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44
Annual Report of the London County Council, 1913.
"trifling bronchial catarrh occurring in an individual with a 'phthisical habitus' should be looked
upon as a dangerous enemy and treated with the utmost care"; or, who had been insistently taught
that a protracted bronchial catarrh frequently leads to consumption," and told that "physical signs
which hitherto have been considered characteristic of pulmonary tuberculosis gain a different meaning
for those who have left Laennec's standpoint," would doubtless be more inclined than practitioners who
did not accept the new German view, to include cases of pneumonia and bronchitis (as they would have
been termed in England) among their cases of pulmonary tuberculosis.
There can thus be practically no doubt that in the main the striking divergence of type of the
Prussian curve from those of England and Wales and Ireland is due to differing views as to nomenclature
in the various countries concerned, and this is confirmed by the fact that in the United States, in
which country both the differing views find expression, the resulting type of curve is intermediate between,
and presents in itself the peculiarities of both, the divergent types. Here again, as Murchison remarked
fifty or more years ago, we have to look for explanation of divergencies of type to "the mental revolutions
of practitioners rather than to the actual revolutions of disease." The differences existing in Prussia
and in England have tended to disappear with time, but that fashion still plays a part in determining
allocation of tuberculosis deaths, more particularly at higher ages, will be realised on referring to the
figures given by the Registrar-General in his Annual Report for 1912, at page 600, where an analysis
is presented of all the deaths from tuberculosis in that year, showing the frequency with which complications
with other diseases were met with in different age-periods.

Thus, in the highest age-group complications are especially common. A further point of interest
in this connection was pointed out by Dr. Dudfield in his annual report for 1912 ; he notes that it is a
common thing to find that among persons notified as being tuberculous and subsequently dying, no
reference whatever is made to the existence of tuberculosis on the death certificate.
Probably no group of causes of death is less satisfactory to deal with from the point of view of
international comparison than that of diseases of the respiratory system, including pulmonary tuberculosis.
The disease which initiated the trend of events resulting in death may be certified, for instance,
as acute bronchitis, but the bronchitic condition itself may have been consequent upon phthisis in
an early stage, the presence of which might never come to light except in the relatively few cases where
post-mortem examination is made. The same remark applies to deaths from pneumonia and bronchopneumonia.
It may be added that while there is as already noted, so considerable a difference between
the death-rates from bronchitis in America and England, the English rate being greatly in excess, on
the other hand the American pneumonia death-rate exceeds the English, and this doubtless in part
explains why it is that on comparing the total death-rates of the two countries from respiratory diseases,
including phthisis, it is found that they do not greatly differ. It is not possible to say precisely how
far the excess of bronchitis in this country may be actual and caused by unfavourable climatic conditions,
but unquestionably it is largely a matter of diagnosis.
The influence of general health conditions and of varying practices as regards terminology having
now been considered it remains to discuss a third factor having influence upon the curves giving phthisis
deaths at ages. It is obvious that any movement of population to or from a country must affect
its death-rate. Such influence as is thus exerted may be expected, moreover, to be especially marked
in the case of mortality rates from diseases which are not rapidly fatal, for in acute disease there is less
likely to be movement away from the country of origin and also less likely to be return to that country
in the event of a serious illness being developed in the new home of the emigrant. The influence in
question may perhaps especially be looked for in the case of phthisis, for the reason that removal from
the country of origin to some more favourable climate, has been freely advocated in phthisis from the
time of the Greek physicians onwards, and has especially been insisted upon since the middle of the
last century ; while during the last fifty or sixty years the facilities for such removal have greatly
increased ; moreover, it needs to be remembered that in the case of phthisis the disease is often of so
protracted a character that it is quite possible for sufferers from it to return home to die.
In England and Wales, Ireland and Germany the movement of population, during the last halfcentury,
has been especially large. In the absence of complete records of actual inward and outward