MORTALITY TRENDS IN DEGENERATIVE DISEASE

244 bifida occulta is accepted. Such findings are rare, and were absent in this series. Constitutional factors were shown to play an important part in the causation of enuresis, particularly the psychological background, both individual and familial. Half of Stalker and Band’s patients had some definite psychiatric disorder (the commonest being a psychopathic state) ; another quarter suffered from a subclinical anxiety state ; and even the remaining quarter, though allowed to be within normal limits, were regarded as having anxious personalities. These findings suggest two questions-to what extent does the bias of the. investigator colour such an assessment, and may not the enuresis be the cause (not the effect) of the milder psychological upsets 1 The family history showed a high incidence of psychiatric conditions among relations, and inquiry for enuresis revealed " an average of almost two other affected persons per case." Stalker and Band make the point that nocturnal enuresis is not an isolated phenomenon but one aspect of a derangement of the pelvic autonomic system, and they support this assertion by showing that in the same patient there are often associated manifestations, such as nocturnal frequency (rising at night), diurnal frequency and urgency, sometimes diurnal enuresis, and more rarely encopresis. In their opinion the disorder is not an overactivity of the local reflexes but a weakness of the cerebral inhibition of these reflexes. An interesting extension of this line of autonomic inquiry leads to the question of sleep, which is a vegetative function and may well bear a close relation to nocturnal enuresis. They say that two-thirds of their patients were heavy sleepers. But here again depth of sleep is hard to assess and to compare, and the normal range must be taken into account. Maybe twothirds of all young people are heavy sleepers. Many other aspects of this difficult problem are con--sidered in this interesting paper, though no fresh ground is broken. Cystometry was done in 15 of the patients, but a routine measure of bladder capacity and of body-weight would have been simpler and perhaps more revealing. Nor do we feel sure of the value of the statement that enuresis is not just a symptom, but a disease in itself." -

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MORTALITY TRENDS IN DEGENERATIVE DISEASE

Tms century has seen a steady rise in the crude deathrate from the cardiovascular-renal diseases which now form a large proportion of the total mortality. The rise in the toll of degenerative disease has prompted alarmist warnings of the ultimate effects on physical health of the crescendo in the stress of modern life. A more cheering note is struck in a recent bulletin1 of the Metropolitan Life Insurance Company in the United States. There, if anywhere, the tempo of life is at a maximum, but among the policy-holders of that company there has been since 1911 a consistent decline in the standardised death-rate from cardiovascular-renal disease. The main source of this disparity lies in the standardisation or adjustment of the death-rate to take into account the ageing of the population ; but there is more to it than that. Even within each age-group there has been a real decline in the death-rate from these diseases, particularly among younger people (under 24) of both sexds, and for both white and coloured races. Since much of this type of disease is the aftermath of a much earlier infection, whether rheumatic or syphilitic, we are now reaping the benefits of therapeutic successes in the treatment of bacterial disease. Decreasing demands for physical effort, from men because of mechanisation in industry and from women because of less frequent childbearing, are no doubt having a beneficial effect. Policy-holders are clearly a selfselected section of the population-they presumably 1. Statist. Bull. Met. Life Ins. Co. 1946,

27, 5.

include the wealthier, more intelligent, and more provident members of society. Among them, then, one would expect to see the influence of better nutrition, better environmental conditions, and medical care in the prevention of premature physical breakdown. However cheering this picture may be it must be remembered that the main advances have been made in the field of infective diseases and their consequences in - heart and kidney. The more strictly degenerative diseases such as arteriosclerosis still constitute a major and growing problem. Stimulated no doubt by the success against bacterial disease, the American lifeinsurance companies have organised a research fund to study the causes of disease in heart and arteries. We too have an ageing population and we must hope that this fund will yield results which can be widely applied in the care of the aged. CHEMOTHERAPEUTIC MISTS

AEROosOLS, long used as vehicles for expectorant and bronchodilator drugs, are finding a more important role in chemotherapy. Quantitative studies have shown that by this means sulphonamides and penicillin can be introduced into the lungs in amounts and concentrations adequate for therapeutic purposes 1 ; absorption takes place rapidly, and the drugs quickly appear in the blood, but a useful proportion is retained by the bronchial secretions, and, on another page, Dr. Humphrey and Dr. Joules report identification of penicillin in the sputum as long as six hours after a single period of inhalation. One benefit from this form of topical treatment is that three-hourly intramuscular injections are replaced by the less exacting routine of three or four inhalations daily. Coarse aerosols deposit in the bronchi, but fine aerosols appear to follow the transalveolar route, by which the drug is conveyed directly to the left side of the heart. Knott and Southwell2 found that the bloodconcentration of penicillin may be ten times greater in the left ventricle than in the right-a notable consideration when extrapulmonary lesions are under treatment. Aerosols cannot penetrate consolidated lung, and in pneumonia become locally effective only after absorption and redistribution by the blood. Their therapeutic value in such circumstances has been assessed by Eleanor Bliss 3 ; working on rats with experimental pneumococcal pneumonia, she found that penicillin administered by inhalation was at least as curative as similar amounts

injected intramuscularly. During the last two years numerous

clinical trials have been carried out in this country and in America. In particular, much useful information is provided by the careful reports of Olsen4 and now, on other pages of this issue, by those of Dr. Humphrey and Dr. Joules, and of Dr. Southwell. There is general agreement that in most cases of bronchiectasis the volume, odour, purulence, and bacterial content of the sputum can be strikingly reduced ; and on several occasions the opinion has been expressed that penicillin inhalations given before and after lobectomy add materially to the safety of the operation. From this, and from the imposing miscellany of conditions treated by Barach,6 Vermilve,and others it seems probable that the method will be more widely employed. Penicillin may presently be replaced or fortified by substances which will widen the range of controllable micro-organisms, and the need for such an extension is emphasised by the observation of Humphrey and Joules that, with the elimination of penicillinsensitive organisms, coliform bacilli appear, owing partly Mutch, N., Rewell, R. E. Lancet, 1944, ii, 775. Ibid, 1945, i, 650. Knott, F. A., Southwell, H. Arch. Dis. Childh. 1946, 21, 16. Bliss, E. A. Bull. Johns Hopk. Hosp. 1945, 77, 411. Olsen, A. M. Proc. Mayo Clin. 1945, 20, 184. Barach, A. L., Silberstein, F. H., Oppenheimer, E. T., Hunter, T. H., Soroka, M. Ann. intern. Med. 1945, 22, 485. 6. Vermilye, H. N. J. Amer. med. Ass. 1945, 129, 250.

1. Mutch, N. 2. 3. 4. 5.