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CHANGING PATTERN OF INFANT MORTALITY
589
Whether the pulseless disease is
a
e1inicopa,tholo,gical
variant or uncommon presentation of some entity more mundane arteritis is debatable. Clinically, it is unusual in that it attacks the large proximal arteries of young women-a distribution very unlike atherosclerosis or Buerger’s disease. There seems no reason, pathologically, to suppose it is a form of disseminated lupus erythematosus, periarteritis nodosa, or rheumatoid arteritis. It is perhaps allied to the arteritis of indeterminate origin which has been described from time to time, and Ask-Upmark 4 takes the view that it is an allergic response to a non-specific infection. Certainly, it is important that these cases should be carefully studied and recorded, if we are to understand what the condition really is. or a
CHANGING PATTERN OF INFANT MORTALITY THE remarkable decline in infant mortality in the last half-century is common knowledge, but less attention has been given to the changing pattern of mortality during this notable period. Wallis Taylor,5 working in the department of medical statistics in the University
of Birmingham, has recently analysed this changing pattern, and from the trends revealed he has predicted likely mortality changes in the near future. fn England and Wales the infant-mortality rate showed no decided trend in the second half of the 19th century,
the
and it remained around 150 per 1000 live births ; but there has been a regular quinquennial fall in the last forty years, and the current rate is under 30. The tempo of the decline was quickest in the decennium 1914-23 and in the quinquennium 1945-49. This transformation has, of course, been produced mainly by progressive improvement in social and economic conditions and nutrition, and to a lesser extent by advances in therapeutics. The infant-mortality rate is still one of the most sensitive indices of social conditions in a community. (Loganfinds, perhaps surprisingly, that despite the tremendous reduction in infant mortality in the past thirty years, the difference between the rates in the various social classes remains the same. Thus both in 1921 and in 1950 the rate of postneonatal deaths [4 weeks to 1 year] in the Registrar-General’s class v [unskilled occupations] was four times that in class i [professional groups]; nor have the differences between the social classes in the stillbirth-rate and the neonataldeath rate tended to diminish in recent years.) Rational forecasting of trends in mortality requires careful analysis of mortality attributable to different diseases. The most spectacular decline has been in summer diarrhoea, with a slower though pronounced reduction in other infections, including tuberculosis. It is noteworthy that the mortality from pneumonia declined at a quicker rate after 1931, although the first quinquennium of this period came before the introduction of sulphonamide drugs. The outstanding feature of the last decade has been the increased rate of decline in the mortality attributable to prematurity. But there has been no sustained reduction in the death-rates from the three conditions which constitute the hard core of infant mortality-birth injury, asphyxia and atelectasis, and congenital malformations-which together account for the majority of neonatal deaths. Apart from this hard core, the last two quinquennia have seen an accelerating decline in mortality in nearly all other categories, and it is particularly significant that in the last quinquennium (1946-50) the number of deaths from pneumonia, diarrheea and enteritis, and prematurity, which together accounted for 48.9% of all deaths, decreased more quickly than ever before. Taylor considers that these three conditions are likely to be the pacemakers of the further improvement to be expected in the next decade. 5. 6.
Taylor, W. Brit. J. prev. soc. Med. 1954, 8, Logan, W. P. D. Ibid, p. 135.
With three exceptions, all the communicable and epidemic diseases have consistently lost their sting throughout the whole period 1911-50, the exceptions being diarrhoea and enteritis, influenza, and congenital syphilis. But the rate at which mortality has fallen has been very variable. Infant mortality from diphtheria fell very slowly until the introduction of systematic immunisation in 1940, but there was a rapid gain in momentum thereafter. As a cause of death, congenital syphilis fell away rapidly after 1920, except during the late war, which almost completely arrested the decline. Deaths from non-meningococcal meningitis and whoopingcough decreased rapidly in the period 1916-20, but slowly in the following quinquennium ; and in 1946-50 there was again a much quicker fall in the mortality-rate. Clearly, the factors contributing to the sustained reduction in infant mortality are not equally applicable to all ’
the individual causes of death. Taylor calculates that, if the tempo of decline in mortality from all causes remains the same as in the last quinquennium (1946-50), an infant-mortality rate of about 20 per 1000 live births can be expected in 1960 ; but the rate of decline in the last few years (29-6 in 1950, 29.7 in 1951, 28 in 1952, and 27 though highly encouraging, gives little promise of such an achievement, for improvement in the rate becomes increasingly Nevertheless the low more difficult the lower it falls. infant-mortality rates already achieved in some countries, notably Sweden with 20 in 1952 and 18 in 1953, are challenging examples and an indication that an infantmortality rate of 20 should be attainable in this country, if not in the present decade, at any rate in the next.
in 1953),
DEATHS DURING ANÆSTHESIA Beecher and Todd1 have made a very detailed and extensive study of deaths during anaesthesia in the United States, which is bound to evoke discussion in this country. They investigated all deaths in the surgical service of ten university hospitals, over a five-year period from the start of 1948 to the end of 1952. At each hospital a surgeon and an anaesthetist examined the particulars of each death, assigned it to one of five categories (of which anaesthesia was one), and reported their findings, with details of the case, to Beecher and Todd. The other categories were " the patient’s disease," " errors of diagnosis," " errors in surgical judgment," and " errors in surgical technique." Beecher and Todd have arranged the information statistically and interpreted the results. Covering nearly 600,000 anaesthetics, they find an anaesthesia death-rate of 1 in 1560. This figure represents deaths wholly due to anaesthesia (amounting to 1 in 2680) and those in which anaesthesia was considered to play a primary part. The principal criticism of these figures concerns the criteria for assigning a death to any of the five categories. This is a difficult task when so many variables are present, and must surely leave’room for disagreement-yet no cases are recorded as unassessable. are valuable as a guide to the Even so, the of anaesthesia. mortality In their analysis Beecher and Todd note, among other things, that when a muscle relaxant is used the mortalityrate increases nearly sixfold : the death-rate was 1 in 2100 when muscle relaxants were not used and 1 in 370 when muscle relaxants were used. These are alarming figures, but they may be misleading since the design of the investigation, as a means of discovering the actual causes of anaesthesia deaths, will not bear scrutiny. Beecher and Todd remark that the increased danger from muscle relaxants is possibly due to induced ciroulatory collapse despite the use of adequate artificial This is contrary to generally accepted respiration. clinical and Dhannacoloaical opinion. and. with the "
"
figures
1. 1.
Beecher, H. K., Todd, D. P.
Ann.
Surg. 1954, 140, 2.
Whether the pulseless disease is
a
e1inicopa,tholo,gical
variant or uncommon presentation of some entity more mundane arteritis is debatable. Clinically, it is unusual in that it attacks the large proximal arteries of young women-a distribution very unlike atherosclerosis or Buerger’s disease. There seems no reason, pathologically, to suppose it is a form of disseminated lupus erythematosus, periarteritis nodosa, or rheumatoid arteritis. It is perhaps allied to the arteritis of indeterminate origin which has been described from time to time, and Ask-Upmark 4 takes the view that it is an allergic response to a non-specific infection. Certainly, it is important that these cases should be carefully studied and recorded, if we are to understand what the condition really is. or a
CHANGING PATTERN OF INFANT MORTALITY THE remarkable decline in infant mortality in the last half-century is common knowledge, but less attention has been given to the changing pattern of mortality during this notable period. Wallis Taylor,5 working in the department of medical statistics in the University
of Birmingham, has recently analysed this changing pattern, and from the trends revealed he has predicted likely mortality changes in the near future. fn England and Wales the infant-mortality rate showed no decided trend in the second half of the 19th century,
the
and it remained around 150 per 1000 live births ; but there has been a regular quinquennial fall in the last forty years, and the current rate is under 30. The tempo of the decline was quickest in the decennium 1914-23 and in the quinquennium 1945-49. This transformation has, of course, been produced mainly by progressive improvement in social and economic conditions and nutrition, and to a lesser extent by advances in therapeutics. The infant-mortality rate is still one of the most sensitive indices of social conditions in a community. (Loganfinds, perhaps surprisingly, that despite the tremendous reduction in infant mortality in the past thirty years, the difference between the rates in the various social classes remains the same. Thus both in 1921 and in 1950 the rate of postneonatal deaths [4 weeks to 1 year] in the Registrar-General’s class v [unskilled occupations] was four times that in class i [professional groups]; nor have the differences between the social classes in the stillbirth-rate and the neonataldeath rate tended to diminish in recent years.) Rational forecasting of trends in mortality requires careful analysis of mortality attributable to different diseases. The most spectacular decline has been in summer diarrhoea, with a slower though pronounced reduction in other infections, including tuberculosis. It is noteworthy that the mortality from pneumonia declined at a quicker rate after 1931, although the first quinquennium of this period came before the introduction of sulphonamide drugs. The outstanding feature of the last decade has been the increased rate of decline in the mortality attributable to prematurity. But there has been no sustained reduction in the death-rates from the three conditions which constitute the hard core of infant mortality-birth injury, asphyxia and atelectasis, and congenital malformations-which together account for the majority of neonatal deaths. Apart from this hard core, the last two quinquennia have seen an accelerating decline in mortality in nearly all other categories, and it is particularly significant that in the last quinquennium (1946-50) the number of deaths from pneumonia, diarrheea and enteritis, and prematurity, which together accounted for 48.9% of all deaths, decreased more quickly than ever before. Taylor considers that these three conditions are likely to be the pacemakers of the further improvement to be expected in the next decade. 5. 6.
Taylor, W. Brit. J. prev. soc. Med. 1954, 8, Logan, W. P. D. Ibid, p. 135.
With three exceptions, all the communicable and epidemic diseases have consistently lost their sting throughout the whole period 1911-50, the exceptions being diarrhoea and enteritis, influenza, and congenital syphilis. But the rate at which mortality has fallen has been very variable. Infant mortality from diphtheria fell very slowly until the introduction of systematic immunisation in 1940, but there was a rapid gain in momentum thereafter. As a cause of death, congenital syphilis fell away rapidly after 1920, except during the late war, which almost completely arrested the decline. Deaths from non-meningococcal meningitis and whoopingcough decreased rapidly in the period 1916-20, but slowly in the following quinquennium ; and in 1946-50 there was again a much quicker fall in the mortality-rate. Clearly, the factors contributing to the sustained reduction in infant mortality are not equally applicable to all ’
the individual causes of death. Taylor calculates that, if the tempo of decline in mortality from all causes remains the same as in the last quinquennium (1946-50), an infant-mortality rate of about 20 per 1000 live births can be expected in 1960 ; but the rate of decline in the last few years (29-6 in 1950, 29.7 in 1951, 28 in 1952, and 27 though highly encouraging, gives little promise of such an achievement, for improvement in the rate becomes increasingly Nevertheless the low more difficult the lower it falls. infant-mortality rates already achieved in some countries, notably Sweden with 20 in 1952 and 18 in 1953, are challenging examples and an indication that an infantmortality rate of 20 should be attainable in this country, if not in the present decade, at any rate in the next.
in 1953),
DEATHS DURING ANÆSTHESIA Beecher and Todd1 have made a very detailed and extensive study of deaths during anaesthesia in the United States, which is bound to evoke discussion in this country. They investigated all deaths in the surgical service of ten university hospitals, over a five-year period from the start of 1948 to the end of 1952. At each hospital a surgeon and an anaesthetist examined the particulars of each death, assigned it to one of five categories (of which anaesthesia was one), and reported their findings, with details of the case, to Beecher and Todd. The other categories were " the patient’s disease," " errors of diagnosis," " errors in surgical judgment," and " errors in surgical technique." Beecher and Todd have arranged the information statistically and interpreted the results. Covering nearly 600,000 anaesthetics, they find an anaesthesia death-rate of 1 in 1560. This figure represents deaths wholly due to anaesthesia (amounting to 1 in 2680) and those in which anaesthesia was considered to play a primary part. The principal criticism of these figures concerns the criteria for assigning a death to any of the five categories. This is a difficult task when so many variables are present, and must surely leave’room for disagreement-yet no cases are recorded as unassessable. are valuable as a guide to the Even so, the of anaesthesia. mortality In their analysis Beecher and Todd note, among other things, that when a muscle relaxant is used the mortalityrate increases nearly sixfold : the death-rate was 1 in 2100 when muscle relaxants were not used and 1 in 370 when muscle relaxants were used. These are alarming figures, but they may be misleading since the design of the investigation, as a means of discovering the actual causes of anaesthesia deaths, will not bear scrutiny. Beecher and Todd remark that the increased danger from muscle relaxants is possibly due to induced ciroulatory collapse despite the use of adequate artificial This is contrary to generally accepted respiration. clinical and Dhannacoloaical opinion. and. with the "
"
figures
1. 1.
Beecher, H. K., Todd, D. P.
Ann.
Surg. 1954, 140, 2.