymen, and vine growers Physicians and surgeons Merchants a nd dealers School teachers Lawyers Policemen, watchmen, and detectives Boot and shoe makers Collectors, auctioneers, and agents Steam railroad employees Clergymen Miners and quarrymen Farmers, planters, and farm laborers Lumbennen and raftsmen Bankers, brokers, and officials of companies FEMALES. Servants Telegraph and telephone operators Bookkeepers, clerks, and copyists All occupied females Mill and factory operatives (textiles) Dressmakers and seamstresses School teachers Nurses and mid wives Laundresses 1 Identical with consumption as shown in the diagram; the latter term was employed in the Mor- tality Statistics of the Census up to the close of the census year 1899-1900. 53046—08 5 66 TUBERCULOSIS IN THE UNITED STATES. Table 13. — Death rates from all forms of tuberculosis in the registration area, its main subdivisions, the registration states, and cities of 100,000 population or over in 1900, for each year since the beginning of the annual reports on mortality statistics: 1900 to 1907. NUMBER OF DEATHS FROM ALL FORMS OF 100,000 OF POPULATION. TUBERCULOSIS PER AEEA.. Annual average: 1901 to 1905. 1900 1901 1902 1903 1904 1905 1906 1907 The registration area 193.2 213.0 18L5 211.5 143.5 214.5 (1) (.') 170.1 177.3 166.3 (') 193.4 103. 2 154.6 192.6 200.0 (') 216.0 (') 139.8 328.0 459.4 200.3 310.1 177.7 205.0 233.7 35L7 266.8 250.5 189.6 203.5 129.6 133.5 132.5 213.4 79.3 224.7 114.7 247.8 268.2 1 20.5.2 ! 149.7 248.0 ' .561.2 ' 223. 1 234.5 . 164.8 215. 4 . 201.2 221.8 194.5 230.2 153.5 213.5 (I) (^) 189.9 187.9 182.5 (1) 212.3 106.8 170.3 205.1 214.2 231.0 (1) 154. 5 330.2 397.4 212.9 326.1 184.6 232.9 227.6 369.2 254.6 288.1 206.0 230.5 130.9 157.4 150.2 205.2 92.2 205.7 119.9 283.4 276.0 221.5 134.5 273.4 '284.2 250. 8 292.9 211.1 235.8 196.8 216.3 189.2 221.6 149.6 210.9 (') (1) 181.8 182.7 181.9 (1) 202.8 103.5 165.3 192.4 211.0 (1) 222.2 (1) 15L7 334.5 430.9 217.7 330.1 168.0 204.0 218.1 339.5 270.9 271.9 164.7 221.8 127.7 155.2 142.5 194.2 87.2 207.8 110.2 245.2 254.3 199.2 148.4 261.4 557.0 234.0 252.3 196.3 222.9 184.7 204.4 173.5 203.6 136.0 205.2 (1) 165.0 170.9 167.7 189.5 98.1 150.5 176.1 190.7 (1) 209.3 (1) 136.5 324.9 437.1 217.1 280. 9 165.7 186. 1 210.1 352.9 252.6 249.9 186.3 188.9 131.6 128.0 130.7 183.6 100.1 201.0 113.9 234.7 254.3 194.0 135.3 240.6 538.6 219.6 227.1 160. 9 211.8 189.0 209.4 176.6 207.3 137.7 211.6 (1) (1) 167.3 171.4 153.8 (1) 183.1 101.4 146.0 189.1 195.9 (1) 125.7 (1) 134.9 339.4 440.5 190.2 303.9 182.2 208.9 233.7 349. 3 257.7 239.7 203.1 203. 6 121.2 145.9 114.5 216.7 62.4 211.2 127.0 245.3 273.1 189.0 145.7 245. 3 564.7 221.1 232.3 146.2 208.3 201.5 222.4 187.8 218.2 148.7 226.6 (1) (1) 164.9 191.4 172.8 (') 199.3 107.9 159.8 207.1 204. 7 (') 209.2 (') 135.0 319.5 493.5 191.7 317.1 184.8 234.9 260.0 370.0 283.4 248.4 223.6 198.1 142.0 129.9 132.0 250.9 72.5 252.1 123. 1 283.1 281.0 234.0 159.4 253.1 584. 4 234. 1 234.4 163.1 186.7 193.6 212.2 180.4 207.2 145. 3 217.4 (1) (') 171.8 170.2 1.55. 5 (') 192.7 104. 9 151.4 197.5 197.9 213.9 0) 141. 2 322.2 490.3 186.5 318. 3 185.8 189.9 244.8 340.2 269.3 243.1 170.2 205.3 125.3 112.2 142.6 219.8 75.3 248.5 99.6 230.4 276.4 208.9 159.2 240.5 558. 5 208.1 227.6 160.8 246.8 184.2 210.0 180.0 213.9 140.4 20L5 267.1 277.6 159.3 165. 3 158.0 204.6 183. 7 106.4 149.8 199.1 2C0.6 155. 6 202. 3 97.6 133.6 r-) 50L6 181.4 291.5 187.2 199.4 228.6 318.0 270.9 237.5 156.7 189.9 136.1 123.4 126.6 196.3 94.9 216.9 104.7 260.5 298.0 242.0 155.0 248.3 534.9 214.0 239.4 165.8 275.2 183.6 Registration cities. . . ... 207.4 Registration states 179.6 Cities in registration states Rural part of registration states . Registration cities in other states. Registration states: California . - - 210.9 142.5 199.7 278.9 Colorado 289.4 Connecticut 167.2 Indiana 165.4 Maine 168.8 Maryland 200.2 Massachusetts 183.4 Michigan . . . 103.5 New Hampshire 130. 5 New Jersey 196.4 New York 198.5 Pennsylvania 153.9 Rhode Island .. 200.9 South Dakota . 105.1 Veimont ... 131. 2 Registration cities of 100,000 population or over in 1900: San Franei'^co, Cal n Denver, Colo ... 486.6 New Haven, Conn 209.8 Washington, D. C 280.0 Chicago, 111 191.6 Indianapolis, Ind 240.7 Louisville, Ky.. 214.7 New Orleans, La 332.0 Baltimore, Md... 2C3.2 Boston, Mass 221.1 Fall River, Mass . ... 195.1 Worcester, Mass. . 180.3 Detroit, Mich 123.8 Minneapolis, Minn. . ... 119.0 St. Paul, Minn. 154.3 Kansas City, Mo 207.6 St. Joseph, Mo . 87.1 St. Louis, Mo. .. 195.6 Omaha, Nebr 112.7 Jersey City, N. J . . . 261.5 Newark, N. J 291.6 Paterson, N.J 173.6 Buffalo, N.Y 152.6 New York, N.Y 242.2 Bronx borough 512.6 Brooklyn borough Manhattan borough Queens borough 204. 8 238.1 162.2 Richmond borough 223.1 1 Nonregistration. - Population not estimated for 1906 and 1907. 3 For this year, but not for subsequent years, many deaths from tuberculosis in hospitals situated in Bronx borough were transferred to Manhattan and other boroughs whence the cases originated. TUBERCULOSIS IN THE UNITED STATES. 67 Table 13. — Death rates from all forms of tuberculosis in the registration area, its main subdivisions, the registration states, and cities of 100,000 population or over in 1900, for each year since the beginning of the annual reports on mortalitrj statistics: 1900 to 1907 — Continued. Eegistration cities of 100,000 pop- ulation or over in 1900— Cont'd. Rochester, N. Y Syracuse, N. Y Cincinnati, Ohio Cleveland, Ohio Columbus, Ohio Toledo, Ohio Allegheny, Pa Philadelphia, Pa Pittsburg, Pa Scranton, Pa Providence, R.I Memphis, Tenn Milwaukee, Wis NUHBEB OF DEATHS FROM ALL FORMS OF TUBERCTn.OSIS PER 100,000 OF POPULATION. Annual average: 1901 to 1905. 154.0 153.5 273.5 138.8 229.0 150.5 163.3 2'JO.ti 171.3 98.4 246.0 234.9 149.4 1900 161.1 184. 5 224.0 132.8 229.4 148.6 183.2 239. 6 140.8 106.8 279.1 256.1 151.1 1901 167.2 174.3 266.1 122.1 225.8 140.6 157.6 233.2 156.4 102.3 259.7 240.4 153.3 1902 128.3 135.9 235.1 129.1 201.3 135.9 173.3 222.7 159.8 92.3 251.1 269.4 119.2 1903 144.6 148.7 268.5 144.3 228.1 129.5 156.5 246.1 171.6 102.9 268.7 190.9 151.0 1904 160.2 170.8 305.8 150.5 257.2 180.0 173.0 262.8 181.6 104.2 232.4 231.6 159.9 1905 168.7 138.3 290.3 140.5 230.8 163.6 156.1 237.5 185.1 90.4 220.5 243.3 162.7 1906 166.4 146.4 307.3 144.0 242.0 152.5 190.0 259.5 160.0 84.3 205.1 214.4 151.0 1907 155.2 149.2 266.8 149.0 232. G 168.8 156.5 253.5 139.1 95.6 201.6 199.5 138.3 o COLUMBIA UNIVERSITY LIBRARY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED ,DATE DUE DATE BORROWED DATE DUE C2e{Z3S)M100 i JAiV ? R 'dfj V Z z^><^ ^ '^ ■ v¥f