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Crowded bridges at 8 a.m. and 6 p.m., the thronged termini, the tram queues, the strap hangers in 'bus
and tube ; note should be made, moreover, of the size of the vast army of toilers in Dr. Greenwood's 28
boroughs, who work every day in a 29th area, the centrally lying City, not included with the 28, owing
to the difficulties arising out of trying to grapple with its quite phenomenal figures.
It is herein, in fact, that the great difficulty resides: if only some of these human units could be
traced from the cradle to the grave as Dr. Greenwood tells us they will be in the years to come. Now,
it is for all the world like counting a flock of sheep, everything is on the move, even the discerning eye of
partial correlation is at a loss. One thing we may be sure of. The movement is there, a factor to be
reckoned with. Bulstrode declared, arguing on now unfashionable a priori principles, that as soon as the
" segregation in sanatoria conception " came to be fairly floated the death rate from phthisis in this
country must, for a time, rise. It seems so obvious. The outflow is checked, the cistern must thereupon
tend to fill. The same contention proved capable of being demonstrated, a posteriori, at the hands of
Prof. Pearson, by the most refined mathematical methods, a few years later. The slackening of the
fall in the phthisis curve, indeed, its decided manifestation of a tendency even to rise, was in fact already
plainly in evidence at the close of the first decade of the present century. The protests from America,
South Africa, Australia against the despatch to them of phthisics from Europe, first voiced 40 or 50
years ago, greatly accumulated in force and volume during the nineties and in the years following.
Legislative action and organised effort to prevent such transfer, moreover, assumed practical shape from
the early nineties onwards. It is true that in the period of more precise statistics, specially considered
by Dr. Greenwood, the removal of tuberculous persons to a better climate had been reduced to comparatively
small proportions, but the fact remains that in the 60 yeffrs from 1851-1911 the number of
persons emigrating from these islands was equal to 25 per cent, of the total number of deaths occurring in
the United Kingdom during those years, and very many of the said emigrants left the country on account
of suspected or declared phthisis.
It is, on the other hand, urged by objectors.: "Show us the mortality returns of the countries
in which it is suggested these consumptives have died." Here is, indeed, a difficulty, as I found, in 1912,
in exploring the data, forthcoming say from Graubiinden, the canton of Swiss Sanatoria, or from South
Africa, or the Western States of America. No one can expect health resorts to make unnecessary
parade of their phthisis death rates. Again, objectors say the effect of the exclusion by America and the
Colonies of phthisics should have produced an even more marked rise than that actually observed in
the England and Wales death rate, but it must be remembered that the strictness exercised with regards
to exclusion has more or less gradually come into operation. Dr. Greenwood suggests that the recent
considerable rise in the rate for young women, noted as early as 1916, may have been due to factory
employment. This is, however, very soon for the presumed cause to show so marked an effect on the
death rate. Moreover, as Dr. Greenwood and Dr. Brownlee both note, the rise has been appreciable
at the age 10—15.
The Influence of Migration.
Dr. Greenwood endorses the views urged by me nine or ten years ago (Proc. Roy. Soc. Med. 1912),
so far as young women are concerned, and concludes that movement of population between rural villages
and cities has exerted considerable influence in modifying phthisis death rates. He asks, " Have we to
do with a consequence of the migration from country to town of healthy and ambitious young women ?"
He supplies (Table 8, page 331) corrected phthisis rates for females, which give " some measure but only
a very rough measure " of the effect produced by the Registrar General's attempt to correct for deaths of
non-residents. It is very interesting to find that the officially recognised transfer of deaths of nonresidents,
which as Dr. Greenwood says does not of course account " for the whole force of migration,
oidy correcting for quite temporary change of residence," does as a matter of fact reduce the considerably
excessive death-rate in rural districts for females at the four ages given in the Table ; and at the
ages 15—20 the corrected rate for all rural districts now falls below that for all urban districts. If it be
borne in mind that the migration is not all one way, the results obtained by correcting for transference
are seen to be " significant of much," and the fact that the effect of the correction is most marked at the
youngest age (15—20) is particularly noteworthy. For, it should be observed, that while the "healthy
and ambitious " girls, to quote Dr. Greenwood's phrase, move from the country to the town, it is clear that
oftentimes when they develop phthisis they return home to die; and they especially tend to do this
when they are still in close relation with home, i.e., at the age 15—20.
This, however, is only the beginning of the migration story. The facts as to the adolescent girls
were emphasised, in 1912, because in this case the phenomenon is gross as a mountain, open, palpable,
but they were meant to be applied not only to one age and sex, but generally and not exclusively to rural
parishes within 50 or 100 miles of London but to the world at large. It should be added here, to prevent
any possible misconception, that there can be no question as to the fact that the great decline of phthisis
in England and Wales in the last 60 or 70 years is in considerable part accounted for by the general improvement
in the condition of the masses of population.
There are two points of special interest arising out of the statistics of the years since the outbreak
of war.
(i.) It was pointed out, in 1912, that the decline exhibited for half a century in the phthisis
death-rate would, with discontinuance of resort of invalids to foreign countries for health
reasons, be likelyjto continue to diminish and perhaps be transformed into a rise. The outbreak
of war practically stopped migration, and correspondingly there followed, as had been anticipated,
decided augmentation of the phthisis rates of this country. (See Table L1V., p. LXX.,
Ann. Rep. of Reg.-Genl., 1918.)