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Counting our Blessings
287
THE LANCET LONDON: SATURDAY, AUGUST 13, 1949
Counting
our
-
Blessings
FoR the melancholy induced by recurrent dollar crises and wet Bank Holidays, perhaps the contemplation of death certificates is hardly the appropriate prescription : yet the Registrar-General’s Review of the six years 1940-451 contains much to interest and hearten us. Certainly we can draw comfort from this chronicle of the trends in the national mortality-rates over the critical war years ; for at least some of the beneficial effects of a war-time economy may still flow from our peace-time austerity. The transatlantic thirst for our best native brew may have deprived us of its solace, but the death-rates from alcoholism and cirrhosis of the liver have fallen abruptly since early in the war. There has been, too, a curious change in the age-sex specific deathrates from degenerative ’heart- disease-a condition generally attributed to excessive stress and strain. Between the wars the death-rate from this cause had rapidly increased ; but during the late war the trend slowed down among younger men and was actually reversed among men of 65 and older, while among women of all ages-but particularly between 35 and 50-there was a dramatic fall. No very convincing explanation can be given, but it is reasonably supposed that the state of full employment, with the consequent relief from economic anxieties, combined with the levelling effect of rationing on both undernutrition and overindulgence to diminish cardiac strain. Again in diabetes mellitus, rationing may have had a beneficial effect. The special rations allowed to diabetics permitted a shrewd estimate of their number to be made on the basis of the claims reaching the Ministry of Food, and from these it was deduced that some 4% of diabetic patients died from the disease during a year. But there were significant differences of specific age and sex groups. In both sexes the mortality-rate notably diminished : for men it was 28%, and for women as a whole 23%, less than before the war. For young women between the ages of 18 and 34, however, there was a large increase in the diabetes death-rate during 1940-43 and a complete absence of any later improvement over the pre-war figure. Between the wars, it is suggested, young women were addicted to’slim-
ming " by taking inadequate meals-a cult which kept up their tuberculosis death-rate and diminished their mortality from diabetes. Now, with better pay and canteet feeding, their diabetes death-rate has increased, while at the same time, and presumably for the same reason, their mortality from anæmia and tuberculosis has decreased. Economic factors in disease, it seems, cannot be ignored. Depression culminating in suicide was at a peak during the years of economic hardship of 1931-35, and the subsequent fall in the frequency of suicide seems to have accelerated in both sexes during the war. As 1.
Registrar-General’s Stationery Office.
Statistical
Pp. 388.
Review 6s. 6d.
for
1940-45.
the Registrar-General suggests, a little cryptically, " fuller employment conduces to lower suicide frequency, even in groups whose work has become so hard as to cause continual complaint." This seeming preoccupation with social factors should not be allowed to obscure the results of therapeutic innovation and sound preventive medicine, which are seen most strikingly among women and children. Maternal mortality continued to fall throughout the war, largely as the continuing result of the introduction of penicillin and the sulphonamides, blood-transfusion services, and better antenatal and postnatal care. The results of the antidiphtheria immunisation campaign are evident in the greatly reduced death-rate from this cause and in the much lower case-fatality rate among children thus protected, to which Sir WILSON JAMESON draws attention in his 1947 report reviewed on p. 298. The diseases of infancy and childhood exacted a continuously decreasing toll, so that the death-rates among girls between 5 and 14, for example, fell by about 40% within a period of ten years, while the proportion of girl infants reaching their 5th birthday rose from 85% in 1910-12 to 95% in 1945. Like previous ones, this Statistical Review is challenging because it raises at least as many questions as it answers. A survey of regional differences in mortality from exophthalmic goitre shows the existence of unexplained divergences in the death-rates in the country as opposed to the town : for example, the rates were higher in coastal areas than inland, and on the west coast and in Wales than in the rest of the country. During the past ten years, too, there has appeared a-large and increasing male excess death-rate from leukaemia, and in neither leuktemia nor in the rapidly increasing death-rate from cancer of the lung do improvements in diagnosis provide a satisfactory explanation. In the regional differences in mortality-e.g., among infants in the first year of life and in respiratory tuberculosis -cause and effect may be more easily related, and some levelling of social or environmental conditions and perhaps of medical care is clearly indicated. Ominous signs of faulty hygiene, such as the present death-rate from diarrhoea and enteritis, must also be recognised ; for the aim of this and succeeding Reviews will be served only " when the national conscience has at last been aroused by the persistent presentation of unpleasant statistical facts."
H.M.
Prognosis
in Disseminated Sclerosis
DISSEMINATED sclerosis is a common disease in. the British Isles ; and yet there is little reliable information on its prognosis. Two valuable studies have recently been made in Scandinavia, by THYGESEN-1 in Copenhagen and by MÜLLER2 in Stockholm, using different methods of case selection and follow-up. THYGBSEN has taken all cases of disseminated
sclerosis and acute disseminated encephalomyelitis admitted to the two largest neurological clinics in Copenhagen within a year of the onset of symptoms, and has re-examined them eight to fifteen years after their first admission ; he has, however, excluded a previous retrobulbar neuritis as an initial symptom His criteria for the diagnosis of of the disease. 1. Thygesen, P. Arch. Neurol. Psychiat. 1949, 61, 339. Acta med. scand. 1949, 133, suppl. 222. 2. Müller, R.
’
THE LANCET LONDON: SATURDAY, AUGUST 13, 1949
Counting
our
-
Blessings
FoR the melancholy induced by recurrent dollar crises and wet Bank Holidays, perhaps the contemplation of death certificates is hardly the appropriate prescription : yet the Registrar-General’s Review of the six years 1940-451 contains much to interest and hearten us. Certainly we can draw comfort from this chronicle of the trends in the national mortality-rates over the critical war years ; for at least some of the beneficial effects of a war-time economy may still flow from our peace-time austerity. The transatlantic thirst for our best native brew may have deprived us of its solace, but the death-rates from alcoholism and cirrhosis of the liver have fallen abruptly since early in the war. There has been, too, a curious change in the age-sex specific deathrates from degenerative ’heart- disease-a condition generally attributed to excessive stress and strain. Between the wars the death-rate from this cause had rapidly increased ; but during the late war the trend slowed down among younger men and was actually reversed among men of 65 and older, while among women of all ages-but particularly between 35 and 50-there was a dramatic fall. No very convincing explanation can be given, but it is reasonably supposed that the state of full employment, with the consequent relief from economic anxieties, combined with the levelling effect of rationing on both undernutrition and overindulgence to diminish cardiac strain. Again in diabetes mellitus, rationing may have had a beneficial effect. The special rations allowed to diabetics permitted a shrewd estimate of their number to be made on the basis of the claims reaching the Ministry of Food, and from these it was deduced that some 4% of diabetic patients died from the disease during a year. But there were significant differences of specific age and sex groups. In both sexes the mortality-rate notably diminished : for men it was 28%, and for women as a whole 23%, less than before the war. For young women between the ages of 18 and 34, however, there was a large increase in the diabetes death-rate during 1940-43 and a complete absence of any later improvement over the pre-war figure. Between the wars, it is suggested, young women were addicted to’slim-
ming " by taking inadequate meals-a cult which kept up their tuberculosis death-rate and diminished their mortality from diabetes. Now, with better pay and canteet feeding, their diabetes death-rate has increased, while at the same time, and presumably for the same reason, their mortality from anæmia and tuberculosis has decreased. Economic factors in disease, it seems, cannot be ignored. Depression culminating in suicide was at a peak during the years of economic hardship of 1931-35, and the subsequent fall in the frequency of suicide seems to have accelerated in both sexes during the war. As 1.
Registrar-General’s Stationery Office.
Statistical
Pp. 388.
Review 6s. 6d.
for
1940-45.
the Registrar-General suggests, a little cryptically, " fuller employment conduces to lower suicide frequency, even in groups whose work has become so hard as to cause continual complaint." This seeming preoccupation with social factors should not be allowed to obscure the results of therapeutic innovation and sound preventive medicine, which are seen most strikingly among women and children. Maternal mortality continued to fall throughout the war, largely as the continuing result of the introduction of penicillin and the sulphonamides, blood-transfusion services, and better antenatal and postnatal care. The results of the antidiphtheria immunisation campaign are evident in the greatly reduced death-rate from this cause and in the much lower case-fatality rate among children thus protected, to which Sir WILSON JAMESON draws attention in his 1947 report reviewed on p. 298. The diseases of infancy and childhood exacted a continuously decreasing toll, so that the death-rates among girls between 5 and 14, for example, fell by about 40% within a period of ten years, while the proportion of girl infants reaching their 5th birthday rose from 85% in 1910-12 to 95% in 1945. Like previous ones, this Statistical Review is challenging because it raises at least as many questions as it answers. A survey of regional differences in mortality from exophthalmic goitre shows the existence of unexplained divergences in the death-rates in the country as opposed to the town : for example, the rates were higher in coastal areas than inland, and on the west coast and in Wales than in the rest of the country. During the past ten years, too, there has appeared a-large and increasing male excess death-rate from leukaemia, and in neither leuktemia nor in the rapidly increasing death-rate from cancer of the lung do improvements in diagnosis provide a satisfactory explanation. In the regional differences in mortality-e.g., among infants in the first year of life and in respiratory tuberculosis -cause and effect may be more easily related, and some levelling of social or environmental conditions and perhaps of medical care is clearly indicated. Ominous signs of faulty hygiene, such as the present death-rate from diarrhoea and enteritis, must also be recognised ; for the aim of this and succeeding Reviews will be served only " when the national conscience has at last been aroused by the persistent presentation of unpleasant statistical facts."
H.M.
Prognosis
in Disseminated Sclerosis
DISSEMINATED sclerosis is a common disease in. the British Isles ; and yet there is little reliable information on its prognosis. Two valuable studies have recently been made in Scandinavia, by THYGESEN-1 in Copenhagen and by MÜLLER2 in Stockholm, using different methods of case selection and follow-up. THYGBSEN has taken all cases of disseminated
sclerosis and acute disseminated encephalomyelitis admitted to the two largest neurological clinics in Copenhagen within a year of the onset of symptoms, and has re-examined them eight to fifteen years after their first admission ; he has, however, excluded a previous retrobulbar neuritis as an initial symptom His criteria for the diagnosis of of the disease. 1. Thygesen, P. Arch. Neurol. Psychiat. 1949, 61, 339. Acta med. scand. 1949, 133, suppl. 222. 2. Müller, R.
’