The argument of Thomas McKeown that the ‘invisible hand’ of natural amelioration, mostly through improved nutrition, was responsible for declining rates of tuberculosis mortality in the late nineteenth century has been challenged in an article by Simon Szreter. But both have largely ignored the case of France, which presents an apparent anomaly: the French mortality rate from tuberculosis improved very little before the First World War. Statistical data were very inadequate for the pre-war period because of faulty bureaucratic reporting and deliberate dissimulation by families anxious to avoid social ostracism. Available calculations indicate that over 100,000 French persons died annually of consumption before 1914. A slight improvement in some urban areas was offset by a spreading epidemic in the countryside. Attempts to gain a precise statistical account of tuberculosis mortality remained ineffectual. We are consequently dependent for the period before 1925 on qualitative evidence, which tends to confirm France's relative retardation among major European nations in combating the most lethal of nineteenth-century diseases. As for the debate between the McKeownites and their critics, the jury is still out. To pronounce definitively, we shall require a more thorough comparative study of national tuberculosis statistics than has hitherto been conducted. If the conclusions of this essay are confirmed, those who advocate the McKeown thesis of a steady amelioration by natural causes will need to explain why this ‘invisible hand’ so conspicuously failed to pass over pre-war France. Sole attention to British and German data ignores the apparent anomaly presented by the less positive experience of the French. Indeed, it would seem that the French mortality rate from tuberculosis before 1914 was nearly double that of its two national competitors. Unless this conundrum can be explained, the case for an automatic improvement through rising living standards is seriously weakened. Is it actually demonstrable that the English and Germans were significantly better nourished than the French? Probably not. And if not, then one is led to conclude that the key to improvement lay in local sanitary measures and national health reforms. In these regards France continued to lag and to pay the price for doing so with an appalling loss of human life.

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   |texte=   An Inexact Science: The Statistics of Tuberculosis in Late Nineteenth-century France
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