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INFANT MORTALITY AND THE BIRTH-RATE.
556
through the dietary substances indispensable
to
the life of bacilli in culture. The proposition is not without attraction, but, needless to say, a long time must elapse before definite conclusions can be drawn. At present the research, at any rate that portion which has been publicly announced, has not advanced beyond the experimental stage. Presumably an attempt is being made to obtain a chemical substance in some way analogous to salvarsan. Of recent years in the investigation of the treatment of tuberculosis attempts have been made to increase the resistance of the body against the causal organism, either directly by introducing substances which induce active or passive immunity, or by auto-inoculation, for the internal use of antiseptics has not proved successful. Professor RENON now proposes to revive the use of drugs intended to directly destroy the bacilli. We need scarcely draw attention to the caution that is necessary in placing confidence in results that have only been obtained in vitro, whilst the value of any remedy against tuberculosis can only be accurately estimated after a large number of patients have been treated and a sufficient length of time (extending into years) has been allowed to elapse in order to observe the permanency or otherwise of the arrest of the disease. Confirmatory results must be obtained by numerous observers before any therapeutic claim of real value can be
Annotations. "Ne quid nimis." INFANT MORTALITY AND THE BIRTH-RATE.
RECENT statistical returns of the births and deaths of infants in this country are disquieting;
regarded individually they are bad enough, but taken collectively they are distinctly alarming. The continued fall in the birth-rate, which has now reached the lowest level heretofore recorded, may have many explanations, but the factor of the deliberate limitation of families, whether from provident or selfish motives, can no longer be ignored. The dissemination of knowledge with respect to the use of contraceptives has undoubtedly contributed to this result, not only among the upper and middle classes, with whom their employment has been reduced almost to an exact science, but even among the poorest, with whom
such practices were quite exceptional a decade Whether this explanation has any bearing ago. the prophecies of the on the falsification of scaremongers with respect to " war babies" still remains to be seen, but from facts which are accessible to all those who keep their eyes open it is by no means improbable. While on these and other grounds the fall in the birth-rate is understandable, the figures published with respect to the mortality of infants under 1 year of age during the
current year certainly demand more explaining than is afforded by the assumption that the position is due to a high prevalence of epidemic established. We must wait until the results of the new disease engendered by the unusual circumstances or to the dearth of doctors and nurses. That researches upon patients suffering from tubercudiseases have exacted a larger toll of epidemic losis are forthcoming before heralding the dis- infant life than usual cannot be gainsaid, but as covery, but doubtless physicians in this country an offset to this we must remember that the meteorowill avail themselves of opportunities that may logical conditions have been distinctly favourable, arise to test the procedure. In the meantime while the many organisations which have been it behoves the public authorities to continue their engaged in alleviating every form of distress have made it highly improbable that poverty has been efforts, stress being laid upon a sufficiently wide concerned in the results. Indeed, it may almost be It is useless to expend claimed that there has never been a time in the grasp of the problem. money upon the establishment of sanatoriums, and history of our country more free from want of to neglect the sanitary housing of the working employment, and the destitution which want of classes. The most powerful weapon against tuber- employment brings in its train, than the present Inquiry at certain important infant culosis is the education of the working classes. moment. welfare centres in London would seem to suggest It is waste of public funds to place patients in that the many social and domestic factors of disexpensive institutions for a time and then to let turbance connected with mobilisation, with the them return to unhealthy surroundings and occupa- distribution of bounties, and with partings and tions. The treatment of advanced cases of pul- meetings, have dislocated the even tenor of many In fact, without imputing a family’s daily regime. monary tuberculosis also presents numerous diffiserious any more possibility it may safely be said culties, and the question of segregation will have to that the conditions have not been favourable to be carefully considered. One great danger is to allow sober domestic life and the pursuit of those too much reliance to be placed upon any specific essentials of mothercraft which are so intitreatment, so permitting general hygienic measures mately associated with a low infant mortality. to be neglected. Extremists are useful in their So serious does the position appear to those who are actively engaged in combating deaths way, but for sure and progressive measures to be established it is absolutely necessary that a com- among infants that the National Association for the Prevention of Infant Mortality has bination of methods should be adopted. The arranged for a conference at the Mansion House instillation into the minds of patients and their on Oct. 28th, at which the Lord Mayor has con. immediate friends of the measures which should sented to preside, and at which the causes that be adopted in cases of tuberculosis is of the highest are responsible for the present state of affairs value; public information should always be forth- will be fully discussed by many of the foremost authorities on the subject. It is to be hoped coming from medical practitioners both as to the that out of the mouths of these many counsellors mode of life that the affected individuals should much wisdom will result, and that their advice, in live, and as to the prevention of the dissemination addition to the benefits which are confidently of the disease. expected from the operation of the new provisions
557 of the Notification of Births Act, will help to relieve a situation which is beset with many
lay much
stress on the presence of neck indicative of meningeal inflammation, rigidity and they go so far as to say that the absence of national dangers. rigidity of the neck muscles may be taken to In regard to the treatment exclude meningitis. EPIDEMIC CEREBRO-SPINAL MENINGITIS. lumbar of their cases, puncture was always pracWHILE the disease known as "spotted fever"" tised immediately, and withdrawal of fluid always occurs sporadically in England and only very seemed to quiet the patient and to hasten the occasionally increases to the dimensions of a grave return of consciousness. They used intrathecal epidemic, as at Glasgow and Belfast in 1906, during injections of sera prepared by Burroughs and the last 12 months it has appeared in the form of Wellcome, Mulford, and the Lister Institute, without, relatively small epidemics of from 40 to 80 cases however, strikingly good results, while in not a few to a much larger extent than ever before. The instances injections were followed by an increase in prominence which its occurrence among the the number of organisms. We hope that other Canadian contingent at Salisbury gave it in the medical officers of health who have been dealing latter part of last year, and the fact also that some with analogous epidemics will record their expericases occurred on transports- from Canada, should ences with equal care and frankness, for the not, needless to say, lead to any idea on the part disease is undoubtedly a menace once it develops, of the uninformed that the disease was " brought and treatment is still not far removed from the over," for this country is never really free from it. experimental stage. Whether the factors that have led to the appearance of the large number of small epidemics above WILLIAM BROMFIELD. referred to are in any way associated with the IT is to be regretted that there exists no roll of movement of troops is a matter for investigation. According to the most recent work on the the Royal College of Surgeons of England on the subject, an epidemic of cerebro-spinal meningitis lines of Munk’s "Roll of the Royal College of is not produced by those affected with the disease, Physicians of London." The old surgeons were but by healthy carriers, who distribute the many of them remarkable and generally very human organisms over large areas and expose many to in- characters, but for an authoritative account of fection of whom only a very small percentage them we are compelled to trust to scattered and actually become infected. The difficulty in con- uncertain authorities or to our individual powers trolling an epidemic is that the healthy must be of research. We therefore welcome any monodealt with as well as the diseased. Sophian has graph such as that recording the life of William also pointed out that another means of dissemina- Bromfield, now reprinted from the Proceedings tion of the infection is by the urine of patients; it of the Royal Society of Medicine, 1915, vol. viii. shows meningococci in abundance, and may be a (Section of the History of Medicine), by Mr. Bromfield was the colleague of source of grave danger. Some interesting clinical G. C. Peachey, observations on the disease have been recorded in John Hunter at St. George’s Hospital, with which the July number of Public Health, by Dr. Duncan he became connected in 1742. Through the influForbes and Dr. D. C. Adam, of the Public Health ence probably of John Ranby with Frederick, Prince Department of Brighton, who have, up to July 9th, of Wales, he was appointed to fill one of the vacancies dealt with some 51 cases in hospital, of which 25 on the surgical staff in 1744. His career thenceforward was that of a successful surgeon. It were discharged cured, 23 died, and 3 remained. Six of the deaths occurred within 48 hours of the reached its zenith in 1769, when he was chosen patients’ admission; two of these received no Master of the Company of Surgeons, having become Dr. Forbes and Dr. Adam think that a member of the Court of Assistants in 1760. In serum. infection leading to the development of the disease 1768 he was chosen a member of the Court of Examiners and Senior Warden, " in which latter occurs in only a small percentage of those who matter of capacity, the Master being absent, he presided over run the risk, and seems largely a chance. They consider that leucocytes from the the Court from whom John Hunter received his nasopharynx, carrying the meningococcus, find diploma to practise on July 7 of that year." Hunter their way directly or indirectly to the blood was then 40 years of age and had already been in stream, and may pass to the subarachnoid space; practice for five years. Bromfield died at the age there an infected leucocyte, breaking down, will of 80 in 1792, thus predeceasing Hunter by one year. infect the cerebro-spinal fluid and so an acute He was Hunter’s senior by 15 years, having been attack develops. A broad rule is that the prognosis born in 1713. Unlike Hunter, however, he was no varies with the number of organisms present; great savant. He " seems to have had a partiality should they remain scanty the prognosis is good, for making claims," many of them of great imnotwithstanding unconsciousness and delirium on portance, but mostly impossible to substantiate. the part of the patient. There are exceptional His many writings were contentious and elicited cases that are eventually fatal, though the meningomuch hostile criticism. A pupil of rough old John cocci have been but few. These investigators note Ranby, he was himself arrogant and self-assertive. what seems to be a new point, that in more " Manually efficient though he was," Mr. Peachey chronic cases the appearance of a readily coagu- has " been unable to discover in him the possession lating, markedly yellow cerebro-spinal fluid is of either exceptional intellect or extraordinary invariably followed by a fatal result. Xantho- intelligence. It would seem that he was inclined chromia of the fluid is well recognised in certain to spurn literature and reading; in this and cases of compression paraplegia from spinal many other respects resembling John Radcliffe." tumour, and it has been described in syphilitic He was bitterly jealous of his contemporaries. meningo-myelitis, but apparently it has not Moreover, an extant letter of his to Lord Bute hitherto been seen in "spotted fever." There is proves him to have been a sycophant. Indeed, a no demonstrable connexion between the severity or less conscientious biographer than Mr. Peachey short by otherwise of the attack and the degree of promin- would have cut the whole matter " unblemished ence of the cutaneous rash. Dr. Forbes and describing him as a man of ____
I
Dr. Adam
as
____
through the dietary substances indispensable
to
the life of bacilli in culture. The proposition is not without attraction, but, needless to say, a long time must elapse before definite conclusions can be drawn. At present the research, at any rate that portion which has been publicly announced, has not advanced beyond the experimental stage. Presumably an attempt is being made to obtain a chemical substance in some way analogous to salvarsan. Of recent years in the investigation of the treatment of tuberculosis attempts have been made to increase the resistance of the body against the causal organism, either directly by introducing substances which induce active or passive immunity, or by auto-inoculation, for the internal use of antiseptics has not proved successful. Professor RENON now proposes to revive the use of drugs intended to directly destroy the bacilli. We need scarcely draw attention to the caution that is necessary in placing confidence in results that have only been obtained in vitro, whilst the value of any remedy against tuberculosis can only be accurately estimated after a large number of patients have been treated and a sufficient length of time (extending into years) has been allowed to elapse in order to observe the permanency or otherwise of the arrest of the disease. Confirmatory results must be obtained by numerous observers before any therapeutic claim of real value can be
Annotations. "Ne quid nimis." INFANT MORTALITY AND THE BIRTH-RATE.
RECENT statistical returns of the births and deaths of infants in this country are disquieting;
regarded individually they are bad enough, but taken collectively they are distinctly alarming. The continued fall in the birth-rate, which has now reached the lowest level heretofore recorded, may have many explanations, but the factor of the deliberate limitation of families, whether from provident or selfish motives, can no longer be ignored. The dissemination of knowledge with respect to the use of contraceptives has undoubtedly contributed to this result, not only among the upper and middle classes, with whom their employment has been reduced almost to an exact science, but even among the poorest, with whom
such practices were quite exceptional a decade Whether this explanation has any bearing ago. the prophecies of the on the falsification of scaremongers with respect to " war babies" still remains to be seen, but from facts which are accessible to all those who keep their eyes open it is by no means improbable. While on these and other grounds the fall in the birth-rate is understandable, the figures published with respect to the mortality of infants under 1 year of age during the
current year certainly demand more explaining than is afforded by the assumption that the position is due to a high prevalence of epidemic established. We must wait until the results of the new disease engendered by the unusual circumstances or to the dearth of doctors and nurses. That researches upon patients suffering from tubercudiseases have exacted a larger toll of epidemic losis are forthcoming before heralding the dis- infant life than usual cannot be gainsaid, but as covery, but doubtless physicians in this country an offset to this we must remember that the meteorowill avail themselves of opportunities that may logical conditions have been distinctly favourable, arise to test the procedure. In the meantime while the many organisations which have been it behoves the public authorities to continue their engaged in alleviating every form of distress have made it highly improbable that poverty has been efforts, stress being laid upon a sufficiently wide concerned in the results. Indeed, it may almost be It is useless to expend claimed that there has never been a time in the grasp of the problem. money upon the establishment of sanatoriums, and history of our country more free from want of to neglect the sanitary housing of the working employment, and the destitution which want of classes. The most powerful weapon against tuber- employment brings in its train, than the present Inquiry at certain important infant culosis is the education of the working classes. moment. welfare centres in London would seem to suggest It is waste of public funds to place patients in that the many social and domestic factors of disexpensive institutions for a time and then to let turbance connected with mobilisation, with the them return to unhealthy surroundings and occupa- distribution of bounties, and with partings and tions. The treatment of advanced cases of pul- meetings, have dislocated the even tenor of many In fact, without imputing a family’s daily regime. monary tuberculosis also presents numerous diffiserious any more possibility it may safely be said culties, and the question of segregation will have to that the conditions have not been favourable to be carefully considered. One great danger is to allow sober domestic life and the pursuit of those too much reliance to be placed upon any specific essentials of mothercraft which are so intitreatment, so permitting general hygienic measures mately associated with a low infant mortality. to be neglected. Extremists are useful in their So serious does the position appear to those who are actively engaged in combating deaths way, but for sure and progressive measures to be established it is absolutely necessary that a com- among infants that the National Association for the Prevention of Infant Mortality has bination of methods should be adopted. The arranged for a conference at the Mansion House instillation into the minds of patients and their on Oct. 28th, at which the Lord Mayor has con. immediate friends of the measures which should sented to preside, and at which the causes that be adopted in cases of tuberculosis is of the highest are responsible for the present state of affairs value; public information should always be forth- will be fully discussed by many of the foremost authorities on the subject. It is to be hoped coming from medical practitioners both as to the that out of the mouths of these many counsellors mode of life that the affected individuals should much wisdom will result, and that their advice, in live, and as to the prevention of the dissemination addition to the benefits which are confidently of the disease. expected from the operation of the new provisions
557 of the Notification of Births Act, will help to relieve a situation which is beset with many
lay much
stress on the presence of neck indicative of meningeal inflammation, rigidity and they go so far as to say that the absence of national dangers. rigidity of the neck muscles may be taken to In regard to the treatment exclude meningitis. EPIDEMIC CEREBRO-SPINAL MENINGITIS. lumbar of their cases, puncture was always pracWHILE the disease known as "spotted fever"" tised immediately, and withdrawal of fluid always occurs sporadically in England and only very seemed to quiet the patient and to hasten the occasionally increases to the dimensions of a grave return of consciousness. They used intrathecal epidemic, as at Glasgow and Belfast in 1906, during injections of sera prepared by Burroughs and the last 12 months it has appeared in the form of Wellcome, Mulford, and the Lister Institute, without, relatively small epidemics of from 40 to 80 cases however, strikingly good results, while in not a few to a much larger extent than ever before. The instances injections were followed by an increase in prominence which its occurrence among the the number of organisms. We hope that other Canadian contingent at Salisbury gave it in the medical officers of health who have been dealing latter part of last year, and the fact also that some with analogous epidemics will record their expericases occurred on transports- from Canada, should ences with equal care and frankness, for the not, needless to say, lead to any idea on the part disease is undoubtedly a menace once it develops, of the uninformed that the disease was " brought and treatment is still not far removed from the over," for this country is never really free from it. experimental stage. Whether the factors that have led to the appearance of the large number of small epidemics above WILLIAM BROMFIELD. referred to are in any way associated with the IT is to be regretted that there exists no roll of movement of troops is a matter for investigation. According to the most recent work on the the Royal College of Surgeons of England on the subject, an epidemic of cerebro-spinal meningitis lines of Munk’s "Roll of the Royal College of is not produced by those affected with the disease, Physicians of London." The old surgeons were but by healthy carriers, who distribute the many of them remarkable and generally very human organisms over large areas and expose many to in- characters, but for an authoritative account of fection of whom only a very small percentage them we are compelled to trust to scattered and actually become infected. The difficulty in con- uncertain authorities or to our individual powers trolling an epidemic is that the healthy must be of research. We therefore welcome any monodealt with as well as the diseased. Sophian has graph such as that recording the life of William also pointed out that another means of dissemina- Bromfield, now reprinted from the Proceedings tion of the infection is by the urine of patients; it of the Royal Society of Medicine, 1915, vol. viii. shows meningococci in abundance, and may be a (Section of the History of Medicine), by Mr. Bromfield was the colleague of source of grave danger. Some interesting clinical G. C. Peachey, observations on the disease have been recorded in John Hunter at St. George’s Hospital, with which the July number of Public Health, by Dr. Duncan he became connected in 1742. Through the influForbes and Dr. D. C. Adam, of the Public Health ence probably of John Ranby with Frederick, Prince Department of Brighton, who have, up to July 9th, of Wales, he was appointed to fill one of the vacancies dealt with some 51 cases in hospital, of which 25 on the surgical staff in 1744. His career thenceforward was that of a successful surgeon. It were discharged cured, 23 died, and 3 remained. Six of the deaths occurred within 48 hours of the reached its zenith in 1769, when he was chosen patients’ admission; two of these received no Master of the Company of Surgeons, having become Dr. Forbes and Dr. Adam think that a member of the Court of Assistants in 1760. In serum. infection leading to the development of the disease 1768 he was chosen a member of the Court of Examiners and Senior Warden, " in which latter occurs in only a small percentage of those who matter of capacity, the Master being absent, he presided over run the risk, and seems largely a chance. They consider that leucocytes from the the Court from whom John Hunter received his nasopharynx, carrying the meningococcus, find diploma to practise on July 7 of that year." Hunter their way directly or indirectly to the blood was then 40 years of age and had already been in stream, and may pass to the subarachnoid space; practice for five years. Bromfield died at the age there an infected leucocyte, breaking down, will of 80 in 1792, thus predeceasing Hunter by one year. infect the cerebro-spinal fluid and so an acute He was Hunter’s senior by 15 years, having been attack develops. A broad rule is that the prognosis born in 1713. Unlike Hunter, however, he was no varies with the number of organisms present; great savant. He " seems to have had a partiality should they remain scanty the prognosis is good, for making claims," many of them of great imnotwithstanding unconsciousness and delirium on portance, but mostly impossible to substantiate. the part of the patient. There are exceptional His many writings were contentious and elicited cases that are eventually fatal, though the meningomuch hostile criticism. A pupil of rough old John cocci have been but few. These investigators note Ranby, he was himself arrogant and self-assertive. what seems to be a new point, that in more " Manually efficient though he was," Mr. Peachey chronic cases the appearance of a readily coagu- has " been unable to discover in him the possession lating, markedly yellow cerebro-spinal fluid is of either exceptional intellect or extraordinary invariably followed by a fatal result. Xantho- intelligence. It would seem that he was inclined chromia of the fluid is well recognised in certain to spurn literature and reading; in this and cases of compression paraplegia from spinal many other respects resembling John Radcliffe." tumour, and it has been described in syphilitic He was bitterly jealous of his contemporaries. meningo-myelitis, but apparently it has not Moreover, an extant letter of his to Lord Bute hitherto been seen in "spotted fever." There is proves him to have been a sycophant. Indeed, a no demonstrable connexion between the severity or less conscientious biographer than Mr. Peachey short by otherwise of the attack and the degree of promin- would have cut the whole matter " unblemished ence of the cutaneous rash. Dr. Forbes and describing him as a man of ____
I
Dr. Adam
as
____