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MORTALITY FROM PHTHISIS IN YOUNG ADULTS
219 After consultation with the Ministry of Health the Medical Research Council has accepted Prof. Wilson’s report as a statement of the scientific evidence on which possible administrative action may be based.
adult females in the county boroughs. The changes in type of employment evident in recent years are more difficult to measure but the evidence available does not implicate such changes as a responsible
agent.
Failing to find support for these explanations Dr. Hill turns his attention to the question of internal MORTALITY FROM PHTHISIS IN migration and the consequent distribution of young adults in different parts of the country. In past YOUNG ADULTS years one striking aspect of the phthisis mortality A STATISTICAL STUDY of young adults in this country has been the higher death-rates registered in the rural areas as compared with the urban areas, a phenomenon observed only THE Registrar-General’s mortality statistics for at these ages. In an investigation carried out by an have revealed unfavourable trend recent years some years ago,’ he concluded that the the author in the death-rate from respiratory tuberculosis at of this position lay in the migration of young adult ages. In the enormous decline that explanation from the country to the town, and adults took place in the death-rate from this cause during young form a physically select group, which the that migrants the latter half of the nineteenth century young the town population at young adult ages strengthens adults had their full share, or even somewhat more and leaves a physically weaker residue behind. It than their full share. But between 1901-10 and volume of that in the this follows migration changes 1930 the mortality at these ages has declined amongst males at a slower rate than is apparent in any other would be expected to produce changes in the regional distribution of the phthisis death-rate. In fact, .age-group, while amongst females there has actually in recent years the excess mortality at the young been a slight rise in mortality at ages 15-25, and at ages 25-35 the decline has been appreciably less adult ages in the rural areas has completely disthan that observed in any other age-group. Division appeared. At the same time the loss of population of England and Wales into its administrative areas in the rural areas has turned to a gain. The rural shows that it is in the highly urbanised areas that this exodus slackened at about the turn of the century, while, in addition, the population of many rural unfavourable change is most apparent. areas may have changed in type due to the improved The basic figures illustrating this trend were set out methods of transport enabling persons to reside in in a paper read before the Royal Statistical Society such areas and work elsewhere. Similarly the on Jan. 21st by Mr. A. Bradford Hill, D.Sc., in which to towns may have changed in type-for the author discussed various explanations of the migrants it appears that London tends now to recruit instance, present position. Some workers-e.g., F. J. H. adults from the depressed areas rather than Coutts-believe that the prodigious fall in the general young from the rural areas. Are these changes in the movedeath-rate from tuberculosis has led to a much ment of population related to the changes in the lower level of infection in early life and this to a death-rate ? Dr. Hill finds that, to some decline of immunisation in childhood, with the result phthisis are. Those county boroughs which that more persons must face the hazards of adolescent extent, they have attracted young adults have, on the average, life with no acquired immunity. A more frequently shown a death-rate from phthisis in young accepted explanation attributes the relatively high adult lifedeclining the past decade, while those that during mortality, especially of young adult females, to the have lost population have tended to show a rising entry of such persons into the " strain and stress of death-rate. This association might, the author competitive wage earning," with the associated suggests, be due to the fact that towns that have changes in their social life. Dr. Hill is unable to ceased to attract population are in a less satisfactory find much statistical support for either of these economic position than those that still recruit young two hypotheses. Taking the death-rate from tuberand this lower economic level is reflected culosis at ages 0-5 as a measure of the pressure of adults, in their death-rates. Alternatively it may be that, infection in childhood, he finds that the course of in towns that are no longer recruiting physically this death-rate in a group of English counties is not fit young adults from the rural districts, the deathrelated to changes in the mortality experienced at rate is now measured upon a physically different young adult ages in later years. Similarly, towns from that of past years. The towns are with a high death-rate from tuberculosis at ages population no longer strengthened, or are less strengthened, by 0-5 do not appear to have a lower phthisis death-rate this selective recruitment, the rural areas are less in young adult life fifteen to twenty years later than towns with a relatively low death-rate in childhood- depleted. Naturally, as we are dealing with a generalphenomgeneral health factors being as far as possible equalised. With regard to occupational changes Dr. Hill shows enon, Dr. Hill does not put this forward as being first that in towns where the death-rate of young more than a contributory factor. In the recently adult females has shown the greatest increase, there issued text volume of the Registrar-General’s has been, on the average, a tendency for the rate of Statistical Review for 1933, attention is directed to of increasing mortality at young young adult males to increase also, or to show a the association adult with unfavourable slower rate of decline than in other towns. Where ages housing standards. the female rate has declined substantially the male Grouping together areas with over 1 per room average rate has also, on the average, declined substantially. density, phthisis mortality of females aged 15-25 increased Dr. Hill argues that this relationship implies a causal from 1911 to 1930-32 by 25 per cent. in the county factor common to both sexes and suggests that the boroughs and 21 per cent. in the counties, whilst in with a mean density about 1 per room it increased occupational changes in female life are therefore London 16 cent. At densities of 0-85-1 per room the by per unlikely to be more than a partial explanation. He towns showed no change and the counties an increase of finds no correlation between changes in the volume of female employment over the years 1911 to 1931 1 Med. Research Coun., Spec. Rep. Series No. 95, London, and changes in the phthisis death-rate of young 1925. "
220 15 per cent., but at densities below 0-85 per room both showed improvement of the order of 20 per cent. On the other hand, at ages 25-45, the fall in mortality was not confined to the better housed areas, but occurred almost irrespective of density."
It will be realised that the problem is intricate and its solution involves, as a first step, the clear presentation and careful analysis of statistical data. Dr. Hill’s paper is a model of such work and will be indispensable in further study.
THE ARMY IN 1934 THE Report1 of the Director-General of Army Medical Services for 1934 makes cheerful reading. Soldiering in that year was an even healthier occupation than in- 1932, previously a record year. The ratio of admissions to hospital fell to 402-6 per thousand compared with 412-5 per thousand in 1932, and there were appreciable reductions in the death, invaliding, and constantly sick ratios. The most notable decrease in disease was that of the malaria-rate in India which fell to 67’5 per thousand. Among officers the admission-rate was 191, a slight increase on 1932. The most important causes of illness were, in order, inflammation of areolar tissues and tonsils, fractures, dysentery, malaria, influenza, and appendicitis. The principal causes of admission to hospital were the same for the soldier as for the officer, except that for the soldier venereal disease appears in the third place while dysentery and appendicitis were less common than sprains, contusions, and inflammations of the upper respiratory tract. Bacillary dysentery is now about five times as frequent as amcebic-a marked contrast to the position ten years ago. Treatment is very satisfactory ; only three patients were invalided from the Service during the year. There has been a striking decrease in the enteric group of fevers, especially in India. Arrangements are being made to extend protective inoculation to children, among whom the incidence is still too high. Improved figures in India are also responsible for a general reduction in sand-fly fever. There has been a general decrease in venereal disease, except in Jamaica. Work on the treatment of gonorrhoea tends towards substituting saline irrigation fluids for potassium permanganate. Specific infectious fevers were rather bad during 1934 and there were three deaths from diphtheria and two from scarlet fever. General immunisation of children at Blackdown may have accounted for the complete absence of
Young unmarried soldiers with ulcers which relapse twice after adequate medical treatment are being recommended for discharge. It is felt that young soldiers are liable at any time to military duties which may, and often do, nullify in a few days the results. of the most careful treatment. Few of the factors important in maintaining freedom from ulceration are within the control of the individual soldiers themselves. While the best possible diet and cooking are provided, the men cannot always be kept from sudden exposure to fatigue or inclement weather or obtain, out of hospital, frequent regular meals specially adapted to their needs. Married non-commissioned officers of long service suffering from ulcer are, if possible, retained and the commissioned officersapart from mobilisation or prolonged manoeuvres’— are in a more hopeful position. The typhus group of fevers is attracting special attention abroad and evidence is accumulating to show that in India there are several hitherto unrecognised sub-groups with differing serological attributes. SURGERY
There was an increase in the number of surgical operations performed during the year, the total being 9157, with a mortality-rate of 0-54 per cent. This includes pensioners and women and children. The chief facts that stand out from the Report are the importance of local injuries and diseases of the areolar tissues-notably boils and carbuncles. The latter are treated conservatively with magnesium sulphate compresses rather than by active interference. There is also a tendency to give up open operations on fractures and to rely more on skeletal traction by wire or pins. Local anaesthetics are more widely used for setting fractures. The use of spinal anaesthetics and Evipan is on the increase, although inhalants are still by far the most popular. The commonest major operations, apart from hernia, appendicitis, and ulcer, were cholecystectomy and for intestinal obstruction. There were 349 operations for recent inguinal hernia and 8 for femoral hernia. Injuries of the knee-joint played a fairly large part in disability and in 36 cases the fluid was aspirated; the time spent in hospital was considerably less than if the cases were treated by elastic pressure and conservative measures. Out-patients" forms a very important part of the work of the surgical specialist, and clinics for the injection treatment of "
varicose veins and haemorrhoids continue to be of great value. There has been a large increase in the work of radiological, massage, and electrotherapeutic
diphtheria on that station, and vigorous steps departments. being taken to spread this form of protection. WOMEN AND CHILDREN The large increase of cerebro-spinal meningitis in the Indian civil population has not so far affected There was an average strength of 18,508 women the troops. There was a high incidence of middle- for which the Army Medical Department provided ear disease in Jamaica, Malaya, and Egypt, probably services during 1934, and of these over 3000 were associated with the fact that bathing is a chief admitted to hospital during the year. The principal recreation in these places. The reduction of tonsillitis causes of admission were abortion, cramp and is deemed to be of the utmost importance because labour pains, malaria, and appendicitis, spurious heart disease of rheumatic origin is the cause of much followed in frequency by inflammation of the tonsils, wastage. and areolar tissue. In addition, 2660 bronchi, There has been a steady increase during the past women were admitted to hospital for confinement 11 years in gastric and duodenal ulceration, and and 13,845 received out-patient treatment. Of the a smaller increase of appendicitis. The figures are 29,521 children on the roll there were just over 5000 believed to depend on improved diagnosis rather admissions to hospital and 26,847 out-patients. The than on any real increase. There has been no change principal causes of admission were enlargement of the in the standard diet, but the aetiological factor of tonsils, scarlet fever, inflammation of bronchi and dental sepsis is under increasingly better control. tonsils, pneumonia and measles, dysentery, diarrhoea, and inflammation of areolar tissue. The 1 Report on the Health of the Army, 1934. H.M. Stationery malaria, are
Office.
Vol. lxx.
Pp. 165.
3s.
wives
and
children
are
not
entitled to medical
adult females in the county boroughs. The changes in type of employment evident in recent years are more difficult to measure but the evidence available does not implicate such changes as a responsible
agent.
Failing to find support for these explanations Dr. Hill turns his attention to the question of internal MORTALITY FROM PHTHISIS IN migration and the consequent distribution of young adults in different parts of the country. In past YOUNG ADULTS years one striking aspect of the phthisis mortality A STATISTICAL STUDY of young adults in this country has been the higher death-rates registered in the rural areas as compared with the urban areas, a phenomenon observed only THE Registrar-General’s mortality statistics for at these ages. In an investigation carried out by an have revealed unfavourable trend recent years some years ago,’ he concluded that the the author in the death-rate from respiratory tuberculosis at of this position lay in the migration of young adult ages. In the enormous decline that explanation from the country to the town, and adults took place in the death-rate from this cause during young form a physically select group, which the that migrants the latter half of the nineteenth century young the town population at young adult ages strengthens adults had their full share, or even somewhat more and leaves a physically weaker residue behind. It than their full share. But between 1901-10 and volume of that in the this follows migration changes 1930 the mortality at these ages has declined amongst males at a slower rate than is apparent in any other would be expected to produce changes in the regional distribution of the phthisis death-rate. In fact, .age-group, while amongst females there has actually in recent years the excess mortality at the young been a slight rise in mortality at ages 15-25, and at ages 25-35 the decline has been appreciably less adult ages in the rural areas has completely disthan that observed in any other age-group. Division appeared. At the same time the loss of population of England and Wales into its administrative areas in the rural areas has turned to a gain. The rural shows that it is in the highly urbanised areas that this exodus slackened at about the turn of the century, while, in addition, the population of many rural unfavourable change is most apparent. areas may have changed in type due to the improved The basic figures illustrating this trend were set out methods of transport enabling persons to reside in in a paper read before the Royal Statistical Society such areas and work elsewhere. Similarly the on Jan. 21st by Mr. A. Bradford Hill, D.Sc., in which to towns may have changed in type-for the author discussed various explanations of the migrants it appears that London tends now to recruit instance, present position. Some workers-e.g., F. J. H. adults from the depressed areas rather than Coutts-believe that the prodigious fall in the general young from the rural areas. Are these changes in the movedeath-rate from tuberculosis has led to a much ment of population related to the changes in the lower level of infection in early life and this to a death-rate ? Dr. Hill finds that, to some decline of immunisation in childhood, with the result phthisis are. Those county boroughs which that more persons must face the hazards of adolescent extent, they have attracted young adults have, on the average, life with no acquired immunity. A more frequently shown a death-rate from phthisis in young accepted explanation attributes the relatively high adult lifedeclining the past decade, while those that during mortality, especially of young adult females, to the have lost population have tended to show a rising entry of such persons into the " strain and stress of death-rate. This association might, the author competitive wage earning," with the associated suggests, be due to the fact that towns that have changes in their social life. Dr. Hill is unable to ceased to attract population are in a less satisfactory find much statistical support for either of these economic position than those that still recruit young two hypotheses. Taking the death-rate from tuberand this lower economic level is reflected culosis at ages 0-5 as a measure of the pressure of adults, in their death-rates. Alternatively it may be that, infection in childhood, he finds that the course of in towns that are no longer recruiting physically this death-rate in a group of English counties is not fit young adults from the rural districts, the deathrelated to changes in the mortality experienced at rate is now measured upon a physically different young adult ages in later years. Similarly, towns from that of past years. The towns are with a high death-rate from tuberculosis at ages population no longer strengthened, or are less strengthened, by 0-5 do not appear to have a lower phthisis death-rate this selective recruitment, the rural areas are less in young adult life fifteen to twenty years later than towns with a relatively low death-rate in childhood- depleted. Naturally, as we are dealing with a generalphenomgeneral health factors being as far as possible equalised. With regard to occupational changes Dr. Hill shows enon, Dr. Hill does not put this forward as being first that in towns where the death-rate of young more than a contributory factor. In the recently adult females has shown the greatest increase, there issued text volume of the Registrar-General’s has been, on the average, a tendency for the rate of Statistical Review for 1933, attention is directed to of increasing mortality at young young adult males to increase also, or to show a the association adult with unfavourable slower rate of decline than in other towns. Where ages housing standards. the female rate has declined substantially the male Grouping together areas with over 1 per room average rate has also, on the average, declined substantially. density, phthisis mortality of females aged 15-25 increased Dr. Hill argues that this relationship implies a causal from 1911 to 1930-32 by 25 per cent. in the county factor common to both sexes and suggests that the boroughs and 21 per cent. in the counties, whilst in with a mean density about 1 per room it increased occupational changes in female life are therefore London 16 cent. At densities of 0-85-1 per room the by per unlikely to be more than a partial explanation. He towns showed no change and the counties an increase of finds no correlation between changes in the volume of female employment over the years 1911 to 1931 1 Med. Research Coun., Spec. Rep. Series No. 95, London, and changes in the phthisis death-rate of young 1925. "
220 15 per cent., but at densities below 0-85 per room both showed improvement of the order of 20 per cent. On the other hand, at ages 25-45, the fall in mortality was not confined to the better housed areas, but occurred almost irrespective of density."
It will be realised that the problem is intricate and its solution involves, as a first step, the clear presentation and careful analysis of statistical data. Dr. Hill’s paper is a model of such work and will be indispensable in further study.
THE ARMY IN 1934 THE Report1 of the Director-General of Army Medical Services for 1934 makes cheerful reading. Soldiering in that year was an even healthier occupation than in- 1932, previously a record year. The ratio of admissions to hospital fell to 402-6 per thousand compared with 412-5 per thousand in 1932, and there were appreciable reductions in the death, invaliding, and constantly sick ratios. The most notable decrease in disease was that of the malaria-rate in India which fell to 67’5 per thousand. Among officers the admission-rate was 191, a slight increase on 1932. The most important causes of illness were, in order, inflammation of areolar tissues and tonsils, fractures, dysentery, malaria, influenza, and appendicitis. The principal causes of admission to hospital were the same for the soldier as for the officer, except that for the soldier venereal disease appears in the third place while dysentery and appendicitis were less common than sprains, contusions, and inflammations of the upper respiratory tract. Bacillary dysentery is now about five times as frequent as amcebic-a marked contrast to the position ten years ago. Treatment is very satisfactory ; only three patients were invalided from the Service during the year. There has been a striking decrease in the enteric group of fevers, especially in India. Arrangements are being made to extend protective inoculation to children, among whom the incidence is still too high. Improved figures in India are also responsible for a general reduction in sand-fly fever. There has been a general decrease in venereal disease, except in Jamaica. Work on the treatment of gonorrhoea tends towards substituting saline irrigation fluids for potassium permanganate. Specific infectious fevers were rather bad during 1934 and there were three deaths from diphtheria and two from scarlet fever. General immunisation of children at Blackdown may have accounted for the complete absence of
Young unmarried soldiers with ulcers which relapse twice after adequate medical treatment are being recommended for discharge. It is felt that young soldiers are liable at any time to military duties which may, and often do, nullify in a few days the results. of the most careful treatment. Few of the factors important in maintaining freedom from ulceration are within the control of the individual soldiers themselves. While the best possible diet and cooking are provided, the men cannot always be kept from sudden exposure to fatigue or inclement weather or obtain, out of hospital, frequent regular meals specially adapted to their needs. Married non-commissioned officers of long service suffering from ulcer are, if possible, retained and the commissioned officersapart from mobilisation or prolonged manoeuvres’— are in a more hopeful position. The typhus group of fevers is attracting special attention abroad and evidence is accumulating to show that in India there are several hitherto unrecognised sub-groups with differing serological attributes. SURGERY
There was an increase in the number of surgical operations performed during the year, the total being 9157, with a mortality-rate of 0-54 per cent. This includes pensioners and women and children. The chief facts that stand out from the Report are the importance of local injuries and diseases of the areolar tissues-notably boils and carbuncles. The latter are treated conservatively with magnesium sulphate compresses rather than by active interference. There is also a tendency to give up open operations on fractures and to rely more on skeletal traction by wire or pins. Local anaesthetics are more widely used for setting fractures. The use of spinal anaesthetics and Evipan is on the increase, although inhalants are still by far the most popular. The commonest major operations, apart from hernia, appendicitis, and ulcer, were cholecystectomy and for intestinal obstruction. There were 349 operations for recent inguinal hernia and 8 for femoral hernia. Injuries of the knee-joint played a fairly large part in disability and in 36 cases the fluid was aspirated; the time spent in hospital was considerably less than if the cases were treated by elastic pressure and conservative measures. Out-patients" forms a very important part of the work of the surgical specialist, and clinics for the injection treatment of "
varicose veins and haemorrhoids continue to be of great value. There has been a large increase in the work of radiological, massage, and electrotherapeutic
diphtheria on that station, and vigorous steps departments. being taken to spread this form of protection. WOMEN AND CHILDREN The large increase of cerebro-spinal meningitis in the Indian civil population has not so far affected There was an average strength of 18,508 women the troops. There was a high incidence of middle- for which the Army Medical Department provided ear disease in Jamaica, Malaya, and Egypt, probably services during 1934, and of these over 3000 were associated with the fact that bathing is a chief admitted to hospital during the year. The principal recreation in these places. The reduction of tonsillitis causes of admission were abortion, cramp and is deemed to be of the utmost importance because labour pains, malaria, and appendicitis, spurious heart disease of rheumatic origin is the cause of much followed in frequency by inflammation of the tonsils, wastage. and areolar tissue. In addition, 2660 bronchi, There has been a steady increase during the past women were admitted to hospital for confinement 11 years in gastric and duodenal ulceration, and and 13,845 received out-patient treatment. Of the a smaller increase of appendicitis. The figures are 29,521 children on the roll there were just over 5000 believed to depend on improved diagnosis rather admissions to hospital and 26,847 out-patients. The than on any real increase. There has been no change principal causes of admission were enlargement of the in the standard diet, but the aetiological factor of tonsils, scarlet fever, inflammation of bronchi and dental sepsis is under increasingly better control. tonsils, pneumonia and measles, dysentery, diarrhoea, and inflammation of areolar tissue. The 1 Report on the Health of the Army, 1934. H.M. Stationery malaria, are
Office.
Vol. lxx.
Pp. 165.
3s.
wives
and
children
are
not
entitled to medical