1263THE DECLINE IN THE BIRTH-RATE

post-arsphenamine encephalitis is a seiisitisation

phenomenon, being possibly similar in pathogenesisto the encephalomyelitis that may complicatevaccination, small-pox, and measles. Since theexact cause is unknown, and there appears to be noway of recognising the susceptible patient, this

opinion will not increase the clinician’s confidence andcomfort. It may, however, serve a useful purposeif it discourages too light-hearted a use of organicarsenical preparations when there is no good reasonfor giving them.

THE DECLINE IN THE BIRTH-RATE

THE general interest that has been aroused in thefuture of our population is at least bringing to birthan ever-increasing number of scientific papers aboutit. Amongst recent ones is a laborious and carefulinquiry by W. J. Martin, a member of the MedicalResearch Council’s statistical staff who is workingat the London School of Hygiene, on the recordedfacts of the declining birth-rate in England andWales.1 For every part of the country he hascalculated the recorded fertility-rate, as measured bythe number of legitimate births per 1000 marriedwomen aged 15-45, for the three years round eachcensus from 1851 to 1931. The resulting figures showthat in most parts of the country the decline beganbetween 1870-72 and 1880-82. But some of the excep-tions are a little odd. In London, for example, therate shows no decline until the triennium 1890-92 ;in Cornwall it apparently fell during the wholeperiod, from 1850-52 onwards, a curious contrast ifwe accept the usual explanation of the decline. Therate of decline has everywhere been very uneven.In the country as a whole it fell by 56 births per1000 married women in the thirty years between1870-72 and 1900-02, while in the next thirty years itfell by another 113 births, or just twice as much.Areas in which the level was maintained till late inthe nineteenth century (for example, mining districts)very efficiently made up for lost time in the twentieth.The result is that in every broad division of the

country the fertility-rate recorded in 1930-32 islittle more than 40 per cent. of the correspondingrate sixty years ago. If the country is divided upinto districts in which particular occupations andindustries predominate relatively slight differencescan be observed.. In the last twenty years the rates ofagricultural areas have declined on the whole least,the rates of mining areas on the whole most, but thereis little in it. The differential birth-rate is a matterfor more concern. Wherever there are districts witha high proportion of males engaged in commerce or

with a high proportion of female domestic servants,conditions typical of residential middle-class areas,the birth-rate is low. Here later age at marriagemay play a part, but as a general rule changes inage of marriage between 1870 and 1930 have playedno material part in causing the decline in fertility.That trade stagnation may be a factor Martin con-cludes from the accelerated rate of decline during1911. to 1932 in South Wales, Northumberland, andDurham. Finally he estimates that in the country asa whole the rate in 1930-32 was 40 births per 1000married women aged 15-45 below the minimum raterequired to maintain a stable population. For thepopulation to continue to increase a 50 per cent. risein the present birth-rate would be necessary, whileto keep the population stationary an average familyof three children is required. It does not, put in thatform, seem a very large family but of course the

1 J. Hyg., Camb. 1936, 36, 402 ; Ibid, 1937, 37, 188, 489.

childless families and the one-child families must becompensated for by fives and sixes and the compensa-tion is not there. In 1901 7-4 per cent. of the popula-tion were aged 60 and over, in 1931 it was 116, anincrease of over 50 per cent. As the number of old agepensioners increases the proportion of contributorsdeclines.

LE MÉDECIN DE FAMILLE

"IT would be a bad thing," wrote Sir WalterLangdon-Brown in the Times a week or two ago," if the day should ever come when people were unableto refer possessively to ’my doctor.’" Such a

prospect is viewed with no less concern in France,where Dr. P. Viard,l of the Nelly Martyl Foundation,ascribes the gradual diminution in family doctors tothe effects of the materialism of the nineteenth

century, which led to the rise of specialism in thesciences in general and in medicine in particular.Dr. Viard has nothing against specialists in their

place, but he thinks they should be used like the high-power objective of the microscope, only when a moregeneral view has not told us all we want to know.What would we think of a motorist, he asks, who haddifferent chauffeurs to drive him on hills and on thelevel, or who expected to find a carburettor specialistand a differential specialist at every garage Clinics,too, have their failings ; he describes the dreadfulfate of the G. family-a working man, his wife, andtwo children-of whom G. was wounded in the lungand contracted syphilis during the war, his wifewas expecting her third, his son suffered from head-aches, and his daughter had a chronic cough. If allhad attended the clinics that prudence suggested theG. income would have been swallowed up by theexpense of travelling to the four corners of Pariswhere the various clinics were to be found. So theG.’s left their troubles untreated and the results weredisastrous. Where parents and patients are oftenindifferent and still more often ignorant, the collabora-tion of the family doctor is essential in any scheme forprotecting the race against disease. He knows thefamily’s hereditary failings and how they affect itsmembers’ reaction to illness, and he alone can takethe necessary broad view of all the circumstances.Social medicine, concludes Dr. Viard, must be

reorganised with the family as its unit, and it willbe for the family doctor to act as liaison officer betweenthe head of the household and the State. He willwatch over the interests of the children from beforetheir birth, advising upon the choice of a schooland of a career, and compiling a dossier of the familyhealth to which the specialist may refer if and whenhis services are required.

CYSTIC DISEASE OF LUNG

CONGENITAL cystic disease of the lungs has onlylately begun to receive much attention. Most of thecases on record have been accidentally discoveredpost mortem, and, as Mr. Holmes Sellors 2 points out,detailed descriptions of pathological findings are fewand far between. He gives a minute account of acase operated upon by himself, in which the leftlower lobe was excised. The patient, a girl of 18,complained of chronic cough and expectoration.Lipiodol injection and radiography showed bronchiec-tasis towards the left base and a small opacity contain-ing many small spaces filled with the contrast fluid.At operation this shadow was found to correspondto the lower lobe, which was reduced to a small,

1 Vie méd. Sept. 25th, 1937, p. 639.2 Sellors, T. H., Tubercle, November, 1937, p. 65.

1264 AN ATLAS OF GAS-POISONING.-THE SERVICES

dark mass, measuring only 3 in. in its longest diameter.On section this mass was seen to contain multiplecystic spaces lined with regular bronchial epithelium.All grades of the finer bronchial tubes were conspicu-ously scanty, and terminal and respiratory bronchiolesabsent, the larger bronchi communicating directlywith the cystic spaces. There was complete absenceof alveoli, but the tissue surrounding the cystsappeared to consist of unexpanded alveolar elements.The condition, which is illustrated by several colouredplates, seemed to be one of maldevelopment of thefiner bronchial tubes and consequent failure of theconnexion between the alveoli and the bronchialtree. The cysts would represent the dilated terminalparts of the bronchi. Dr. Adams,3 who reports twocases in which a diagnosis was made by means ofbronchograms, found very similar appearances in theright upper and middle lobes in one of his patients,a boy of 6, successfully treated by operation. Here

again the cysts were lined by typical bronchialepithelium, and the intervening tissue, thoughcontaining some fairly normal-looking alveoli, con-sisted largely of unexpanded alveolar elements.Adams suggests that the condition would best bedesignated " telangiectatic bronchiectasis."

ADDUCTOR SPASM IN APPENDICITIS

Richet and Netter draw attention 4 to a diagnosticsign in appendicitis which they think deserves furtherstudy. It is increased tone in the adductor musclesof the right side. The spasm is not severe enoughto prevent full movement at the hip-joint, and istherefore not to be confused with spasm due toinflammatory lesions of the hip. In testing for thesign the patient is placed on his back, with the kneesand hip-joints semiflexed and the heels flat on thebed. The mouth is open and muscular relaxationshould be as complete as possible. The inner bordersof the knees just touch one another. A finger placedon the inner side of each knee exerts a gentle, steadypressure tending to force the. knees outwards anddownwards. In cases of appendicitis Richet andNetter have found that equal pressure exerted onthe two sides rotates the left leg with great ease,whereas the right limb remains almost upright. Theyinsist that the force exerted must be very slight ;otherwise the spasm will be overcome and both limbswill move freely. They have found the sign positivein about one case in three of appendicitis, and, apartfrom coxalgia, in only one case that did not proveto be appendicitis. Adductor spasm was associatedwith all positions of the appendix except the retro-caecal. It was present in the ordinary type of acuteappendicitis, and was often found in chronic appendi-citis ; it was present in a case of appendicular abscessseen late, but absent when -there was gangrene.The really important point about the sign seems tobe that it is not found with other lesions of the rightiliac fossa, and so serves to distinguish the less obviousforms of appendicitis from other causes of right-sided abdominal pain, whether functional or organic.Richet and Netter think that any explanation of theadductor spasm that presupposes direct irritationof the obturator nerve is too far-fetched. Theysuggest that it is a reflex phenomenon, starting in theafferent visceral nerves of the appendix, but on thatbasis it seems difficult to explain the absence of thesign in the retrocaecal appendix and in gangrenousappendicitis. If Richet and Netter’s sign is con-

firmed by other observers it seems more likely that its

3 Adams, A., Lpool med.-chir. J. 1937, 45, 87.4 Richet, C., and Netter, H., Paris méd. Oct. 23rd, 1937, p. 317.

explanation will lie in a, reflex motor stimulus startingin sensory irritation of the parietes in the neighbour-hood of the pelvic brim and lower part of the iliacfossa. Surgeons are well aware that in cases of

gangrenous appendicitis the surrounding structures

may escape infection until the appendix ruptures.Unless the appendix touches the anterior parietalperitoneum the signs may be very slight beforerupture takes place. Adductor spasm may prove tobe a sign of the contact of an inflamed appendixwith another part of the parietes. ,

AN ATLAS OF GAS-POISONING

Now that increasing attention is being paid toair-raid precautions, it is probable that medical

practitioners will be asked by their patients (quiteapart from any official positions they may hold) foradvice about danger from gas attacks and precautionsthat may be taken to minimise it. To give suchadvice they will have to be familiar not only withanti-gas measures but also with the effects producedby the various types of gas. In 1918 the MedicalResearch Committee issued an " Atlas of Gas Poison-ing " for official circulation amongst medical prac-titioners serving in the forces, and the air-raidprecautions department of the Home Office has nowissued a new edition of this pamphlet. 1 It consistsof a number of coloured plates Illustrating the morbidanatomical, and in some cases histological, lesionsresulting from phosgene and mustard-gas. Thereproductions are excellent and the short accountsof the clinical and pathological changes are adequate.In describing the changes in phosgene poisoning,emphasis is rightly laid on the extreme pulmonarycedema that plays the chief part in the clinical picturewhether it is of the cyanotic or anoxsemic character;it is not made clear, however, that this pulmonarychange is not merely a serous exudate into the alveolibut is accompanied by fibrinous consolidation anda mononuclear infiltration. These pneumonic areas,alternating with an extreme emphysema, appear asearly as five hours after exposure, before a secondarybacterial infection has had time to complicate thepicture ; further the emphysema may be so severeas to cause rupture of the distended vesicles and aspreading surgical emphysema. The illustrations ofthe eye changes caused by mustard-gas are particu-larly clear, but there is little mention of the late

pulmonary changes when fibrosis and bronchiectasismay occur and totally incapacitate the sufferer.More surprising is the omission from the atlas of anyaccount of the pathological lesions caused by thesternutators, Lewisite or chlorpicrin.

THE SERVICESARMY MEDICAL SERVICES

Maj.-Gen. G. G. Tabuteau, D.S.O., is appointed Hon.Surg. to the King, vice Maj.-Gen. D. S. Skelton, C.B.,D.S.O., retd.

TERRITORIAL ARMY ’

The King has conferred the Efficiency Decoration onCol. E. M. Cowell, D.S.O., and Lt.-Col. E. Scott, D.S.O.

ROYAL AIR FORCE

The annual dinner of the R.A.F. medical and dentalservices will be held at the May Fair Hotel on Dec. 10that 7.30 for 8 P.M.’ The hon. secretary is Squadron-LeaderR. G. Freeman, 5, Clement’s-inn, London, W.C.2.

1 An Atlas of Gas Poisoning. 2nd ed. London: H.M.Stationery Office. 1937. Pp. 16. Plates XI. 1s.