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Report of the County Medical Officer—General.
43
at the higher ages form a relatively smaller proportion of the deaths from all causes than in the poorer
populations.
If the greater mortality from all causes at higher ages in Prussia is to be regarded as indicating
that the marked improvement in economic conditions in Prussia only dates from thirty or forty years
ago, it might suffice to explain, in some measure, why the phthisis death rate at the higher ages still
compares unfavourably with that of England and Wales.

The table clearly shows that with increasing age the death-rate from tuberculosis contributes
more largely towards increasing the death-rate from all causes in Prussia than in England and Wales.
It must, however, be borne in mind, in this connection, that other influences may be operative here;
in particular the influence of migration, and of varying practices in connection with nomenclature of
disease (to both of which reference will almost immediately be made) need to be kept in view.
It will be observed that while both the English and Prussian curves show well-defined maxima of
incidence at about the fortieth, and at about the sixty-fifth year respectively, the American curve has
two periods of high incidence at about the fortieth and seventieth years. Perhaps this may be in part
accounted for by the fact that a considerable proportion (nearly 10 per cent.) of the population of
America is of German origin. It may be assumed, therefore, that German influence has been markedly
exerted in the United States, and the traditions and training of practitioners of German origin, who
have migrated to America, may have played an appreciable part in determining the fact that the
United States curve is, as it were, a blend of the curves of England and Wales and Prussia. It
may be added that in Wisconsin, with 24 per cent, of its population of German origin, the buckling
of the mortality curve of age-incidence of tuberculosis is particularly marked.
A little consideration will make it clear that one of the most conspicuous aberrations of the
German curve from that of the other countries dealt with, is in all probability due in the main to the
influence of fashion in nomenclature. The excessive rates from tuberculosis at the higher ages in Prussia
cannot in fact be held to betoken any peculiar natural phenomenon, for if the death-rates at ages,
from all respiratory diseases plus tuberculosis, in Prussia and in England and Wales, be compared,
it will be found that there is almost precise correspondence. This fact suggests that the notable differences
observed in death-rates at higher ages in the case of tuberculosis alone must be due to some, so to
speak, artificial transference of disease from one heading to another. This view is confirmed when it
is found that bronchitis is a far more frequent cause of death, at these same higher ages, in England
and Wales than it is in Prussia, and in point of fact the excess in tuberculosis at these ages in Prussia
is broadly speaking equivalent to the defect in bronchitis. Thus it would appear that much of the
disease called tuberculosis forty years ago in Prussia would have been called bronchitis in England
and Wales, and though this divergence of view has tended to disappear to some extent as years have
gone by, it still remains a phenomenon to be reckoned with. Since the discovery of the tubercle bacillus
there has been modification of the views held with regard to tuberculosis in both countries ; but there
has apparently been more considerable change of view in Prussia than in England and Wales.
That this should be so will be readily understood if reference be made to teaching which had
a marked influence upon German opinion fifty years ago. Professor Felix von Niemeyer, of Tubingen
was wont to insist that "pulmonary tuberculosis" did not necessarily originate as the result of
"specific new growth" (Laennec's dogma, so Niemeyer termed it); but that it might develop "out of
acute or chronic pneumonia, take its rise from a bronchial haemorrhage, or from a neglected or
protracted cold." Niemeyer held that "a bronchitis out of which phthisis is developed", might
primarily be a genuine cold and, further, "that in very many cases there is not a single tubercle found in
phthisical lungs." Again, Niemeyer wrote "most phthisical patients have no tubercles in the beginning,
but many of them become tuberculous in the course of the disease"—thus "tuberculosis is in most cases
a secondary disease"—and he declared that in the cases in which tuberculosis had been developed in
the course of phthisis, treatment was "indeed impotent." It is not possible here to discuss the issues
raised by Niemeyer as against Laennec,but it may be pointed out that Niemeyer's contentions commanded
much attention and greatly influenced opinion. Practitioners who were exhorted to remember that a
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