Chart·П·A·

Pneumonia

nomenclature would make us much better acquainted with actual conditions.

In further analyzing the chart (II, A and B) we see that for the successive decades (from 15 to 60) the mortality from Pneumonia is fairly uniform, and that it becomes somewhat higher for the following fifteen years, very markedly so when analyzed in relation to the number living at those ages (B). Taking into consideration the fact already alluded to that the prognosis of Pneumonia in adult age is quite favorable and that the greatest percentage of deaths is amongst those individuals affected by other

(chronic) diseases and especially amongst alcoholics, we may safely conclude that the great majority of individuals dying of pneumonia at this age belong to this class. This is most important from an economic and prophylactic point of view. Individuals suffering from heart and kidney diseases and the alcoholics as well as those between the ages of 70 and 80 belong to the "economically weak," their importance to the prosperity of a community is relatively small and this holds especially for the alcoholics. A wise but energetic action against the excessive use of alcohol will probably have a

marked bearing on the mortality from Pneumonia, much more so than general hygienic measures, which as far as our present knowledge goes, has only an indirect influence on the mortality of the disease. The very fact of an increasing mortality from Pneumonia in late years when general hygienic conditions have steadily improved would disprove the efficiency of such a course of prophylaxis.

When we now glance at the corresponding figures for consumption during the adult period, and when we consider the length of the preceding disabling sickness and that it is quite within the range of permissible theory that even these high figures underestimate actual conditions for reasons already given, we can draw only one conclusion, that is, that the two diseases in their relative economic importance to the community can hardly be compared.

The Proportions of Deaths from Consumption and Pneumonia at Each Age per 1,000 at Known Ages from These Diseases, 11th and 12th Census 1890 and 1900.

But we will furthermore analyze the nature of the increase and decrease of the death-rate of the two diseases. The chart (III. A and B) gives the ratios of mortality from Pneumonia and Tuberculosis, respectively, for the two Census years 1890 and 1900, arranged as to the different age-groups. Again we see a similar distribution of the figures at the age-periods, as that given by the total mortality figures. We further note that the greatest increase in the death-rate of Pneumonia has taken place in the period under five years of age, and also, but to a lesser extent in the period above 65 years. On the other hand, we note a quite ap

preciable decrease in the age-period from five to 65 years

For Consumption we note that the deathrate in the two years has remained about stationary for the period under 9 years of age, has decreased some from 10 to 25 years and from above 50 years, but that for the age period of from 25 to 50 years there has been an increase.

These figures are, of course, only comparable with the restrictions already alluded to. However, the marked increase of the deathrate of Pneumonia amongst children under 5 years of age, which is so large responsible for the apparent general increase in the death-rate from this disease, must command attention, and it would be valuable to investigate the factors responsible for the increase, which for reasons stated above, cannot be due to a greater mortality from lobar Pneumonia. On the other hand, we have again an illustration of the fact of the overwhelming prevalence of deaths from Consumption in the most active age-period of

life.

In summing up, we must come to the following conclusions:

1. That the relative economic importance of Pneumonia and Tuberculosis cannot be estimated by a mere comparison of total mortality figures for each disease.

2. That the high mortality figure and its increase of late, for Pneumonia is produced by the enormous death-rate and its increase attributed to this disease, in early childhood.

3. That, therefore, the high mortality from Pneumonia and to a certain extent its increase is due to a classification of different ill-defined pathologic conditions under one name, while that from Tuberculosis represents that of a well-defined morbid entity.

4. That for this reason and on account of the relative shortness of disabling sickness and frequent recovery in Pneumonia, the great length of disabling sickness and infrequent recovery in Tuberculosis, the relative importance of the two diseases is so vastly different, that a comparison on economic grounds reveals the overpowering danger from Tuberculosis.

5. That the steady decrease of the Tuberculosis death-rate can be explained on the grounds of increasing improvement of hygienic conditions in late years and as the result of specific prophylactic measures.

6. That the increase of the Pneumonia death-rate occurring in a time of improving hygienic and sanitary conditions and of a general application of antiseptic principles, shows its independence of these features.

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7. That, therefore, and in view of the still enormous mortality from Tuberculosis, demonstrated preventability and the possibility of its arrest only in its earliest stages, the institution of educational measures in regard to personal and public hygiene widely and specifically applied, for the prevention of this disease, seem to be distinctly indicated.

8. That since for pneumonia, as pointed out by E. F. Wells, "the fundamental information on which prophylactic rules may be formulated is not yet at hand," this subject needs further investigation from a bacteriological and epidemi

ological standpoint as well, before "exaggerated and irrational notions in regard to its dangers and its avoidance" are communicated to the public, which in view of the facts given are out of all proportion.

Discussion.

Homer M. Thomas: It is refreshing to have refuted the claims of the Chicago Health Department, that pneumonia is now "the captain of the hosts of death."

I recently gave a paper before the State Board of Charities, at their annual meeting in Quincy, Ill., on the Economic Loss to Illinois from Tuberculosis, and hence had to thoroughly investigate and ascertain the probable number of cases of tuberculosis at the present time. I estimated that there were at the present time in Illinois, from 16,000 to 20,000 cases of tuberculosis. This total was secured in the following way. There exists in the State of Illinois, authentic records of a death rate from tuberculosis of 8,000 deaths during 1901. This death rate in all probability is entirely too low a number, as many cases dying from tuberculosis are not reported as such, for self evident reasons. In the State of Illinois, there are 102 counties and 1620 townships. In Cook County alone, there are only 27 townships, and the population of Chicago, is at least 2,100,000. It is entirely fair to assume that there are at least 10 cases of tuberculosis in every township. This would represent a total of over 16,200 cases of tuberculosis in the State of Illinois, at the present time. In all probability 20,000 cases at the present time, would more nearly approximate the truth. It does not seem possible that the wildest and most imaginative statistical mind could estimate that there are from 16,000 to 20,000 cases of pneumonia in the State of Illinois, at the present time. The economic phase of this question naturally comes to the foreground when we consider the relative value of the lives that may be lost from tuberculosis and from pneumonia. If we have 10,000 deaths from tuberculosis every year in the State of Illinois, what is the approximate economic loss to the State from these lives? This must be considered from the standpoint of the least possible value that could be placed upon an individual life. It will cost at the very lowest calculation, two dollars a week to raise a child to the age of fifteen years. This is much below what the actual expenditure would be. A child's life then would be worth at the age of 15 years, $1,500, and 10,000 lives would be worth $15,000,000. Thus, we have an annual economic loss to the State of Illinois, from tuberculosis of $15,000,000. The deaths from pneumonia will range from one to five years of age, relatively, or from fifty-five to sixty years of age. The deaths from tuberculosis, as a rule are in the most productive period of the individuals life, namely from fifteen to forty years of age. It therefore, follows that the relative importance to the State, considered purely from a standpoint of economic loss, is vastly in favor of tuberculosis as against pneumonia. There can be no escape from this conclusion. I heartily concur in the opinion of the essayist, as to the relative importance of these diseases being markedly in favor of that of tuberculosis.

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Frank S. Churchill: I am particularly interested in the chart which represents all deaths from pneumonia under one year of age. To my mind what that chart really means is that a great many of the cases upon which it is based were undoubtedly cases, not of lobar but of broncho- or lobular pneumonia, which probably secondary to some of the infectious diseases, or, to some of the intestinal troubles which are so frequent at that time of life, and which we know are complicated with lobular pneumonia. Furthermore, I venture to say that a certain number of these cases were probably of the tubercular variety. In other words, they of tubercular broncho-pneumonia, and that is what this line is based on. The number of cases of croupous pneumonia in infancy is comparatively few and the mortality is very low. Personally, I never worry over a case of lobor pneumonia in a child, except it be an extreme case, which cases fortunately very exceptional. Most of the cases are so mild that one need not worry over them. Hence, as the discussion is upon the relative importance of lobar pneumonia and tuberculosis, there can be no doubt as to the effects of the two maladies in early life, so much more frequent and disastrous are cases of tuberculosis. These little patients are not of course wage earners or producers at present, but they do represent much potential energy and any condition which destroys them is well worthy of most careful study and in the crusade against tuberculosis I would urge that its ravages among infants and children be not overlooked.

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Dr. Klebs (closing the discussion): I agree with what Dr. Wells has said absolutely, that a good deal depends on the standpoint in comparing the two diseases. I have indicated my standpoint in the title of my paper, namely, the relative importance to the community of the two diseases. That is their economic importance. I do not wish, as I stated in my paper, to minimize the importance of pneumonia. It is most important from every standpoint, but I tried to point out in my paper that the nature of the increase of pneumonia had better be more thoroughly studied. I have given you the distribution of the mortality figures from this disease as to ages, showing that the subject needs further investigation. The statistics for pneumonia need to be studied more thoroughly than I have done it, I have attempted it only in one direction. It is very necessary to determine the morbid process in the returns of deaths from pneumonia. I have shown you that there must be not only one cause of death, but perhaps three or four, returned as pneumonia.

As to the Bulletin of the City Health Department, in that Bulletin comparisons have been drawn between the two diseases. The Bulletin has undertaken comparisons between the two diseases since the beginning of this year when Dr. Reynolds read, I think, in Detroit, a paper on the "Pneumonia Problem." Since these comparisons were misleading in many respects, I thought it timely, on account of the interest which the public has taken in this matter, but not against the Health Department, to point out and show exactly how these figures were dis