View report page

In the Annual Report for 1909, Sir Shirley Murphv commented upon the decrease in the London
death-rate from tubercular diseases in children, a phenomenon which was already apparent at that
time (see p. 22 Annual Report, 1909). Examination of the death rates from tuberculous meningitis
in London, and in England and Wales, shows a fairly steady decline for the last fifteen years. The
rapidity of decline is greater in London than in England and Wales, but the rate for the former, though
it has in recent years rather closely approached, still exceeds that of the latter. On turning to tuberculous
peritonitis, decline is apparent in both London and England and Wales, and the rapidity of
this decline is again rather greater in London; it is particularly noteworthy, however, that for the last
fifteen years (with only two exceptions) the rate in London has been lower than that in England and
Wales (see Diagram E).
The Registrar.General, in his Annual Report for 1913, specially comments upon the fact that
there is a low rate of mortality from abdominal tubercle in London, whereas meningeal tubercle causes
a heavier mortality in London than in other classes of area. He says : " The London rate, indeed, is
less than half that in the county boroughs, though, London apart, the usual rule of increase in mortality
with increasing aggregation of population holds good for each of the three years dealt with in the table.
Unless, as seems unlikely, exposure of children to infection by means specially liable to implicate the
intestine and peritoneum is at a minimum in London, the question must arise whether the extraordinary
difference shown by the figures represents the facts. We have seen that the mortality tends to rise
in years when fatal diarrhoea is prevalent. The most obvious explanation of this fact would seem to
be the return as tuberculous of certain deaths from diarrhoea not of tuberculous origin, unless, indeed,
diarrhoea can be held to prepare the ground for local infection with tubercle. If the deaths returned
under this heading are not all due to tubercle, this was probably the case still more thirty years ago,
which would help to explain the very great reduction in recorded mortality since that time. It might
also account for the low mortality in London, where there is much reason to believe that death certification
is at its best."
It is, of course, conceivable that the action taken with regard to tuberculous milk coming into
London may have had some influence in reducing the London mortality from tuberculous meningitis
and tuberculous peritonitis. With a view to further examination of such an hypothesis, the rates for
Manchester, which are available since 1897, when the present area of the City was determined, have
been plotted out on diagram (E). It will be seen that in Manchester, which took action with regard
to tuberculous milk in 1899, nine years prior to the date (1908) when action was taken in London, the
decline in mortality has been rather less marked than in London, and in neither instance does the extent
of the decline greatly differ from that observed in England and Wales. This behaviour of the rates
in these three populations tends to confirm Dr. Stevenson's view that the fall in the London rate is
in the main due to improved death certification.
In the light of this evidence with regard to the influence exerted by improved diagnosis upon
the nomenclature of tubercular disease in children, and in view of the fairly steady decline in the rates
from tuberculous meningitis and tuberculous peritonitis over a long series of years, it seems clear that
it would be premature to ascribe the decline which has occurred in the last few years to the undertaking
of special measures for the protection of the milk supply against tubercular infection.
The figures in the above table show a marked decline in the infant mortality from all
causes during the period covered. This decline is not peculiar to London or even to England and
Wales ; in most of the principal European countries a similar fall has, in varying degrees, been experienced.
Coincident with this decline in the mortality, there appears to have been a similar, though
not proportionate, fall in the birthrate, and it might be suggested that the two phenomena may be
in some way correlated, although variations from this rule may be apparent in different localities as
well as at different periods of time. The relationship between the decrease in birth-rate and in mortality
when large populations are considered, will be seen from the following table, which relates to European