Society in March, 1884, and published in vol. xlvii of this Journal, directs attention to the fact that phthisis had diminished between the ages 5 and 35 to an extent varying from 15 to 28 per cent., whereas at all these ages the mortality from diseases of the lungs remained comparatively stationary (p. 226); and for other reasons detailed elsewhere, he inferred that substantially the diagnosis of phthisis from bronchitis corresponds with nature. Again, Dr. Ogle, in his letter to the Registrar-General, on the mortality in the registration districts of England and Wales during the ten years 1871-80, in the Supplement to the 45th annual report (at p. xiv), expresses his belief that the opinion that the apparent diminution of phthisis was due simply to a transference from one heading to another, while the mortality really underwent little change, was probably to some extent true; still, as the registered mortality from phthisis fell at every one of the successive age periods, the registered mortality from diseases of the respiratory organs remained practically unaltered between 5 and 26 years of age, and only rose among children under 5 and among persons over 25, this can hardly be supposed to be the explanation of the whole matter. Dr. Ogle, adds, "how much of the fall in the registered "mortality from phthisis was real, and how much was really due "to transference, it is impossible to say; but it must be noted that "the mortality ascribed to other forms of tuberculosis, with the "exception of hydrocephalus, showed no decline."

As the military returns dealt with in this paper embrace data, both anterior, and subsequent to, those referred to in the three communications just noticed, it is necessary to trace the course of phthisis among the civil male population at military ages for a corresponding period. The details are given in Table II in the Appendix for the ages 15, 20, 25, 35-45; the ratios of deaths per 1,000 living at each age for the successive quinquenniads mentioned are the following:

From this table it appears that phthisis was considerably more

prevalent from 1838 to 1842 than from 1850 to 1854; that in the next quinquenniad it fell a little, and remained practically at the same rate the following one, and, in each of these two, the ratio per 1,000 of deaths was nearly the same in each age-period from 20 to 45, while that at 15 was very close to three-fifths of that at A change is apparent in 1865-69; above 35 the mortality increased considerably, and from 25 to nearly the same extent; there was an increase also from 20, but to a less extent, while at 15 there was an actual decrease. In 1870-74 the high ratio above 35 was continued, but at all previous ages there was a marked decrease of the death-rate. In 1875-79 the rate above 35 began to decline, while the fall continued at the other ages; and finally, in 1880-84 there was a still further fall in the death-rate at all the ages in the table. The marked decrease in the death-rate from phthisis from 1838-42 to 1850-54, while the relative mortality at 15 remained unaltered, shows a general amelioration in the social condition of the population during the interval; but the rise in the rate at ages above 25 in 1865-69, while at 20- the rise was evidently checked, and at 15— there was a sensible decrease, indicates that, with an active cause favouring an increase of mortality, there were other factors in operation with a contrary tendency, the action of which was first apparent among the young, but ultimately became obvious at every age in the table. From the numbers given by the Registrar-General at page lxx of his report for 1870, and in subsequent ones, it appears that the population of England and Wales was distributed between the chief towns, and small towns and country parishes, in the following proportions per

and as it is well ascertained that residence in towns leads to a much greater mortality from phthisis and respiratory diseases than country life, the gradually increasing excess of the inhabitants in towns must actually have led to an augmented death-rate from these diseases, unless the injurious factors in urban life, which favour their origin, were kept in check by sanitary measures, and improvement in the social condition of the mass of the population. The reduction of the death-rate in recent years seems mainly attributable to hygienic measures, and these have no doubt influenced the occurrence of phthisis.as well as other diseases. At the same time the medical treatment of phthisis also has been

more successful than formerly in prolonging life, if not actually in curing the disease in a very large portion of cases. The beneficial operation of these ameliorations would naturally be looked for among the younger part of the population at first, and as it became more diffused its influence would gradually become apparent at more advanced ages, as the table shows it to have done.

The question of how far the reduction of phthisis was referable to transference of deaths from under that head to those for the inflammatory affections of the lungs, was also examined for males of the different ages, for the same period, but to save space the details have not been given here. As regards those between 15 and 45 however-during which period about 65 per cent. of the total deaths from phthisis among males take place, while about 1 per cent. only of the deaths from diseases of the lungs then occur- some notice is necessary. The inflammatory affections include bronchitis, pleuritis, pneumonia, and congestion of lungs; their numbers at the different ages, and in the successive quinquenniads, are given in Table III in the Appendix. The following are the results :

From these figures it is obvious the mortality from the inflammatory affections of the lungs, at the ages 15- and 20— was low, and the increase in the successive periods moderate; at 25—, with a higher initial rate, the subsequent increase was greater, and at 35-45 both were still higher. All reached their maximum in 1875-79, and in 1880-84 they showed a distinct reduction except at 15-.

the

Comparing the ratios in this table with those for the corresponding ages and periods in the previous one, it is found that the reductions in the death-rate from phthisis at 15— and 20— far excced the increases of the inflammatory affections. At 25-, reduction of phthisis from 1838-42 to 1855-59 was largely in excess of the increase of the inflammatory affections; in the next two quinquenniads both forms of disease increased, phthisis con

siderably more than the other; but a fall then commenced, which, in 1875-79 amounted to o'55, while the ratio for inflammatory diseases had risen o'15 only. Between 35 and 45, after the great reduction from 1838-42 to 1850-54, phthisis increased during the uext four quinquenniads by o'33, the inflammatory affections rising in the same period o'49, and in 1875-79 there was a further rise in the latter of 0.22, while phthisis declined 0*11. In 1880-84 there was a marked fall in the mortality from the inflammatory affections at all the ages except 15-, accompanied by a much greater fall from phthisis at all the life-periods in the table. Taking a general view of these fluctuations, it appears there was a great fall in the mortality from phthisis from 1838-42 to 1855-59; it then showed a tendency to rise, and in 1865-69, reached its highest point since 1842 at the different ages in the table except 15-; in 1870-74 the ratios again declined in a marked manner at all except the most advanced age, in which the decline commenced in the following quinquenniad, and this fall has continued to the last quinquenniad in the table. Accompanying these changes the inflammatory affections of the lungs had presented a pretty regular increase at each age from 1838-42 to 1875-79. In 1865-69, when the phthisis mortality rose, the increase at the age-periods from 20 to 35-45 exceeded the corresponding increase of the inflammatory affections, but when the former was decreasing, the diminution was much larger than the accompanying increase of the inflammatory affections, until in 1880-84 both forms of disease declined together. The obvious inference from these circumstances is that the reduction in the rate of phthisis was not due to transference of deaths from that disease to the inflammatory affections of the lungs.

On proceeding to compare the mortality from phthisis in the army with that among the male population, it must be borne in mind that the numbers under observation, at each age, differ very much from what is found in civil life, and to obtain a proper basis for comparison it is necessary to multiply the strength of the troops (in thousands and fractions thereof), by the ratio per 1,000 of deaths from phthisis among the civil population, of the same age for the corresponding years. The sums of these products for the different age-periods give the number of deaths that would have occurred among males in civil life similarly distributed as to age; but as the ages of those who die in the Army are not given in the returns, these must be treated as a single group, and the death-rate obtained for the whole force. These results are worked out in Table IV for the decade 1837-46, and for the five quinquenniads 1860 to 1884. In Table I the deaths from phthisis are given; in the first part of the table the results are for corps

which had passed the whole year at home; these extend from 1860 to 1873; the second part includes all corps which passed any part of the year at home, the strength is the mean of that for the several months of the year, and includes men on detached duty who did not appear in the first part; the deaths are those of all men borne on strength who died during the year, whether with their corps or detached; and it will be seen on reference to the table that the ratios per 1,000 calculated on these different data agree as closely as could have been expected. The men discharged are slightly more numerous in the second than in the first part of the table, and their ratios being calculated from the whole strength, including detached men, are evidently lower than those in the first part where these were omitted.

As many of the men who are discharged for phthisis contracted in the service die of that disease soon afterwards, the numbers so dying should be added to those whose complaints terminated fatally while serving, in order to show how far phthisis is more common among soldiers than in civil life. Unfortunately however there is little information available on this point; allusion was made, at p. 3, to an inquiry into the subsequent history of 305 men pensioned for phthisis and hæmoptysis, of whom 187 had died in sixteen years; allowing half of them or 153 to have died from these affections within a few years after their discharge, the remaining 34 deaths would allow of a very high mortality among the other 152 for sixteen years. In the statistical and sanitary report for the army for 1860, it is mentioned at page 22 that of 57 men discharged from the Foot Guards (apparently in 1860) for tubercular diseases, and whose history could be traced, 15 had been awarded temporary pensions which had ceased at different periods prior to 1st September, 1861, leaving 43 who could be followed up to that date; of these 10 died in 1860, and 14 in 1861, or 24 deaths among 43 individuals, rather more than one half. From these data it seems probable that about a half of the men who leave the service with phthisis or hæmoptysis die of these diseases within a few years of their discharge, and no very serious error will be committed if this conclusion be adopted. Proceeding on this assumption, the following table shows the ratio per 1,000 of deaths which would have occurred among troops serving in this country, calculated at the rate prevailing among the civil male population of corresponding ages, as given in Table IV, and also the actual ratio per 1,000 of deaths, and a half of those discharged, from the second part of Table I.

VOL. L. PART III.

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