1331

Infantile Mortality in Hospitals.

THE LANCET.

LONDON: SATURDAY, MAY 8, 1909.

, THE recent Privy Council Committee on Physical De-

terioration, after a prolonged and laborious investigationrespecting the nature and extent of the waste of infant lifestill taking place in this country, declared its conviction

t,hat the means by which this excessive waste can be pre-vented is a problem of supreme importance to the welfare ofour race One of the practical results of the publication ofthe recommendations of that committee has been a decidedand manifest awakening of the public conscience as to the

necessity of providing for the more effective protection ofinfant life, especially in view of the continued decline in the

English birth-rate ; and it is probable that the practicallyunopposed passing of the "Children’s Charter,"1 which hasrecently found a place in the Statute Book, was due in a

large measure to the conclusive nature of the evidence

collected by that committee, emphasised by its very ablediscussion, in the detailed report. Although the national

returns. of causes of death have recently been vastlyimproved by the addition of columns showing the

mortality in the earliest days and weeks of life,still, no-attempt has as yet been made to record the vastamount of "sickness that is not unto death," but the ultimateeffects of which on the health of the community must

unquestionably be very serious. In this connexion it should

be remembered that preventive science has yet much to

learn before the possession can be attained of a knowledgeof the causes of ill-health and deterioration in the infantile

section of the community sufficiently accurate to warrant

the imposition by the legislature of serious compulsoryadditions to parental responsibility. The only safe founda-tion for the systematic study of infant mortality is

obviously a register of sickness not necessarily fatal, and

although in this country registration is limited to the

ordinary infectious maladies, notification of which is requiredby law, nevertheless there are grounds for hope that in thenot distant future records of at any rate the more prevalentand destructive diseases occurring in private practice may besecured. To show the practicability of a system of sicknessregistration on these lines we may quote the opinion of SirSHIRLEY MURPHY, who in his report for 1904 as medicalofficer of health of the Administrative County of London,says : " The idea has long been entertained, and the timeappears to have now arrived for carrying such a scheme intoeffect. If it were thought well to make a beginning withthe figures of a compact and more or less homogeneous area,such as the County of London, there should be no difficultyin making arrangements for communication to a central

1 Children Act, 1908. (8 Edw. VII., Ch. 67.)

authority of weekly statements df sickness of certain specialkinds brought recently under treatment in infirmaries,hospitals, and dispensaries. Such’ returns would probablybe of value, and’ if this fact ’were’ demonstrated in London,ah’extension of the system to the Test of the country couldlater readily be made"To the Section for Study of’’Disease in Children of

the Royat Society of Medicine a paper was read recentlyby Dr. DAVID FORSYTH, ori " Infant ’Mortality as seen ina Children’s Hospital." In ’that’ paper, which has since

been circulated in pamphlet form,’ an attempt is made to

determine’ I the relative fatality ’of the several pathologicalconditions that contribute’ to the death-toll in the first yearof life, the material for study having been derived from an

analysis of about 1200’ consecutive deaths at the Evelina

Hospital for Sick’Children. The criterion adopted for com-

parison’with the mortality in his own hospital is that of theentire English community as set forth in the returns of theRegistrar-General, and Dr. FoRSYTH expresses surprise atsome of the discrepancies that exist between those returnsand his own experience at the hdspital named. But

the standard of comparison was’not a wholly fortunateone for the following amongst other reasons. In the

first place, we note that the Evelina Hospital’s statisticsreferred to in the paper are exclusively concerned with the

mortality of infants under the age of one year, but that

nothing is stated respecting their exact ages, in weeks ormonths of that period. Now, in both the official reportsreferred to in ’the paper the mortality of infants in the first

week after birth is shown to be enormously greater than in

any later period of life. We must suppose that the majorityof Dr. FORSYTH’S patients had survived to the later monthsof the first year of life in order to account for their removal

from home to the hospital.’ Nevertheless, it is known that

of the total mortality under one year more than half is dueto deaths occurring within three months of birth ; and it

is unlikely that any considerable number of deaths at that

age of highest mortality would occur among the patientsat the Evelina Hospital. Again, with respect to pre-natalcircumstances, and especially to the parentage, of the infantsin Dr. FORSYTH’s clinic we are not informed; but the

death-rate of infants born in workhouses certainly exceedsthat of infants born under other circumstances, for example,in the maternity wards of those hospitals, admission

to which is restricted to respectable married woman.

Nevertheless, the deaths in Poor-law institutions form a verylarge proportion of the mortality returns of the Registrar-General with which the Evelina returns are here compared.For the foregoing, as -well as for other statistical reasons,the strict comparability of the two series of returns is opento question; the limitation of such comparison was,

indeed, insisted upon in the course of the discussion which

followed the reading of the paper, mainly on the groundthat the conditions of hospital practice differ so widely fromthose of everyday life.

-But Dr. FORSYTH’S paper was by no means confined to thepoints we have here considered. In the course of his re-

marks he reported a number of obvious inaccuracies in the-

national returns of causes of death. Whilst duly appreciat-ing the value of the Registrar-Genetal’s reports, because of

1332

the wide extent of the data on which his calculations are

based, Dr. FORSYTH contends that in the nature of the, casethese returns cannot generally be pathologically exact. He

therefore raises’ the question, Whether the official figurestruly reflect the fatal conditions of infancy at the presentday, and how far they carry us in devising remedial

measures." In the course of an able criticism of the

national death records, Dr. FORSYTH comments on the

prominent positions occupied by "marasmus" and con-

vulsions, and on the relatively subordinate importanceapparently attaching to syphilis, tubercle, and rickets.

Whilst fully recognising the difficulty met with by even

experienced clinicians in interpreting the symptomato-logy of infancy, he expresses astonishment that so largea proportion as 16 per cent. of the total mortalityshould be referred to marasmus, and 12 per cent. to

convulsions, whilst only 5 per -cent. are attributed to

tubercle, 1. 3 per cent. to congenital syphilis, and 0’ 6 percent. to rickets. It is not easy to harmonise clinical ex-

perience with these figures. Marasmus, with its official

synonyms atrophy and debility, is a term of vague signifi-cance, and is generally employed in connexion with diseasesof which wasting is merely a symptom. Congenital syphilisis frequently met with in out-patient departments, and is

particularly fatal to young children. Yet in the whole of

England it is stated to be responsible for little more than1 per cent. of the total infantile mortality. If hospitalexperience is to be trusted, this figure considerably under-states the fact, The large proportion of deaths, some 20

per cent. of the whole, attributed to premature birth

almost certainly includes a considerable number that

should have been referred to this disease, and the scarcelyless proportion referred to marasmus probably containsothers. The general tenour of this criticism applies evenmore forcibly to convulsions, a term the use of which inmedical certification has been forbidden by the Royal Collegeof Physicians of London. The official figures under this

heading are believed by many to be worthless for

advancing our acquaintance with the fatal conditions of

infancy, and we hold them to be actually misleading.They hide, under a meaningless designation, important fatalconditions, the returns for which are unduly minimised.In conclusion, Dr. FORSYTH expresses the hope, in which

we heartily concur, that the publication of the Evelina

Hospital statistics will lead to the preparation of correspond-ing figures for other hospitals. By this means a far-reachingand practical measure will have been secured for diminishingthe present excessive waste of infant life.

Rheumatic Fever.IN the Lumleian Lectures delivered this year before the

Royal College of Physicians of London (the concluding lecturebeing published at p. 1297 of this issue) Dr. NORMAN MOOREselected a subject which is of widespread interest-namely,Rheumatic Fever and Valvular Disease. In the older text-

books rheumatic fever, or as it was, and indeed is, frequentlycalled acute rheumatism," was classified under <’Diseasesof the Joints," bnt in the I I Nomenclature of Diseases,"drawnup by a joint committee appointed by -the Royal College

of Physicians of London, it is now rightly placed underInfective Diseases." As Dr. MOORE pointed out, it is socommon a disease that every physician has seen very manyexamples of it, yet its natural history is still obscure in.

several directions. He also remarked that its name recalls a

pathology long anterior to the revival of learning. His

erudite and interesting account of the historical litera-

ture of the disease will be found most attractive.

Following the usual course of knowledge about any

particular disease, some - prominent symptom was first

noticed and then assumed to be the whole disease

-in the case of "acute rheumatism " the affection of

the joints was naturally selected as the predominant feature-but progressive observation has gradually demonstratedthat this prominent symptom may be a result of several

distinct morbid conditions. Thus, the single disease of pastgenerations of medical authorities comes to be divided intotwo or more separate maladies, and separate terms are

necessary to distinguish them. The distinction between

typhoid and typhus fevers is an example of this advance ofknowledge. In the case of "rheumatism," although the

nosology of affections of the joints leaves much to be desired,yet it is now recognised that rheumatic fever is a distinctdisease, entirely apart from other acute, subacute, or chronicaffections of the joints, such as septic arthritis, gonorrhoea!rheumatism, chronic rheumatism, and the various conditionsclassified under the term rheumatoid arthritis. We endorse

Dr. MOORE’S contention that since it is desirable to avoid

the suggestion of any pathological relation to chronic

rheumatism, it would be better for the term &laquo; acute

rheumatism " to fall out of use, and that the words rheu-

matic fever" be invariably adopted. We also join in the

protest against the term subacute rheumatism," which heconsiders should never be used, as it naturally suggests anabsence of importance which attaches to no case, however

slight, of rheumatic fever.We have said that it is now generally accepted that the

COnQHlOn we are consiaering musti De piacea amongsli the

specific fevers, but at present it must be reckoned amongstthose fevers the bacteriology of which remains uncertain.Numerous investigations have been made on the subject, andseveral observers have claimed to have isolated the patho-genic organism. Dr. F. J. POYNTON and Dr. A. PAINE

described a diplococcus which they concluded was a causeof rheumatic fever and from further experiments believed itto be the cause, and Dr. J. M. BEATTIE isolated a

similar organism. By intravenous inoculation the last-

named observer produced endocarditis, polyarthritis, andchorea-a combination of lesions similar to those occur-

ring in connexion with rheumatic fever. Other investi-

gators, however, have failed to corroborate these obser-

vations, and the micrococcus rheumaticus" cannot yetbe accepted as the true bacteriological factor of the

disease. Dr. W. BULLOCH maintains that it does not fulfil

all, or indeed any, of KOCH’S postulates. It is not found,he says, in every case of the disease, and the effects whichit produces experimentally do not differ essentially fromthose produced by cocci having nothing to do with rheu-matic fever. But although the bacteriology must still be leftin doubt, there is no uncertainty about the pathology of the