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9
of pulmonary tuberculosis (i.e. notifications per 100,000) is plotted on
Figure 3. It will be noted that between 1920 and 1938 there was little
real improvement, in 1940 and 1941 there were spectacular rises in
notifications, and since then a gradual fall but the attack rate is still above
that in 1939. Accordingly more notifications are partly the cause of the
rise in numbers on the register. There is another important factor, the
death rate of the disease is declining. In this connection it is more
important to consider the case mortality rate, i.e., the number of deaths
per 100 cases on the register, rather than the mortality rate per
100,000 of the general population, for the latter figure takes no cognisance
of the number of cases of the disease among whom the deaths are
occurring. Figure 4 shows how dramatically the death rate from
tuberculosis is declining. This graph includes both pulmonary and nonpulnionary
cases, but as the latter are over the years a steadily
decreasing proportion, and include a large group of mild non-fatal types,
it is apparent that the mortality rate from pulmonary tuberculosis is also
decreasing.
A conclusion from these figures is difficult to come by. Is tuberculosis
becoming milder, is the resistance of the public to severe disease becoming
stronger, are cases being notified earlier and in a state more amenable to
treatment, and is modern treatment, both surgical and by means of drugs,
keeping people alive longer? Another, and most disturbing conclusion,
must be excluded. Are we keeping tuberculosis patients alive who would
previously have died, keeping them alive, at home, and mixing with the
general public, and in an infectious state so that we have more foci of
infection abroad than before? Is this the cause of the obstinate tendency
of the attack rate to remain higher than before the war? Unfortunately
these questions cannot be answered by notifications and visits of sanitary
inspectors.
It is also of interest to review the provision of sanatorium accommodation
over the last 30 years. The lower graph in Fig. 5 shows a
steady increase in the number of cases in sanatoria, but the upper graph
shows that since 1928 no improvement has occurred when related to the
increase in pulmonary cases in the town. In Fig. 5 the pulmonary cases
found to be in sanatoria are shown as a percentage of pulmonary cases
visited by the Sanitary Inspectors.
Finally, is the notification of tuberculosis becoming more exact?
Ideally each fatal case of tuberculosis should be recognised and notified
before death. Anything less than this means a human error or neglect
on the part of some person. The upper graph in figure 6 is the annual
record of deaths of tuberculosis in Ilford, the lower graph those of them
that were notified as suffering from the disease before death. Both graphs
should ideally coincide, but the gap is still too large, although narrowing
very slightly. In this regard 1948 was the best year, 63 of the 69 deaths
being notified. If there is this gap in those cases which are so ill that they
die of the disease, what is the gap in mild and early cases, which may
recover without treatment? No one can answer this, but it will inevitably
be considerable.
As before, I would like to thank all the members of my staff who
have co-operated so effectively in the past year, and have helped in the
collation of this report; also to my fellow officers for their kind aid during
the past year. I would like to make special mention of the help I have
received from the Chairmen, Vice-Chairmen and members of the Committees
and Sub-Committees of the Ilford Borough Council and Essex