PHTHISIS 1881-90. Chart 4. 5 to 10 to 15 to 20 to 25 to 35 to 45 to 55 to Under 5 by malnutrition and further damaged by climatic influence. This prepares the soil for the seeds of tuberculosis to such an extent that the phthisis rate of Wales continues nearly to double that of Herefordshire. RURAL COUNTIES COMPARED TO TOWNS. Taking the age curve of either district and comparing it with the samples of the English towns Dudley and West Ham, two features distinguish urban from rural populationsthe maximum is at a later age and the rate is comparatively high in old age. Cambridge, by its rural attributes, presents little of this urban feature. These samples are but instances of a rule which seems to hold good for the rural counties and the towns of England. The explanation seems largely to lie in a remark of the experienced Mr. Booth, who writes: "Life for old people is easier in the country, rents are lower, continued earnings more possible, friendly assistance in case of need more sure. We must not, however, neglect another agent perhaps of equal influence-overcrowding; in the towns it is half as prevalent again as it is in the country, and Chart 3 shows that an increasing effect is produced as age advances, accounting for the maximum appearing at a later age period in the towns and for the prevalence in old age. On proceeding to compare these three towns, Dudley, West Ham, and Cambridge, their curves form no doubt good illustration of how different occupations and surroundings affect the mortality from phthisis; for all that, the intricacies of the subject defy full investigation. All of these towns have made much progress since the 65 to -75 & over period 1861 to 1870. Dudley then suffered much as West Ham did in the period 1881 to 1890. West Ham stood where Cambridge stands and Cambridge was almost in the position Paris is depicted in. West Ham is an instance of a densely populated and thriving town whose inhabitants are occupied as much indoors as out, the male rate considerably exceeding the female rate. Here zymotic disease is prevalent and overcrowding is moderate, yet it is below the phthisis rate for England and Wales. Its good health is somewhat exaggerated, those of its inhabitants dying in London institutions not being included in the past three years it would represent an addition of 10 per cent. Cambridge may be taken as an example of old residential towns; neither the presence of undergraduates nor of a county hospital determines the curve of incidence drawn. Cambridge exhibits (among its men especially) a phthisis rate exceeding such towns as West Ham, for which I can find no further reasons than such as were noted when comparing North Wales with Herefordshire-namely, a lower standard of nutrition (implied by lower wages and higher priced food) and damp. Zymotic disease, unhealthy occupations, diseases of the respiratory system, and overcrowding do not seem to be attributes of this town. Dudley enjoys a comparative immunity from phthisis which one was at first sight inclined to attribute to the smoke of the Black Country, from the heart of which it rises, built on the top of a long slope of hill with a good fall on nearly every side. It has many attributes-slums, overcrowding, abundant zymotic disease, and exceptional prevalence of respiratory disease-all of which may dispose EQUAL INCIDENCE. to phthisis. Though not engaged in textile industry women suffer more than men whose occupation, largely in collieries, Attention has repeatedly been called to the inequalities of exercises a good influence, the origin of which has not yet the phthisis rate in different sanitary areas. Attention may been fully determined. The situation of Dudley by its equally be given to the remarkable evenness of rates in the airiness, elevation, and dryness of soil, the nutrition of its counties of England-I have found it necessary to use inhabitants by their very high wages and decidedly meat-gradations of only 7 per cent. to map them-and, further, eating propensities mark alone conditions which should place that evenness extends to the sanitary areas. The rate is so the town above many. While from a distance it seems to be steady that small areas having only from 100 to 200 deaths covered by a pall of smoke, Dr. T. F. Higgs notes that gases in a decennium will show but very little variation in rate are quickly driven away. SO2, the agent which the late Dr. throughout their county. Suburban counties are often an Andrew considered conferred some immunity on Röros, is exception to this rule; Essex beyond the suburban district not more prevalent according to Mr. H. D'A. Ellis and other is as bad as Suffolk, and Kent and Surrey are very variable; informants than in other large towns. Dr. C. A. MacMunn, but even here nothing like the incidence of London appears, while calling attention to the great production of phenols where the Strand and St. Giles triple the rate for Lewisham and gases from the furnaces, does not suggest that the and Hampstead. London stands almost alone in its tremendous heavy gases are permeating the atmosphere. However, contrasts. Except in those areas where differences in seeing how low the rate is on either side of the age of occupations and prosperity are nearly as vast as in London, occupation some exceptional influences are probably at work. instances of phthisis rate for one sex only being doubled can with difficulty be found when we compare one sanitary area with another in the same county. PARIS AND PRUSSIA. Paris and Prussia are a contrast to what usually obtains in this country. Paris, while equalling in adults the Cambridge mortality of 30 years ago, is conspicuously different from Cambridge at that time in the heavier incidence on youths to age 20. I understand that this heavy mortality without declension has been the fate of Paris for 30 years. The early age incidence and the absence of declension are alike due in my opinion to the vegetable diet and to those economical conditions which have allowed the Paris ouvrier to advance so little compared with the British workman. It is true that the Office of Works of French Industry shows that the rise of wages in Paris has been no less than in England, but it also tells that the present wage is 10 per cent. less and the cost of living, according to M. Bienaymê, has since 1860 increased 10 per cent. We know the enormous decrease in the cost of living here. As to Prussia I have made no inquiry; the curve forcibly suggests by its resemblance to that of the most overcrowded districts of London that it has its explanation in the same cause, faulty ventilation. The only rate in England which I have seen to exceed this is found among the tin and lead miners, in whom the rate is nearly double that of Prussia between the ages of 55 and 65 years and after 65 years, judging, however, from small figures, only 80 deaths from phthisis. Damp, malnutrition, and exposure affect these men, but it is doubtless the stagnancy of the mine atmosphere (styled with a fine unconscious irony "natural ventilation ") that induces this enormous mortality late in life. Sir Hermann Weber, in the Croonian Lectures, said of these Prussian figures: "Part of the difference (from other countries) may be accounted for by the fact that during the much colder winters in Prussia old people are more confined to narrow, ill-ventilated, stove-heated rooms than is the case in England, where the cold is never great and where open fireplaces do not allow the air to be vitiated to the same degree." Despite the great declension of phthisis all over England different districts like those already mentioned still exhibit much evidence of difference in susceptibility. It seems not too much to say that nothing more haphazard is seen than in non-infective diseases-fortuitous increase of mortality is not apparent; when death returns and local agencies inducing susceptibility are considered together they confirm the common opinion: avoiding susceptibility one avoids infection. COUNTIES OF ENGLAND. A general observation of available data in the counties of England tells the same tale of a mortality rising as visible agents of susceptibility preponderate. The Registrar-General has afforded the best opportunity of comparison in counties, having corrected the death-rate and the phthisis rate in the past decennium for age and sex distribution of their populations. The advantage of comparing larger numbers of population outweighs any disadvantage in comparing areas which by their size lose some distinctness in local characters; these local attributes will still be found to be sufficiently distinct. Before briefly comparing the mortality from phthisis in the counties of England it is well to consider, first, the general equality of incidence of that mortality; secondly, how far migration has effect upon the death returns; and, further, what kind of additional information is afforded by taking into account the concurrent mortality from all causes. Men vary more than women in their mortality from phthisis and in their occupation, so men by their indoor occupation in towns of some rural counties are found to have double the phthisis rate of the area which has the lowest rate in the county. Such towns are Canterbury, Chichester, Oxford, Cambridge, Exeter, Bristol, Worcester, Coventry, Leicester, Nottingham, Redruth, and Biggleswade. Occupa tional influence in northern counties can often provide several instances. On the other hand, no such instance is to be found in Norfolk, Essex, Bucks, Hertfordshire, Wilts, Somerset, Dorset, Hereford, Shropshire, Lincolnshire, and Northamptonshire, while Surrey, Berkshire, Suffolk, and Cumberland are probably in the same category. Towns are not infrequently among the least affected districts in a county; such towns are usually well-to-do and often new, as those within London influence-West Ham, Romford, Richmond, Croydon, and Watford; also the growing towns-Eastbourne, Reading, and Lowestoft. In manufacturing towns this exceptionally good position is rare; Dudley and Pontypridd with their coal-mining and smelting of iron may be noted. That a specific and contagious disease should be so stable in its incidence and so independent of density of population is remarkable. This aspect of phthisis harmonises with that straightness of the curve year after year in England which was commented upon by Dr. Longstaff whe in this respect compared it to cancer, apoplexy, paralysis, and convulsions. MIGRATION. The question of the influence of migration upon the death returns is not unimportant. Is it true that migration (people returning home or seeking the country to die) accounts for the healthiness of towns? in other words, are rural districts not responsible for their phthisis rate? Inquiring first of medical officers of health of district areas, West Ham sends a large number of its patients to the neighbouring London hospitals; its artisan inhabitants cannot afford to send many away to a distance. Dr. Sanders states that in the past three years there has been referred to his district a number of deaths from phthisis occurring in London institutions which amount to 10 per cent. of those occurring in the district. It is not, then, migration which has been responsible for the low phthisis rate of West Ham. In Norfolk two rural districts have recently had every death from phthisis in the past 20 years surveyed, Dr. Plowright investigating the Freebridge Lynn district, a population of about 12,000, and Mr. T. L. Lack the village of Hingham. They found that 10 per cent. were imported cases, several being from other parts of the county and several from the army; no record of any cases leaving the district and dying elsewhere could be given. If their few figures, relating to in all about 300 deaths from phthisis, are, as I believe, a fair sample of the experience of rural districts the rural incidence cannot be said to be masked by migration. Seeking evidence, secondly, from age incidence in the counties, at the ages of 10 to 20 years emigrants from the towns are few (they were less than 4 per cent. in the Norfolk data); yet on taking the phthisis rate of London and the four surrounding populous counties at this age of less migration and again the rate of the age groups from 20 te 35 years when emigrants are more numerous it is evidently ir either case a lower rate than that for England, as has been 25 to 35 to noted by Dr. Niven. Conversely in rural counties the rate is, as a rule, equal to, or higher than, the rate for London and suburban counties at age 10 to 20, as well as for the ages 20 to 35. Finally, if the county of least immigrationCornwall-is analysed the rate is no lower than in other rural counties and it is higher than in London. Figures are appended giving age group rates; they show that in early life rural districts have higher rates, for girls particularly. From all these data I conclude that rural counties have no such increase by immigration at any age as to mask the phthisis that originates in the county and that the figures of the Registrar-General's returns truly tell the county phthisis rates. I am satisfied that in these maps a county would rarely if ever have to change a grade on that account. If one attempted to correct the map of phthisis mortality further than for age and sex there are only two or three 75%& ovor instances in which the evidence appears to make it desirable. Surrey might claim that it had an unfair share of asylums which add to the rate as much as a hospital for consumption; Hampshire that it held military and naval hospitals with many deaths from phthisis, and in the latter county the medical men at Bournemouth would doubtless protest that their patients came there too late. PROPORTION OF DEATHS FROM PHTHISIS. In explanation of Map E giving the proportion of deaths from phthisis to all deaths for the counties Chart 2 may be referred to which expressed this liability to die from phthisis for every age group of England and Wales. The map expresses it for each county by combining all the age groups into an all age proportion rate. This combination can as reasonably be made as in the case of mortality per Chart 5. All causes. 1000 living or even more so, because the character of the curve of ratio of deaths from phthisis to all deaths runs more consistently through all age groups than does the curve for mortality. If one age group is above or below the mean for England and Wales almost all are, while the curve mortality per 1000 living shows much less consistency. Figures are appended (Appendix II.) giving the ratio at ages from 25 to 35 years for all the counties. They have just the same local relations as when taken for all ages, except in a few cases where the incidence is exceptionally heavy in later life. Chart 5 gives an example of the consistency of the curve for either sex, comparing North Wales with Lancashire. mark this coincidence by the rate of death proportion showing a greater number bordering upon the mean than the rate of mortality per 1000 living. The death ratio map then eliminates much of widespread evil influences, as overcrowding in towns, which Mr. Shirley Murphy showed predisposed to many causes of death, increasing the death-rate for such districts in London by one-half, while it doubled the phthisis rate. Good influences are similarly in part eliminated, especially those attributes which give rural districts such a low mortality. Clearer indications remain as to the influence of locality upon liability to phthisis by thus discounting the healthiness or unhealthiness of counties as shown by the total death-rate. TABLE VI.-Showing the Comparative Mortality of Males from 25 to 65 Years of Age (1890-92) from all Causes and from Phthisis, corrected for Age Constitution in the Four Decennia for 61,215 Men engaged in each Occupation. (Part II., Supplement, 55th Report of the Registrar-General.) Phthisis (occupied males taken as 100). All causes. Phthisis. Phthisis (occu pied males taken as 100). 1222 175 1228 324 175 1109 301 160 1099 260 1014 920 276 149 140 256 133 Costermonger (224) Docker Innkeeper (139) ... Tobacconist... Law clerk Tailor (134) Chimney sweep... 19 13 18 18 17 16 16 15 ... 15 14 Farmer... 14 A table of occupations draws this same comparison among classes of men at those ages during which phthisis is twice as prevalent as it is during the whole of life. You may judge whether the liability to phthisis is best expressed first, by comparing their mortality in the middle column; secondly, by comparing the frequency with which they die from this disease in proportion to all other forms of death in the last column. The docker and the innkeeper have a very high mortality from phthisis but not higher than that from many other diseases. Their liability to die from phthisis is but a part of their liability to all kinds of death; a fuller judgment of liability to phthisis is afforded by taking into view their low proportion of deaths from this cause as shown in the last column. The last column, on the other hand, shows that such indoor workers as grocers, carpenters, and domestic servants, though with a low rate in the mortality column, possess a proclivity above the average to this kind of death. (In the table deaths from accidents have not been eliminated; such amendment would not alter the order set down.) The causes leading to death from phthisis are numerous, diverse, and comprehensive, so much so, it would seem, that the same are also the agencies leading to a large proportion of other deaths. Both occupations and counties In considering for locality the causes that affect the phthisis rate in the counties the local influence of tuberculous, zymotic, and respiratory system disease will be neglected. Their relation to phthisis is neither close nor constant. OCCUPATION. Occupational influence is marked by the death-rate for all causes falling upon the counties according to the aggregation of their population in the towns. The 11 counties, London, Monmouth, Warwick, Staffordshire, Notts, East York, West York, Lancashire, Cheshire, Northumberland, and Durham, alone have a general death-rate above the mean for England, owing to their population being mainly concerned with trade and manufacture, and to their dwelling in the towns. (Map C.) Worcester, Gloucester, Derby, and London suburban counties also consist largely of trading populations, but they join all the other counties in England in being below the mean death-rate. Intimate as is the connexion of the phthisis rate (Map D) with the general death-rate it fails to follow that rate when it is above the mean in the manufacturing counties as often as not; it is only in London, Lancashire, West York, Durham, and Northumberland that the phthisis rate rises above the mean; the comparative immunity of the other counties shows that excess of phthisis need not accompany town occupations. Occupations placed in order of the proportion per cent. phthisis deaths bear to deaths from all causes. |