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Report of the County Medical Officer—General.
3
The 74th Annual Report of the Registrar General, published in 1913, contains a diagram showing
deaths from all causes at different ages in "various classes of area," and in commenting upon the approximation
of curves in early adult life, reference is made by the Superintendent of Statistics to "the explanation
of this feature in the diagram." "It has," Dr. Stevenson continues, "often been pointed out,
that especially in the case of females, the mortality of young adults from phthisis is understated in large
towns and overstated in rural areas, owing to the fact that young immigrants to the towns when disabled
by the disease return to their homes in the country, and in many cases die there." Unfortunately,
as Dr. Stevenson says, "the resulting mis-statement of mortality cannot be fully corrected by any
means at present available. He further adds," The diagram suggests that, as indeed might reasonably
be expected, this fallacy in the returns is not restricted to phthisis. It probably applies to all
diseases of at all a chronic nature. It is natural that it should apply more in the case of females, who
probably do not remove so far from their homes as males, and remain in close touch with them. It
is also natural that the fallacy should apply more to London and the rural districts than to the other
two area groups." Dr. Stevenson further proceeds to remark that, if the explanation of the curves
be a true one, "this peculiarity should appear more markedly in a similar diagram relating exclusively
to a chronic disease such as phthisis, and should be absent in the case of a disease such as lobar pneumonia,
which strikes down its victims suddenly, giving them 110 opportunity of returning to the old
home to die there." He finds the anomaly more pronounced in the case of phthisis than in that of deaths
from all causes, but, with one curious exception, absent in the case of pneumonia. He says, "We
may, therefore, conclude that such transfer of deaths does, in the main, account for the approximation
in youth of urban and rural mortality."
The curious exception referred to is further discussed on p. Ixxxviii. It appears that, while
at most ages the mortality from lobar pneumonia is higher at all periods of life in the county boroughs
than in the rural areas, the London death-rate 1906-10 was lower than that of the country generally
at ages 5-30 in males and 15-30 in females. Dr. Stevenson says (p. lxxxix.): "The explanation of
the similar feature in the case of deaths from all causes, and from phthisis, cannot apply to lobar
pneumonia, sufferers from which are struck down too suddenly, as a rule, to return to distant homes
before their death." He considers the possibility that the influence of industrial conditions may
explain the difference, but finds no proof of this, and he then enquires whether the proportion of
deaths occurring in institutions may contribute to the explanation, "if it may be assumed that for
persons in the vigour of youth recovery from this disease is largely a matter of careful nursing." He
gives a table showing that a larger proportion per cent, of total deaths from lobar pneumonia and
"pneumonia" occurs in institutions in London than in the other classes of area, and he says: "The
difference between the various classes of area must be assumed to have had some effect upon the
mortality, and probably also upon its age distribution."
In connection with appendicitis, Dr. Stevenson has something further to say on the same subject.
In the Annual Report of the Registrar General for 1913, p. Ixxiii., he Writes, "Comparing urban
and rural mortality at different ages it may be noted that the rural excess, pointed out on p. xxx.
for the general mortality of young women, is well marked in the case of appendicitis. At all ages
from 10.35 the death rates of females are higher in the rural than in the urban districts, though those
of males are lower. This is the more interesting, as the explanation put forward to explain the similar
facts met with in the case of tuberculosis—that young women infected in the towns, frequently return
to their country homes when invalided—cannot Well apply in the case of an acute disease like
appendicitis. The phenomenon may be compared with the depression in the mortality curve of
pneumonia in London at similar ages."
The influence of hospital treatment and careful nursing does, no doubt, as Dr. Stevenson suggests
play its part, but it is perhaps deserving of remark that attacks of appendicitis may go on in seme
instances for a considerable period of time ; and again, pneumonia may be a terminal event in a chronic
disease; moreover, it may supervene in cases of arrested or ameliorated phthisis; and if it be granted
that there is a general tendency for young persons developing phthisis in urban districts to return to
their homes in rural districts, where conditions are more favourable to recovery, then it is not impossible
that the relatively high prevalence at these ages of pneumonia in rural districts may be directly correlated
with the similar relative excess in phthisis. It is generally recognised that it is the fact that young women,
particularly domestic servants whose homes are in the country, when they become unfit for work tend
to return to their homes to a greater extent than young men do, and this view the figures given in the
Registrar General's Annual Reports clearly support; though it is, at first sight at any rate, rather surprising,
as Dr. Stevenson points out, that the phenomenon should be so marked in the case of pneumonia
and appendicitis. It is, moreover, necessary to remember that the population migrating to the towns
is to a large extent a selected population, and that a less resistant residue is left in the country villages.
The illustrations which have been given furnish further proof than has been already adduced that the
movements of population which have so continuously occurred in the last half century have had very
far reaching, though not in all instances very obvious, influence upon vital statistics, and study of
these influences is especially necessary in dealing with London.
In Part I. of the supplement to the 75th Annual Report of the Registrar-General there will be found
a life-table for London, calculated by Mr. George King, F.I.A., F.F.A., based 011 the mortality for the two
years 1911 and 1912. The system of transferring to London the deaths of Londoners occurring anywhere
in England and Wales was brought into operation in 1911, and consequently the life-table is the first
to be computed upon the new series of figures. It should be pointed out that while the deaths allocated
to London by transfers render the total deaths belonging to London as complete as possible, no addition
lias been made to the London Census population in respect of the occupants of institutions outside
London chiefly or exclusively occupied by London residents. Were such an addition made, the
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