- Email: [email protected]
THE VITAL STATISTICS OF 1917.
1126 assembled and built up into a complete machine. The operations took place at a rate which allowed a demonstrator to name each part, point out their features, and explain their uses. It was probably a recollection of his student days at St. Thomas’s Hospital which induced Major Maddick to apply a similar method to the study of human osteology. The skeleton which appeared on the screen, after presenting its various aspects to the audience, underwent a gradual process of dismemberment until only the backbone remained. The various parts then began to reassemble, each bone, before falling into its place in the skeleton, displaying its more important features to the audience. The films shown will prove most useful in introducing large audiences to an elementary knowledge of human anatomy and also serve to demonstrate that the kinematic method has an assured future in all branches of medical education. The members of the Anatomical Society, while congratulating Major Maddick on the fine technique shown inhis preliminary films, expressed the hope that he would continue his pioneer work and prepare films from the living body showing muscles in action, so that teachers of anatomy could bring before their students the mechanism of movement in health and in disease. Those who saw the remarkable films of " abdominal reflexes" which Major Maddick prepared to illustrate Professor David Ligat’s lecture at the Royal College of Surgeons during last winter term will have no doubt as to the high educational value of such films. "
MALIGNANT TERTIAN .
MALARIA.
IN THE LANCET of May 3rd we drew attention to series of studies in the treatment of malaria carried out by a band of experts in the Liverpool School of Tropical Medicine, including Professor J. W. W. Stephens, Professor W. Yorke, Dr. B. Blacklock, Dr. J. W. S. Macfie, Mr. C. Forster Cooper, and Mr. H. F. Carter, and published in the Annals of Tropical Medicine and Parasitology (Vol. XII., The studies on which we then Nos. 3 and 4). commented dealt with the treatment of simple tertian malaria, but in a further series of four studies now published in the first number of Volume XIII. of the above-mentioned Annals the same authorities deal with the treatment of the malignant tertian form of the disease. The studies now under review were undertaken at the request of the War Office. The first contribution gives the results of the- treatment of malignant tertian by intramuscular injections of 15 gr. of quinine bihydrochloride in 2 c.cm. of water on each of two consecutive days only, the conclusion being that this method causes the cessation of febrile effects the disappearance of paroxysms and trophozoites from the cutaneous blood. The effect, however, is only temporary, a relapse occurring within three weeks, occasionally within The next study deals with treatment a few days. of malignant tertian malaria by the oral administration of 30 gr. of quinine bisulphate on each of two consecutive days weekly over a period of five weeks. The result of this experimental study is the opinion that as a palliative this method suffices to keep the blood free from trophozoites and to prevent relapses in the great majority of cases. It is noteworthy that the percentage of cases with crescents in the peripheral blood diminishes each week-namely, from 50 per cent. in the first week to 6 per cent. in the fifth week of treatment. In
the third study the authors discuss the disappearance of crescents from the blood under quinine treatment, and they give a record of their observations made on 89 crescent cases. Their conclusion is that under quinine treatment, 30 to 45 gr. daily, crescents do not persist in the cutaneous blood in the majority of cases for more than three weeks. The last of the present series of studies contains the authors’ observations made in order to determine the effects of arsenic in malignant tertian malaria. They came to the conclusion that novarsenobillon intravenously injected in doses varying from 0’45 to 0’9 g. is of no value in the treatment of this form of malaria ; and that a combination of arsenic (novarsenobillon or liquor arsenicalis) with quinine, in the doses used, is not more effective than quinine alone. CEREBRO-SPINAL FEVER REGULATIONS.
THE Local Government Board issued last week Order increasing the powers of the local sanitary authority in dealing with cases of cerebro-spinal fever. The Public Health (Cerebro-spinal Fever) Regulations, 1919, as the official title runs, empower the council of any administrative county or county borough to provide or arrange for :— an
1. The examination and treatment of any person who is to be suffering from cerebro-spinal fever, or has been in contact with a person suffering or suspected to be suffering from the disease. 2. The provision of serum and vaccine for the treatment of cases or suspected cases of the disease, together with the necessary apparatus for the use of the serum or vaccine.
suspected
The expenses incurred may be expenses for’general eounty purposes
regarded as coming
or as
under the Public Health Acts.
a
THE VITAL STATISTICS OF 1917.
WE discussed in these columns a fortnight ago the figures and facts supplied in the annual report of the Registrar-General for 1917, particularly in respect of the birth-rate and the infantile deathThe general civilian death-rate in 1917 rate. 14’4 per 1000 living at all ages, being was slightly lower than the average rate of the last ten years of peace experience, 1905-1914. These average rates represent the mortality of the total population up to the end of 1914. Although the civilian rate in 1917 was higher than the total rate in some of the years immediately preceding the war, there are good reasons for regarding it as
representing a mortality approximately equal to the lowest hitherto recorded, provided that due allowance be made for the effect of enlistment on the population. When we look into the causes of death we find that, compared with the previous year, the mortality from the more familiar infectious diseases showed a gratifying decrease in 1917, the death-rates from enteric and scarlet fevers being the lowest on record and the rates from diphtheria and whooping-cough being also below the corresponding rates in the preceding year. Measles, on the contrary, showed a rate nearly double the exceptionally low one of 1916. Diseases of the respiratory and circulatory systems showed little variation from the rateR of the preceding year. Tuberculous diseases in the aggregate accounted for the deaths of no less than 55,934 persons, or 2076 more than those recorded in 1916. Of these persons, 1173 were non-civilians. The mortality among civilians amounted to 1624 per million, a figure in excess of the total mortality recorded for any year
1127
largelymore
since 1906. No doubt this menacing rise is the result of war conditions, and as far as that is the case its permanence is the less to be feared. One manifestation of these war conditions can be measured numerically, and proves to be accountable for a considerable share in the increase observed. During the war several English lunatic asylums have been evacuated of their customary inmates in order to devote the buildings to military purposes. This led to some overcrowding, which is one at least of the factors leading to the increase
considerable increases at-later ages. While these changes may be partly due to errors in estimation of population, they are consistent with the apparent tendency of the disease to become more and more one of old age; but although this tendency has hitherto shown itself chiefly in the female sex, it is less clearly manifest for that sex in the present comparison. The cancer deaths of non-civilians registered in this country numbered only 362, of which 189 were those of men aged 40 years and over. There were thus only 173 military service ages," or more than one-fifth of of tuberculous fatality occurring in asylums. In deaths at the total deaths the which event, by cancer among males aged 15 to heightened any asylums mortality, may be regarded as a direct outcome of the war, 40. It seems probable that this total includes the accounts for 41 per cent. of the total increase cancer mortality of the whole army, so that the There is 18,145 male deaths registered may be regarded as in deaths by tubercle since 1914. for of a fall in representing practically the complete mortality of good ground hope accordingly this mortality on the restoration of peaceful the year, notwithstanding the absence of so large a conditions. The serious increase in tuberculous portion of the normal population. Cases met with mortality is confined to ages from 5 to 25, where on foreign service have doubtless, as a rule, been it ranges from 21 to 42 per cent. It has been sent home before death, and the deaths of any men suggested that the rise might be due to work in the invalided out of the service on account of cancer factories. This might certainly account for the chief would be included with the civilian total. part of it-namely, that at ages 15 to 25. But it is noteworthy that the usual comparatively small mortality at 5 to 15 has also risen to a significant THE "MEDICAL TREATMENT" OF EMPYEMA extent, and factory conditions obviously cannot AT a meeting of the Societe Médicale des H6pitaux account for this rise. Possibly these children have of Paris MM. P. Emile-Weil and Loiseleur called suffered from some dietary changes, such as attention to a " medical treatment"of empyema deprivation of fat. Whatever the cause may be, it which had given excellent results-puncture and has not affected children under 5 years, at which injection of air, which enables the last drop of pus age the decline in mortality which has been a to be evacuated, followed by injection into the notable feature of the history of tuberculosis in pleural cavity of 2 c.cm. of a .1 in 20 solution of England during the present century has continued, methylene-blue. The chest is then examined daily if in lesser degree. with the screen for reproduction of pus. If this The two other great scourges of the population, occurs rapidly the case is passed on to the surgeon malignant disease and venereal disease, show for operation. If, on the other hand, the pus is The total deaths reproduced slowly and in diminishing quantity, the as yet no sign of abatement. ascribed to syphilis in 1917 numbered 2177; general condition improving meanwhile, the treatthe deaths of civilians corresponded to a mor- ment by puncture is repeated. Twelve cases were so tality of 61 per million living at all ages. As treated, of which 11 were consecutive to influenza almost two-thirds of the deaths from syphilis and one to removal of a projectile from the chest. are those of infants in their first year of life, Five of the empyemas involved the main pleural it might have been anticipated that the large cavity and 7 were partial (3 affecting the posterior decrease of births would have led to a fall in mediastinum, 1 the whole mediastinum, 1 diasyphilis mortality. On the contrary it was higher phragmatic, and 2 axillary). Bacteriological exathan it had been since 1895. The new measures for mination showed that 5 were pneumococcic, 1 the control of venereal disease have been little streptococcic, 3 due to mixed infection, and 3 associated with Poor-law and largely with hospital amicrobial. All the patients were cured except one, practice. And by a process of exclusion it seems who was in a desperate condition when he came probable that the war has actually increased the under treatment from cardiac and pulmonary number of deaths of infants, particularly illegitimate complications. In 7 cases surgical operation was infants, although it has had comparatively little eventually necessary. Thus the delay was not effect in increasing illegitimacy. As for malignant prejudicial. A typical case was one of empyema disease, the deaths referred to cancer in 1917 of the whole pleural cavity with streptococci and amounted to 41,148, of which 18,145 occurred bacilli. June 13th, 1918, first puncture, 4’8 litres of among males and 23,013 among females. These pus withdrawn; June 28th, second puncture,1 litre; are the highest figures for both sexes and imply July 25th, third puncture, 450 c.cm., August 12th the heaviest crude mortalities yet recorded. Un- 600 c.cm., August 24th 900 c.cm. of thick blackish fortunately the years are very few respecting amicrobial fluid withdrawn. Oct. 7th 500 c.cm. which a similar statement might not have been withdrawn. Recovery was then complete. In On made. Part of the increase is surely owing to the another case there was double empyema. exclusion from the population of a large number of the right side the posterior mediastinum was On Sept. 10th 300 c.cm. of thick pus men furnishing very few deaths from cancer, but affected. and air and methylene-blue were withdrawn even after correction the increase remains appreciable. The rate for females is not influenced by were injected. No more pus was reproduced. On these considerations, and is reported to have been the left there was an encysted axillary collection of practically unchanged since 1916. So far as male pus which was discharging into the lung. On mortality in 1917 at ages 45 and upwards is com- Sept. 9th 300 c.cm. of pus were withdrawn; on the parable with that of 1911-14, which is taken as 12th 100 c.cm.; on the 19th 100 c.cm.; on Oct. llth representing the most recent experience under 200 c.cm.; on the 29th 150 c.cm.; and on Nov. 6th peace conditions, there has been some slight 120 c.cm. After this, no more pus was expectorated, decline at ages up to 65. accompanied by much and at the end of November radioscopy showed that "
MALIGNANT TERTIAN .
MALARIA.
IN THE LANCET of May 3rd we drew attention to series of studies in the treatment of malaria carried out by a band of experts in the Liverpool School of Tropical Medicine, including Professor J. W. W. Stephens, Professor W. Yorke, Dr. B. Blacklock, Dr. J. W. S. Macfie, Mr. C. Forster Cooper, and Mr. H. F. Carter, and published in the Annals of Tropical Medicine and Parasitology (Vol. XII., The studies on which we then Nos. 3 and 4). commented dealt with the treatment of simple tertian malaria, but in a further series of four studies now published in the first number of Volume XIII. of the above-mentioned Annals the same authorities deal with the treatment of the malignant tertian form of the disease. The studies now under review were undertaken at the request of the War Office. The first contribution gives the results of the- treatment of malignant tertian by intramuscular injections of 15 gr. of quinine bihydrochloride in 2 c.cm. of water on each of two consecutive days only, the conclusion being that this method causes the cessation of febrile effects the disappearance of paroxysms and trophozoites from the cutaneous blood. The effect, however, is only temporary, a relapse occurring within three weeks, occasionally within The next study deals with treatment a few days. of malignant tertian malaria by the oral administration of 30 gr. of quinine bisulphate on each of two consecutive days weekly over a period of five weeks. The result of this experimental study is the opinion that as a palliative this method suffices to keep the blood free from trophozoites and to prevent relapses in the great majority of cases. It is noteworthy that the percentage of cases with crescents in the peripheral blood diminishes each week-namely, from 50 per cent. in the first week to 6 per cent. in the fifth week of treatment. In
the third study the authors discuss the disappearance of crescents from the blood under quinine treatment, and they give a record of their observations made on 89 crescent cases. Their conclusion is that under quinine treatment, 30 to 45 gr. daily, crescents do not persist in the cutaneous blood in the majority of cases for more than three weeks. The last of the present series of studies contains the authors’ observations made in order to determine the effects of arsenic in malignant tertian malaria. They came to the conclusion that novarsenobillon intravenously injected in doses varying from 0’45 to 0’9 g. is of no value in the treatment of this form of malaria ; and that a combination of arsenic (novarsenobillon or liquor arsenicalis) with quinine, in the doses used, is not more effective than quinine alone. CEREBRO-SPINAL FEVER REGULATIONS.
THE Local Government Board issued last week Order increasing the powers of the local sanitary authority in dealing with cases of cerebro-spinal fever. The Public Health (Cerebro-spinal Fever) Regulations, 1919, as the official title runs, empower the council of any administrative county or county borough to provide or arrange for :— an
1. The examination and treatment of any person who is to be suffering from cerebro-spinal fever, or has been in contact with a person suffering or suspected to be suffering from the disease. 2. The provision of serum and vaccine for the treatment of cases or suspected cases of the disease, together with the necessary apparatus for the use of the serum or vaccine.
suspected
The expenses incurred may be expenses for’general eounty purposes
regarded as coming
or as
under the Public Health Acts.
a
THE VITAL STATISTICS OF 1917.
WE discussed in these columns a fortnight ago the figures and facts supplied in the annual report of the Registrar-General for 1917, particularly in respect of the birth-rate and the infantile deathThe general civilian death-rate in 1917 rate. 14’4 per 1000 living at all ages, being was slightly lower than the average rate of the last ten years of peace experience, 1905-1914. These average rates represent the mortality of the total population up to the end of 1914. Although the civilian rate in 1917 was higher than the total rate in some of the years immediately preceding the war, there are good reasons for regarding it as
representing a mortality approximately equal to the lowest hitherto recorded, provided that due allowance be made for the effect of enlistment on the population. When we look into the causes of death we find that, compared with the previous year, the mortality from the more familiar infectious diseases showed a gratifying decrease in 1917, the death-rates from enteric and scarlet fevers being the lowest on record and the rates from diphtheria and whooping-cough being also below the corresponding rates in the preceding year. Measles, on the contrary, showed a rate nearly double the exceptionally low one of 1916. Diseases of the respiratory and circulatory systems showed little variation from the rateR of the preceding year. Tuberculous diseases in the aggregate accounted for the deaths of no less than 55,934 persons, or 2076 more than those recorded in 1916. Of these persons, 1173 were non-civilians. The mortality among civilians amounted to 1624 per million, a figure in excess of the total mortality recorded for any year
1127
largelymore
since 1906. No doubt this menacing rise is the result of war conditions, and as far as that is the case its permanence is the less to be feared. One manifestation of these war conditions can be measured numerically, and proves to be accountable for a considerable share in the increase observed. During the war several English lunatic asylums have been evacuated of their customary inmates in order to devote the buildings to military purposes. This led to some overcrowding, which is one at least of the factors leading to the increase
considerable increases at-later ages. While these changes may be partly due to errors in estimation of population, they are consistent with the apparent tendency of the disease to become more and more one of old age; but although this tendency has hitherto shown itself chiefly in the female sex, it is less clearly manifest for that sex in the present comparison. The cancer deaths of non-civilians registered in this country numbered only 362, of which 189 were those of men aged 40 years and over. There were thus only 173 military service ages," or more than one-fifth of of tuberculous fatality occurring in asylums. In deaths at the total deaths the which event, by cancer among males aged 15 to heightened any asylums mortality, may be regarded as a direct outcome of the war, 40. It seems probable that this total includes the accounts for 41 per cent. of the total increase cancer mortality of the whole army, so that the There is 18,145 male deaths registered may be regarded as in deaths by tubercle since 1914. for of a fall in representing practically the complete mortality of good ground hope accordingly this mortality on the restoration of peaceful the year, notwithstanding the absence of so large a conditions. The serious increase in tuberculous portion of the normal population. Cases met with mortality is confined to ages from 5 to 25, where on foreign service have doubtless, as a rule, been it ranges from 21 to 42 per cent. It has been sent home before death, and the deaths of any men suggested that the rise might be due to work in the invalided out of the service on account of cancer factories. This might certainly account for the chief would be included with the civilian total. part of it-namely, that at ages 15 to 25. But it is noteworthy that the usual comparatively small mortality at 5 to 15 has also risen to a significant THE "MEDICAL TREATMENT" OF EMPYEMA extent, and factory conditions obviously cannot AT a meeting of the Societe Médicale des H6pitaux account for this rise. Possibly these children have of Paris MM. P. Emile-Weil and Loiseleur called suffered from some dietary changes, such as attention to a " medical treatment"of empyema deprivation of fat. Whatever the cause may be, it which had given excellent results-puncture and has not affected children under 5 years, at which injection of air, which enables the last drop of pus age the decline in mortality which has been a to be evacuated, followed by injection into the notable feature of the history of tuberculosis in pleural cavity of 2 c.cm. of a .1 in 20 solution of England during the present century has continued, methylene-blue. The chest is then examined daily if in lesser degree. with the screen for reproduction of pus. If this The two other great scourges of the population, occurs rapidly the case is passed on to the surgeon malignant disease and venereal disease, show for operation. If, on the other hand, the pus is The total deaths reproduced slowly and in diminishing quantity, the as yet no sign of abatement. ascribed to syphilis in 1917 numbered 2177; general condition improving meanwhile, the treatthe deaths of civilians corresponded to a mor- ment by puncture is repeated. Twelve cases were so tality of 61 per million living at all ages. As treated, of which 11 were consecutive to influenza almost two-thirds of the deaths from syphilis and one to removal of a projectile from the chest. are those of infants in their first year of life, Five of the empyemas involved the main pleural it might have been anticipated that the large cavity and 7 were partial (3 affecting the posterior decrease of births would have led to a fall in mediastinum, 1 the whole mediastinum, 1 diasyphilis mortality. On the contrary it was higher phragmatic, and 2 axillary). Bacteriological exathan it had been since 1895. The new measures for mination showed that 5 were pneumococcic, 1 the control of venereal disease have been little streptococcic, 3 due to mixed infection, and 3 associated with Poor-law and largely with hospital amicrobial. All the patients were cured except one, practice. And by a process of exclusion it seems who was in a desperate condition when he came probable that the war has actually increased the under treatment from cardiac and pulmonary number of deaths of infants, particularly illegitimate complications. In 7 cases surgical operation was infants, although it has had comparatively little eventually necessary. Thus the delay was not effect in increasing illegitimacy. As for malignant prejudicial. A typical case was one of empyema disease, the deaths referred to cancer in 1917 of the whole pleural cavity with streptococci and amounted to 41,148, of which 18,145 occurred bacilli. June 13th, 1918, first puncture, 4’8 litres of among males and 23,013 among females. These pus withdrawn; June 28th, second puncture,1 litre; are the highest figures for both sexes and imply July 25th, third puncture, 450 c.cm., August 12th the heaviest crude mortalities yet recorded. Un- 600 c.cm., August 24th 900 c.cm. of thick blackish fortunately the years are very few respecting amicrobial fluid withdrawn. Oct. 7th 500 c.cm. which a similar statement might not have been withdrawn. Recovery was then complete. In On made. Part of the increase is surely owing to the another case there was double empyema. exclusion from the population of a large number of the right side the posterior mediastinum was On Sept. 10th 300 c.cm. of thick pus men furnishing very few deaths from cancer, but affected. and air and methylene-blue were withdrawn even after correction the increase remains appreciable. The rate for females is not influenced by were injected. No more pus was reproduced. On these considerations, and is reported to have been the left there was an encysted axillary collection of practically unchanged since 1916. So far as male pus which was discharging into the lung. On mortality in 1917 at ages 45 and upwards is com- Sept. 9th 300 c.cm. of pus were withdrawn; on the parable with that of 1911-14, which is taken as 12th 100 c.cm.; on the 19th 100 c.cm.; on Oct. llth representing the most recent experience under 200 c.cm.; on the 29th 150 c.cm.; and on Nov. 6th peace conditions, there has been some slight 120 c.cm. After this, no more pus was expectorated, decline at ages up to 65. accompanied by much and at the end of November radioscopy showed that "